Medicine of older adult

Question 1

Alzheimer’s disease

Answer 1

• Most common form of dementia
• progressive neurodegenerative disorder that leads to cognitive decline, memory impairment, and a range of behavioural and psychological symptoms.

Question 2

Epidemiology of Alzheimer’s disease

Answer 2

• common in older patients
• More common in women than men
• genetic association (APOE e2,3,4)

Question 3

Pathophysiology of alzheimer’s

Answer 3

• accumulation of beta-amyloid protein fragments outside nerve cells in the form of plaques is a hallmark feature
• disruption of neural communication
• abnormal tau protein accumulates, forming neurofibrillary tangles; nutrients cant be transported
• neurotransmitter imbalance
• neural loss and brain atrophy
• inflammatory response

Question 4

Risk factors for alzheimers

Answer 4

• APOE gene
• advancing age
• family hx
• poor lifestyle (lack of exercise, drinking, smoking)
• CVD risk
• low attainment at school

Question 5

Features of Alzheimer’s disease

Answer 5

• Memory Impairment
• Language Impairment:
• Executive Dysfunction:
• Behavioural Changes:
• Psychological Symptoms:
• Disorientation:
• Loss of Motor Skills

Question 6

Investigations for Alzheimer’s

Answer 6

• FBC, TFT and U+Es (rule out underlying delirum
• PET scan and MRI to identify brain atrophy
• CSF to identify biomarkers associated with alzheimers.
• cognition assessment- MOCA, MMSE, 10 pojnt scale

Question 8

Managment of Alzheimer’s

Answer 8

• Non-pharmalogical (CBT, brain enrichment)
• family and patient education
• **cholinesterase inhibitors **(e.g. donepezil)
• N-methyl-D-aspartate (NMDA) receptor antagonists (e.g. memantine), may be prescribed to manage cognitive symptoms.

Question 9

Charles Bonnet syndrome

Answer 9

• complex, vivid visual hallucinations generally in individuals with significant vision loss.
• Commonly associated conditions include age-related macular degeneration, glaucoma, and cataract.

Question 10

Signs and symptoms of Charles Bonnet syndrome

Answer 10

• well-formed, vivid, elaborate, and often stereotyped visual hallucinations in a partially sighted person.
• The imagery can be varied, including groups of people or children, animals, and panoramic countryside scenes.

Question 11

Investigations of Charles Bonnet syndrome

Answer 11

• Clinical presentation and patient history.
• Neurological and ophthalmic examinations
• FBC, U+E
• CBS hallucinations may persist despite treatment of underlying eye conditions

Question 12

What is the managment of CBS?

Answer 12

• education and reassurance
• optimise eye sight
• Medication can be used to ease symptoms rather than cure it.

Question 13

Drugs used in managment of CBS

Answer 13

Atypical Antipsychotics:
* Risperidone (brand name Risperdal)
* Quetiapine (brand name Seroquel)
* Olanzapine (brand name Zyprexa)

Selective Serotonin Reuptake Inhibitors (SSRIs):
* Sertraline (brand name Zoloft)
* Citalopram (brand name Celexa)
* Escitalopram (brand name Lexapro)

Antiepileptic Drugs:
* Gabapentin (brand names Neurontin, Gabapentin)
* Pregabalin (brand name Lyrica)
* Levetiracetam (brand name Keppra)

Question 14

Constipation

Answer 14

infrequent bowel movements, hard stools, excessive straining, tenesmus and sometimes necessitating manual evacuation.

Question 15

Rome IV criteria for

Answer 15

• Fewer than three bowel movements per week
• Hard stool in more than 25% of bowel movements
• Tenesmus in more than 25% of bowel movements
• Excessive straining in more than 25% of bowel movements
• A need for manual evacuation of bowel movements

Question 16

Primary constipation

Answer 16

• no organic cause, thought to be due to dysregulation of the function of the colon or anorectal muscles

Question 17

Secondaryconstipation

Answer 17

due to factors such as diet, medications, metabolic, endocrine or neurological disorders or obstruction

Question 19

Risk factors of constipation

Answer 19

• Advanced age
• Inactivity
• Low calorie intake
• Low fibre diet
• Certain medications
• Female sex

Question 20

2WW criteria for constipation

Answer 20

• Constipation (or diarrhoea) with weight loss
• 60 and over.
• Consider an urgent, direct access CT scan, or an urgent ultrasound scan if CT is not available, to rule out pancreatic cancer

Question 21

Bedside investiagtions for Secondary constipation

Answer 21

• PR exam
• Stool culture – MC&S, ova,cysts,parasites
• FIT testing (if accompanied with new rectal bleeding and signs suggestive of colorectal cancer), faecal calprotectin

Question 22

Constipation-what blood tests to do?

