REVISION Flashcards
Which body cells do not divide and therefore have to last a lifetime?
Neurons
Renal cells
Myocardial cells
What are the big ‘I’s in care of the elderly?
Important presenting complaints which need to be considered Instability Incontinence (new) Immobility Intellectual changes Inability to look after SLE
What is polypharmacy?
The use of multiple drugs, normally >4
Pharmacokinetics = what the body does to the drug
Pharmacokinetics = what the drug does to the body
Give some differences in the physiology of elderly patients which may affect drug distribution and action
1) Delayed gastric emptying
2) More fat, less lean tissue
3) Reduced liver and renal function
4) Reduced plasma albumi
START and STOPP criteria
STOPP = screening tool of older peoples prescriptions START = screening tool to alert doctors to the right treatment
Which drug is used for delirium tremendous e.g. alcohol withdrawal
Chlordiazepoxide
The dose depends on the severity of drinking
Elderly patient with failing vision develops vivid visual hallucinations. Most likely diagnosis?
Charles-Bonnet syndrome
important that people are normally aware that they are hallucinating
Management of a patient with COPD who is still symptomatic on a SABA/ SAMA
FEV1 >50 = LABA or LAMA
FEV1 <50 = LABA + ICS (or LAMA)
Main differential for bilateral Hilary lymphadenopathy
TB or sarcoid
Define delirium
Transient, reversible decline in cognitive function, that is acute and fluctuating and occurs in the presence of an acute illness
Loads of causes including infection, stroke, head injury, pain and emotional distress
Neurotransmitters involved in delerium?
Low ACh
Dopamine excess
Classically causes reversal of sleep wake cycle, clouding of consciousness, hallucinations, lucid intervals,delusions etc
What is the confusion assessment method?
A diagnostic algorithm used in the assessment of delerium. 4 components 1) Acute onset and fluctuating course 2) Inattention 3) Disorganised thinking 4) altered conscious level
Needs features 1+2 and 3 or 4 to be diagnosed
Define dementia
A syndrome of acquired, chronic, global impairment of higher brain function in an alert patient which interferes with there ability to cope with daily living
Features of normal pressure hydrocephalus
1) Incontinence
2) Gait disturbance
3) Dementia
Dementia may benefit from shunting
What is the first feature of Alzheimer’s disease?
Usually impaired short term memory
Remember My - memory Old - orientation Granny - grasp e.g. difficulty planning and with executive functions Converses - communication Pretty - personality changes Badly - behaviour changes
Investigations in a patient with suspected dementia
FBC, UE, LFT, calcium TFT, B12 and folate
ECG
Consider CT
Pathology features of alzheimers
Amyloid plaques
Neurofibrillary plaques from tau protein
Which gene is associated with alzheimers?
APOE e4
What are the 4 alzheimers drugs?
1) Donepezil
2) Galantamine
3) Rivastigmine
(All AChE inhibitor)
4) Memantine (only for severe disease)
A N methyl-D aspartame receptor antagonist
Which drugs should be used in a patient with severe Alzheimers?
Memantine (a N methyl D aspartame receptor antagonist)
What are the cut offs for diagnosing Alzheimers using MMSE?
MMSE is out of 30
Mild = 21-26 Moderate = 10-20 Severe = <10
Which group of patients should you always avoid giving anti-psychotic drugs in?
Levy body dementia
(if you have too, use quetiapine)
Rivastigmine and L-dopa can help symptoms)
Best anti-psychotic drug in levy body dementia?
Quetiapine
List some features of fronto-temporal dementia?
Impaired executive function e.g. cannot problem solve/ plan
Social disinhibition - ‘private things in public’
Compulsive behaviour e.g eating
Loss of empathy
SSRIs may be useful - ACHe worsen symptoms
Important that memory and orientation are well preserved
What is the SPLATT pnuemonic for assessing falls?
S = symptoms P = previous falls L = location A = activity e.g. standing, peeing, hanging out washing T = time e.g. first thing, after tablets etc T = trauma?
List some common drugs that can cause falls?
1) Anti-hypertensive e.g. diuretics, CCB —> can cause postural hypotension
2) opiates/ benzodiazepines —> cause drowsiness
3) Ant-psychotics —> extra-pyramidal side effects
4) Anti-depressants, especially TCA —> slow central processing
How do you check for postural hypotension?
Measure BP lying and after standing for 3 minutes
A drop of >10mmg diastolic and >20 systolic is significant
Baseline investigations for a patient who falls?
FBC, TFT, B12
ECG
Consequences of a long lie (>1 hour)
Hypothermia (if outside/ unseated room)
Pressure sores
Rhabdomyolysis
Death (its a very bad prognostic indicator)
List a good differential for a dizzy patient
1) ENT = BPPV, Acoustic neuroma, Labyrinthitis, meniere’s
2) Cardio = hypotension, syncope, arrhythmias
3) Drugs
4) CNS - vertebro-basilar syndrome/ cerebellar disease
Trabecular bone is spongy bone
Cortisol bone is the hard outer bone
What tests should be done to exclude secondary causes of osteoporosis?
