TO DO GERIATRICS Flashcards
DELIRIUM
what are the causes of delirium?
PINCH ME –
- Pain
- Infection (UTI, pneumonia, septicaemia)
- Nutrition (thiamine, B12 + folate deficiency)
- Constipation (faecal impaction)
- Hydration (dehydrated)
- Metabolic/medication
- Environment/electrolytes (changes in environment, hyper/hypo Ca2+, Na+, K+)
DELIRIUM
What are some metabolic/medication causes of delirium?
- Hyper/hypo thyroid + glycaemia
- Hypercortisolaemia
- Substance misuse
- Withdrawal (incl. delirium tremens)
- Opioids, anticholinergics, Parkinson’s meds, steroids, BDZs, interactions
DELIRIUM
What is a suitable screening tool for delirium?
4AT (≥4 = likely) –
- Alertness
- AMT4 (age, DOB, hospital name, year)
- Attention (list months backwards)
- Acute change or fluctuating course
DELIRIUM
What general investigations would you do/enquiry about in a patient with delirium?
- FBC
- blood glucose
- LFTs
- bone profile
- TFTs
- U&Es
- folate + B12
- drug levels (digoxin, lithium, alcohol)
- inflammatory markers
to consider
- CXR
DELIRIUM
Sometimes conservative de-escalation is inadequate and medications may be required. What are some options?
- Short-term antipsychotics – haloperidol 0.5mg or olanzapine
- Short-acting BDZ like lorazepam 0.5mg (caution may exacerbate confusion + over sedate)
- Long-acting BDZ if withdrawing (chlordiazepoxide, diazepam)
DEMENTIA
What might a MMSE score indicate in dementia?
MMSE (/30) –
- 21–26 = mild, 14–20 = mod, 10–14 mod-severe, <10 = severe cognitive impairment
DEMENTIA
What type of imaging may be used in dementia?
- SPECT to differentiate between Alzheimer’s + frontotemporal
- DaTscan shows ‘comma’ in normal but 2 dots in Lewy body + Parkinson’s dementia at the basal ganglia
DEMENTIA
What biological treatment can be used in dementia?
- Bio = risperidone for agitation (apart in Lewy-Body)
ALZHEIMER’S DISEASE
What is the clinical presentation of Alzheimer’s
4As of Alzheimer’s –
- Amnesia (recent memories poor, disorientation about time)
- Apraxia (unable to button clothes, use cutlery)
- Agnosia (unable to recognise body parts, objects, people)
- Aphasia (later feature, mixed receptive/expressive)
Insidious + progressive course of short-term memory loss Sx in early disease
ALZHEIMER’S DISEASE
On CT/MRI head in Alzheimer’s disease, what are the macroscopic pathological changes?
Diffuse cerebral atrophy (shrunken brain) particularly involving the cortex and hippocampus,
increased sulcal widening, enlarged ventricles
ALZHEIMER’S DISEASE
What is the management of Alzheimer’s?
- No cure, does not improve life expectancy but thought to slow rate of decline + allow functioning at higher level
- 1st line = AChEi (donepezil, rivastigmine) for mild–mod
- 2nd line = NMDA antagonist (memantine) for mod–severe
VASCULAR DEMENTIA
What is the management of vascular dementia?
Not reversible but prevent further decline –
- Lifestyle (lose weight, healthy diet, stop smoking + alcohol)
- Atorvastatin 80mg if high cholesterol
- Optimise co-morbidities (HTN, DM)
- Aspirin or clopidogrel (75mg OD)
LEWY-BODY DEMENTIA
What is the pathophysiology of Lewy-Body dementia?
- Presence of Lewy bodies (protein deposits) in the basal ganglia + cerebral cortex, typically presents between 50–80y
LEWY-BODY DEMENTIA
What is the clinical presentation of Lewy-Body dementia?
- Fluctuating onset, progression, cognition + consciousness
- Vivid visual hallucinations (small children, animals)
- Parkinsonism (tremor, stooped + shuffling gait, hypomimia)
- Frequent falls
- REM sleep behaviour disorder (sleep walking, aggression) commonly precedes other Sx
- Rapid decline more so than other types
LEWY-BODY DEMENTIA
What is the management of Lewy-Body dementia?
- Conservative management
- mild/mod = donepezil or rivastigmine (galantamine if both are contraindicated)
- severe = donepezil or rivastigmine (memantine if both are contraindicated)
- SENSITIVE to antipsychotics, can make worse + lead to neuroleptic malignant syndrome
FT DEMENTIA
What are 2 common features in frontotemporal (FT) dementia?
- Early personality changes + relative intellectual sparing.
FT DEMENTIA
What causes FT dementia?
- Unknown, younger mean age of onset
- Can be due to neurosyphilis (typically causes frontal lobe Sx such as aggression + personality change), associated with MND
FT DEMENTIA
What is the management of FT dementia?
