Pass Med

Question 1

How is orthostatic hypotension diagnosed?

Answer 1

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).

Question 2

Name some risk factors for falls

Answer 2

Previous fall
Lower limb muscle weakness, arthritis
Vision problems
Balance/gait disturbances 
Polypharmacy,
Incontinence
>65
Have a fear of falling
Postural hypotension
Cognitive impairment

Question 3

Name some medication classes that can cause postural hypotension

Answer 3

Nitrates
Diuretics
ACE inhibitors
Beta Blockers
L-Dopa
Anticholinergics

Question 4

Name some drug classes that cause falls

Answer 4

Benzodiazepines
Sedatives
Opiates
Anti Epileptics
Digoxin

Question 5

What bedside tests, bloods and imaging might you consider for a fall?

Answer 5

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

Question 6

Describe the timed up and go test

Answer 6

• 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.

Question 7

Describe the 180 degree turn test

Answer 7

• 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

Question 8

Describe how we might assess gait speed

Answer 8

• 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.

Question 9

What drug class should be avoided in delirious patients with Parkinsons disease?

Answer 9

Anti psychotics e.g. haloperidol or olanzapine. They have strong anti dopaminergic action will make their condition significantly worse. Lorazepam most suitable option instead

Question 10

Name some predisposing factors for delirium

Answer 10

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

Question 11

Name some precipitating factors for delirium

Answer 11

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

Question 12

Name some clinical features of delirium

Answer 12

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention

Question 13

What is the waterlow score?

Answer 13

Used to identify patients at risk of pressure ulcers

Question 14

What factors might predispose to the development of pressure ulcers?

Answer 14

• Malnourishment
• incontinence
• immobility
• pain

Question 15

Describe the 4 grades of pressure ulcers

Answer 15

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

Question 16

Give a brief overview of how to manage a pressure ulcer

Answer 16

• 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

Question 17

How might alcohol withdrawal present?

Answer 17

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).

Question 18

Which dementia commonly involves visual hallucinations?

Answer 18

Lewy body dementia. Often has recurrent visual hallucinations that take the form of people or animals being in their presence.

Question 19

What is the characteristic pathological feature of Lewy Body dementia?

Answer 19

alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

Question 20

What are the features of Lewy Body dementia?

Answer 20

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)

Question 21

how is Lewy Body dementia diagnosed?

Answer 21

Usually clinical. DaTscan for imaging

Question 22

How is lewy body dementia managed?

Answer 22

Acetylcholinesterase inhibitors e.g. Donepazil, rivastigmine and memantine can be used.

Avoid neuroleptics - LBD pts are extremely sensitive and may develop irreversible parkinsonism

Question 23

what is frontotemporal lobar degeneration?

Answer 23

Gradual-onset dementia at a young age with relatively preserved memory and visuospatial skills

There are 3 recognised types of FTLD

1. Frontotemporal dementia (Pick’s disease)
2. Chronic progressive aphasia, CPA)
3. Semantic dementia

Question 24

What are the common features of fronto-temporal lobar dementias?

Answer 24

• onset before 65
• insidious onset
• relatively preserved memory and visuospatial skills
• personality change and social conduct problems

Question 25

Name the characteristic features of Fronto temporal dementia (picks disease)

Answer 25

personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.

Question 26

Outline the first and second line pharmacological management of Alzheimers disease

Answer 26

• 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

Question 27

What is the onset of dementia in parkinsons vs lewy body?

Answer 27

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.

Question 28

what are the roles of the following drugs in Lewy body dementia?
Donepezil
carbidopa/levodopa
clonazepam
sertraline

Answer 28

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

Question 29

name some factors that help differentiate delirium from dementia

Answer 29

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

Question 30

As part of the ‘confusion screen’ bloods, what other blood tests are commonly performed?

Answer 30

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