Geriatrics Flashcards

1
Q

Pharmacokinetic changes in the elderly

ADME?

Absorption

  • _______ which reduces oral bio-availability
  • ______ (even if not taking PPI), which decreases breakdown of enteric coatings (decreases absorption); increases absorption of some drugs (eg methyldopa)
  • ______ in the gut for calcium, folate, vitamin B12

Distribution

  • Reduced skeletal muscle mass with increased ratio body fat to water
  • Volume of distribution for water soluble drugs decreases, increasing serum concentration (e.g. paracetamol, digoxin)
  • Volume distribution for fat soluble drugs increases, leading to prolonged half-life and more toxicity (e.g. diazepam, amiodarone, verapamil)
  • Decreased albumin levels
  • Increased free fraction of highly albumin-bound drugs (e.g. warfarin, phenytoin)
  • However, increased free fraction leads to increased clearance
  • Increased penetration across blood-brain barrier

Metabolism

Reduced liver mass and reduced ____ metabolism

  • Prolonged half life, higher steady state concentrations of some drugs (eg. diazepam, metoprolol, phenytoin)
  • Unchanged conjugative metabolism in liver
  • Decreased ____ blood flow
  • Affects drugs with high hepatic extraction ratio, reducing first pass metabolism and increasing drug concentration (eg morphine, verapamil)

Excretion

  • Reduced glomerular filtration rate affects drugs like ____ (i.e gentamicin)
  • Reduced tubular function reduces active tubular excretion of drugs like beta-lactam antibiotics
  • Increased susceptibility to nephrotoxic drugs such as _____
  • Acute illness (with dehydration) can rapidly reduce renal clearance
  • Important in drugs with narrow margin between therapeutic and toxic dose (e.g. ____ )
A

Reduced eGFR (i.e reduced renal clearance)

Reduced Liver Mass and Metabolic capacity

Reduced skeletal muscle mass and increased body fat:water ratio

Absorption

  • Increased gastric emptying time, which reduces oral bio-availability
  • Increased gastric pH with reduced gastric acid secretion (even if not taking PPI), which decreases breakdown of enteric coatings (decreases absorption); increases absorption of some drugs (eg methyldopa)
  • Decreased active transport mechanisms in the gut for calcium, folate, vitamin B12

Distribution

  • Reduced skeletal muscle mass with increased ratio body fat to water
  • Volume of distribution for water soluble drugs decreases, increasing serum concentration (e.g. paracetamol, digoxin)
  • Volume distribution for fat soluble drugs increases, leading to prolonged half-life and more toxicity (e.g. diazepam, amiodarone, verapamil)
  • Decreased albumin levels
  • Increased free fraction of highly albumin-bound drugs (e.g. warfarin, phenytoin)
  • However, increased free fraction leads to increased clearance
  • Increased penetration across blood-brain barrier

Metabolism

Reduced liver mass and reduced oxidative metabolism

  • Prolonged half life, higher steady state concentrations of some drugs (eg. diazepam, metoprolol, phenytoin)
  • Unchanged conjugative metabolism in liver
  • Decreased portal venous blood flow
  • Affects drugs with high hepatic extraction ratio, reducing first pass metabolism and increasing drug concentration (eg morphine, verapamil

Excretion

  • Reduced glomerular filtration rate affects drugs like aminoglycosides (i.e gentamicin)
  • Reduced tubular function reduces active tubular excretion of drugs like beta-lactam antibiotics
  • Increased susceptibility to nephrotoxic drugs such as ACE-I/ARB, diuretics, NSAIDs
  • Acute illness (with dehydration) can rapidly reduce renal clearance
  • Important in drugs with narrow margin between therapeutic and toxic dose (e.g. digoxin)
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2
Q

Resources for prescribing in the elderly?

A

STOPP/START criteria

*NB - STOPP criteria is indicated in BNF but not START*

Look in the Cautions section For STOPP criteria related to single drugs or drug classes • Where criteria relate to a drug class without a class monograph, look in the relevant treatment summaries.