- No specific treatment
- SSRIs may help behavioural symptoms
FALLS
What are some power causes of falls?
- Inactivity > muscle weakness
- Dizziness/loss of balance or proprioception (vertigo)
- Pain/MS > osteoarthritis
FALLS
What can cause rhabdomyolysis?
- Crush injuries
- Prolonged immobilisation following a fall
- Prolonged seizures
- Hyperthermia
- Neuroleptic malignant syndrome
POSTURAL HYPOTENSION
What is the pathophysiology of postural hypotension?
- When standing, gravity causes blood to pool in legs + abdo which decreases BP as less blood circulating back to heart
- Normally, baroreceptors near heart + carotid arteries sense this lower BP + send signals to brain to signal heart to beat faster, pump more blood, cause vasoconstriction + stabilise BP
- In postural hypotension, something interrupts this mechanism
POSTURAL HYPOTENSION
What investigations would you do to diagnose postural hypotension?
Lying + standing blood pressure
- Abnormal drop in BP of ≥20/10mmHg within 3 minutes of standing (<20/10 is physiological)
Investigate medical causes (FBC, U+Es, B12 + folate, TFTs, LFTs, CRP/ESR, ECG)
POSTURAL HYPOTENSION
What is the pharmacological management of postural hypotension?
- Med review + stop causative agent
- Fludrocortisone (raises BP by raised Na+ levels + affecting blood volume) but can cause uncomfortable oedema
- Midodrine (when cause if autonomic dysfunction) but can cause retention, itchy scalp + paraesthesia
PRESSURE ULCERS
What are 4 contributing factors to pressure ulcer development?
- Pressure
- Shear
- Friction
- Moisture
PRESSURE ULCERS
Explain how friction causes pressure ulcers.
Rubbing skin decreases integrity
PRESSURE ULCERS
What score is used to screen for risk of pressure ulcer development?
Waterlow score
PRESSURE ULCERS
What are the different grades for pressure ulcers?
- 0 = skin hyperaemia
- I = non-blanching erythema with intact skin
- II = broken skin or blistering (epidermis ± dermis only)
- III = full-thickness skin loss involving damage/necrosis of subcutaneous tissue
- IV = extensive loss, destruction/necrosis of muscle, bone, joint or tendon
- Unstageable = depth unknown, base of ulcer covered by debris
PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?
- Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD
PHARMACOLOGY
Give an example of NMDA?
- Memantine
INCONTINENCE
What are some causes of incontinence?
- MS
- Stroke
- Parkinson’s
- Spinal trauma
- Cauda equina/cord compression
- Brian tumour
- Normal pressure hydrocephalus
URINARY RETENTION
What are some causes of urinary retention?
- BPH (#1 cause in men)
- Urethral strictures
- Anticholinergics
- Alcohol
- Constipation
- Infection
- Cancer
URINARY RETENTION
What other management is there for urinary retention?
- Catheterise acutely with ?intermittent self-catheterisation at home needed
- Alpha-blocker tamsulosin to relax muscles in bladder neck making easier to urinate (+ effect on prostate for BPH)
DEMENTIA
What might an Addenbrooke’s cognitive examination III (ACE-III) score indicate in dementia?
ACE-III (/100) –
- <82 likely dementia + need abnormal scores in ≥2 domains (attention/orientation, memory, language, visuospatial, fluency)
ALZHEIMER’S DISEASE
What neurotransmitters are affected?
- ACh, noradrenaline, serotonin, somatostatin
ALZHEIMER’S DISEASE
On CT/MRI head in Alzheimer’s disease, what are the microscopic or histological pathological changes?
Neuronal loss, neurofibrillary tangles, beta-amyloid plaques
FT DEMENTIA
What are some pathological features of frontotemporal dementia?
- Microscopic = ubiquitin + tau deposits (pick bodies)
FT DEMENTIA
What are the symptoms of FT dementia?
TEMPORAL
Speech disturbances (progressive non-fluent aphasia, may end up mute), expressive dysphasia
FRONTAL LOBE
Euphoria, disinhibition, personality changes + emotional blunting
FALLS
What clinical scale can be used to assess frailty?
- Rockwood clinical frailty scale (from very fit, vulnerable, moderately frail to terminally ill)
PRESSURE ULCERS
Explain how shear causes pressure ulcers.
Skin pulled away from fixed axial skeleton so blood vessels can be kinked or torn (may occur during lifts or transfers)
PRESSURE ULCERS
Explain how moisture causes pressure ulcers.
Sweat, urine + faeces cause maceration + decrease integrity
PHARMACOLOGY
Give some examples of acetylcholinesterase inhibitors
Donepezil, rivastigmine
PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?
- D+V,
- nausea,
- abdo pain (work systemically so GI upset)
- bradycardia
PHARMACOLOGY
When should NMDA be avoided?
Do not give in renal failure (low GFR) as nephrotoxic
PHARMACOLOGY
What are some side effects of NMDA?
