medicine for older people Flashcards
medications which increase risk of falls
diazepam sertraline doxazosin zopiclone risperidone gliclazide amitriptyline (tricyclic, neuropathic pain - strong anticholinergic effect) codeine oxybutynin diuretics - for first month then returns to normal with reduced fracture risk
management of faller
- fraxx risk - bisphosphonates
- review medications
- physio
- treat hypotension
anticholinergic burden
cholinergic drugs help cognition like Alzheimers
anti-cholinergics have negative effects on cognition
anticholinergic burden is a build up of the effects from using multiple anticholinergics
most common cause of incontinence
faecal loading
stool typically soft not hard
most common cause of faecal incontinence
faecal loading
- stool typically soft not hard
- in rectum
constipation
not been more than 3 times in a week
treatment: laxatives
focal impaction
hard stool
immobile
building up in colon
can have diarrhoea
faecal incontinence and constipation - investigations
examination
PR - to differ faecal loading or impaction
AXR
overactive bladder syndrome treatment
physio behaviour changes: - caffeine restriction eight loss timed voiding
medications: - anticholinergics: solifenacin 5mg OD tolterodine trospium chloride avoid oxybutinin (crosses BBB- decrease cognition)
consider mirabegron in elderly with cognitive impairment
- side effects: HTN
stress urinary icontinence treatment
physio
fluoxetine
elderly fall sudden onset dizziness and nausea nystagmus on right lateral gaze * past pointing on the right * power is preserved
cerebellar stroke
nystagmus
past pointing
medication to slow cognitive decline
galantamine
fall gradual onset of weakness in both legs over few days increased tone in both legs reduced power in all leg muscles brisk reflexes * bilateral upgoing planters *
spinal cord compression
brisk reflexes
upgoing plantars
treatment for reducing fracture risk
if over 75: osteoporosis
bisphosphonate (alendrotnic acid) + calcium/vitamin D
reduced power in all limbs
generalised muscle wasting - especially in hands
fasciculations *
sensation intact
motor neurone disease
fasciculations
alcoholic hypotension perifollicular haemorrhages over limbs gingival hyperplasia loosening teeth
what is the most likely micronutrient deficiency
ascorbic acid (vit C deficiency)
alcoholic:
- hypotension
- perifollicular haemorrhages over limbs
- gingival hyperplasia
- loosening teeth
what is the most likely micronutrient deficiency ?
ascorbic acid (vit C deficiency)
when can bisphosphonates not be used
renal impairment
when can bisphosphonates not be used for fracture risk?
alternative?
renal impairment
denosumab
90yrs fall gradual onset bilateral weakness in legs over 3 days increased tone reduced power brisk reflexes reduced sensation up going plantars*
spinal cord compression
fall
clinical feature associated with frailty
unintentional weight loss over the last few years
dementia definition
group of progressive neurodegenerative brain disorders
cause global decline in cognition and memory function
interferes with social/ professional activity leading to death
dementia diagnosis - investigations
obs and examination (CVS & neuro)
exclusion of: - delirium - depression - drugs bloods: - FBC (anaemia/infection) - U&Es (dehydration, renal failure, hyponatraemia) - glucose - TFT - LFT (alcohol misuse/ dementia, Korsakoffs) - B12 & folate - calcium - HIV test
cognitive assessment:
- MMSE (<26 abnormal)
- MOCA
- addenbrooke’s
collateral hx
septic screen
CT or MRI head if:
- unusual presentation
- first onset psychotic symptoms
- prior to anti-dementia medication
general early features of dementia
- loss of RECENT MEMORY
- impairment of judgment
- alteration in personality
- disorientation in time and space
manifests as: missed appointments, anxious or irritable, depression
general later features of dementia
language:
- expressive aphasia
