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Geriatrics > Y4 - Lecture Notes > Flashcards

Y4 - Lecture Notes Flashcards

1
Q

State some reasons why the population is getting older

A 
Better sanitation 
Improvements in housing, education and nutrition 
Smaller family size
Higher incomes
Vaccination 
Increased life expectancy
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2
Q

State some impacts of an ageing population

A

Affects:
Retirement age
Pensions

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3
Q

Name some social aspects of ageing

A

Health loss due to increasing pathology
Wealth loss
Companionship loss due to bereavement
Loss of independence due to disabilities
Loss of homeostasis due to impairments of body systems
Loss of status following retirement and loss of independence

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4
Q

How much exercise is recommended in the elderly?

A

30m moderate intensity on most days

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5
Q

What % of older adults report a limiting longstanding sickness or disability?

A

65-74y: 1/3rd

>75y: 1/2

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6
Q

Describe sheltered housing

A

Group of small flats with communal facilities for meals/social activities
Provided by local authority/voluntary sector
Buzzer system to allow residents help
Assistive devices etc. but patients usually able to mobilise/do personal care independently

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7
Q

When should an elderly patient be institutionalised (put in a nursing home)?

A

When they are no longer able to supported at home within the resources available, due to severe physical disability, immobility, severe mental disability req. constant supervision, unpredictable and frequent care needs

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8
Q

Give a few examples of institutions?

A

Long stay hospitals

Care homes providing nursing or personal care

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9
Q

How might an elderly person prevent themselves from getting influenza?

A

Annual flu jab

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10
Q

How might an elderly person prevent themselves from getting pneumonia?

A

5 yearly vaccination for pneumococcal pneumonia

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11
Q

How might an elderly person prevent themselves from getting dementia/having a stroke?

A

Treat high BP

Anticoagulation for AF

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12
Q

How might an elderly person prevent themselves from getting osteoporosis?

A

Achieving good peak bone mass in adult life and continuing to exercise

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13
Q

How might an elderly person prevent themselves from getting ischaemic heart disease?

A

Avoid tobacco

Exercise and healthy diet

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14
Q

How might an elderly person prevent themselves from getting alcoholic dementia, heart failure, pancreatitis, cirrhosis?

A

Safe drinking

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15
Q

How might an elderly person prevent themselves from getting type 2 diabetes?

A

Exercise and maintaining ideal body weight

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16
Q

How might an elderly person prevent themselves from getting COPD and lung cancer?

A

Not smoking

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17
Q

What must you be very careful of when prescribing antibiotics to the elderly?

A

Avoiding C. diff

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18
Q

What is the cut off to go to old age psychiatry?

A

65+

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19
Q

For patients that stay in their own home, what types of care can be provided?

A 
Twenty four hour care
Regular visits for care
Meals on wheels/frozen meals service
Lucheon clubs
Day centres
Respite care
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20
Q

Who do the vast majority of strokes occur in?

A

> 55s

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21
Q

Define stroke

A

Rapidly developing clinical signs of focal disturbance of cerebral function lasting 24h or longer or leading to death, with no apparent cause other than of vascular origin

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22
Q

Define TIA

A

Ischaemic (usually embolic) neurological event with symptoms lasting less than 24 hours

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23
Q

What causes a stroke? What are the two kinds of stroke?

A

Interruption of the blood supply to the brain
Due to:
Infarction
Haemorrhage

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24
Q

What is an infarct?

A

Area of ischaemia

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25
Q

What can cause an infarct in the brain?

A

Thrombosis in situ
Embolus from the carotids or heart
Low BP

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26
Q

What things may cause a haemorrhage in the brain?

A

Arterial aneurysm

Most infarcts and bleeds are due to vessels being damaged by atheroma and HTN

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27
Q

What are the risk factors for stroke and how can these be combated?

A

Increased age
HTN - diet, exercise, medical Rx
Heart disease
AF - CHA2DS2Vasc risk and Mx appropriately
Sticky platelets - aspirin (75-300mg) or clopidogrel
Carotid stenosis - surgery, antiplatelets
Smoking
Unhealthy diet
Obesity
Excess alcohol
Adverse lipid profile - diet, exercise, wt loss, 2ndary prevention - start simvastatin 40mg
DM
Lack of exercise
Previous TIA

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28
Q

What tool is used to assess risk of stroke in AF patients?

