Older persons care & Learning Disability

Question 1

What are the key things to estabilish in a history of a fall?

Answer 1

• What were they doing?
• How did the fall happen?
• How did they feel before the fall?
• Any dizziness or lightheaded feelings?
• Loss of consciousness?
• Cardiac symptoms?
• Weakness?
• Has this happened previously?
• Any witnesses
• Medications- sedatives, cardiac meds, anticholinergics, hypoglycaemics, opiates
• How do they normally mobilise?

Question 2

What does normal gait involve?

Answer 2

• Neurological system- basal ganglia & cortical basal ganglia loop
• MSK system- tone & strength
• Effective processing of senses- sight, sound, sensation (fine touch & proprioception)

Question 3

What factors may predispose patients to fall?

Answer 3

• Hx of falls = strongest risk factor
• Conditions affecting mobility or balance: arthritis, diabetes, incontinence, stroke, syncope, Parkinson’s
• Postural hypotension
• Polypharmacy (4+ medications)
• Psychoactive drugs (benzos)
• Drugs causing postural hypotension (anti-hypertensives)
• Home hazards- loose rugs, mats, poor lighting, wet surfaces eg in bathroom, loose fitting eg handrails

Question 4

How can psychological state increase falls risk status?

Answer 4

• Anxiety:
  
  • Gait- individuals taking shorter strides and having slower gait speed
  • Pts may focus more internally (own feet) rather than externally increasing falls risk
• Depression
  
  • Isolated symptoms of depression can have a direct role in promoting falls in the elderly- insomnia, poor appetite, weight loss
  • Associated cognitive deficits- affecting attention, executive function, processing speed

Question 5

What medications can predispose patients to fall?

Answer 5

• Drugs causing sedation, with slowing of reaction times and impaired balance, such as:
  
  • Benzodiazepines
  • Zopiclone
  • Amitriptyline
  • MAO inhibitors
  • Drugs for psychosis- chlorpromazine, haloperidol
  • SSRIs
  • Anti-epileptics- phenytoin
  • Carbamazepine
  • Vestibular sedatives- prochlorperazine
  • Sedating antihistamines- chlorphenamine, promethazine
  • Anticholinergics acting on bladder- oxybutynin
• Drugs acting on the heart & circulation, causing hypotension
  
  • ACEi, ARBs
  • Thiazide & loop diuretics
  • Beta blockers
  • CCBs- amlodipine, nifedipine
  • Ach esterase inhibitors (for dementia)- donepezil, rivastigmine- may cause bradycardia & syncope

Question 6

How to assess someone’s risk of a fall?

Answer 6

• Assess hx of falls
• Assess gait, balance and mobility, muscle weakness
• Osteoporosis risk
• Visual impairment
• Cognitive, neurological, cardiovascular problems
• Urinary incontinence
• Home hazards
• Polypharmacy & the use of drugs that increase the risk of falling
• Perceived impaired functional ability and fear relating to falling

Question 7

How do you perform a focused clinical assessment in someone who has fallen?

Answer 7

• Cardiovascular examination – include an ECG and a lying and standing BP (at immediate, 3 and 5 mins)
• Neurological examination
• MSK examination – assess their joints
• Gait assessment- – how do they mobilise, what with and what is their gait like

Question 8

How do you perform & interpret a lying and standing blood pressure?

Answer 8

• Measure blood pressure supine or sitting
• Measure blood pressure after standing for 3 minutes
• A fall of >20 systolic or > 10 mmHg diastolic BP = postural hypotension
• Take heart rate as well-
  
  • A normal rise in HR accompanying the fall in BP is typical of pts with depletion of intravascular volume (dehydration or haemorrhage) or impaired vasoconstrictor tone (usually caused by drugs)
  • Expect tachycardia in response to hypotension to be blunted when there is an underlying neurogenic cause (eg peripheral neuropathy)

Question 9

Define postural hypotension?

Answer 9

• Also called orthostatic hypotension
• Defined as a fall of systolic blood pressure >20 mmHg upon standing after sitting or lying down (occurs within 3 minutes of standing)
  
  • Fall of at least 30 mmHg in pts with hypertension
• Or a fall of 10mmHg diastolic blood pressure
• Symptoms: dizziness, light-headedness, fainting, possible falls

Question 10

What are some causes of postural hypotension?

Answer 10

• Hypovolaemia, dehydration
• Autonomic dysfunction: diabetes, Parkinson’s
• Drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives
• Alcohol

Question 11

If a patient gives a history suggestive of postural hypotension but it is not detected on the posture test, what other test can you perform?

Answer 11

• Tilt-table test
• BP and HR are measured continuously in the supine position and during passive head-up tilt

Question 12

How can postural hypotension be treated?

Answer 12

• First-line: eliminate aggravating factors and implement lifestyle changes
  
  • Drinking more water
  • Using compression garments to enhance orthostatic tolerence
  • first sit when going from supine to standing
  • Learning body movements to counteract the drop in blood pressure- leg-crossing, standing on tip-toes, muscle tensing, enhance orthostatic tolerance
  • Avoid straining during bowel movements or perofrming Valsalva-like maoevres
  • Eat frequent small meals to lessen postprandial hypotension
  • Review medications that aggravate orthostatic hypotension eg amitriptyline, diuretics, other anti-hypertensives such as alpha blockers
• Fludrocortisone (oral mineralcorticoid), used to raise blood pressure by increasing sodium levels in blood and affecting blood volume

Question 13

Suggest some falls prevention strategies?

Answer 13

• Avoiding falls at home- eg immediately mop up spillages, remove clutter, make sure all rooms are well lit, don’t wear loose trailing clothes that can trip you up
• Take care of feet
• Strength exercises and balance exercises
• Sight tests
• Avoiding or reducing alcohol- XS can contribute to osteoporosis

Question 14

How do you perform a bone health assessment?

Answer 14

• FRAX tool is the first step in assessing someone at risk of osteoporosis; gives you the risk of a fragility fracture over the next 10 years
• Bone mineral density is assessed using a DEXA scan- how well X-rays penetrate the bones, giving you an idea of the bone density

Question 15

Why does osteoporosis occur? (pathogenesis recap)

Answer 15

• Imbalance of bone breakdown (osteoclasts) and bone formation (osteoblasts)
• Excessive bone resorption or decreased bone formation during remodelling
• Failure to achieve peak bone mass
  
  • Osteoclasts increase, not matched by osteoblasts
• Reduced density of bones

Question 16

How does prolonged glucocorticoid use cause osteoporosis?

