Old Peoples Care Flashcards

Question

What are the different types of BPSD?

Answer 1

Affective- Low mood; agitated, anxious, pacing, wandering, anxiety. Psychotic- delusions (fixed false beliefs- think body is breaking down, think the news is about you etc), hallucinations (false perception in absence of stimuli, nothing there but Px thinks there is. Hyperactive- aggression, disinhibition irritability, lability, night disturbance. Apathetic- indifference, appetite, eating problems.

Answer 2

Choose an appropriate setting Treat any discomfort i.e. pain, constipation, retention etc Non-pharmacological interventions i.e. music therapy, massage therapy. Antipsychotic/antidepressant- use with caution. UPDATE WHEN PPT UP

Answer 3

Common cause of disability in later life, more than CVD, stroke, cancer Even more costly than these. Diagnosis is often missed Its always a progressive disorder Stressful for all members of the family Those most dependent and vulnerable often have the least awareness of their disabilities.

Answer 4

Impaired cognition. Disturbed consciousness/attention (more common than memory problem). Disturbed sleep-wake cycle (sleep in day but in night awake and wandering). Abnormal psychomotor behaviors Acute onset- can last hrs to days to a few months. Visual hallucinations Symptoms fluctuate- typically worse at night.

Answer 5

1) Hypoactive- Most common form. Quiet, sleepy, inactive, unmotivated, easily overlooked. 2) Hyperactive- heightened arousal, restlessness, irritability, wandering, carphologia (picking at clothes). On acute wards this can lead to agitation towards staff, refusal of care/treatment, falls, may not engage in physical examinations- vicious cycle can't manage the health issue causing delirium therefore the delirium gets worse and so does the underlying condition. 3) Mixed picture is also possible.

Answer 6

``` Previous dementia Severe trauma (Hip fracture) >65yrs Polypharmacy Increased Frailty ```

Answer 7

``` T- Trauma (head injury, intracranial event) H- Hypoxia (PE, CCF, MI, COPD, Pneumonia I- Increasing age/frailty N- NOF fracture K- smoKer or alcohol withdrawal. ``` D- Drugs E- Environment (i.e. ward changes) L- Lack of sleep, reversal of sleep-wake cycle. I- Imbalanced electrolytes (renal failure, Na+, Ca2+, glucose, liver function R- Retention (urinary/constipation) I- Infection/sepsis U- Uncontrolled pain M- Medical conditions (dementia, Parkinson's disease)

Answer 8

Hx, examination, collateral Hx, investigating a cause, along with: 1) CAM- Short confusion assessment method. Px is examined on the following; a) Irritability (2) b) Acute onset and fluctuating course (2) c) Altered consciousness (1) d) Disorganized thinking (1) CAM >/= 5 THINK DELIRIUM Need a + b + c/d for a diagnosis of delirium. 2)Meet the DSM-5 criteria 3) AMT- Abbreviated mental test, where the Px is asked the following; a) How old are you? b) What is your DOB? c) Where are we right now? d) What year is it? If >65yrs with AMT<4 THINK DELIRIUM Most Px will need admittance to hospital.

Answer 9

``` Early on- Inattention Clouding of consciousness Repetitive Rambling Speed of thinking is slower Drifting off point Distractible ``` Then can develop perceptual abnormality- usually transient visual hallucination i.e. seeing insects, lasting briefly, not causing much distress usually.

Answer 10

Psychotropic drug i.e. antidepressants, antipsychotic, benzodiazepines. Anti parkinsonian drugs Anti cholinergic Opiates Diuretics Recreational drug intoxication and withdrawal

Answer 11

CAM >/= 5 THINK DELIRIUM Age >65yrs and AMT<4 THINK DELIRIUM

Answer 12

Manage underlying cause. First line treatment is haloperidol unless Parkinson’s, where this can worsen the symptoms. Therefore consider reducing Parkinson’s medication dose.

Answer 13

Not all Px get better In acutely ill Px the prognosis is worse Increased mortality Can take >3months to full resolve, may get diagnosis of dementia. Some evidence that certain delirium can precipitate/permanently worsen dementia.

Answer 14

``` Delirium Acute onset Fluctuates more Change in consciousness Clouded consciousness Lack of attention Visual hallucinations Delusions Agitation/fear Delirium can resolve ```

Answer 15

Mild cognitive impairment- is memory impairment more than should be expected for their normal, but no functional impairment on ADL therefore not a diagnosis of dementia. It is a RF for developing dementia, therefore should be monitored. MCI is a clinical diagnosis, may impact higher cognitive function; memory, problem solving, planning or language.

