Y4 - Lecture Notes Flashcards
State some reasons why the population is getting older
Better sanitation Improvements in housing, education and nutrition Smaller family size Higher incomes Vaccination Increased life expectancy
State some impacts of an ageing population
Affects:
Retirement age
Pensions
Name some social aspects of ageing
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
How much exercise is recommended in the elderly?
30m moderate intensity on most days
What % of older adults report a limiting longstanding sickness or disability?
65-74y: 1/3rd
>75y: 1/2
Describe sheltered housing
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
When should an elderly patient be institutionalised (put in a nursing home)?
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
Give a few examples of institutions?
Long stay hospitals
Care homes providing nursing or personal care
How might an elderly person prevent themselves from getting influenza?
Annual flu jab
How might an elderly person prevent themselves from getting pneumonia?
5 yearly vaccination for pneumococcal pneumonia
How might an elderly person prevent themselves from getting dementia/having a stroke?
Treat high BP
Anticoagulation for AF
How might an elderly person prevent themselves from getting osteoporosis?
Achieving good peak bone mass in adult life and continuing to exercise
How might an elderly person prevent themselves from getting ischaemic heart disease?
Avoid tobacco
Exercise and healthy diet
How might an elderly person prevent themselves from getting alcoholic dementia, heart failure, pancreatitis, cirrhosis?
Safe drinking
How might an elderly person prevent themselves from getting type 2 diabetes?
Exercise and maintaining ideal body weight
How might an elderly person prevent themselves from getting COPD and lung cancer?
Not smoking
What must you be very careful of when prescribing antibiotics to the elderly?
Avoiding C. diff
What is the cut off to go to old age psychiatry?
65+
For patients that stay in their own home, what types of care can be provided?
Twenty four hour care Regular visits for care Meals on wheels/frozen meals service Lucheon clubs Day centres Respite care
Who do the vast majority of strokes occur in?
> 55s
Define stroke
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
Define TIA
Ischaemic (usually embolic) neurological event with symptoms lasting less than 24 hours
What causes a stroke? What are the two kinds of stroke?
Interruption of the blood supply to the brain
Due to:
Infarction
Haemorrhage
What is an infarct?
Area of ischaemia
What can cause an infarct in the brain?
Thrombosis in situ
Embolus from the carotids or heart
Low BP
What things may cause a haemorrhage in the brain?
Arterial aneurysm
Most infarcts and bleeds are due to vessels being damaged by atheroma and HTN
What are the risk factors for stroke and how can these be combated?
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
What tool is used to assess risk of stroke in AF patients?
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
How should you manage patients to reduce their stroke risk based on their CHA2DS2-Vasc score?
0 = nothing 1 = aspirin 2+ = anticoagulant (e.g. elderly patients consider warfarin, alternatives may be rivaroxaban and apixiban)
What are SEs of using warfarin in older patients?
Recurrent falls
Dementia
How do rivaroxaban and apixaban work?
Factor Xa inhibitors
What is the typical presentation of stroke?
Onset is abrupt
If the onset of stroke like symptoms occurs over weeks/days, what should you consider?
Tumour
Subdural haematoma
What are common stroke mimics?
Hypoglycaemia Partial seizures Todd's paralysis after a partial seizure Hemiplegic migraine Metabolic disturbances
In which situations may a stroke present with a coma?
Brain stem infarct
Large cortical infarct with brain stem compression
Seizure after stroke
When should you be cautious giving a patient aspirin?
History of asthma or GI haemorrhage
In stroke the patient looks away/towards the lesion. In brain tumours, the patient looks away/towards the lesion.
Stroke - towards
Tumour - away
What tends to cause TIAs?
Platelet emboli from an atheromatous plaque or ulcer in the aorta or carotids or red cell emboli from the heart
A TIA in the internal carotid region may lead to what signs?
Monocular loss of vision
Hemiparesis or monoparesis
Dysphasia
Unilateral sensory loss
How should TIAs be managed?
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
What ABCD2 score indicates a high risk of subsequent stroke after TIA?
