LOs Flashcards
(105 cards)
1
Q
Why are acutely ill patients cared for within elderly care in preference to general patient wards.
A
- more proficient at managing some of the illnesses common in elderly people- e.g., dementia, delirium, falls
- end of life care specialists
- has a high presence of other healthcare professionals there (e.g, PD nurses, occupational health)
- allows you to share services- e.g., board games
2
Q
what is a comprehensive geriatric assessment
when should one be carried out?
A
gold standard for emasuring frailty
multidimentional interdisciplinary diagnostic process for 65+
when should a CGA be carried out?
- frailty syndrome identified
- suspected frailty syndrome based off of an incident implied
- when in a care home
3
Q
the presence of 1 or more of the following frailty syndromes should trigger a comprehensive geriatric assessment
A
- falls
- immobility
- delirium and dementia
- polypharmacy
- incontinence
- end of life care
4
Q
key elements of a comprehensive geriatric assessment
A
- medical assessment
- problem list
- comorbidities
- medications
- nutritional assessment
- functional assessment
- basic activities of daily living
- instrumental activities of daily living
- gait and balance
- exercise and activity
- psychological assessment
- cognitive status
- assessment of mood
- social assessment
- informal social suppore
- environmental assessment
- care resource eligibility
- home safety
- access to transport facilities
5
Q
stroke definition
TIA definition
A
Stroke- “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin”
TIA- lasts <24 hours and there is an eventual return to baseline
6
Q
features of a stroke
(7)
A
- sudden onset
- face/ arm/ leg weakness or senosry loss
- loss of co-ordination
- speech problems (dysphasia, dysarthria of speech (slurred))
- visual field defects (homonymous hemianopia- half the visual field of either eye)
- swallowing problems (dysphagia)
- dynamic phenomenon- as the clot changes size
7
Q
what are the 2 classifications of stroke?
how common are they?
A
ischaemic- 85% when a thrombus blocks blood flow in a cerebral artery
haemorrhagic- 15% when there is a bleed in one of the arteries in and supplying the brain
8
Q
what are the 2 kinds of ischaemic stroke
what are risk factors
A
- thrombotic stroke
- atheroscleoris causes a plaque to form on the inner wall of an artery, this decreases the lumen size and decreases the amount of blood that can pass it. Think carotid.
- embolic stroke
- atherosclerosis causes plaque to form, eventually this ruptures and embolises, travelling up an artery that feeds the brain and then blocks blood flowing through it. AF big risk factor
risk factors
age, hypertension, AF, CHF, valvular disease, diabetes, dyslipidaemia
9
Q
where are the 2 locations that a haemorrhagic stroke can occur?
A
the tissue of the brain (intracerebral haemorrhage)
subarachnoid space (subarachnoid haemorrhage) bleed on the surface of the brain
10
Q
- differences between ischaemic and subarachnoid stroke
- essential problem
- proportion of strokes
- risk factors
- treatment
A
- essential problem
- Ischaemic- blockage in the blood vessel stops blood flow
- haemorrhagic- bloof vessel burstys leading to reduction in BF
- proportion of strokes
- Ischaemic- 85%
- Haemorrhagic- 15%
- risk factors
- Ischaemic- age, hypertension, moking, hyperlipidaemia, diabetes mellitus, AF
- haemorrhagic- age, hypertension, arteriovenous malformation, anticoaguilation therapy
- treatment
- ischaemic
- haemorrhagic
11
Q
Subarachnoid specific symptoms and signs
A
symptoms
- sudden onset excruciating headache- thunderclap
- vomiting
- collapse
- seizures and coma
- preceding sentinel headache
- visual chanhges
- later–> personality change
- cerebellar damage–> vertigo
signs
- neck stiffness
- kernigs sign
- retinal bleeds
focal neurology may give indication as to where the
12
Q
in stroke are symptoms bilateral or unilateral?
A
usually unilateral
13
Q
specific causes of haemorrhagic strokes
A
80%- berry aneurysm rupture:
- junctions of posterior communicating artery with internal carotid OR
- anterior communicating artery with the anterior cerebral artery
20%- arteriovenous malformations:
14
Q
On CT is harmorrhagic or ischaemic better demarcated?
A
ichaemic is better demarkated
15
Q
What is the bamford/oxford classification?
what are the 4 divisions?
A
- Most used classification system for ischaemic stroke
- Classifies strokes based on the initial presenting symptoms and clinical signs
- Does not require imaging and relies on clinical findings alone
- Lacunar (LACS)
- Partial Anterior Circulation (PACS)
- Total Anterior Circulation (TACS)
- Posterior Circulation (POCS)
16
Q
Which of the 4 bamford classifications are considered anterior circulation strokes?
A
TACS
PACS
LACS
17
Q
What is the criteria for a TACS calssification?
which arteries are involved?
A
All 3 of the following:
- unilateral weakness (and/or sensory deficit) of the face, arm and leg
- homonymous hemianopia (one eye loses half of its vision)
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
Dysphasia is dominant
middle and anterior cerbral arteries are involved.
