HCoLL Flashcards
(185 cards)
1
Q
Advanced Directives / Advanced decision to refuse treatment
A
Made when the patient has capacity for when they lose capacity.
Pt can set out the treatment they do not want and in which circumstances.
Cannot demand treatment or refuse basic care
2
Q
Can a patient with an ADRT be treated when detained under the mental health act?
A
yes
3
Q
What are things to consider when thinking about DNACPR?
A
- Survival chances
- QoL after resuscitation – hypoxic brain damage/pain/broken ribs/etc
- Will ITU be able to support this patient post-arrest
4
Q
DNACPR
A
Only covers CPR and not any other treatments.
= A medical decision but should be discussed with the patient and family.
Needs a medical reason other than age to be valid (e.g. not fit for ITU post-arrest/frailty/terminal/etc).
5
Q
ReSPECT form
A
= personalised recommendations for clinical care in a future emergency, where the patient is unable to make or express decisions.
A more holistic summary of end-of-life care than DNACPR
Relevant for people with complex health needs/nearing end of life/at risk of sudden deterioration.
6
Q
What is mental capacity?
A
= a person’s ability to make their own decisions and choices.
Judged according to a specific decision and at the time at which the decision is being made.
Capacity can be regained (e.g. acute confusion/delirium)
7
Q
5 principles of capacity
A
- Assume capacity unless proven otherwise.
- Individuals should be supported to make their own decisions where possible.
- Unwise decisions must still be respected.
- If someone lacks capacity, you must act in their best interests.
=> Consider person’s wishes, feelings, beliefs, values.
=> Consider the views of close friends/family (but if they are not acting in best interests, can refer to court of protection).
=> Consider whether they will regain capacity. - If someone lacks capacity, you must choose the least restrictive option.
8
Q
Lasting Power of Attorney
A
A person is appointed to make decisions about a specific area of a patient’s life when they lose capacity (e.g. finances, health and well-being).
9
Q
How do you assess capacity?
A
Stage 1: Does the person have an impairment of the mind or brain?
If no, there is no reason to question capacity.
Stage 2: can the person… • Understand information? • Retain information? • Weigh up consequences? • Communicate the decision?
If they cannot demonstrate these criteria, this indicates that they LACK capacity for this particular decision
10
Q
What is elder abuse?
A
= a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.
11
Q
Types of elder abuse
A
- Financial
- Emotional/psychological
- Physical
- Sexual
- Neglect/abandonment (not always intentional – passive neglect).
12
Q
What should be done if elder abuse is suspected?
A
If you are concerned you MUST TAKE ACTION.
=> Document concerns and escalate to someone more senior.
=> Consider adults safeguarding referral
13
Q
What is the difference between euthanasia and assisted suicide, and what are the laws in the UK surrounding these?
A
Euthanasia = the act of deliberately ending a person’s life to relieve suffering
Assisted-suicide = deliberately assisting another person to kill themselves
Both are illegal in UK law.
Euthanasia is considered manslaughter/murder.
14
Q
Who is required for a MHA assessment?
A
2 doctors (who are deemed able to complete the assessment)
A specialist social worker.
15
Q
what needs to be considered in a mental health act assessment?
A
Consider:
the previous nature of the illness, progression, the current severity of illness, risks to themselves/others, compliance with medication, engagement with healthcare professionals
16
Q
Mental Health Act
A
Guides compulsory inpatient admission for assessment and treatment of people of and disorder/disability of the mind.
A last resort – the most restrictive way to take someone into hospital, does deprive the patient of their liberty.
Usually comes into play when a person is at risk of harming themselves/others/their own health and safety
ONLY applies to psychiatric disorders
17
Q
What aspects of cognitive function are important for driving?
A
spatial awareness,
attention,
concentration
18
Q
Deprivation of Liberty Safeguards (DOLS)
A
Used when it is necessary to deprive a patient of their liberty when they lack capacity to consent to their care and treatment, in order to keep them safe from harm.
If all of the following are true, you need to apply for a deprivation of liberty:
- Patient is deemed to lack capacity for self-discharge.
- Person is subject to continuous supervision and control
- If the person wishes to leave and you wouldn’t be happy with them doing so.
19
Q
What is delirium?
A
a common clinical syndrome characterised by disturbed consciousness/attention, cognitive function or perception, which has ACUTE ONSET and FLUCTUATING COURSE
20
Q
Causes of Delirium?
A
Drugs / dehydration Electrolyte disturbances Level of pain / lack of analgesia Infection / inflammation Respiratory failure Impaction of faeces / Intracranial Urinary retention Metabolism / MI
21
Q
Risk factors for developing delirium
A
- Having dementia (~50% of delirium cases occur in patients with prior dementia)
- Over 65
- Frailty
- Multiple comorbidities
- Poor hearing/vision
- Polypharmacy
- Recent surgery
- Terminal illness
- Previous Hx of delirium
22
Q
What are the types of delirium?
A
Hyperactive
Hypoactive
Mixed
23
Q
Delirium - Sx
A
HYPERACTIVE
Abnormally alert, Agitation/restlessness, disorientation, hallucinations, aggression, wandering, inappropriate behaviour.
HYPOACTIVE:
Often unrecognised, presents similar to depression.
Withdrawn, not eating/drinking, drowsy, disorganised
24
Q
?delirium - assessment
A
“Is the patient more confused than normal?”
CAM = Confusion Assessment Methods
- More confused than normal
- Inattentive
3a. Disorganised thinking
3b. Altered state of consciousness
If yes to 1 AND 2 AND 3a or 3b, then is the course acute and fluctuating?
