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4th year > Medicine for older people > Flashcards

Medicine for older people Flashcards

1
Q

Geriatric giants of frailty

A

Incontinence
Immobility
Intellectual decline
Instability

  • tend to present first with acute functional decline (eg first symptom of pneumonia is a fall)
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2
Q

Dementia

A

Needs all of:
- impairment of memory and
- involvement of at least one other aspect of cognitive function (eg executive function/language) and
- impact on daily activities
(if just 2/3 then is mild cognitive decline)

Diagnosis

  • exclude delirium, depression, drugs
  • don’t make diagnosis in hospital as too alien a place
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3
Q

Alzheimer’s dementia

A
  • most common dementia (50%) especially in younger
  • symmetrical cortical atrophy in temporal and parietal lobes, amyloid plaques, tau aggregates (Pick bodies)
  • insidious onset and progression of memory loss and personality changes, affecting cognition, ADLs and behaviour
  • death within 5-10 years of diagnosis

Risk factors

  • increasing age
  • female
  • genetics
  • head injury
  • Downs syndrome
  • severe depression
  • vascular risk factors

Give acetylcholinesterase inhibitor to reduce symptoms (in 50%) but not slow progression - galantamine, donepezil, rivastigmine
(SEs - nausea, vomiting, weight loss, syncope, urinary retention, bradycardia. Not if uncontrolled obstructive airway disease, angle-syncope, sever hepatic/renal impairment)

  • or if severe memantine (NMDA receptor antagonist to reduce glutamate)
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4
Q

Vascular dementia

A
  • 20% of dementias (and more common than AD in >85)
  • caused by multiple infarcts, small vessel disease, or single strategic infarct
  • more abrupt onset, then stepwise progression
  • mood and behavioural changes common, with insight retained until late (so associated depression)
  • limited life expectancy

Risk factors

  • older age
  • male
  • cardiovascular / cerebrovascular / valvular disease
  • coagulation disorders
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • smoking
  • alcohol

No treatment, except managing vascular risk factors

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5
Q

Lewy Body dementia

A
  • Lewy bodies in cortex (alpha-synuclein inclusion bodies) and loss of dopaminergic neurones
  • associated parkinsonism - diagnosis depends on which symptoms start first

Need 2 of

  • fluctuating cognition with variation in attention and alertness
  • recurrent visual hallucinations
  • spontaneous motor features of parkinsonism (repeated falls, syncope)

Give cholinesterase inhibitor - rivastigmine first, galantamine, donepezil
- sometimes use antipsychotic eg Quetiapine (never the more atypicals)

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6
Q

Frontotemporal dementia

A
  • rarer cause of dementia
  • aggregates of tau (Pick bodies), frontal hypoperfusion, knife blade atrophy, progranulin mutations
  • more in females, peak onset 45-60 years
  • unclear aetiology ?genetics
  • early personality and behavioural changes, mood change, language abnormalities, cognitive impairment, motor signs

No treatment (but try antidepressant, antipsychotic for symptom improvement)

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7
Q

Parkinson’s disease

A

Four cardinal features

  • bradykinesia (decrement with fatigue, PVA glue sign on finger taps)
  • rigidity (cogwheel / lead pipe, consistent hypertonia throughout the range of movement)
  • tremor (resting, pill-rolling, exacerbated by distraction)
  • postural instability

All signs start unilateral, then progress to bilateral. MUST remain worse on the side it started on, if symmetrical then don’t have the right diagnosis.

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8
Q

Atypical parkinsonian syndromes

A

= Parkinson’s plus

  • non-curable, rare
  • diagnose if lack of response to treatment

Multiple system atrophy (MSA)

  • symmetry
  • early autonomic dysfunction – urinary incontinence, erectile dysfunction, constipation, falls (orthostatic hypotension)

Progressive supranuclear palsy (PSP)

  • symmetry
  • supranuclear gaze palsies (usually vertical), with slow circades
  • falls relating to postural instability – very positive pull test

Cortico-basal syndrome (CBD)
- symptoms stay unilateral and progress

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9
Q

Vascular and drug-induced parkinsonism

A

Vascular parkinsonism (= subcortical white matter disease)

  • previous stroke – unilateral (long track) weakness, spasticity
  • symmetry
  • onset in lower limbs before or more than upper limbs

Drug induced parkinsonism

  • current drug use – all antipsychotics (except quetiapine), anti-emetics (metachlopromide, cyclozine), middle-ear drugs (pro-chlorperazine)
  • don’t necessarily get better when withdraw drug
  • if ever been a psychiatric patient then high risk
  • symmetry
  • oromandibular dyskinesia (from antipsychotics usually)

Other causes of parkinsons, eg recurrent head trauma, space occupying lesion

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10
Q

Pre-motor phase, and motor complications of drug treatment of Parkinson’s

A

Motor complications with the drug – not a side effect but in normal treatment, within 6-10 years, if don’t get these then will not be PDs

