Selected Notes gerries Flashcards
What is benign paroxysmal positional vertigo?
<ul><li>Sudden episodic attacks of vertigo induced by changes in head position</li></ul>
Describe the epidemiology of benign paroxysmal positional vertigo
<ul><li>Leading cause of vertigo</li><li>Increased incidence in the elderly</li><li>Increased risk in those with gallstones(calcium deposits)</li></ul>
Describe the aetiology of benign paroxysmal positional vertigo
<ul><li>Detachment of otoliths from the utricle of the inner ear</li><li>Detached particles migrate into semicircular canals where they stimulate hair cells and lead to vertigo symptoms</li><li>Acummulation of cholelithiasis in semi circular cells of inner earrr</li></ul>
Describe the presentation of patient with benign paroxysmal positional vertigo
<ul><li>Vertigo triggered by changes in head position (e.g. rolling in bed, looking up)</li><li>Recurrent episodes lasting aroung 30secs-1 minute</li><li>May be associated with nausea </li><li>No auditory symptoms</li></ul>
How is benign paroxysmal positional vertigo diagnosed?
<ul><li>Positive Dix-Hallpike maneouvre</li><li>Lie down with one ear pointed to ground-> check for nystagmus</li></ul>
Name some differentials for benign paroxysmal positional vertigo
<ul><li>Menieres disease</li><li>Vestibular neuritis</li><li>Labyrinthitis</li></ul>
How is benign paroxysmal positional vertigo managed?
<ul><li>Epley manouvere-works in around 80%(aims to detach otoliths out of semicircular canal and back to utricle)</li><li>Usuaully resolves spontaneously after a few weeks/months</li><li>Can teach patients at home exercises: 'vestibular rehab': e.g Brandt-Daroff exercises</li><li>Betahistine not very useful</li></ul>
Describe the prognosis for benign paroxysmal positional vertigo
<ul><li>1/2 will have recurrence of sx 3-5 years after diagnosis</li></ul>
What group of patients are more at risk of developing pressure ulcers?
<ul><li>Patients who are unable to move parts of their body due to illness, paralysis or advancing age</li></ul>
Where do pressure ulcers typicallly develop?
<ul><li>Over bony prminences like the sacrum or heel</li></ul>
Name some risk factors for developing pressure ulcers?
<ul><li>Malnourishment</li><li>Incontinence-> urinary and faecal</li><li>Lack of mobility</li><li>Pain-> leads to decreased mobility</li></ul>
What scoring system is used to grade pressure ulcers?
<ul><li>Waterlow score</li></ul>
<b>Pressure ulcers grading:</b><br></br>Grade 1: {{c1::non-blanchable erythema of intact skin. Discolourationof skin, warmth, oedema or hardness used as indicators}}<br></br>Grade 2: {{c2::Partial thickness skin loss involving epidermis/dermis or both. Ulcer is superficial and present clinically as an abrasion/blister}}<br></br>Grade 3: {{c3::Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to but not through underlying fascia}}<br></br>Grade 4: {{c4::Extensive destruction, tissue necrosis ordamage to muscle, bone or supporting structures with/wihtout full thickness skin loss}}
How are pressure ulcers manageed?
<ul><li>Moist wound environemnt: hydrocolloid dressings and hydrogels(no soap)</li><li>Wound swabs not routinely done-> systemic abx use decided on clinical basis(surrounding cellulitis etc)</li><li>Consider referral to tissue viability nurses</li><li>Surgical debriedement for selected wounds</li></ul>
Whata re lower urinary tract sympotms?
<ul><li>Group of sx that occur as a result of abnormal storage, voiding or post micturition function of bladder, prostate or urethra</li></ul>
Describe the aetiology of LUTS
<ul><li>Neurological</li><li>Bladder</li><li>Prostate</li><li>Urethral</li><li>Other mass effect</li></ul>
How can LUTS be classified?
