Passmedicine Questions Flashcards
In which groups of people do pressure ulcers most commonly form?
Those unable to move parts of their body e.g. due to illness, paralysis, advanced age
Where to pressure ulcers most commonly form?
Over bony prominences, e.g. sacrum/heel
What factors predispose to the development of pressure ulcers?
Malnourishment
Incontinence
Lack of mobility
Pain (–> reduced mobility)
What score is used to assess risk of developing a pressure ulcer?
Waterlow score
What factors are included in the waterlow score?
BMI Nutritional status Skin type Mobility Continence
What system is used to grade pressure ulcers?
European Pressure Ulcer Advisory Panel classification system
What are grade 1 pressure ulcers?
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)
What are grade 2 pressure ulcers?
Partial thickness skin loss involving epidermis or dermis or both
The ulcer is superficial + presents clinically as an abrasion/blister
What are grade 3 pressure ulcers?
Full thickness skin loss involving damage to or necrosis of the subcutaneous tissue that may extend down to, but not through, underlying fascia
What are grade 4 pressure ulcers?
Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with or without full thickness skin loss
How do you manage pressure sores?
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
What drugs should you not use in a delirious patient with a background of Parkinson’s disease?
Antipsychotics
How common is acute confusional state/delirium?
It affects up to 30% of elderly patients admitted to hospital
What are the predisposing factors for delirium?
Age >65 Background of dementia Significant injury, e.g. hip fracture Frailty/multimorbidity Polypharmacy
What may precipitate a delirium?
(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
What are the features of delirium?
Memory disturbances Agitation/withdrawal Disorientation Mood change Visual hallucinations Disturbed sleep cycle Poor attention
How do you manage delirium?
Treat underlying cause/modify environment
1st line: 0.5mg haloperidol (alt: olanzapine)
Lorazepam in those with hx of Parkinson’s
How common are falls in the elderly living in the community?
They occur in 1/3rd of this group every year
What are the consequences of falls?
Injuries
Reduced independence
Reduced confidence
What three things does normal gait rely on?
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
What are some risk factors for falling?
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
Define polypharmacy
4+ medications
Who should be screened for falls risk?
Ideally all to establish the level of support they need, particularly when in hospital or a home
What are the key components of a falls history?
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
What is the aim of doing a medication review in someone after they have a fall?
Unnecessary or contributory medications should be stopped/swapped
What drugs can cause postural hypotension?
Nitrates Diuretics Anticholinergic medications Antidepressants Beta-blockers L-Dopa ACEi
What drugs can cause increase risk of falls?
Benzodiazepines Antipsychotics Opiates Anticonvulsants Codeine Digoxin Sedatives
What bedside tests should you do after someone has a fall?
Basic obs BP Blood glucose Urine dip ECG
What bloods should you do after someone has a fall?
FBC, U+Es, LFTs, bone profile
What imaging might you do after someone has a fall?
CXR/X-Ray of injured limbs
CT head
Cardio echo
What are the NICE CKS recommendations for those who have had a fall?
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
Who should be offered a multidisciplinary assessment by a qualified clinician?
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
How do you do a lying/standing BP?
Measure BP after 5 min of lying down, then after 1m standing + 3m standing
When can you diagnose orthostatic hypotension?
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
What is the characteristic pathological feature in Lewy Body Dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
What drugs MUST be avoided in Lewy Body dementia and why?
Neuroleptics
THEY MAY CAUSE IRREVERSIBLE PARKINSONISM
What are the features of Lewy Body Dementia?
Progressive cognitive impairment
Parkinsonism
Visual hallucinations (delusions/non-visual hallucinations may be seen as well)
How do you diagnose lewy body dementia?
Usually clinical
SPECT/DaTscan can be used
How do you manage lewy body dementia?
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
What is an important differential for the patient who deteriorates following the induction of an antipsychotic agent?
Lewy body dementia
Parkinsons
Is haloperidol safe to use in Parkinson’s disease?
Absolutely not
It is a dopamine antagonist that can worsen Parkinson’s symptoms
Is domperidone safe to use in those with Parkinson’s disease?
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
Is olanzapine safe to uses in PD?
Yes, it is not CI
When should antibiotics be used for treatment of pressure ulcers?
ONLY if there are signs of infection
What should be involved in the management of all pressure ulcers?
Dressings
Analgesia
Nutritional assessment
What are the indications for antibiotic use in pressure ulcers?
Clinical evidence of systemic sepsis
Spreading cellulitis
Underlying osteomyelitis
How do you differentiate between Lewy body dementia and Parkinson’s disease?