Answer 16

• Cause increased bone resorption
• Prolonged use can result in a reduced turnover state (less bone breakdown) even though here synthesis (bone formation) is affected more leading to a loss of bone mass

Question 17

List some risk factors for osteoporosis

Answer 17

• Post-menopause
• Female
• CKD
• Vitamin D deficiency
• Multiple myeloma
• Osteogenesis imperfecta
• Age
• Previous fragility fracture
• Corticosteroid use
• Alcohol
• Smoking
• Rheumatoid arthritis
• Low BMI

Question 18

Discuss medications used for osteoporosis & the risks associated with them?

Answer 18

• Oral bisphosphonates- alendronate (oral), zoledronic acid (IV)
  
  • S/E: GI disturbance, oesophagitis, headache
  • C/I: pregnancy/ BF, renal impairment, hypocalcaemia, hypersensitivity
• Denosumab- monoclonal antibody, blocks osteoclast activity (subcut)
  
  • S/E: cellulitis, hypocalcaemia (monitoring calcium required)
• Raloxifene- SERM, for post-menopausal osteoporosis
  
  • S/E: hot flushes, vaginal dryness, leg cramps. Risk fo VTE and stroke (don’t use in ppl w/ hx of this)
  • C/I: hx of VTE/ stroke, cholestasis, endometrial cancer, undiagnosed uterine bleeding, child-bearing age, lactation, breast cancer
• HRT- unopposed oestrogen or oestrogen + progesterone
  
  • S/E: breast tenderness, leg cramps, mood changes, VTE, stroke, endometrial cancer (oestrogen only preparations), breast cancer

Question 19

ADH revision recap: where is it made, why is it released?

Answer 19

• Synthesis: supraoptic and paraventricular nuclei in hypothalamus
• Release: from posterior pituitary, in response to high blood osmolality detected by osmoreceptors in hypothalamus
• Causes increased reabsorption of water from urine in collecting ducts of kidney
• Causes vasoconstriction and increase in arterial blood pressure

Question 20

Define hyponatraemia

Answer 20

• Na < 135 mmol/L

Question 21

How are the causes of hyponatraemia divided?

Answer 21

• Hypovolaemic (Na lost)
  
  • Extra-renal loss: diarrhoea, vomiting, sweating, burns
  • Urinary loss: Addison’s disease, diuretics
• Euvolemic (water gained)
  
  • SiADH
  • Hypothyroidism
• Hypervolemic (Oedematous, water excess)
  
  • Cardiac failure, liver failure, CKD
  • Hypoalbuminemia (cirrhosis, nephrotic syndrome)

Question 22

How can hyponatraemia in the elderly present?

Answer 22

• Acute hyponatraemia: N&V, headache, coma, seizures
• Chronic: fatigue, cognitive impairment, gait deficit, falls, osteoporosis, fractures

Question 23

Discuss some causes of hyponatraemia in the elderly?

Answer 23

• Diuretics make up one of the most common causes of hyponatraemia in the elderly
  
  • Thiazide diuretics usually (Bendroflumethiazide, indapamide)
  • Loop diuretics occasionally (furosemide)
• Other causative drugs- antipsychotics, benzodiazepines, carbamazepine (AEDs)
• SiADH causes more severe hyponatraemia
• Tea and toast hyponatraemia- may occur in those with a low GFR who follow a diet poor in salt & protein but drink a lot of water
  
  • Low rate of osmoles excretion hence increased water reabsorption so when water consumption exceeds renal water excretion capacity, hyponatraemia occurs

Question 24

What are pressure ulcers?

Answer 24

• Caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply
• Typically occurs in pts confined to bed or chair by an illness
• Referred to as pressure sores or bed sores

Question 25

What are some risk factors for developing pressure ulcers?

Answer 25

• Seriously ill
• Neurological condition
• Impaired mobility, inability to reposition themselves
• Impaired nutrition
• Poor posture or deformity
• Significant cognitive impairment
• Incontinence
• Pain (leads to reduction in mobility)

Question 26

How are pressure ulcers prevented?

Answer 26

• Those assessed to be at risk need to change position frequently, at least every 6 hrs- if unable to do themselves, offer help to do so, & document repositioning
  
  • Those at high risk- every 4 hrs
• High-specification foam mattress
• Barrier creams in those with high risk of developing moisture lesion or incontinence-associated dermatitis, eg those with incontinence, oedema, dry or inflamed skin

Question 27

What are some common sites for pressure ulcers?

Answer 27

• Buttocks area (on tailbone or hips)
• Heels of feet
• Shoulder blades
• Back of head
• Backs and sides of knees

Question 28

Name 3 screening tools used to assess Pressure Ulcers

Answer 28

1. Braden scale
2. Norton scale
3. Waterlow scale

Question 29

Braden scale- What are the 6 components?

Answer 29

• 6 factors that contribute to either higher intensity & duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development
  
  1. Sensory perception
  2. Nutrition
  3. Friction and shear
  4. Mobility
  5. Moisture
  6. Activity
• Each item is scored between 1 and 4, lowest score = greatest risk

Question 30

How are pressure ulcers managed?

Answer 30

• Measure ulcer
• Categorise ulcer according to a validated classification tool
• Nutritional assessment
• Pressure-redistributing devices- foam mattress, seating pads
• Assess need for debridement- necrotic tissue, size and extent, co-morbidiites
• Evidence of cellulitis/ osteomyelitis/ systemic sepsis- over systemic abx
• Dressing that promotes warm, moist wound haling environment (do not offer gauze dressing)
• Strategies to offload heal for heal ulcers

Question 31

What is polypharmacy?

Answer 31

• Occurs when 6 or more drugs are prescribed at any one time
• Not all drugs are positive and may interact & have side effects

Question 32

What is the STOPP/START criteria?

