Geriatric

Question 1

investigations done when originally diagnosing dementia

Answer 1

primary care:
blood tests to look for reversible causes

FBC, U&Es, LFTs, TFTs, glucose, calcium, vitamin B12 and folate, ESR/CRP

secondary care: neuroimaging
e.g. subdural haematoma, normal pressure hydrocephalus

Question 2

role of acetylcholine

Answer 2

has a role in parasympathetic innervation
- smooth muscle contraction
- blood vessel dilation
- slows heart rate
- releases secretions

Question 3

management of Alzheimer’s disease

Answer 3

non-pharmacological:
- offer a range of activities to promote wellbeing based on preference
- group cognitive stimulation therapy for patients with mild and moderate dementia
- to consider include group reminiscence therapy and cognitive rehabilitation

pharmacological:
acetylcholinesterase inhibitors
e.g. donepezil, galantamine, rivastigmine
for mild to moderate dementia

memantine = NMDA receptor antagonist
monotherapy in severe Alzheimer’s
add on drug to acetylcholinesterase inhibitors for patient’s with moderate/severe Alzheimer’s
moderate alzheimer’s where intolerance/contraindication to acetylcholinesterase inhibitors

NOT to recommend antidepressants
anti-psychotics used for patients at risk of harming themselves or others, or when agitation, hallucinations, delusions causing them severe distress

Question 4

contraindications for donepezil

Answer 4

bradycardia
adverse effects include insomnia

should be started with caution in patients with conduction abnormalities or those already taking negatively chronotropic medications such as beta blockers, rate-limiting calcium channel blockers or digoxin

Question 5

first line neuroimaging for diagnosing dementia

Answer 5

MRI

Question 6

what is a Q risk score

Answer 6

identifies the 10 year risk of heart disease and who should be started on statins

Question 7

role of STOPP tool

Answer 7

identifies medications where the risk outweighs the therapeutic benefits in certain conditions

Question 8

what is frontotemporal dementia

Answer 8

form of dementia more common in those < 65yrs
various forms, where individuals can experience changes in personality & behaviour

e.g. primary progressive aphasia = inability to produce speech and loss of literacy skills

Question 9

common features of frontotemporal lobar dementias

Answer 9

onset before 65yrs
insidious onset
relatively preserved memory & visuospatial skills
personality change & social conduct problems

Question 10

what are the 3 types of frontotemporal lobar dementia

Answer 10

frontotemporal dementia (Pick’s disease)
chronic progressive aphasia/ progressive non-fluent aphasia
semantic dementia

Question 11

what is Pick’s disease & its presentation

Answer 11

most common type of fronto-temporal dementia
characterised by personality change & impaired social conduct

hyperorality
disinhibition
increased appetite
perseveration behaviours

Question 12

macro/microscopic changes seen in Pick’s disease

Answer 12

Focal gyral atrophy with a knife-blade appearance = characteristic

macroscopic: atrophy of the frontal and temporal lobes

microscopic:
pick bodies (spherical aggregations of tau protein, silver-staning)
Neurofibrillary tangles
gliosis
senile plaques

Question 13

management of Pick’s disease

Answer 13

NICE do not recommend acetylcholinesterase inhibitors or memantine

Question 14

presentation of chronic progressive aphasia

Answer 14

chief factor is non-fluent speech
short utterances that are agrammatic
comprehension relatively preserved

Question 15

presentation of semantic dementia

Answer 15

speech is fluent but empty and conveys little meaning

unlike in Alzheimer’s memory is better for recent than remote events

Question 16

predisposing factors to delirium

Answer 16

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty/multimorbidity
polypharmacy

Question 17

precipitating factors to delirium

Answer 17

infection: particularly UTIs
change of environment
constipation
severe pain
metabolic e.g. hypoglycaemia, dehydration, hypercalcemia
alcohol withdrawal
any significant condition

Question 18

features of acute confusional state/delirium

Answer 18

memory disturbances
agitated
mood change
hallucinations
disorientation
disturbed sleep cycle
poor attention

Question 19

management of delirium

Answer 19

treat underlying cause
modification of environment

haloperidol 0.5mg
** can also use olanzapine

Question 20

management of delirium in those with Parkinson’s disease

Answer 20

antipsychotics can make symptoms worse

careful reduction of Parkinson’s medication may be useful
if need urgent treatment, atypical antipsychotics preferred e.g. quetiapine, clozapine

could use lorazpam

Question 21

characteristic pathological feature in Lewy body dementia

Answer 21

alpha synuclein cytoplasmic infusions (Lewy bodies) in the substantia nigra, paralimbic, and neocortical areas

Question 22

features of Lewy body dementia

Answer 22

progressive cognitive impairment
** in contrast to Alzheimer’s, early impairments in executive function & attention than memory loss
cognition may be fluctuating
usually develops before Parkinsonism