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3
Q

Pharmacodynamic changes in the elderly

A

Increased susceptibility to drug toxicity

Anti-cholinergic side-effects of tricyclic antidepressants such as constipation and confusion

  • Increased adverse effects with anticoagulants
  • Frequency of bleeding events increases with age
  • Increased sensitivity to opiates (by about 50%)
  • Increased sensitivity to CNS depressants (eg. propofol)

Reduced Homeostatic Mechanisms

  • Postural hypotension in response to vasodilators
  • Combination of diminished baroreceptor reflexes and impaired cardiac conduction increases susceptibility to _bradyarrhythmias and hypotensio_n in response to verapamil and diltiazem
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4
Q

Which drugs should be avoided in the elderly where possible?

A

NSAIDS

Benzodiazepines

Anti-cholinergics

Tricyclic Antidepressants

Glibenclamide (causes hypoglycaemia)

Doxasozin (adrenergic antagonist - BPH)

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5
Q

Which phenotyoical frailty assessment score can be used to assess a patients frailty on acute admission to the hospital?

Remember frailty can be assessed by 4 major main themes:

Cumulative

Phenotypical

Surrogates

“Eyeball”

A

Bournemouth Criteria:

> 90 - automatically frail

Age: 75-89 - 2 of the following to be considered frail:

Immobility

Incontinence

Cognitive impairment (i.e dementia/delirum - does not include learning disabilities)

Instability (i.e falls)

Iatrogenesis (i.e polypharmacy - > 5 drugs)

*65-75 - need to be instituionalised (nursing/residential home)

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6
Q

A comprehensive geriatric assessment includes which team members and which domains of assessment?

A

Patient/ Their care giver and

  • Doctors • Nurses
  • Therapy (OT/PT/Nutrition/swallow etc)
  • Social services
  • Community services
  • Pharmacist

*CGA is not a form but a process of accumulating data on patient by all team members*

Includes:

- Physical Assessment (illness/pain/incontinence/nutrition?ADL’s etc)

- Psychological (Sleeping/Mental Health/Alcohol)

- Social

- Medication review

These domains all inform care plan for patient.

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7
Q

Which medication is contraindicated with Sildenafil (Viagra) concurrent use?

A

Nitrates

Sildenafil is a PDE5 inhibitor which enhances the effect of nitric oxide and thus leads to vasodilation of the peripheral vasculature leading to a drop in the blood pressure in a similar way to how nitrates work. When taken together the effect is compounded and has led to several deaths in the 1990s.

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8
Q

A 72 year old woman with Parkinson’s disease is managed with Ropinirole (a _____ ). Which is the most important side effect to monitor for?

A

Dopamine agonist

Impulsivity

Due to the fact that Ropinirole is a dopamine agonist, it can lead to impulsivity. This can then lead to pathological gambling and hypersexuality, which can be a very devastating side effect for patients with Parkinson’s and their families to manage.

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9
Q

What is the pharmacological treatment of Alzheimer’s disease?

A

Acetylcholinesterase inhibitors aka anti-cholinesterases:

Donepezil - mild

Rivastigmine/Galantamine - moderate

Memantine (NMDA antagonist) - severe or Achesterase inhibitor contraindication

If you have Alzheimer’s disease, your cells can make too much glutamate. When that happens, the nerve cells get too much calcium, and that can speed up damage to them. NMDA receptor antagonists make it harder for glutamate to “dock” – but they still let important signals flow between cells.

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10
Q

A useful mnemonic to remember the features of Alzheimer;s is the ‘4As’:

A

Amnesia (recent memories lost first)

Aphasia (word-finding problems, speech muddled and disjointed)

Agnosia (recognition problems)

Apraxia (inability to carry out skilled tasks despite normal motor function)

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11
Q

Associated with visual loss, these patients often describe smaller versions of real life objects commonly of faces or cartoons.

Importantly, they realise that the hallucinations are not real. It is thought that this is due to damage of the visual system itself and is not a mental health disorder. Unfortunately there are little treatments or support to offer besides from reassurance of the patient’s sanity.

This is called ____ syndrome.

A

Charles Bonnet Syndrome

The common conditions leading to the syndrome are age related macular degeneration, followed by glaucoma and cataract.

The imagery is varied and may include groups of people or children, animals, and panoramic countryside scenes.

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12
Q

___ is type of corticosteroid mainly used for its mineralocorticoid properties leading to sodium retention and effective blood volume and therefore pressure.

Indications include orthostatic intolerance and adrenal insufficiencies. Notable side effects include oedema due to fluid retention, hypokalemia and supine hypertension.

