Geriatrics

Question 1

Neural causes of syncope

Answer 1

• Neural causes:
○ Vasovagal (most common):
§ Severe pain, fear, blood phobia
§ Orthostatic stress eg prolonged standing or in hot places
○ Situational eg micturition, Cough, sneeze
Carotid sinus hypersensitivity - while shaving, tight collar

Question 2

Postural hypotension causes of syncope

Answer 2

Postural hypotension:
○ Autonomic failure - postprandial, medication, MSA, parkinsons, diabetic neuropathy
Hypovolemia - haemorrhage, addisons, dehydration

Question 3

Cardiac arrhythmia causes of syncope

Answer 3

○ Long QT
○ Drug induced arrhythmia
AV conduction disease

Question 4

Structural cardiopulmonary causes of syncope

Answer 4

○ Aortic stenosis
○ ACS
○ Pericardial tamponade
HOCM

Question 5

Hx of syncope

Answer 5

• Was LOC complete?
	• How long LOC? How quickly did it come on?
		○ Vasovagal is brief complete LOC not lasting more than 20 secs
	• Warning sx?
	• Recovery spontaneous and total?
		○ Postictal sx - seizure
	• Situational trigger?
	• Change In meds?
FHx of sudden death? - HOCM

Question 6

Ix of syncope

Answer 6

Ix:
	• LS BP
	• Cardiac exam
	• ECG
	• FBC - anaemia
Fasting BM - hypoglycaemia

Question 7

Syncope differentials

Answer 7

Syncope differentials:
	• Epilepsy
	• Narcolepsy
	• Dizziness without LOC
	• TIA/Stroke
Hypoglycaemia

Question 8

Rules on driving for seizures

Answer 8

Seizures:
• 1st seizure - No driving for 6 mths
• Multiple seizures:
Seizure free for 12 months - may qualify for license

Question 9

Rules on driving for syncope

Answer 9

Syncope:
• Simple faint - no restriction
• Single episode, explained & treated - 4 wks off
• Single episode, unexplained - 6 mths off
2+ eps - 12 mths off

Question 10

Stroke driving rules

Answer 10

• 1 mth off driving may not need to inform DVLA if no residual neurological deficit
Multiple TIAs over short period of time - 3 mths off + inform DVLA

Question 11

Tremor differentials and classification

Answer 11

Classifying tremors:
• Rest - PD (pill rolling, bradykinesia)
• Intention - Cerebellar disease
• Tremor on movement - Essential tremor, thyrotoxicosis, anxiety, drugs (beta agonists)

Question 12

inheritance of essential tremor, S&S, tx

Answer 12

Benign auto dom condition which affects both upper limbs

S&S:
• Postural tremor worse if arms outstretched
• Improved by alcohol and rest

Tx:
• Propanolol

Question 13

guillan barre S&S and causes

Answer 13

S&S:
	• Ascending weakness
	• Parasthesia
	• Hyporeflexia
	• Severe cases lead to muscle weakness and resp failure

Caused by:
	• Often triggered by infection Campylobacter jejuni
	• Lymphomas esp hodgkins
	• Pregnancy
	• Surgery
	• Drugs

Question 14

Explain ROSIER tool

Answer 14

ROSIER tool to assess stroke likelihood:
• New onset asymmetrical facial weakness, limb weakness, speech disturbance, or visual field defect - 1 point each
• LOC or seizure = -1 point
• Stroke likely if >0 points

Question 15

Tx of stroke

Answer 15

Acute Tx:
	• ABCDE
	• High flow o2
	• Optimise BM
	• Ischemic stroke:
		○ IV alteplase if within 4.5 hrs of symptoms
		○ 300mg Aspirin
	• Hemorrhagic stroke:
		○ Neurosurgery referral

Question 16

S&S of intracranial abscess

Answer 16

S&S:
	• Fever
	• Headache
	• GCS lowered
	• Focal deficits
	• Generalised tonic clonic seizures
	• Meningism
	• Infants - Bulging fontanelles

Question 17

ix and tx of intracranial abscess

Answer 17

Ix:
	• FBC
	• Blood cultures
	• LP - rules out meningitis. Only if no signs of raised ICP
	• CT head
	• Abscess aspiration for culture