  • on-off side effects, abrupt change when waiting for next dose
  • Levodopa induced dyskinesias (LIDs) – like wriggly movements

Pre-motor phase

  • already lost 70-80% of dopaminergic neurones by the time you get motor symptoms
  • REM sleep behaviour disorder – loss of normal REM sleep paralysis, so acting out dreams, falling out of bed, thrashing around etc (not purposeful movement) – almost certainly will go on to develop PD, CBD or MSA
  • restless leg syndrome
  • anosmia – loss of sense of smell
  • constipation
  • depression, often harder to treat
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11
Q

Delirium criteria

A

1) Disturbance of attention and awareness
2) Onset over hours-days, tendency to fluctuate over the course fo the day (sundowning affect)
3) Change in cognition/perceptual disturbance, delusions/hallucinations
4) Changes not accounted for by underlying disease/coma
5) Disturbance is caused by a general medical condition (must find the cause)

Hyperactive – increased motor activity, wandering, hallucinations, agitation, inappropriate/challenging behaviour
Mixed – fluctuating
Hypoactive – reduced motor activity, ‘off-legs’, drowsiness, picking at blankets/the air (most dangerous, easily ignored)
4AT to assess in clerking - alertness, AMT4, attention, acute change/fluctuating course

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12
Q

Risk factors and triggers for delirium

A

Risks

  • dementia
  • frailty
  • drug/alcohol dependence
  • polypharmacy
  • multi-morbidity
  • male gender
  • depression
PINCH ME causes
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment/electrolytes
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13
Q

Risk factors for fall

A

Medical

  • general – anaemia, low glucose, low sodium, dehydration, infection (B12 deficiency -> symmetric paraethesias, gait problems, numbness, impaired proprioception)
  • cardiovascular – arrythmias, ACS, orthostatic hypotension
  • neurological – stroke, Parkinson’s, epilepsy
  • balance disorders
  • vertigo

Environmental
- unsafe walking aids, inappropriate footwear, home hazards, transfers

Physiological
- reduced balance, walking problems, slow reactions, reduced muscle strength in legs and arms, poor hearing/vision, loss of sensation in feet, impaired proprioception

Psychological and cognitive impairment
- reduced motivation/depression, dementia/delirium

Polypharmacy
- sedatives, antipsychotics, drugs causing arrythmias, antihypertensives, diuretics, vasodilators, steroids, diabetic drugs, ototoxics

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14
Q

Types of syncope

A

Cardiac

  • structural – aortic stenosis, hypertrophic cardiomyopathy
  • arrythmias – complete HB, ventricular tachycardia
  • coronary ischaemia

Neutrally mediated
- carotid sinus hypersensitivity - oversensitive to stretch, so increased vagal tone and bradycardia, exacerbated by turning head/tightening collar, usually elderly men, diagnose with carotid sinus massage test, treatable with pacemaker
- vasovagal, neurocardiogenic – diagnose with tilt table test (situational – micturition, defecation, cough, swallow - recurrent idiopathic, postprandial, simple isolated faint)
Classification:
• Type I (mixed) - BP drops to <80mmHg, slight drop in HR
• Type IIa and IIb (cardioinhibitory) – treatable with pacemaker
o IIa – BP drops, HR drops a lot
o IIb – no BP drop, HR drops a lot
• Type III (vasodepressor) – treatable with fludrocortisone - BP drops a lot, HR doesn’t drop

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15
Q

Causes of vertigo

A

Peripheral vertigo
o BPPV - lasts less than 1 min, Hallpike to diagnose, Epley to treat
o Acute labyrinthitis - lasts hours, self limiting, prochlorperazine to treat
o Meniere’s - lasts hours, need salt restriction, diuretics, betahistine
o Cervical vertigo

Central vertigo
o	Posterior fossa mass
o	Demyelination
o	Brainstem vascular disorder
o	Migraine (rare)

Disequilibrium is not vertigo - feeling of about to fall, bad balance when erect or moving, felt in trunk and lower limbs not head

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16
Q

Neck of femur fracture

A
  • present in acute pain and complete inability to weight bear – first step is always analgesia
  • mainly in elderly, osteoporosis + increased risk of falls - so from low impact injury

Intracapsular
- shortened and internally rotated leg
- Garden classification (but unnecessary, just need to know if displaced or undisplaced)
- needs surgery in next 36 hours – avascular necrosis
- surgery (broad categories, depends on mobility)
• If under 55 or undisplaced – cannulated screws
• If aged 55-75 – total hip replacement
• If aged 75+ – hemiarthroplasty