If yes => DELIRIUM.
25
1st Line Investigations for Confusion
- Collateral Hx (establish baseline cognition).
- Physical examination (conscious level, ?infection, neurology).
- Confusion Bloods
- Urinalysis
- CXR, ECG, CT/MRI
- Assess nutritional status
- Medication review
26
What are "confusion bloods"?
FBC, CRP, U&Es, LFTs, TFTs, glucose, Ca, B12, folate
27
Delirium - Management
TREAT UNDERLYING CAUSE (if ignored => high mortality).
Reduce medications – avoid opiates, anticholinergics.
Reassure and keep orientated, active, hydrated, nourished.
Optimise senses and promote good sleep hygiene.
Only use drugs if other interventions have failed and patient is a risk to themselves or others.
=> Haloperidol 0.5mg = 1st line
=> Lorazepam 0.5mg (if haloperidol is contraindicated – Parkinson’s, LB dementia).
=> Only use short-term (usually 1 week or less).
28
What is the 1st line drug in management of delirium?
What are some contraindications of this drug?
Haloperidol 0.5mg
CIs - Parkinson’s, LB dementia
29
Delirium vs Dementia
```
DELIRIUM
Develops over hours/days
Fluctuating course
Altered consciousness
Usually reversible
Psychomotor changes – increased/decreased
Impaired attention
```
DEMENTIA
Develops over years/months
Progressive
Consciousness usually clear
Irreversible
No psychomotor changes (until late disease)
Often good attention (until late disease)
30
What is dementia?
Dementia is a PROGRESSIVE and IRREVERSIBLE syndrome describing a set of symptoms due to degenerative changes in the brain.
It causes impaired function with no other medical explanation
31
Dementia - symptoms
1. Memory Loss
2. Difficulties with higher cognitive processes (at least 1 of):
- Impaired executive function (e.g. problem solving, emotions).
- Apraxia (difficulty motor planning)
- Agnosia (difficulty recognising objects)
32
How long must the symptoms have been going on for a possibility of a diagnosis of dementia?
At least 6 months
33
How common is dementia?
~7% of people aged >65 have dementia
Affects F>M
34
What are the different types of dementia?
| How common are they?
1. Alzheimer’s Disease – 2/3rd
2. Vascular Dementia – 20%
3. Lewy Body Dementia – 5%
4. Frontotemporal Dementia – 2%
5. Other rarer causes
35
What are the other rarer causes of dementia?
- Wernicke-Korsakoff Syndrome
- Down’s Syndrome
- Huntington’s
- Multiple Sclerosis
- Parkinson’s Disease Dementia
- Creuzfeldt-Jakob disease
- Pugilistic Dementia (repetitive head trauma).
36
What is the most common type of dementia?
Alzheimer's Disease
37
Alzheimer's - Pathophysiology
- Characteristic beta-amyloid plaques and neurofibrillary tangles.
- Brain atrophy, particularly the hippocampus.
- Enlarged ventricles
38
Alzheimer's - Symptoms
= Progressive memory loss that affects function.
Later on - Problems finding words, Mood/behaviour problems
There tends to be a gradual, progressive decline.
39
Cause of Alzheimer's
Cause is unknown.
Early onset (<65) there is some familial risk
Association with APO-E gene
Association with CVD risk factors.
40
What is the average life expectancy of someone diagnosed with Alzheimer's
7 years
41
Vascular Dementia - cause
Caused by reduced blood supply to the brain (due to diseased blood vessels)
42
Vascular Dementia - symptoms
Usually stepwise progression - stable and then sudden decline
Symptoms = problems with memory, thinking and reasoning.
Often overlaps with symptoms of Alzheimer’s.
43
Risk factors for vascular dementia
HTN, cholesterol, alcohol, smoking, DM, male, etc
44
Lewy body Dementia - pathophysiology
Characterised by alpha-synuclein deposits in the brain
45
Lewy body Dementia - early and late symptoms
Early stages – hallucinations and delusions, mood swings/ short tempered, short attention span, fluctuating alertness.
Late stages – Motor deterioration, similar to Parkinson’s.
46
Lewy body Dementia - differentials
Parkinson’s (but here the motor problems develop before cognitive decline.
Alzheimer’s
Schizophrenia – hallucinations/delusions
47
Fronto-temporal Dementia - pathophysiology
Involves damage to upper and middle frontal lobe and temporal lobe
48
Fronto-temporal Dementia - variants
Behavioural (2/3)
Progressive non-fluent aphasia
Semantic dementia
49
Fronto-temporal Dementia - symptoms of behavioural variant
Loss of inhibition – rude and compulsive
Personality changes – loss of interest in people, loss of sympapthy/empathy
Crave food – often sweet/fatty, eat until vomit.
Speech, language difficulties
(A cognitive deficit is not so obvious).
50
Dementia - investigations/diagnosis
```
Detailed History (often collateral)
=> Duration of Sx, effects on ADLs
```
Physical examination
=> CNS/PNS, gait, CVS, thyroid.
Blood tests +/- lumbar puncture
Medication Review
=> Look for any correlation of medications and duration of symptoms
Cognitive tests
CT/MRI
=> To exclude other causes.
51
Dementia - differentials
* Delirium
* Other mental illness (e.g. depression)
* Substance misuse
* Traumatic brain injury
* Metabolic (hypothyroidism, B12 deficiency).
* Medications (steroids, anti-depressants).
52
Dementia - management
There is NO CURE – eventually progresses to dependence and palliative care.