18
Q
What is the criteria for a PACS stroke?
which arteries are involved?
A
2 of the following:
- unilateral weakness (and/or sensory deficit) of the face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia, visuspatial disorder, inattention)
involves smaller artiers of anterior circulation e.g., upper or lower division of middle cerebral artery
19
Q
What is the criteria for a LACs?
which arteries are affected?
A
1 of the following:
- pure senory stroke
- pure motor stroke
- sensori-motor stroke
- ataxic hemiparesis (ataxia and weakeness of one side)
characteristically no higher cortical deficit like dysphasia or visuosptial disorder (lack of whereness in location)
25% of strokes
involves the perforating arteries around the internal capsule, thalamus and basal ganglia
20
Q
what is the criteria for a POCS
and which arteries are involved
A
one of the following:
- cranial nerve palsy and a contralateral motor/ sensory deficit)
- bilateral motor/ sensory deficit
- conjugate eye movement disorder (e.g., gaze palsy)
- cerebellar dysfunction (e.g., ataxia, nystagmus, vertigo)
- isolated homonymous hemianopia or cortical blindness
- loss of consciousness?
“locked in syndrome” quadraparesis with preserved cortical function and eye movements. basilar arteries
25%
involves the vertebrobasilar arteries
21
Q
brainstem infarcts
A
more symptoms inc. quadriplegia
22
Q
what are the risk factors for stroke?
A
- increasing age
- male
- raised BP
- cholesterol
- AF- atrial appendages- emboli (ischaemic)
- diabetes
- thrombophilia
- HRT
- Anticoagulation (haemorrhagic)
23
Q
DDx stroke
A
- TIA
- syncope
- hyper/ hypo glycaemia
- spinal defect (no clear problem above the neck)
- subdural haematoma (not actually in the brain, venous blood as well so symptoms take longer to manifest, unilateral symptoms)
- Extradural - trauma
- Bell’s palsy- stroke would spare the forehead
24
Q
Diagnosis of stroke
A
- Recognise symptoms: FAST in community or ROSIER in hospital
- Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause if these symptoms
- CT head– look for hemorrhage (high attenuation– white area that isn’t as white as bone appears) e.g., is this thrombolysable – to improve detection and characterisation choose a CT angiography (CT best in acute setting, MRI better long term). Infarct = dark. Haemorrhage = light
- Bloods
- Examination – UMN signs – increased tone after a while, brisk reflexes after a while, clonus
- Post stroke
- MRI of the head – MR angiography
- Carotid ultrasound– check for stenosis– endarectomy (take out carotid)
25
perform a CT head ASAP if a y of the following apply:
* Indications for thrombolysis or thrombectomy
* On anticoagulant therapy
* Known bleeding tendency
* GCS below 12
* Unexplained progressive or fluctuating symptoms
* Papilloedema, neck stiffness or fever
* Severe headache at onset of stroke symptoms
26
additional tests to look for stroke:
ECG- look for Af cause
carotid ultrasound to look for carotid stenosis
27
what is the most sensitive test for stroke?
diffusion weighted MRI.
however due to logistics is not first line
28
acute management of ischaemic stroke
1. **Thrombolysis**--**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).
2. **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**.
29
treatment for ischaemic stroke chronic management HALTSS
* _***H**ypertension*_
* *_**A**ntiplatelet 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.
* *_**L**ipid-lowering therapy_*: patients should be prescribed high dose atorvastatin 20-80 mg once nightl
* ***_T_****_obacco_* use cessation
* _***S**ugar*_: patients should be screened for diabetes and managed appropriately.
* _***S**urgery*_: patients with ipsilateral carotid artery stenosis more than 50% should be referred for carotid endarterectomy.
30
ratio of intracerebral haemorrhage to sub-arachnoid
intracerebral haemorrhage- 75%
subarachnoid- 25%
31
acute management of haemorrhagic stroke
* Neurosurgical and neurocritical care evaluation due to the **potential for surgical intervention** (e.g. **decompressive hemicraniectomy**).
* Admission to the **neuro ICU** or stroke unit (the patient may require **intubation** and **ventilation** or invasive monitoring of ICPs).
* **Aim to keep blood pressure \<140/80** as poor blood pressure control in the acute stage is associated with poorer outcomes later on
32
what is the role of the MDT in stroke care
Re-enablement should be started ASAP to maximise improvement and evade the problems associated with immobility (pressure sores, aspiration pneumonia, constipation, and contractures.
Frequent meetings with staff help adjust goals and safety net for depression.
* Watch closely for the patient to see if they have swallow control-- if they’re lacking then make them nil by mouth and get the reassessed
* Position to minimize spasticity and get prompt physiotherapy. Botulinum toxin injections are useful for focal spasticity.
