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MRCP Part 1 > Geriatrics & Palliative > Flashcards

Geriatrics & Palliative Flashcards

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1
Q

What is Acute Confusional state ??

A

aka Delirium or Acute Organic Brain synd. AFFECTS upto 30% of elderly pts. admitted in the hospital
RF-
- > 65yrs old. - Dementia
- Significant injury (eg. Hip #)
- Frailty or Multi-morbidity
- Polypharmacy

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2
Q

Rx. strategy in Alzheimer’s pts. ??

A

Non-pharmacological:
- Mild- Moderate dementia: Cognitive Stimulation Therapy
- Grp. Reminiscence Therapy & Cognitive Rehabilitation
Pharmacological Therapy
Non-Cognitive c/f management
- Antipsychotics : used for pts. at risk of harming themselves/ others or when agitation, hallucinations or delusions are causing severe distress

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3
Q

MCC of Dementia in the UK ??

A

Alzheimer’s disease - progressive degenerative brain disease
- followed by Vascular & Lewy Body dementia
- FTLD (3rd MC cause)

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4
Q

Rx. of Acute Confusional State ??

A

Treat the underlying cause
- 1st line sedative: HALOPERIDOL or Olanzapine
- Parkinson’s pts. : Atypical anti-psychotics - Quetiapine & Clozapine

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5
Q

What are the ppt. event & Features of Delirium ??

A
  • Infection (UTI)
  • Metabolic (Hyper Ca2+, Hypo/Hyper- glycaemia, Dehydration
  • Change in environment
  • Significant systemic condition
  • Severe pain. - Constipation
    FEATURES
  • Memory disturbed (Short term> Long term)
  • Disoriented, Poor attention
  • Mood Changed, Disturbed sleep
  • Visual hallucinations
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6
Q

Pharmacological Rx. for Alzheimer’s disease ??

A

Mild to moderate dementia
- 1st line: ACh-esterase inhibitors- Donepezil, Galantamine, Rivastigmine

Memantine
- Moderate dementia + intolerant or CI of 1st line Rx.
- Add on to 1st line Rx. for Moderate or Severe cases
- Monotherapy in SEVERE cases

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7
Q

Relative CI of Donepezil ??

A

BRADYCARDIA
[s/e: Insomnia]

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8
Q

Risk Factors of Alzheimer’s disease ??

A
  • Increasing age, Family Hx.
  • Autosomal D inheritance (5% cases)
  • Apoprotein E allele E4: encodes a cholesterol transport protein
  • Caucasians
  • Down’s synd.
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9
Q

What mutations are seen in the A D variant of Alzheimer’s disease ??

A
  • Amyloid precursor protein (Chr. 21)
  • Presenilin 1 (Chr. 14)
  • Presenilin 2 (Chr. 1)
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10
Q

What is Dementia ??

A

Umbrella term for loss of memory & other thinking abilities, which is severe enough to interfere with daily life

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11
Q

Pathological changes seen in Alzheimer’s disease ??

A

MACROSCOPIC
- Widespread Cerebral atrophy (Cortex & Hippocampus)
MICROSCOPIC
- Cortical plaques due to Type-A-Beta-amyloid protein deposition & Intraneural Neurofibrillary tangles caused by abnormal aggragation of TAU protein
- Hyperphosphorylation of Tau protein
BIOCHEMICAL
- Ascending Forebrain projection damage ==> ACh deficit

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12
Q

Name the following about dementia
- Assessment tools for Non- specialists ??
- Assessment tools NOT recommended by NICE for Non-specialists ??

A
  • 10- Point Cognitive Screener (10-CS)
  • 6-Item Cognitive Impairment Test
    NOT recommended-
  • Abbreviated Mental Score Test
  • General Practitioner Assessment of Cognition (GPCOG)
  • Mini-mental Score Test (MMSE) : a score of < 24/ 30 suggests dementia
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13
Q

What are Neurofibrillary tangles ??

