Yr4 Geriatrics - Study Points Flashcards

Question

**Parkinson’s Disease Dementia** - Clinical features? - Meds? **Normal Pressure Hydrocephalus** - Triad? - Findings: CT brain? MRI brain? - Gait Apraxia? Opening pressure on LP?

Answer 1

**Normal Pressure Hydrocephalus - “Gait Apraxia”** - Impaired initiation. - Magnetic (feet appear as if ‘stuck’ to the floor) - May improve markedly after a few steps. - Slow, shuffling, wide-based, poor turning. - Can perform gait-related leg movements when lying in bed (i.e. it is an apraxia – motor is ok) - Normal opening pressure on LP.

Answer 2

**Pharmacotherapy for Alzheimer’s Dementia - Treatment Targets** 1. Underlying Disease (none yet). 2. Cognitive symptoms * Cholinesterase inhibitors * Memantine (NMDA receptor antagonist) 3. Non-cognitive symptoms (e.g. behavioural and psychological symptoms).

Answer 3

**BPSD - Non-cognitive symptoms of dementia** - Tend to occur late - Common, may be very distressing. 1. Agitation 2. Aggression 3. Delusions 4. Hallucinations 5. Shouting 6. Touching 7. Wandering 8. Pacing 9. Insomnia 10. Withdrawal

Answer 4

**Memory** - **Definition**: Process of learning involving the registration of information, storage of that information, and the retrieval of the information at a later time. - Memory is a mesial temporal lobe and hippocampal function.

Answer 5

**Memory Impairment in Dementia** * Impairment of memory tends to be the first feature of Alzheimer’s disease. * Memory impairment may follow general intellectual decline in Vascular Dementia. * People with Alzheimer’s dementia: Learn slower, learn less, Recognise poorly, Forget more quickly. * Anterograde Memory (new learning) is affected first, often with better preservation of Retrograde Memory (memory for past events). i.e. can remember the past well but cannot remember three words after a few minutes (poor recall). * Impairment of episodic memory commonly seen in Alzheimer’s disease (also MCI, PDD, depression).

Answer 6

**Epidemiology** - Second most common neurodegenerative disorder after Alzheimers. - Incidence increases rapidly after 60 years of age. - Mean age at diagnosis 70.5 years. - Prevalence 0.3% general population, 1% over 65 years of age. - Mortality 2-5 x higher than age-matched controls.

Answer 7

**Pathophysiology** - Lewy (1912) – presence of cytoplasmic inclusion bodies in neurons in various brain region - Tretiakoff (1919) – loss of neurons in substantia nigra - 1950s – dopamine depletion in basal ganglia - Idiopathic - Genetics– mostly sporadic, first-degree relatives 2.3 times higher risk (ask family history)

Answer 8

**Clinical Features** **Motor** 1. **Tremor** (typically resting) - Unilateral tremor is the most common presenting symptom and sign. 3. **Rigidity** (may be cogwheel or lead-pipe). 4. **Bradykinesia** - Prior symptoms may include difficulties writing, doing up buttons, a feeling of stiffness or slowness, voice fluctuations. 5. **Postural instability**. **Non-Motor**: Sensory, autonomic, neuropsychiatric, sleep.

Answer 9

**Parkinsonian Gait** 1. Difficulty getting up from chair/bed. 2. Initial apraxia/freezing. 3. Stooped posture, reduced arm swing. 4. Short and rapid steps – festination. 5. Difficulty stopping and turning around.

Answer 10

**Non-Motor Symptoms (NMS)** - Very common, about 97% of patient in a multicentre study reported NMS. - Each patient experiencing average of eight NMS. - Often affect QOL more than motor symptoms.