Answer 16

Both common cause is Alzheimer's, but <65yrs only 1/3 compared to 2/3. <65yrs also likely to get FTD and LBD. Early onset dementia is more likely to present with language difficulties (grammar sounds odd), motor symptoms i.e. tremors/myoclonic jerks, visual symptoms w/o cause, behavioral symptoms. Early- Prognosis can be between weeks to years. Older- More likely to have prognosis of yrs.

Answer 17

Neurodegenerative- AD, vascular, FTD, Pakrinsons, LB Infective- HIV, Herpes Prion- CJD Inflammatory- vasculopathies, autoimmune Metabolic- diabetes poor controlled, vitamin deficiencies Genetic- Presentalin gene, APP gene, Downs sydnrome and AD. Others

Answer 18

Working age Px is not limited as much physically, so can wander further. Driving Stigma and poor understanding of others They are a carer for someone else or their carer (wife/child/sibling) has other commitments Multiple losses/bereavements May not be accepted as much socially, i.e. people will think Px are drunk.

Answer 19

Need to know the timeline- when did it start and how was the Px before? Symptoms and how do they relate to each other. MEMORY LANES PMH or psychosis DHx- Do they comply to their medications SHx- Finances, job, support system, normal daily activities, alcohol, substance misuse, withdrawal. FHx Personal Hx Assess the risk: Self harm/suicide/aggression to others. Wandering, found out at night, neglect, medication compliance (diabetes), carer strain, being left alone. Mental state examination Cognitive assessments- Mainly ACE-11, MMSE, GPCOG. Physical examination concentrating on neurological aspect.

Answer 20

M- Memory (recent and far back) E- Employment (what do they do i.e. quite skill/management, are they having trouble?) M- Motor symptoms (tremors, falls, stiffness) O- Overeating (esp sweet food- increased desire) R- Risk (driving/wandering/cooking/impulsive) Y- Usual self (aka personality/social etiquette) ``` L- Language (expression/comprehension) A- Accidents (continence) N- Night E Exclude other illnesses (ask about mood and psychosis) S- Sight (occipital lobes affected) ```

Answer 21

Assessment: MSE (Mental State Examination), Cognitive Assessments (MMSE, ACE-11, GPCOG, etc) Investigations: Baseline bloods MRI for neurological changes/inflammatory processes PET ECG/EEG/OT functional assessment, CSF for genetics or clarifying diagnosis etc.

Answer 22

-Explain the diagnosis and prognosis -Consider medication: Cholinesterase inhibitor +/- memantine in Alzheimer's Rivastigmine in PD Antipsychotic/antidepressant for BPSD- use with caution. -Plan: Referral to OT Referred for FDG-PET Scan Follow up with results

Answer 23

Onset between 50-65yrs old. Potential variant of Alzheimer's, where Alzheimer's disease is also cortical atrophy, but this is specifically posterior. Since the affected area is where the visual cortex exists, common symptoms include; difficulty judging distances, distinguishing between two points (moving/stationary), disorientation, some experience hallucinations. Px can also develop anxiety (because they know something is wrong- have insight). It is a rare disease. investiate with RO

Answer 24

In the first instance the Px would present to the ophthalmologist because of what they perceive as visual changes. The vision tests would be normal. There is no specific test but neuropsychological tests, blood tests, brain scans and a neurological examination can be used to diagnose the condition and rule out other potential explanations for symptoms.

Answer 25

``` Explain diagnosis and prognosis including driving and working. Cholinesterase inhibitors MDT- SALT, SS, CMHT Rare dementia groups Support for the carer ```

Answer 26

``` Delirium Other psychiatric illness Substance misuse Menopause Fibromylagia Normal pressure hydrocephalus Sensory deprivation ```

Answer 27

``` Delirium Other psychiatric illness Substancemisuse Menopause fibromyalisgia Sensory deprivation ```

Answer 28

Raoidly progressive dementia- devellps wothin wks to mnths Imp o get diangosis correct CAuses include

Answer 29

refer to social serviecs r Hibbert believes Bill has carer strain • You will hear more about this in the block • Unpaid care is vital to support people in the community • Nearly 3 quarters of carers in England have sufered mental ill health such as stress and depression, while over 60% have experienced physical ill health due to caring. • Many have not had a carer’s assessment. • It is important to recognise and implement early assessments to keep them well so that they are supported to care for their loved ones just for clarification - community hospitals are not for social admissions they are for step up care i.e. medical issues - they won't accept pure social unless they need medical intervention. If pure social then this would be an urgent social care admission to a care facility or emergency care package

Answer 30