A

Paired Helical filaments, partly made of a protein called Tau
- Tau interacts with Tubulin to stabilise microtubules & promote Tubulin assembly into Microtubules
- in A D, tau are Hyperphosphorylated, impairing its function

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14
Q

Rx. of Dementia ??

A

Primary Care
- Blood screening (to rule out Reversible causes- FBC, U&E, LFTs, Ca2+, Glucose, ESR, CRP, TFTs, Vit.-B12, Folate)
- Pts. are now commonly referred to Old-age Psychiatrists in Memory clinic
SECONDARY Care
- Neuro-imaging (to exclude secondary causes- SDH, NPH)

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15
Q

What are the factors that favours DELIRIUM over dementia ??

A
  • Impaired consciousness
  • Fluctuation of symptoms: Worse at night, periods of normalcy
  • Abnormal perception (eg. Illusions, hallucinations)
  • Agitation, fear
  • Delusions
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16
Q

What are the types of Fronto-temporal Lobar Degeneration (FTLD) ??

A

FTLD is the 3rd MC type of Cortical dementia after Alzheimer’s & Lewy Body dementia
- Fronto-temporal Dementia
- Progressive Non-fluent Aphasia (Chr. Prograssive Aphasia, CPA)
- Semantic Dementia

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17
Q

What are the treatable causes of Dementia ??

A
  • Hypothyroidism, Addison’s
  • B12/ Folate/ Thiamine deficiency
  • Syphilis
  • Brain tumour
  • NPH
  • SDH (Sub-dural Haematoma)
  • Depression
  • Chr. Drug use (eg.- Alcohol, Barbiturates)
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18
Q

Causes of Dementia ??

A

Common causes
- Alzheimer’s disease
- CerebroVascular disease: Multi-infarct dementia (10-20%) cases
- Lewy Body Dementia (10-20%)
RARER Causes (5% cases)
- Huntington’s
- CJD
- Pick’s dementia
- HIV (50% of AIDS pts.)

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19
Q

What are the common features of FTLD ??

A
  • Onset < 65 yrs
  • Insidious onset
  • Relatively Preserved Memory & Visuo-spacial skills
  • Personality change & Social conduct problems
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20
Q

What is Pick’s Dementia ??

A

MC type of FTLD; Personality change & Impaired Social Conduct
- Hyperorality, Disinhibition, Increased Appetite, Perverse behaviour
Rx-
- AChE inhibitors or Memantine but NICE do NOT recommend this

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21
Q

Features/ Changes seen in Pick’s dementia ??

A

Macroscopic
- Frontal & Temporal lobe atrophy
Microscopic
- Pick bodies: Spherical aggregations of Tau proteins (Silver-staining)
- Gliosis
- Neurofibrillary Tangles
- Senile Plaques
CT
- “Focal gyral atrophy with a knife-blade appearance”

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22
Q

What is
- CPA (Chr. Progressive Aphasia)
- Semantic Dementia

A

CPA
- Non-fluent speech
- Short utterances that are Agrammatic.
- Comprehension is relatively preserved
Semantic Dementia
- Fluent progressive aphasia
- Fluent speech but Empty & conveys little meaning.
- Short term memory better than Long term memory (opposite in Alzheimer’s)

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23
Q

What is Lewy Body Dementia ??

Study These Flashcards
A

Lewy body: Alpha-synuclein cytoplasmic inclusion bodies deposition in
- Substantia nigra
- Paralimbic area
- Neocortical area

24
Q

Features of Lewy Body Dementia ??