Answer 11

**Sleep Disorders in Parkinson’s Disease** - Sleep difficulty – most common NMS as reported by PD patients. - Significant effect on QOL. - Most common sleep disturbance reported by patients is Sleep Fragmentation and Early Morning Awakening. - Causes - nocturia, difficulty turning over in bed, cramps, vivid dreams, pain, dystonia and depression. - ‘Sleep disorders’ include:

Answer 12

**Autonomic Dysfunction in PD** 1. **Postural Hypotension** – in up to 60% of patients. Could be due to drugs. Increases risk of falls 2. **Urinary problems** – frequency, nocturia, urgency and urge incontinence – reduced bladder capacity due to involuntary detrusor contraction. 3. **Constipation**– slow colonic transit, very common and important as it interferes with drug absorption. 4. **Sexual Dysfunction** – decreased interest and low drive due to depression, fatigue, bradykinesia and rigidity. Excessive sexual drive can be associated with medications.

Answer 13

**Absolute Exclusion Criteria** 1. Cerebellar abnormalities. 2. Gaze palsy. 3. Diagnosis of probable behavioural variant FTD or PPA. 4. Lower limb parkinsonism for more than three years. 5. Treatment with a dopamine antagonist. 6. Absence of observable response to high-dose levodopa. 7. Unequivocal cortical sensory loss, clear limb ideomotor apraxia, or progressive aphasia. 8. Normal functional neuroimaging of the presynaptic dopaminergic system. 9. Documentation of an alternative condition known to produce parkinsonism.

Answer 14

**Investigations** 1. **Cranial Imaging** done to exclude specific structural abnormalities (eg, hydrocephalus, tumour, or lacunar infarcts). 2. **DaTscan** – Dopamine Transporter Scan (diagnostic method to look for loss of dopaminergic neurons in the striatum). Parkinsonism vs ET but cannot differentiate PD vs Parkinson’s-plus. 3. **MIBG scan** – tests cardiac sympathetic denervation. Relatively sensitive and specific in differentiating PD vs. Parkinson’s-plus.

Answer 15

**Management of PD** **Medications** 1. Levodopa 2. Dopamine Agonists 3. MAO-B inhibitors 4. Anticholinergics 5. Catechol-O-methyl transferase (COMT) inhibitors **Surgical** - DBS **PD Multidisciplinary team management** - PT, OT, Nurse, Doctor, Speech Pathologist, Dietician, Social Work, Clinical Psychologist

Answer 16

**Levodopa** - Most effective drug therapy. - Very effective for bradykinesia, helps with rigidity and tremors (not so much for postural instability). - Usually combined with a peripheral decarboxylase inhibitor (Carbidopa/benserazide) to block conversion to dopamine in the systemic circulation and liver (before it crosses the blood-brain barrier).. - Available as immediate release or controlled release.

Answer 17

**Dopamine Agonists - Adverse Effects:** 1. Nausea, vomiting, somnolence, postural hypotension, confusion, hallucinations, psychosis. 2. Excessive sleepiness and “sleep attacks” 3. Impulse control disorders (gambling, shopping) – warn. 4. **Dopamine Dysregulation Syndrome** - Compulsive use of dopaminergic drugs despite dyskinesias. - More common younger onset, male. - Dopaminergic agents cause mood elevation with withdrawal effects with lower doses. - Impulse control disorder may accompany DDS. - DA > levodopa

Answer 18

**Advanced Therapies** **Indications** 1. Severe Disease 2. Pronounced motor fluctuations 3. Dyskinesias 4. Nocturnal Akinesia **Options** 1. Continuous dopaminergic drug delivery * Apomorphine Injection/Infusion * Levodopa/Carbidopa intestinal Gel (Duodopa) 2. Deep Brain Stimulation (DBS)

Answer 19

**Constipation** 1. Adequate fluid and dietary fibre intake. 2. Most patients need laxatives/stool softeners. 3. Movicol. 4. Coloxyl and Senna. 5. More severe cases needs regular suppositories/ enemas.

Answer 20

**Drooling of Saliva** 1. Conscious swallowing 2. Chewing sugar free gum 3. Atropine eye drops orally 4. Botox injection to parotids – often lasts for 3-6 months **Overactive bladder syndrome** 1. Rule out UTI/BPH in males/medications like diuretics 2. Bladder diary 3. Anticholinergics 4. Beta 3 agonist – mirabegron – promising results 5. Botox injection in severe cases

Answer 21

**Non-Pharmacological Therapies in PD** - Mainly includes the support of the multidisciplinary PD team. - Increasingly important as the disease progresses. - Evidence supports the MDT model.