1. Referral to Memory Clinic / RRLP
2. Pharmacological – alleviate symptoms/slow progression
3. Non-pharmacological
=> Social services care plan – home help, equipment, meals on wheels, day care.
=> Consider capacity – organise ADs/LPAs/DNACPRs while the patient still has capacity.
53
Dementia - pharmacological options
Cholinesterase Inhibitors – e.g. donepezil, rivastigmine, galantamine.
=> Alzheimer’s, LBD and Parkinson’s (mild-moderate disease).
NMDA Receptor Antagonists – e.g. Memantine
=> Alzheimer’s only (moderate-severe disease).
54
What is the pharmacological treatment for vascular dementia?
There isn't one
55
What is the pharmacological treatment for FT dementia?
There isn't one
56
What is the pharmacological treatment for Alzheimer's disease?
Cholinesterase Inhibitors
| NMDA Receptor Antagonists
57
What are the components of a mini-ACE ?
Patient Demographics - include occupation, handedness, age at leaving full-time education
Orientation - day, date, month, year
Memory - address
Fluency – Animals
Visuo-spatial – Clock drawing
Memory Recall - address
58
What is the mini-ACE?
A cognitive assessment
Used as a SCREENING TOOL to identify cognitive impairment.
59
What are the cut-off scores in the mini-ACE?
<25 - likely to have come from a dementia patient
<21 - almost certainly a score to have come from a dementia patient
60
Charles-Bonnet Syndrome
= Hallucinations
Often associated with diminished eyesight (e.g. macular degeneration), due to overcompensation of the brain.
Patients will mostly still have insight into these hallucinations
61
Old Age Psych History components
Demographics + reason for referral
PC and HPC
=> Onset – insidious vs. rapid.
=> Non-cognitive symptoms.
=> Impact on ADLs
Hx of psychiatric illness
PMHx
=> Pre-morbid personality.
=> Hx of delirium?
=> Vascular risk factors – stroke, TIA, MI, peripheral vascular disease, HTN, diabetes, falls.
DHx
FHx
```
SHx
=> Current living arrangements
=> Amount of care – family/friends or district nurses/day care?
=> Drugs/smoking/alcohol/benzodiazepines
=> Driving – concerns, incidents?
```
62
What are the things to assess in a Mental State Examination ?
Appearance and Behaviour
Speech
Emotion
=> Mood/affect
Perception
=> auditory/visual/olfactory hallucinations
Thoughts
=> content and expression
Insight
Cognitive Function
=> mini-ACE
63
How common is later life depression?
affects 1 in 5 in the community (more common in nursing homes)
affects F > M.
64
“monoamine hypothesis” of depression
Depression results as a deficiency of one or more of Dopamine, Noradrenalin and Serotonin.
=> Anti-depressants increase the levels of these neurotransmitters
65
Risk factors for later life depression
- Chronic Pain/Long-term conditions
- Loss – spouse/job/independence
- Isolation
- PMHx or FHx of depression/anxiety
66
ICD-10 Diagnostic Criteria for Depression - core and other Sx
CORE SYMPTOMS
1. Low Mood - worse in the morning
2. Anhedonia
3. Fatigue
```
OTHER SYMPTOMS
• Guilt/hopelessness
• Suicidal thoughts/self-harm
• Psychosis (hallucinations/delusions)
• Sleep disturbance/poor memory
• Change in appetite
• Agitation
• Psychosomatic (pain/GI complaints, excessive concern over physical health)
```
67
Severity of depression by ICD-10 criteria
Mild – 2 core and 2 other Sx.
Moderate – 2/3 core and 3 other Sx.
Severe – 3 core and 5 other Sx.
68
Agitation as a Sx of depression
Usually depression presents as slowing of everything (speech, movement, thinking, etc.) but, in the elderly, agitation is often seen (inability to relax).
69
Psychosis as a Sx of depression
If the mood symptoms start before the psychosis, then it can be considered depression.
If the psychotic symptoms start first, then it’s more likely to be a psychotic disorder
70
Geriatric Depression Scale
= 15 yes/no questions to help screen for, assess severity of and monitor clinical depression in an older person.
71
DDx for depression
Endocrine/metabolic
- Hypothyroidism
- Anaemia
- Hypercalcaemia
- Malignancy
Dementia
Parkinson’s Disease
72
What are important things to assess when assessing for suicide risk?
```
Risk to self
Risk to others
Non-compliance with medication
Self-neglect
Exploitation/vulnerability
Driving
Physical Health/Falls
```
73
Suicide assessment - risk to self
Previous Hx or attempted self-harm/suicide
FHx of suicide
Current episode – ongoing thoughts (frequency, severity, intrusiveness), planning, final acts, the future
74
Suicide assessment - risk to others
Verbal/physical threats of harm to others
| Thoughts or attempted harm
75
What can cause non-compliance with medications?
Memory issues, side effects, lack of insight, stigma
76
Management of Depression
BIOLOGICAL:
- Antidepressants – SSRIs are 1st line
=> Wait 2-4 weeks, if no improvement then change to another.
- Anxiolytics – BZDs (short-term use)
- Hypnotics – Z-drugs (e.g. Zopiclone, etc.)
- ECT
PSYCHOLOGICAL:
- CBT
SOCIAL:
- Support networks/groups
- Social services referral
- Lifestyle – limit alcohol, increase exercise, meaningful activity, etc.
77
What is pseudo-dementia?
Temporary dementia-like symptoms (attention and memory deficit) secondary to depression.
78
What are the main differences between dementia and pseudo-dementia?
Pseudodementia does not cause actual degeneration of the brain, while dementia does.
