B GERIATRICS TO DO

Question 1

DEMENTIA
What is dementia?

Answer 1

• Syndrome of acquired, chronic, global impairment of higher brain function in an alert patient, which interferes with ability to cope with daily living

Question 2

DEMENTIA
How does subcortical dementia present?
Give some examples

Answer 2

• Psychomotor slowing, impaired memory retrieval, depression/apathy, executive dysfunction, personality change, language preserved
• PD, Huntington’s, alcohol-related + AIDS

Question 3

DEMENTIA
What might a MMSE score indicate in dementia?

Answer 3

MMSE (/30) –
- 21–26 = mild, 14–20 = mod, 10–14 mod-severe, <10 = severe cognitive impairment

Question 4

ALZHEIMER’S DISEASE
What is the clinical presentation of Alzheimer’s

Answer 4

4As of Alzheimer’s –
- Amnesia (recent memories poor, disorientation about time)
- Apraxia (unable to button clothes, use cutlery)
- Agnosia (unable to recognise body parts, objects, people)
- Aphasia (later feature, mixed receptive/expressive)
Insidious + progressive course of short-term memory loss Sx in early disease

Question 5

FALLS
How may rhabdomyolysis present?

Answer 5

• Urine may be dark (‘Coca-Cola urine) + urinalysis +ve to Hb but without RBCs

Question 6

MALNUTRITION
What are the components of MUST?

Answer 6

• BMI = 18.5-20 (1), <18.5 (2)
• Hx of weight loss = 5-10% (1) ≥10% (2)
• Acutely unwell or likely to have no intake >5d (2)

Question 7

OSTEOPOROSIS
What are 2 important factors in osteoporosis development/primary causes?

Answer 7

• Increasing age
• Post-menopause as oestrogen is protective

Question 8

OSTEOPOROSIS
What are the secondary causes/risk factors for osteoporosis?

Answer 8

SHATTERED
- Steroids
- Hyper/hypothyroid
- Alcohol/smoking
- Thin (low BMI)
- Testosterone low (F)
- Early menopause
- Renal/liver failure
- Relatives (FHx)
- Erosive bone disease (RA)
- Dietary Ca2+ low

Question 9

OSTEOPOROSIS
What factors are assessed in the FRAX score?

Answer 9

• Personal = age, sex, weight, height
• PMH = RA, previous #, secondary osteoporosis (renal/liver disease, coeliac, thyroid issues)
• DH = glucocorticoids, lithium
• FHx = parental hip #
• Social = smoking, alcohol (≥3 drinks/day)
• Other = femoral neck BMD

Question 10

OSTEOPOROSIS
What is an alternative to HRT?

Answer 10

• Selective oestrogen-receptor modulators (SERMs) like raloxifene
• Less breast cancer risk as stimulates oestrogen receptors just on bone

Question 11

OSTEOPOROSIS
How do bisphosphonates, denosumab, HRT + SERMs compare to teriparatide?

Answer 11

• First lot are anti-resorptive meds which inhibits osteoclast activity + bone turnover
• Teriparatide is anabolic which increases osteoblast activity + bone formation

Question 12

OSTEOPOROSIS
What are some adverse effects of bisphosphonates?

Answer 12

• Reflux + oesophagitis
• Osteonecrosis of jaw
• Atypical stress # (proximal femoral shaft)

Question 13

PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?

Answer 13

• Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD

Question 14

URINARY RETENTION
What are some causes of urinary retention?

Answer 14

• BPH (#1 cause in men)
• Urethral strictures
• Anticholinergics
• Alcohol
• Constipation
• Infection
• Cancer

Question 15

MILD COG IMPAIRMENT
How does it present?

Answer 15

• Reduced fluency + some short-term memory difficulties

Question 16

FALLS
What markers are elevated in rhabdomyolysis?
Is that an issue?

Answer 16

• K+, phosphate, myoglobin + creatinine kinase
• Myoglobin is nephrotoxic as causes acute tubular necrosis

Question 17

POSTURAL HYPOTENSION
What are some endocrine causes of postural hypotension?

Answer 17

DM, hypoadrenalism, hypothyroidism

Question 18

PRESSURE ULCERS
What are some risk factors for pressure ulcers?

Answer 18

• Peripheral vascular disease (poor healing, reduced tissue perfusion)
• Immobility (#, pain)
• Dehydration + malnourishment
• Obesity
• Incontinence

Question 19

PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?

Answer 19

• D+V,
• nausea,
• abdo pain (work systemically so GI upset)
• bradycardia

Question 20

PHARMACOLOGY
When should NMDA be avoided?

Answer 20

Do not give in renal failure (low GFR) as nephrotoxic

Question 21

PHARMACOLOGY
What are some side effects of NMDA?

Answer 21

• Confusion,
• hallucinations,
• agitation,
• paranoid delusions

Question 22

BPPV
what are the causes?

Answer 22

50-70% = primary (idiopathic)

secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines

Question 23

HEART FAILURE
What are the compensatory mechanisms in heart failure?