Extracapsular
- intertrochanteric and subtrochanteric
- within 5cm distally of lesser trochanter, caused by traumatic impact to side of pelvis
- 2x as common as intracapsular
- better, as blood supply not compromised
- surgery – to promote micromotion, to heal by secondary bone healing
• Intertrochanteric – dynamic hip screw (DHS)
• Subtrochanteric – long intermedullary nail (ess stable, needs more support. The DHS is fixed laterally so puts more leverage and stress on the joint, unsuitable for the more unstable subtrochanteric fractures)

17
Q

Osteoporosis

A
  • low bone mass, micro-architectural deterioration of bone tissue, leading to reduced bone strength and increased fracture risk
  • > fragility fractures especially in NOF, vertebrae, distal radius (Colles’)

Pathology
- most treatments target osteoclasts (reducing absorption), only one licensed (teriparathide) targets osteoblasts

FRAX score = 10 year osteoporotic fracture risk, depending on risk factors: - anyone at risk of falls needs this
- T scores: > -2 = normal, -2.5 - -1 = osteopenia, < -2.5 = osteoporosis

18
Q

Risk factors for osteoporosis

A

Age – ~60s more likely wrist fractures, older more likely hip and spine
Gender – female more likely, + age at menopause
Previous fractures
Parental fragility fractures – hip especially 2x risk
Race – Caucasian and Asian higher risk
Diet – should have 700mg calcium a day – dairy, leafy greens, tofu
Vitamin D deficiency
Alcohol
Smoking
Steroid use + antiepileptics, aromatase inhibitors (breast cancer), androgen deprivation therapy, heparin, thyroxine overtreatment
Rheumatoid arthritis/inflammatory diseases
BMI – if low, increased risk
Diabetes – type I and II
Falls

19
Q

Treatment for osteoporosis

A

Conservative
 Physiotherapy
 Patient education
 Walking aids

Bisphosphonates – eg zoledronic acid, alendronate
 Inhibit osteoclasts by working on RANKL receptors
 Need 2 years treatment, then 2 years off
 Alendronic acid 1st line, oral, then if not tolerated zolendronic acid IV

Calcium and vitamin D supplementation

Surgery (joint replacements)
 Benefits – reduce pain, improve mobility and function
 Risks – before: bleeding, nerve damage, implant malpositioning, anaesthetic risk; early complications: bleeding, DVTs, wound problems, early infection; late complications: dislocation, late infection

20
Q

Vertebral fractures

A

Osteoporosis is diagnosis of exclusion – primary and secondary bone tumours, multiple myeloma, infection, trauma first

Primary osteoporosis

1) post-menopausal (for 7 years post menopause will lose BMD every year)
2) senile (everyone gets)

Secondary osteoporosis

21
Q

Stroke

A

= sudden loss of perfusion to brain resulting in neurological deficit lasting more than 24 hours
- 1/6 will have in lifetime

Ischaemic 80% (thrombosis, embolism, or systemic hypoperfusion)
Haemorrhagic 20% (intracerebral or subarachnoid)

  • TIA if less than 24 hours, and no visible changes on imaging (having had a TIA, you are at increased risk of stroke in the next few days, so need to treat with aspirin and refer to TIA clinic)
22
Q

Risk factors and symptoms of stroke

A

Risk:

  • hypertension
  • smoking
  • diabetes
  • hyperlipidaemia
  • inactivity/overweight
  • atrial fibrillation – easily managed, risk reduction 2/3 if anticoagulated
  • hypercoagulable states

Symptoms
- weakness
- loss of sensation
- speech disturbance – receptive/expressive dysphasia, + slurred speech
 Brocas and Wernickes on the left – if dysphasic patient then probably right sided weakness
- visual disturbance – specific field loss, classically homonymous hemianopia
- swallowing difficulty
- inattention/neglect – visual, sensory, etc
- dizziness, nausea, ataxia
- confusion

Need CT asap to ensure not haemorrhagic (don’t need MRI to confirm)

23
Q

Stroke mimics

A
  • seizures, eg Todd’s palsy – paresis (+ other symptoms)
  • migraine with aura
  • syncope
  • hypoglycaemia
  • metabolic encephalopathy
  • sepsis
  • drug overdose
  • tumour
  • SAH
  • cerebral venous infarction
  • viral encephalitis
  • subdural haematoma
  • peripheral nerve compression
  • Bell’s palsy – not forehead sparing
  • BPPV – benign paroxysmal positional vertigo / viral labyrinthitis
  • conversion disorder/functional disorder
24
Q

Total anterior circulation stroke

A

TACS (worst to have)

Need all three of
• Unilateral weakness (and/or sensory deficit) of the face, arm and leg
• Homonymous hemianopia
• Higher cerebral dysfunction (dysphasia, visuospatial disorder, inattention/neglect etc)