A

CHA2DS2-Vasc

C - CHF/LVEF 40% or less - 1
H - Hypertension - 1
A - Age 75+ - 2
D - Diabetes - 1
S - Stroke/TIA/TE - 2
V - Vascular disease - 1
A - Age 65-74 - 1
SC - Sex Category: Female - 1
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29
Q

How should you manage patients to reduce their stroke risk based on their CHA2DS2-Vasc score?

A 
0 = nothing
1 = aspirin 
2+ = anticoagulant (e.g. elderly patients consider warfarin, alternatives may be rivaroxaban and apixiban)
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30
Q

What are SEs of using warfarin in older patients?

A

Recurrent falls

Dementia

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31
Q

How do rivaroxaban and apixaban work?

A

Factor Xa inhibitors

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32
Q

What is the typical presentation of stroke?

A

Onset is abrupt

33
Q

If the onset of stroke like symptoms occurs over weeks/days, what should you consider?

A

Tumour

Subdural haematoma

34
Q

What are common stroke mimics?

A 
Hypoglycaemia
Partial seizures
Todd's paralysis after a partial seizure
Hemiplegic migraine
Metabolic disturbances
35
Q

In which situations may a stroke present with a coma?

A

Brain stem infarct
Large cortical infarct with brain stem compression
Seizure after stroke

36
Q

When should you be cautious giving a patient aspirin?

A

History of asthma or GI haemorrhage

37
Q

In stroke the patient looks away/towards the lesion. In brain tumours, the patient looks away/towards the lesion.

A

Stroke - towards

Tumour - away

38
Q

What tends to cause TIAs?

A

Platelet emboli from an atheromatous plaque or ulcer in the aorta or carotids or red cell emboli from the heart

39
Q

A TIA in the internal carotid region may lead to what signs?

A

Monocular loss of vision
Hemiparesis or monoparesis
Dysphasia
Unilateral sensory loss

40
Q

How should TIAs be managed?

A

300mg aspirin straight away (unless CI or on warfarin)
Refer to rapid access TIA clinic
Complete ABCD2 score
If confident about diagnosis start statin and antihypertensives straight away

41
Q

What ABCD2 score indicates a high risk of subsequent stroke after TIA?

A

4 or more

42
Q

What is the ABCD2 score?

A

Used for assessing risk of stroke after a TIA

A - age 60+ - 1
B - BP at assessment 140/90+ - 1
C - clinical features (unilateral weakness, speech disturbance) - 2 (if no weakness = 1)
D - duration >60m - 2
D - diabetes - 1
43
Q

What patients will have their cartoids scanned and how is this done?

A

After anterior circulation TIA or acute non-disabling stroke if patient suitable for carotid endarectomy

Doppler duplex imaging/MRA

44
Q

What patients should have a carotid endarectomy?

A

if there is between 70-90/99% stenosis of the cartotids

NB - carotid endarectomy is preferred over cartoid stenting in 70+

45
Q

What are the major clinical problems following stroke?

A 
Dysphasia 
Delirium 
Dysphasia
Dysarthria
Dyspraxia 
Sensory neglect
Visuospatial perception 
Executive function loss
Sensory loss
Weakness of limbs
Depression 
Shoulder pain 
Thalamic pain
46
Q

What is dysphagia?

A

Poor swallow

47
Q

What is dysphasia?

A

Disorder of language

48
Q

Who does dysphasia tend to affect?

A

Right handed patients with left hemisphere lesions

49
Q

What is dysarthria?

A

Disrupted articulation but normal content of speech

50
Q

What is dyspraxia?

A

Inability to perform purposeful movement despite adequate comprehension and motor function

51
Q

What are the kinds of sensory neglect?

A

Visual

Tactile

52
Q

How can you treat depression after stroke?

A

Antidepressants

53
Q

When is depression post stroke most common?

A

After dominant hemisphere lesion

54
Q

Give examples of symptoms/signs of a cerebellar stroke

A 
Vertigo 
Vascular RF often present 
Severe ataxia 
Difficulty walking 
Nystagmus 
Focal neurological signs
55
Q

What are the symptoms of spinal stroke?

A

Paraplegia/quadriplegia
Intermittent sharp or burning back pain
Loss of pain and temperature sensation
Incontinence

56
Q

What are the symptoms of spinal cord ischaemia?