``` aids home modifications walking aids assess bills look at relative too ```

Answer 31

``` Comprehensive geriatric assessment. Co morbidiites medicationas nutritional assessment functional assessmet ``` carried out by several health care professionals

Answer 32

Need to know well fro exam | Gives accurate infromation about Px

Answer 33

Fill out when a person has the capacity Only becomes active when the person has lost the capacity. If dont fill in with capacity then family need to go tp courts (of protections?) o be deemed as lacking capacity someone must have a medical or mental health conditon that means they lack the ability to undertake the following – Understand informaton given to them about a partcular decision – Retain that informaton long enough to be able to make the decision – Weigh up the informaton available to make the decision – Communicate their decision. • Capacity is decision specifc and is for that decision alone and in that point of tme. • Capacity can be fuctuant- during the day, throughout the condition, or with more complex topics.

Answer 34

Is a term used to describe measures to protect the health, well-being and human rights of individuals, which allow people — especially children, young people and vulnerable adults — to live free from abuse, harm and neglect • Safeguarding concerns can be raised to either the locality safeguarding team or social services • Where a crime has been commited and others may be at risk police input may be required

Answer 35

Px continues to eat/drink despite the risk of aspiration pneumonia. This is more for enjoyment adn imrpoving QoL, as opposed to nutritional advancement. Reasons: dvanced stage of illness • The person’s swallow safety is not likely to improve • When the preference to eat and drink takes priority over swallow safety • Tube feeding optons are declined or inappropriate

Answer 36

Need to ensure that an underlying diagnosis is not missed; FBC, U+Es, LFTs, B12/folate,

Answer 37

``` Detailed contnence history • Review of bladder and bowel diary • Abdominal examinaton • Urine dipstck and MSU • PR examinaton including prostate assessment in a male • External genitalia review partcularly looking for atrophic vaginits in females • A post micturiton bladder scan ```

Answer 38

Drug therapy or pads are not frst line management • Switch to decafeinated drinks • Good bowel habit • Improving oral intake • Regular toiletng • Pelvic foor exercises and bladder retraining • Remember that antcholinergics are not good in older people and oxybutynin whilst good for younger patents is not good for older people. • Many of the drugs used for bladder stabilisaton can also cause postural hypotension leading to increased falls.

Answer 39

Both residental and nursing care homes provide 24 hour care with trained staf • A nursing home is stafed at all tmes by registered nurses supported by care assistants. People in nursing home need nursing interventon. • In residental care homes, staf are trained too, but not in nursing care. • All care homes have to be registered by the Care Quality Commission and they register homes either as a care home or a care home with nursing.

Answer 40

Warfarin treatment and head injury warrants CT wihtin 8hrs cheeck NICE guidelines Older people get vomiting later since have more space in their crainial cavity for fluid to build up

Answer 41

difficulty eating unhygenic mouth- harder to eat; clean mouth then Px will increase eating difficulty chewing swallowing deteriorates thirsty forget how to use cutlery- better to use finger foods/food in bite size peices 1 to 1 in eating SALT assessment birhgtly couloured nutrition pods- bright blue better responsive Focus on what they want to eat to get them to eat- even if ice cream fro breakfast artificial/PEG tube- dont really give because dementia is not reversibel, this does not improve the life expectancy and a risk of aspiration still exist. These can cause distress and so Px can pull it out. Therefore not useful to give to a dementia Px. Also v.difficult to give to dementia Px.