Answer 22

**Drug-induced Parkinsonism** 1. Typical anti-psychotics (haloperidol, chlorpromazine, phenothiazine) 2. Atypical anti-psychotics (risperidone, olanzapine, aripiprazole) 3. Anti-emetics (metoclopramide, prochlorperazine) 4. Calcium channel blockers (amlodipine) 5. Mood stabiliser (lithium) 6. Anticonvulsant (sodium valproate) 7. Antidepressant (SSRI - fluoxetine, citalopram, paroxetine, sertraline)

Answer 23

**Progressive Supranuclear Palsy** - Progressive supranuclear palsy (PSP), also known as Steele Richardson Olszewski syndrome. - Tau protein. - Vertical supranuclear palsy with downward gaze abnormalities. - Postural instability with early unexplained falls. - Bradykinesia and rigidity are typically symmetrical in onset. - Apathy, disinhibition, dysphoria, and anxiety are common. - Typical resting tremor of PD is rare in PSP.

Answer 24

**Multiple System Atrophy (MSA)** 1. **Parkinsonism** – akinesia/ bradykinesia, rigidity, postural instability, tremor (irregular jerky postural and action tremor in arms), resting tremor in 1/3. Poor L-dopa response. Early postural instability and falls (within 3 years of onset). Rapid progression regardless of dopaminergic therapy. 2. **Pyramidal signs** (including extensor plantar responses). 3. **Cerebellar**– ataxia, dysarthria, nystagmus. 4. **Dysautonomia**- MSA-C and MSA-P, early. Urinary dysfunction (urgency, incontinence, voiding difficulty, nocturia), postural hypotension, decreased sweating (anhidrosis in 50%), erectile dysfunction in men. 5. **Dysphagia** common.

Answer 25

**Corticobasal Degeneration (CBD)** - Clinical features heterogenous. - Tau protein - Symptoms initially affect one limb (upper or lower). - Asymmetric parkinsonism including akinesia/ bradykinesia, rigidity, and postural instability and falls. - Cortical dysfunction. - Hyperreflexia, Axial rigidity, Tremor (jerky and irregular), Dystonia (hand or foot), Myoclonus, Speech (dysarthria, apraxia). - Oculomotor dysfunction (pursuit eye movements slow and saccadic - this is an oculomotor apraxia)

Answer 26

**Dementia with Lewy Bodies (DLB)** - Neurolept sensitivity (avoid typical antipsychotics, risperidone and olanzapine, maxolon and stemetil). Use quetiapine to treat distressing hallucinations. - Pathologically: loss of dopaminergic neurons in substantia nigra and cingulate gyrus. Lewy bodies (containing protein alpha synuclein found in these affected areas).

Answer 27

**What is a fall?** - An event which results in a person coming to rest inadvertently on the ground or floor or other lower level. - This includes collapse and syncope but not seizure. - 30% of adults aged over 65 will fall annually. - Global disease burden of nearly 17 million years of life lost in 2017. - Falls-related expenditure close to 1% of healthcare costs. - Prevalence of falls will increase due to increase in older adults numbers and increase in multimorbidity, polypharmacy and frailty.

Answer 28

**Intrinsic Falls Risk Factors** 1. Medical Co-morbidities 2. IMpaired Vision & Hearing - Multifocal glasses increases risk of falls – looking at the floor (bottom part) – not in focus (for reading) 3. Age related changes in neuromuscular function, gait & postural reflexes **Extrinsic Falls Risk Factors** 1. Medications? 2. Improper use of assistive devises for ambulation 3. Environmental hazards “Mechanical” fall = nothing term & causes early closure & bias

Answer 29

**Examination** - General state - frailty - Cognition - AMT4, 4AT - Postural BP and HR - Full neurological and cardiovascular examination - Mobility - Assess transfers out of chair/bed - Gait assessment

Answer 30

Can have a lot bigger subdural bleed before neuro is affected as there is more space to bleed into.