Study These Flashcards
A

Progresive Cognitive Impairment
- Attention & Executive function impairment rather than memory impairment
- Fluctuating COGNITION
- Develops BEFORE Parkinsonism
Parkinsonism
VISUAL Hallucinations (delusions & non- visual hallucinations may also be seen)

25
Dx. & Rx. of Lewy Body Dementia ??
Clinical Dx. Single Photon Emission CT which is commercially known as DaT scan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-1 FP-CIT) is used as the radioisotope - Sensitivity: 90% - Specificity: 100%
26
Rx. of Lewy Body Dementia ??
- AChE inhibitor (Donepezil, Rivastigmine) & Memantine - Neuroleptics are AVOIDED as they may develop Irreversible Parkinsonism [Pt. can deteriorate following the introduction of an antipsychotic]
27
What are Pressure ulcers & list a few predisposing factors ??
Ulcers develops in part of body which cannot be moved due to Illness, Paralysis, advancing age; typical over bony prominences (heel, sacrum) - Malnourishment - Lack of mobility - Incontinence - Pain (leads to a reduction in mobility)
28
What is Waterlow score ??
Widely used to screen for pts. who are at risk of developing pressure areas. It includes - BMI - Nutritional status - Skin type - Continence
29
Rx. of Pressure sores ??
MOIST Wound environment encourages ulcer healing- Hydrocolloid dressing & Hydrogels help this - Routine wound swabs are NOT recommended - Consider referral to Tissue Viability Nurse - Surgical debridement in selected cases
30
Features & Causes of Vascular Dementia ??
A group of synd. of COGNITIVE impairment caused by different mechanisms causing ischaemia/ haemorrhage secondary to cerebrovascular disease - Stroke doubles the risk of developing dementia - Increases with age
30
What are the types & risk factors of Vascular dementia ??
Stroke related VD: Multi/ Single infarct dementia Subcortical VD: caused by Small vessel disease Mixed Dementia: Both VD + Alzheimer's are present RISK Factors - H/o Stroke or TIA; CAD - Atrial Fibrillation - DM, HTN, Hyperlipidaemia - Smoking & Obesity - FHx of Stroke or CVS disease
30
Which is the inherited cause of Vascular dementia ??
CADASIL (Cerebral A D Arteriopathy with Subcortical infarcts & Leukoencephalopathy)
30
Features of Vascular dementia ??
Presents with Several months or several years of a history of a sudden or Stepwise Deterioration of cognitive function - FND/ abnormalities eg.- Visual disturbance, Sensory or Motor c/f - Attention & Conc. difficulty - Seizures - Memory, Speech, GAIT disturbance - Emotional disturbance
31
How is Vascular Dementia diagnosed ??
- Comprehensive history & GPE - Formal Screening for Cognitive impairment - Medication review - MRI scan Dx.- NINDS-AIREN criteria
32
What is NINDS-AIREN criteria ??
Used for the dx. of Vascular D - Cognitive decline + interferes with daily living activity which is NOT due to secondary effects of CVA (Clinical examination & Neuropsychology tests used) - Cerebrovascular disease: defined by neurological signs &/or brain imaging - Relation b/w the above 2 disorders inferred by -----Dementia onset in < 3 months after a stroke -----Abrupt deterioration of Cognitive func. -----Fluctuating, stepwise progression of cognitive deficits
33
Rx. of Vascular Dementia ??
Drug Rx. - No specific Rx. is approved for Cognitive symptoms - AChE inhibitors or Memantine: VD + Alzheimer's/ Parkinson's dementia/ Lewy body dementia suspected - Aspirin & Statins use are baseless Non-pharmacological - Cognitive stimulation programmes, Multisensory stimulation, Music & art therapy, Animal assisted therapy
34
Rx. for Agitation & Confusion ??
Underlying cause should be treated (eg. Hyper Ca2+, Infection, Urinary retention & Medication) - 1st line: HALOPERIDOL - 2nd line: Chlorpromazine, Levomepromazine - Terminal phase of illness: Treat with MIDAZOLAM
35
General principles followed for the Rx. of PAIN in Palliative care ??
