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Geriatrics Flashcards

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1
Q

What is delirium?

A

an acute and fluctuating state of confusion, usually precipitated by illness, injury or drug toxicity or withdrawal

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2
Q

Types of delirium?

A

Hyperactive
Hypoactive
Mixed

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3
Q

4 Key Characteristics of delirium?

A

Fluctuating Pattern
Inattention
Acute change in cognition
Temporary in relation to illness

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4
Q

Causes of Delirium?

A

Pain
Infection
Constipation/Urinary Retention
Hydration/Nutrition
Medications
Electrolyte Disturbances/Environment

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5
Q

What medications can trigger delirium?

A

tricyclic antidepressants
anticholinergics
benzodiazepines
tramadol
anti-histamines

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6
Q

Screening test for delirium?

A

4-AT Test

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7
Q

Components of 4-AT Test

A

Alertness (4)
AMT-4 (age, DOB, place, yr) (2)
Attention (2)
Acute change/fluctuating (4)

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8
Q

Delirium vs Dementia?

A

acute onset
altered consciousness/drowsiness
inattention
disorganised thinking

can have both -> not mutually exclusive

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9
Q

Treatment for delirium?

A

primarily non-pharmacological
treat any underlying cause

person -> minimise sensory deprivation, sleep deprivation, hydration, nutrition, elimination, engage family

environment -> keep constant, clocks right, calendars right, room with windows, items from home, limit restraints, discontinues unnecessary lines

occupation -> re-establish pre-existing routines, sleep hygiene, stimulate an appropriate amount

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10
Q

Pharmacological Treatment of Delirium?

A

anti-psychotics (haloperidol, risperidone, quetiapine, olanzapine)

start low, go slow

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11
Q

When is pharmacological treatment of delirium necessary?

A

if the patient is posing a risk to themselves or to other patients

last resort as does not treat the delirium and may in fact lengthen it

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12
Q

When are benzos used in delirium?

A

Alcohol/Benzo withdrawal
Patients with Parkinson’s or Lewy Body Dementia

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13
Q

Subtypes of dementia?

A

Alzheimer’s Disease
Vascular Dementia
Frontotemporal Dementia
Dementia with Lewy Bodys
Parkinson’s Dementia
Progressive Supranuclear Palsy
Corticobasal Degeneration

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14
Q

Pathology of Alzheimer’s Disease?

A

build-up of beta amyloid plaques and Tau protein neurofibrillary tangles

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15
Q

Presentation of Alzheimer’s?

A

gradually progressive decline in cognitive function
short-term memory affected first
neuropsychiatric symptoms common

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16
Q

Features of Vascular Dementia?

A

‘step-wise’ deterioration
associated with CVS risk factors and stroke
more acute than AD

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17
Q

Lewy Body Dementia vs Parkinson’s Disease Dementia?

A

dementia symptoms within 1 year of PD onset -> Lewy Body Dementia
dementia symptoms after more than 1yr with PD -> Parkinson’s Disease Dementia

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18
Q

Features of Lewy Body Dementia?

A

motor features of PD
cognitive impairment
visual hallucinations v common

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19
Q

Features of PD Dementia?

A

v similar to Lewy Body
early impairment in executive function

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20
Q

Features of Frontotemporal Dementia?

A

early decline in social interpersonal contact
emotional blunting
overlap with MND and PD

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21
Q

Evaluating Suspected Dementia Patient?

A

detailed Hx -> collateral is key
medication review (STOPSTART)
full exam
cognitive screening (MoCA, MMSE)
Bloods (Ca, U&Es, TFTs, B12 and folate, HIV/Syphillis)
ECG
neuroimaging
LP

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22
Q

Pharmacological Tx of Alzheimer’s Disease?

A

1st line -> cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
More severe -> memantine (NMDA receptor antagonist)

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23
Q

Non-pharmacological Tx for AD?

A

cognitive stimulation exercises
exercise
diet
early management of CVS RFs
support groups
art and music therapy
support for family and carers

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24
Q

Treatment of BPSD?

A

patient-centred psychosocial interventions
memantine
antipsychotics if risk to selves or others -> quetiapine