<ul><li>Voiding</li><li>Storage</li><li>Post-micturition</li></ul>
Name somee voiding symptoms LUTS
<ul><li>Hesitancy</li><li>Straining</li><li>Terminal dribbling</li><li>Incomplete emptying</li><li>Weak/intermittent urinary stream</li></ul>
Name some storage sx LUTS
<ul><li>Urgency</li><li>Frequency</li><li>Nocturia</li><li>Urinary incontinence</li></ul>
Name some post-micturition sx LUTS
<ul><li>Post-micturition dribbling</li><li>Sensation of incomplete emptying</li></ul>
Name some differentials for LUTS
<ul><li>Bladder outlet obstruction</li><li>Overactive bladder syndorme</li><li>Urethral stricture</li><li>Prostatitis</li><li>Bladder cancer</li></ul>
What investigations might be done in a patient presenting with LUTS?
<ul><li>Urinalysis: exclude infection and check for haematuria</li><li>DRE: size and consistency of prostate</li><li>PSA test may be considered</li><li>Bladder diary</li><li>Urodynamic studies</li></ul>
How are LUTS managed?
<ul><li>Treat undelrying cause</li><li>Depends on type of LUTS</li></ul>
How aare voiding LUTS managed?
<ul><li>Conservatrive: pelvic floor/bladder trianing</li><li>BPH-5-alpha reductase inhibitor-finasteride</li><li>Alpha blocker if severe-doxazosin</li></ul>
How are voiding and storage LUTS managed?
<ul><li>Alpha blocker-doxazosin</li><li>Add anticholinergic-oxybutinin</li></ul>
How are overactive bladder symptoms managed?
<ul><li>Conservative: fluid management</li><li>Antimuscarininc if persistent-oxybutinin, tolteridone</li></ul>
How is nocturia managed?
<ul><li>Manage fluid intake at night</li><li>Furosemide 40mg in late afternoon</li><li>Desmopressin</li></ul>
What are the different types of urinary incontinence?
<div><ul><li>Stress-> leaking small amounts when laughing/coughing</li><li>Urge/overactive-> detrusor overactivityy</li><li>Mixed: urge/stress</li><li>Overflow-> bladder outlet obstruction</li><li>Functional</li></ul></div>
What causes overflow incontinence
<ul><li>Bladder outlet obstruction(e.g. prostate enlargement)</li></ul>
Name some reversible causes of urinary incontinence
DIAPPERS<br></br><ul><li>Delirium</li><li>Infection</li><li>Atrophic vaginitis/urethritis</li><li>Pharmaceutical(medications)</li><li>Psychiatric disorders</li><li>Endocrine disorders(diabetes)</li><li>Restricted mobility</li><li>Stool impaction</li></ul>
What investigations migh tbe done to look for causes of urinary incontinence?
<ul><li>Physical exam: organ prolapse ad ability to contract pelvic floor muscles</li><li>Bladder diary: number and types of incontinence</li><li>Urinalysis: rule out infection</li><li>Cytometry: measurees bladder presure whilse voiding(not recommended where clear diagnosis)</li><li>Cystogram: Contrast in bladder and imaging(fistula)</li></ul>
What is stress incontinence?
Leaking of urine when abdominal pressure is high-> increases pressure on bladder
Name some risk factors for stress incontinence
<ul><li>Childbirth(especially vaginal)-> injury to pelvic floor muscles and connective tissue</li><li>Hysterectomy</li></ul>
Name some triggers for stress incontinence
<ul><li>Coughing</li><li>Laughing</li><li>Sneezing</li><li>Exercise</li><li>Anything that increases abdominal pressure</li></ul>
Describe the management of stress icontinence
<ul><li>Conservative: avoid fizzy, caffeinated drinks, pelvic floor exercises</li><li>Medical: Duloxetine</li><li>Surgical: GS: mid urethral slings(minimally nvasive, done as outpatients)</li></ul>
Name some risk factors for urge incontinence
<ul><li>Recurrent UTI</li><li>High BMI</li><li>Increasing age</li><li>Smoking</li><li>Caffeine</li></ul>
Describe the management of urge incontinence
<ul><li>Conservative: Bladder training, avoid alcoholic/caffeinted/sugary drinks</li><li>Medical: anticholinergics: oxybutinin, tolterodine, fesoterodine</li><li>Surgical: bladder instillation, sacral neuromodulation</li></ul>
Name a side effect of tolterodine
<ul><li>Increased risk of delirium</li></ul>
Name the causes of overflow incontinence
<ul><li>Underactivity of detrusor muscle(e.g from nerve damage) or if urinary outlet pressures are too high(constipation, prostatism)</li></ul>
What is functional incontinence?
