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Geriatrics Flashcards

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1
Q

What can be used to manage hyperactive delirium?

A

Treat underlying cause
Modification of environment
Haloperidol 0.5mg if not PD patient
Lorazepam in PD patients

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2
Q

What are the pathological changes seen in Alzheimer’s?

A

Widespread cerebral atrophy: especially medial temporal lobe (hippocampus), widened sulci

Cortical plaques due to deposition of type A-Beta-Amyloid protein

Neurofibrillary tangles caused by abnormal tau protein

Deficit of ACh in neural pathways

Neurone apoptosis

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3
Q

What is the general pattern of Alzheimer’s Dementia?

A 
Gradual progression over 8-10 years
Episodic memory first affected (short term)
Anhedonia
Language impairment
Temporal and spatial disorientation
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4
Q

What are the 4 key features of Alzheimer’s?

A

4 As:

Agnosia, Aphasia, Apraxia, Amnesia

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5
Q

How is Alzheimer’s diagnosed?

A

Cognitive assessment: ACE III, MoCA, MMSE
CT scan: cerebral atrophy, widened sulci, narrowed gyri
MRI: medial temporal lobe atrophy

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6
Q

What treatment is available for Alzheimers?

A

First line: AChE inhibitors e.g. donepezil, rivastigmine, galantamine

+ NMDA antagonist: memantine

Non-pharm: wellbeing activities, cognitive stimulation therapy, group reminiscence therapy, CBT, treating any concurrent depression

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7
Q

What are the features of vascular dementia?

A

Stepwise deterioration in memory with ischaemic events
CV risk factors + history of CVD usually
Symptoms depend on area affected

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8
Q

How is vascular dementia diagnosed?

A

Hx CVD risk factors
CT scan: microangiopathy in the white matter, subcortical lacunar infarcts
MRI: global atrophy, lacunae, infarcts, diffuse white matter lesions

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9
Q

What are the features of frontotemporal dementia?

A

Earlier age of onset, steady deterioration
Intelligence, memory and orientation tend to be spared
Behaviour and language impairment

  • Behavioural (Picks): personality change, disinhibition
  • Non-fluent aphasia: language, speech + grammar impaired
  • Lopogenic: impaired phonology and repetition
  • Semantic: language + agnosia
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10
Q

How is frontotemporal dementia diagnosed?

A

MRI: Frontotemporal atrophy, asymmetric degeneration which later affects both hemispheres

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11
Q

What is the pathological change in lewy body dementia?

A

Intracellular deposition of a-synuclein

Pathological dopaminergic transmission

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12
Q

What is the difference between Lewy body dementia and Parkinson’s dementia?

A

LBD: memory deficit + psychotic symptoms start >1 year before motor symptoms

PD = vice versa

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13
Q

What are the features of Lewy body dementia?

A

Fluctuation in symptom severity

Visual hallucinations
Visuospatial and executive dysfunction (falls)
REM sleep disorder
Attention deficit
Development of parkinsonian symptoms
Urinary incontinence in some
Very sensitive to psychotropic medication - high risk of neuroleptic malignant syndrome

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14
Q

How is Lewy body dementia diagnosed?

A

DAT scan to demonstrate abnormal dopamine transmission

MRI usually unremarkable

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15
Q

How is Lewy body dementia diagnosed?

A

Rivastigmine

Most antipsychotics contraindicated so if necessary can use low dose quetiapine

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16
Q

What are differentials for dementia?

A 
Mild cognitive impairment
Delirium
Pseudodementia
Normal pressure hydrocephalus
Wernicke-Korsakoff's syndrome
Neurosyphilis / HIV
Creutzfeldt-Jakob disease
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17
Q

What is mild cognitive impairment?

A

Gradual onset, present most of the time for at least 2 weeks
Still able to independently perform ADLs & loss of <2 cognitive functions
Risk of developing dementia
ACE III score 80-88%

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18
Q

What is pseudodementia?

A

Memory loss associated with major depressive disorders in the elderly
Cognitive deficit onset after mood symptoms
Memory loss, low mood, anhedonia, flat affect, short answers
Responds well to antidepressant therapy

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19
Q

What triad of symptoms characterise normal pressure hydrocephalus?

A

Dementia + ataxia + urinary incontinence

Wet + wacky + wobbly

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20
Q

How is normal pressure hydrocephalus diagnosed?

A

Imaging: hydrocephalus with ventriculomegaly
LP: normal opening pressure but may alleviate symptoms

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21
Q

How is normal pressure hydrocephalus managed?

A

ventriculoperitoneal shunting

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22
Q

What is Creudzfeldt Jakob Disease?

A

rapidly progressive neurological condition caused by prion proteins

Prodrome: sleep disorder, headaches and fatigue

Rapidly progressing dementia, myoclonus, hallucinations, depression, ataxia, seizures

Mean onset 60 + patients normally die within a year

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23
Q

What are the main causes of falls?

