Integrated Specialties B - Ageing Assessment - Acquired brain injury, drugs, Falls (causes), delirium, hypothermia, Re-feeding syndrome, M.U.S.T

Question 1

ALL QUESTIONS IN THIS FLASHCARD SET ARE TRUE OR FALSE UNLESS A DIRECT QUESTION IS ASKED What does acquired brain injury mean? What can it be caused by?

Answer 1

Acquired brain injury is a non degenerative injury to the brain since birth and can occur at any age. These can be due to trauma or due to non traumatic causes like hypoxic brain damage, toxins, stroke, tumors and metabolic conditions.

Question 2

Acquired brain injury * causes mainly physical problems * is a common cause of disability among younger adults * always required a period of inpatient rehabilitation * is associated with an increased risk of relationship breakdown * lends itself well to a goal-setting approach

Answer 2

Even a small insult can cause physical, mental, social, intellectual, behavioural problems and lead to breakdown of personal functioning. causes mainly physical problems - FALSE is a common cause of disability among younger adults - TRUE always required a period of inpatient rehabilitation - FALSE is associated with an increased risk of relationship breakdown - TRUE lends itself well to a goal-setting approach - TRUE

Question 3

Drugs in old age: * Expensive drugs should not be prescribed to old people due to lack of resources * Drugs are handled by the body in the same way as in younger adults * Being on 4 drugs increases the risk of falls * All old people require memory aids to assist compliance * Counselling by a medical student improves compliance

Answer 3

Expensive drugs should not be prescribed to old people due to lack of resources - FALSE Drugs are handled by the body in the same way as in younger adults - FALSE Being on 4 drugs increases the risk of falls - TRUE All old people require memory aids to assist compliance - FALSE Counselling by a medical student improves compliance - TRUE

Question 4

An 87 year old gentleman presents with poor mobility and falls. He has previously fractured his wrist following a fall. He is a smoker who has been admitted many times with COPD exacerbations. He is on medication to control his hypertension. The following factors increase the risk of fracture in this gentleman: * Smoking * Previous fracture * Prednisolone for his COPD exacerbation * Hypothyroidism * Antihypertensive medication

Answer 4

TRUE Smoking Previous fracture Prednisolone for his COPD exacerbation Hypothyroidism Antihypertensive medication - FALSE Several factors increase the risk of fractures like increasing age, FH of osteoporosis, Vit D deficiency, corticosteroid use, sex hormone deficiency, smoking and reduced calcium intake. A history of previous fragility fractures is a strong risk factor for future falls.

Question 5

* His pulse will be regular * Beta blocker is contraindicated * Digoxin is used to control the rhythm * Anticoagulation is indicated * There is a high risk of deep vein thrombosis

Answer 5

Patient is clearly in atrial fibrillation His pulse will be regular - FALSE Beta blocker is contraindicated - FALSE Digoxin is used to control the rhythm - FALSE Anticoagulation is indicated - TRUE There is a high risk of DVT - FALSE Both beta blockers (CCB) and digoxin can be used to slow the ventricular rate. Beta blockers can also help prevent recurrences of paroxysmal atrial fibrillation

Question 6

Investigating falls: 12 lead ECG is an essential test in investigating falls Postural hypotension should be tested by measuring BP before and after lying for 3 minutes 24 hour ambulatory ECG is a first line investigation Visual acuity assessment is part of falls assessment Urea & electrolytes may reveal a cause for falls

Answer 6

12 lead ECG is an essential test in investigating falls - TRUE Postural hypotension should be tested by measuring BP before and after lying for 3 minutes - FALSE 24 hour ambulatory ECG is a first line investigation - FALSE Visual acuity assessment is part of falls assessment - TRUE Urea & electrolytes may reveal a cause for falls - TRUE

Question 7

An 82 year old woman has been admitted to your ward, having been found on the floor by nursing home staff. She seems to be talking to herself, but it is difficult to catch what she is saying. She appears anxious, argues with nursing staff and angrily refuses to have a blood sample taken. * This lady is suffering from dementia * Obtaining a history is not possible * She needs to be sectioned under Mental Health Act * A test for attention should be carried out * She should be mobilised as soon as possible

Answer 7

This lady is suffering from dementia - FALSE Obtaining a history is not possible - FALSE She needs to be sectioned under Mental Health Act - FALSE A test for attention should be carried out - TRUE She should be mobilised as soon as possible - TRUE Good sensory environment (appropriate lighting, cues to improve personal orientation-clocks, hearing aids, spectacles; continuity of care; encourage mobility, gentle approach, avoid noise, family visits, familiar objects) will all help.