<ul><li>Urge to pass urine but can't access facilities so experience incontinence</li></ul>
Name some causes/risk factors for functional incontinence
<ul><li>Sedating meds</li><li>Alochol</li><li>Dementias</li></ul>
What is quamous cell carcinoma?
<ul><li>Locally invasive malignant tumour of epidermal keratinocytes</li><li>With invasion of basement membrane as it is a cancer</li></ul>
Name some risk factors for SCC
<ul><li>Excessive exposure to sunlight/UV light</li><li>Actinic keratosis and Bowen's disease-> predisposing lesions</li><li>Genetics: xeroderma pigmentosum</li><li>Immunosuppresion</li><li>Smoking</li><li>Old age</li><li>Male</li></ul>
How might patients with SCC present?
<ul><li>Keratinised, scaly irregular nodules</li><li>Might be ulcerating or have everted edges</li><li>Often in sun exposed areas</li><li>Usually slow growing(months)</li><li>Pain, tenderness, bleeding</li><li>Complicaotins for local invasion-distant metastases is rare</li></ul>
How is SCC diagnosed?
<ul><li>Excision biopsy with 4mm margin</li><li>Might require 6mm margin if high risk</li></ul>
Name some features of a possible SCC that make it more high risk
<ul><li>>2cm diameter</li><li>Located on ear, lip, hands, feet or genitals</li><li>Elderly or immunosuppressed</li><li>Histology: poor differentiation, blood/nerve involvement, SC tissue invasion</li></ul>
How is SCC treated?
<div><ul><li>Surgical excision</li><li>Radiotherapy may be needed</li><li>Lifestyle to prevent further lesions-> sunscreen</li></ul></div>
What is the prognosis for SCC
<ul><li>5 year survival of 99% if detected early</li></ul>
Name some poor prognostic factors for SCC
<ul><li>Poorly differentiated</li><li>>2cm diameter</li><li>>4mm deep</li><li>Immunosuppression</li></ul>
How can constipation be classified?
<ul><li>Primary: no organic cause: dysregulation of function of colon/anorectal muscles</li><li>Secondary: diet, medications, metabolic, endocrinee, neuro, obstruction</li></ul>
What criteria is used for classifying constipation?
<ul><li>Rome 6 criteria</li></ul>
Describe the Rome 6 criteria for constipation
<ul><li><3 bowel movements/week</li><li>Hard stool in >25% of movements</li><li>Teenesmus in >25% of movements</li><li>Increased straining in >25% of movements</li><li>Need for manual evacuation</li></ul>
<div><br></br></div>
<div>Any or all of them can constitute a diagnosis of constipation</div>
Name some risk factors for constipation
<ul><li>Increasing age</li><li>Inactivity</li><li>Low calorie diet</li><li>Low fibre diet</li><li>Certain medications</li><li>Female</li></ul>
Name some possible causes of constipation
<ul><li>Inadequate fibre or fluid intake</li><li>Behavioural: inactivity of avoidance of defaecation</li><li>Electrolyte distrubances like hypercalcaemia</li><li>Drugs: opiates, CCBs, antipsychotics</li><li>Neurological: spinal cord lesions, Parkinson's, diabetic neuropathy</li><li>Endocrine-> hypothyroidism</li><li>Colon disease-> strictures/cancer/obstruction</li><li>Anal disease-> fissures</li></ul>
Name some red flag associated features of constipation
ALARMS<br></br><ul><li>Anaemia</li><li>Lost weight</li><li>Anorexia</li><li>Recent onset</li><li>Melaena/bleeding</li><li>Swallowing difficulties</li></ul>
What investigations might be done in a patient with constipation?