* Input of mental health teams-- look out for outbursts in relation to failure or spontaneous
33
what is thrombolysis?
use **alteplase** to break the thrombus that is occluding an artery and causing a distal infarct in ischaemic stroke. Consider as soon as haemorrhage has been excluded provided that diagnosis **\<4.5 hours** ago and the patient has not had a previous intracranial haemorrhage, pregnant etc. Ideal window is within 90 mins
Alteplase is preferred choice
Follow up with **CT 24hours** later to check for bleeding.
34
Which scoring system can be used to calculate the risk of stroke in AF patients? Which score would indicate warfarin + NOAC?
**CHA****₂****DS****₂****-VASc Score**
* CHF
* Hypertension 140/90
* Age 75+ (2)
* DM
* Stroke, TIA or TE (2)
* Vascular disease
* Age 65-74
* Sex Category (female +1 male +0)
35
***_What is sheltered accommodation_***?
You live in a block of flats. There is a “warden” who is there to help should you need it but they aren’t going to burst into your room unannounced.
36
examination for stroke
ABCDE if acute
***_National institute of health scale_*** this is exhaustive, most clinicians to a pragmatic exam
Objectively quantify stroke
* 11 items each having a score of ¾ where 4 is a severe stroke
* Score to 42 telling you the severity
* 1) consciousness
* a. responsive or rousable
* b. current month and age
* c. open both hands, grip and release
* 2) gaze- horizontal eye movement, H movement
* 3) visual fields
* 4) facial palsy- raise eyebrows, bare teeth
* 5) motor function of arm, arms out palm down hold for 10
* 6) motor function of leg- lie supine and raise leg to 30\*
* 7) look for ataxia, finger to nose and heel to shin for coordination
* 8) sensation- pinprick test upper and lower limb
* 9) language- describe picture
* 10) dysarthria- can they verbally communicate
* 11)extinction and inattention
Come back to this
37
1. *_Which paired arteries are responsible for blood supply to the brain?_*
2. *_What is the circle of willis?_*
3. W*_here do the internal carotid arteries originate from?_*
4. *_What structure do they internal carotids travel within?_*
5. *_Do the internal carotid arteries supply the face or neck?_*
1. The vertebral arteries and internal carotid arteries.
2. An anastamotic circle whos branches supply the majority of the cerebrum
3. The bifurcation of the left and right common carotid arteries (C4)
4. The carotid sheath
5. No
38
1. *_Once in the cranial cavity the internal carotids pass anteriorly through what?_*
2. _Distal to the cavernous sinus the internal carotids give rise to which arteries?_
3. After giving off these branches the internal carotids continue as the?
4. The right and left vertebral arteries arise from the??
5. Once entering the cranial cavity the vertebral arteries give off some branches
The cavernous sinus
1. Ophthalmic artery- supplies structures of the orbit
2. Posterior communicating artery- acts as an anastomotic (communicating) artery for the circle of Willis.
3. Anterior choroidal artery- motor control and vision
4. Anterior cerebral artery - part of the cerebrum
middle cerebral artery.
Subclavian arteries
1. Meningeal branch
2. Anterior and posterior spinal arteries
3. Posterior inferior cerebellar arteries
39
*_After this the 2 vertebral arteries converge into the???_*
*_Which artery supplies the anteromedial portion of the cerebrum?_*
*_Which*_ _*artery supplies the medial and lateral parts of the posterior cerebrum_*?
*_Which artery supplies the majority of the lateral cerebrum?_*
* basilar artery
* Anterior cerebral arte
* The posterior cerebral artery
* Middle cerebral artery
40
![]()label red blue an dyellow circulation
* yellow- anterior cerebral artery
* red- middle cerebral artery
* blue- posterior cerebral artery
41
label this
![]()
![]()
42
what is frailty?
“a clinically recognized state of increased **vulnerabilit**y. It results from ageing associated with a decline in the body’s **physical and psychological reserves**”
* A state associated with low energy, slow walking speed and poor strength.
* It is not inevitable
* Is often associated with multiple LTC but can occur in the absence of these
* Amenable to treatment
43
what are the symptoms of frailty
* Weakness
* Fatigue
* Weight loss
* Low physical activity
* Poor balance
* Low gait speed
* Visual impairment
* Cognitive impairment
44
what are the frailty syndromes?
* Immobility
* Falls
* Delirium
* Incontinence
* Susceptibility to side effects of medications
45
name 2 frailty scale
rockward
edmonton
46
what is the Rockward clinical frailty scale?
![]()
47
what is the Edmonton frailty scale?
![]()
48
what is an atypical presentation in the elderly?
who is at risk?
when an older adult presents with a disease state that is missing some of the traditional core features of the illness usually seen in younger patients.
* Increasing age (especially over 85)
* Mulitmorbidities
* Multiple medications (polypharmacy)
* Cognitive or functional impairment
49
name 2 cognitive tests
the 4AT and the CAM
50
what is the 4AT? how does it work?
A screening instrument designed for rapid and sensitive initial assessment of cognitive impairment and delirium. A score of 4 or more suggests delirium but is not diagnostic.