Answer 32

• Older people are known to have increased risk of adverse effects with drugs due to age related alteration in PK and PD
• STOPP: Screening Tool of Older Persons’ potentially inappropriate Prescriptions
  
  • Can be found in BNF cautions section
• START: Screening Tool to Alert to Right Treatment
  
  • Can be used to prevent omissions of indicated, appropriate medicines in older patients with specific conditions

Question 33

What are the main types of urinary incontinence? For each, list symptoms, relevant ix, and mx

Answer 33

• Stress incontinence (increased intra-abdo pressure)
  
  • Triggered by coughing, sneezing, exertion
  • Risk factors- age, pregnancy, vaginal delivery, constipation, obesity, fhx
  • Ix- bladder scan
  • Mx- lifestyle (lose weight, avoid caffeine & smoking), pelvic floor muscle training, surgery, intramural bulking agent, duloxetine
• Urge incontinence (overactive bladder)
  
  • Detrusor muscle overactivity leads to involuntary bladder contractions, can be idiopathic or secondary to neuro conditions
  • Mx- lifestyle, bladder training, anticholinergic (oxybutynin first-line; S/E: dry mouth, constipation, UR, constipation- oxybutynin not preferentially prescribed in the elderly )
• Mixed incontinence (stress and urge)
  
  • Mx- bladder training 6 weeks
  • Treat according to the predominant type of incontinence
• Overflow incontinence (urinary retention)
  
  • Bladder outlet obstruction eg from prolapse, fibroids, following pelvis surgery
  • Detrusor underactivity eg in peripheral neuropathy, spinal cord pathologies such as MS, secondary to antimuscarinics
  • Ix- bladder scan, cytometry
  • Mx- surgical intervention for obstructive causes, intermittent/ indwelling/ suprapubic catheterisation
• Functional incontinence
  
  • Normal bladder & urethral function but pt has difficulty getting to the toilet in time
  • Causes- physical, intellectual, environmental issues
  • Problems with walking (arthritis, cerebral palsy), memory problems (dementia, intellectual disability)
  • Mx- bladder training (schedule trips), pelvic floor muscle training

Question 34

What are some lifestyle changes patients can make to aid incontinence?

Answer 34

• Avoid caffeine and alcohol
• Avoid smoking
• Improve oral intake
• Regular toileting
• Pelvic floor exercises
• Bladder retraining

Question 35

What is the rationale behind asking patients to keep a bladder diary?

Answer 35

• Useful for monitoring effects of treatment
• Helps understand when urgency or leakage occurs, which is important when considering mx options
• Lifestyle advice can be given
• Minimum of 3 days need to be completed

Question 36

What is bladder training?

Answer 36

• Teaches pt how to hold more urine in bladder to reduce the number of times they need to pass urine
• Teaches pt to urinate on schedule rather than urgency
• Includes lifestyle advice on the amount & type of fluids to drink and coping strategies to reduce urgency
• First-line treatment for mixed urinary incontinence alongside pelvic floor training

Question 37

What are some of the key Qs to ask in a urinary incontinence history?

Answer 37

• Onset- acute: UTI, renal stone, gradual- neuro, idiopathic detrusor instability, incompetent sphincter
• Intermittent or continuous dribble (stress or overflow)
• Frequency during daytime, explore effects on lifestyle
• Nocturia- diabetes/ organic causes of UI
• Enuresis- UTI, diabetes, cancer, psychological
• Volume- little (stress) or lots (urge)
• Triggers (stress- increased abdo pressure)
• Associated symptoms- haematuria, painful urinating, fever, poor flow/ terminal dribble (BPH), night sweats (renal cancer), constipation, symptoms of prolapse, weight loss
• Smoking and occupation- bladder cancer risks
• Explore fluid intake & what fluids
• Red flags- cauda equina syndrome

Question 38

How do you examine a person with urinary incontinence?

Answer 38

• Review of bladder and bowel diary
• Abdominal examination & PR examination including prostate in male
• Urine dipstick & MSU
• External genitalia review particularly looking for atrophic vaginitis in females
• Post micturition bladder scan

Question 39

How to assess a bladder scan?

Answer 39

• Bladder ultrasound, can detect urinary retention, residual urine
• If post-voiding residual urine is found, renal function and LUTS are assessed, catheterisation may be implemented
• A PVR < 50ml is normal, 50-100ml in elderly is acceptable. In general >200ml PVR is abnormal and could be due to incomplete bladder emptying or bladder outlet obstruction

Question 40

What is the role of a PR examination in urinary incontinence?

Answer 40

• Check anal sphincter tone, faecal impaction, presence of occult blood or rectal lesions, BPH or prostate cancer
• All these things can cause overflow incontinence

Question 41

What sort of containment products are used to keep a person continent?

Answer 41

• Absorbent products, hand-held urinals, toileting aids
• Offered as a temporary coping strategy or as long-term management if treatment is unsuccessful

Question 42

What medications are used for incontinence for those whom non-pharmacological approaches have failed?

Answer 42

Question 43

Is a urine dipstick ever required for the elderly patient?

Answer 43

• No
• For those >65 do not perform urine dipstick, up to 50% of them will have a positive dipstick w/o infection
• Only treat symptoms of UTI with abx

Question 44

What is the most common cause of faecal incontinence?

Answer 44

• Faecal impaction with overflow diarrhoea- 50% cases
• Other causes- severe haemorrhoids, IBD Crohn’s, diabetes, stroke (affecting nerves controlling anal sphincter), muscle damage (damage during episiotomy or forceps in childbirth)

Question 45

Describe the clinical frailty scale

Answer 45

1. Very Fit- People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age
2. Well- – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally
3. Managing Well- People whose medical problems are well controlled, but are not regularly active beyond routine walking
4. Vulnerable- While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day
5. Mildly Frail- These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework
6. Moderately Frail- People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing
7. Severely Frail- Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months)
8. Very Severely Frail- – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness
9. Terminally Ill- Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail

Scoring frailty in people with dementia:

The degree of frailty corresponds to the degree of dementia.

• Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal.
• In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting.
• In severe dementia, they cannot do personal care without help.

Question 46

Define frailty

Answer 46

• Loss of resilience that means people don’t bounce back quickly after a physical or mental illness, an accident or another stressful event

Question 47

Broadly there are 5 frailty syndromes, what are these?