<ul><li>Constipation/diarrhoea+ weight loss+ >60yrs-> 2wwk wait urgent CT/US to rule out pancreatic cancer</li><li>Often no need for further ix</li><li>PR exam</li><li>Stool sample: mcs, ova, cysts, parasites</li><li>FIT testing</li><li>Faecal calprotectin</li><li>Bloods: anaemia, hypercalcaemia, hypothyroidism</li><li>Barium enema if suspicion of impaction/rectal mass</li><li>Colonoscopy-> lower GI malgnancy</li></ul>
Describe the management of constipation
<ul><li>Conservative: dietary imrpovements and increase exercise</li><li>Laxatives</li></ul>
What are the different types of laxatives
<ul><li>Bulking agents</li><li>Stool softeners</li><li>Stimulants</li><li>Osmotic laxatives</li><li>Phosphate enemas</li></ul>
Give an example of a bulking agent
<ul><li>Ipsaghula husk</li></ul>
How do bulking agents work?
<ul><li>Increase faecal bulk and peristalsis</li></ul>
When might bulking agents be contraindicated?
<ul><li>Dysphagia</li><li>GI obstruction</li><li>Faecal impaction</li></ul>
Name a side effect of bulking agents
<ul><li>Cramps</li></ul>
Give an example of a stool softener
<ul><li>Docusate</li><li>Macrogol</li></ul>
How do stool softeners work and when might they be used
<ul><li>Soften bowel movements</li><li>Good for fissures</li></ul>
When are stool softeners contraindicated?
<ul><li>IBD</li><li>Ileus</li><li>Risk of inttestinal perforation</li></ul>
Name some side effects of stool softeners
<ul><li>Flatulence</li><li>Nausea</li></ul>
Give an example of a stimulant laxative
<ul><li>Senna</li><li>Biisacodyl</li></ul>
How do stimulant laxatives work?
<ul><li>Increase intestinal motility</li></ul>
When might stimulant laxatives be contraindicated?
<ul><li>Obstruction</li><li>Colitis</li></ul>
Give a side effect of stimulatn laxatives
<ul><li>Cramps</li></ul>
Give an example of on osmotic laxative
<ul><li>Lactulose</li><li>Movicol</li></ul>
How do osmotic laxatives work?
<ul><li>Retain fluid in the bowel</li><li>Decrease NH3</li></ul>
Give a side effect of osmotic laxatives
<ul><li>Electrolyte imbalances</li><li>Diarrhoea</li></ul>
What must be done before a phosphate enema?
<ul><li>DRE first</li><li>Will cause rapid bowwel evacuation</li></ul>
Give some contraindications to a phosphate enema
<ul><li>Renal faioure</li><li>Heart failure</li><li>Electrolyte abnormalities</li></ul>
Give some side effects of a phosphate enema
<ul><li>Abdominal cramps</li><li>Dehydration</li></ul>
Define malnutrition
<ul><li>BMI<18.5 OR</li><li>Unintentional weight loss >10% in the last 3-6 mths OR</li><li>BMI<20 and unintentional weight loss >5% in the last 3-6 mths</li></ul>
How is malnutrition diagnosed?
<ul><li>Malnutrition Universal Screen Tool (MUST)</li><li>Takes into account BMI, unplanned weight loss score and acute disease effect</li><li>Should be done on admission of if there is cause for concern</li><li>Categorises patients into low, medium and high risk</li></ul>
How is malnutrition managed?
<ul><li>Dietician support if patient is high risk</li><li>'Food-first' approach with clear instructions(add full fat cream to potatoes etc)</li><li>Oral nutritional supplements between meals</li></ul>
What is re-feeding syndrome?
<ul><li>Caused by reintroduction of glucose into the body after a period of malnutrition or fasting</li></ul>
Describe the pathophysiology of re-feeding syndrome?