Question 8

A 71 year old gentleman is admitted to hospital with a pneumonia. He is very agitated and is wandering around the ward rummaging in the lockers of other patients. He is diagnosed with delirium. * Delirium is a preventable condition * Development of delirium is a risk factor for future institutionalization * Physical restraints should be used initially to stop the patient from wandering * Sedation can be used to treat delirium * Sedation can precipitate delirium

Answer 8

* Delirium is a preventable condition - TRUE * Development of delirium is a risk factor for future institutionalization - TRUE * Physical restraints should be used initially to stop the patient from wandering - FALSE * Sedation can be used to treat delirium - TRUE * Sedation can precipitate delirium - TRUE Physical restraints are to be avoided unless absolutely necessary. The least restrictive method should then be used. It is estimated that up to 18% of patients who develop delirium end up in institutional care.

Question 9

Delirium * always leads to a patient being agitated and aggressive * is not often recognised in hospital in-patients * can be caused by infections * has a greater incidence on older patients than younger ones * patients should be nursed in a quiet dark room

Answer 9

* always leads to a patient being agitated and aggressive - FALSE * is not often recognised in hospital in-patients - TRUE * can be caused by infections - TRUE * has a greater incidence on older patients than younger ones - TRUE * patients should be nursed in a quiet dark room - FALSE Non-pharmacological measures are first line treatments in delirium.

Question 10

Postural hypotension: * Is defined as a fall in systolic blood pressure of >10mmHg in a symptomatic patient * Is defined as a fall in systolic blood pressure of >20mmHg in a symptomatic patient * Symptoms can include visual disturbance * Can occur with dehydration * Is most often caused by autonomic failure

Answer 10

Is defined as a fall in systolic blood pressure of >10mmHg in a symptomatic patient - FALSE Is defined as a fall in systolic blood pressure of >20mmHg in a symptomatic patient - TRUE Symptoms can include visual disturbance - TRUE Can occur with dehydration - TRUE Is most often caused by autonomic failure - FALSE

Question 11

What is postural hypotension defined as? What are the symptoms? What is one of the primary causes?

Answer 11

Postural hypotension is defined as the fall in blood pressure of 20mmHg systolic or 10mmHg diastolic on standing up from a supine or sitting posture. - measure lying BP after 5 minutes, standing BP after 3 minutes This may or may not be accompanied by symptoms of dizziness, syncope or visual disturbances. One of the primary causes of postural hypotension is hypovolaemia as a result of dehydration due to decreased intake or diuresis.

Question 12

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Answer 12

* The ECG shows complete heart block. No communication between atria/ventricle. While complete heart block may occur with an MI, there is insufficient evidence of a recent event here. * Antiarrhythmic drugs like BBs, digoxin and CCBs are all associated with the development of complete heart block. Medication review is essential. * Thrombolysis is a treatment for STEMI which is not present here. * Continous cardiac monitoring and pacemarker should be considered

Question 13

An 81 year old gentleman presents with falls, poor balance and a tremor. You suspect cerebellar infarction. In patients with pure cerebellar disease * Muscle tone will be increased * Gait is broad based * Deep tendon jerks are exaggerated * Horizontal nystagmus is common * Rhomberg’s test is positive

Answer 13

Muscle tone will be increased - FALSE Gait is broad based - TRUE Deep tendon jerks are exaggerated - FALSE (pdenular reflexes) Horizontal nystagmus is common Rhomberg’s test is positive

Question 14

The Mini-Mental State Examination score is: * The gold standard method for diagnosing dementia * Vaild for use internationally * A score of

Answer 14

The gold standard method for diagnosing dementia - FALSE Vaild for use internationally - FALSE A score of A score of 30/30 rules out pathology - FALSE 10 points are allocated for orientation - TRUE The MMSE is a screening instrument used for the assessment of cognitive impairment. Ten of the 30 points are allocated for orientation. Dementia is a clinical diagnosis based on a typical history, and by exclusion of other contributory factors. MMSE score is influenced by literacy, vision, hearing, comprehension, depression and level of educational attainment.

Question 15

Which of the following statements are true after acquired brain injury? * Expressive dysphasia reflects damage to the dominant parietal lobe. * It is uncommon to have long-term visual field disturbances. * Frontal lobe damage can cause impairment of planning skills. * There is an increased risk of epilepsy. * Children with brain injury usually make a complete recovery

Answer 15

Expressive dysphasia reflects damage to the dominant parietal lobe. - FALSE (Broca’s area located in frontal lobe) It is uncommon to have long-term visual field disturbances. - FALSE Frontal lobe damage can cause impairment of planning skills. - TRUE executive functioning and behaviour There is an increased risk of epilepsy. - TRUE Children with brain injury usually make a complete recovery - FALSE

Question 16

Which of the following drugs are common precipitants of delirium? * Amitriptyline * Codeine * L-dopa * Thyroxine * Lormetazepam