Answer 31

Chest Injuries * Age is the strongest predictor of mortality and mortality increased proportionally with number of rib fractures (OR 1.19) * Surrogate markers of polytrauma * Plain XR may miss up to 50% of fractures. * Early Pain Control: Multi-modal and regional analgesia * Early Mobilisation and Physiotherapy * Complications: 34% develop pneumonia, respiratory failure, pain leading to agitation and delirum

Answer 32

**Elder Abuse** - Prevalence is roughly 6% - Maintain a high index of suspicion for elder abuse, especially in the elderly trauma patient presenting with usual patterns and inconsistent history **Risk factors for victims:** 1. Female gender 2. Poor physical health 3. Cognitive impairment, particularly with disruptive behaviours 5. Poor future planning 6. Dysfunctional family setting **Risk factors for Perpetrators:** 1. Drug and alcohol dependence 2. Mental illness 3. Financial dependence on the victim 4. Carer stress

Answer 33

**Delirium is an acute deterioration of cognition.** - Inattention, Disorganised Thinking, Altered Conscious State **Dementia is progressive deterioration of cognition.** - Apraxia (loss of function/ability to use tools), Aphasia, Agnosia (inability to recognise or name objects), Loss of Executive Functioning **Depression** - Less likely to express sadness - Somatic, psychomotor retardation

Answer 34

**Why does Delirium matter?** - It may be the only sign of a medical illness - 20% patients aged over 70 admitted to hospital have a CI - 10% of older patients admitted with delirium - 8% develop delirium during their hospital stay - Increases morbidity and mortality - 11% of healthcare associated complications in SMHS were due to delirium

Answer 35

**Delirium - Assessment** - History from patient, nursing staff and family - Examination for signs of infection or pain - Medication review - Review charts – fluid balance, bowel chart, sleep and behaviour chart - Check previous blood tests

Answer 36

**Definition of a Fall** ‘A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.’

Answer 37

**Epidemiology of Falls** - 30% community dwellers >65 years - 40% hospitalised (rehabilitation/ subacute) patients - 50% of residents in long term care facilities (one or more falls in 12 months) - People living in residential care settings at higher risk of falls and falls related injuries than those living in the community. **Costs** - **Individual**: loss of function and diminished QOL; fear of falling (increases risk of future falls). - **Community**: Health costs attributable to falls-related injury. Hospital bed-days. Additional residential care beds required.

Answer 38

**Injury Rates** * Roughly: * 1 in every 3 falls results in an injury. * 1 in every 30 falls results in fracture. (Rates are higher or lower, depending on the study)

Answer 39

**Precipitating Event** Older people fall because these intrinsic and extrinsic risk factors …..then interact with a precipitating event. 1. Changes in medications 2. Slips and trips 3. Hazardous activities (e.g., climbing a ladder …) 4. Acute medical illness: Pain, Weakness, Syncope/hypotension, Seizure, Delirium, Dizziness/poor balance/ gait disturbance **Risk factors** - **Extrinsic** = Related to a person’s environment or their interaction with the environment. - **Intrinsic** = Related to a person’s behaviour or condition.

Answer 40

Falls usually occur when a threat to the normal homeostatic mechanisms that maintain postural stability (e.g., acute illness, environmental stress, unsafe walking surface, medications) is superimposed on age-related declines in balance, ambulation and cardiovascular function. A person’s risk of falling increases as their number of risk factors accumulates.

Answer 41

**Age-Related Functional Decline** **Sensory changes:** - Visual - Proprioceptive - Vestibular **Physical changes** - BP regulation - Central processing - Gait - Neuromotor function - Postural control **Cognitive changes**

Answer 42

**Environment** - A significant interaction exists between environment and intrinsic factors. i.e., often multifactorial. - Visual impairment + unfamiliar surrounds (+ dim light at night) - Urinary incontinence + toilet far away… - Restraints + delirium… - E.g., One study (Donald 2000) found that carpet flooring, compared to vinyl flooring, was associated with a statistically significant increased rate of falling. (Rate ratio 14.73, 95% CI 1.88 to 115.35)

