Clinical Flashcards
(100 cards)
1
Q
How can we assess functioning in a comprehensive geriatric history?
A
Basic activities of daily living
Extended activities of daily living
Activity status
Gait and balance
2
Q
How is physiology typically impaired in older patients?
A
Blunted heart rate
Impaired BP response
3
Q
How might the treatment of MI differ in an older patient?
A
Might not tolerate dual antiplatelet
Might not tolerate a high dose statin
Cannot tolerate quick beta-blocker titration
4
Q
What happens to BP in sepsis in older patients?
A
Drops early
5
Q
What happens to temperature in sepsis in older patients and why?
A
Often remains low
Hypothermia is due to increased incidence of gram negative infections (E. coli. Legionella. Pseudomonas)
6
Q
What happens to HR in sepsis in older patients?
A
Tachycardic response may be absent
7
Q
What changes in CRP and the WCC might we see in sepsis in older patients?
A
May not rise as steeply
8
Q
What antibiotics should we avoid when treating sepsis in older patients and why?
A
Co-amoxiclav, Ciprofloxacin, Cephalosporins (eg. Ceftraixone, Clarithromycin and Clindamycin
Increased C. diff risk
9
Q
Why is random molecular damage increased with age?
A
Inactivity
Poor diet
Inflammation
10
Q
What DNA bases comprise a telomere in humans?
A
Multiple repeats of TTAGGG
11
Q
What do the DNA bases in a telomere form?
A
A DNA loop
12
Q
How long is a telomere in humans?
A
~15 kilobases
13
Q
What is the Hayflick limit?
A
The number of cell divisions in a human body that a cell can undergo before cell division stops
14
Q
What can cause macromolecular damage?
A
Ionising radiation Reactive oxygen species (most important cause of damage, often due to chronic inflammation) Extrinsic toxins (eg. Bisphenols)
15
Q
How do the causes of macromolecular damage result in damage?
A
DNA mutations/breaks
Lipid peroxidation
Protein misfolding, aggregation and cross-linking
16
Q
What are the 4 possible cellular responses when macromolecules are damaged?
A
Repair
Apoptosis
Senescence
Malignant transformation
17
Q
What is the disposable soma hypothesis?
A
After reproduction there is little need for body maintenance
Damage accumulates = Organ failure = Death
18
Q
What is the antagonistic pleiotropy theory?
A
Genes that may be beneficial in early life are harmful in later life
19
Q
What is frailty?
A
Loss of homeostasis and resilience
Increased vulnerability to decompensation after a stressor event
20
Q
What is the Rockwood method of operationalising frailty?
A
Take 20-80 body systems
Count how many have a deficit (low walking speed, renal impairment, diabetes etc.)
Divide number of deficits by systems assessed
Score between 0-1
21
Q
What is the Fried score for frailty?
A
1 point each for:
- Unintentional weight loss
- Low grip strength
- Self reported exhaustion
- Low physical activity
- Slow walking speed
22
Q
What is the prevalence of disability in those older than 16 years old?
A
14%
23
Q
What is the prevalence of disability in those older than 75 years old?
A
50-60%
24
Q
What is the prevalence of disability in those older than 85 years old?
A
80%
25
What is the commonest type of disability?
Problem with locomotion
26
What is the commonest cause of disability?
Musculoskeletal condition
27
What is sarcopenia?
Progressive and generalised loss of skeletal muscle
28
What is the European Working Group definition of sarcopenia?
1. Low muscle mass
2. Low muscle strength
3. Low physical performance
Criterion 1 AND EITHER 2 OR 3 present
29
At what age does muscle mass start to decline?
30
30
When dose muscle mass deterioration accelerate?
~60
31
What are the age-related mechanisms resulting in sarcopenia?
Sex hormones
Apoptosis
Mitochondrial dysfunction
32
What are the endocrine mechanisms resulting in sarcopenia?
Steroids
GH and IGF-1
Abnormal thyroid function
Insulin resistance
33
What is sarcopenic obesity?
Reduced muscle mass with increased fat
34
What does sarcopenic obesity result in?
Increased risk of cardiometabolic disorders:
- Insulin resistance
- Metabolic syndrome (High blood sugar, high BP and obesity [abdominal/high cholesterol/ high triglycerides])
- CVS disease
35
What is the only proven method of intervention for sarcopenia?
Exercise
36
What are the exercise targets?
>150 minutes of moderate activity in >10 bouts OR
>75 minutes of vigorous activity
Both in conjunction with strength and balance training >2 times a week
37
What effects can allopurinol have on skeletal muscle function?