When Starting Rx. - Regular Oral Modified release (MR) or Immediate release Morphine + Oral Immediate release Morphine (for Breakthrough pain) - If no co-morbidities; use 20-30 mg of MR a day + 5 mg Morphine for breakthrough pain (eg. 15mg Morphine- BD + 5mg oral Morphine solution as required) - Oral MR Morphine prferred over Transdermal patch - Laxatives are started for all pts. initiated on Strong Opioids - Antiemetics (if Nausea persists) - Dose adjustment (if Drowsiness persists)
36
How much is the dose of Morphine for Breakthrough pain ??
1/6 th of the daily Morphine dosage
37
Opioid of choice in the following - Mild to moderate Renal disease ?? - Severe Renal impairment ??
- OXYCODONE preferred over Morphine - Alfentanil, Buprenorphine & Fentanyl (eGFR < 30 ml/min) are preferred
38
Rx. for Intractable Hiccups ??
- CHLORPROMAZINE - Haloperidol & Gabapentin can also be used - DEXAMETHASONE (particularly if there are Hepatic lesions)
38
Pain Rx. in Metastatic Bone disease ??
Strong Opioids > Bisphosphonates > Radiotherapy, Beta-emitting Radioisotope (Strontium 89therapy) - Strong Opioids have the lowest NNT for pain & provides quick relief in contrast to the other 2 - Referred to Oncologist if considering further Rx like Radiotherapy - 30- 50% dose increment is done if at all the Opioid dose is increased - Denosumab can also be used
39
Conversions b/w Opioids ??
- Oral Codeine or Tramadol to Oral Morphine => Divide by 10 - Oral Morphine to Oral Oxycodone => Divide by 1.5 to 2 - Oral M to SC M => Divide by 2 - Oral M to SC DiaM => Divide by 3 - Oral Oxy to SC DiaM=> Divide by 1.5
40
Conversion factors for Transdermal patches ??
12 ug of T-fentanyl => 30mg Oral M 10 ug T-Buprenorphine => 24mg Oral M
41
Oxycodone advantage & disadvantage ??
Less sedation, vomiting & pruritis than M but MORE Constipation
42
Which are the Transient & Persistent S/E of Opioids ??
Transient: Nausea & Drowsiness Persistent: Constipation
43
How to treat Secretions in Palliative pts. ??
Avoid Fluid overload- stop IV or SC fluids - Educate the family that- pt. is NOT troubled by secretions - 1st line: Hyoscine hydrobromide or Hyoscine butylbromide - H butylbromide may be less sedative than H hydrobromide - Glycopyrronium bromide may also be used
44
Indications & Types of Syringe drivers ??
Considered when a palliative pt. is UNABLE to take Oral medication due to Nausea, Dysphagia, Intestinal obstruction, weakness or coma 2 Main Types - Graseby MS16A (Blue): delivery rate is given in 'mm/hr' - Greseby MS26 (Green): delivery rate is given in 'mm/24 hrs'
45
Which drugs are compatible with Water for injection ??
Drug + 0.9% NaCl - Granisetron - Ondansetron - Ketamine - Ketorolac - Octreotide
46
Name the commonly used drugs for the following- - N & V ?? - Agitation & Restlessness ?? - Pain ??
- Cyclizine, Levomepromazine, Haloperidol, Metoclipramide - Midazolam, Haloperidol, Levomepromazine - Diamorphine is the preferred opioid
47
DoC for the following- - Agitation ?? - Acute psychotic episode ??
- Haloperidol - Risperidone
48
Morphine Slow Release dose is increased ONLY after the Top-Ups dose has been titrated to the pt needs so the dose can be ascertained(Initial increase in Slow release can lead to side effects)
49
Parkinson's + Motor symptoms well controlled + Visual hallucinations & Delusions Rx. ??
Atypical antipsychotics (eg. Quetiapine) - Typical antipsychotics are DA agonists => worsens Parkinson/s
50
Acute methods to reduce Intracerebral pressure ??
Hyperventilation & IV Mannitol
51
What is Progressive Supranuclear Palsy ??
It is a Parkinson's plus syndrom - Falls seen very shortly after the onset of symptoms - DYSPHAGIA - Loss of Vertical gaze (Supranuclear gaze palsy) - Decreased verbal fluency - Poor response to Levodopa therapy - Symmetrical (Proximal >> Distal) Rigidity Autonomic dysfunction is uncommon
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MRCP Part 1 (26 decks)

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