Tx:
• Drain and culture
• Sepsis 6
• IV dexamethasone if cerebral oedema suspected
• Surgery - surgical excision of abscess

Question 18

S&S of NPH

Answer 18

Wet, wobbly, and whacky:

• Urinary incontinence, gait ataxia, dementia

Question 19

Ix and tx of NPH

Answer 19

Ix:
• Imaging reveals hydrocephalus with enlarged 4th ventricle

Tx:
• Ventriculoperitoneal shunting

Question 20

Patho and S&S of degenerative cervical myelopathy

Answer 20

Spinal stenosis at the cervical level

S&S:
	• Pain in limbs and neck
	• Loss of motor function
	• Loss of sensory function - numbness
	• Loss of autonomic function - continence, impotence

Question 21

Ix and tx of degen cerv myelopathy

Answer 21

Ix:
• MRI cervical spine

Tx:
• Surgical Decompression

Question 22

S&S of parkinsons

Answer 22

S&S:
	• Classic triad:
		○ Bradykinesia - short shuffling steps (MUST HAVE)
		○ Tremor - pill rolling typical
		○ Rigidity - lead pipe rigidity
	• Mask like facies
	• Drooling of saliva
	• Depression

Sx worse on one side than other usually

Question 23

Tx of parkinsons

Answer 23

Tx:
• Delay tx until onset of disabling sx and then introduce dopamine receptor agonist (DRA)
• DRA:
○ Bromocriptine
○ ADR - day time somnolence, impulse control disorders
• Levodopa:
○ Reduced effectiveness over time usually 2 yrs
○ ADR - dyskinesia, dry mouth, anorexia, postural hypotension

Question 24

Patho of huntingtons

Answer 24

Patho:
• Auto dom
• Huntingtin protein accumulates in brain and causes damage

Question 25

S&S and ix of huntingtons

Answer 25

``` S&S: • Involuntary movements • Argumentative behaviour • Depression • Chorea - quick, "dancing" movements of hand and face • Rigidity • Dystonia • Dementia • Weight loss ``` Ix: • FHx • DNA analysis • CT head

Question 26

Tx of huntingtons

Answer 26

Tx: • Antidepressants • Tranqs to control chorea

Question 27

S&S of multi systems atrophy

Answer 27

S&S: • Parkinsonism • Postural hypotension • Ataxic gait - uncoordinated movements, drunk like

Question 28

S&S of myasthenia gravis. when is it a crisis

Answer 28

``` S&S: • Weakness and fatiguability • Ptosis • Diplopia • Dysphagia • Dysarthria • Myasthenic crisis - Resp function affected ```

Question 29

Ix and tx of MG

Answer 29

Ix: • Ach receptor antibodies • Tensilon test - anticholinesterase test • CXR - look at thymus (thymus abnormal in majority) ``` Tx: • Anticholinesterases eg pyridostigmine • Surgery - thymectomy • Immunosuppressants - steroids, DMARDs • Myasthenic crisis - IV immunoglobulins, plasmapheresis ```

Question 30

Patho of syringomyelia and S&S

Answer 30

Patho: • Development of cysts in spinal cord that compress ``` S&S: • Asymmetrical initially • Wasting and weakness of arms • Spinothalamic sensory loss - pain and temp • Loss of reflexes ```

Question 31

Causes of sensory neuropathy

Answer 31

``` Sensory neuropathy causes: • Diabetes • Alcohol • RA • Drugs • Malignancy • B12 deficiency ```

Question 32

Causes of motor neuropathy

Answer 32

``` Motor Neuropathy causes: • Guillan Barre Motor neurone disease • Charcot-marie-tooth disease • Lead toxicity ```

Question 33

Ix of peripheral neuropathies

Answer 33

``` Ix: • Urine dipstick • BM • FBC • B12 levels • History of alcohol ```

Question 34

Diseases of motor neurone disease

Answer 34

Diseases: • Amyotrophic lateral sclerosis • Progressive muscular atrophy • Bulbar palsy

Question 35

S&S of MND

Answer 35

``` S&S: • Fasciculations • Absence of sensory signs/symptoms • Mix of lower motor neurone and upper motor neurone signs - eg absent reflexes in upper limb and exaggerated reflexes in lower limb • Wasting of small hand muscles ```

