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Geriatrics > Passmedicine Questions > Flashcards

Passmedicine Questions Flashcards

1
Q

In which groups of people do pressure ulcers most commonly form?

A

Those unable to move parts of their body e.g. due to illness, paralysis, advanced age

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2
Q

Where to pressure ulcers most commonly form?

A

Over bony prominences, e.g. sacrum/heel

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3
Q

What factors predispose to the development of pressure ulcers?

A

Malnourishment
Incontinence
Lack of mobility
Pain (–> reduced mobility)

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4
Q

What score is used to assess risk of developing a pressure ulcer?

A

Waterlow score

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5
Q

What factors are included in the waterlow score?

A 
BMI
Nutritional status
Skin type
Mobility
Continence
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6
Q

What system is used to grade pressure ulcers?

A

European Pressure Ulcer Advisory Panel classification system

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7
Q

What are grade 1 pressure ulcers?

A

Non-blanchable erythema of intact skin
Discolouration of the skin, warmth, oedema, induration or hardness may be used as indicators (esp. in those with darker skin)

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8
Q

What are grade 2 pressure ulcers?

A

Partial thickness skin loss involving epidermis or dermis or both
The ulcer is superficial + presents clinically as an abrasion/blister

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9
Q

What are grade 3 pressure ulcers?

A

Full thickness skin loss involving damage to or necrosis of the subcutaneous tissue that may extend down to, but not through, underlying fascia

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10
Q

What are grade 4 pressure ulcers?

A

Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with or without full thickness skin loss

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11
Q

How do you manage pressure sores?

A

Moist environment encourages healing (hyrocolloid dressings/hydrogels)
Avoid use of soaps (as these are drying)
Decision to use antibiotics is clinical + not based on wound swabs
Referral to tissue viability nurse
Surgical debridement for some wounds

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12
Q

What drugs should you not use in a delirious patient with a background of Parkinson’s disease?

A

Antipsychotics

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13
Q

How common is acute confusional state/delirium?

A

It affects up to 30% of elderly patients admitted to hospital

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14
Q

What are the predisposing factors for delirium?

A 
Age >65
Background of dementia
Significant injury, e.g. hip fracture
Frailty/multimorbidity
Polypharmacy
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15
Q

What may precipitate a delirium?

A 
(Often multifactorial)
Infection, e.g. UTI
Metabolic (hyperCa, hypoglycaemia, hyperglycaemia, dehydration)
Change of environment
Significant CV/resp/neuro/endocrine condition 
Severe pain
Alcohol withdrawal 
Constipation
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16
Q

What are the features of delirium?

A 
Memory disturbances
Agitation/withdrawal 
Disorientation
Mood change
Visual hallucinations
Disturbed sleep cycle
Poor attention
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17
Q

How do you manage delirium?

A

Treat underlying cause/modify environment
1st line: 0.5mg haloperidol (alt: olanzapine)
Lorazepam in those with hx of Parkinson’s

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18
Q

How common are falls in the elderly living in the community?

A

They occur in 1/3rd of this group every year

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19
Q

What are the consequences of falls?

A

Injuries
Reduced independence
Reduced confidence

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20
Q

What three things does normal gait rely on?

A

Neurological system - basal ganglia + cortical basal ganglia loop

MSK system - tone + strength

Processing of the senses (e.g. sight, sound, sensation)

NB as people age they are more likely to have problems affecting these systems –> gait abnormalities + increased risk of falls

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21
Q

What are some risk factors for falling?

A 
Previous fall
Lower limb muscle weakness
Vision problems
Balance/gait problems (DM, RA, PD)
Polypharmacy
Incontinence
>65
Fear of falling
Depression
Postural hypotension
Arthritis in lower limbs
Psychoactive drugs
Cognitive impairment
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22
Q

Define polypharmacy

A

4+ medications

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23
Q

Who should be screened for falls risk?

A

Ideally all to establish the level of support they need, particularly when in hospital or a home

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24
Q

What are the key components of a falls history?

A 
Where was the fall?
When did they fall?
Did anyone else see the fall? (collateral history)
What happened? 
Were there any associated features before/during/after
Have they fallen before?
Systemic review
PMH (issues re. sight/balance/gait)
Social hx
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25
Q

What is the aim of doing a medication review in someone after they have a fall?

A

Unnecessary or contributory medications should be stopped/swapped

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26
Q

What drugs can cause postural hypotension?

A 
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
ACEi
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27
Q

What drugs can cause increase risk of falls?