Parkinsonism

Visual hallucinations/delusions

Question 23

diagnosis of Lewy body dementia

Answer 23

mainly clinical
but can do a SPECT scan

Question 24

management of Lewy body dementia

Answer 24

acetylcholinesterase inhibitors & memantine

neuroleptics should be avoided
** these patients are sensitive to these and might develop irreversible parkinsonism
e.g. patient has deteriorated following the introduction of an antipsychotic agent

Question 25

what is a pressure ulcer

Answer 25

develops in patients unable to move parts of their body due to illness, paralysis, advancing age typically develop over bony prominences e.g. sacrum, heel

Question 26

what predisposes someone to a pressure ulcer

Answer 26

malnourishment incontinence immobility (icl pain which might lead to immobility)

Question 27

screening tool used to screen for patients at risk of developing pressure sores

Answer 27

Waterlow score **includes BMI, nutritional status, mobility, continence

Question 28

grading of pressure sores

Answer 28

grade 1 = non-blanchable erythema of intact skin, warmth, oedema, hardness grade 2 = partial thickness skin loss involving epidermis or dermis, or both grade 3 = full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. grade 4 = Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss

Question 29

management of pressure ulcers

Answer 29

wound dressings, analgesia, nutritional assessment need a moist wound environment to encourage healing - Hydrocolloid dressings and hydrogels AVOID soap DO NOT swab, antibiotics done on clinical findings e.g. cellulitis, systemically unwell, osteomyelitis may need referral to tissue viability nurse/surgical debridement

Question 30

what 3 factors does normal gait involve?

Answer 30

neurological system e.g. basal ganglia MSK - normal tone & strength effective processing of the senses e.g. sight, sound, sensation As individuals get older they are more likely to experience medical problems affecting these systems, which leads to gait abnormalities and increases the risk of falls

Question 31

risk factors that increase the risk of falls

Answer 31

lower limb weakness vision problems balance/gait disturbances e.g. diabetes, RA, parkinson's polypharmacy (>4 drugs) incontinence >65 yrs arthritis in lower limbs depression postural hypotension psychoactive drugs

Question 32

medications linked to increased risk of falls

Answer 32

drugs that cause postural hypotension: diuretics ACE-i beta-blockers nitrates anti-cholinergic antidepressants Levodopa other drugs: benzodiazepines opiates codeine antipsychotics anti-convulsant digoxin

Question 33

investigations of falls

Answer 33

bedside: BP, ECG, basic obs, urine dip, blood glucose bloods: Full Blood Count, Urea and Electrolytes, Liver function tests and bone profile imaging: X-ray of chest/injured limbs, CT head and cardiac echo

Question 34

management of falls in the elderly

Answer 34

identify all individuals who have fallen in the last month & identify why for those with a history of falls or at risk: complete 'Turn 180° test' or the 'Timed up and Go test'. Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with: >2 falls in the last 12 months A fall that requires medical treatment Poor performance or failure to complete the 'Turn 180° test' or the 'Timed up and Go test'

Question 34

management of falls in the elderly

Answer 34

identify all individuals who have fallen in the last month & identify why for those with a history of falls or at risk: complete 'Turn 180° test' or the 'Timed up and Go test'. Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with: >2 falls in the last 12 months A fall that requires medical treatment Poor performance or failure to complete the 'Turn 180° test' or the 'Timed up and Go test'

Question 35

cut off level that suggests dementia in the mini mental state examination

Answer 35

24 or less

Question 36

factors favouring delirium over dementia

Answer 36

impairment of consciousness fluctuation of symptoms e.g. worse at night, periods of normality abnormal perception e.g. hallucinations agitation, fear delusions

Question 37

symptoms of digoxin toxicity

Answer 37

gastrointestinal disturbance (nausea, vomiting, abdominal pain) dizziness confusion blurry or yellow vision arrhythmias.

Question 38

side effects of anti-cholinergic drugs

Answer 38

dry mouth, dry eyes hypotension constipation urinary retention arrhythmias (QT interval prolongation)

Question 39

how should frailty be assessed?

Answer 39

evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire PRISMA-7 involves questions considering the age, sex, health problems, assistance required and walking aid use of the patient

Question 40

causes of dementia

Answer 40

common: Alzheimer's vascular dementia Lewy body dementia rarer: Huntington's CJD Pick's disease HIV (50% of aids patients)

Question 41

reversible causes of dementia

Answer 41

hypothyroidism, Addison's folate/b12/ thiamine deficiency syphilis brain tumour normal pressure hydrocephalus subdural haematoma depression chronic drug use e.g. Alcohol, barbiturates

Question 42

pathophysiology of Alzheimer's disease

Answer 42

progressive degenerative disease of the brain, accounting for majority of dementia in the UK pathological changes: macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein hyperphosphorylation of the tau protein has been linked to AD, impairing its function biochemical: deficit of acetylcholine from damage to an ascending forebrain projection