Reduced muscle oxidative damage
Increased vascular function
Increased ATP available for muscle contraction
38
What is Principle 1 of the Scottish Guidance on EoLC?
Informative, timely and sensitive communication for each individual
39
What is Principle 2 of the Scottish Guidance on EoLC?
Decisions made on basis of a MDT discussion
40
What is Principle 3 of the Scottish Guidance on EoLC?
Recognise and address each individuals needs
41
What is Principle 4 of the Scottish Guidance on EoLC?
Consider the wellbeing of relatives and carers
42
What is the smoothest method of drug delivery in end-of-life care?
Syringe driver (S/C infusion)
43
What is typically prescribed for pain and shortness of breath in EoLC?
Morphine
44
What is typically prescribed for distress in EoLC?
Midazolam
45
What is typically prescribed for nausea and aggitation in EoLC?
Levomepromazine
46
What is typically prescribed for respiratory secretions in EoLC?
Buscopan (Hyoscine Butylbromide)
47
What is a stroke?
- Rapidly developing clinical symptoms/signs
| - Of focal loss of brain function
48
How long do symptoms have to last for a CVA to be classed as a stroke?
>24 hours
49
What is the other criteria for diagnosis of a stroke if the time criterion isn't met?
Leading to death with no cause other than vascular origin
50
What can cause a haemorrhagic stroke?
Structural abnormality
Hypertension
Amyloid angiopathy
51
What can cause an ischaemic stroke?
Cardioembolic disease
Small vessel disease
Atheroembolic disease
Other (eg. Hypoperfusion in shock)
52
What type of stroke is fibrin dependent and what colour is it?
Cardioembolic
| Red
53
What type of stroke is platelet dependent and what colour is it?
Atheroembolic
| White
54
What type of stroke do the following describe:
- Cranial nerve deficit with contralateral hemiparesis or sensory deficit OR
- Bilateral stroke OR
- Disorders of conjugate eye movement (nystagmus) OR
- Isolated cerebellar stroke OR
- Isolated homonymous hemianopia
Posterior Circulation Infarct/Haemorrhage
55
What are the symptoms of a cerebellar stroke?
Vertigo
Hemorrhage
Nausea
Ataxia
56
What type of stroke do the following describe:
- Pure motor or Pure sensory deficit affecting 2 of face, arm or leg OR
- Sensorimotor stroke (basal ganglia and internal capsule) OR
- Ataxic hemiparesis (Cerebellar type with ipsilateral pyramidal signs - Internal capsule or pons) OR
- Dysarthria plus clumsy hand OR
- Acute onset movement disorders
Lacunar stroke
57
What type of stroke do the following describe:
1. New higher cerebral function dysfunction (Dysphasia/Dyscalculia/Apraxia/Neglect/Visuospatial problems) AND
2. Homonymous visual field defect AND
3. Ipsilateral motor and/or sensory deficit of 2 or more of face, arm or leg
Total anterior circulation stroke
58
What type of stroke do the following describe:
- 2 of the 3 criteria for a TACI OR
- Isolated dysphasia or other cortical dysfunction OR
- Motor/Sensory loss more limited than for a LACI
Partial anterior circulation stroke
59
What are the functions of the frontal lobe?
Personality
Emotional response
Social behaviour
60
What are the functions of the dominant parietal lobe?
Calculation
Language
Planned movement
Appreciating size, shape etc.
61
What are the functions of the non-dominant parietal lobe?
Spatial orientation
| Constructional skills
62
What are the functions of the occipital lobe?
Functions mainly to analyse vision
63
What are the functions of the dominant temporal lobe?
Auditory perception
Speech and language
Verbal memory
Smell
64
Where does the perception of speech occur?
Wernicke's area in the temporal lobe
65
Where does the production of speech occur?
Broca's area in the temporal lobe
66
What are the functions of the non-dominant temporal lobe?
Auditory perception
Music and tone sequences
Non-verbal memory (faces, shapes, music)
Smell
67
Lesions to which part of the brain result in:
- Neglect
- Spatial disorientation
- Constructional and dressing apraxia
- Homonymous hemianopia
Non-dominant parietal lobe
68
Lesions to which part of the brain result in:
- Lack of initiative
- Impaired memory
- Incontinence
- Poor grasp reflexes
- Anosmia
Frontal lobe
69
Lesions to which part of the brain result in:
- Homonymous hemianopia
- Hemianopic scotomas
- Visual agnosia
- Prosopagnosia
- Visual hallucinations
Occipital lobe
70
What is prosopagnosia?