A

Fludrocortisone

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13
Q

_____

Also known as depressive dementia, this is an important differential in the elderly, severe depression can lead to psycho-motor slowing, memory impairment and difficulties in concentration similar to dementia in appearance. These patients often present with self neglect and significant weight loss as a result.

A

Pseudo-dementia

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14
Q

Haloperidol is contraindicated in patient’s with ____ due to the fact that it promotes dopamine blockade. This can result in ____ and a deterioration in motor function.

A

Parkinson’s disease

Psychosis

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15
Q

This patient is suffering from Lewy body dementia, evidenced by the fact that she has presented with dementia, fluctuating cognition and mild features of Parkinsonism.

The criteria for diagnosing Lewy body dementia is the presence of dementia alongside two of the three (2/3) core features:

A
  1. Fluctuating attention and concentration
  2. Recurrent well-formed visual hallucinations
  3. Spontaneous Parkinsonism.
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16
Q

Lobar pneumonia pattern is much less common than bronchopneumonia and is caused by which organism?

A

Streptococcus Pneumonia (aka pneumococcus)

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17
Q

Empyema is a collection located in the ____ whereas an abscess is in the lung parenchyma.

A

Pleura

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18
Q

‘_____’ lung is the name given to end stage ILD - much like cirrhosis in the liver

A

‘Honeycomb’ lung

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19
Q

Polypharmacy can be defined as ____ or more medicines used daily.

A

5 or more medicines used daily

  • Threshold can vary from ≥2 and ≥11 medications
  • In children, the accepted definition is 2 or more medicines
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20
Q

Causes of acute confusion?

A

D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)

E - Eyes, ears and emotional

L - Low Output state (MI, ARDS, PE, CHF, COPD)

I - Infection

R - Retention (of urine or stool)

I - Ictal

U - Under-hydration/Under-nutrition

M - Metabolic (Electrolyte imbalance, thyroid, wernickes

(S) - Subdural, Sleep deprivation

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21
Q

Dementia

Typically progressive clinical syndrome of deteriorating mental
function significant enough to \_\_\_\_\_

Affects memory, thinking, orientation, comprehension,
calculation, learning capacity, language and judgement.

• Diagnosis – requires impairment in > than ___ cognitive domains
(memory, language, behaviour and visuospatial/executive
function) significant enough to affect ADLs that can’t be
explained by another cause (eg condition or medications)

A

Interfere with activities of daily
living (ADLs)

2+

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22
Q

Most common types of dementia:

  • ____ (50-75%)
  • _____ (up to 20%)
  • _____ (10-15%)
  • _____(2%)
A

Alzheimer’s

Vascular

Lewy body

Frontotemporal

• Other (rarer) causes – list not exhaustive
Parkinson’s disease
Associated with Down’s Syndrome (prevalence may be up to 75% aged >=60)
Huntington’s disease

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23
Q

Management of Dementia

A

Conservative management:

  • Environmental modification as previous
  • Cognitive stimulation/ cognitive rehab/ group reminiscence therapy/ OT (mild to moderate)

Medical management (largely for Alzheimers or Lewy Body dementia):

https://www.bmj.com/content/bmj/suppl/2018/06/27/bmj.k2438.DC1/Dementia_v19_web.pdf

o Acetylcholinesterase inhibitors:

donepezil (mild), rivastigmine or galantamine (moderate)

o Glutamate antagonists: eg memantine (severe or with C/I to Ach inhibitors)

• Limited role for antipsychotics (haloperidol)

• Future development: Aducanumab: monoclonal antibody: targets amyloid build up
Licensed in US only June 2021

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24
Q

Frailty Syndromes

A

 Falls: collapse, legs gave way, ‘found lying on floor’

 Immobility: sudden change in mobility, ‘gone off legs’ ‘stuck in
toilet’

 Delirium: new acute confusion or sudden worsening of confusion in someone with previous dementia/memory loss

 Incontinence: new onset or worsening of urine or faecal incontinence

 Susceptibility to side effects of medication: confusion with
codeine, hypotension with antidepressants

25
Q

Frailty Management

A

• Gold Standard: Comprehensive Geriatric Assessment: MDT
approach holistic assessment considering physical issues, function,
environment/ support, _mobility and balanc_e, psychological issues
and medication
. Care plans can be put in place

  • Exercise interventions: core strength, flexibility, balance, endurance training
  • Good nutrition, considering total protein intake, calcium and vitamin D
  • Role for BMI reduction? Raised BMI associated with poor outcomes

• Medication reviews

• Advance care planning

26
Q

Other than falls, what other risk factors increase the risk of a fragility fracture? (2 mark)

A

•Previous osteoporotic fragility fracture.

