HCOLL Flashcards
What is the frail phenotype
Unintentional weight loss / sarcopenia
Weakness, exhaustion, slow walking
Low level physical activity
Falls, immobility, delirium, memory loss, incontinence
Epidemiology of dementia
7.1% of >65y
F>M
Age biggest RF
Aetiology of dementia
Neuronal loss: location in brain determines symptoms
Temporal lobe involvement = STM
Symptoms of dementia
Memory loss
Difficulty with higher cognitive processes: impaired executive function, apraxia, agnosia (difficulty recognising objects)
Impaired function
>6m
Types of dementia and their prevalence
Alzheimer’s : 50-75%
Vascular : 20%
LBD: 10-15%
FTD: 2%
Aetiology of Alzheimer’s disease
Characteristic beta amyloid plaques and neurofibrillary tangles
Symptoms of Alzheimer’s
Progressive memory loss that affects function
Forget names, people, places
Repeats self
Can’t remember new info
Misplace items
Confusion about time
Getting lost
Cant find words
Mood / behaviour problems
CT brain findings of alzheimers disease
Volume loss and enlarged ventricles
Pathogenesis of vascular dementia
Diseased blood vessels -> multiple small areas of ischaemia -> brain cell death
CT brain findings of vascular dementia
Small vessel ischaemic change
Aetiology of LBD
Lewy body protein deposits in the basal ganglia and thalamus
History of illness with LBD
Parkinsonism
Motor symptoms occur after or within 1 year of memory problems
Aetiology of FTD
Tau protein deposits in frontal and temporal lobes
Protein deposits cause brain cell death
History of illness with FTD
Earlier age onset (56-61) and 40% have family history
Slow onset
Progressive non fluent aphasia
DD of dementia
- delirium
- substance misuse
- depression / psychosis
- traumatic brain injury
- metabolic (hypothyroid / B12)
- meds (steroids / antidepressants)
Symptoms of vascular dementia
Problems with:
Memory, thinking, reasoning
Planning and organising
Decision making / problem solving
Concentrating
Following instructions
Slower thoughts
Early Symptoms of Lewy body dementia
Fluctuating memory loss
Hallucinations and delusions
Parkinsonism
REM sleep disorder
Falls
Later symptoms of LBD
Motor problems
Mood swings / short tempered
Speech and swallow problems
What does confusion screening bloods include
FBC
U&Es
LFT
TFT
Glucose
Calcium
B12
Folate
Medical management of dementia
Cholinesterase inhibitors (for mild / moderate alzheimers, LBD or Parkinson’s) -> donepezil, rivastigmine
NMDA receptor antagonists (for moderate alzheimers if intolerant to ACh or severe): Memantine
Psychological management of dementia
Interventions to promote cognition, independence and wellbeing
Group cognitive stimulation therapy
Group reminiscence
OT / cognitive rehab
What is hyperactive delirium
Agitation, confusion, hallucinations / delusions
Mood disturbance
Disturbed sleep
What is hypoactive delirium
Similar to depression
Withdrawn, not eating / drinking
Sleeping a lot
Hallucinations / delusions
Causes of delirium (DELIRIUM)
Drugs / dehydration
Electrolyte imbalance
Level of pain / lack of analgesia
Infection / inflammation
Respiratory failure
Impaction of faeces
Urinary retention
Metabolic / MI
Management of delirium
Reduce medications
Only use drugs if other interventions have failed and patient is a risk to themselves or others
Haloperidol
Lorazepam
Aetiology of Parkinson’s disease
Loss of dopamine producing cells in substantia nigra
Pre clinical signs of Parkinson’s
Symptoms dont manifest clinically until 80% of dopamine producing cells are lost
Depression
Anosmia
Constipation
REM sleep disorder
Postural hypotension
4 main symptoms for Parkinson’s diagnosis
Rigidity + bradykinesia
+/- postural instability
+/- resting tremor
Motor symptoms of Parkinson’s
Bradykinesia
Rigidity
Postural instability
Resting tremor
Non motor symptoms of Parkinson’s
Depression / anxiety
Psychosis
Cognitive impairment
Autonomic dysfunction
Suggestive features of progressive supranuclear palsy
Vertical gaze palsy
Frontal disinhibition
Not responsive to dopaminergic treatment
Suggestive features of Multi system atrophy
Prominent, autonomic features (postural hypotension, incontinence, impotence)
Cerebellar signs
Medical management of PD
- L-dopa mono therapy : time and dose critical
- Dopamine agonists patch eg rotigotine
- L-dopa dual therapy
- Treat non motor symptoms
Causes of acute urinary incontinence (DIAPERS)
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmaceuticals / psychiatric