Hx of disturbance in pseudodementia is often short and abrupt onset, while dementia is more often insidious.
79
What is useful to establish in the Hx to help differentiate between dementia and pseudo-dementia ?
if the changes in mood preceded any changes in cognition
80
Pseudo-dementia and cognitive assessments
Often people with pseudodementia can perceive their changes in cognition, but actually perform quite well on cognitive assessments (often the opposite with dementia)
81
What is total bladder volume?
| When is the first desire to void normally?
~600mL total volume
~250mL = desire to void
82
How is continence maintained?
co-ordinated interaction of the bladder, urethra, pelvic floor muscles and the nervous system.
=> Maintained so long as the urethral pressure exceeds the bladder pressure
83
Nervous input to micturition
Frontal Cortex – provides voluntary control of micturition.
Parasympathetic NS – initiates micturition reflex (contraction of detrusor muscle in bladder – S2-S4)
Sympathetic NS – inhibits micturition reflex, allows bladder filling (contraction of smooth muscle sphincter and proximal urethra – T11 – L2)
84
What is required for normal bladder function?
- Intact nerve pathways
- Normal muscle tone – in detrusors, sphincters and pelvic floor
- Absence of any outflow obstruction
- Normal cognition
- Absence of environmental/psychological factors which may inhibit micturition
85
Causes of faecal incontinence
- Diarrhoea
- Faecal impaction
- Nerve damage (spinal cord injury, MS, DM)
- Anal damage (e.g. post-radiotherapy)
- Cognitive (dementia, stroke)
- Other causes – IBD, malignancy, poor diet/fluid intake.
86
Urinary incontinence
= the complaint of any involuntary leakage of urine sufficient to be a health or social problem.
Prevalence increases with age – VERY common in the elderly (30% at home, 50% in care homes).
More common in women
87
Causes of established urinary incontinence
Outlet incompetence (childbirth, prostatectomy)
Outlet obstruction (BPH, strictures, etc.)
Detrusor overactivity
Detrusor underactivity (neurological)
Cognitive (dementia)
88
Causes of acute urinary incontinence
```
Delirium
Infection (UTI)
Atrophic urethritis/vaginitis
Drugs
Psychiatric disorders (especially depression)
Polyuria (DM, excess intake)
Restricted mobility
```
89
What drugs can cause urinary incontinence?
How?
CCBs, antidepressants, antipsychotics – decreased detrusor activity
Alpha blockers – relax urinary sphincter
ACEIs – cough worsens stress incontinence
Sedatives – reduce awareness of full bladder
Diuretics – increase urine output (including alcohol and caffeine)
90
Types of urinary incontinence
1. Urge incontinence
2. Stress/Pressure Incontinence
3. Overflow Incontinence
4. Functional Incontinence
91
What is the most common type of incontinence in the elderly?
= urge incontinence
92
Functional Incontinence
due to a cognitive failure to inhibit reflex (e.g. dementia, stroke)
Risk factors – immobility, sedation, unfamiliar surroundings
93
Investigations for urinary incontinence
History + Examination
Urinalysis
Bloods - FBC, U&E, creatinine, glucose
Frequency/Volume Charts
Pre- and Post-void Bladder Scan
Uroflowmetry
94
What volume of urine in 24 hours is considered polyuria?
>2000mL / 24h
95
What residual post-void volume in the bladder is considered abnormal?
>100mL = abnormal
96
What are important points to identify in a Hx for incontinence?
- Urgency? Frequency? Dysuria? Nocturia?
- Hesitancy/dribbling/poor stream?
- Haematuria? Weight loss?
- Fevers/rigors/N+V?
- PMHx/PSHx (also obstetric Hx)
- DHx
- Alcohol/caffeine/smoking/fluid intake
97
What examinations are relevant in investigating incontinence?
Neurological - Mental status, spinal cord (lower limb weakness), perineal sensation
Abdo - Kidneys and bladder
Pelvic - Organ prolapse/wall weakness
Rectal - Faecal impaction, rectal masses
98
Management of urinary incontinence - Lifestyle
- Smoking cessation, weight loss
- Restrict fluids (especially in evenings)
- Reduce alcohol and caffeine
- Pelvic floor exercises
- Absorbent pads/commodes
99
Management of urinary incontinence - Medication
- Antibiotics – UTI
- Tamsulosin/finasteride – BPH
- Oxybutynin/solifenacin (anticholinergics) – urge incontinence
- Duloxetine (serotonin/NA reuptake inhibitor) – stress incontinence
100
Incontinence - red flag symptoms
- Haematuria
- Prolapse beyond vaginal opening
- Suspicion of prostate cancer
- Abnormal neurology
- Saddle anaesthesia
- Recent back trauma
- Recent pelvic surgery
101
What is osteoporosis?
= reduced bone mineral density with altered microarchitecture causing the bones to be weak and fragile.
Caused by osteoclast (bone resorption) activity being greater than osteoblast (bone formation activity).
102
Result of osteoporosis
Gradual bone weakening – especially hip, spine, wrist.
