Elderly/Stroke/Dementia PPT

Question 1

why is creatinine level usually normal in elderly people even though the renal function is substantially reduced?

Answer 1

because they have reduced muscle mass so are producing less creatinine so there is less for the kidneys to eliminate.

Question 2

What equation for creatinine clearance takes into account age and sex?

Answer 2

The Cockcroft and Gault equation.

Question 3

What bedside observation is the most powerful predictor of stroke?

Answer 3

HTN

Question 4

Name 6 things that can be done as primary prevention of ischaemic stroke

Answer 4

BP reduction, smoking cessation, reduced platelet aggregation, inhibition of blood clotting, cholesterol reduction, carotid endarterectomy or stenting

Question 5

what is the primary prevention of haemorrhagic stroke?

Answer 5

BP reduction

Question 6

If an acute ischaemic stroke has been diagnosed, what is the time frame in which you can thrombolyse with alteplase?

Answer 6

within 4.5hrs of onset of stroke symptosm

Question 7

What is the time window in which you can do a thrombectomy for people with acute ischaemic stroke?

Answer 7

6hrs

Question 8

what must you exclude before deciding to thrombolyse when you suspect an acute ischaemic stroke?

Answer 8

exclude intracranial haemorrhagaea by immediate head CT or MRI

Question 9

Name 5 contraindications to thrombolysis

Answer 9

head trauma or prior stroke in past 3 months.
GI or genitourinary haemorrhage in pervious 21 days.
major surgery in previous 14 dayas
history of previous intracranial haemorrhage,
evidence of acute trauma or haemorrhage,
taking an oral anticoagulant (or INR >1.4),
heparin within 48hrs, seizure at onset of stroke,
systolic BP >185 or diastolic >110,
platelet count of <100/10^10,
Blood glucose <2.7

Question 10

how much is the risk of an ischaemic stroke reduced by 2-5yrs after smoking cessation?

Answer 10

40%

Question 11

how much does reducing cholesterol with a statin reduce the risk of a first stroke?

Answer 11

25%

Question 12

What class of drugs is apixaban?

Answer 12

DOAC

Question 13

what class of drug is dabigatran?

Answer 13

DOAC (factor Xa inhibitor)

Question 14

What is the difference in mechanism of action of apixaban compared to dabigatran?

Answer 14

Apixaban prevents conversion of prothrombin to thrombin, whereas dabigatran directly inhibits thrombin preventing conversion of fibrinogen to fibrin.

Question 15

Clots in the arterial circulation are largely driven by what?

Answer 15

platelets

Question 16

clots in teh venous circulation are largely driven by what?

Answer 16

fibrin clot driven by the coagulation cascade

Question 17

what is the mechonism of action of warfarin?

Answer 17

prevents liver production of vitamin K-dependent coagulation factors (factors II, VII, IX and X and proteins C and S).
It does this by inhibiting vitamin K epoxide reductase, the enzymre responsible for restoring vitamin K to its reduced form, necessary as a co-factor in teh syntehsis of these clottign factors.

Question 18

after starting warfarin how long does it take to achieve full anticoagulation?

Answer 18

usually a few days

Question 19

when starting someone on warfarin for anticoagulation but who needs immediate anticoagulation effects, what else should you start them on at teh same time?

Answer 19

heparin for immediate cover. stop once INR is in desired range.

Question 20

what is the mechanism of action of clopidogrel, ticagrelor, prasugrel?

Answer 20

they prevent plateley aggregation by binding to adenosine diphosphate (ADP) receptors on teh surfeace of platelets.

Question 21

What is the MOA of aspirin?

Answer 21

inhibits COX to reduce production of the pro-aggregatory factor thromboxane from arachidonic acid

Question 22

what class of drug is dipyridamole?

Answer 22

anti-platelet

Question 23

what is the MOA of statins?

Answer 23

HMG CoA reductase inhibitor - an enzyme involved in making cholesterol. they decrease cholesterol production by liver and increase clearance of LDLs. they slightly increase HDLs. through these effects they slow the atherosclerotic process.

Question 24

name 3 acetylcholinesterase inhibitors used in Alzheimer’s disease

Answer 24

donepezil
galantamine
rivastigmine

Question 25

what are the 3 most common side effects from acetylcholinesterase inhibitors?

Answer 25

N&V and diarrhoea

Question 26

what is the mecahnism of memantine?

Answer 26

NMDA receptor antagonist. prevents glutamate-induced excitotoxicity but without interfering with actions of glutamate that are involved with memeor and learning.

Question 27

What score does someone need to score on the MMSE to be classed as having moderate dementia, and thus able to start drug treatment?

Answer 27

10-20 points

Question 28

what is the effect of cholinesterase inhibitors, such as rivastigmine, on mental function?

Answer 28

delays decline by 3-6 months

Question 29

can you use a combination of cholinesterase inhibitor and memantine in Alzheimer’s?

Answer 29

yes - a combo can give additive benefits

Question 30

after a pt with an ischaemic stroke has been treated with alteplase successfully, what further treatmetn should be prescibed int eh first few days following thrombolysis?

Answer 30

aspirin 300mg (should start it 24hrs after thrombolysis) for 2 wks before converting to long-term anti-thrombotic treatment

Question 31

what is the best long-term antiplatelet that pts who have had an ischaemic stroke should be switched to

Answer 31

clopidogrel (75mg daily) as it is better tolerated long-term than aspirin

Question 32

what is the MOA of clopidogrel

Answer 32

targets adenosine diphosphate (ADP) receptor and irreversibly inhibits it inhibiting ADP from binding to its platelet receptor. this overall inhibits platelet aggregation.

Question 33

how long before surgery should you stop clopidogrel?

Answer 33

7 days

Question 34

name 3 contra-indications for clopidogrel?

Answer 34

active bleeding, avoid in pregnancy, caution in hepatic/renal impairment

Question 35

apart from antiplatelet therapy, what needs to be considered as secondary prevention for ischaemic stroke? (8 things)

Answer 35

ix for risk factors, 
lipid modification (statins),
BP,
physical activity, 
smoking cessation (if applicable),
diet optimisation,
reduce alcohol consupmtion,
control of other co-morbidities e.g. diabetes

Question 36

what routine ix should be performed on a pt who has had an ischaemic stroke with regards to specific risk factors for stroke?

Answer 36

carotid doppler - to check for carotid artery stenosis.
ECG - to check for AF.
ECHO - to check for structural cardiac disease

Question 37

what is the CHADSVASC score for>

Answer 37

calculates stroke risk for pts with AF

Question 38

what is the HASBLED score for?

Answer 38

checks the bleeding risk for pts on anticoagulants for AF

Question 39

what do the letters in CHADSVASC stand for?

Answer 39

Congestive HF
HTN
Age 75yrs or older.
DM
Stroke/TIA hx
Vascular disease
Age 65-74
Sex Category (females at higher risk)

Question 40

What does HASBLED stand for?

Answer 40

HTN,
Abnormal renal or liver function,
Stroke, 
Bleeding (hx or disposition).
Labile INR
Elderly (>65),
Drugs or Alcohol (other antiplatelet agents or NSAIDs, >8units per week)

Question 41

what should the systolic BP target be for a person who has had an ischaemic stroke in the past?

Answer 41

< 130mmHg

Question 42

which groups of pts are at an increased risk of muscle toxicity from statins?

Answer 42

those with a personal or family hx of muscular disroders, high alcohol intake, hypothyroidism, renal impairment

Question 43

how long must you not drive for after having a stroke?

Answer 43

one month then you can drive after this is there is satisfactory clinical recovery