Answer 22

Full blood count (may show an anaemia), U+Es (including calcium), TFTs

Question 23

Constipation imaging

Answer 23

• Abdominal x-ray if suspicious of a secondary cause of constipation such as obstruction (may reveal faecal loading)
• Barium enema if suspicious of impaction or rectal mass
• Colonoscopy if suspicious of lower GI malignancy

Question 24

Managment of constipation

Answer 24

• lifestyle changes
• laxatives
  1. Bulk forming laxative
  2. osmotic laxative
  3. stimulant laxative
  4. stool softners
  5. enemas

Question 25

Acute confusional state

Answer 25

• Is a frequent condition, primarily observed among elderly individuals.
• It manifests through symptoms such as disorientation, hallucinations, inattention, memory problems, mood or personality changes, and disturbed sleep.

aka delirium

Question 26

Pre-disposing factors for ACS

Answer 26

• age > 65 years
• background of dementia
• significant injury e.g. hip fracture
• frailty or multimorbidity
• polypharmacy

Question 27

Multifactoral events which can lead to ACS

Answer 27

• infection: particularly urinary tract infections
• metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
• change of environment
• any significant cardiovascular, respiratory, neurological or endocrine condition
• severe pain
• alcohol withdrawal
• constipation

Question 28

Features of ACS

Answer 28

• memory disturbances (loss of short term > long term)
• may be very agitated or withdrawn
• disorientation
• mood change
• visual hallucinations
• disturbed sleep cycle
• poor attention

Question 29

ACS managment

Answer 29

• Treat the underlying cause
• Haloperidol 0.5 mg as the first-line sedative
• Parkinson patients may need to be weaned off medications
• if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred

Question 30

Olazapine side effects

Answer 30

• weight gain
• increased appetite
• sedation
• dry mouth
• Ortostatic hypertension
• Extrapyrimidal symptoms
• constipation
• dry mouth
• elevated liver enzyme
• WCC change

Question 31

Dementia with Lewy bodies (DLB)

Answer 31

rogressive, complex condition, accounting for approximately 10-15% of dementia cases.

Question 32

Featured of DLB

Answer 32

• Fluctuating cognition: Changes in attention and alertness may occur.
• Parkinsonism: Rigidity, bradykinesia, and postural instability are common.
• Visual hallucinations: Patients often experience complex and recurrent visual hallucinations.
• High sensitivity to neuroleptics: These drugs can induce or worsen parkinsonism.

Question 33

LBD vs Dementia

Answer 33

if cognitive impairment and parkinsonism develop <1 year of each other, it is likely LBD.

Question 34

DLB investigations

Answer 34

• Dopamine transporter (DaT) scan: This can help distinguish DLB from other types of dementia.
• Neuropsychological testing: To assess cognitive functioning and fluctuations.
• Electroencephalography (EEG): Although not diagnostic, a slowing background rhythm may be seen in DLB.

Question 35

Managment of DLB

Answer 35

• Non-pharmacological interventions: These include cognitive stimulation, physical therapy, and occupational therapy.
• Supportive care: As DLB is a progressive disorder, palliative and end-of-life care considerations are essential.
• Medications: Cholinesterase inhibitors can help manage cognitive symptoms. However, caution is required with antipsychotic medications due to neuroleptic sensitivity.

Question 36

Complications of DLB

Answer 36

• Rapid disease progression: Compared to other dementias, DLB may progress more rapidly.
• Severe neuroleptic sensitivity: This can lead to severe parkinsonism and potential neuroleptic malignant syndrome, a life-threatening neurological disorder.

``

Question 37

Trimethoprim and renal function

Answer 37

• lead to a transient rise in creatinine levels by reducing the creatinine excretion of the kidneys
• Does not reflect actual eGFR
• not reflective of AKI