Answer 42

``` Issues to think about  Swallowing  Chewing  Mouth care  Thirst sensation/hunger sensation  Risk of aspiration  PEG feeding in advanced dementia  Does not stop risk of aspiration of gastric contents/saliva  No evidence that it increases life expectancy  Procedure is associated with risks and discomfort, risk of patient dislodging tube  What is feeding at risk? ```

Answer 43

Px can eat/drink whilst accepting the risk of aspiration. | Importance on Px QoL

Answer 44

Heels Sacrum Also back of head, shoudlers, elbow, @ risk- immobility, incontinence, diabetes, vascualr insufficiency, female, age, skin type, Screening/assessment- WAterlow

Answer 45

PREVENTION!!!!- Boots given on wards but dmentia Px may kick these off. Dementia Px more likely to move and rub skin against the sheets. If inconitnent of urine with sacral sore catherterise to ensure sore isnt drenched in urine. ``` -Wound management removal of necrotic tissue  pain and tolerance  position of the ulcer  amount of exudate  frequency of dressing change. ``` - Friction Reduction - Nutrition-to allow rebuilding and healing - Pressure redistribution and repositioning- correct mattress. - Antimicrobials if required - Utilise expertise of TVN- osteomyeltiis risk- treat w/o a bone biopsy in older Px- treat with empirical Abx.

Answer 46

Are they unable to make their own decisions? Do they understand the info, retain it, understand/weigh up the info and relay the info back to you. 2 stages: Speak to them and discuss all info. Then come back to see if they could retain it, weigh it up and relay it. Capacity is not global, should assess capacity for each situ.

Answer 47

When someone lacks acapcity and unable to make a decision themselves. Makin the decision based on what they feel the Px would have wanted. It is an MDT decision and takes into saccount those who knew the Px and what they wouldve wanted. Not what they feel best for the Px, BUT what the Px wouldve wanted if they couldve consented. If they have a POA, these can make the decisions on their behalf. If thePx doesnt have anyone, get an IMCA- Independent mental capacity advocate.

Answer 48

Px who can't consent to their care, we protect the arrangements which deprive them of their liberties. I.e. if a Px on ward with dementia wnated to go home, we put a DoLS in place and escalate to the social services. Framework to ensure those who can't consent are protected if they are being held against their will i.e. depreived of their liberties.

Answer 49

Own home (POC)- 2 carers QDS Community hospital Specialist Accommodation (Warden control) Discharge to Assessment (D2A) Bed- funded placmeents in care homes, where Px ids there for 6 weeks then reassessed. RH- resendential NH- nursing- has one trained nurse overnight Fast Track- Px apporaching end of life- fast tracked home or to care homes.

Answer 50

Drop in >20mmHg systolic or 10mmHg diastolic Lying bp, then immediate after standing, then after 3mins then again after 5 mins

Answer 51

Good history and examination- Px cant usually give detail, 'may have tripped over something' Do you remember the sensation of flying through the air? Do you remember falling? If they remember then they did not lose consciousness. ```  Look for injuries  ECG  Lying/standing BP – interpret with caution  Medication review  Gait / functional assessment (MDT)  Bone health review  Fear of falling (will lean back since lost confidence) / loss of confdence  Exercise programme ``` Fludrocortisone used to treat orthostatic hypotension

Answer 52

Good history and examination- Px cant usually give detail, 'may have tripped over something' Do you remember the sensation of flying through the air? Do you remember falling? If they remember then they did not lose consciousness. ```  Look for injuries  ECG  Lying/standing BP – interpret with caution  Medication review  Gait / functional assessment (MDT)  Bone health review  Fear of falling / loss of confdence  Exercise programme ```

Answer 53

Older people are known to have increased risk of adverse effects with medication due to age related alteration in pharmacokinetics and pharmacodynamics.  Evidence suggest some common drug groups associated with preventable drug related admissions especially in older people.  NICE guidance on Medicines Optimisation recommends using a screening tool – for example the STOPP/START tool in older people ``` Is it actually indicated?  Is the diagnosis correct?  Are there non-pharmacological alternatives?  Are the long term benefts tangible?  Are there any interactions?  Start low and go slow  What is the time frame? ```

Answer 54

FRAT Timed up and go turn 180 test

Answer 55

Detailed continence history • Review of bladder and bowel diary • Abdominal examination • Urine dipstick (look for blood/protein) and MSU • PR examination including prostate assessment in a male • External genitalia review particularly looking for atrophic vaginitis in females • A post micturition bladder scan

Answer 56

Drug therapy or pads are not frst line management  Switch to decaffeinated drinks  Good bowel habit  Improving oral intake  Regular toileting  Pelvic foor exercises and bladder retraining  Remember that anticholinergics are not good in older people and oxybutynin whilst good for younger patients is not good for older people.  Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.

Answer 57

Fragility Fracture: Fracture from falling from standing height or lower at walking speed or slower.  Occur most commonly in the spine (vertebrae),hip (proximal femur) and wrist (distal radius).They may also occur in the arm (humerus), pelvis, ribs and other bones. Excludes pathological fractures, fractures of digits, and skull fractures.  Osteoporosis: syndrome associated with low bone mass and micro architectural deterioration of bone tissue with increased risk of fractures – bloods normal  Previous fracture increases future risk and particularly in the frst few months

Answer 58

First line (oral). Inhibit bone resorption and increase BMD  Check calcium, Vitamin D, renal function ( eGFR>30)  Controlled GI symptoms can use  Mild symptom – risedronate or soluble alendronate rather then alendronate  Avoid – achalasia, stricture, ulcers  Encourage compliance (empty stomach, NBM 30 mins after, 240ml of water, upright for 30 mins)- difficult to achieve in cognitively impaired Px.  Poor compliance and only 1% of drug absorbed  6-12 months fully effective  5-10 years

Answer 59