\<2 mins
Easy and simple
* Alertness (4)
* AMT4 (age, DOB, Place, year) (2)
* Attention (2)
* Acute change or fluctuating course (2)
**Score (/12)**
* 0= unlikely
* 1-3= possible cognitive impairment
* \>4 = possible delirium +/- cognitive impairment
51
What is the CAM?
* Screening tool for identifying delirium or dementia (doesn’t differentiate)
* Based around the DSMv criteria for delirium
***_Scoring_***
For a diagnosis of delirium by CAM, the patient must display:
1. Presence of acute and fluctuating discourse
AND
1. Inattention (inability to maintain attention to external stimuli and to sift attention to new external stimuli)
AND EITHER
1. Disorganized thinking
OR
1. Altered level of consciousness
52
what does the CAM look like?
![]()
![]() ![]()
53
what is a pressure sore?
what causes a pressure sore?
Pressure sores are areas of skin damage resulting from a lack of blood flow due to prolonged pressure. Often occurs in addition to the action of friction and moisture, particularly over bony areas.
* Pressure- cuts off blood flow. Think comatose, paralysed, sedated or restrained
* Traction- (sideways pulling force)
* Friction
* Moisture- perspiration, urinary and faecal incontinence
54
* treatment of a pressure sore
* common places for them
* rfx
* complications
* treatment of a pressure sore
* stage pressure sores can heal very well with appropriate management
* Cleansing
* Early
* Removal of pressure from the affected area
* Special dressings
* Antibiotics and/ or surgery
* common places for them
* Where bone is close to skin:
* Hip bones
* Tailbone
* Heels
* Ankles
* Elbows
* rfx
* Age over 65 years- thinner skin
* Decreased mobility- e.g., neurological issues
* Long-term exposure to skin irritants (such as faeces or urine)
* Impaired capacity for wound healing because of a disorder susch as inadequate nutrition, diabetes, peripheral arterial disease or venous insufficiency
* complications
* Bacterial infection- pus and visible odour -leads to cellulitis, osteomyelitis or infectious arthritis
55
what are the 2 kinds of incontinence that I need to know about?
stress and urge incontinence
56
stress incontinence what is it?
aetiology
* Involuntary leakage on effort or exertion, or on sneezing or coughing (leakage from incompetent sphincter e.g., when intra-abdominal pressure rises (e.g., coughing, laughing)).
* Increasing age and obesity are risk factors
***_aetiology_***
no single cause however rf include:
* Increasing age
* Pregnancy and vaginal delivery
* Obesity
* Constipation
* Deficiency in supporting tissues:
* Prolapse
* Hysterectomy
* Lack of oestrogen at the menopause
* Family history
* Smoking
* Drugs- e.g., ACEi
57
what is the key to diagnosing stress incontinence?
* recognising small but frequent episodes of urine when coughing
* Examine for pelvic floor weakness/ prolapse
* \>50% in post-menopausal women
58
what is urge incontinence or overactice bladder syndrome?
**The urge to urinate is quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts.**
Most often idiopathic in women but may be precipitated by:
* Arriving home (latchkey incontinence, a conditioned reflex)
* Cold
* The sound of running water
* This is a neurological problem of the central inhibitory pathway.
* Comorbidities such as obesity, T2DM and chronic urinary tract infection can increase urgency symptoms.
* Drugs: parasympathomimetic, antidepressants, and hormone replacement
* Can be exacerbated by caffeinated, acidic or alcoholic drinks
59
diagnostic investigations to order for urinary incontinence
management of incontinence
***_Diagnostic investigations to order_***
1st – empty supine stress test
* Urinalysis
* Cough stress test
2nd- pad test, urodynamic testing, Q-tip test, transperineal ultrasound
***_management of urinary incontinence_***
Refer urgently within 2 weeks using a suspected cancer pathway referral
* Refer to appropriate specialist based on symptoms present
* Advise on fluid intake and lifestyle measures
* Exclude or manage reversible causes
* Referral for bladder training (from continence nurse)/ pelvic florr exercises
* _+ in if others have failed_
* Antimuscarinic e.g., oxybutynin, tolterodine, darifenacin
* If post-menopausal, consider intravaginal oestrogen therapy
60
DNACPRs
* When a person is undergoing cardiac or repertory arrest, CPR can be used to restart their heart and breathing and restore circulation.
* CPR Is invasive, involving chest compression, delivery of shocks from a defibrillator injection of drugs and ventilation of the lungs.
* Generally, CPR has a very low success rate and burdens include damage to internal organs, rib fractures and adverse outcomes like hypoxic brain damage and physical disability
* If someone doesn’t have capacity refer to lasting power of attorney in regard to healthcare
* If not then do what you think is best for the patient, whatever the decision is it is good practice to inform the patients family
* A recorded DNACPR decision is not in itself legally binding and should be regarded as a clinical assessment and decision, made and recorded in advance. A DNACPR is a purely clinical decision.
