Passmed geriatrics Flashcards
acute confusional state predisposing fx
age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy
acute confusional state precipitating fx
infection: particularly urinary tract infections
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation
clinical fx acute confusional state
memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention
how to manage acute confusional state
- non medical
- medical
tx underlying cause - ie, constipation
modify environment - side room
1st line for delirium - haloperidol or olanzapine, except in parkison’s - reduction of parkinson meds and if require urgent tx then atypical antipsychotics (quetiapine, clozapine)
non pharmacological mx of alzheimer’s
activities to promote wellbeing
cognitive stimulation therapy
group reminiscence therapy and cognitive rehab
pharmacological mx of alzheimer’s
acetylcholinesterase inhibitors - donepezil, galantamine, rivastigmine
2nd line - memantine (NMDA receptor antagonist) - used when intolerant of 1st line, as an add on in severe, or monotherapy in severe
mx non cognitive sx of alzheimer’s
NO ANTIDEPRESSANTS
antipsychotics used if risk of harming themselves, agitation, hallucination, delusions
other tx options of alzheimer’s
donepezil
donepezil c/i and adverse effect
in pts with bradycardia
s/e - insomnia
alzheimer’s risk fx
increasing age
family history of Alzheimer’s disease
5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
apoprotein E allele E4 - encodes a cholesterol transport protein
Caucasian ethnicity
Down’s syndrome
macroscopic changes in alzheimer’s
widespread cerebral atrophy, particularly involving the cortex and hippocampus
microscopic change alzheimer’s
cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
hyperphosphorylation of the tau protein
biochemical changes alzheimer’s
a deficit of acetylcholine from damage to an ascending forebrain projection
define neurofibrillary tangles and how affect in AD
paired helical filaments are partly made from a protein called tau
tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules
in AD are tau proteins are excessively phosphorylated, impairing its function
factors favouring delirium over dementia
acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
order of prev in dementia types
1.alzheimers
2. vascular
3. lewy body
assessment tools for dementia
10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT)
other ways to assess dementia but not NICE recommended
abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE)
MMSE score indicated dementia
24 or less /30
dementia ix
blood screen to exclude reversible causes - FBC, UE, LFT, calcium, ESR/CRP, TFT, vit B12, folate
neuroimaging - subdural haematoma, normal pressure hydrocephalus
rare causes of dementia
Huntington’s
CJD
Pick’s disease (atrophy of frontal and temporal lobes)
HIV (50% of AIDS patients)
ddx dementia
hypothyroidism, Addison’s
B12/folate/thiamine deficiency
syphilis
brain tumour
normal pressure hydrocephalus
subdural haematoma
depression
chronic drug use e.g. Alcohol, barbiturates
what parts of body involve normal gait
The neurological system - basal ganglia and cortical basal ganglia loop.
The musculoskeletal system (which must have appropriate tone and strength).
Effective processing of the senses such as sight, sound, and sensation (fine touch and proprioception).
risk fx for falling
Lower limb muscle weakness
Vision problems
Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
Polypharmacy (4+ medications)
Incontinence
>65
Have a fear of falling
Depression
Postural hypotension
Arthritis in lower limbs
Psychoactive drugs
Cognitive impairment