``` IV Zolendronate Intolerant of oral bisphosphonates or non compliant  3 years, once a year  30 min infusion  Optimise calcium and vit D  CrCl> 35  One off infusions useful for frail patients with cognitive impairment (no evidence)  Check teeth and post infusion calcium ```

Answer 60

Human monoclonal antibody  It inhibits osteoclast formation, decreases bone resorption and increases BMD  Denosumab is not considered initial therapy for most patients with osteoporosis  Intolerant of or unresponsive to other therapies (including intravenous bisphosphonates) and in those with impaired renal function  Skin infections  Denosumab suppresses bone remodeling – ONJ and stress fractures  Denosumab (60 mg) is administered by subcutaneous injection once every six months. Cannot be stopped abruptly.

Answer 61

``` Mortality rate 50% per year NH, 25% in RH compared to 5% for over 65’s  Why operate: To ensure pain control To reduce opioid requirements To allow good nursing care To allow sitting out To allow chance to regain function Bed rest for 6 weeks a poor alternative treatment  Always speak to family or carers ```

Answer 62

Functional unti of the CNS. Includes neurnes, gial cells and endothelium (inc BBB) Raitonale between CNS dysfunction and pathologies i.e. MS get a myelin sheath dysfunction.

Answer 63

It is a sydnrome Hypoperfusion occurs in every case. Leasds to a depletion of ATP therefore energy. So anything requiring AT wil malfunction i.e mitosis, action potential. More importantly need ATP for membrane transport- action potential. AP need to be full, cant have half or whole. Where there is not enough ATP for a full AP, you move to a phase of having no AP.

Answer 64

Sudden onset- due to phase transition from ability for AP t inability. Focal- Since only neurovascular units playing up. Dizziness, loss of consciousnes, confusion. Predominantly negative symptoms since cessation of AP. Negative refer to loss of function symptoms. Cannot have +ve/gain of function. Vascular territory hypoperfusion can explain the cllection of symptoms. -Symptoms dont tyicaly migrate -Episodes dont typicaly stereotype i.e. no episodic recurrence in identical fashion, with complete resolution in between episdes. I.e. wont likely come wiht the exact same presentation.

Answer 65

TACS, PACS, LACS, POCS. If finding it difficult to ace into a vascualr terrirty but x complains of Isolated dysarthria, vertigo, diplopia- realise that hypoperfusion in a vascular territory is difficult. There are no one place in the brain which causes dysarthria, vertigo or dplopia. Islated dysarthria are more likely due to global brain pathology (tired, alcohol) or peripheral fcal aparatus (sore throat tongue) Isolated vertigo- dysfunction in midde ear rather than CNS Isolated diplopia- Dysfunction of extraoccular muscles or dysfunction of the CN themselves. So with these would consider alternative causes (stroke mimic), rather than vacular hypoperfusion. Peripheral motor/sensory dysfunction Sequential onset of diferent symptoms during same episode- Also mimic where there are different symptoms but onset is at different times. If phase transition occurs at one point, then there would be no reason for symptoms to occur after.

Answer 66

Basal ganglia, caudate nucleus, lentiforme nucleus and thalamus. Hypoperfusion in all the branches of these. M1- suppies internal capsule, dviiton of MCA P1- From PCA basilar artery- thalamus A1- caudate ncueus Hypoperfusion of M1 wi lead to HP of lenticulostriate nucleus, since reduced pressure. Get recurrent events due to variable hpyoperfusion in end arteries, episodes tend to be

Answer 67