* Even if the family resist this decision you can go ahead with this, however in situations like DNACPR for children and the family resists you can take this to court
61
explain the symptoms of a dying patitnt and how these can be managed
* **Fatigue**- short naps, engage in low energy demand hobbies
* **Weakness**
* **Sleeping more or being drowsy**
* **Feeling hot or cold**
* **Eating and drinking less**
* **Bladder or bowel problems**- constipation give laxatives, dietary changes, fluids, fibre supplements, removal om impacted faeces via decompaction
* **Dyspnoea**- sit upright, medication to relieve breathlessness like opioids, oxygen prescription
* **Pain- analgesics.** Common SE’s; constipation, nausea, drowsiness or confusion, dry mouth, itchy skin
* **Nausea**- anti-emetics-
* **Death rattle**- anti-secretories for resp secretions like hyoscine butylbromide
* **Anxiety**- midazolam
* **Vomiting-** Levomepromazine
* **Weight loss**
* **Confusion and delirium-** treat casues,
* **Talking or communicating less**
62
importance of falls
* Kills your confidence
* Stress on family members around future falls
* Family don’t trust you to not fall again, put into care home prematurely
* Economic cost of lengthy hospital stay and hip replacement
* Long hospital stay- increase chance of stasis diseases like VTE and bed sores
* Use up hospital beds that could be done elsewhere
63
perform a competent falls history
How did you end up on the floor?
***_Pre-fall_***
* Was there any warning?
* What were you doing at the time?
* Dizzy? Lightheadedness?
* Unwell at all recently?
* Mobility?
* Just because you can’t remember pre-syncope symptoms doesn’t mean that you had them
***_During the collapse_***
* Do you recall events?
* Witnessed?
* Injuries give clues?
***_Post-fall_***
* Jerking? Incontinence?
* Recovery time?
* Confusion?
* Mobility?
* How many times have you fallen before?
***_Past medical Hx and drug Hx_***
* DM?
* ↑BP?
* Epilepsy
* Previous falls
Neurological history
* Vision
* Cognition
* Bone health
* Alcohol
* Medications
Cardiac history
***_Falls examination_***
* Head to toe examination
* Neurological exam
* CVS exam
* Respiratory exam
***_Assessments_***
* Bp- lying/ standing BP
* Gait assessment- compare to previous
64
what kind of fall is hinted at if thhe patient has a bruised face?
this suggests that the patient lost consciousness and didn't guard their face
65
common causes of falls
***_Cardiovascular_***
* **Arrhythmia**- e.g., AF, flutter (tap out rhythm, heart racing, skip a beat)
* **Orthostatic** (postural) **hypotension** (drop of 20 systolic) - look out for people on antihypertensives especially B blockers
* **Vasovagal syncope** (faint)- reflex, if the body thinks that there’s a sudden fall in BP, it brings you to the floor very quickly
***_Neurological_***
* Stroke
* Epilepsy
* Acute spinal cord lesion or compression (think spondylosis for chronic)- ask for back pain (whether they had it before or after as a result)
***_Vision_***
***_Locomotor_***
* Stiff
* Lower limb weakness
* Arthritis of the lower limb joints
***_Vestibulocochlear_***
***_Cognition_***
***_Polypharmacy_***
***_External_***
* Environment (lighting, rugs, pets etc.)
* Footwear
* Walking aids/ frames
* Crowded areas
***_Drugs linked to falls by causing postural hypotension_***
* **Nitrates**- GTN spray
* **ACEi**- ramipril
* **Diuretics**- furosemide (loop diuretic), spironolactone (aldosterone antagonist), anticholinergics (atropine)
* **Levodopa**- lack of leads to festinating gait
* **Antiplatelet**
* **SSRIs** (citalopram, fluoxetine, sertraline) and tricyclics (amitriptyline)
***_Drugs linked to falls by other mechanisms_*** e.g., sedation/ confusion/ unsteadiness
* **Benzodiazepines**
* **Antipsychotics e.g., haloperidol**
* **Opiates**
* **Codeine based analgesics**
* **Anticonvulsants**
66
what is syncrope
***_Syncope-_***
* “Transient loss of consciousness due to global hypoperfusion. Spontaneous, rapid recovery.”