<ul><li>Reintroduction of glucose-> insulin secretion resumes-> shift in electrolytes</li></ul>
How might patients with re-feeding syndrome present?
<ul><li>Low phosphate: weakness, resp failure, delirium, seizures</li><li>Low magnesium: muscle weakness, arrhythmias, NM excitability</li><li>Low potassium: weakness, paralysis, cardiac arrhythmias</li><li>High glucose: diabetes sx: increased thirst, urination, fatigue, blurred vision</li></ul>
How is re-feeding syndrome managed?
<ul><li>Monitoring and correctin of electrolyte imbalances</li><li>Slow reintroduction of food and fluids to avoid sudden shiffts in electrolytes</li><li>Thiamine replacement for at risk patients to prevent Wernicke's encephalopathy</li></ul>
Name some risk ffactors for non-accidental injury
<ul><li>Caergive substance abuse</li><li>Caregiver mental health issues</li><li>Socioeconomic disadvantage</li></ul>
How might elderly patients with non accidental injury ppresent-history?
<ul><li>Delayed presentation followwing injury</li><li>Inconsistencies in caregiver's narratives</li><li>Unwitnessed injuries</li><li>Evidence of drug/alcohol use </li></ul>
How might elderly patients with non accidental injury present-examination?
<ul><li>Injuries of varying ages</li><li>Subconjunctival/retinal haemorrhages</li><li>Bruises on arms, legs, or face consisten with grippping, burns, scalds</li></ul>
Name some differentials for non accidental injury
<ul><li>Accidental injury</li><li>Bleeding disorders</li><li>Haematological malignancy</li></ul>
What investigations might be done if non accidental injury is suspected?
<ul><li>Radiology: comprehensive skeletal survey(rib fractures, skull, finger, clavice etc)</li><li>Bloods: organic causes like clotting problems and blood cancers</li></ul>
How should non accidentl injury be managed?
<ul><li>Report suspicions to informed senior or safeguarding lead</li><li>Measures: admit and ensure safety of anyone else in the home</li><li>Treat other injuries</li><li>Document everything</li><li>Contact social care liaison</li></ul>
What is a DoLS?
<ul><li>Procedure used by law when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment/care to keep them safe from harm</li></ul>
How must a DoLS be authorised by?
<ul><li>Supervisory authority(e.g. local authority)</li></ul>
What conditions must be met to put a DoLS in place?
<ul><li>>18yrs and mental disorder</li><li>In hospital or care home</li><li>Pt lacks capacity to decide for themselves about the roposed restrictions</li><li>Proposed restrictions in person's best interest and would deprive person of their liberty</li><li>Not suitablee for detention under the MHA</li></ul>
What is Power of Attorney
<ul><li>Legal document that nominates another person to make decisions on their behalf related to financial/property or health/welfare</li></ul>
What is an advanced decision?
<ul><li>Legally binding document to ensure an individual can refuse a specific treatment(s) they don't want in the future</li></ul>
What criteria must be met for an advanced decision to be put into place?
<ul><li>Valide(made when person had capacity)</li><li>Applicable(wording specific to medical decision)</li><li>>18 yrs and fully informed wheen made</li><li>Not made under duress or influence of other people</li><li>Writeen down, signed and witnessed(if it concerns life saving treatment)</li></ul>
What does an advanced decision cover?
<ul><li>Refusal of treatments including life sustaining treatments</li><li>Can't refuse basic care, food/drink by mout, measures designed purely for comfort(painkillers) or treatment of a mental health disorder if sectoined under the MHA</li><li>Can't demand specific treatment/somethign illegal</li></ul>
What is an advanced statement?
<ul><li>Statement of wishes and care preferences</li><li>Not legally binding by itself but legally must be taken into account when making a 'best interests' decision</li></ul>
What creiteria must be met to make an advanced statement?
<ul><li>Can be made verballyy butbetter written down for documentation</li><li>Copies can be given t anyone like GPs, carers, relatives</li></ul>
What kind of things might be covered in n advanced statement?