Answer 23

1. Sympathetic system
2. RAAS
3. Natriuretic peptides
4. Ventricular dilation
5. Ventricular hypertrophy

Question 24

HEART FAILURE
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation

Answer 24

Improves ventricular function by increasing HR and contractility = CO maintained
BUT it also causes arteriolar constriction which increases afterload and so myocardial work

Question 25

HEART FAILURE Explain how the RAAS system is compensatory in heart failure and give one disadvantage of RAAS activation

Answer 25

Reduced CO leads to reduced renal perfusion, this activates RAAS --> increased fluid retention so increased preload BUT it also causes arteriolar constriction which increase afterload and so myocardial work

Question 26

HEART FAILURE what are the clinical signs of left heart failure?

Answer 26

1. Pulmonary crackles 2. S3 and S4 and murmurs 3. Displaced apex beat 4. Tachycardia 5. fatigue

Question 27

HEART FAILURE what is the management for chronic HF?

Answer 27

1st line = ACEi, beta blocker 2nd = ARB + nitrate 3rd = cardiac resynchronization or digoxin 4th = diuretics (furosemide) 5th = aldosterone antagonist (spironolactone)

Question 28

CONSTIPATION what are the primary and secondary causes?

Answer 28

Primary - disordered regulation of colonic and anorectal neuromuscular function - IBS Secondary - metabolic - hypercalcaemia, hypothyroidism - medicines - opiates, CCBs, antipsychotics - neurological disorders - parkinsons, spinal cord lesions, DM - bowel diseases - cancer, stricture, anal fissure

Question 29

CONSTIPATION what is the management?

Answer 29

- treatment of underlying cause - increased dietary fibre - increased fluid intake - exercise - bulk laxatives - stool softeners - osmotic laxatives - lactulose, macrogol

Question 30

COTE ASSESSMENT What is frailty?

Answer 30

- State of increased vulnerability resulting from ageing-associated decline in reserve + function across multiple physiological systems resulting in compromised ability to cope with everyday or acute stressors

Question 31

COTE ASSESSMENT What are the geriatric giants? What do they represent?

Answer 31

``` 4Is – - Instability (falls) - Immobility - Intellectual impairment (confusion) - Incontinence They are not diagnoses but more general things that COTE pts present with, often indicator of underlying problem ```

Question 32

COTE ASSESSMENT What are the geriatric 5Ms?

Answer 32

- Mind = dementia, delirium, depression - Mobility = impaired gait + balance, falls - Medications = polypharmacy, medication burden, adverse effects, de-prescribing/optimal prescribing - Multi-complexity = multi-morbidity, biopsychosocial - Matters most = individual meaningful health outcomes + preferences

Question 33

POLYPHARMACY What is pharmacodynamics? How does this change for the elderly?

Answer 33

- What the DRUG does to the BODY | - In elderly, effects of similar drug conc. may be different to younger so prone to adverse drug reactions

Question 34

POLYPHAMRACY What is pharmacokinetics? How does this change for the elderly?

Answer 34

- What the BODY does to the DRUG - Changes in absorption, distribution, metabolism + excretion of drugs - May mean drugs hang around longer or elderly pts may experience more toxicity from smaller dose

Question 35

POLYPHARMACY Give some specific pharmacokinetic issues in geriatrics.

Answer 35

- Hepatic first pass metabolism declines - Reduced absorption as gastric pH increases due to atrophy - Vascular system less responsive due to calcification of vessels

Question 36

POLYPHARMACY What are some common adverse drug reactions in geriatrics?

Answer 36

- Falls (postural hypotension with ACEi, beta-blockers) - Confusion (sedation with anticholinergics) - Bowel problems (opioids, PPIs)

Question 37

MENTAL CAPACITY ACT What is the purpose of the Mental Capacity Act, 2005?

Answer 37

- Empower + protect people >16y who lack capacity to make their own decisions about their care + treatment since 1/10/07

Question 38

MENTAL CAPACITY ACT What is the two-step test in MCA?

Answer 38

- Does the person have an impairment of their mind or brain? E.g. dementia, severe LD, brain injury, coma - Is this impairment significant enough to deem them unable of making a particular decision?

Question 39

MENTAL CAPACITY ACT What are the 5 principles underpinning the MCA?

Answer 39

- Assume capacity until proven otherwise - Maximise decision-making capacity (all practical support to help them make decision given) - Freedom to make seemingly unwise choice (unwise decision ≠ incapacity) - All decisions on behalf of patient in best interests - Least restrictive option should be chosen

Question 40

BEST INTERESTS What are some important considerations when making best interest decisions?

Answer 40

- Encourage participation of the patient wherever possible - Find out person's views (past + present wishes, feelings, beliefs + values) - Avoid discrimination (don't make assumptions on any personal features) - Regaining capacity (can the decision wait?) - Identify all relevant circumstances to identify what they would have taken into account if they were making this decision

Question 41

DOLS What is the acid test for DoLS?

Answer 41

Must meet 3 criteria – - Lack of capacity to consent to the arrangements or their care - Subject to continuous supervision + control - Not free to leave their care setting

Question 42

MEDICO-LEGAL ASPECTS What is an advanced refusal of treatments? Is it legally binding?

Answer 42

- A living will - Yes if: – Adult ≥18y – Was competent + fully informed when made decision – Decision is clearly applicable to current circumstances – No reason to believe changed mind

Question 43

MEDICO-LEGAL ASPECTS What is an advanced requests for treatment? Is it legally binding?

Answer 43

- Patient's wish for treatment - Less legal binding but if it's patient's known wish to be kept alive then reasonable efforts (nutrition, hydration) should be considered