Impaired face recognition
71
Lesions to which part of the brain result in:
- Dysphasia
- Dyslexia
- Poor memory
- Complex hallucinations (smell, sound, vision)
- Homonymous hemianopia
Dominant temporal lobe
72
Lesions to which part of the brain result in:
- Poor non-verbal memory
- Loss of musical skills
- Complex hallucinations
- Homonymous hemianopia
Non-dominant temporal lobe
73
Lesions to which of the brain result in:
- Dyscalculia
- Dysphasia
- Dyslexia
- Apraxia
- Agnosia
- Homonymous hemianopia
Dominant temporal lobe
74
What is the first line investigation for stroke?
CT
75
What other investigation may be first line for minor strokes or those presenting late (>1 week after stroke)?
MRI:
- Diffusion weighted (DWI) AND
- Gradient Echo Sequences (GRE)
76
When is thrombolytic therapy considered in a stroke patient?
When presenting <4.5 hours from onset of symptoms
77
What drug is used for thrombolytic therapy in a stroke patient?
IV rtPA - Alteplase
78
Why is there an initial increase in risk of death from a stroke in the first week following thrombolysis? At what point is this risk equal?
Haemorrhage
| 6 months
79
If thrombolysis is contra-indicated or unsuccessful, what other treatment may be offered?
Endovascular surgery
80
When are anticoagulants used in secondary stroke prevention?
If stroke was cardioembolic or the patient has AF:
| - Warfarin
81
When (and what) antiplatelets are used in secondary stroke prevention?
Confirmed non-cardioembolic stroke
| Clopidogrel 75mg daily
82
When is aspirin used in stroke?
Treatment when thrombolysis is not possible:
- Commenced within 48 hours of stroke (75mg daily)
- Continued for 2 weeks (Then switch to clopidogrel)
83
When might aspirin be used in secondary stroke prevention and what is co-prescribed with it?
If clopidogrel is contraindicated
| Prescribed with dipyridamole 75mg daily
84
What is prescribed in conjunction with antiplatelets in ischaemic stroke/TIA?
A statin:
- Typically atorvastatin 20mg daily
- 80mg if non-cardioembolic stroke/TIA in patients who need aggressive cholesterol-lowering therapy
85
What does the CHA2DS2-VASc score consist of?
```
Congestive heart failure/LVF = 1 point
Hypertension (persistent >140/90 or on meds) = 1 point
Age >= 75 = 2 points
Diabetes = 1 point
Stoke/TIA/VTE = 2 points
Vascular disease = 1 point
Age >= 65 = 1 point
Sex (female) = 1 point
```
86
What does the CHA2DS2-VASc score calculate?
The risk of CVA due to VTE (not due to AF)
87
What CHA2DS2-VASc score indicates oral anticoagulants should be started? What drug should be used?
>= 2
| - Warfarin
88
When might warfarin not be used?
Poor INR control
Allergy/Poor tolerance
Difficulty monitoring INR (travel etc)
1 month pre-cardioversion if not already on warfarin
89
What are the alternatives to warfarin in anticoagulation to prevent future strokes due to VTE?
1st choice - Rivaroxaban 20mg once daily OR
| 2nd choice - Apixaban 5mg twice daily
90
What CHA2DS2-VASc score indicates oral anticoagulants should be considered?
1
91
What does a CHA2DS2-VASc score of 0 indicate in terms of treatment?
1st line - No therapy
| 2nd line - Aspirin (75mg-325mg)
92
What does the HAS-BLED score consist of?
Hypertension (uncontrolled; >160 systolic) = 1 pont
Abnormal renal and/or liver function = 1 or 2 points
Stroke = 1 point
Bleeding (Prior or predisposition) = 1 point
Labile INRs = 1 point
Elderly (>= 65 years) = 1 point
Drugs and/or alcohol (>8 units/week) = 1 or 2 points
93
What 4 features define delirium?
- Disturbance in attention
- Change in cognition (eg. Memory, orientation)
- Develops over a short period (usually hours to days)
- Evidence it is caused by direct physiological consequence (eg. Medical condition, intoxication or medication)
94
What is delirium tremens?
Delirium due to alcohol dependence
95
What is the first line treatment of aggressive/agitated behaviour in delirium?
Haloperidol starting at 0.25-0.5mg
| Max dose is 5mg in 24 hours
96
When is Quetiapine used in delirium?
If history of Parkinson's disease or Lewy Body dementia
97
What is a noticeable side effect of Quetiapine?
Hypotension
98
When are benzodiazepines used in delirium?
If alcohol/benzo withdrawl or seizures
99
What is the preferred benzodiazepine to use in delirium and why?
Lorazepam 0.5mg
Shorter acting
Fewer active metabolites
100
Why are benzodiazepines not recommended in usual delirium?
Can worsen it