<ul><li>Religious/personal views and how these relate to care</li><li>Food preferences</li><li>Info about dialy routine</li><li>People who youw ould like to be consulted when best interest decisions are being made on your behalf(not the same as creaitng a lasting power of attorney)</li></ul>
What is osteoporosis?
<ul><li>Systemic skeletal disease characterised by decreased bone mass and altered micro-architecture of bone tissue resultin in increased bone fragility and fracture risk</li></ul>
Describe the pathophysiology of osteoporosis
<ul><li>Primary: post menopausal(Type 1) and age related(type 2)-most commmon</li><li>Secondary: hyperthyroidism/hyperparathyroidism/alcohol abuse/immobilisation</li><li>Increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts</li></ul>
What genes are involved in osteoporosis?
<ul><li>Collagen 1A1</li><li>Vitamin D receptor</li><li>Oestrogen receptor gene</li></ul>
How does oestrogen deficiency result in osteoporosis?
<ul><li>Increases number of remodelling units</li><li>Premature arrest of osteoblastic synthetic activity and trabeculae perforation</li><li>Loss of resistance to fracture</li></ul>
How do glucocorticoids cause osteoporosis?
<ul><li>Increase turnover atate initially(increased fracture risk in first 3 months)</li><li>The decreased turnover rate with net loss due to decreased synthesis by osteoblasts</li><li>Usually when used minimum 10mg OD for >3 months</li></ul>
How does ageing contribute to osteoporosis?
<ul><li>Increased turnover at the bone/vascular interface with cortical bone-> weak structure for stresses in long bones9trabeculazation of cortical bone)</li></ul>
Name some risk factors for osteoporosis
<div>SHATTERED</div>
<div><ul><li>Steroid use</li><li>Hyperthyroidism/hyperparathyroidism</li><li>alcohol and smoking</li><li>thin: BMI<22</li><li>testosterone deficiency(men wwith long term androgen deprivation therapy for prostate cancer)</li><li>early menopause</li><li>renal/liver failure</li><li>erosive/inflammatory bone disease</li><li>diabetes</li></ul><div>Also family history</div></div>
How do patients with osteoporosis present?
<ul><li>Pathological or fragility fractures(often from a fall at first</li><li>Most commonly vertebral compression fractures of appendicular fractures</li></ul>
What are the most common frfactures for patients with osteoporosis?
<ul><li>Vertebral compression fractures</li><li>Appendicular fractures(proximal femur/distal radius)</li></ul>
How do patients present with a vertebral fracture?
<ul><li>Sudden episode of acute back pain on rest/bending/lifting</li><li>restricted spinal felxion and intensified pain with prolonged standing</li><li>Dowager's hump: thoracic kyphosis-. anterior thoracic spine</li><li>Paravertebral muscle spams and tenderness on deep palpation</li></ul>
How do patient with appendicular fractures present?
<ul><li>NOF: hip pain, inability to weight bear, shortened and externally rotated leg</li><li>Colles: fall on outstrtched arm: wrist pain and decreased range of motion</li></ul>
What is the gold standrad for diagnosing osteoporosis?
<ul><li>DEXA sacn(dual energy x-ray absorptiometry)</li></ul>
<div>Can also use x-rays/MRI for suspected vertebral/other fractures</div>
How might you identify secondary causes of osteoporosis?
<ul><li>History and full exam</li><li>FBC, U&Es-Creatinine, calcium phosphate TFTs</li><li>LFTs</li><li>25OH vit D and 1-25 OH vit D</li><li>Serum testosteerone and prolactin</li><li>Lateral radiographs of thoracic and lumbar spine</li><li>Protein immunoelectrophoresis and urinary Bence Jones proteins</li></ul>
Name some differentials for osteoporosis
<ul><li>Osteomalacia: similar but also generalised bone pain and myopathy</li><li>Paget's: bone pain, joint pain, bone deformities, neuro complications</li><li>Malignancies: myeloma, lymphoma, metastatic/primary bone disease</li><li>Secondary causes: hyper(para)thyroidism, mastocytosis, Cushing's, sickle cell</li></ul>
For a patient with osteoporosis, what would their calcium, phosphate, ALP and PTH look like?
