Medicine for older people Flashcards
Geriatric giants of frailty
Incontinence
Immobility
Intellectual decline
Instability
- tend to present first with acute functional decline (eg first symptom of pneumonia is a fall)
Dementia
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
Alzheimer’s dementia
- 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)
Vascular dementia
- 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
Lewy Body dementia
- 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)
Frontotemporal dementia
- 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)
Parkinson’s disease
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.
Atypical parkinsonian syndromes
= 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
Vascular and drug-induced parkinsonism
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
Pre-motor phase, and motor complications of drug treatment of Parkinson’s
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
Delirium criteria
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
Risk factors and triggers for delirium
Risks
- dementia
- frailty
- drug/alcohol dependence
- polypharmacy
- multi-morbidity
- male gender
- depression
PINCH ME causes Pain Infection Nutrition Constipation Hydration Medication Environment/electrolytes
Risk factors for fall
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
Types of syncope
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
Causes of vertigo
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
Neck of femur fracture
- 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)
Osteoporosis
- 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
Risk factors for osteoporosis
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
Treatment for osteoporosis
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
Vertebral fractures
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
Stroke
= 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)
Risk factors and symptoms of stroke
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)
Stroke mimics
- 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
Total anterior circulation stroke
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)
Partial anterior circulation stroke
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)
Posterior circulation syndrome
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)
Lacunar syndrome
LACS
Need one of • Pure sensory stroke • Pure motor stroke • Senori-motor stroke • Ataxic hemiparesis
Management of ischaemic stroke
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
Management of haemorrhagic stroke
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
Extradural haemorrhage
- 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
Subdural haemorrhage
- 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
Subarachnoid haemorrhage
- 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
Urinary incontinence
- 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
DIPPERS causes of incontinence
Delirium Infection Pharmaceuticals/alcohol Psychological Excess urine output Reduced mobility Stool impaction
Red flags - haematuria, new onset constipation, obstructive symptoms
Investigations for incontinence
- 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?
Assessment tools for cognition
Folstein Mini-Mental test-MMSE
Abbreviated mental test score AMT
Addenbrooks Cognitive Examination ACE-R
MOCA (Montreal Cognitive assessment)
+ remember also geriatric depression scale