Increased risk of fracture – e.g. from standing height/low trauma
Back pain/kyphosis/loss of height
103
Osteoporosis - Risk Factors
Primary:
- Age / female gender
- Genetics
- Low BMI
- Calcium/VitD deficiency
- Previous low trauma fracture
Secondary:
- Chronic inflammation (RA, malignancy)
- Hyperthyroidism/hyperparathyroidism
- Malabsorption of Calcium
- Premature menopause
- Steroid use
- Smoking
- Alcohol excess (>3 units per day)
104
FRAX Score
= 10-year risk of osteoporosis and hip fractures
FRAX Score Parameters:
- Age, gender, BMI
- Smoking/alcohol Hx
- Steroid use
- RA
- Fracture Hx
105
Osteoporosis - Ix
Hx and Examination
=> Calculate FRAX Score
U&E, bone profile, Vit D, TFTs, PTH, ESR, sex hormones
X-Ray
DEXA Scan
=> Measures bone mineral density
=> Gold standard Ix if intermediate/high FRAX risk
106
what DEXA Scan results indicate osteoporosis?
Osteoporosis = T-score >2.5 s.d. below average.
Osteopenia = T-score 1-2.5 s.d. below average.
107
DEXA scan - T-score
= s.d.s below average for young adult male.
108
DEXA scan - Z-score
= s.d.s below average for age-matched control.
109
Osteoporosis - Management
1. Lifestyle:
- Improve calcium intake
- Exercise (especially weight-bearing)
- Smoking cessation/reduced alcohol consumption.
2. Physio/OT => Reduce falls risk
3. Medication:
- VitD and Calcium supplements.
- Bisphosphonates
- Medication review – ?stop steroids
110
What is important counselling information when prescribing bisphosphonates?
• Can cause GI upset/oeseophageal ulcers and rarely jaw necrosis
* Tablets/injections once per week
* Swallow with water and sit upright for 30 mins after
111
Definition of malnutrition
= a state of nutrition in which a DEFICIENCY or EXCESS of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (shape, size, composition) and function to affect clinical outcome.
112
Malnutrition - symptoms
- Loss of appetite
- Weight loss
- Tiredness/loss of energy
- Reduced physical performance
- Altered mood
- Poor concentration
113
Risk factors for malnutrition
Cognitive:
- Unable to vocalise desires
- Misinterpret sensation of hunger
- Reduced appetite/early satiety
- Depression/bereavement
- Dementia/delirium
Social:
- Access to food
- Isolation/loneliness (don’t eat socially)
- Finances
Physical:
- Dental problems
- GI/swallowing problems
- Medications
- Poor mobility/reduced dexterity
- Reduced sense of smell/taste
114
Why is there an increased risk of malnutrition in hospitals?
* Unpleasant environment (smell, sights, sounds, etc.)
* Limited time for eating
* Can’t access food
* Limited provision for religious/dietary needs
* NBM or missed meals (e.g. while undergoing tests)
* Increased nutritional requirements due to illness
115
Malnutrition Universal Screening Tool (MUST)
= a 5-step tool to screen for malnourishment/risk of malnourishment.
Done within 24 hours of admission and repeat weekly (or sooner if the patient’s condition changes).
0 = low risk
=> Repeat screening weekly/situation changes
1 = medium risk
=> Document intake for 3 days
=> Decide if further intervention is needed
≥2 = high risk
=> Dietetic support to improve intake
=> Close monitoring.
116
Malnutrition - Management
Always try food first!
1st LINE
Dietary Alterations
e.g. little and often, full-fat options, nourishing drinks, multivitamins
2nd LINE
Oral Nutritional Supplements
e.g. Fortisips
3rd LINE
Enteral Nutrition
e.g. NG, PEG, RIG Tube
117
Indications for Enteral Nutrition
Inability to take sufficient nutrition orally
| Functioning gastrointestinal tract
118
Definition of TIA
= acute focal neurological deficit of cerebrovascular cause, lasting <24 hours.
Usually resolves in minutes
119
Definition of stroke
= acute focal neurological deficit of cerebrovascular cause lasting >24 hours/results in death.
120
Types and subtypes of stroke
Ischaemic stroke (85%)
- Thrombotic
- Embolic
Haemorrhagic stroke (15%)
- Intracerebral
- Subarachnoid
121
Ischaemic Stroke - Sx
Motor – unilateral weakness, slurred speech
Sensation – numbness
Coordination problems
Higher cognitive dysfunction – dysphasia, agnosia, apraxia, inattention, memory loss.
Vision – amaurosis fugax, homonymous hemianopia
122
Ischaemic Stroke - Risk Factors
Modifiable:
- HTN
- Alcohol/smoking
- Obesity/DM
- Lack of exercise
- Hyperlipidaemia
Non-modifiable:
- Age, male
- FHx
- Previous stroke/TIA
- AF
123
Amaurosis fugax - what is it and how is it managed?
= transient loss of vision in one eye.
90% due to atherosclerotic disease in carotid artery.
Mx – aspirin 300mg PO and refer to TIA clinic
124
Presentation of haemorrhagic stroke
1. Intracerebral Haemorrhage:
• Focal neurological deficits
• Reduced consciousness
• Headache, nausea, vomiting.
2. Subarachnoid Haemorrhage
• Sudden thunderclap headache.
• Reduced consciousness
• Meningism – photophobia, stiff neck, vomiting.
125
Risk factors for haemorrhagic stroke
```
Berry aneurysms (SAH)
Charcot-Bouchard microaneurysms (intracranial haemorrhage)
```
AVMs
Uncontrolled HTN
Alcohol/cocaine/smoking
Anticoagulants, coagulopathies
126
Bamford Classification of stroke - TACS
= Total anterior circulation stroke
A large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries.
All 3 of:
• Higher cerebral dysfunction
• Homonymous hemianopia
• Contralateral hemiparesis/hemisensory loss (at least 2 of face, arm, leg)
127
Bamford Classification of stroke - PACS
= Partial anterior circulation stroke
Involves small branches of the MCA and ACA – i.e. only part of the anterior circulation is compromised.