4 or more
What is the ABCD2 score?
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
What patients will have their cartoids scanned and how is this done?
After anterior circulation TIA or acute non-disabling stroke if patient suitable for carotid endarectomy
Doppler duplex imaging/MRA
What patients should have a carotid endarectomy?
if there is between 70-90/99% stenosis of the cartotids
NB - carotid endarectomy is preferred over cartoid stenting in 70+
What are the major clinical problems following stroke?
Dysphasia Delirium Dysphasia Dysarthria Dyspraxia Sensory neglect Visuospatial perception Executive function loss Sensory loss Weakness of limbs Depression Shoulder pain Thalamic pain
What is dysphagia?
Poor swallow
What is dysphasia?
Disorder of language
Who does dysphasia tend to affect?
Right handed patients with left hemisphere lesions
What is dysarthria?
Disrupted articulation but normal content of speech
What is dyspraxia?
Inability to perform purposeful movement despite adequate comprehension and motor function
What are the kinds of sensory neglect?
Visual
Tactile
How can you treat depression after stroke?
Antidepressants
When is depression post stroke most common?
After dominant hemisphere lesion
Give examples of symptoms/signs of a cerebellar stroke
Vertigo Vascular RF often present Severe ataxia Difficulty walking Nystagmus Focal neurological signs
What are the symptoms of spinal stroke?
Paraplegia/quadriplegia
Intermittent sharp or burning back pain
Loss of pain and temperature sensation
Incontinence
What are the symptoms of spinal cord ischaemia?
Aching pain down legs (neurogenic claudication)
What is a subarachnoid haemorrhage?
Bleeding where the brain blood vessels lie between the pia and arachnoid mater
What can cause a SAH?
Vascular malformation
Aneurysm
Bleed from cerebral BV
What is the typical presentation of SAH?
Thunderclap headache
Vomiting
Often without neurological signs
If someone presents with suspected SAH what should you do?
Urgent CT
If CT negative - LP to check for xanthochromia
How should you manage a confirmed SAH?
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
How do you manage stroke?
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
What is the penumbra?
In stroke, there is a central area of irreversibly damaged cells, but around this is a ‘penumbra’ of ischaemic but potentially salvageable cells
What are the threats facing the penumbra?
Oedema
Glutamate, lactate, aspartate
Influx of Ca ions
What is involved in the management of haemorrhagic stroke?
Vitamin K and pro-thrombin
Lowering BP
Mannitol (to maintain cerebral perfusion)
How long can patients who have had a stroke not drive for?
1 month
Must inform insurance
If no residual deficit may drive again after 1m
If deficit, must inform DVLA and be re-assessed
What is involved in primary prevention of stroke?
Treat HTN, DM Lower lipids Rx cardiac dx Quit smoking Exercise Life long anticoagulation in AF/prosthetic heart valves
What is involved in secondary prevention of stroke?
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
Name some cardiac causes of stroke
AF Cardioversion Prosthetic valves Acute MI with large left ventricular wall motion abnormalities on ECG Patent foramen ovale/septal defects Cardiac surgery Infective endocarditis
How does your eye sight change as you get older?
Reduced visual acuity
Reduced contrast sensitivity
Slower dark adaptation
Why does your balance become impaired as you age?
Loss of labyrinth hair cells reducing vestibular input
Define sarcopenia
Loss of muscle mass and therefore strength
How is reaction time affected by age?
Reduced
How does walking change as you age?
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)
How common are falls?
1/3rd of 65yo+
1/2 of 80yo+
Fall every year
What is a useful pneumonia for remembering the causes of falls?
DAME
Drugs (polypharmacy, alcohol)
Age-related changes (e.g. gait, balance, sarcopenia, sensory impairment)
Medical (stroke, heart disease, PD)
Environmental (lighting, obstacles, footwear)
Vertigo in relation to someone having a fall may suggest what two things?
If its only a few minutes after changing position - benign paroxysmal vertigo
Longer history may be suggestive of vestibular neuronitis
What drugs are associated with a high risk of falling?
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