All normal
For a patient with osteomalacia, what would their calcium, phosphate, ALP and PTH look like?
<ul><li>Low calcium</li><li>Low phosphate</li><li>High ALP</li><li>High pTH</li></ul>
For a patient with Paget’s, what would their calcium, phosphate, ALP and PTH look like?
<ul><li>Normal calcium</li><li>Normal phosphate</li><li>High ALP</li><li>Normal PTH</li></ul>
How should you interpret DEXA scan scoring?
<ul><li>T>-1: normal</li><li>-1>T>-2.5: osteopenia</li><li>T<-2.5: osteoporosis</li></ul>
How is osteoporosis diagnosed?
<ul><li>DEXA scan and T score</li></ul>
What scoring tool is used to determine the risk of fracture in a patient with osteoporosis?
<ul><li>FRAX score</li><li>Estimates 10 year probability of a major osteoporotic fracture</li></ul>
What factors are used when calculating FRAX score?
<ul><li>Age: 40-90yrs</li><li>Gender</li><li>Previous fracture</li><li>Parental hip fracture</li><li>Smoking</li><li>Gluccocorticoid use(>3 months at >5mg OD)</li><li>Rheumatoid arthritis</li><li>Secondary osteoporosis causes</li><li>Alcohol consumption</li><li>BMD</li></ul>
How is FRAX score interpreted?
<ul><li><10% :normal</li><li>10-20%: osteopenia</li><li>>200%: osteoporosis</li></ul>
How is osteoporosis managed?
<ul><li>Lifestylee: decrease risk factors</li><li>Bisphosphonates</li><li>Denosumab</li></ul>
What lifestyle modifications might be suggested in a patient with osteoporosis?
<ul><li>Decrease risk factors(smoking etc)</li><li>Increase calcium and vitamin D intake</li><li>Increase weight bearing and muscle stengthening exercises</li></ul>
When might bisphosphonates be used as a treatment?
<ul><li>T score<-2.5 OR</li><li>-1->-2.5 with a FRAX >20%</li></ul>
How do bisphosphonates work?
<ul><li>Adhere to hydroxyapatite and inhibit oscteoclasts</li></ul>
Give some examples of bisphosphonates and how they are used
<ul><li>Oral alendronate and risedronate(1 weekly doses)</li><li>Xoledronic acid(once a year infusion)</li></ul>
How should bisphosphonates be taken?
<ul><li>On an empty stomach with water and remain upright for at least 30 minutes afterwards</li></ul>
Name some side effects of bisphosphonates
<ul><li>Oesophagitis</li><li>Dyspepsia</li></ul>
What is denosumab and when is it used?
<ul><li>Monoclonal antibody</li><li>Used for extensive osteoporosis</li></ul>
How is denosumab administered?
SC injection every 6 months
How does denosumab work?
<ul><li>Anti-resorptive agent that increases BMD and decreases fracture risk at spine</li></ul>
Name some side efffects of denosumab
<ul><li>Limited mobility</li><li>Increased fracture risk</li><li>Depression</li><li>Pain</li><li>Complications of medication</li></ul>
What systems are required to function to have a normal gait?
<ul><li>Neurological: basal ganglia and cortical basal ganglia loop</li><li>MSK: appropriate tone and strength</li><li>Senses: sight, sound and sensation(including fine touch and proprioception)</li></ul>
Name some risk factors for falls
<ul><li>lower limb muscle weakness</li><li>Vision problems</li><li>balance/gait disturbances</li><li>polypharmacy</li><li>postural hypotension</li><li>psychoactive drugs</li><li>incontinence</li><li>>65 years</li><li>fear of falling</li><li>depression</li><li>cognitive impairment</li></ul>
Name some drugs that can cause postural hypootension
<ul><li>Nitrates</li><li>Diuretics</li><li>Anticholinergics</li><li>Antidepressants</li><li>Beta blockers</li><li>Levodopa</li><li>ACE inhibitors</li></ul>
Name some drugs that can cause falls through mechanisms other than postural hypotension
<ul><li>benxos</li><li>antipsychotics</li><li>opiates</li><li>anticonvulsants</li><li>codeine</li><li>digoxin</li><li>sedative agetns</li></ul>
What investigations might be done in patients who have had a fall?
