AGE

Question 1

4 types of dementia

Answer 1

1) alzhiemers
2) vascular
3) with lewy bodies
4) frontotemporal

Question 2

ADME changes with increasing age

Answer 2

absorption

• decrease in gastric secretions–> alkaline–> decreased absorption as most drugs are WA
• decreased gastric motility
• decreased gastric BF

distribution

• low body water
• low lean body mass
• increase in fat

reduced vol of distribution of hydrophilic drugs but inc. conc for set volume in elderly (low water)
increased for lipophilic

metabolism

• low liver mass
• low hepatic BF
• dec. enzyme activity (eg, P450)

elimination
-low renal bf–> low GFR
-low kidney mass/function for excretion
increase half-life of drugs

Question 3

7As of alziehmers clinical presentation

Answer 3

anosognosia
aphasia
ataxia
amnesia
apraxia
agnosia
apathy
altered perception

Question 4

pathophysiology main features of Alzheimers dementia

Answer 4

• amyloid beta plaques (from improper cleavage of amyloid precursor protein) - toxic to nerves
• neurofibillary tangles (hyperphosphorylated Tau protein) - axonal damage
• vascular pathology–> inflammation

Question 5

difference between Parkinsons and DWL

Answer 5

PDD = symptoms before 12 months / more motor symptoms

DWL = within 12 months of having / cognitive symptoms before motor

Question 6

types of vascular dementia

Answer 6

small vessel

• occlusion of single deep perforating artery
• white matter

large vessel

• one infarct
• grey matter

Question 7

2 language subtypes of frontal temporal dementia

Answer 7

semantic - fluent talking but forgetting words

progressive non-fluent aphasia - slow, hesitant speech

Question 8

what can alcoholism cause

Answer 8

frontal damage/change
thiamine (vit. B1) deficiency

wernicke’s encephaly (reversible/manageable)

• ataxia
• impaired consciousness
• ophthalmoplegia

korsakoff’s (irreversible)

• anterograde/retrograde amnesia
• good attention
• confabulates a lot

Question 9

strehler’s concept for true ageing process (helps differentiate disease vs age)

Answer 9

universal - changes present in every species
(disease = individual)

intrinsic - changes not due to exogenous source
(disease = intrinsic/extrinsic)

progressive - changes occur progressively over time - one direction
(disease = progressive but can be halted/reversed)

deleterious - should eventually be harmful to organism
(disease = can be cured/halted)

Question 10

difference between primary and secondary prevention

Answer 10

primary = preventing developing a disease
secondary = preventing progression of disease via early treatment

Question 11

syncope

Answer 11

loss of consciousness

Question 12

age related changes resulting in fall

Answer 12

NEURO

• brain atrophy–> loss of neurones–> less synaptic transmission–> slower processing speed
• loss of proprioceptive activity –> loss of tone

VESTIBULAR

• balance impairment
• bradykinesia (slow)

SENSORY impairment

SARCOPENIA

GAIT CHANGE
-decreased stride length/speed/hip flexion + extension

VISUAL

• lower acuity
• decreased reaction to light changes

Question 13

what is poly pharmacy

Answer 13

taking more than 4/5 drugs regularly

appropriate poly pharmacy = EACH drug is required/necessary

can lead to prescribing cascade

Question 14

what do you see with Dementia with lewy bodies

Answer 14

neuronal inclusions (lewy neutriles, amyloid plaques)
phosphorylated neurofilaments
ubiquinated alpha-synuclein

Question 15

drug treatment for dementia

Answer 15

AchE inhibitors = rivastigmine(patch)/donepezil(oral)

NMDA receptor antagonist = memantine

avoid antipsychotics (they block DA receptors)

Question 16

geriatric giants (5)

Answer 16

1. immobility
2. instability (Causes =DAME)
3. intellectual impairment
4. incontinence (reversible causes= diapers)
5. iatrogenic

Question 17

risk factors of delirium

Answer 17

hip fracture
>65yrs
dementia
severe illness

Question 18

brain mainly affected with the 4 different dementias

Answer 18

alzheimers = frontal/parietal (hippocampus)

vascular =

LWD = brainstem / paralimbic/neocortical

fronto temporal = frontal/temporal

Question 19

criteria for true ageing process (s

Answer 19

Strehler’s concepts

• universal
• intrinsic (photo-ageing is not true ageing)
• progressive (happens over time)
• deleterious

Question 20

most common cause for falls

Answer 20

Incorrect shifting of bodyweight

Question 21

presbycusis

Answer 21

hearing loss

Question 22

fragility fractures

Answer 22

fractures that occur as a result of normal activities e.g. a fall from standing height.

colles fracture = a type of fragility fracture - putting their hands out as they fall

Question 23

2 types of management with hip fractures

Answer 23

conservative - don’t operate (almost 100% mortality)

operative - perform surgery on the hip, the exact type of surgery depends on the type of fracture and the patient’s pre-morbid state