Answer 47

1. Falls eg collapse, legs gave way, found lying on floor
2. Immobility eg sudden change in mobility, gone off legs, stuck in toilet
3. Delirium eg acute confusion, muddledness, sudden worsening of confusion in someone with dementia/ known memory loss
4. Incontinence eg new onset or worsening
5. Susceptibility to side effects of medication eg confusion with codeine, hypotension w/ antidepressants

Question 48

What is CGA?

Answer 48

• Comprehensive Geriatric Assessment
• Multidimensional, interdisciplinary diagnostic process to determine medical, psychological & functional capabilities of a frail older person to develop a coordinated & integrated plan for treatment & long term follow up
• Emphasises QoL & functional status, prognosis, outcome

Question 49

When is CGA done?

Answer 49

• When an older person presents to their GP with 1+ obvious frailty syndromes ie falls, confusion, reduced mobility, increasing incontinence
• When a GP or community team learns of an incidence which implies frailty- eg ambulance called after a fall
• When an older person is discharged from hospital after presenting with a frailty syndrome even if another diagnosis has been offered as the cause
• In care homes- most residents have frailty

Question 50

What is cognitive impairment?

Answer 50

• Disturbance of higher cortical functions including memory, thinking, judgement, language, perception, awareness
• Description of someone’s condition, not a specific illness

Question 51

What is dementia?

Answer 51

• Persistent cognitive impairment: decline in both memory and thinking sufficient to impair personal ADLs
• Problems with processing of incoming information- problems maintaining & directing attention
• Clear consciousness
• Above syndrome present >6 months

Question 52

What things reduce the risk of dementia?

Answer 52

• Diet- healthy balanced diet can prevent dementia progression
• Exercise
• Social interaction
• Learning new things- cognitive stimulation

Question 53

A range of disease may cause dementia, name some?

Answer 53

• >65:
  
  • Alzheimer’s dementia
  • Vascular dementia
  • Cerebrovascular disease- multi-infarct dementia
• <65:
  
  • Frontotemporal dementia
  • Dementia with Lewy bodies
  • Alcoholic
  • Huntington’s Disease

Question 54

What are the key features of dementia- include early, mid and late stage signs/ symptoms

Answer 54

• Early stage:
  
  • Forgetfulness & other memory symptoms
  • Subtle changes in mood & behaviour eg loss of motivation/ interest
• Mid stage:
  
  • More prominent memory problems
  • Changes in behaviour more marked
  • Other cognitive difficulties may emerge eg difficulty w/ language & executive function
  • Disability more obvious- problems with complex ADLs- finances, planning activities, dealing w/ unexpected events becomes a problem
  • Awareness of disability diverges from reality
• Late stage
  
  • Severe & pervasive memory problems accompany major cognitive disabilities eg severe disorientation, failure to recognise familiar people
  • Marked (+ve & -ve) changes in behaviour eg agitation or restlessness, irritability, disinhibition, severe apathy
  • Disability is severe, basic aspects of personal ADLs are failing, require continuous supervision

Question 55

What is the most common type of dementia?

Answer 55

• Alzheimer’s dementia
• Second most common: Vascular

Question 56

Compare the subtypes of dementia- Alzheimer’s, vascular, frontotemporal, Lewy body & alcoholic dementia

Answer 56

Question 57

Key things in a history & examination of suspected dementia?

Answer 57

• Hx
  
  • Course of symptoms over time
  • Evidence of disability/ impact on day-to-day life
  • Why have they come now- anything happened?
  • Changes in general health
• Examination
  
  • Cognitive screening- GPCOG, AMT, 6-CIT, MMSE etc
  • Check for new physical findings if prompted by hx

Question 58

How is dementia different to normal ageing?

Answer 58

• Normal ageing: difficulty finding words, forgetting things and events, not being able to remember the name of an acquaintance, family not worried about memory, not remembering conversations which occurred >1 year ago
• Dementia is different because of the effect on ADLs (activities of daily living)

Question 59

What is BPSD?

Answer 59

• Behavioural and Psychological symptoms in Dementia
• Include a range of neuropsychiatric disturbances such as agitation, aggression, depression, apathy
• Affects up to 97% of community-dwelling pts with dementia
• Significant impact on prognosis, caregiver well-being
• 5 domains
  
  1. Cognitive/ perceptual- delusions, hallucinations
  2. Motor- pacing, wandering, repetitive movements, physical aggression
  3. Verbal- yelling, calling out, repetitive speech, verbal aggression
  4. Emotional- euphoria, depression, apathy, anxiety, irritability
  5. Vegetative- disturbances in sleep & appetite

Question 60

What are some risk factors for developing dementia?

Answer 60

• Age
• Genetics
• Mild cognitive impairment
• PD
• Cerebrovascular, cardiovascular
• Smoking
• DM
• Lack of exercise, obesity

Question 61

What ix to do in suspected dementia?

Answer 61

• Dementia screen bloods- screening for other active contributing problems
• Structural brain imaging- CT or preferably MRI
• Functional brain imaging- perfusion, glucose metabolism, dopamine transporter turnover
• Specialised tests- ECG, LP

Question 62

How can cognitive assessment be carried out?

Answer 62

• Using a recognised cognitive assessment tool
• Mini-cog: 3 item word memory & clock drawing, done in GP
• Abbreviated mental test score (AMTS): 10 scoring tool used in hospital
  
  • If pt > 65 and AMT <4 – consider high risk for delirium
• MMSE: 11 items, measures cognitive function, done in memory clinic or hospital

Question 63

Describe the non-pharmacological mx of dementia?

Answer 63

• NICE recommend offering a range of activities to promote wellbeing that are tailored to patient’s preference
• NICE recommend offering group cognitive stimulation therapy for mild-moderate dementia
• Other options to consider include group reminiscence therapy & cognitive rehabilitation
• Manage physical health needs
• Inform DVLA
• End of life care

Question 64

What are some drug treatments used for dementia?

Answer 64

• Pharmacological agents primarily for patients with AD, should not be used in pts with mild cognitive impairment
• Mild to moderate AD: acetylcholinesterase inhibitors eg donepezil, rivastigmine
  
  • Memantine monotherapy can be used if pt is intolerant of/ have a contraindication to AChE inhibitors
• Moderate to severe AD: N-methyl-D-aspartic acid receptor antagonist eg memantine, may be used in combination w/ AChE inhibitors

Question 65

What is the Abbreviated Mental Test Score?