  • Current or frequent recent use of oral corticosteroids.
  • Low body mass index (less than 18.5 kg/m2)
  • Smoker.
  • Alcohol intake > 14 units per week.
  • A secondary cause of osteoporosis
27
Q

How would you assess risk of a fragility fracture ?

A
  • Calculate 10 year fragility fracture score (eg FRAX or Qfracture)
  • https://www.sheffield.ac.uk/FRAX/ - Fracture Risk Assessment Tool
  • DEXA if score >10% or Straight to DEXA if PMH fragility fracture
28
Q

Maureen returns to her GP having had a DEXA scan showing a T-score of -1.5.

What does the T-Score on a DEXA scan relate to?

  • Osteopenia: T score _____
  • Osteoporosis T-score ____

Normal range T score _____.

A

A measurement of bone mineral density as compared to that of a 30 year old adult(Z score compares your BMD to what is normal in someone your age and body size)

  • Osteopenia: T score -1 to -2.4
  • Osteoporosis T-score -2.5 and below

Normal range T-score -1 and above

29
Q

Drugs particularly associated with adverse outcomes in
frailty

A

• Anticholinergics: unsteadiness, blurred vision, dry mouth,
urinary retention, confusion

• Benzodiazepines: falls, regular use increases all-cause
mortality, confusion

• Opioids: constipation, falls, delirium

• NSAID: AKI and gastric ulceration

Antihypertensives: AKI, falls

30
Q

Causes of Falls in the elderly?

A

Sensory Disturbance: (visual impairment/vestibular dysfunction/peripheral neuropathy)

Cognitive impairment: Dementia/Delirium

Polypharmacy: Anticholinergics/Opiates/Benzo’s/Antihypertensives

Co-morbidities

Enviromental Hazards: (loose rug)

Physical Ageing Process/Frailty

Orthostatic Hypotension

Motor problems: Gait and Balance problems/ Muscle weakness

31
Q

When a health professional feels that the person with power of attorney may not be acting in the patients best interests, who could they contact?

A

Alert the office of the public guardian who will investigate and can apply to the court of protection. Colleagues, safeguarding lead, defence union also useful

32
Q

What measures should be taken to reduce the risk of delirium during an admission?

A
  • Ensure team of healthcare professionals who are familiar to the person at risk.
  • Avoid moving people within and between wards; worth reflecting on the realityof hospital care and the difficulty in achieving this.
  • Specialist MDT assessment and personalised care plan. Liaison geriatrics / joint care.
  • Appropriate lighting and clear signage / a clock and a calendar should also be easily visible.
  • Re-orientate frequently.
  • Facilitate regular visits from family and friends.
  • Address dehydration and / or constipation.
  • Avoid unnecessary catheterisation / lines / restrictions.
  • Encourage mobility and keep mobile / active when able.
  • Assess for pain, including non-verbal clues of pain and address pain adequately.
  • Carry out a medication review.
  • Encourage good nutritional intake
  • Ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order.
  • Promote good sleep patterns and sleep hygiene.
  • Consider alcohol withdrawal regime.

Be vigilant for withdrawal symptoms and
treat if required.

33
Q

Common causes of delirium can be remembered using the mnemonic ______ :

A

DELIRIUMS

D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)

E - Eyes, ears and emotional (reduced input)

L - Low Output state (MI, ARDS, PE, CHF, COPD) - low oxygen

I - Infection

R - Retention (of urine or stool)

I - Ictal

U - Under-hydration/Under-nutrition

M - Metabolic (Electrolyte imbalance, thyroid, wernickes

(S) - Subdural, Sleep deprivation

or can use

PINCH ME

  • Pain
  • Infection
  • Nutritional compromise
  • Constipation
  • Hydration (dehydration / electrolyte disturbance)
  • Medication
  • Environmental
34
Q

_____ is more likely to present with locked in syndrome (quadriparesis with preserved consciousness and ocular movements), loss of consciousness, or sudden death.