2/3 of the criteria for TACS
OR isolated higher dysfunction.
128
Bamford Classification of stroke - POCS
= Posterior circulation syndrome
Involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).
1 of:
• CN palsy, PLUS contralateral motor/sensory loss.
• Bilateral motor/sensory deficit.
• Isolated homonymous hemianopia.
• Cerebellar dysfunction (nystagmus, uncoordinated).
129
Bamford Classification of stroke - LACS
= Lacunar stroke
A subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).
1 of:
• Pure unilateral hemiparesis OR hemisensory loss.
• Pure unilateral hemi-sensorimotor loss.
• Ataxic hemiparesis.
130
Stroke - Assessment
ABCDE
History:
- Onset, duration, symptoms, etc.
Examination:
- GCS, Neurological, General SR (especially CVS)
Recognition of stroke screening tool / NIHSS severity assessment.
131
Investigations in ischaemic stroke
Bloods – FBC, U&Es, CRP/ESR, lipids, glucose, clotting, TFT
ECG – check for AF/evidence of MI
Brain Imaging
=> CT – exclude haemorrhage
=> MRI – usually done later if diagnostic uncertainty remains.
Carotid artery doppler – detect ICA stenosis
Other tests to determine cause
=> ECHO, CXR, antibody screen, thrombophilia screen.
132
Indications for urgent CT in ?stroke
* Anticoagulated
* Known bleeding disorder
* Decreased GCS
* Papilloedema/stiff neck
* Severe headache
* Being considered for thrombolysis
133
Investigations in Haemorrhagic Stroke
* Bloods
* ECG
* IMAGING – CT
* Lumbar Puncture – xanthochromia (yellow discolouration) confirms SAH.
134
Ischaemic Stroke - Mx
1. Antiplatelets:
=> Aspirin – 300mg PO o.d. for 2 weeks.
=> Clopidogrel – 75mg PO o.d. for life.
2. Thrombolysis – if within 4.5 hours of onset.
=> Alteplase (unless contraindicated)
3. Statins
=> Atorvastatin 80mg PO
4. Surgery
=> Carotid endarterectomy considered if ICA stenosis >50%
5. Address Risk Factors - BP, AF, Smoking, alcohol, diet, exercise, DM
6. Rehabilitation = key in stroke management
=> MDT input – physio/OT, SALT, optometry
135
Contraindications of thrombolysis in ischaemic stroke
```
ABSOLUTE –
Hx of IC haemorrhage/seizure/neoplasm,
Pregnancy,
Stroke in last 3/12,
GI bleed in last 3 weeks,
BP >180/110,
Clotting disorder,
Sx suggesting SAH.
```
```
RELATIVE –
Anticoagulated,
Cancer,
>75 years,
Major surgery in past 2 weeks.
```
136
Haemorrhagic stroke - Mx
STOP ANTIPLATELETS/ANTICOAGULANTS
Reverse anticoagulants
- Vit K for warfarin
- Protamine sulphate for heparins
BP control
Discuss with neurosurgeons
Monitor obs and neurological signs.
137
Driving Advice following stroke
Not able to drive for a minimum of 4 weeks after a stroke or TIA.
Do necessarily need to inform DVLA unless:
- Seizures
- LGV or passenger-carrying vehicle driver.
- Brain surgery
- If driving is still affected 1 month after stroke/TIA.
- More than one stroke in 3 months
- SAH
138
What is a pressure ulcer?
localised damage to the skin and/or underlying tissue,
| usually over a bony prominence, resulting from sustained pressure
139
Who are most at risk of pressure ulcers?
- Reduced mobility/immobility.
- Vascular disease.
- Sensory impairment.
- Extremes of age (poor circulation)
- Previous Hx of pressure damage (weak skin)
- Malnutrition / dehydration
- Significant cognitive impairment
140
Common locations of pressure ulcers
Heels, elbows, hips and base of the spine.
Can also be related to a medical device (e.g. NG-tube).
141
Categories of Pressure Ulcer
Category I – non-blanchable erythema.
- People with pale skin tend to get red patches
- People with darker skin get purple/blue-ish patches rather than red.
Category II – partial thickness skin loss.
Category III – full thickness skin loss.
- Bone, tendon or muscle are not exposed.
Category IV – full thickness tissue loss.
Deep tissue injury (DTI) – depth unknown.
Unstageable (US) ulcer – depth unknown
142
When is osteomyelitis likely due to pressure ulcer?
A category IV ulcer where there is full thickness tissue loss and the bone is exposed.
143
Pressure Ulcer risk assessment
Carry out and document a pressure ulcer risk assessment WITHIN 2 HOURS of admission
High risk (<10-12 Braden score) => red skin bundle
Medium risk (13-14 Braden score) => amber skin bundle
Low risk (>15 Braden score)
144
Skin assessment for identification of pressure ulcers
The skin should be checked for:
- Skin integrity in areas of pressure
- Colour changes or discolouration
- Variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).
BLANCH TEST
145
Pressure ulcer blanch test
Use finger palpation or diascopy to determine whether erythema or discolouration (identified by skin assessment) is blanchable.
- Press on the skin for 10 secs
- Check for blanching and re-filling.
- If the skin doesn’t blanch, this indicated damage has already occurred.