Answer 65

• 10 Qs to rapidly assess elderly pts for possibility of dementia
  
  1. Age
  2. Time
  3. Address
  4. Year
  5. Location
  6. Recognise 2 persons eg nurse, doctor
  7. DoB
  8. When did WW1 begin
  9. Name the current PM
  10. Count backwards down from 20 to 1
• Score <6 suggest delirium or dementia
• Score <4, pt > 65- consider high risk for delirium

Question 66

What is delirium?

Answer 66

• Impairment of cognition; disturbances of attention & conscious level; abnormal psychomotor behaviour & affect; disturbed sleep-wake cycle
• Acute onset- hrs/days
• All symptoms fluctuate during daytime & are typically worse at night

Question 67

What are the 2 behavioural subtypes of delirium?

Answer 67

1. Hyperactive- heightened arousal, restlessness, irritability, wandering, carphologia (picking at clothing)
2. Hypoactive- quiet, sleepy, inactive, unmotivated & easily overlooked

Question 68

What are some factors favouring delirium over dementia?

Answer 68

• Impairment of consciousness
• Fluctuations of symptoms: worse at night, periods of normality
• Abnormal perception: illusions, hallucinations
• Agitation, fear
• Delusions- talking about things that haven’t happened or happened years ago

Question 69

Causes of delirium?

Answer 69

THINK DELIRIUM:

• Trauma- head injury, intracranial event
• Hypoxia- PE, CCF, MI, COPD, pneumonia
• Increasing age/ frailty
• Neck of femur fracture
• smoKer or alcohol withdrawal
• Drugs- opioids, sedatives, L-dopa
• Environment, eyes, ears, other sensory deficits
• Lack of sleep
• Infection- UTI, pneumonia, sepsis
• Retention of urine/ faeces
• Imbalanced electrolytes- renal failure, sodium, calcium, glucose, liver function
• Uncontrolled pain
• Medical conditions- dementia, PD

Question 70

What are some risk factors for developing delirium?

Answer 70

• Previous dementia
• Severe trauma eg #NOF
• >65 yrs
• Polypharmacy
• Increased frailty

Question 71

What drugs can induced delirium?

Answer 71

• Psychotropic drugs- antidepressants, antipsychotics, benzodiazepines
• Antiparkinsonian drugs
• Anticholinergic drugs
• Opiates
• Diuretics
• Recreational drug intoxication & withdrawal

Question 72

What is the Confusion Assessment Method (CAM)?

Answer 72

• Tool for identifying delirium
• 4 criteria
  
  1. Acute onset or fluctuating course = 2
  2. Inattention- counting from 20-1 is a simple test for this =2
  3. Disorganised thinking =1
  4. Altered levels of consciousness =1
• Score of 5 or more- think delirium

Question 73

What do you do immediately when you encounter a delirious patient?

Answer 73

• Collateral hx- GP, relatives, carers- new or worsening confusion, falls, mobility, continence, hallucinations
• Identify and treat underlying causes
• SIRS criteria- sepsis pathway?
• Cognitive assessment- AMT 10/ MMSE
• Medication review- refer to STOPP/START
• Heighten level of supervision & position pt in high visibility bed
• Refer to FOPAL/ mental health for complex and challenging pts
• Update & involve relatives with care, provide delirium leaflet

Question 74

How to manage delirium?

Answer 74

Question 75

How long does delirium take to resolve?

Answer 75

Can take up to 3 months

Question 76

What is capacity?

Answer 76

• There is a presumption that every adult patient has capacity to make decisions about their treatment care
• A person has capacity if they can do all of the following
  
  • Understand information relevant to the decision in question
  • Retain that information
  • Use that information to make their decision
  • Communicate a decision
• Capacity is decision specific and is for that decision alone at that point of time
• Capacity can fluctuate with disease severity

Question 77

What is the difference between implied and expressed consent?

Answer 77

• Express consent is valid consent given in writing or orally
• Implicit consent occurs through the actions or conduct of the pt rather than direct communication through words
  
  • Eg from pts nodding of head or by them showing up at the agreed time for surgery

Question 78

What is the Mental Capacity Act?

Answer 78

• 5 key principles-
  
  1. A person must be assumed to have capacity unless it is established he lacks capacity
  2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
  3. A person is not treated as unable to make a decision merely because he makes an unwise decision
  4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
  5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

Question 79

What are the stages of a capacity assessment?

Answer 79

• The Mental Capacity Act sets out a clear test for assessing whether a person lacks capacity
• Decision specific & time specific test
• An adult can only be considered unable to make a particular decision if:
  
  1. They have an impairment of, or disturbance in, the functioning of the mind or brain whether permanent or temporary AND
  2. They are unable to undertake any of the following-
     
     • Understand the information relevant to the decision
     • Retain that information
     • Use*** or ***weigh that information as part of the process of making the decision
     • Communicate the decision made by talking, sign language or other means
• No individual can be labelled incapable simply because of a particular medical condition
• Lack of capacity cannot be assumed by age, appearance, or any other aspect of behaviour

Question 80

What are the principles of making decisions when a patient lacks capacity?

Answer 80

• Make the care of the patient your first capacity
• Treat patients as individuals & with dignity
• Support patients in their decisions
• Do not discriminate against patients
• Consider whether the lack of capacity is temporary or permanent
• Consider which option provides the best clinical benefit
• Consider the views of anyone with legal authority to make decisions on behalf of the patient
• Consider any advance statements or opinions on treatments already offered by the patient

Question 81

Why might people lack capacity?

Answer 81

• Dementia
• Severe learning disability
• Brain injury
• Mental health illness
• Stroke
• Unconsciousness caused by anaesthetic or sudden accident

Question 82

What is Best interests decision making?

Answer 82

• An act done, or decision made, under the Mental Capacity Act, for or on behalf of a person who lacks capacity must be done, or made in his best interests

Question 83

Who is involved in best interest decision making?

Answer 83

• Practitioner or team responsible for providing health or social care intervention
• Attorney appointed by the individual
• Court Appointed deputy

Question 84

What is DoLS?

