Geriatric Medicine

Question 1

The precipitating events of Acute confusional stateare often multifactorial

Answer 1

infection: particularly urinary tract infections

metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration

change of environment

any significant cardiovascular, respiratory, neurological or endocrine condition

severe pain

alcohol withdrawal

constipation

Question 2

management of delirium in older people:

Answer 2

1. treatment of the underlying cause
2. modification of the environment

If not working then
3. recommended haloperidol 0.5 mg as the first-line sedative

Question 3

factors predispose to the development of pressure ulcers:

Answer 3

malnourishment

incontinence: urinary andfaecal

lack of mobility

pain (leads to a reduction in mobility)

Question 4

Management of Pressure ulcers

Answer 4

surgical debridement may be beneficial for selected wounds

moist wound environment encourages ulcer healing.

Hydrocolloid dressings and hydrogels may help facilitate this.
The use of soap should be discouraged to avoid drying the wound

Question 5

mini-mental state examination (MMSE)suggests dementia if the score….

Answer 5

Score < 24 of 30

Question 6

Risk factors of Alzheimer’s disease

Answer 6

1. increasing age
2. family history of Alzheimer’s disease
3. Down’s syndrome
4. Caucasian ethnicity
5. apoprotein E allele E4- encodes a cholesterol transport protein
6. of cases are inherited as an autosomal dominant trait

mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause theinheritedform

Question 7

biochemical pathological changes of Alzheimer’s disease

Answer 7

there is a deficit of acetylcholine from damage to an ascending forebrain projection

Question 8

microscopic pathological changes of Alzheimer’s disease

Answer 8

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

Question 9

macroscopic pathological changes of Alzheimer’s disease

Answer 9

widespread cerebral atrophy, particularly involving the cortex and hippocampus

Question 10

Management of Alzheimer’s disease

Answer 10

1. acetylcholinesterase inhibitors(donepezil,galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
2. memantine(an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment.

Question 11

Indications for memantine in Alzheimer’s disease

Answer 11

1. moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
2. as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
3. monotherapy in severe Alzheimer’s disease

Question 12

In Alzheimer’s, antipsychotics should only be used for patients at risk of

Answer 12

1. harming themselves or others.
2. when the agitation, hallucinations, or delusions are causing them severe distress.

Question 13

Donepezil is relatively contraindicated in patients with

Answer 13

bradycardia

Question 14

Donepezil adverse effects include

Answer 14

insomnia

Bradycardia

Question 15

Focal gyral atrophy with a knife-blade appearance is characteristic of….

Answer 15

Frontotemporal dementia (Pick’s disease)

Question 16

Microscopic changes seen in Pick’s disease

Answer 16

Pick bodies - spherical aggregations of tau protein (silver-staining)

Gliosis

Neurofibrillary tangles

Senile plaques

Question 17

Macroscopic changes seen in Pick’s disease

Answer 17

Atrophy of the frontal and temporal lobes

Question 18

Management of Frontotemporal dementia (Pick’s disease)

Answer 18

not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia

Question 19

Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
Features of

Answer 19

frontotemporal lobar dementias

Question 20

Features of Lewy body dementia

Answer 20

1. parkinsonism
2. visual hallucinations
3. progressive cognitive impairment

Question 21

Diagnosis of lewy body dementia

Answer 21

usually clinical

single-photon emission computed tomography (SPECT)

Question 22

Management of Lewy body dementia

Answer 22

both acetylcholinesterase inhibitors(e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s

• neuroleptics should be avoidedin Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism.

Question 23

The main subtypes of Vascular dementia:

Answer 23

Stroke-related VD - multi-infarct or single-infarct dementia

Subcortical VD - caused by small vessel disease

Mixed dementia - the presence of both VD and Alzheimer’s disease

Question 24

Risk factors of Vascular dementia

Answer 24

History of stroke or transient ischaemic attack (TIA)

Atrial fibrillation

Hypertension

Diabetes mellitus

Hyperlipidaemia

Smoking

Obesity

Coronary heart disease

A family history of stroke or cardiovascular

Question 25

VD can be inherited as in the case of ….

Answer 25

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

Question 26

Stepwise deterioration in cognitive function? - think ….

Answer 26

vascular dementia

Question 27

Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected ….

Answer 27

comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.

Question 28

Haloperidol is contraindicated in patients with

Answer 28

Parkinson’s disease

Question 29

Symptoms worsen with neuroleptics in ….

Answer 29

Lewy body dementia

Question 30

Antipsychotics are associated with a significant increase in mortality in

Answer 30

dementia patients

Question 31

Typical antipsychotics should be avoided in delirious patients with a background of…….

Answer 31

Parkinson’s disease

Question 32

Mini mental test score

Mild dementia :
Moderate dementia :
Severe dementia:

Answer 32

Mild dementia : > 20

Moderate dementia : 10 - 20

Severe dementia: < 10