146
Pressure Ulcer Assessment
Assess and document:
- Location
- Cause of ulcer
- Dimensions of ulcer (Surface Area, estimate of depth)
- Category of ulcer
- Exudate and signs of local infection
- Pain/odour
- Photo of ulcer
147
Pressure Ulcer - Mx
Care to the wound - dressing, cleaning, debridement
Prevent worsening - SSKIN bundle
- Support surface
- Skin assessment
- Keep moving (change position frequently, at least every 4-6 hours)
- Incontinence/moisture monitoring (consider barrier creams)
- Nutrition management
Antibiotics if any evidence of:
- Systemic sepsis
- Spreading cellulitis
- Underlying osteomyelitis
148
Risk factors for falling
```
INTRINSIC
Cardiovascular (arrythmias, syncope, postural hypotension).
Balance and gait
Visual impairment
Cognitive impairment/confusion
Incontinence
Malnourishment
Medications
```
```
EXTRINSIC
Poorly fitting footwear
Inappropriate walking aid
Insufficient equipment
Insufficient lighting
Unfamiliar environment
Trip hazards
Medications
```
```
BEHAVIOURAL
Alcohol
Risky behaviour (lifting, bending)
Rushing to answer phone, etc.
Poor diet/fluid intake
Non-compliance with advice
Fear of falling
Lack of exercise
```
149
Which medications are more likely to cause falls in the elderly?
Antihypertensives (incl. diuretics & vasodilators & anti-arrythmics)
Sedatives/opioids/hypnotics,
Antidepressants.
150
What investigations must be done in ALL fall patients?
Hx and Examination – gait (GALS), heart sounds, neurological, vision
ECG
Lying and Standing BP
151
What L/S BP drop indicates postural hypotension?
A drop in SBP >20mmHg or DBP >10mmHg indicated orthostatic/postural hypotension.
152
What other investigations may be useful in fall patients?
- FBC, U&E, TFTs
- CRP
- CK – if a long lie (rhabdomyolysis)
- Bone biochemistry – for osteoporosis
- Echo/24-hour tape – if ECG abnormal/CV symptoms
- CT – if head injury
153
Falls - management
1. Patient Education:
- e.g. getting up slowly, using aids, etc.
2. Physiotherapy:
- Strength and balance training
3. Occupational Therapy:
- Home hazards assessment
4. Medical Review:
- Analgesia
- Medication review
- Diagnose any new medical conditions
- Optimise comorbidities
- Cognitive Screen
- Bone health assessment
154
Falls prevention
RISK ASSESSMENT - All patients should be considered high risk of falls and need assessment if:
- >65 years
- 50-64 years with medical conditions predisposing to falls.
MOBILITY - Encouraging mobility is key!
=> Sedentary behaviour contributes to deconditioning and functional loss.
155
What is Parkinson's disease?
= a neurodegenerative disorder caused by a loss of the dopamine producing cells in the Substantia Nigra.
(Dopamine is a neurotransmitter chemical particularly associated with control of movement by the basal ganglia)
156
Parkinson's disease - Risk factors
MOST CASES ARE IDIOPATHIC
RFs:
- Age, male sex, FHx/identical twin affected
- (Possible – herbicides/pesticides, heavy metal/industrial work, farming community, repeated head trauma)
157
Parkinson's - Criteria for Diagnosis
Criteria for Diagnosis:
- Rigidity and Bradykinesia
- +/- postural instability
- +/- resting tremor (4-6 Hz)
158
How long does it take motor symptoms to manifest in Parkinson's disease?
Motor symptoms often don’t manifest clinically until ~80% of dopamine producing cells are lost.
Often non-motor symptoms precede motor symptoms and also have a greater impact on life.
159
Motor Symptoms of Parkinson's
* Bradykinesia
* Rigidity
* Postural instability
• Resting tremor
=> Worse if anxious/angry/excited
=> Better with activity
• Freezing
=> Narrow/confined spaces, when changing direction
• Dystonia (painful cramping in feet/legs)
=> Worse at night
* Dysphagia
* “Classic Parkinson’s Gait” – shuffling/small steps, stooped over, reduced arm swings.
160
Non-motor Sx of parkinson's
* Masked face
* Hypophonia (deep, soft, monotonous voice)
* Micrographia (progressively smaller handwriting)
* Depression/ Anxiety/ Psychosis
* Anosmia
* Insomnia/REM sleep disorder/restless legs
* Fatigue
* Constipation/urinary incontinence
* Seborrhoeic dermatitis
* Cognitive impairment
161
"on-off" phenomena of Parkinson's
There is a massive fluctuation in Sx – unpredictable “on-off” phenomena.
Sudden switch from mobility (“on”) to immobility (“off”) in seconds or minutes.
162
Parkinson's disease - cognitive problems
1. Mild Cognitive Impairment (MCI)
• In 25% of those newly diagnosed with PD.
• Possible risk factor for developing PDD.
2. Parkinson’s Disease Dementia (PDD)
• A dementia syndrome with insidious onset and slow progression within the context of established PD.
163
How to differentiate between PDD and LBD
If dementia occurs before PD symptoms, then LB dementia.
164
Falls in Parkinson's Disease
very common
Risk Factors:
- More advanced PD
- Cognitive impairment/dementia
- Depression/anxiety
- Prior fall Hx
- Postural Hypotension
- Postural Instability/freezing
- Reduced lower extremity strength
- Dyskinesia
- Polypharmacy
165
Suggestive features of Idiopathic PD
Unilateral Onset + persistent asymmetry
Upper limb predominance
Presents with bradykinesia
Treatment responsive (to L-dopa)
166
Suggestive features of Vascular PD
Bilateral onset
Lower limb predominance (upper limbs spared)
Presents with falls/gait problems
Hx of atherosclerosis/strokes
Stepwise progression
Will have a poor response to Levodopa.