A 
Benzodiazepines
Antipsychotics
Opiates
Anticonvulsants
Codeine 
Digoxin 
Sedatives
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28
Q

What bedside tests should you do after someone has a fall?

A 
Basic obs
BP
Blood glucose
Urine dip
ECG
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29
Q

What bloods should you do after someone has a fall?

A

FBC, U+Es, LFTs, bone profile

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30
Q

What imaging might you do after someone has a fall?

A

CXR/X-Ray of injured limbs
CT head
Cardio echo

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31
Q

What are the NICE CKS recommendations for those who have had a fall?

A

Identify why they are at risk
Identify all those who have fallen in the last 12 months
For those with a falls history/at risk complete the turn 180 degrees test or the timed get up and go test

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32
Q

Who should be offered a multidisciplinary assessment by a qualified clinician?

A

Those over 65y with:
>2 falls in the last 12 months
A fall that req. medical Rx
Poor performance/failure to complete the turn 180 test or the timed get up and go

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33
Q

How do you do a lying/standing BP?

A

Measure BP after 5 min of lying down, then after 1m standing + 3m standing

34
Q

When can you diagnose orthostatic hypotension?

A

a. Drop in systolic BP of 20mmHg or more (w/w.o symptoms)
b. Drop to below 90mmHg on standing even if drop is less than 20mmHg (w/w.o symptoms)
c. Drop in diastolic BP of 10mmHg w. symptoms

35
Q

What is the characteristic pathological feature in Lewy Body Dementia?

A

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

36
Q

What drugs MUST be avoided in Lewy Body dementia and why?

A

Neuroleptics

THEY MAY CAUSE IRREVERSIBLE PARKINSONISM

37
Q

What are the features of Lewy Body Dementia?

A

Progressive cognitive impairment
Parkinsonism
Visual hallucinations (delusions/non-visual hallucinations may be seen as well)

38
Q

How do you diagnose lewy body dementia?

A

Usually clinical

SPECT/DaTscan can be used

39
Q

How do you manage lewy body dementia?

A

Acetylcholinesterase inhibitors (e.g. donepezil is first line for cognitive + behavioural symptoms)
Carbidopa/levodopa used to treat motor symptoms
Clonazepam used to treat REM sleep behaviour disturbances
Memantine
Sertraline is preferred for treating depression

40
Q

What is an important differential for the patient who deteriorates following the induction of an antipsychotic agent?

A

Lewy body dementia

Parkinsons

41
Q

Is haloperidol safe to use in Parkinson’s disease?

A

Absolutely not

It is a dopamine antagonist that can worsen Parkinson’s symptoms

42
Q

Is domperidone safe to use in those with Parkinson’s disease?

A

Yes, despite it being a dopamine antagonist, it does not easily cross the BBB and so is safe for treating GI symptoms in those with PD

43
Q

Is olanzapine safe to uses in PD?

A

Yes, it is not CI

44
Q

When should antibiotics be used for treatment of pressure ulcers?

A

ONLY if there are signs of infection

45
Q

What should be involved in the management of all pressure ulcers?

A

Dressings
Analgesia
Nutritional assessment

46
Q

What are the indications for antibiotic use in pressure ulcers?

A

Clinical evidence of systemic sepsis
Spreading cellulitis
Underlying osteomyelitis

47
Q

How do you differentiate between Lewy body dementia and Parkinson’s disease?

A

Lewy body more likely if dementia starts before or within 1 year of parkinsonism
Lewy body has a poor response to antiparkinsonian drugs
Parkinson’s more likely if dementia occurs 4-5y (or at least 1y) after motor symptoms

48
Q

What type of visual hallucinations are most common in lewy body dementia?

A

Seeing people or animals

49
Q

What are the three recognised types of frontotemporal lobar degeneration?

A

Frontotemporal dementia (pick’s disease)
Progressive non-fluent aphasia
Semantic dementia

50
Q

What are the common features of the frontotemporal lobar dementias?

A

Onset before 65
Insidious onset
Relatively preserved memory + visuospatial skills
Personality change + social conduct problems

51
Q

What is Pick’s disease most characterised by?

A

Personality change
Impaired social conduct

Other features: hyperorality, disinhibition, increased appetite, perseveration behaviours

52
Q

What does the brain appear like macroscopically in Pick’s disease?

A

Focal gyral atrophy with knife-blade appearance

Atrophy of the fronal and temporal lobe

53
Q

What does the brain appear like microscopically in Pick’s disease?