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
What type of visual hallucinations are most common in lewy body dementia?
Seeing people or animals
What are the three recognised types of frontotemporal lobar degeneration?
Frontotemporal dementia (pick’s disease)
Progressive non-fluent aphasia
Semantic dementia
What are the common features of the frontotemporal lobar dementias?
Onset before 65
Insidious onset
Relatively preserved memory + visuospatial skills
Personality change + social conduct problems
What is Pick’s disease most characterised by?
Personality change
Impaired social conduct
Other features: hyperorality, disinhibition, increased appetite, perseveration behaviours
What does the brain appear like macroscopically in Pick’s disease?
Focal gyral atrophy with knife-blade appearance
Atrophy of the fronal and temporal lobe
What does the brain appear like microscopically in Pick’s disease?
Pick bodies (spherical aggregations of tau protein)
Gliosis
Neurofibrillary tangles
Senile plaques
What drugs do NICE recommend to manage Pick’s disease?
AChE inhibitors/memantine are not recommended
What is the presentation of chronic progressive aphasia (CPA) aka. progressive non-fluent aphasia?
Non-fluent speech
They make short utterances that are agrammatic
Comprehension is relatively preserved
What is the presentation of semantic dementia?
Patient has fluent progressive aphasia
Speech is fluent but empty + conveys little meaning
Memory is better for recent rather than remote events
What bloods should be done as part of the confusion screen?
TSH, B12, folate, glucose, bone profile (hyperCa can cause confusion)
What is involved in the non-pharmacological management of Alzheimer’s disease?
Activities to promote wellbeing tailored to the person’s preferences
Group cognitive stimulation for mild/moderate Alzheimer’s
Group reminiscence therapy and cognitive rehab
What is involved in the management of Alzheimer’s?
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
What does NICE recommend to treat mild-moderate depression in Alzheimer’s?
Does not recommend antidepressants
When should antipsychotics be used in dementia?
Only if patient at risk of harming themselves or others, or when agitation, hallucinations/delusions causing them severe distress
What is a relative CI to using donepezil?
Bradycardia
What is an AE of donepezil?
Insomnia
What are the three AChEi?
Donepezil, galantamine, rivastigmine
How common is dementia in the UK?
Affects >700, 000 people in the UK
What are the most common dementias in order?
- Alzheimer’s
- Vascular
- Lewy body
What assessment tools are recommended for the non-specialist setting for helping to diagnose dementia?
10 point cognitive screener
6 item cognitive impairment test
A score of MMSE is suggestive of dementia?
24 or less out of 30
What tests should be done in the primary care setting when you suspect dementia?
FBC, U+E,LFTs, Ca, Glucose, FTFs, vit B12, folate
For reversible causes of dementia
Who are people with dementia commonly referred to now?
Old age psychiatrists
What is involved in the secondary care management of individuals with dementia?
Neuroimaging is performed to exclude reversible conditions (e.g. subdural haematoma, normal pressure hydrocephalus) + provide information on aetiology to guide prognosis + management
What type of antidepressant should not be used in those with dementia and why?
TCAs
They carry a risk of worsening cognitive impairment
What is the mechanism of action of memantine?
NMDA antagonist
What are the three subtypes of delirium?
Hyperactive
Hypoactive (sleepy, withdrawn, slow to respond)
Mixed
What are some rarer causes of dementia?
Huntington’s
CJD
Pick’s disease
HIV
What are some of the potentially treatable causes of dementia?
Hypothyroidism, Addison's B12/folate/thiamine deficiency Syphilis Brain tumour Normal pressure hydrocephalus Subdural haematoma Depression Chronic drug use, e.g. alcohol, barbiturates
How many cases of Alzheimer’s are sporadic vs inherited?
Most cases sporadic
5% inherited as an AD trait
Mutations in which genes are thought to causes the inherited form of Alzheimer’s?
Amyloid precursor protein (chromosome 21)
Presenilin 1 (chromosome 14)
Presenilin 2 (chromosome 1)
Apoprotein E allele E4 (encodes cholesterol transport protein)
What are the risk factors for Alzheimer’s disease?
Down’s syndrome
What does Alzheimer’s disease look like macroscopically?
Widespread cerebral atrophy (esp. in cortex + hippocampus)
What does Alzheimer’s look like microscopically?
Cortical plaques due to deposition of type A-beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
What does Alzheimer’s look like biochemically?
Deficit of Ach from damage to ascending forebrain projection