Answer 43

**Key risk factors for falling in hospital:** 1. Age 2. A history of falls 3. Impaired cognition and 4. Impaired mobility **Falls Prevention - Considerations:** 1. Strength and balance 2. Education 3. Medications 4. Environmental modifications 5. Prevent Complications Good evidence for multifactorial interventions (individual fall-risk assessments followed by tailored interventions and referrals to address identified risks)

Answer 44

**Falls Evaluation** - History (especially of the fall, medical history, medications, environment, consequences of fall etc.) - Examination - Investigations - Targeted to history. **Falls History** - Circumstances of the fall: - Activity at time of fall - Location - Use of walking aid (or not) - Footwear - Time of day (night versus day) - Lighting - Eyewear (e.g., glasses - bifocals, multifocal)

Answer 45

**Major Causes of Syncope** 1. **Orthostatic** (postural hypotension) – meds, fluid, GI losses, autonomic (diabetes, PD) etc. 2. **Cardiac arrhythmias** (tachy/brady) or Structural cardiopulmonary disease (AS, HOCM, PE, severe PHT). No warning – be suspicious for a cardiac cause. 3. **Reflex syncope** (vasovagal– typical triggers include emotion, pain, prolonged standing; situational– cough, strain, micturition; carotid sinus). Pre-syncopal symptoms typically associated with reflex syncope.

Answer 46

**Medical assessment post-fall** - Neurological observations and assessments, including Glasgow Coma Scale (especially if head strike). - Identify: Delirium, new/increasing confusion, headache, clinical deterioration, amnesia, vomiting, change in conscious level. **Investigations post-fall** **Consequences** - X-ray and/or CT (i.e., hips, spine, pelvis, wrist, head etcetera) **Causes** - Consider further investigation re cause of fall (depends on history and examination).

Answer 47

**Indications for Urgent CT head** 1. **Suspect a head injury** - Altered level of consciousness or a headache, or amnesia or vomiting. Note GCS (may decline later with serial review) 2. **Patient hit head and coagulopathic** (DOAC, warfarin, clexane, aspirin or clopidogrel) 3. **Canadian CT Head Rules**

Answer 48

A range of services are available in WA to deliver falls prevention interventions. The WA Falls Action Plan represents an overarching approach to falls prevention in different settings. - The red items demonstrate population health strategies, the orange items are services involved in screening, referring and assessing and the green items are the types of available interventions and where they are delivered. - Multicoloured items are an indication of the dual role of these behaviours or services i.e. exercise can be promoted as both a general population health strategy and also an individualised intervention for people at risk of falls.

Answer 49

**Immediate Actions** **1) Assess for physical injury:** * Neck pain/ injury indicate the neck should be immobilised. * Head injury, hip or other fracture and/ or soft tissue injury following a fall dictates specific action. * Medical review as soon as possible for assessment and investigations (imaging such as XR or CT). **Bedside investigations**: 1. Vital signs observations (including BSL). 2. Neurological observations and assessments, including Glasgow Coma Scale. 3. Cognitive assessment using AMT4/4AT/CAM. **Identify**: Delirium, new/increasing confusion, headache, clinical deterioration, amnesia, vomiting, change in conscious level.

Answer 50

**Syncope** - Clinical syndrome in which transient loss of consciousness (TLOC) is caused by a period of inadequate cerebral blood flow and oxygenation. - Usually of brief duration (by definition, syncope is self-limited). - Initial evaluation relies heavily on a comprehensive history, physical examination, ECG, assessing the heart for structural heart disease (ECHO). - Can experience pre-syncope (near syncope) symptoms alone, or pre-syncopal symptoms prior to a syncopal episode. - Be suspicious for a cardiac cause if no warning.

Answer 51

**Major Causes of Syncope** 1. Orthostatic syncope 2. Cardiac arrhythmias 3. Structural cardiopulmonary disease 4. Reflex syncope

Answer 52

**Implications of Frailty** - Increased body fat + decreased lean body mass (affecting Vd) = 'sarcopenia'. - Greater age-related reduction in albumin. - Total drug levels of albumin-bound drugs can be unreliable- e.g., valproate, phenytoin. Can be ‘toxic’ at apparently ‘therapeutic’ drug levels. - Prescribers need to take extra care in the setting of frailty– there is an increased risk of adverse outcomes, including adverse drug effects.

