Pass Med Flashcards
How is orthostatic hypotension diagnosed?
Lying/standing blood pressure involves measuring blood pressure after 5 minutes of lying down, then after the first minute of standing, then after the third minute of standing
- A drop in systolic BP of 20mmHg or more (with or without symptoms)
- A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
- A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).
Name some risk factors for falls
Previous fall Lower limb muscle weakness, arthritis Vision problems Balance/gait disturbances Polypharmacy, Incontinence >65 Have a fear of falling Postural hypotension Cognitive impairment
Name some medication classes that can cause postural hypotension
Nitrates Diuretics ACE inhibitors Beta Blockers L-Dopa Anticholinergics
Name some drug classes that cause falls
Benzodiazepines Sedatives Opiates Anti Epileptics Digoxin
What bedside tests, bloods and imaging might you consider for a fall?
Bedside - Basic obs, BP inc. standing/sitting, blood glucose, urine dip, ECG
Bloods - FBC, UEs, LFTs, bone profile
Imaging - CXR, XRay of any injured limbs e.g. hip, wrist, CT head, cardiac echo
Describe the timed up and go test
• This test measures functional mobility in the older population.
• The patient should sit in a chair of knee height. They should be asked to stand up, walk 3 metres, turn round, return to the chair and sit down.
• You should time the patient starting timing when the patient starts to try and stand up and stopping when the patient is sitting down again.
• The patient may not use a walking aid so if they need one then this is not an appropriate test and they already have a mobility problem rendering the test unnecessary.
• Timed up and go duration increases with worsening mobility.
Normal score are between 8 and 11 seconds for people between 65 and 99. If a patient takes more than 12 seconds then their mobility may be considered impaired.
Describe the 180 degree turn test
- measures dynamic balance - not suitable for those with mobility aid
- sit pt in chair from which they can stand easily
- handholds should surround the pt in front and to the side
- stand behind pt and ask them to turn around and face you (without holding on to anything - if they do they fail)
- Count the number of steps taken 5 or more considered to have a balance impairment + are at greater risk of falls
Describe how we might assess gait speed
- Ask a patient to walk a distance of 4 metres.
- If they take longer than 5 seconds then their gait speed can be considered slow( i.e. less than 0.8 m/s).
- Gait speed is correlated with increased risk of falling.
What drug class should be avoided in delirious patients with Parkinsons disease?
Anti psychotics e.g. haloperidol or olanzapine. They have strong anti dopaminergic action will make their condition significantly worse. Lorazepam most suitable option instead
Name some predisposing factors for delirium
age > 65 years background of dementia significant injury e.g. hip fracture frailty or multimorbidity polypharmacy
Name some precipitating factors for delirium
infection: UTI, URTI
metabolic: e.g. hypercalcaemia, hypo/hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation
Name some clinical features of delirium
memory disturbances (loss of short term > long term) may be very agitated or withdrawn disorientation mood change visual hallucinations disturbed sleep cycle poor attention
What is the waterlow score?
Used to identify patients at risk of pressure ulcers
What factors might predispose to the development of pressure ulcers?
- Malnourishment
- incontinence
- immobility
- pain
Describe the 4 grades of pressure ulcers
Grade 1: non blanchable erythema of intact skin.
Grade 2: partial thickness skin loss involving epidermis, dermis or both. superficial, presents as blister
Grade 3: full thickness kin loss, damage to subcut tissue but does not go through fascia
Grade 4: extensive destruction and necrosis to muscle/bone or supporting structures
Give a brief overview of how to manage a pressure ulcer
- hydrocolloid or hydrogels to maintain a moist wound environment
- consider referal to tissue viability nurse
- surgical debridement may be necessary
- systemic antibiotics may be needed e.g. for cellulitis
How might alcohol withdrawal present?
Alcohol withdrawal typically presents within the first 24 hours of cessation in patients who have abruptly stopped. Acute alcohol withdrawal may present with tremor, nausea, sweating, seizures, hallucination. Delirium tremens may occur typically 3 days in to cessation with global confusion and sympathetic overdrive (fever, tachycardia and hypertension).
Which dementia commonly involves visual hallucinations?
Lewy body dementia. Often has recurrent visual hallucinations that take the form of people or animals being in their presence.
What is the characteristic pathological feature of Lewy Body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
What are the features of Lewy Body dementia?
progressive cognitive impairment
in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
cognition may be fluctuating, in contrast to other forms of dementia
usually develops before parkinsonism
parkinsonism
visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
how is Lewy Body dementia diagnosed?
Usually clinical. DaTscan for imaging
How is lewy body dementia managed?
Acetylcholinesterase inhibitors e.g. Donepazil, rivastigmine and memantine can be used.
Avoid neuroleptics - LBD pts are extremely sensitive and may develop irreversible parkinsonism
what is frontotemporal lobar degeneration?
Gradual-onset dementia at a young age with relatively preserved memory and visuospatial skills
There are 3 recognised types of FTLD
- Frontotemporal dementia (Pick’s disease)
- Chronic progressive aphasia, CPA)
- Semantic dementia
What are the common features of fronto-temporal lobar dementias?
- onset before 65
- insidious onset
- relatively preserved memory and visuospatial skills
- personality change and social conduct problems
Name the characteristic features of Fronto temporal dementia (picks disease)
personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
Outline the first and second line pharmacological management of Alzheimers disease
- the 3 acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
- memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, used when:
→ moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
→ as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
→ monotherapy in severe Alzheimer’s
What is the onset of dementia in parkinsons vs lewy body?
Parkinson’s disease dementia is more likely if dementia occurs around 4-5 years after motor symptoms (but at the very least should be 1 year after).
Lewy body dementia is more likely if dementia starts before or within 1 year of the onset of the parkinsonian symptoms.
what are the roles of the following drugs in Lewy body dementia? Donepezil carbidopa/levodopa clonazepam sertraline
Donepezil is a cholinesterase inhibitor which is the first-line treatment for cognitive impairment and behavioural symptoms
Carbidopa/Levodopa are dopaminergic agents used to treat motor symptoms
Clonazepam is used to treat REM sleep behaviour disturbances and should be given in low doses 30 minutes before bedtime.
Sertraline is an SSRI which are the preferred drugs to treat depression with Lewy body dementia because they have limited side-effects and favourable pharmacokinetics
name some factors that help differentiate delirium from dementia
Factors favouring delirium over dementia:
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
As part of the ‘confusion screen’ bloods, what other blood tests are commonly performed?
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