``` Hypoglycaemia Migraine with aura MS Focal seizure Bells palsy BPPV Raised ICP Hemiplegic migraine Brain tuout brain abscess Subdurl/extra dural haematoma functional syndrome Apparent neurlogical deficits- after a stroke the damaged tissue becomes scar tissue- gliosis; within the gliosis get new dendrites- there neuroplasticity looks normal function wise. The connections in areas of gliosis is not as good as normal brain so will give underperformance in the area of gliosis. ```

Answer 68

Group 1- Readily identifiable n brain imaging Group 2- Syndronomically dsitinguishable from the stroke syndrome on clinical grounds after general medical assessnetn. Group 3- exclusion of stroke syndrome requires specialist stroke assessment including brain imaging

Answer 69

Dysfunction of episodic memories biograhical memor- who are your brothers, siters etc Procedural memory TGA-only episdoic memory (the memory f evens) is impaired. Stages of episodic memory- Brain registers the info i.e. voice- then stores the memory- then brain retrieves the memory. these are all affected in TGA. Therefoer Px will kee asing the same Qs over 9cant register, cant store. Since cant retrieve memories, even memories of events before the dysfucntion. Procedural memory is still preserved so on the outside seems normal. In recovery they can remember the info frm time ago, but anything during the period of TGA, cnanot be remembered since the events were not registered or stored. In foca seizure wont be able to carry out functional tasks.

Answer 70

Stereotyping- similar episdes in the past. AP still occuring but a little disturbed- sequential evolution f epsidoes and impairents in migraine. If spreads to aprietal cortex- sensory impairments T temporal lobe- language difficulty, difficulty concentrating

Answer 71

Caused by hypoperfusion in a vascualr territory presents in an atypical way. Venous infarcts – gradual onset, preponderance for seizure activity  Small cortical strokes – peripheral nerve lesions  Limb shaking TIA – ?seizure  Occipital strokes – predominant presentation with confusion ?delirium (visual feld examination should still reveal feld loss)  Stroke amnestic syndromes  Stroke mimicking vestibular dysfunction

Answer 72

Diagnosis of stroke is incomplete unless you can attach an aetiology. can categorise into type of brain parenchymal damage i.e. infarct Mechanism of hypoperfusion i.e. embolisation, vasoconstriction Disease/pathology process responsible mainly for the mechanism of hypoerfusioni i.e. AF, APLS, vasculitis etc Climate in which disease has thrived i.e. smoking,

Answer 73

Look for clues from radiology OCSP classification can help narrow down the causes. Targeted assessment tools (ECG, 24 hr tape, Echo, carotid US, thrombophilia screen, angiography etc) but these targeted assessment tools are directed from other Hx/suspicions.

Answer 74

Multiple diseases cause the same syndrome therefore a single treatment wont manage the stroke. Classified into- ``` Large arter atherosclerosis Cardio embolic Small vesse disease Other determined i.e. vasculitis Undetermined ```

Answer 75

Depression/mood/other cognitive issues Apsiration pneumonia DVT/PE immoblitiy (bed sores, VTE, constipation) Pressure sores Furhter strokes Raised ICP (malignnat odemea, hydrocephalus, haemorrage transformation) Infections Post stroke fatigue Post stroke pain Spascicity, contractures secondary epilepsy

Answer 76

Anticipate a complication- think esp with Px which Hx of depression i.e Surveillance- daily obs, mood, examine chest, legs, bowel, urine The imapriment of the storke will define the disbaility. Only brainstem strokes will kill a Px. Will more likely die with recurrent stroke.

Answer 77

``` Central role of problem list  Care bundle  Admission to stroke unit  Reperfusion therapy  Optimising physiology and surveillance, prevention and early intervention of complications  Nutritional support  Secondary prevention  Rehabilitation NIHSS ```

Answer 78

For Px with intracranial bleed the biggest concern is raised ICP. Therefore everything is concerened with reducing haematma expansion i.e BP control, corrected clotted deragnement, maintaing good glycaemic control. c ```  Anticipating, preventing and managing raised intracranial pressure and other complications  BP control  Correcting clotting derangements  Maintaining good glycaemic control  Neurosurgery for ICH, balance between;  Surgical accessibility  Neurological stability ```

Answer 79

``` Steps to prognosis estimation  NIHSS, OCSP  Functional prognosis (role of neuroplasticity- good neuroplasticity can regain the functions, recovery trajectory and impairment type)  Mortality prognosis-  Influence of complications  Stable  Stable but at risk of complications  Unstable ``` ``` Guiding patients through life changes (adjustment)  Driving restriction  Employment and education  Leisure  Palliation ``` Transfer of care- dishcarge planning, setting for supervision of stroke care