Excess urine output
Restricted mobility
Stool impaction
Medications causing urinary incontinence
CCBs, antidepressants, antipsychotics
A blockers
ACEis
Opioids
Sedatives
Diuretics
Cause of urge incontinence
Overactivity of detrusor muscle
Bladder over sensitivity
Abnormal neuro stimulation
Risk factors for urge incontinence
Idiopathic
Diuretics
UTIs
Caffeine / increased fluid intake
Alcohol / smoking
Constipation
Neurogenic
Medical management of urge incontinence
Anticholinergics : avoid oxybutynin as increases risks of falls / confusion
Botulinum toxin A
Intravaginal oestrogens
Cause of stress incontinence
Increased IAP
Weak pelvic floor and sphincter
Risk factors for stress incontinence
Urethral sphincter weakness (cannot withstand increased IAP)
- pregnancy, obesity, age
- previous vaginal delivery
- prolapse / hysterectomy
- muscular diseases
Medical management of stress incontinence
After pelvic floor training
Duloxetine increases sphincter activity
Injectable bulking agents
Surgical management of stress incontinence
Colposuspension
Cause of overflow incontinence
Chronic urinary retention
Obstruction to outflow
Detrusor muscle failure
Risk factors for obstruction to outflow
Constipation
Pelvic surgery / strictures
BPH / prostate tumour
Bladder calculi
Risk factors for detrusor failure
Neurological / DM
Medication
Key investigations for all falls patients
Hx and examination - Gait, heart sounds, neuro, visual
ECG
Lying and standing BP
Medical management of falls
Analgesia
Cognitive screen
Bone health assessment - FRAX score
Common osteoporosis fractures
Neck of femur
Colles
Vertebral crush
Aetiology of osteoporosis
Bone resorption (osteoclasts) > bone formation resulting in:
- gradual bone weakening
- increased risk of fracture
- back pain / kyphosis / loss of height
Primary RF for osteoporosis
Age / female
Genetics
Low BMI
Calcium / vit D deficiency
Previous low trauma fracture
Medical management of osteoporosis
- Bisphosphonates
- Denosumab (inhibits osteoclasts)
- Teriparatide (increase osteoblasts activity)
Bisphosphonates counselling
Tablets or injections once weekly
Take with water
Sit upright 30min after
Empty stomach
Side effects of Bisphosphonates
GI upset
Oesophageal ulcers
Jaw necrosis
Features of a pressure ulcer
Base : if bone = osteomyelitis
Floor: necrosis / pus suggests infection
Edge: sloped = normal ulcer
Undermined edges = TB
Rolled up / everted = risk of malignancy
Complications of pressure ulcers
Skin and soft tissue infection (cellulitis)
Bone infection (osteomyelitis)
SCC : chronic inflammation
Sinus tract formation : chronic inflammation
Sepsis
Define ischaemic stroke
Blockage in the blood vessel stops blood flow
Define haemorrhagic stroke
Blood vessel bursts leading to reduction in blood flow
2 types of ischaemic stroke
Thrombotic : thrombosis from large vessel
Embolic: usually a blood clot can be fat, air or clumps of bacteria - can be caused by AF
2 types of haemorrhagic stroke
Intracerebral haemorrhage
Subarachnoid haemorrhage
Risk factors for ischaemic stroke
General CVD RF’s
AF
RF’s for haemorrhagic stroke
Age
HTN
Arteriovenous malformation
Anticoagulation therapy
RF for haemorrhagic stroke
Age
HTN
Arteriovenous malformation
Anticoagulation therapy
Features of a stroke
Motor weakness
Speech problems
Swallowing problems
Visual field defects
Balance problems
Symptoms of cerebral hemisphere infarcts
Contralateral hemiplegia
Contralateral sensory loss
Homonymous hemianopia
Dysphasia
Symptoms of brainstem infarction
Quadriplegia
Lock in syndrome
Symptoms of lacunar infarcts
Ataxia
Pure motor signs
Pure sensory sings
Mixed signs
What are the initial symptoms in the oxford stroke classification
- Unilateral hemiparesis and / or hemisensory loss of face, arm, leg
- Homonymous hemianopia
- Higher cognitive dysfunction
Arteries involved in total anterior circulation infarcts
Middle and anterior cerebral arteries
Arteries involved in partial anterior circulation infarcts
Smaller arteries of anterior circulation eg upper or lower division of middle cerebral artery
Arteries involved in lacunar infarcts
Perforating arteries around internal capsule, thalamus and basal ganglia
Arteries involved in posterior circulation infarcts
Vertebrobasilar arteries
What symptoms are more common in haemorrhagic stroke over ischaemic
Decrease in consciousness level
Headache
N&V
Seizures