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25
Members of MDT?
doctors nurses GP OT physio SALT Dieticians Discharge Coordinator Social Work
26
Osteoporosis Definition?
T-Score on DEXA <-2.5 or prev. frailty fracture
27
What is a frailty fracture?
fracture from a fall from standing or sitting down common sites include hip, wrist (FOOSH), pubic ramus
28
Blood results in osteoporosis?
Ca normal, phosphate normal, alk phos normal, PTH normal
29
Risk Factors for osteoporosis?
Incr. age Female post-menopause FHx red. mobility long-term corticosteroid use PPI use low BMI low Ca or Vit D intake alcohol and smoking prev fractures CKD, hyperthyroidism, RA
30
Who should be screened for osteoporosis?
anyone on long-term corticosteroids anyone with prev frailty fracture anyone > 50 with RFs women > 65 men > 70
31
How to screen for osteoporosis?
QFracture Tool FRAX tool
32
How to diagnose osteoporosis?
DEXA scan gold standard but not always necessary
33
Management for Osteoporosis?
address modifiable RFs supplement with Vit D and Ca bisphosphonates first-line denosumab teripartide
34
Examples of bisphosphonates?
alendronate weekly oral risedronate weekly oral zoledronic acid yearly IV
35
How to take oral bisphosphonates?
first thing in morning empty stomach take and stay upright for 30 minutes to minimise GI SEs
36
Side Effects of bisphosphonates?
oesophagitis and oesophageal erosions atypical femoral fractures osteonecrosis of jaw osteonecrosis of external auditory canal hypocalcaemia
37
What is Denosumab?
monoclonal antibody that targets osteoclasts
38
How is Denosumab taken and for how long?
S/C injection every 6 months initially cont. for 10 yrs but risk of rebound osteoporosis on stopping Tx
39
What is Teripartide?
PTH anabolic function daily injection
40
Parkinson's Disease Symptoms?
Tremor Rigidity Akinesia/Bradykinesia Postural instability Postural hypotension Sleep Disorders Psychosis (visual hallucinations) Depression/Dementia
41
Parkinson's Pathology?
neurodegenerative disease caused by loss of dopaminergic neurons in the substantia nigra in the basal ganglia
42
Differentials for Tremor?
Parkinson's Disease Benign Essential Tremor Cerebellar (intention) Tremor Postural Tremor (lithium, inhalers, anxiety, hyperthyroidism)
43
PD Medications?
Dopamine Agonists (ropinirole, pramipexole) MAOb inhibitors (selegeline, rasagiline) Levodopa + prevent breakdown
44
SEs of dopamine agonists?
impulsive behaviour nausea, constipation nightmares hallucinations sleep attacks (NB for driving) hypotension
45
Issues with medications for PD?
slow in the mornings waiting for effect to kick in 'wearing off' phenomenon
46
Parkinson's + Conditions?
Multiple Systems Atrophy Progressive Supranuclear Palsy Corticobasilar Degeneration
47
Differentiating Multiple Systems Atrophy?
Parkinsonism + autonomic dysregulation orthostatic hypotension urinary incontinence/retention anhidrosis
48
Differentiating Progressive Supranuclear Palsy?
Parkinsonism + vertical gaze palsy axial rigidity with head tilted backwards
49
Differentiating Corticobasilar Degeneration?
speech problems astereognosis alien limb phenomenon
50
Key Features Suggestive of Stroke?
abrupt onset focal neurological signs and symptoms maximal deficit occurring within seconds negative symptoms
51
What investigations if suspected stroke?
CT brain non-contrast (rule out haemorrhage, check for ischaemia) CT angiogram (check for LVO) CT perfusion (see infarcted areas and penumbra)
52
Acute Interventions for Stroke?
Thrombolysis and Thrombectomy
53
Time-set for thrombolysis?
Within 4.5hrs of onset of symptoms
54
Time-set for thrombectomy?
Within 24hrs of onset of symptoms
55
Assessing for cause of stroke?
Atherosclerosis of Large Vessels Small Vessels arteriosclerosis Cardio-embolic events Others
56
What is the one thing that improves outcome in 100% of stroke patients?
Early admission to an acute stroke unit
57
Prevention of further strokes?
dual antiplatelet therapy for 3 wks (aspirin 300mg and clopidogrel 75mg) monotherapy clopidogrel 75mg statin therapy BP <130/80 If AFib -> anticoagulate
58
Risk Factors for Stroke?
Age A Fib Prev. stroke or TIA carotid artery disease CVD HTN diabetes smoking vasculitis thrombophilia COCP
59
Initial management of suspected stroke?
exclude hypoglycaemia CT brain non-contrast to rule out haemorrhagic stroke aspirin 300mg thrombolysis thrombectomy if appropriate don't treat HTN (risk of hypoperfusion)
60
Management of TIA?
urgent referral to stroke specialist (24hrs) aspirin 300mg daily secondary prevention measures for CVD
61
Rehab for stroke?
MDT!!!!!!!! doctors, nurses, OTs, physio, SALTs, dieticians, psychology, social work, discharge coordinators, family
62
What is syncope?
transient LOC and postural tone with spontaneous recovery
63
Discriminating syncope from other pathology?
Sudden Cardiac Death -> recovery in syncope TIA -> no LOC in TIA Seizure -> discriminating features include lateral tongue bite, faecal incontinence and recovery time