A

Pick bodies (spherical aggregations of tau protein)
Gliosis
Neurofibrillary tangles
Senile plaques

54
Q

What drugs do NICE recommend to manage Pick’s disease?

A

AChE inhibitors/memantine are not recommended

55
Q

What is the presentation of chronic progressive aphasia (CPA) aka. progressive non-fluent aphasia?

A

Non-fluent speech
They make short utterances that are agrammatic
Comprehension is relatively preserved

56
Q

What is the presentation of semantic dementia?

A

Patient has fluent progressive aphasia
Speech is fluent but empty + conveys little meaning
Memory is better for recent rather than remote events

57
Q

What bloods should be done as part of the confusion screen?

A

TSH, B12, folate, glucose, bone profile (hyperCa can cause confusion)

58
Q

What is involved in the non-pharmacological management of Alzheimer’s disease?

A

Activities to promote wellbeing tailored to the person’s preferences
Group cognitive stimulation for mild/moderate Alzheimer’s
Group reminiscence therapy and cognitive rehab

59
Q

What is involved in the management of Alzheimer’s?

A

AChEi for mild/moderate dx
Memantine for moderate dx + CI to AChEi, OR as add on to AChEi w. moderate/severe Alzheimer’s OR monotherapy in severe alzheimer’s

60
Q

What does NICE recommend to treat mild-moderate depression in Alzheimer’s?

A

Does not recommend antidepressants

61
Q

When should antipsychotics be used in dementia?

A

Only if patient at risk of harming themselves or others, or when agitation, hallucinations/delusions causing them severe distress

62
Q

What is a relative CI to using donepezil?

A

Bradycardia

63
Q

What is an AE of donepezil?

A

Insomnia

64
Q

What are the three AChEi?

A

Donepezil, galantamine, rivastigmine

65
Q

How common is dementia in the UK?

A

Affects >700, 000 people in the UK

66
Q

What are the most common dementias in order?

A
  1. Alzheimer’s
  2. Vascular
  3. Lewy body
67
Q

What assessment tools are recommended for the non-specialist setting for helping to diagnose dementia?

A

10 point cognitive screener

6 item cognitive impairment test

68
Q

A score of MMSE is suggestive of dementia?

A

24 or less out of 30

69
Q

What tests should be done in the primary care setting when you suspect dementia?

A

FBC, U+E,LFTs, Ca, Glucose, FTFs, vit B12, folate

For reversible causes of dementia

70
Q

Who are people with dementia commonly referred to now?

A

Old age psychiatrists

71
Q

What is involved in the secondary care management of individuals with dementia?

A

Neuroimaging is performed to exclude reversible conditions (e.g. subdural haematoma, normal pressure hydrocephalus) + provide information on aetiology to guide prognosis + management

72
Q

What type of antidepressant should not be used in those with dementia and why?

A

TCAs

They carry a risk of worsening cognitive impairment

73
Q

What is the mechanism of action of memantine?

A

NMDA antagonist

74
Q

What are the three subtypes of delirium?

A

Hyperactive
Hypoactive (sleepy, withdrawn, slow to respond)
Mixed

75
Q

What are some rarer causes of dementia?

A

Huntington’s
CJD
Pick’s disease
HIV

76
Q

What are some of the potentially treatable causes of dementia?

A 
Hypothyroidism, Addison's
B12/folate/thiamine deficiency
Syphilis
Brain tumour
Normal pressure hydrocephalus
Subdural haematoma
Depression
Chronic drug use, e.g. alcohol, barbiturates
77
Q

How many cases of Alzheimer’s are sporadic vs inherited?

A

Most cases sporadic

5% inherited as an AD trait

78
Q

Mutations in which genes are thought to causes the inherited form of Alzheimer’s?

A

Amyloid precursor protein (chromosome 21)
Presenilin 1 (chromosome 14)
Presenilin 2 (chromosome 1)
Apoprotein E allele E4 (encodes cholesterol transport protein)

79
Q

What are the risk factors for Alzheimer’s disease?

A

Down’s syndrome

80
Q

What does Alzheimer’s disease look like macroscopically?

A

Widespread cerebral atrophy (esp. in cortex + hippocampus)

81
Q

What does Alzheimer’s look like microscopically?

A

Cortical plaques due to deposition of type A-beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein

82
Q

What does Alzheimer’s look like biochemically?

A

Deficit of Ach from damage to ascending forebrain projection

Geriatrics (13 decks)

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