Answer 84

• Deprivation of Liberty Safeguards
• These relate to people who lack the mental capacity to make decisions about their care & treatment and who are deprived of their liberty in a care home or hospital
  
  1. Definition of deprivation of liberty: the person is under continuous supervision & control & is not free to leave, and the person lacks consent to these arrangements
• A set of checks that ensure that a person who is deprived of their liberty is protected and that this course of action is both appropriate and in the person’s best interests
  
  1. Part of the Mental Capacity Act 2005
• Key elements of these safeguards are-
  
  1. To provide the person with a representative- a person who is given certain rights & who should look out for & monitor the person receiving care
  2. To the give the person (or their representative) the right to challenge a deprivation of liberty through the Court of Protection
  3. To provide a mechanism for deprivation of liberty to be reviewed & monitored regularly

Question 85

Who is part of the DoLS assessments and what are the 6 parts of the assessment?

How long does a DoLS authorisation last?

Answer 85

• DoLS assessments are carried out by at least 2 people
  
  1. The best interests assessor
  2. The mental health assessor
• The assessment process has 6 parts-
  
  1. Age- >18?
  2. Mental health disorder?
  3. Mental capacity
  4. Best interests
  5. Eligibility
  6. No refusals
• DoLS authorisation should last for as little time as possible and only for a maximum of 12 months

Question 86

What is Lasting Power of Attorney?

Answer 86

• Appointed by patients under the Mental Capacity Act when pt has capacity to make decision
• The LPA cannot make treatment decisions if the pt still has capacity
• Separate applications for health and welfare and property and financial affairs
• Have to be registered with the office of the public guardian
• If concern not acting in best interests of donor would need to apply to court of protection

Question 87

Define a Mental Disorder

Answer 87

• Conditions that affect mood, thinking, feeling, behaviour

Question 88

Define carer strain

Answer 88

• Carer strain is experienced when a caregiver feels overwhelmed & is unable to perform their role to the best of their ability

Question 89

What is the role of community hospitals in the mx of older people?

Answer 89

• Play a role in intermediate care
• Inpatient rehabilitation
• Outpatient consultations

Question 90

Explain the concept of NHS ‘Continuing Healthcare’

Answer 90

• NHS continuing healthcare checklist
• Screening tool for eligibility for continuing healthcare
• The needs assessed are breathing, nutrition, continence, skin (wounds and ulcers), mobility, communication, psychological and emotional needs, cognition, behaviour, drug therapies and medication, altered states of consciousness, other significant care needs

Question 91

Describe the Discharge to Assess (DtA) process?

Answer 91

• When people who are clinically optimised & do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting
• Assessment for longer-term care & support needs is then undertaken in the most appropriate setting and at the right time for the person
• Essential criteria-
  
  • Supporting people to go home as the default pathway
  • Free at point of delivery regardless of ongoing funding arrangements
  • Safe if the person is going home, assessment within 2 hours with rapid access to care and support if required
  • Support services should be time limited- up to 6 weeks
  • Nonselective, a service that tries to always say yes- to include support for end of life care

Question 92

What is the meaning of fast-track discharge?

Answer 92

• Seamless discharge from hospital to preferred place of care within normal working hours
• Provide support for family and carers
• Facilitate a peaceful death at preferred place of care
• It is used if pt has urgent health needs or nursing needs and is rapidly deteriorating or in the terminal phase of life
• It allows a quick decision to be made about Continuing Healthcare funding
• The Fast Track assessment should be carried out by GP, consultant, registered nurse, hospice clinician etc

Question 93

What is the difference between nursing care homes and residential homes?

Answer 93

• Both provide 24hr care with trained staff
• Nursing home: always staffed by registered nurses supported by care assistants, people in nursing home need nursing intervention
• Residential care home: staff trained but not in nursing care

Question 94

Define and give an example of: impairment, disability and handicap

Answer 94

• IMPAIRMENT
  
  • Pathological defect in an organ/ tissues
  • Any loss or abnormality of psychological, physiological, anatomical structure or function
  • Eg dementia, impairment to move legs due to cerebral palsy
• DISABILITY
  
  • Restriction of functional ability due to an impairment
  • Eg inability to walk
• HANDICAP
  
  • A mental, physical, or social disadvantage as a result of disability

Question 95

What is feeding at risk?

When is it appropriate?

Answer 95

• When a person continues to eat & drink despite a significant risk of aspiration or choking
• The option is often appropriate when ensuring QoL is the highest priority
• Allows continued enjoyment, comfort, pleasure, social interaction associated with eating & drinking
• May be appropriate in the following situations-
  
  • Advanced stage of illness
  • Person’s swallow safety is not likely to improve
  • When the preference to eat and drink takes priority over swallow safety
  • Tube feeding options are declined or inappropriate

Question 96

When are elderly patients at nutritional risk?

Answer 96

• Those living independently
  
  • Limited transport to local shops
• Underlying disease
• Decreased mobility
• Poverty

Question 97

What is the NICE definition of malnutrition?

Answer 97

• BMI of < 18.5; or
• Unintentional weight loss >10% within the last 3-6 months; or
• BMI < 20 & unintentional weight loss >5% within the last 3-6 months
• Those at risk of malnutrition-
  
  • Not eaten for >5 days or anticipated to not eat for next 5 days
  • Have poor absorptive capacity or high nutrient losses or nutritional needs increased from causes such as catabolism

Question 98

How is screening for malnutrition done? When is this done?

Answer 98

• Using MUST: Malnutrition Universal Screening Tool
• Should be done on admission to care/ nursing homes & hospital, or if there is concern eg elderly, thin pt w/ pressure sores
• Takes into account BMI, recent weight change & presence of acute disease
• Categorises pts into low, medium & high risk

Question 99

Suggest some causes of nutritional decline

Answer 99

• Reduced dietary intake
• Malabsorption
• Increased losses or altered requirements- burns
• Energy expenditure

Question 100

What are the consequences of malnutrition?

Answer 100

• Muscle function decline
• Cardio-respiratory function
• GI function
• Immunity & wound healing
• Psychological- apathy, depression, anxiety, self-neglect

Question 101

How can malnutrition be managed?