***_Causes:_***
* Neurally mediated (vasovagal, carotid sinus hypersensitivity and situational- cough / micturition syncope)
* Orthostatic hypotension
* Arrhythmias (heart block or VF usually, SVTs unlikely) deli
* Structural cardiac (e.g., aortic stenosis)
* Cerebrovascular
67
perform a competent postural blood pressure assessment
* Patient lies for 5 mins
* Measure blood pressure and pulse rate
* Have the patient stand
* Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes
Drop of \>20mmHg of systolic OR
Drop of \>10mmHg of diastolic BP OR
Experiencing light-headedness or dizziness is considered abnormal
68
what is osteoporosis
risk factors
how do you assess
***_Osteoporosis_***
Systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue (poor quality bone) making it more likely to break
***_Rfx:_***
* Female
* Age
* Smoking
* Low BMI (little fat)
* Alcohol consumption
* SteroidsPrevious fracture
* Parent fractured hip
* Rheumatoid arthritis
* Secondary osteoporosis- e.g., T1DM, hyperthyroidism, hypogonadism, or premature menopause (\<45 years), chronic malnutrition, malabsorption
***_Assessing for osteoporosis_***
* History
* Examination
* FRAX- online risk tool
* DEXA (dual energy x-ray absorptiometry) scan- non-invasive at the hip and vertebrae
69
treatment for osteoporosis
Treatment
* Address lifestyle factors and falls risk
* Optimise calcium and vitamin D status
* Minimise risk from other medications
* Give anti-catabolics:
* Bisphosphonates e.g., alendronate, risedronate
* Deonsumab
* Anabolic e.g., teriparatide (PTH type of drug)
70
Rfx for someone with osteoporosis
what are the 2 most important rfx
SHATTERED FAMILY
* age \>50 in women,,, \>65 in men
* female sex
***_rfx:_***
* **S**-steroid use
* **H**-hyperthyroidism, hyperparathyroidism
* **A**-alcohol and smoking
* **T**-thin BMI \<22
* **T**-testosterone deficiency
* **E**-early menopause
* **R**-renal/ liver failure
* **E-**erosive/ inflammatory bone disease
* **D**-diabetes
* **FAMILY**- family history
71
Who should be investigated for oesteoporosis?
* All men and women \>75
* All men and women if they have:
* Fhx of hip fracture
* Falls history
* Previous fragility fracture
* Low BMI
* Drinks \>4u a day
* Are/ were on steroids
* Disease associated with osteoporosis (e.g., coeliac disease, IBD, hyperparathyroidism)
72
How do you confirm osteoporosis?
which investigations can be used to exclude metabolic bone disease?
1. DEXA scan- gold standard
2. X-rays- wrist, heel, spine, hip if fractrues are suspected
3. MRI spine to lool for vertebral fractures
***_Investigations to exclude metabolic bone disease_***
* Bone profile (calcium, phosphate, albumin, total protein, ALP)
* Vitamin D level
* TFTs
* Urinary free cortisol
* Testosterone
* Bence-jones protein
73
interpretation of DEXA
Use risk tools like FRAX to determine whether someone needs more investigation via a DEXA
A score which shows a **10 year fracture risk** \> 10% requires further assessment using **DEXAT-scores compare their bone density to that of a young patient of the same gender**
* A score of **0 is average**
* -1 -\> -2.5 = **osteopaenia**
* \>-2.5 is **osteoporosis**
The Z-score corrects bone density for sex and age
74
lifestyle advice for someone with osteoporosis
reduce modifiable risk factors:
## Footnote
smoking cessation
diet- adequate vitamins, calcium and protein
regular weight bearing exercises
hip protectors in nursing hpme patients
75
what is the 1st line treatment for osteoporosis?
how do they work?
what should patients do for at least 30 mins after?
which supplement may help?
give examples of this class of drug
1st line- **bisphosphonates** given weekly. They interfere with osteoclast activity. Patients should sit upright for at least 30 minutes afterwards.
Vit D may help
***_examples of bisphosphonates_***
* Rised**ronate** (Actonel)
* Alendronate (Fosamax)
* Ibandronate (Boniva)
* **Zoledronic Acid** (Reclast)
76
what are 2nd line drugs for osetoporosis
* **denosumab**- monoclonal antibody which inhibits receptors, which when activated lead to maturation of osteoclasts
* **Raloxifene-** used in post-menopausal women, binds to oestrogen receptors and exhibits same bone protective properties that oestrogen does
* **HRT**
* **Teriparatide**- parathyroid hormone analogue stimulating bone growth
* **Strontium ranelate**
77
how can you differentiate between dementia and delirium? (5)
1. **chronicity of onset** (dementia takes longer and is usually gradual)
2. **reversibillity**- delirium is reversible
3. **attention**- delirium shows inattention whereas dementia has full attention
4. **fluctuation**- delirium fluctuates thorughout the day- e.g,. sundowning
5. **hallucinations-** much more common in delirium
78
what is cognition and the 6 domains that make it up
***_What is cognition_***
“the mental action or process of acquiring knowledge and understanding through thought, experience and the senses… the ability to perceive and react, process and understand, store and retrieve information, make decisions and produce appropriate responses.”
***_What are the 6 cognitive domains_***
* Attention
* Memory
* Intelligence
* Executive functions
* Social cognition
* Judgement
79
give examples of short term or reversible causes of caognitie dysfunction
give long term causes
***_Short term or reversible causes of cognitive dysfunction_***
* Delirium
* Infection
* Vitamin deficiency
* Dehydration
* Reaction to medication
* Depression
* Anxiety
* Pain
* Psychosis
* Drug/ medication
***_Long term causes of cognitive dysfunction_***
* Dementia
* Stroke
* Brain injury
80
examinations and tests in cognitive impairment
* Pshycial examination
* Relevant neurological system examination
* MSE
* Cognitive tests- MoCA, 4AT, CAM
* Brain imaging
* Bloods- TFTs, calcium, B12 folate, drugs, toxicity
81
common drugs used in treatment of dementia
**Cholinesterase inhibitors.**
* e.g,. donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne)
* work by boosting levels of a chemical messenger involved in memory and judgment.