A

DAMES

Drugs
Ageing
Medical conditions
Environment
Social factors
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24
Q

What should be included in confusion bloods?

A 
FBC
U&E
LFT
CRP
Glucose
Bone profile
TFT
Coagulation studies
Vitamin B12 + folate

Blood cultures
HIV/syphilis

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25
What examination should you do in a fall presentation?
``` A-E and full set of obs CV and resp exam Neuro and MSK assessment Gait assessment Cognitive assessment Vestibular + visual assessment ```
26
How can bone health be assessed?
Fracture risk should be calculated in anybody: >50 with hx of falls, >65 female, >75 male DEXA scan and FRAX score Check vitamin D and calcium levels
27
How can bone health be improved?
Conservative: Increase activity, stop smoking, lose weight, nutrition, reduce alcohol Medication review Medical: Calcium and vitamin D supplementation (adcal) HRT in women bisphosphonates first line
28
How can frailty be assessed?
- Clinical Frailty Scale: 1-9 - Frailty Index: ratio of actual health deficits: potential ones - Barthel Index of ADLs
29
What tools can be used to assess confusion?
AMTS10 : abbreviated mental test score CAM: confusion assessment method 4AT test: Alertness, AMT4, Attention, Acute + fluctuating course
30
What is a good way to differentiate between dementia and delirium?
Testing for inattention- Dementia patients can generally count from 20-1 with no difficulty whereas delirium patients tend to demonstrate poorer attention
31
What are the criteria for treating UTI in the elderly?
Clinical sign and symptoms of UTI- not just urine dip If presence of dysuria and 2+ symptoms, consider abx Try to get an MSU before initiating treatment
32
How should you manage clinical signs of UTI in a catheterised patient?
Remove catheter MSU New catheter Start abx
33
What are the most common causes of delirium?
PINCH ME ``` Pain Illness Nutrition Constipation Hydration (de) ``` Medication Environment change
34
How does Parkinson's disease usually present?
Constipation, anosmia, loss of arm swing Sleep disturbance and mood disturbance Unilateral motor symptoms: resting pin-rolling tremor, shuffling gait, bradykinesia, rigidity ``` Stooped posture Micrographia Postural instability + orthostatic hypotension Hypomimia Hypophonia ```
35
How is a diagnosis of Parkinson's made?
1. Bradykinesia + rigidity/tremor/postural instability 2. Exclude other causes 3. Supportive: (3+) unilateral onset, resting tremor, progressive symptoms, persisting asymmetry, response to levodopa, levo-induced chorea, gradual clinical cause
36
What is the best antiemetic to use in PD?
Domperidone Cyclizine and ondansetron also safe to use Metoclopramide and chlorperazine contraindicated
37
How is PD managed?
1. Conservative: physiotherapy, SALT, movicol/enema, OT, cognitive engagement, support groups 2. Medical management - reserve for when symptoms become problematic a) Co-careldopa: levodopa + carbidopa to prevent peripheral metabolism Increases in dose size may be needed over time but ^ risk side effects b) dopamine agonists e.g. ropinirole / pramipexole c) MAO-B inhibitors e.g. seligiline, rasagiline d) COMT inhibitors e.g. entacapone Anticholinergics can help with tremor but worsen cognitive symptoms
38
What are differentials for PD?
``` Vascular parkinsonism Lewy body dementia Drug-induced PD Multi-systems atrophy Progressive supranuclear palsy Normal pressure hydrocephalus Corticobasal degeneration ```
39
What are features of vascular Parkinsonism?
Predominantly lower body symptoms- leg rigidity Loss of expression Tremor less common 50% respond to levodopa
40
What medications commonly cause drug-induced Parkinsonism?
Anti-psychotics Metoclopramide Prochlorperazine Differs from PD as typically symmetrical symptoms
41
What is multi-systems atrophy?
Autonomic instability - postural / essential hypotension Bladder instability Symmetrical Parkinsonism
42
What is progressive supranuclear palsy?
Early falls, truncal rigidity and vertical gaze palsy | Hummingbird sign on MRI - reduced midbrain volume
43
What are differentials for tremor?
``` Essential tremor Parkinsonism Drug-induced tremor Hypoglycaemia Anxiety Intention tremor Alcohol withdrawal Hyperthyroidism CO2 retention Encephalopathy/encephalitis ```
44
What are the causes of intention tremor?
MS Cerebellar pathology Midbrain stroke Wilson's disease
45
What are the features of refeeding syndrome?
``` Hypomagnesaemia Hypokalaemia Hypophosphataemia Water retention Anaemia Low serum thiamine Hyperglycaemia ``` Arrhythmias, bradycardia, hypotension, SOB, respiratory muscle weakness, neurological symptoms