A

Basilar artery occlusion

35
Q

_____ artery ischaemia/infarction results in lateral pontine syndrome, a condition similar to the lateral medullary syndrome but with additional involvement of pontine cranial nerve nuclei.

A

Anterior Inferior Cerebellar

cranial nerves - 5,6,7,8 - expect ipsilateral facial paralysis or hearing loss - as labyrinthine artery is branch of AICA.

36
Q

_____ (______ ) causes ipsilateral Horner’s syndrome (ptosis/meiosis/anhidrosis), ipsilateral loss of _____ on the face, and loss of pain and temperature sensation over the _____ body. This syndrome is caused by ischaemia/infarction to _____ artery that supplies the cranial nerves to the medulla

A

Wallenberg’s syndrome (lateral medullary syndrome) - or posterior inferior cerebellar artery (PICA)

pain and temperature sensation

contralateral

Posterior inferior cerebellar artery (PICA)

Thus

*AICA - causes lateral pontine syndrome (CN 5,6,7,8)

*PICA - causes lateral medullary syndrome (makes sense as medulla is below pons)

37
Q

_____/ _____ syndrome (paramedian branches of the upper basilar and proximal posterior cerebral arteries): causes an _____ nerve palsy and contralateral hemiparesis.

A

Weber’s syndrome/medial midbrain

Ipsilateral oculomotor (CN3) - sits right above midbrain just beside posterior cerebral artery and posteromedial basilar arteries.

Webers syndrome- causes an ipsilateral oculomotor nerve palsy (i.e down and out) and contralateral hemiparesis

*Again makes sense as Posterior cerebral artery is above pons and medulla and thus serves the midbrain

38
Q

_____ is defined by: a pure motor stroke, pure sensory stroke, sensorimotor stroke, or ataxic hemiparesis.

There should be NO:_____ , _____ , or ____

These strokes affect small deep perforating arteries, typically supplying _____ or _____ .

A

A lacunar infarct (LACI)

higher cerebral dysfunction, brainstem dysfunction.

internal capsule or thalamus

A lacunar stroke (LACS) is a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).

39
Q

A posterior circulation infarct (POCI) is defined by:

Cerebellar dysfunction, OR

Conjugate eye movement disorder, OR

____ motor/sensory deficit, OR

____ cranial nerve palsy with ____ deficit, OR

Cortical blindness/isolated hemianopia.

A POCI involves the vertebrobasilar arteries and associated branches (supplying the cerebellum, brainstem, and occipital lobe)

A

Bilateral

Ipsilateral cranial nerve palsy with contralateral motor/sensory

Note this type of stroke can also present with vertigo, ataxia and dysarthria due to involvement of the vestibular and cerebellar systems.

40
Q

Strong risk factors for ischaemic stroke include:

Weaker risk factors for ischaemic stroke include:

A

Age, male sex, family history of ischaemic stroke, hypertension, smoking, diabetes mellitus, and atrial fibrillation.

Hypercholesterolaemia, obesity, poor diet, oestrogen-containing therapy, and migraine.

41
Q

Parietal lobe damage manifests as a defect of attention in the ____, astereognosis, constructional apraxia (non-dominant), dressing apraxia (non-dominant) and ideomotor apraxia (dominant). Right hemisphere (i.e. non-dominant) parietal lesions are particularly prone to producing visual neglect.

A

Contralateral visual field

Astereognosis is used to describe both the inability to discriminate shape and size by touch and the inability to recognize objects by touch. These are apperceptive and associative types of agnosia. The term tactile agnosia is used for the associative type.

Constructional apraxia refers to the inability of patients to copy accurately drawings or three-dimensional constructions. It is a common disorder after right parietal stroke, often persisting after initial problems such as visuospatial neglect have resolved.

Dressing apraxia refers to inattention to the left side when dressing; it signifies a feature of the neglect syndrome rather than the loss of the ability to use tools. Typically, a right hemisphere lesion is implicated. It has no relationship to ideomotor apraxia.

Ideomotor apraxia (IMA) is the impaired ability to perform a skilled gesture with a limb upon verbal command and/or by imitation. It can be shown for both meaningful motor acts that do not imply objects and gestures that imply object use.