Question 36

Causes of 4th nerve palsy and S&S

Answer 36

Cause: • Head trauma • CV risk factors S&S: • Eye is elevated • Unable to look down and in or read

Question 37

Causes of 6th nerve palsy and S&S

Answer 37

Cause: • CV risk factors • Raised ICP • Vasculitis S&S: • Eye unable to abduct beyond the midline

Question 38

Causes of 3rd nerve palsy and S&S

Answer 38

Causes: • DM • Vasculitis • Posterior communicating artery aneurysm S&S: • Eye down and out • Ptosis • Pupil dilated

Question 39

Causes of Horners and S&S

Answer 39

``` S&S: • Miosis (constricted pupil) • Ptosis • Anhidrosis (loss of sweating over half of face) • Apparent enopthalmos ``` Causes: • Pancoast tumour • Iatrogenic - thyroidectomy • MS

Question 40

Bells palsy patho, epi

Answer 40

Epidemiology: • 20-40 years peak incidence • Pregnant women more common Acute, unilateral, idiopathic facial nerve palsy

Question 41

S&S of bells palsy and tx

Answer 41

S&S: • Lower motor neuron facial nerve palsy - FOREHEAD AFFECTED: ○ In upper motor neuron lesion, upper face is spared • Post auricular pain • Altered taste • Dry eyes Tx: • Prednisolone • Artificial tears

Question 42

S&S of trigeminal neuralgia and tx

Answer 42

S&S: • Severe unilateral pain - sudden, shock like • Triggered by touch to face or using face Tx: • Carbamazepine • Referral to neurology if no response

Question 43

S&S of alzheimers, lewy body, frontotemporal dementia, vascular dementia, and normal pressure hydrocephalus and pseudodementia

Answer 43

Alzheimers - 50% of cases: • Presentation: ○ Gradual with progressive cognitive decline ○ Diagnosis supported via radiology Vascular Dementia - 25% of cases: • Presentation: ○ CVA evidence ○ Deterioration in cognitive function Frontotemporal Dementia - 7% of cases: • Presentation: ○ Decline in social and personal conduct - personality change and disinhibition ○ Emotional blunting ○ Echolalia, mutism ○ Lack of insight but sparing other cognitive functions Lewy Body Dementia - 15% of cases: • Presentation: ○ Day to day fluctuations in cognitive performance ○ Visual hallucinations ○ Parkinsonism ○ Extreme sensitivity to anti-psychotics Normal Pressure hydrocephalus: • Triad of symptoms - urinary incontinence, gait ataxia, dementia. whacky, wobbly, wet Pseudodementia: Reversible and due to depression - SSRIs

Question 44

Steps for nutrition if malnourished

Answer 44

Steps for nutrition: 1. Oral nutrition 2. Enriched oral nutrition - high calorie foods eg butter 3. Oral nutritional supplements - fortisip 4. Alternative routes of feeding

Question 45

Alternative routes of feeding for malnourished. when to use each.

Answer 45

``` Alternative routes of feeding: • NG tube: ○ <14 days • Gastrotomy: ○ Tube feeds directly into stomach via abdo surface ○ LT feeding ```

Question 46

How can you monitor someones nutrition?

Answer 46

Monitoring nutrition: • Weight changes • Fluid balance • Nutrient intake - prescribed vs delivered

Question 47

Mechanism of refeeding syndrome

Answer 47

Mechanism: 1. In the catabolic state, body turns to fat and protein metabolism which depletes phosphate 2. When body reintroduced to carbs, insulin rises which increases cellular phosphate demand. 3. Mg, sodium, potassium, and thiamine also required for cellular pumps 4. Leads to hypophosphatemia, hypomagnesemia, hypokalaemia

Question 48

Pts at risk of refeeding syndrome

Answer 48

At risk pts: • Very little food intake >5days, especially if already undernourished • Undernourished - BMI <20, unintentional weight loss >5% within last 3-6 mths CANCER

Question 49

Tx of refeeding syndrome

Answer 49

``` Tx: • Before and during first 10 days of feeding: ○ Oral thiamine ○ Vitamin B complex ○ Multivitamin and mineral supplement • Monitor biochemistry - K, P, Mg ```