* primarily for Alzheimer's disease, these medications might also be prescribed for other dementias
* SE's: nausea, vomiting and diarrhea. less common = slowed heart rate, fainting and sleep disturbances.
**Memantine**. (Namenda) works by regulating the activity of glutamate, another chemical messenger involved in brain functions, such as learning and memory. In some cases, memantine is prescribed with a cholinesterase inhibitor. Common SE= dizziness.
Other medications. Your doctor might prescribe medications to treat other symptoms or conditions, such as depression, sleep disturbances, hallucinations, parkinsonism or agitation.
82
which scans are useful in diagnosing dementia?
CT/ MRI to exclude stroke or hydrocephalus as a cause
PET scan- useful for monitoring brain activity and for identifying tau proteins and amyloid plaques- hallmarks of Alzheimers
83
What is delirium?
DSM features (5)
clinical features (5)
delirium- acute confusional state that predominentley affects the elderly
***_DSM features:_***
1. Disturbance of **attention and awareness**
2. Onset short, acute change from baseline, fluctuating
3. Additional disturbance in cognition (e.g., memory, language, orientation)
4. A and C are not due to dementia
5. History supports underlying medical condition
***_clinical features:_***
* Disorientation- place person time
* Hallucinations
* Inattention- lack of focus on a given event or situation when required
* Change in mood or personality
* Disturbed sleep
84
85
causes of delirium DELIRIUMS
* **D**- Drugs and Alcohol (anti-cholinergics, opiates, anti-convulsant, recreational)
* **E**- Eyes, ears, emotional and environment
* **L**- Low output state (MI, ARDS, PE, CHF, COPD)
* **I**- Infection
* **R**-Retention (of urine or stool)
* **I**- Ictal (epilepsy)
* **U**-Underhydration/ under-nutrition
* **M**- Metabolic (Electrolyte imbalance, thyroid, Wernickes) hypercalcaemia, low blood sugar
* (**S**)- Subdural, sleep deprivation
86
predisposing factors for delirium
precipitating factors
* Age
* Pre-existing dementia/ PD
* Severe medical illness
* Visual and hearing impairment
* Depression
* Polypharmacy
* Alcohol use
* Pain
* Surgery
* Malnutrition and dehydration
* Metabolic and electrolyte imbalance
* Anaesthesia and hypoxia
* Use of physical restraint
* Indwelling catheter
* Environment changes
87
criteria for diagnoaing delirium (4)
1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention
2. Change in cognition/ perceptual disturbance (exc. Pre-existing dementia)
3. Develops quickly and fluctuates during day
4. Physiological cause
88
what are the classifications of delirium
1. **Hyperactive** (classical)
1. Increased sympathetic activity, agitation
2. Restless and disturbed sleep cycle
3. Rapid mood changes and hallucinations
4. Most easily recognised
2. **Hypoactive** (underdiagnosed)
1. Poor oral intake
2. Worse prognosis- prone to malnutrition and dehydration
3. Inactivity or reduced motor activity
3. **Mixed** (most common)
1. Fluctuates- hyperactivity evident at night but lacks insight and recollection during the day
89
***_demtentia is a syndrome characterised by:_***
aetiological rfxs for dementia
progressive, irreversible global cognitive deficits
***_Aetiological Rfxs for dementia:_***
* Age
* Genetics
* Vascular risks (stroke, atherosclerosis, hypertension, cholesterol, T2DM)
* PD
* Depression
* Downs syndrome
* Head injury
* Heavy alcohol consumption
90
clinical features of dementia
* **Cognitive impairment**- follows defined patterns depending on cause of dementia, short term memory typically goes first then develops into more extensive memory loss, apraxia, agnosia and dysphasia.
* **History of personality change**- social withdrawal, disinhibition, diminished self-care
* **Anxiety and or depression** (50%)
* **Neurological features**- seizures, primitive reflexes, hyperreflexia
* **Emotional lability**
91
name 5 kinds of dementia
* alzheimers
* lewy-body
* fronto-temporal
* vascular
* wernicke-korsakoff
92
what is alzheimers disease
which people get it
caused by what kind of characteristic pathology in the brain
clinical features: 4 A's
1st line medication
most common form of dementia
patients are typically older in this dementia
chronic and progressive form
stong fhx
caused by amyloid plaques and tau protein tangles . cerebral and hippocampal atrophy. deficit in actylcholine.