Answer 80

```  Rapid access TIA clinics  Hyperacute stroke unit with access to neurosurgical and interventional radiology services  Acute stroke wards  Inpatient rehabilitation  Outpatient rehabilitation including Early Supported discharge services  Outpatient stroke clinics ```

Answer 81

``` Ai to reverse hypoperfusion Main treatment is: Altelase thrombolysis or thrombectomy ```

Answer 82

quick rcongition with FAST Call 999 Paramedics respond quick and see if fast +ve Then call ED who alert on cal stroke team Raid Access protocol (RAP)- Core stroke tea

Answer 83

Clinically confirm diagnosis and see if thrombolysis indicated, get venous access, do bloods, obs, weigh- crucial, can be done by the ambulance!, request CT scan  Identify contraindications (outside of imaging) i.e.  Complete consent/assent (or best interest)  Imaging- minimise delays.  Bolus and infusion

Answer 84

Alteplase can be administered within 4.5 hrs ``` Disabling impairments (NIH >4, dysphasia, inability to self care or mobilise independently, visual feld defect, dysphagia)- dont want to subject them to the risk of thrombolyisis. ```  No contraindications

Answer 85

``` Consider on Px to Px basis. History of GI or urinary tract bleed in last 6 weeks  Previous CNS bleeding, e.g. SDH  Glucose <2.7 or >22 mmol/L  Seizure at stroke onset  Possibility of pregnancy  Greater than 90-minute delay post scan  Symptoms that start during sleep  Severe pre-morbid dependency ```

Answer 86

Pipes Parnechyma Perfusion Penumbra Optimal imaging is angiography Non contrast CT scan CT vs MRI perfusion

Answer 87

1/3 benefit from having treatment compared to no treatment 1/10 full recovery 1/20 symptomatic ICH no increased risk of death

Answer 88

Bolus- 10% calcated on x weight then infusion in 90% Monitor haemodynamic and neuro/ COmplications include Main concerns are symptomatic ICH and reaction to alteplase (anaphylaxis)  Stop infusion and repeat scan upon concern

Answer 89

 Thrombolysis/alteplase adverse effect  Evolution of stroke causing rising ICP  Oedema  Hydrocephalus  Seizure  Infection  Metabolic disturbance Extracerebral haemorrhage  Thin thready pulse, drop in BP  Malaena  Distended abdomen ``` Intracerebral haemorrhage  Neurological decline  New headache  Rising BP  Nausea and Vomiting ```

Answer 90

Ischameia more obvious after 24hrs on the CT, will see the effects of thrombolysis.

Answer 91

Give someone the alteplase, in cntact with fibrin and activates plasminogen. Therefore if a large volume clot, alteplase won't be able t hit the entire clot. Therefore Px with proximal occlusion should have thrombectomy. Indicated in: Indicated in large vessel occlusion stroke, pre stroke MRS 0 or 1, NIHSS=5 or more  Get your angiogram ready and images transferred to QMC; asolooks fr cllateral circulation  Contact QMC to arrange transfer if no response to alteplase

Answer 92

Main effort to reduce the recurrence of another stroke. Need to know the tye of brain damage, the mechanism of hypoperfusion, pathology of hypoperfusion adn the climate in which the dsiease arised

Answer 93

Antithrombotic therapy (antiplatelet versus anticoagulation)  BP control(average BP<130/80)  Lipid control (t. chol<4, LDL chol<2)  Glycaemic control (HbA1c <7)  Carotid endarterectomy (symptomatic ICA >50% lumen reduction NASCET)  Lifestyle changes (smoking cessation, weight loss, optimisation of sleep, exercise)  Other interventions

Answer 94

Very common cause of stroke and common condition. Clots are from the heart so tend to be larger therefore will block larger vessels. ECG, prolonged cardiac monitoring. AF and primary prevention for CHADVASc Anti coagulation should be given DOAC vs warfarin depending on HASBLED Left atrial appendage closure alternative to anticoagulation.

Answer 95

Vasculitis | Steroid therapy

Answer 96

Want to change the climate which has made stroke possible. Obesity, HTN, insulin resistance, dysliaemia. Comlications include sleep apnoea. Encourage weightl loss

Answer 97

BP control Lipid control Glycameic control HRT

Answer 98