Answer 53

**= Periodically review long-term medications** - Effects on drug pharmacodynamics and pharmacokinetics change with ageing may alter the effectiveness and safety of long-standing medications over time with ageing. - Prescription doses may need to change with time (due to physiological changes that occur with ageing).

Answer 54

**Examination** - HR 54bpm, Afebrile, BP 110/50, SaO2 98% RA - BSL 4.8. - Chest clear. - Cardiovascular - dual heart sounds, no murmurs. AF. - Peripheral oedema to ankle. JVP not elevated. - Abdomen - unremarkable. - Neuro - peripheral and cranial nerves intact. **Medication Issues to Consider in this case** - 6 Practical considerations? 6 Specific drug considerations?

Answer 55

**Iatrogenesis** - **Definition**: Refers to any unintended and untoward consequence of a well-intended healthcare intervention. - An adverse reaction to a medication is the most common example of iatrogenesis in healthcare. - Iatrogenesis is often preventable. - Iatrogenesis is associated with increased length of hospital stay, increased patient mortality and morbidity, and increased cost. **ADR in Older Persons – Why?** * Drug-drug interactions - More drugs to interact. * Individual drug adverse effects - More common in older persons.

Answer 56

**Polypharmacy** = Defined as simultaneous use of ≥ 5 medications. **Risk Factors** 1. Older age 2. Female gender 3. Increasing number of diagnoses 4. Hospitalisation 5. Depression

Answer 57

**Common Exclusion Criteria for Clinical Trials That Do Include Older Persons** 1. Presence of co-morbid diseases 2. Multiple Medications 3. Residents of aged-care facilities 4. Cognitive Impairment 5. Need for Interpreter

Answer 58

**Prescribing Cascade** - Occurs when a new medication is prescribed to treat symptoms that have arisen from an unrecognised adverse drug effect that is the result of an existing therapy.

Answer 59

**Prescribing Omissions** - Also known as under-prescribing. - Failure to prescribe a medication for which there is a clinical indication and which, for the patient, is appropriate to prescribe. **Common Examples:** 1. Anticoagulation for stroke prevention in AF. 2. ACEI/ARB for patient with heart failure. 3. Bone protection for patient on long-term steroid therapy. **Potentially Inappropriate Medications (PIMS)** - Definition: Medications where the risk of adverse events from the drug outweighs the clinical benefit. - 20 - 40% of community-living people. - 30 - 50% in residential care.

Answer 60

1. Polypharmacy - Complicated treatment regimes 2. Cognition (memory) 3. Social factors - Education, finances etc. 4. Physical Factors may also affect compliance - Dexterity (affected by arthritis or PD) e.g., unable to open bottle or packets. - Swallowing difficulties - difficult to take tablets **Improving Adherence** 1. Simplify regimes 2. Use dispensing aids 3. Supervise medications 4. Involve carers.

Answer 61

**DEPRESCRIBING** = The process of withdrawal of an inappropriate medication, supervised by a healthcare professional with the goal of improving outcomes. - Should occur as part of a medication review. - Steps to Deprescribing: 1) Prioritize medications for discontinuation based on risk-benefit and ease of discontinuation & 2) Discuss the recommendations with the patient, provide information, allow shared decision making. **Benefits of Deprescribing** 1. Resolve related adverse drug effects. 2. Improve patient satisfaction and QOL. 3. Improve physical and cognitive function. 4. Reduce financial cost to patient and community.

Answer 62

**History** - The son tells you he was staring blankly for 5 minutes whilst in the GP’s office, then mentions he had a similar episode a year ago. On both occasions it took him about 24 hours to “come right”. MRI brain reveals a right parietal cortical infarct (old) as well as the internal capsule infarct on the left.

Answer 63

**Introduction** * The prevalence and incidence of epilepsy are highest in later life with almost 25% of new cases occurring in older patients. * The relationship between age and incidence of epilepsy is bimodal. **Causation** * Seizures in elderly patients are nearly exclusively partial in onset and complex partial seizures are the most common seizures in this age group. * Cerebrovascular disease is the single most common pathological factor underlying epilepsy in the elderly.