64
Causes of syncope?
Neurally-mediated Cardiogenic
65
Neurally-mediated types of syncope?
vasovagal situational orthostatic hypotension postprandial hypotension carotid sinus syndrome
66
Cardiogenic types of syncope?
structural (aortic stenosis, HOCM, myxoma, dissection, PE) arrhythmias (SVT, brady/tachyarrhythmias, Brugada Syndrome)
67
Diagnosing neurally-mediated syncope?
tilt-table test orthostatic hypotension (>20mmHg systolic, >10mmHg diastolic) carotid sinus massage
68
Diagnosing cardiogenic syncope?
CVS Exam (murmurs, HR) ECG CXR Echo
69
Treatment for syncope?
explain and reassure avoid precipitating factors medication review (antihypertensives, anticholinergics, antidepressants)
70
Consequences of Urinary Incontinence?
psychosocial (embarrassment, depression, isolation, dec. self-esteem, institutionalisation) medical (pressure ulcers, rashes, UTI, falls, fractures, red. mobility, red. ADLs)
71
Types of Urinary Incontinence?
Mixed Functional Urge/OAB Overflow Stress
72
Reversible causes of urinary incontinence?
Delirium Infection Atrophic vaginitis Pharmaceuticals Psychological Excessive urine output Restricted mobility Stool impaction
73
What medications can cause urinary incontinence?
anti-cholinergics diuretics
74
Treatment for urinary incontinence?
maximise independence (mobility, prompted voiding, avoid catheter) minimise precipitants (caffeine, alcohol, weight loss) muscle exercises (bladder retraining, pelvic floor exercises)
75
Medications for urinary incontinence?
try to avoid inc. risk of falls, incontinence and retention, cognitive impairment tamsulosin (alpha blocker) finasteride (5 alpha reductase inhibitor) oxybutynin (anti-cholinergic) mirabegron (beta 3-adrenoceptor agonist -> best in elderly frail patients)
76
Confusion Screen Bloods?
FBC U&Es LFTs coagulation screen TFTs Calcium B12/Folate/Haematinics Glucose Blood cultures
77
Scale for assessing ADLs?
Barthel Index
78
Scales for assessing cognitive impairment?
AMTS (/10) MoCA (/30) MMSE (/30)
79
Scales for assessing degree of disability after a stroke?
Modified Rankin Scale (0-6)
80
Scale for quantifying stroke severity?
NIHSS (/42 -> thrombolysis advised if >4)
81
Scale for assessing frailty?
Clinical Frailty Scale (1-9)
82
Medications which increase risk of falls?
Antipsychotics Benzos Antidepressants Antihypertensives Diuretics Anticholinergics
83
Medications which increase risk of orthostatic hypotension?
beta blockers alpha blockers diuretics calcium channel blockers
84
DDx for Stroke?
Sepsis Space-occupying lesion Sugars -> hypoglycaemia Seziures -> post-ictal weakness Syncope Sore -> migraine Silly -> delirium Stroke functional -> functional disorder
85
When is warfarin used over DOACs?
mechanical heart valve antiphospholipid syndrome eGFR < 15ml/min
86
Scale for assessing risk of pressure ulcers developing?
Waterlow Score
87
What is the MMSE test used for?
To assess cognitive function
88
What is the MoCA test used for?
To assess cognitive function
89
What is the AMTS used for?
To assess cognitive function (abbreviated)
90
What is the 4AT test used for?
To assess for delirium
91
What is the Barthel Index used for?
To assess a person's independence in completing their ADLs
92
What is the Waterlow Score used for?
To assess for the risk of a person developing pressure ulcers
93
What is the Clinical Frailty Score used for?
To assess how frail a person is
94
What is the Modified Rankin Score used for?
To assess a person's level of disability after a stroke
95
What is the NIHSS used for?
To assess the severity of a stroke and thus if the person will benefit from thrombolysis
96
What are senile purpura?
common benign condition characterised by the formation of ecchymosis on the extensor surfaces of the arm
97
What are pressure ulcers?
localised injury to tissue (usually over a bony prominence) as a result of pressure
98
Risk Factors for pressure ulcers?
exposure to sustained pressure and shear immobility increased age incontinence malnutrition
99
What is a stage 1 pressure ulcer?
non-blanching erythema of intact skin, usually over a bony prominence (sacrum)
100
What is a stage 2 pressure ulcer?
partial thickness skin loss or blistering ***reportable to HIQA
101
What is a stage 3 pressure ulcer?
full thickness skin loss with visible S/C fat
102
What is a stage 4 pressure ulcer?
full thickness tissue loss with exposed bone, muscle and tendon ***if exposed bone -> assume osteomyelitis
103
Management of pressure ulcers?
prevent further injury -> prevent pressure, friction, shearing identify RFs and reduce if possible promote new tissue growth manage exudate protect surrounding skin remove devitalised tissue promotion of granulation from base of wound
104
Prevention of pressure ulcer formation?
Skin Assessment (head to toe, focus on bony prominences) Surface (special mattresses) Keep moving Incontinence Nutrition (MUST score)

Geriatrics (1 decks)

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