Question 24

hip surgical options for intracapsular fractures (no blood flow)

Answer 24

hemiarthroplasty -(half hip replacement) replace the head of femur

total hip replacement - if patient is young

cannulated screws - using your own bone is better than putting in the prosthesis

Question 25

hip surgical options for extra capsular fractures (blood flow maintained)

Answer 25

trochanteric - dynamic hip screw (screws slides down on itself as fracture heals) subtrochanteric (less common) -intradmedullary nail - form head of femur and pinned at the knee

Question 26

ADME of older people

Answer 26

absorption - higher pH - decreased gastric motility/BF distribution - decreased water/lean body mass(muscle) --> high conc of drug when drank but low hydrophilic distribution - increased body fat - less albumin (proteins in blood due to nutrition) --> more free drugs in blood metabolism - atrophy liver - increased half life excretion -poor liver/kidney function

Question 27

aims of using the STOPP/START on patients

Answer 27

Improve the appropriateness of their medication Prevent them suffering ADRs due to their drug regime Reduce the drug costs

Question 28

Factors affecting compliance

Answer 28

cognitive impairment - not understanding why they are taking it - forgetting manual dexterity - immobile - cant open visual impairment -cant see unpleasant side effects

Question 29

rules for rational prescribing for elderly people

Answer 29

Avoid prescribing prior to diagnosis Start with a low dose and titrate slowly Avoid starting 2 agents at the same time Reach therapeutic dose before switching or adding agents Consider non-pharmacologic agent regular review and discussions Consider different formulations  

Question 30

what memory is preserved in elderly

Answer 30

semantic and primary memory

Question 31

difference between delirium and dementia

Answer 31

``` delirium = fluctuating dementia = progressive ``` ``` delirium = acute onset hrs to days dementia = months to yrs ``` attention/consciousness is altered in delirium (not in dementia) ``` delirium = hopefully irreversible dementia = irreversible ``` psychomotor is altered in delirium - not in dementia

Question 32

how do we diagnose osteoporosis/ osteopenia

Answer 32

do a DEXA scan/ measure BMD T score = number of SDs from mean expected adult (0=normal) Z score = age matched osteopenia = t score between -1 and -2.5 osteoporosis = > -2.5

Question 33

treatment for osteoporosis

Answer 33

first: ensure diet includes calcium/vit D - HRT (but bad long term usage) - bisphosphonates (inhibit osteoclasts) eg. risedronate/alendronate - PTH analogues - Denosumab - antibody against RANK ligand thus preventing osteoclast differentiation

Question 34

difference between osteoporosis and osteomalacia

Answer 34

osteoporosis = reduced bone mass--> brittle bones osteomalacia = reduced bone mineralisation--> soft bones

Question 35

why do we age theories

Answer 35

wear + tear evolutionary non-evolutionary - antagonistic pleiotropic gene - mutation accumulation (due to a collection of late acting deleterious genes that were passed on because as you age the powers of natural selection decline) - disposable soma theory

Question 36

how do we age theories

Answer 36

neuroendocrine cellular/molecular - wear and tear - HSP - cross-linkages (altering function) - hayflick (+fibrobalsts of young people vs older) Genetic - telomeres (length eventually shorten) - Geronto-genes and longevity assurance genes genomic stability - error catrostrophe (accumulation) - Somatic mutation and DNA repair (repair ability declines--> accumulation) - free radicals (protection reduces) - mitochochondrial cell senescence normal pre-senescent cell-----insults over time--> senescent cell (Stops dividing + resistant to apoptosis)--> accumulation

Question 37

what kind of hypertension is common in elderly

Answer 37

isolated systolic HT | high systolic BP but low diastolic BP

Question 38

changes in arteries of elderly

Answer 38

- stiffen (loss of elastin/ increased collagen/calcification) - reduced compliance (due to stiffening) - reduced NO production--> constrcited--> increased atheroma risk - raised systolic also contributes to stiffening wall

Question 39

resp changes in elderly

Answer 39

- reduced SA (alveoli = thinner/more dilated/reduced elastic recoil) - V/Q mismatch - but no change to CO2 excretion (if there is = pathological cause not ageing) -no change to total lung capacity but decrease in FEV/FVC higher residual volume

Question 40

diagnosis of frailty

Answer 40

phenotype model : testing present/absent - slow walking speed - self report exhaustion - reduced muscle strength - sedentary behaviour - unintentional weight loss cumulative deficit model - 32 baseline variables - more individuals have wrong with them, the more they are likely to be frail - allows frailty to be gradable

Question 41

comprehensive geriatric assessment (CGA)

Answer 41

process of good, holistic care delivered within a geriatric medicine focused MDT, which goes above and beyond simply managing the acute problem the person has presented with(looking at whole picture) provides patient centred care for frail older people ``` looks at PHYSICAL FUNCTIONAL PSYCHOLOGICAL SOCIOECONOMIC/ENVIRONMENTAL ```