167
Suggestive features of Essential Tremor
Bilateral
FHx in 50%
Stable – doesn’t progress.
Improves with alcohol
Treat with beta-blockers (Propranolol)
168
Suggestive features of Drug-induced Parkinsonism
History of antipsychotics (olanzapine, risperidone, quetiapine, etc.) or metoclopramide.
169
Parkinson's disease - Investigations
History
Examination (PD focused)
- Bradykinesia – finger thumb pinching.
- Rigidity – tone when resting
- Resting tremor
- Postural instability – gait assessment/shoulder-tug test.
- Speech, face (masked?), writing (small)
Confusion bloods – r/o acute/reversible causes
CT/MRI – r/o other cause
Levodopa test
=> If responsive, suggests idiopathic PD.
PET/SPECT (DAT) scan
=> To detect decreased dopaminergic activity in basal ganglia.
Medication review – antipsychotics.
170
Prognosis of Parkinson's
Prognosis varies and depends on age, genetics, and comorbidities/frailty.
There is no cure.
171
Management of Parkinson's Disease
1. Levodopa Monotherapy
2. Dopamine Receptor Agonists
3. Levodopa Dual Therapy – Dopamine Metabolism inhibitors
```
4. Non-pharmacological
=> Patient education – advice to minimize “freezing”
=> Comprehensive Geriatric Assessment
=> Social support
=> Physio/OT
```
5. Treatment of Non-motor Symptoms
172
Advice to minimise "freezing" in parkinson's
* Avoid multitasking while walking
| * Use cues to help overcome freeze
173
What is Levodopa?
What is the usual dose per day?
When might there be complications?
= a dopamine precursor (dopamine itself cannot cross the BBB).
=> Increases synaptic dopamine.
Combined with carbidopa to prevent peripheral metabolism to dopamine (but cannot cross the BBB so allows action of L-dopa in the CNS).
Usual maximum dose 600-1000mg / day
Complications may arise after 4-6 years and efficacy reduces (narrowed therapeutic window).
174
Side effects of Levodopa
SEs – dyskinesia (uncontrollable wriggling), confusion, depression, insomnia.
175
Dopamine Receptor Agonists in managing Parkinson's
e.g. Ropinirole, Rotigotine (patch), bromocriptine
Activates post-synaptic receptors.
Used more in early disease or can also be used as a levodopa adjunct in later stages of disease.
SEs – confusion, hallucinations, impulsive control disorder (gambling, hypersexuality).
176
Parkinson's Follow-up
PD medications need regular review.
```
At follow-up, always ask about:
• Parkinsonian Sx
• Hallucinations
• Fluctuations in motor capabilities
• Dyskinesias
```
Also enquire how any symptoms relate to timing of dopaminergic therapy – adjust time and dose accordingly.
177
What medications should always be AVOIDED in parkinson's patients?
Haloperidol, metoclopramide and prochlorperazine
178
Cognitive Stimulation Therapy in Dementia
CST = a brief, evidence-based treatment for people with mild to moderate dementia.
Involves 14 themed sessions of structured 45-minute group therapy sessions.
Aims:
=> To actively stimulate and engage people with dementia.
=> Improve confidence and hopefully cognition and memory.
=> Social benefits – relaxing, fun, sociable, opportunities to discuss topics
179
What are the 5 domains of CGA?
1. Medical:
- Co-morbid conditions and disease severity
- Medical review
- Nutritional status
- Problem list
2. Psychological:
- Cognition (e.g. AMT, Mini-ACE)
- Mood and anxiety (GDS)
- Fears
3. Functional:
- ADLs (Barthel index)
- Gait and balance
- Anxiety/exercise status
- Instrumental activities of daily living.
4. Social:
- Informal support from family and friends
- Social network such as visitors or daytime activities
- Eligibility for access to care resources
5. Environmental:
- Home comfort, facilities, safety
- Use or potential use of telehealth technology, etc.
- Transport facilities
- Accessibility to local resources
180
What are important factors to pay attention to when clerking an older person?
Their pre-morbid status (collateral Hx)
Any recent changes – medications, home circumstances, life events.
Social Hx:
=> Who do they live with? Exercise tolerance?
Problem list – medical/ mental/ functional/ social/ environmental issues
Ongoing management
=> Who else has assessed the patient (OT/PT/SALT/Dietician) – what were their conclusions?
181
Timed Up and GO (TUG) Test
Involves getting the patient to stand up from a chair, walk 3 metres, turn around and go back to the chair and sit down.
<10 secs is normal, 20 seconds or more indicates they are likely to need outside assistance.
182
Braden Scale
Used to judge risk of developing pressure sores
Based on mobility, nutrition, moisture, sensation, activity and friction.
183
Barthel Index
An objective standardised tool used to test for “dependency” in ADLs by quantifying the patient’s performance in 10 activities (centred on self-care and mobility).
Measured out of 20 (with 20 being fully independent).
184
National Institute for Health Stroke Scale (NIHSS)
Score of stroke severity based on neurological abnormalities on examination.
<5 mild, >20 severe.
185
Abbreviated Mental Test (AMT)
A rapid tool to identify cognitive impairment in older people and monitor change in cognitive function.
Limited validity – an abnormal score (<7) needs more detailed cognitive assessment.
Includes:
- Age
- Time (nearest hour)
- Address for recall at end of test (42 West Street)
- Year
- Name of this place
- Identify 2 people
- Date of birth
- Year of 1st world war
- Present Monarch’s name
- Count backwards from 20
- Address recall correct?