``` Familial hypercholesterolaeia Disease progression  Laminar fow  Endothelial injury and repair- causes a build up of atheroma  Stroke mechanisms – the unstable plaque and “symptomatic carotid disease” Want to reverse the unstable plaque.  Intervention ``` Occurs at the junction becuase the most trubuance is here

Answer 99

isolated problems with speciifc skills only i.e. reading, wriitng, numeracy- learning difficulty. Emotional/behavioural problems that may distrupt schooling

Answer 100

Interface between physcial and mental health. People with learning difficulties have poorer health outcomes Diagnostic overshadowing may occur- i.e. rule out other diagnosis and just say 'this Px has LD'. Px with LD find it harder to access assessments and treatments. Good to make reasonable adjustments i.e. double appt- gives mroe time for appt.

Answer 101

``` COnstipation Dental problems Epilepsy GI reflux Infections (UTI/RTI/Ear) Mobility problems ``` Px cannot articulate pain i.e. may have pain on tooth but cant articulate; will therfore hit the site of their face. Side effects of AED lead to behavioural changes

Answer 102

Obesity Sensory Impairments- can be hypo or hyperactive to sensory imputs i.e. hearing imapirment. Swallowing rpobems Sydnroem specific- Downs- sensory, hypoT, CVS, respiratory. Injuries- sefl infliced/accidental/physcial abuse

Answer 103

-understadnin/communicating symptoms -capaciyt o consent -Non complciance with Px- Start slow and titrate slow. Sensitivity to meds/side efffects

Answer 104

``` Have igh index of suspicion Blood tests- challenging best interest decisions Desensitisation Liason nurses] books annual health checks supporting when Px is in hospital ```

Answer 105

``` Language difficulties Sensory impariments Epilepsy- more common to have psychiatric disroders Mobility issues Physical ill health ``` ``` Often have; Limited coping strategies Limited choices and opportunities Limited social netowrks Limited or adverse life experiences- repeated broken relatioshisp i.e. hopsital care, multiple moves, foster homes. Bullying harrastments ```

Answer 106

``` Person may describe syptoms/feelings May dsiplay theri symptoms Biological feautres i.e. sleep, appetite Increase in physcial health complaints Change in behaviour i.e. aggression, self harm, social withdrawal Change in communication ```

Answer 107

The presentatio of one condition is contributed to another. I.e. a Px will present a certain way and the GP will assume this is due to their ID, as opposed to giving a clear diagnosis.

Answer 108

Give sufficient time- allow information processing, understadnign and relaying. Talk to informants See them where they are comforabtle, dont keep them waitng. If communicaion is difficult get help

Answer 109

Physsical factors- sensory imapiermnts, hypoT, cosntipation Mental health- Greif reaction, depression, anxiety disorder, dementia socail facotrs- loss of social network, changes at centre, abuse

Answer 110

Consent- can they make it themselves, do they need a best interest decision, who is involved? MCA May need extra support- OT, SALT to communicate emotions, pshycology Meds- go 'low and slow' and ensure dont over treat.

Answer 111

Triad of impairments. Each triad has its own spectrum Social spectrum Restricted activities/imagination spectrum Communication spectrum

Answer 112

could be underlying genetics i.e. fragile X

Answer 113

MAnifestation of triad- in different ways | Sleep and appetite difficulty

Answer 114

Anxiety Challenging behaviour- due to anxiety aggression depression- in those more intellecutally able elaborate fantasy worlds OCD_ rituals (person chooses to do them to relax and enjoyment- if you try breakign this will get a repsonse from them) vs obsessiosn Sensory sensitivities- hypo/hyper to stimuli i.e. will have to wear headphoens

Answer 115

Anxiety Challenging behaviour- due to anxiety aggression depression- in those more intellecutally able elaborate fantasy worlds OCD_ rituals (person chooses to do them to relax and enjoyment- if you try breakign this will get a repsonse from them) vs obsessiosn

Answer 116

Visual timetable to help understand order of things. TRansitiosn using pictures can be helpful.

Answer 117

behaviour which dies not fit in with the culture, and the intensity/freuqency/duration of the behaviour.

Answer 118

``` Aggression Self injuru Damage to objects/environments Loud or other behaviour maing people scared Absconding Innappropratie sexual behaviour Spiting, smearing stereotypical behaviour ```

Answer 119

Try everyhting else before meds