***_clinical features:_***
* **Amnesia** (recent memories lost first)
* **Aphasia** (trouble finding words, speech muddled and disjionted)
* **Agnosia** (recogmitino problems)
* **Apraxia** (inability to carry out skilled tasks despite normal motor function)
1st line treatment- **donezapil /+ memantine**
93
Lewy body dementia
progression?
rarity of dementia?
pathology
3 core features
patients are susceptible to what?
medication to go to
progressive
3rd most common dementia
Lewy bodies (alpha synuclein) deposits in the substantia-nigra, paralimbic and neocortical areas
***_3 core features:_***
1. fluctuating cognition
2. Parkinsonism (rigidity, tremor and bradykinesia)
3. visual hallucinations
patients are highly susceptible to what? neuroleptics, making parkinson symptoms far worse
**rubestigmine**
94
fronto-temporal dementia
affects which patients
effect on personality and memory
presents with:
affects younger dementia patients
personality change early on, memory relatively preserved
***_presents with:_***
1. cognitive impairment
2. personality change
3. disinhibition
4. atrophy of frontal and temporal lobes
95
vascular dementia
how common is it within demntias
affects who?
results from?
progression?
second most common dementiaaffects younger dementia patients
results from multiple infarcts in the brain
sudden onset and stepwise progression
focal problems- e.g,. gait and often has CV risk factors
treatment involves managing underlying vascular risk factors
96
Wernicke-Korsakoffs syndrome
progression
chronicity
pathology
presents as a typical triad of:
starts as wernicke's then becomes korsakoffs
wernicke's encephalopathy is somewhat reversible whereas korsaoffs is permanent
thiamine (vitamin B1) deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
***_typical triad:_***
1. ataxia
2. opthalmoplegia
3. nystagmus
4. acute confusional state
97
In AF which classes of drugs are used in 1st line rate control? what are their common side effects?
***_1) beta blockers_***- e.g., atenolol, bisoprolol. allowed to be used with digoxin. B1 antagonists so decrease HR, CO and adrenaline activation
***_SE:_*** bradycardia, high degree AV block, hypotension, acute worsening of heart failure symptoms (DON'T USE IN HF), reduced ecercise tolerance, fatigue. Renally cleared so contraindicated in it.
2) ***_Ca2+ channel blockers_***- e.g., diltiazem, verapamil as monotherapy but don't ,ix with digoxin. Decreases the contractility of the heart
***_CI:_*** heart failure or LV dysfunction
***_SE:_*** tachycardia, dizziness, drowsiness, oedema, headache and hypertension
3) ***_Digoxin_***
***_se:_*** Digoxin toxicity- caution use in kidney disease or in combo use with amiodarone and verapamil
reduces your exercise tolerance so not preferable in younger patients. infrequently used nowadays
98
in rhythm control for AFwhich drugs do you use and what are the side effects
flecainide (Na+ blocker)
SE: Arrhythmias; asthenia; dizziness; dyspnoea; fever; oedema; vision disorders
amiodarone
arrythmias??
hyper and hypothyroidism
99
Side effects od DOACs
warfarin SE:
DOAC-- e.g,. apixaban-- SE- anaemia, haemorrhage
Warfarin-- SE- bleeding
100
medications for symptom control of heart failure
**diuretics**- furosemide- reduces blood volume
SE: dizziness, electrlyte imbalances
**nitrates**- glyceryl trinitrate- relief of angina
SE: dizziness, cerebral oedema, hypotension
**cardiac glycoside**- digoxin
increases force of contraction
SE: arrhythmias, cerebral impairment, dizziness, vision disorders
101
medications for increasing survival of heart failure
**ACE inhibitors**- e.g., ramipril
SE: dizziness, drowsiness, diarrheoa, renal impairment
**Beta blockers**- E.g., bisoprolol
SE: bradycardia, abdo discomfot, nausea, dizziness
**ARB**- e.g,. valsartan
SE: hypotension and tachycardia
102
dementia medication SEs
**acetylcholinesterase inhibitors--** e.g,. donepezil, galantamine
SE: aggression, decreased appetite, diarrheoa, dizziness, fatigue, GI disorders, urinary incontinence, syncope
**Memantine monotherapy-** e.g., memantine hydrochloride
SE: impaired balance, constipation, dizziness, drowsiness, dyspnoea, headache, hypertension
103
side effects of antidepressants
constipation
loss of libido
confusion
nausea
emesis
104
side effects of diabetes medication
**metformin**
SE: Gi symptoms- diarrheoa, abdo pain, nausea, vomiting, altered taste, decreased appetite, beware of lactic acidosis
**SGLT2 inhibitors**
SE: back pain, DKA, dizziness, infections, urinary disorders, hypoglycaemia
**Sulfonylurea**
SE- abdo pain, nausea, diarrhoea, hypoglycaemia
**insulin**
SE- oedema, be aware of overdose--\> hypoglycaemic shock
105
what is a T score?
a Z score?
T score- a comparison of a person's bone density with that of a healthy 30-year-old of the same sex.
Z score- a comparison of a person's bone density with that of an average person of the same age and sex