42
Q

Broca’s dysphasia is also known as ____ and is characterised by difficulties in expressing and producing language. Usually patients will exhibit making great effort when speaking.

Wernicke’s dysphasia is also known as _____ would be characterised by difficulty in comprehension of language. Reading and writing are more severely affected than the act of producing connected speech in cases of Wernicke’s dysphasia.

A

expressive dysphasia

receptive dysphasia

43
Q

CT scans are useful for detecting haemorrhagic strokes, but can be normal in the first ____ of an ischaemic stroke. ____ can confirm early ischaemic stroke, which appears bright.

A

Few hours

Diffusion-weighted MRI

44
Q

The ischaemic ____ describes the cerebral area surrounding the ischaemic event where there is ischaemia without necrosis. This area is amenable to recovery with thrombolysis.

A

penumbra

45
Q

Cranial nerve lesions are ipsilateral, except ____.

A

Trochlear (Superior Oblique)

46
Q

A total anterior circulation infarct (TACI) is defined by:

A

Contralateral hemiparesis or hemiplegia, AND

Contralateral homonymous hemianopia, AND

Higher cerebral dysfunction (e.g. aphasia, neglect)

A TACI involves the anterior AND middle cerebral arteries on the affected side.

*Hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body.

47
Q

Which cranial nerve nuclei can be found in the pons?

A

(5,6,7,8):

Trigeminal (CN V)

Abducens (CN VI)

Facial (CN VII)

Vestibulocochlear nerve (CN VIII)

It also contains the inferior salivatory nucleus of the glossopharyngeal nerve (CN IX).

48
Q

A total anterior circulation infarct (TACI) is defined by:

A

Contralateral hemiplegia or hemiparesis,

AND

Contralateral homonymous hemianopia,

AND

Higher cerebral dysfunction (e.g. aphasia, neglect)

A TACI involves the anterior AND middle cerebral arteries on the affected side.

49
Q

What is the actue management of Ischaemic Stroke?

A

Patients should be approached in the DR ABCDE manner.

Airway protection (in patients presenting with depressed consciousness) and aspiration precautions (in patients presenting with swallowing impairment) are very important.

Subsequent stroke management depends on whether the stroke is ischaemic or haemorrhagic. CT head should be performed on arrival to the emergency department to distinguish ischaemic from haemorrhagic stroke. (The most sensitive test for confirming ischaemic infarct is a diffusion weighted MRI. This is generally used if the diagnosis is unclear but is not normally possible in the emergency setting due to logistical challenges)

Alteplase (tissue plasminogen activator) is indicated in patients presenting within 4.5 hours of symptom onset and with no contraindications to thrombolysis (e.g. recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, and INR).

Mechanical Thrombectomy can be performed in patients with anterior circulation strokes within 6 hours of symptom onset, provided that they have a good baseline functional status and lack of significant early infarction on initial CT scan. Mechanical Thrombectomy can also be performed in posterior circulation strokes up to 12 hours after onset.

If hyper-acute treatments are not offered, patients should receive aspirin 300 mg orally once daily for two weeks. If hyper-acute treatments are offered (i.e thrombolysis or Thrombectomy), aspirin is usually started 24 hours after the treatment and following a repeat CT Head that excludes any new haemorrhagic stroke.

50
Q

What Stroke investigations would you do to identify cause of strome? (post-acute)

A

In ischaemic stroke: carotid ultrasound (to identify critical carotid artery stenosis), CT/MR angiography (to identify intracranial and extracranial stenosis), and echocardiogram (if a cardio-embolic source is suspected). In young patients further investigation e.g. a vasculitis screen or thrombophilia screen may be necessary.

In haemorrhagic stroke: serum toxicology screen (sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke).

Further investigations to quantify vascular risk factors include:

- serum glucose (all patients with stroke should be screened for diabetes with a fasting plasma glucose or oral glucose tolerance test)

- serum lipids (to check for raised total cholesterol/LDL cholesterol).

51
Q

Stroke management (chronic i.e secondary stroke prevention)

A

Mnemonic HALTSS:

Hypertension:

No benefit in lowering the blood pressure acutely (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure >180 mmHg). Anti-hypertensive therapy should, however, be initiated 2 weeks post-stroke.