Answer 16

Amitriptyline - TRUE Codeine - TRUE L-dopa - TRUE Thyroxine - FALSE Lormetazepam - TRUE I think all the true ones are acetycholine inhibitors and therefore contribute to sedatory effects

Question 17

You are the FY on call for ortho. The nurse asks you to assess a patient day 1 post hip replacement who seems to have become acutely confused. He has a long term catheter and his urinalysis is positive. * Immediate management would be sedation with 5mg of haloperidol. * Due to the urinalysis, UTI can be confidently assumed to be the most likely diagnosis. * Patient is best nursed 1to1 in a well lit sideroom. * Delirium and dementia are interchangeable terms that can describe an acute confusional state. * This patient has an increased incidence of cognitive impairment in the future

Answer 17

Immediate management would be sedation with 5mg of haloperidol. - FALSE Due to the urinalysis, UTI can be confidently assumed to be the most likely diagnosis. - FALSE Patient is best nursed 1to1 in a well lit sideroom. - TRUE Delirium and dementia are interchangeable terms that can describe an acute confusional state. - FALSE This patient has an increased incidence of cognitive impairment in the future - TRUE

Question 18

Hypothermia: * Could be eliminated by giving all older people central heating. * Is diagnosed if the auricular temperature is

Answer 18

Could be eliminated by giving all older people central heating. - FALSE Hypothermia is defined as core body temperature Reflexes often absent - TRUE The ECG often show a bradycardia with a J wave after QRS complex. - TRUE The prognosis for recovery with temperature

Question 19

Why are older people at an increased risk of hypothermia?

Answer 19

Older people are at a higher risk of hypothermia because of reduced shivering response, lower muscle bulk, reduced physical activity and poor nutrition.

Question 20

Occupational therapy * focuses on the ability to perform activities of daily living * excludes assessment of cognitive function * is useful in assessing perceptual problems after stroke * rarely contributes to the multidisciplinary team approach * provides aids and devices to allow patients to regain lost abilities

Answer 20

focuses on the ability to perform activities of daily living - TRUE excludes assessment of cognitive function - FALSE is useful in assessing perceptual problems after stroke - TRUE rarely contributes to the multidisciplinary team approach - FALSE provides aids and devices to allow patients to regain lost abilities - TRUE

Question 21

Which of the following can lead to postural hypotension? * Diabetes Mellitus * Amytriptyline * Hyperthyroidism * Sudden cessation of long term steroids * Normal ageing

Answer 21

Diabetes Mellitus - TRUE Amytriptyline - TRUE Hyperthyroidism - FALSE Sudden cessation of long term steroids - TRUE Normal ageing - FALSE The commonest causes of postural hypotension are drugs and diseases including Parkinson’s Disease and diabetes mellitus. Long term corticosteroids can suppress the adrenal-pituitary axis and stopping suddenly can leave the patient without the ability to mount an endogenous response.

Question 22

An 85 year old man attends the falls service having fallen three times in the past 3 weeks. Falls in old age * Usually result in fracture * Occur more commonly in men than women * Usually have several causes * Require a multi-disciplinary approach * Are often a risk factor for care home admission

Answer 22

Usually result in fracture - FALSE Occur more commonly in men than women - FALSE Usually have several causes - TRUE Require a multi-disciplinary approach - TRUE Are often a risk factor for care home admission - TRUE

Question 23

Essential tremor is: * Always inherited * Bilateral * Involves the feet * Cogwheeling is often present * May be caused by environmental factors

Answer 23

Always inherited - FALSE (positive family history of essential tremor in 50-70% of individuals) Bilateral - TRUE Involves the feet - FALSE (affects hands mainly, my also affect head/neck) Cogwheeling is often present - TRUE May be caused by environmental factors - TRUE (Lead and manganese exposure have been implicated in its aetiology.)

Question 24

Essential tremor aka postural tremor * Progressive, mainly symmetrical, rhythmic, involuntary oscillation movement disorder of the hands and forearms (69% of patients) that is usually absent at rest and present during posture and intentional movements. (BMJ BEST PRACTICE) What is the management of an essential tremor?

Answer 24

First line treatment includes beta-blockers (propanolol)and primidone.

Question 25

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Answer 25

* A continence nurse should take over her care - FALSE * Her Aricept dose should be increased - FALSE * She can no longer stay in her own home - FALSE * She should be started on antibiotic therapy immediately - FALSE * An MMSE should be performed - TRUE

Question 26

What are the three parts of calculating a MUST Score? What does MUST stand for?