<ul><li>Full hx, risk assessment and examination</li><li>Bedside: Obs, BP, glucose, urine dip, ECG</li><li>Bloods: FBC, U&Es, LFTs, bone profile</li><li>Imaging: x-rays of injured limbs, CT head, cardiac echo</li></ul>
Describe the management of patients with falls
<ul><li>'Turn 180 test' or 'Timed get up and go' test</li><li>Consider MDT assessment</li><li>Treat underlying cause</li><li>Manage risk factors</li><li>Lifestyle/home changes</li></ul>
When should an MDT assessment be considered in patients with falls?
>65 yrs with:<br></br><ul><li>>2 falls in the last 12 months</li><li>Fall requiring medical treatment</li><li>Poor performance or failure to complete above tests</li></ul>
What is delirium?
<ul><li>Acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness</li></ul>
What are the 3 subtypes of delirium?
<ul><li>Hyperactive: increased psychomotor activity, restlessness, agitation and hallucinations</li><li>Hpoactive: lethargy, reduced responsiveness and withdrawal</li><li>Mixed: features of both hyper and hypo</li></ul>
Descrieb the epidemiology of delirium
<ul><li>Common</li><li>Elderly</li><li>Incidence increases with age, severity of illness and pre-existing cognitive impairment</li></ul>
Describe the aetiology of delirium
DELIRIUMS<br></br><ul><li>Drugs and alcohol</li><li>Eyes, ears and emotional disturbances</li><li>Low output state(MI, ARDS, PE, CHF, COPD)</li><li>Infection</li><li>Retention(urine or stool)</li><li>Ictal</li><li>Under-hydration or under-nutrition</li><li>Metabolic(electrolyte imbalances, thyroid disorders, Wernicke’s</li><li>Subdural haematoma, sleep deprivation</li></ul>
Name some drugs that can cause delirium?
<ul><li>Anti-cholinergics</li><li>Opiates</li><li>Anti-convulsants</li><li>Recreational</li></ul>
Name some symptoms of delirium
<ul><li>Disorientation</li><li>Hallucinations</li><li>Inattention</li><li>Memory problems</li><li>Change in mood or personality</li><li>Sundowning-> worse agitation/confusion in late afternoon/evening</li><li>Disturbed sleep</li><li>Hpoactive can be easily misssed</li></ul>
Give some differential diagnoses for delirium
<ul><li>Dementia</li><li>Psychosis</li><li>Depression</li><li>Stroke</li></ul>
How is delirium diagnosed/assessed?
<ul><li>4AT and CAM: tools</li><li>Bedside: bladder scan, review meds, ECG, urine MCS</li><li>Bloods: FBC, U&E,LFTs, TFTs, blood cultures</li><li>Imaging: CXR, US, neuroimaging if suspected cause</li></ul>
Describe the management of delirium
<ul><li>Treat unerlying cause</li><li>Good lighting, regular sleep-wake cycle, regular orientation and reassurance, glassess and hearing aids if needed</li><li>If severely agitated: haloperidol/lorazepam, olanzapine as last resort due ot side effects</li><li>Don't give haloperidol for Parkionsonism(blocks dopamine receptors)</li></ul>
Name some factors favouring delirium over dementia
<ul><li>Acute onset</li><li>Impairment of consciousness</li><li>Fluctuation of symptoms(worse at night, periods of normality)</li><li>Abnormal perception(hallucinations, illusions)</li><li>Agitation, fear</li><li>Delusions</li></ul>
Name some risk factors for delirium
<ul><li>Age >65 yrs</li><li>Backgound of dementia</li><li>Significant injury(hip fracture)</li><li>Frailty or multimorbidity</li><li>Polypharmacy</li></ul>