Answer 101

• Dietician support if high risk
• Food first approach with clear instructions eg add full fat cream to mashed potato, rather than just prescribing oral nutritional supplements (ONS) such as Ensure
• If ONS are used they should be taken between meals rather than as meal supplementation

Question 102

What is the daily recommended intake that you need to take into account when giving a nutritional prescription?

Answer 102

• 25-35 kcal/kg/day
• 0.8-1.5g protein/kg/day
• 30-355 ml fluid/kg
• Adequate electrolytes, minerals, micronutrients, fibre if appropriate
• (This is for patients not at risk of re-feeding syndrome or severely ill or injured)

Question 103

Who is at risk for re-feeding syndrome?

Answer 103

• High risk if any of the following:
  
  • BMI < 16
  • Unintentional weight loss > 15 % over 3-6 months
  • Little nutritional intake > 10 days
  • HypoK, hypophosphataemia, hypoMg prior to feeding
• If two of the following:
  
  • BMI < 18.5
  • Unintentional weight loss > 10% over 3-6 months
  • Little nutritional intake > 5 days
  • Hx of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids

Question 104

What is re-feeding syndrome?

Answer 104

• The metabolic abnormalities which occur on feeding someone following a period of starvation
• Occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism
• Hypophosphate, hypoK, hypoMg (torsades de pointes), abnormal fluid balance

Question 105

What is advance care planning?

Answer 105

• Involves helping people to plan for their future care & support needs, including medical treatment, and therefore to exercise their personal autonomy as far as possible
• This is offered to everyone who is at risk of losing capacity (eg through progressive illness), as well as those with fluctuating capacity (eg through mental illness)
• Written record should be made by practitioner
  
  • Advanced refusals of treatments eg ventilation must be recorded, signed & witnessed
• Advance decisions cannot demand treatment

Question 106

What is a DNAR form?

Answer 106

• A Do Not Attempt Resuscitation form is a document issued & signed by an appropriate health professional, which tells the medical team not to attempt CPR
• It is not a legally binding document
• Should be discussed with pt & family
• Ultimately is a medical decision

Question 107

What is a learning disability and what are the common causes?

Answer 107

• Department of Health definition of learning disability: significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning) which started before adulthood
• Most cases unknown aetiology
• Causes:
  
  • Inherited condition eg Fragile X
  • Chromosome abnormality eg Down’s syndrome
  • Very premature birth
  • Mother’s illness during pregnancy
  • Foetal Alcohol Syndrome
  • RTA or child abuse during early childhood which affected brain development
  • Contact with damaging material like radiation
  • Neglect or lack of mental stimulation early in life

Question 108

What is the most common inherited cause of learning disability?

Answer 108

• Fragile X syndrome

Question 109

What is the most common genetic cause of learning disability?

Answer 109

• Down’s syndrome

Question 110

What is the most common cause of learning disability worldwide?

Answer 110

• Malnutrition

Question 111

What IQ scores define a learning disability?

Answer 111

• Normal IQ: 100 +/-15
• Borderline: 70-84
• 50-70 = mild learning disability
• 35-49 = moderate learning disability
• 20-34 = severe learning disability
• <20 = profound learning disability

Question 112

What is Borderline Intellectual Functioning?

Answer 112

• Not classified as LD but still vulnerable due to cognitive status
• Living independently
• Subtle communication difficulties
• High school drop out or special education
• Difficulty keeping a job, receiving government assistance
• At risk of abusive relationships, challenges rearing children

Question 113

How do you assess the functional ability of pts with a Learning Disability?

Answer 113

• Mild
  
  • Relative independence in self-care and daily living skills
  • Can hold a conversation and engage in clinical interview
  • Abstract concepts eg time are difficulty
  • Requires varying levels of service support
  • May have paid employment
• Moderate
  
  • Basic communication skills
  • Requires supervision with self-care
  • Living in supported accommodation
  • Can engage in a structured day programme or workshop activities
  • Community access with staff
• Severe
  
  • Limited communication
  • Motor impairment
  • Needs supervision in daily activities
  • Living in 24 hour staffed home
  • In alternative day programmes w/ combination of skills- based & recreational activities
• Profound
  
  • 24 hour supervised care
  • Living either with family or in-group home or nursing home
  • Multiple medical problems
  • Inner world largely unavailable to others due to communication difficulty

Question 114

Is dyslexia a learning disability?

Answer 114

• No, it is a learning difficulty

Question 115

What is the difference between a learning disability and a learning difficulty?

Answer 115

• A learning disability constitutes a condition which affects learning and intelligence across all areas of life
• A learning difficulty constitutes a condition which creates an obstacle to a specific form of learning but does not affect the overall IQ of an individual
• Eg Down’s syndrome = learning disability
• Dyslexia = learning difficulty, in that it only affects an individual’s relationship to the processing of information, usually manifested in problems with reading, writing, spelling

Question 116

What are some examples of learning difficulties?

Answer 116

• Dyslexia
• Dyspraxia
• Dyscalculia

Question 117

What psychiatric disorders & behavioural problems commonly occur in a population with learning disability?

Answer 117

• Schizophrenia
• Mood disorder
• Anxiety

Question 118

Define autism

Answer 118

• Lifelong neurodevelopmental condition, the core features of which are persistent difficulties in social interaction and communication and the presence of stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests

Question 119

Is autism a learning disability?

Answer 119

• No, it is a neurodevelopmental disorder
• But around half of autistic people may also have a learning disability

Question 120

How many people with learning disability are affected by epilepsy?

Answer 120

• 20-30%
• In comparison to 1% of general population

Question 121

How is normal function of an individual measured in healthcare?

Answer 121

• Activities of daily living- ADLs
  
  • a series of activities people should be able to do without assistance
• These can be broadly divided into personal tasks and domestic tasks
  
  • Personal: washing, dressing, toileting, continence, transferring (eg from bed to chair)
  • Domestic: cooking, cleaning, shopping, managing finances, taking medications

Question 122

What is the pathophysiology of Alzheimer’s disease?