46
Which preceding medical legislation is legally binding with regards to refusing treatments?
Advanced decision to refuse treatment Advanced statement = non-legally binding, used to help make BI decisions
47
What are the grades of pressure sore?
1: erythema, non-blanching 2: partial-thickness skin loss involving epidermis and dermis, superficial ulcer 3: Full thickness skin loss with damage/necrosis to subcutaneous tissue 4: Extensive destruction, tissue necrosis and damage to muscle/bone/supporting structures
48
What are the features of a left anterior cerebral artery stroke?
Right sided hemiplegia Cognitive dysfunction / behavioural change Speech disturbance
49
What are the symptoms of right cerebral artery stroke?
Left sided hemiplegia | Executive dysfunction and disinhibition
50
What are the symptoms of left middle artery stroke?
Right sided hemiplegia: face, arm, leg Right homonymous hemianopia Speech and language disturbance- dysphasia, dysarthria
51
What are the symptoms of right middle artery stroke?
Left hemiplegia: face, arm, leg, similar sensory loss Left-sided neglect Left homonymous hemianopia
52
What are the symptoms of posterior cerebral artery stroke?
Contralateral homonymous hemianopia or cortical blindness Memory deficit Contralateral sensory loss Decreased consciousness if thalamus affected May have pure sensory loss
53
What are the symptoms of brainstem stroke?
Ipsilateral facial nerve numbness and weakness Contralateral limb numbness and weakness Nystagmus, vertigo, ataxia Diplopia, ophthalmoplegia, dysarthria, tongue deviation Locked in syndrome
54
What are the symptoms of cerebellar stroke?
``` Ataxia Vertigo, nausea, nystagmus Dysarthria Decreased consciousness Increased risk of oedema, herniation and transtentorial coning ```
55
How would you manage somebody presenting with suspected TIA?
FAST tool EXCLUDE HYPOGLYCAEMIA Loading dose aspirin 300mg for 14 days Referral to TIA clinic within 24 hours
56
What is secondary prevention following a TIA?
``` Lifestyle change 75mg clopidogrel daily Atorvastatin ACE-I / CCB / Thiazide for BP control If AF, anticoagulate if indicated by SPARC / CHADSVASC ```
57
What are features of carotid artery stenosis?
Often asymptomatic Stroke / TIA / amaurosis fugax / CRAO Carotid bruit may be heart Sudden dizziness/loss of balance
58
How is carotid artery stenosis managed?
Lifestyle change Medical management: statin, antiplatelet, BP and DM control Surgical management: carotid endarterectomy - done within 2 weeks if significant Indications for surgery: symptomatic + >70% stenosis / >50% with other comorbidity asymptomatic + >80% stenosis / >60% with other comorbidity
59
What scoring system should be used on presentation of stroke and after treatment?
NIHSS score
60
How does ischaemic stroke differ from haemorrhagic?
haemorrhagic stroke symptom onset tends to be more gradual | Very sudden with ischaemic
61
What imaging modality is best in stroke?
Non-contrast CT head ASAP May be supplemented by CT angio to identify location of a clot Ischaemic tissue goes hypodense initially and when chronic may become hyperdense with mineralisation
62
How should somebody presenting with stroke be managed?
1. FAST tool, A-E + obs 2. Neuro exam 3. Rule out hypoglycaemia 4. Urgent non-contrast CT If no signs of haemorrhage and stroke confirmed: Thrombolysis <4 hrs / thrombectomy <24 if salvageable tissue If not, 300mg aspirin 14 days -> secondary prevention
63
How do you manage haemorrhagic stroke?
Reverse any anticoagulation and correct any clotting abnormality Lower SBP to 130-140 (not lower to prevent cerebral ischaemia) Consider decompressive craniotomy
64
What are contraindications to thrombolysis?
``` Stroke >4.5 hours ago Current bleeding Recent surgery/bleed Current anticoagulation Recent / previous stroke ```
65
What are the Bamford criteria for total anterior circulation stroke?
Unilateral hemiplegia and sensory loss Homonymous hemianopia Higher cerebral dysfunction
66
What are the Bamford criteria for a partial anterior circulation stroke?
2 of: Unilateral hemiplegia and sensory loss Homonymous hemianopia Higher cerebral dysfunction
67
What are the Bamford criteria for a lacunar syndrome?
``` One of: Pure sensory stroke Pure motor stroke Sensori-motor Ataxic hemiparesis ```
68
What are the features of posterior circulation syndrome?
1 of: Cranial nerve palsy + contralateral motor/sensory deficit Bilateral motor/sensory deficit Gaze palsy Cerebellar dysfunction Isolated homonymous hemianopia / cortical blindness

Finals Revision (23 decks)

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