Answer 64

**Definitions: Seizure Aetiology** - **Idiopathic**: No obvious cause - **Remote Symptomatic**: Due to previous but not acute cerebral insult - **Provoked**: Seizure(s) occurring in close temporal association with an acute systemic, metabolic, or toxic insult or in association with an acute CNS insult (within 7 days).

Answer 65

**Immune Mediated Encephalopathies:** NMDA receptor antibody encephalitis causes rapidly progressive encephalopathy, neuropsychiatric features, dyskinesias and autonomic disturbance. Seizures occur in about 75%. It is more common in women and is associated with underlying malignancy, usually ovarian teratoma, and is treatable with IVIG. Limbic encephalitis occurs in association with anti-voltage gated potassium channel Abs and presents with a more indolent cognitive decline, neuropsychiatric features and partial-onset seizures that may secondarily generalize. Treatment is with immunosuppression.

Answer 66

**VASCULAR CAUSES** 1. **Arterial Infarction**: Stroke causes both acute symptomatic seizures and epilepsy. 2.5-5 % of patients develop early seizures, and these suggest a worse prognosis. Seizure risk is higher with larger infarcts, especially if it involves the cortex; seizures are less likely with deep white matter ischemic lesions. 2. **Venous Infarction**: Cerebral venous sinus thrombosis is an uncommon cause of cortical infarction and intracerebral haemorrhage. It is slightly more common in women. It presents with headache (either non-specific or with raised pressure features), encephalopathy, focal neurological symptoms, or seizures and papilledema in some cases.

Answer 67

**Metabolic Causes:** 1. Hyper and hypoglycaemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypo and hypercalcemia 5. Liver failure and hepatic encephalopathy **Seizures from other Pathologies** - Alzheimer’s patients have a 20% risk of developing seizures by the 5th year of their illness. Recurrent seizures (ie epilepsy) is common. - Although seizures may occur early after SAH, the risk of these patients developing epilepsy is low.

Answer 68

**Clinical Manifestations of Epilepsy in the Elderly** - The most common clinical manifestations of CPS - confusion, disorientation and unresponsive staring - may be both subtle and quite prolonged. - Some ictal behaviours such as orofacial automatisms, rubbing, tapping, stroking, disrobing and wandering may not be recognised as possible seizure activity by carers and clinicians, especially in those with dementia. - Altered mental state/memory lapses have many other possible explanations in the elderly, and as a consequence delays in diagnosis are common.

Answer 69

The ideal AED should be: DOESN’T EXIST 1. completely absorbed 2. undergo linear pharmacokinetics 3. have a clearance unaffected by renal impairment 4. not induce or inhibit hepatic enzymes 5. not produce neurotoxic side effects 6. achieve its target dose without titration 7. come in a range of formulations

Answer 70

**Carbamazepine** - Effective against partial and generalised TCS in all age groups. - Controlled release formulation allows bd dosing. - 100 mg nocte, then after 2 weeks 100 mg bd, increasing to 200 mg bd after a month. - Induces metabolism of other lipid-soluble drugs. - Rash (5%) more common in later life. - NOT found to impair psychomotor activity in old age, but dose related nausea, headache, dizziness, diplopia and ataxia occurs. - May be assoc. with osteomalacia/ osteoporosis.

Answer 71

**Counselling and Education** - Seizures, medication - Epilepsy is controlled but not cured by these medicines - Treatment may be needed life-long - Minimise possible seizure-inducing factors: fatigue, sleep-wake cycle, alcohol and substance abuse/withdrawal - Activities of Daily Living - Safety issues - First aid/help at hand in case of a seizure - Driving restrictions

Answer 72

Appropriate Monitoring * CLINICAL = the most important * MONITORING BLOOD LEVELS - Can be overvalued and even abused. - The lower limit = meaningless - The upper limit = ill-defined (except PHT) * Do not alter AED’s on the basis of blood levels alone!