A

Aching pain down legs (neurogenic claudication)

57
Q

What is a subarachnoid haemorrhage?

A

Bleeding where the brain blood vessels lie between the pia and arachnoid mater

58
Q

What can cause a SAH?

A

Vascular malformation
Aneurysm
Bleed from cerebral BV

59
Q

What is the typical presentation of SAH?

A

Thunderclap headache
Vomiting
Often without neurological signs

60
Q

If someone presents with suspected SAH what should you do?

A

Urgent CT

If CT negative - LP to check for xanthochromia

61
Q

How should you manage a confirmed SAH?

A

Oral nimodipine 60mg 4 hourly
Analgesia, e.g. codeine
Neurosurgery - e.g. after MRA/CT angiography, aneurysms may be clipped/clamped/blocked with endovascular coil

62
Q

How do you manage stroke?

A

Protect airway
Ensure normal BG, BP (only if risk of hypertensive emergency, e.g. encephalopathy, aortic dissection)
Nil by mouth until swallow assessment
CT/MRI w.i. 1h
Once haemorrhagic stroke ruled out - give 300mg aspirin for 2 weeks, then give 75mg thereafter
If symptom onset <4.5h ago, give alteplase (rt-PA) - delay aspirin for 24h if do this
Consider thrombectomy

63
Q

What is the penumbra?

A

In stroke, there is a central area of irreversibly damaged cells, but around this is a ‘penumbra’ of ischaemic but potentially salvageable cells

64
Q

What are the threats facing the penumbra?

A

Oedema
Glutamate, lactate, aspartate
Influx of Ca ions

65
Q

What is involved in the management of haemorrhagic stroke?

A

Vitamin K and pro-thrombin
Lowering BP
Mannitol (to maintain cerebral perfusion)

66
Q

How long can patients who have had a stroke not drive for?

A

1 month
Must inform insurance
If no residual deficit may drive again after 1m
If deficit, must inform DVLA and be re-assessed

67
Q

What is involved in primary prevention of stroke?

A 
Treat HTN, DM 
Lower lipids
Rx cardiac dx 
Quit smoking 
Exercise
Life long anticoagulation in AF/prosthetic heart valves
68
Q

What is involved in secondary prevention of stroke?

A

Controlling RFs
Aspirin 300mg for 2 weeks, then switch to long term clopidogrel/low dose aspirin if this is CI
Check for AF and Rx
Carotid doppler/MRA - ?carotid endarectomy

69
Q

Name some cardiac causes of stroke

A 
AF
Cardioversion 
Prosthetic valves
Acute MI with large left ventricular wall motion abnormalities on ECG 
Patent foramen ovale/septal defects
Cardiac surgery 
Infective endocarditis
70
Q

How does your eye sight change as you get older?

A

Reduced visual acuity
Reduced contrast sensitivity
Slower dark adaptation

71
Q

Why does your balance become impaired as you age?

A

Loss of labyrinth hair cells reducing vestibular input

72
Q

Define sarcopenia

A

Loss of muscle mass and therefore strength

73
Q

How is reaction time affected by age?

A

Reduced

74
Q

How does walking change as you age?

A

Reduced walking speed
Shorter broad based, or more irregular gait pattern
Less effective heel strike
More time spent in double support (both feet on the ground)

75
Q

How common are falls?

A

1/3rd of 65yo+
1/2 of 80yo+
Fall every year

76
Q

What is a useful pneumonia for remembering the causes of falls?

A

DAME

Drugs (polypharmacy, alcohol)
Age-related changes (e.g. gait, balance, sarcopenia, sensory impairment)
Medical (stroke, heart disease, PD)
Environmental (lighting, obstacles, footwear)

77
Q

Vertigo in relation to someone having a fall may suggest what two things?

A

If its only a few minutes after changing position - benign paroxysmal vertigo

Longer history may be suggestive of vestibular neuronitis

78
Q

What drugs are associated with a high risk of falling?

A 
Antihypertensives (diuretics, CCBs, beta blockers) 
Opiates (drowsiness) 
Long-acting hypoglycaemics
Antipsychotics (EPS)
Hypnotics (benzos - drowsiness) 
Antidepressants e.g. TCAs
Anti-epileptics (dizziness)
Digoxin (arrhythmias) 
Alcohol

Geriatrics (13 decks)

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