Antiplatelet therapy:

Patients should be administered Clopidogrel 75 mg once daily for long-term antiplatelet therapy.

In patients with ischaemic stroke secondary to atrial fibrillation, however, warfarin (target INR 2-3. or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke.

Lipid-lowering therapy:

Patients should be prescribed high dose atorvastatin 20-80 mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke).

Tobacco:

Offer smoking cessation support.

Sugar:

Patients should be screened for diabetes and managed appropriately.

Surgery:

Patients with ipsilateral carotid artery stenosis more than 70% should be referred for carotid endarterectomy.

Rehabilitation and supportive management will include an MDT approach with involvement of physiotherapy, occupational therapy, speech and language therapy, and neurorehabiliation.

52
Q

Anterior Cererbral Artery Strokes are most likely to cause ____ and ____ weakness (due to the motor homunculus).

A

The anterior cerebral arteries supply the medial and supero-medial edge of the cortex, along the falx cerebri.

Lesions of the ACA would cause foot and lower leg weakness, and are less likely to cause speech disturbance (patients can repeat sentences but struggle to initiate). ACA lesions can also causes a sensory loss of the lower limb

https://www.youtube.com/watch?v=5j1MsyJeLmc

53
Q

Postural aka Orthostatic hypotension is defined as a fall in systolic blood pressure of at least ____ mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least ___ mmHg within ____ minutes of standing.

A

20

30

10

3

When orthostatic hypotension has an underlying neurogenic cause (e.g., peripheral neuropathy) it is associated with a blunted increase in heart rate, typically less than 15 bpm.

Orthostatic hypotension becomes clinically significant if it is accompanied by symptoms of cerebral hypoperfusion, which can lead to syncope and falls.

54
Q

Risk Factors for Falls

A

A history of falls is one of the strongest risk factors for a fall - after a first fall, people have a 66% chance of having another fall within a year

Conditions that affects balance, mobility or strength, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson’s disease.

Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.

Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).

Environmental hazards, such as loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially in the bathroom), loose fittings (such as handrails), and poor footwear.

The more risk factors a person has, the greater their risk of falling.

Falls can also be a sign of underlying health issues, such as frailty

55
Q

MDT Management of Falls in the Elderly

A
  • Analgesia titration to allow mobility.
  • Orthopaedic support, but likely non-surgical (“conservative”) management.
  • Delirium risk reduction (Lighting/clock/continuation of staff).
  • Medication review - hold ACEi / beta-blocker / alpha blocker with low B.P.
  • Multi-factorial falls assessment, including gait and balance / lying and standing B.P / medication review / Alert technology whilst inpatient, certainly patient activated “call bell” for assistance but with dementia consider automated system such as a falls alert mat / consider “bay tag” observation
    with cognitive impairment.
  • Treat other co-morbidities (for example, constipation,pneumonia)
  • Patient education with falls risk.
  • Further cardiac monitor (ECG)
  • Further falls risk assessment as MDT as part of discharge planning including:

o Medication review when lying and standing B.P are known.
o Gait and balance specialist assessment and balance and strengthening exercise programme and review walking aids.
o Environmental review with interventions.
o Vitamin D supplementation - check levels, fragility fracture / osteoporosis secondary prevention.
o Assistive technology (falls sensor for possible future falls to alert and avoid “long lie”).

56
Q

Key points to ascertain in a history of falls?

A

When did you fall?

Did anyone see you fall?

Where did you fall?

What happened before/during/and after?

How many times have you fallen over the last few months?

Bone health - previous fractures / family history of fracture / smoking, alcohol /
calcium intake

Previous Mobility

57
Q

Which tools can be used to identify non-specific cognitive dysfunction?

And which tool can be used to specifically assess for delirium?

A

Non-specific

MOCA

MMSE

10/4 AMT

6-CIT

Delirum Specific

4AT

58
Q

How do you assess capacity?

A

Assume capacity unless patient gives you reason to doubt

59
Q

Public Health England Guidance on diagnosis of UTI in people > ___ states: “Do not perform urine dipsticks.

A

65

Dipsticks become more unreliable with increasing age over 65 years.

Up to half of older adults, and most with a urinary
catheter, will have bacteria present in the bladder / urine without an infection.

This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.”