25
Q

Partial anterior circulation stroke

A

PACS

Need 2/3 of
• Unilateral weakness (and/or sensory deficit) of the face, arm and leg
• Homonymous hemianopia
• Higher cerebral dysfunction (dysphasia, visuospatial disorder, inattention/neglect etc)

26
Q

Posterior circulation syndrome

A

POCS

Need one of
• Cranial nerve palsy and a contralateral motor/sensory deficit
• Bilateral motor/sensory deficit
• Conjugate eye movement disorder (e.g. horizontal gaze palsy)
• Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
• Isolated homonymous hemianopia – further back (closest to final image)

27
Q

Lacunar syndrome

A

LACS

Need one of
•	Pure sensory stroke
•	Pure motor stroke
•	Senori-motor stroke
•	Ataxic hemiparesis
28
Q

Management of ischaemic stroke

A

Acute

  • if within 4.5 hours, thrombolysis/clot thrombectomy (must be severe disabling, no contraindications (anticoagulated, active bleeding, very high bp, very high glucose), using rTPA to thrombolyse (alteplase))
  • aspirin 300mg
  • stop anti-coagulation if taking (even if due to AF)
  • swallow assessment
  • maintain homeostasis – hydration, avoid pyrexia
  • maintain blood glucose 5-10
  • VTE prophylaxis via intermittent pneumatic compression
  • avoid dropping bp at all (unless >230mmHg systolic) – but don’t discontinue current bp medication, aim for their normal
  • avoid catheters if possible

Chronic

  • 2 weeks aspirin 300mg, then 75mg clopidogrel
  • investigate with carotid dopplers if anterior circulation, and not too frail for carotid endarterectomy
  • investigate for AF, with ECG/telemetry/48hr tape + anticoagulate at 2 weeks if present
  • control of bp, cholesterol, diabetes
  • smoking cessation
  • physio, occupational therapy, SALT, psychology, dietician etc
29
Q

Management of haemorrhagic stroke

A

Acute

  • control BP so not too high - aim for around 160mmHg systolic – labetalol/GTN
  • swallow assessment
  • maintain homeostasis – hydration, avoid pyrexia
  • maintain blood glucose 5-10
  • VTE prophylaxis via intermittent pneumatic compression
  • avoid catheters if possible

Chronic

  • control of bp, cholesterol, diabetes
  • smoking cessation
  • physio, occupational therapy, SALT, psychology, dietician etc
30
Q

Extradural haemorrhage

A
  • typically in the young with high impact trauma
  • associated with temporal skull fracture, shearing middle meningeal artery
  • initial loss of consciousness, lucid interval and then reduced GCS
  • lentiform shape seen on CT, as dura pinned tightly to skull so can’t push around but into brain tissue
31
Q

Subdural haemorrhage

A
  • both acute (white blood) and chronic (dark)
  • in the elderly, alcoholics, neurodegenerative disease, where brain shrinkage pulls on the fragile bridging veins
  • crescent moon shape seen
32
Q

Subarachnoid haemorrhage

A
  • 10/10 pain, thunderclap headache, maybe associated nausea/vomiting/photophobia/seizure
  • often due to rupture of berry aneurysm (associated with FHx and PCKD)
  • bleeding into space where CSF should be, between sulci
33
Q

Urinary incontinence

A
  • 1/3 women, 1/10 men

Stress

  • urinary leakage with raised intra-abdominal pressure
  • associated with bladder neck or sphincter weakness, obesity, poor pelvic floor strength, nerve damage
  • mainly women (often in pregnancy or following childbirth)

Urge

  • involuntary detrusor contractions (‘detrusor instability / overactive bladder’)
  • associated with lesions affecting motor or sensory pathways eg MS, diabetes, stroke, Alzheimer’s
  • men and women
  • exclude causes eg infection, stones first

Mixed
- combination of stress and urge

Overflow

  • inability to expel urine
  • with detrusor atony or bladder outlet obstruction eg enlarged prostate, uterine prolapse, previous surgery, incontinence procedure, or neuropathic

Functional
- unable to get to toilet in time or manage buttons/zips

34
Q

DIPPERS causes of incontinence

A 
	Delirium
	Infection
	Pharmaceuticals/alcohol
	Psychological
	Excess urine output
	Reduced mobility
	Stool impaction

Red flags - haematuria, new onset constipation, obstructive symptoms

35
Q

Investigations for incontinence

A
  • inspection including prolapse/leakage on coughing
  • post void residual, trial of catheter if >200ml
  • urine MC+S
  • PR for faecal impaction - soft = loading, common, impaction = hard, rare
  • BM / Hba1c?
36
Q

Assessment tools for cognition

A

Folstein Mini-Mental test-MMSE

Abbreviated mental test score AMT

Addenbrooks Cognitive Examination ACE-R

MOCA (Montreal Cognitive assessment)

+ remember also geriatric depression scale

4th year (11 decks)

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