- followed by receptive aphasia (doesn’t understand meaning)
social:
- deterioration in personal hygiene
- behavioural changes become problematic (wandering, aggression, disinhibited behaviour)
incontinence
Alzheimers disease pathology
most common form of dementia
- symmetrical atrophy - HIPPOCAMPUS affected early
- beta amyloid plaques
- neurofibrillary tangles
- loss of acetylcholine
risk factors for Alzheimers disease
- AGE
- women
- familial early onset dementia: presenilin 1 &2 gene, beta-amyloid precursor protein (APP) gene
later onset linked to Apo-E4 (>65) - vascular risk factors
- downs syndrome
- diabetes
- binge drinking
- obesity
Alzheimer’s clinical presentation
4A’s
- AMNESIA: recent memory loss
- APHASIA: word finding problems, speech muddled and disjointed
- AGNOSIA: recognition problems e.g. faces
- APRAXIA: inability to carry out skilled tasks despite normal motor function e.g. dressing
Alzheimer’s management
mild/ moderate:
- acetylcholinesterase inhibitors:
- -> galantamine
- -> donepezil - oral
- -> rivastigmine - patches
moderate/ severe:
- NMDA receptor antagonist
- -> memantine
- drugs to treat behavioural and psych symptoms
- BP, cholesterol check
vascular dementia types
small vessel disease - most common
- large vessel/ multi-infarct - step wise progression
- strategic infarcts e.g. thalamic
- vasculitis e.g. neurosyphilis
vascular dementia risk factors
large vessel:
- FHx
- HTN
- vascular disease
- cardiac disease
small vessel:
- above +
- diabetes
- vasculitis related disease
vascular dementia presentation
stepwise progression + abrupt onset
- step- sudden deterioration with infarct
- multiple small infarcts cause smoother progression
- one large strategic infarct e.g. thalamus can cause dementia
- symptoms reflect sight of lesion - ‘patchy cognitive impairment’
- relative preservation of personality and insight
- fluctuations in severity
vascular dementia
investigations
- signs of CVD, DM, heart disease
- Hachinski Ischaemia Score (7 or more)
- brain CT
vascular dementia
management
- control vascular risk factors
- aspirin
- acetylcholinesterase inhibitors have no benefit unless mixed (AD) dementia
Lewy body dementia
pathology
Lewy body - alpha-synuclein with ubiquitin
Parkinson’s disease lewy bodies in brain stem (basal ganglia)
Lewy body dementia
presentation
core features:
- fluctuating confusion (day to day)
- marked variation in alertness
- vivid visual hallucinations
- parkinsonian symptoms
supportive features:
- repeated falls
- syncope
- neuroleptic sensitivity (NO ANTIPSYCHOTICS)
common in this condition:
- falls
- postural hypotension
- REM sleep disorder
- restless legs
Lewy body investigations and management
investigations:
- +ve DAT test - support
management:
- social
- antiparkinsonian drugs
- AVOID PHENOTHIAZINES (antipsychotic) –> neuromalignant syndrome
differentials to NMS
- serotonin syndrome
- in Parkinson’s disease when a dopaminergic drug is stopped it can present like NMS
Parkinson’s disease diagnosis
Parkinsonism:
- BRADYKINESIA + 1 or more:
- muscular RIGIDITY
- low freq TREMOR
- postural INSTABILITY
extra symptoms:
- pill rolling tremor
- shuffling gait
- mask-like blank expression
- cog wheel rigidity
- apathy (reduced interest & motivation)
- stooped posture
- sleep disorders
- bladder dysfunction
- constipation - can make the symptoms worse
supportive criteria: >/=3 for definitive - unilateral onset - rest tremor - persistent asymmetry - excellent response to levodopa - levodopa response >5yrs - clinical course >10rs
what Hz is the pill rolling tremor at
4-6Hz
investigations and management of Parkinson’s disease
investigations:
- DAT - dopamine transmission scan - DA reuptake
conservative:
- refer to specialist quickly
- inform DVLA
- active planning
- sleep hygiene
medical:
- LEVO-DOPA
- -> combined with madapor (co-beneldopa) or sine met (co-caredopa) (prevent peripheral conversion)