What is the FAST campaign
Face - has face fallen on one side? Can they smile
Arms - can they raise both arms and keep them there
Speech - slurred
Time - call 999 if any 1 of these signs
Criteria for thrombolysis in ischaemic strokes
Patients present within 4.5hrs of onset
No prev intracranial haemorrhage, uncontrolled HTN, pregnancy
Then give aspirin 300mg and antiplatelet therapy
Immediate management of TIA
Aspirin 300mg unless contraindicated
Management of haemorrhagic strokes
Stop anticoagulation and antithrombotics
Lowered BP
Management of acute ischaemic stroke
Blood glucose, hydration, o2 sats and temp maintained
BP should not be lowered unless being considered for thrombolysis
Aspirin 300mg
Anticoagulants after 14 days
Statin if cholesterol >3.5
Absolute contraindications to thrombolysis
Previous intracranial haemorrhage
Seizure at time of stroke
Intracranial neoplasm
Suspected subarachnoid haemorrhage
Stroke / brain injury in prev 3 months
Lumbar puncture prev 7 days
GI bleeding prev 3w
Active bleeding
Oesophageal varices
Uncontrolled HTN
Relative contraindications to thrombolysis
Pregnancy
Concurrent anticoagulation (INR >1.7)
Haemorrhagic diathesis
Active diabetic haemorrhagic retinopathy
Suspected intracardiac thrombus
Major surgery in prev 2 weeks
When is thrombectomy indicated
Within 6h of onset
Together with thrombolysis (if within 4.5hrs)
In people who have confirmed occlusion of the proximal anterior circulation
Secondary prevention of strokes
Clopidogrel
Aspirin
Secondary prevention of strokes
Clopidogrel
Aspirin
What is the rosier score for assessing stroke
Loss of consciousness -1
Seizure activity -1
New acute:
Asymmetrical facial weakness +1
Asymmetrical arm weakness +1
Asymmetric leg weakness +1
Speech disturbance +1
Visual field defect +1
Stroke likely if >0
Symptoms caused by stroke in anterior cerebral artery
Contralateral hemiparesis and sensory loss
Lower extremity > upper
Symptoms caused by stroke in anterior cerebral artery
Contralateral hemiparesis and sensory loss
Lower extremity > upper
Symptoms caused by stroke in middle cerebral artery
Contralateral hemiparesis and sensory loss
Upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Symptoms caused by stroke in the posterior cerebral artery
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Symptoms caused by stroke in the posterior cerebral artery
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Symptoms of Webers syndrome (branches pf posterior cerebral artery)
Ipsilateral CNIII palsy
Contralateral weakness of upper and lower extremity
Symptoms of a stroke in the posterior inferior cerebellar artery
Ipsilateral: facial pain and temp loss
Contralateral: limb / torso pain and temp loss
Ataxia
Nystagmus
Symptoms of a stroke in the posterior inferior cerebellar artery
Ipsilateral: facial pain and temp loss
Contralateral: limb / torso pain and temp loss
Ataxia
Nystagmus
Symptoms of a stroke in the anterior inferior cerebellar artery
Ipsilateral: facial paralysis and deafness
Symptoms of stroke in the basilar artery
Locked in sydnrome
Symptoms of stroke in the retinal / ophthalmic artery
Amaurosis fugax
Symptoms of lacunar strokes
Present with either isolated hemiparesis, hemisensory loss of hemiparesis with limb ataxia
Associated with HTN
Basal ganglia, thalamus and internal capsule
What is waterlow score used for
To identify patients at risk of pressure sores
What medications should be avoided in LBD
Neuroleptics
Especially risperidone and typical antipsychotics such as haloperidol
CT findings in Alzheimer’s
Atrophy of the cortex and hippocampus
How to differentiate between dementia with Lewy bodies and Parkinson’s disease dementia
In PD dementia the tremor, bradykinesia and rigidity will develop before dementia
In DLB the opposite
Presentation of frontotemporal dementia
Social disinhibition
Family history
How to differentiate between mania and FTD
Mania causes reduced appetite
FTD increases appetite
What conditions is haloperidol contraindicated in
PD
LBD
Define frailty
A state of impaired homeostasis leading to increased vulnerability to minor stressor events
Most likely diagnosis for a middle aged adult with insidious onset dementia and personality changes
FTD
Most likely diagnosis for a middle aged adult with insidious onset dementia and personality changes
FTD
MOA of Memantine
NMDA receptor antagonism
MOA of Memantine
NMDA receptor antagonism