- Confusion,
- hallucinations,
- agitation,
- paranoid delusions
BPPV
what are the causes?
50-70% = primary (idiopathic)
secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines
CONSTIPATION
what are the primary and secondary causes?
Primary
- disordered regulation of colonic and anorectal neuromuscular function
- IBS
Secondary
- metabolic - hypercalcaemia, hypothyroidism
- medicines - opiates, CCBs, antipsychotics
- neurological disorders - parkinsons, spinal cord lesions, DM
- bowel diseases - cancer, stricture, anal fissure
COTE ASSESSMENT
What is frailty?
- State of increased vulnerability resulting from ageing-associated decline in reserve + function across multiple physiological systems resulting in compromised ability to cope with everyday or acute stressors
COTE ASSESSMENT
What are the geriatric giants?
What do they represent?
4Is – - Instability (falls) - Immobility - Intellectual impairment (confusion) - Incontinence They are not diagnoses but more general things that COTE pts present with, often indicator of underlying problem
COTE ASSESSMENT
What are the geriatric 5Ms?
- Mind = dementia, delirium, depression
- Mobility = impaired gait + balance, falls
- Medications = polypharmacy, medication burden, adverse effects, de-prescribing/optimal prescribing
- Multi-complexity = multi-morbidity, biopsychosocial
- Matters most = individual meaningful health outcomes + preferences
POLYPHARMACY
What is pharmacodynamics?
How does this change for the elderly?
- What the DRUG does to the BODY
- In elderly, effects of similar drug conc. may be different to younger so prone to adverse drug reactions
POLYPHAMRACY
What is pharmacokinetics?
How does this change for the elderly?
- What the BODY does to the DRUG
- Changes in absorption, distribution, metabolism + excretion of drugs
- May mean drugs hang around longer or elderly pts may experience more toxicity from smaller dose
POLYPHARMACY
Give some specific pharmacokinetic issues in geriatrics.
- Hepatic first pass metabolism declines
- Reduced absorption as gastric pH increases due to atrophy
- Vascular system less responsive due to calcification of vessels
POLYPHARMACY
Why might inappropriate drug use occur in geriatrics?
- May not understand instructions
- May be unable to read instructions
- May make own interpretation of instructions
- Could be due to lack of treatment supervision
POLYPHARMACY
What are some potential problems with polypharmacy?
- Drug interactions + increased SEs
- Can affect compliance + lead to decreased pt satisfaction
- Pill burden
POLYPHARMACY
What are the reasons for problematic polypharmacy?
- Multimorbidity (increased prevalence with increasing age)
- Incremental prescribing (prescribing cascade) = prescribers may not recognise Sx iatrogenic so prescribe more meds to counter SEs of other drugs
- End-of-life considerations
MENTAL CAPACITY ACT
What are the 4 aspects of assessing capacity?
- Does the pt UNDERSTAND the information?
- Can the pt RETAIN that information?
- Can the pt use the information to WEIGH UP the pros + cons?
- Can the pt COMMUNICATE their decision back (ensure different methods explored)
MENTAL CAPACITY ACT
What are the 5 principles underpinning the MCA?
- Assume capacity until proven otherwise
- Maximise decision-making capacity (all practical support to help them make decision given)
- Freedom to make seemingly unwise choice (unwise decision ≠ incapacity)
- All decisions on behalf of patient in best interests
- Least restrictive option should be chosen
BEST INTERESTS
What are some important considerations when making best interest decisions?
- Encourage participation of the patient wherever possible
- Find out person’s views (past + present wishes, feelings, beliefs + values)
- Avoid discrimination (don’t make assumptions on any personal features)
- Regaining capacity (can the decision wait?)
- Identify all relevant circumstances to identify what they would have taken into account if they were making this decision
DOLS
What is the acid test for DoLS?
Must meet 3 criteria –
- Lack of capacity to consent to the arrangements or their care
- Subject to continuous supervision + control
- Not free to leave their care setting
ADVANCED CARE PLANNING
What can an advanced directive include?
- Where they would like to be cared for (home, nursing home), concerns about practical issues (who will look after pet if ill)
- Can authorise or request specific procedures (Where suitable)
- Can refuse treatment in a predefined future situation
MEDICO-LEGAL ASPECTS
What is an advanced refusal of treatments?
Is it legally binding?
- A living will
- Yes if:
– Adult ≥18y
– Was competent + fully informed when made decision
– Decision is clearly applicable to current circumstances
– No reason to believe changed mind
MEDICO-LEGAL ASPECTS
What is an advanced requests for treatment?
Is it legally binding?
- Patient’s wish for treatment
- Less legal binding but if it’s patient’s known wish to be kept alive then reasonable efforts (nutrition, hydration) should be considered
ALZHEIMER’S DISEASE
what are the microscopic pathological changes?
beta amyloid plaques
neurofibrillary tangles
FT DEMENTIA
what is FT dementia also known as?
Pick’s disease