Answer 26

Malnutrition Universal Screening Tool (MUS * Step 1 - BMI * >20 = 0 * >18.5=1 * Step 2 -Unplanned weight loss in past 3-6 months * 10% = 2 Step 3 - Acute disease effect score =2 * Acutely ill AND no nutritional intake >5 days

Question 27

Overall risk of malnutrtion for the MUST score comes from adding the three parts together * BMI score * Unplanned weight loss in past 3-6 months * Acutely ill AND nutritional intake What is recommended for a MUST score of * 0 * 1 * 2or more

Answer 27

* 0 - Low risk - routine screening * 1 - Medium risk - document dietary intake for 3 days * 2 or more - High risk - refer to dietitian, nutritional support team or local policy

Question 28

Nutrition in older people: * Nutritional goal set with patients are specific, measureable, achievable, realistic and timed. * Refeeding syndrome only occurs in tube fed patients. * Nutritional supplements should not be used in patients with diabetes. * All patients with a MUST score of > 1 should be referred to the dietician within 24 hours of admission to hospital. * Solutions to improve nutritional status require a multi disciplinary approach.

Answer 28

Nutritional goal set with patients are specific, measureable, achievable, realistic and timed. - TRUE Refeeding syndrome only occurs in tube fed patients. - FALSE Nutritional supplements should not be used in patients with diabetes. - FALSE All patients with a MUST score of > 1 should be referred to the dietician within 24 hours of admission to hospital. - TRUE Solutions to improve nutritional status require a multi disciplinary approach. - TRUE

Question 29

Refeeding syndrome is a potentially fatal medical condition that may affect malnourished and/or ill patients in response to an inappropriately high protein-calorie intake via any route. Why does refeeding syndrome occur?

Answer 29

* As the body turns to fat and protein metabolism in a starved state, there is a drop in circulating insulin (due to decreased carbohydrate levels). The catabolic state also depletes intracellular stores of phosphate, potassium and magnesium although serum levels may remain normal. When refeeding begins, the level of insulin rises in response to carbohydrate load, and one consequence is to increase cellular uptake of phosphate, magnesium and potassium causing hypophosphataemia, hpomagnesiumia, hypokaelaemia to develop usually within 4 days - responsible for most features

Question 30

How may refeeding manifest due to both * Metabolic changes? * Physiological changes?

Answer 30

Refeeding syndrome can manifest as either * Metabolic changes * Hypokalaemia, Hypophosphataemia, Hypomagnesaemia, * Altered glucose metabolism and * Fluid balance abnormalities Physiological changes (ie arrhythmias, altered level of conciousness, seizures) and potentially death

Question 31

What is the treatment of refeeding syndrome? (prevention and treatment)

Answer 31

Refeeding syndrome can be prevented by giving high-dose pabrinex during re-feeding window Pabrinex injections contain the water-soluble vitamins C (ascorbic acid), B1 (thiamine), B2 (riboflavin), B3 (nicotinamide) and B6 (pyridoxine) Treatment is of the complicating features - Monitor the potassium, phosphate and magneisum levels - if blood levels become low provide oral, enteral or intravenous supplements

Question 32

A 75 year old lady fell while shopping and fractured her right neck of femur. She is usually quite active and gardens. This was repaired 6 weeks ago and she is now independently mobile. For this patient fracture risk: Can be reduced with multivitamin supplements Can be reduced by bisphosphonate treatment Can be reduced by corticosteroid treatment Can be appropriately managed with hip protectors Can be reduced with Calcium supplements

Answer 32

Can be reduced with multivitamin supplements - FALSE Can be reduced by bisphosphonate treatment - TRUE Can be reduced by corticosteroid treatment - FALSE Can be appropriately managed with hip protectors - FALSE Can be reduced with Calcium supplement - FALSE

Question 33

Non-steroidal anti-inflammatory drugs: Are the agents of choice for arthritic pain in old age Act by increasing the production of prostaglandins COX-2 inhibitors are preferred for patients with heart disease Aspirin should not be co-prescribed with a NSAID May worsen asthma

Answer 33

Are the agents of choice for arthritic pain in old age - FALSE Act by increasing the production of prostaglandins - FALSE COX-2 inhibitors are preferred for patients with heart disease - FALSE Aspirin should not be co-prescribed with a NSAID - TRUE May worsen asthma - TRUE COX-2 selective inhibitors such as celecoxib are associated with an increased risk of thrombotic events.

Question 34

A 75 year old gentleman has been diagnosed with Parkinson’s disease. The following support the diagnosis * His speech is soft * Unilateral resting tremor * Exaggerated deep tendon jerks * Reduced arm swing * Reduced muscle tone

Answer 34

His speech is soft - TRUE Unilateral resting tremor - TRUE Exaggerated deep tendon jerks - FALSE Reduced arm swing - TRUE Reduced muscle tone - FALSE Parkinson’s disease can present initially with unilateral symptoms. Typical features are braykinesia, rigidity and tremor. Tone is increased and deep tendon jerks are normal. Gait is short stepping with reduced arm swing. Problems with speech, swallow, bowel movement and sleep are common non motor features of the disease.