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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
What is the aim of doing a medication review in someone after they have a fall?
Unnecessary or contributory medications should be stopped/swapped
26
What drugs can cause postural hypotension?
``` Nitrates Diuretics Anticholinergic medications Antidepressants Beta-blockers L-Dopa ACEi ```
27
What drugs can cause increase risk of falls?
``` Benzodiazepines Antipsychotics Opiates Anticonvulsants Codeine Digoxin Sedatives ```
28
What bedside tests should you do after someone has a fall?
``` Basic obs BP Blood glucose Urine dip ECG ```
29
What bloods should you do after someone has a fall?
FBC, U+Es, LFTs, bone profile
30
What imaging might you do after someone has a fall?
CXR/X-Ray of injured limbs CT head Cardio echo
31
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
32
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
33
How do you do a lying/standing BP?
Measure BP after 5 min of lying down, then after 1m standing + 3m standing
34
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
35
What is the characteristic pathological feature in Lewy Body Dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
36
What drugs MUST be avoided in Lewy Body dementia and why?
Neuroleptics | THEY MAY CAUSE IRREVERSIBLE PARKINSONISM
37
What are the features of Lewy Body Dementia?
Progressive cognitive impairment Parkinsonism Visual hallucinations (delusions/non-visual hallucinations may be seen as well)
38
How do you diagnose lewy body dementia?
Usually clinical | SPECT/DaTscan can be used
39
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
40
What is an important differential for the patient who deteriorates following the induction of an antipsychotic agent?
Lewy body dementia | Parkinsons
41
Is haloperidol safe to use in Parkinson's disease?
Absolutely not | It is a dopamine antagonist that can worsen Parkinson's symptoms
42
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
43
Is olanzapine safe to uses in PD?
Yes, it is not CI
44
When should antibiotics be used for treatment of pressure ulcers?
ONLY if there are signs of infection
45
What should be involved in the management of all pressure ulcers?
Dressings Analgesia Nutritional assessment
46
What are the indications for antibiotic use in pressure ulcers?
Clinical evidence of systemic sepsis Spreading cellulitis Underlying osteomyelitis
47
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
48
What type of visual hallucinations are most common in lewy body dementia?
Seeing people or animals
49
What are the three recognised types of frontotemporal lobar degeneration?
Frontotemporal dementia (pick's disease) Progressive non-fluent aphasia Semantic dementia
50
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
51
What is Pick's disease most characterised by?
Personality change Impaired social conduct Other features: hyperorality, disinhibition, increased appetite, perseveration behaviours
52
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
53
What does the brain appear like microscopically in Pick's disease?
Pick bodies (spherical aggregations of tau protein) Gliosis Neurofibrillary tangles Senile plaques
54
What drugs do NICE recommend to manage Pick's disease?
AChE inhibitors/memantine are not recommended
55
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
56
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
57
What bloods should be done as part of the confusion screen?
TSH, B12, folate, glucose, bone profile (hyperCa can cause confusion)
58
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
59
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
60
What does NICE recommend to treat mild-moderate depression in Alzheimer's?
Does not recommend antidepressants
61
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
62
What is a relative CI to using donepezil?
Bradycardia
63
What is an AE of donepezil?
Insomnia
64
What are the three AChEi?
Donepezil, galantamine, rivastigmine
65
How common is dementia in the UK?
Affects >700, 000 people in the UK
66
What are the most common dementias in order?
1. Alzheimer's 2. Vascular 3. Lewy body
67
What assessment tools are recommended for the non-specialist setting for helping to diagnose dementia?
10 point cognitive screener | 6 item cognitive impairment test
68
A score of MMSE is suggestive of dementia?
24 or less out of 30
69
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
70
Who are people with dementia commonly referred to now?
Old age psychiatrists
71
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
72
What type of antidepressant should not be used in those with dementia and why?
TCAs | They carry a risk of worsening cognitive impairment
73
What is the mechanism of action of memantine?
NMDA antagonist
74
What are the three subtypes of delirium?
Hyperactive Hypoactive (sleepy, withdrawn, slow to respond) Mixed
75
What are some rarer causes of dementia?
Huntington's CJD Pick's disease HIV
76
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 ```
77
How many cases of Alzheimer's are sporadic vs inherited?
Most cases sporadic | 5% inherited as an AD trait
78
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)
79
What are the risk factors for Alzheimer's disease?
Down's syndrome
80
What does Alzheimer's disease look like macroscopically?
Widespread cerebral atrophy (esp. in cortex + hippocampus)
81
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
82
What does Alzheimer's look like biochemically?
Deficit of Ach from damage to ascending forebrain projection

Geriatrics (13 decks)

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