FBC, LFT, UE, ESR, serum immunoglobulins and urinary Bence Jones proteins to exclude myeloma
Calcium
TFT
How do bisphosphonates work?
They bind to hydroxyapatite within the bone which inhibits osteoclast recruitment and therefore bone respiration
Which drug can be used to increase bone density?
Teriparatide
Given by daily sub-cut injection in people with severe disease who are not tolerant of bisphosphonate
Very expensive
Which bone drug is given by 3 monthly injection?
Denosumab
A monoclonal antibody against RANKL
What is osteomalacia?
Reduced calcification due to vitamin D deficiency
E.g. there is a normal amount of bone but it is very weak
Features include fractures, skeletal pain, muscle weakness and waddling gait
Alk phos will be high, Ca and phosphate low
What is Paget’s disease of bone?
An increase in bone tunorver, producing expanded but weakened bone. Usually the skull, pelvis, spine and femur that is affected
Bone pain or nerve entrapment may be the presenting feature - often the 8th nerve
Alk phos and calcium are high in patients with Pagets
Remember that many will be asymptomatic and diagnosed with finding of raised Alk phos for other reasons
Treatment is usually with risedronate (a bisphosphonate)
What is the Sestamibi scan?
A technetium scan used in the detection of a parathyroid adenoma e.g. in primary hyperparathyroidism- used to determine anatomy pre-surgery
List 5 causes of hypercalcaemia in older patients
1) Primary hyperparathyroidism
2) Hypercalcaemia of malignancy
3) Renal disease
4) Myeloma
5) drug induced e.g. thiazides, lithium and vit D
What is the CHA2DS2-Vasc score?
Calculates the risk of stroke in patient with AF E.G. age, sex, CHF, HT, previous stroke DM etc 0 = low risk 1 = low-moderate e.g. consider aspirin 2+ = high —> warfarin
Remember that amarousis fugax is a type of TIA
Remember that amarousis fugax is a type of TIA
What is the ABCD2 score?
A tool used to calculate the risk of stroke after a TIA
Age
BP
Clinical features e.g. unilateral weakness (2), speech disturbance (1)
Duration <10 min (0), <1 hour (1), >1hr (2)
DM?
Total anterior circulation infarct
Middle coronary artery occluded - very bad prognosis
All 3:
1) Higher cortical dysfunction e.g. dysphasia
2) hemianopia
3) Motor/ sensory defect in 2 out of face, arm and leg
Partial anterior circulation infarct
2/3 of TACI symptoms
E.g. hemianopia, executive dysfunction and motor/ sensory deficit
Branch of MCA or ACA, reasonable outcome but very high chance of recurrence
Features of lacunar infarct
Occlusion of deep perforating arteries, often with good recovery
Any 1 of: Motor deficit Sensory deficit Hemiparesis Ataxia
Features of posterior circulation infarct
Any one of:
Homonymous hemianopia
Brain stem signs
Cerebellar dysfunction
Good recovery but also high recurrence rate
Remember that vertigo can be a feature of a cerebellar stroke
Other signs are a focal neurological deficit, ataxia and nystagmus
Which drugs should be used in the managment of a SAH?
Nimidopine (dyhydropirodine CCB)
Codeine for analgesia
Aspirin is given in ALL ischaemic stroke patients
300mg acutely and then 75mg daily for at least the first 2 weeks
Indications for thrombolysis in stroke?
Main one is within 4.5 hours of symptom onset
Also no haemorrhaging stroke, no previous stroke within 3 months and not on anticoagulation
Secondary prevention in stroke patients?
1) Lifestyle - smoking, diet, salt and alcohol
2) Anti-platelet e.g. clopidogrel 75mg
3) Statin
4) BP
What are the 6 features of dependence?
1) Strong desire to use substance
2) Withdrawal if not using
3) Tolerance
4) Lack on interest in other things’
5) Using despite harm
6) difficulty controlling substance use
What is the main side effect/ risk of MAOI?
Mono-amine oxidase inhibitors e.g. moclobemide, hydrazine and phelzine can cause drug reactions and potentially fatal hypertensive crisis
Patients must limit tyramine in their diet —> liver, alcohol etc due to the risk of crisis
Patients should carry a card around - being on a MAOI affects dose of drugs e.g. adrenaline
What is the CGA?
Comprehensive geriatric assessment, gold standard assessment of older people. Fast, effective and should be used
How is tone and reflexes in PD?
Tone = increased Reflexes = normal
For BPH, alpha blockers have an effect within a few days
5 alpha reductase inhibitors e.g. finestaride take several weeks -
Treatment of delirium
Treat cause, orientation and good nursing
Oral haloperidol may be required
Avoid benzos as they worsen delirium