Answer 122

• Microscopic: neurodegeneration secondary to altered amyloid and tau protein metabolism…
• Senile plaques: deposits of beta-amyloid, dense, insoluble, extracellular (outside of neurones)
  
  • These can also be seen in normal ageing
• Neurofibrillary tangles: aggregations of hyperphosphorylated tau proteins, typically in areas of brain involved in memory, promotes neuronal cell death, intracellular (form inside neurones)
• Macroscopic changes: widespread cerebral atrophy, particularly involving the cortex and hippocampus
• Biochemical changes: deficit of acetylcholine from damage to an ascending forebrain projection

Question 123

Compare some specific clinical features of Alzheimer’s disease and Vascular dementia?

Answer 123

• Alzheimer’s Disease
  
  • Early impairment of memory
  • Manifests as short term memory loss and difficulty learning new information
• Vascular Dementia
  
  • Typically a stepwise decline in function
  • Predominant gait, attention and personality changes
  • May have focal neurological signs (eg previous stroke)

Question 124

When assessing cognition in a potential dementia patient, what domains need to be assessed?

Answer 124

• Attention & concentration
• Recent & remote memory
• Language
• Praxis- planned motor movement (eg perform a task)
• Executive function
• Visuospatial function

Question 125

What is the diagnostic criteria for dementia?

Answer 125

• Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
• To put simply, there are 3 key components
  
  • Functional ability: inability to carry out normal functions, represents a decline from previous functional level
  • Cognitive domains: impairment involving 2 or more cognitive domains
  • Differentials excluded: other psychiatric disorders or delirium cannot explain these clinical features

Question 126

Patients with mild cognitive impairment may have a risk of progression to dementia, how should you manage these patients?

Answer 126

• Regular follow up
• Advise to undertake healthy brain activities- exercise, socialising

Question 127

What differentials to consider for dementia?

Answer 127

• Depression, psychosis
• Drugs- anti-cholinergic effects eg anti-histamines, anti-psychotics, anti-epileptics
• Delirium

Question 128

What is the role of imaging in Alzheimer Disenase?

Answer 128

• To assess the volume change in characteristic locations which can yield a diagnostic accuracy of up to 87%
• The diagnosis should be made on the basis of 2 features
  
  • Medial temporal lobe atrophy- particularly the hippocampus
  • Temporoparietal cortical atrophy

Question 129

What acetylcholinesterase inhibitors are used in Alzheimer’s disease? What are the common side effects?

Answer 129

• Donepezil (commonly), Rivastigmine, galantamine as monotherapies as options for managing mild to moderate Alzheimer’s disease
• These drugs improve cognition, neuropsychiatric symptoms and ADLs
• Common S/E: nausea, diarrhoea, vomiting are the most common adverse effects from increased cholinergic activity in the peripheral nervous system
  
  • Pts with asthma/ COPD may have exacerbation of their symptoms
• Less common S/E: peptic ulcers, bleeding, bradycardia, heart block
• Conduct ECG prior to starting donepezil
  
  • Relatively contraindicated in pts with bradycardia
  • Adverse effects include insomnia
• Rivastigmine worsens Parkinson tremor

Question 130

What is memantine? What are the common side effects?

Answer 130

• N-methyl-D-aspartic acid receptor antagonist
• Memantine reduces functional decline
• Caution in epilepsy

Question 131

What are the features of Lewy body dementia?

Answer 131

• Characteristic pathological feature: alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
• Relationship with Parkinson’s disease
• Progressive cognitive impairment- early impairments in attention and executive function (compare to AD- where just memory loss)
• Cognition may be fluctuating
• Usually develops before PD
• Parkinsonism
• Visual hallucinations

Question 132

How is a diagnosis of Lewy body dementia made? How is the disease managed?

Answer 132

• Diagnosis: Usually clinical, single-photon emission computed tomography may be used (DaTscan)
• Management: AChE inhibitors- donepezil and rivastigmine- and memantine can be used
• Avoid neuroleptics (dopamine antagonists)- may develop irreversible parkinsonism
• Neuroleptics could also cause neuroleptic malignant syndrome which is a psychiatric emergency- fever, encephalopathy (confusion), tachycardia, fluctuating BP, rigidity

Question 133

What are the key things to ask in a collateral history?

Answer 133

• Baseline cognition
  
  • Do they usually have problems with memory, how long has this been going on for?
  • Has there been a change in behaviour- aggression, hallucinations?
  • Is there a diagnosis of dementia?
• Baseline mobility
  
  • How far can they walk when well?
  • Assistance required- walking stick, frame, wheelchair?
    
    • Indoors and outdoors
• Living arrangements
  
  • Who do they live with?
  • Carers- how often do they visit, can they address all the pt’s needs?
  • What type of home do they live in- house, flat, care home
  • Stairs?
• Continence
  
  • Urine & faeces
  • How is any incontinence managed?
• Activities of daily living
  
  • Washing, dressing, toileting, managing medications
  • Cooking, cleaning, shopping, finances
  • Driving
  • Alcohol, smoking
• Advance care planning
  
  • Thoughts about CPR- ever been discussed with GP or someone close to them?
  • Medical treatments they wouldn’t want?
  • Lasting power of attorney for health and welfare?
  • What is the most important to the patient?

Question 134

What are the core components of the definition of learning disability?

Answer 134

• Lower intellectual ability (IQ < 70)
• Significant impairment of social or adaptive functioning
• Onset in childhood

Question 135

What are some risk factors for a learning disability?

Answer 135

• Chromosomal & genetic anomalies- Down’s syndrome, William’s syndrome, Rhett syndrome, fragile X syndrome
• Some non-genetic congenital malformations- spina bifida, hydrocephalus, microcephaly
• Prenatal exposures- alcohol, sodium valproate, congenital rubella infection, zika virus
• Birth complications resulting in hypoxic brain injury/ cerebral palsy
• Extreme prematurity (usually <33 weeks gestation)
• Childhood illness- meningitis, encephalitis, measles
• Childhood brain injury caused by accidental/ physical abuse
• Childhood neglect/ lack of stimulation in early life

Question 136

What type of dementia is associated with motor neurone disease?

Answer 136

• Frontotemporal dementia

Question 137

What are the features of frontotemporal lobar dementias?

Answer 137

• Onset before age 65
• Insidious onset
• Relatively preserved memory & visuospatial skills
• Personality change & social conduct problems