Medicine of older adult 👵🏼 Flashcards

Question

Acute confusional state

Answer 1

* 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

Answer 2

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

Answer 3

* 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

Answer 4

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 long term) * may be very agitated or withdrawn * disorientation * mood change * visual hallucinations * disturbed sleep cycle * poor attention

Answer 5

* 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

Answer 6

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

Answer 7

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

Answer 8

* **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.

Answer 9

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

Answer 10

* **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.

Answer 11

* **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.

Answer 12

* **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. ## Footnote ``

Answer 13

* 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

Answer 14

- hallucinations (e.g. auditory) - delusions - thought disorganisation - agitation/aggression - neurocognitive impairment (e.g. in memory, attention or executive function) - depression - thoughts of self-harm

Answer 15

- alogia: little information conveyed by speech - tangentiality: answers diverge from topic - clanging - word salad: linking real words incoherently → nonsensical content

Answer 16

schizophrenia: the most common psychotic disorder depression (psychotic depression, a subtype more common in elderly patients) bipolar disorder puerperal psychosis brief psychotic disorder: where symptoms last less than a month neurological conditions e.g. Parkinson's disease, Huntington's disease prescribed drugs e.g. corticosteroids certain illicit drugs e.g. cannabis, phencyclidine

Answer 17

- two or more voices discussing the patient in the third person - thought echo - voices commenting on the patient's behaviour

Answer 18

- thought insertion - thought withdrawal - thought broadcasting

Answer 19

- bodily sensations being controlled by external influence - actions/impulses/feelings - experiences which are imposed on the individual or influenced by others

Answer 20

a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'

Answer 21

- impaired insight - negative symptoms incongruity/blunting of affect - anhedonia (inability to derive pleasure) - alogia (poverty of speech) - avolition (poor motivation) - social withdrawal - neologisms: made-up words - catatonia

Answer 22

1. A person must be assumed to have capacity unless it is established that he lacks capacity 2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision 4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action

Answer 23

- age around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms around 80% of 80-year-old - men have evidence of BPH ethnicity: black > white > Asian

Answer 24

weak or intermittent urinary flow straining hesitancy terminal dribbling incomplete emptying

Answer 25

urgency frequency urgency incontinence nocturia

Answer 26

urinary tract infection retention obstructive uropathy

Answer 27

tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life Score 20-35: severely symptomatic Score 8-19: moderately symptomatic Score 0-7: mildly symptomatic

Answer 28

- Urine dip - U&Es - PSA - urinary frequency chart -IPPS

Answer 29

- Observation - alpha-1 antagonists e.g. tamsulosin, alfuzosin - 5 alpha-reductase inhibitors e.g. finasteride - if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried - surgery

Answer 30

decrease smooth muscle tone of the prostate and bladder considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8) improve symptoms in around 70% of men adverse effects: dizziness, postural hypotension, dry mouth, depression

Answer 31

block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months may also decrease PSA concentrations by up to 50% adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

Answer 32

advancing age previous pregnancy and childbirth high body mass index hysterectomy family history

Answer 33

bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) urine dipstick and culture urodynamic studies

Answer 34

- bladder retraining (6 weeks) bladder stabilising drugs: antimuscarinics are first-line NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation) Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patien

Answer 35

- pelvic floor training - surgical procedures - duloxetine

Answer 36

a combined noradrenaline and serotonin reuptake inhibitor mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 37

look for possible underlying causes/triggers constipation diabetes mellitus UTI if recent onset general advice fluid intake toileting patterns: encourage to empty bladder regularly during the day and before sleep lifting and waking

Answer 38

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

Answer 39

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

Answer 40

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

Answer 41

treatment of the underlying cause modification of the environment haloperidol 0.5 mg as the first-line sedative the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine management can be challenging in patients with Parkinson's disease, as antipsychotics can often worsen Parkinsonian symptoms careful reduction of the Parkinson medication may be helpful if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred

Answer 42

both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's. Avoid neuroleptics

Answer 43

progressive cognitive impairment parkinsonism visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

Answer 44

usually clnical - PET scan be used

Answer 45

malnourishment incontinence: urinary and faecal lack of mobility pain (leads to a reduction in mobility)

Answer 46

a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis) consider referral to the tissue viability nurse surgical debridement may be beneficial for selected wounds

Answer 47

Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin

Answer 48

Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister

Answer 49

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Answer 50

Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss

Answer 51

dietician support if the patient is at high-risk a 'food-first' approach with clear instructions (e.g. 'add full-fat cream to mashed potato'), rather than just prescribing oral nutritional supplements (ONS) such as Ensure if ONS are used they should be taken between meals, rather than instead of meals

Answer 52

- interstitial oedema - bat's wing appearance upper lobe diversion (increased blood flow to the superior parts of the lung) - Kerley B lines - pleural effusion - cardiomegaly may be seen if there is cardiogenic cause

Answer 53

Pulmonary oedema

Answer 54

Obesity Diuretics ACE inhibitors Beta-blockers Angiotensin 2 receptor blockers Aldosterone antagonists

Answer 55

Left ventricular hypertrophy Ischaemia Tachycardia Right ventricular overload Hypoxaemia (including pulmonary embolism) GFR < 60 ml/min Sepsis COPD Diabetes Age > 70 Liver cirrhosis

Answer 56

- ACE-inhibitor and a beta-blocker - second line: aldosterone antagonist - SGLT-2 inhibitors - third line must be started by a specialist.

Answer 57

vabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Answer 58

- annual influenza vaccine - one-off pneumococcal vaccin those with splenic or rCHD should have vaccine every 5 years

Answer 59

Ischaemic heart disease Dilated cardiomyopathy Myocarditis Arrhythmias

Answer 60

Hypertrophic obstructive cardiomyopathy Restrictive cardiomyopathy Cardiac tamponade Constrictive pericarditis

Answer 61

High-output heart failure refers to a situation where a 'normal' heart is unable to pump enough blood to meet the metabolic needs of the body.

Answer 62

Acute Inflammatory Demyelinating Polyneuropathy (AIDP) ## Footnote AIDP is characterized by an immune-mediated attack on the myelin sheath of peripheral nerves.

Answer 63

T-cells and macrophages ## Footnote These cells are involved in the immune-mediated attack on the myelin sheath.

Answer 64

Progressive, symmetrical ascending weakness, loss of reflexes, mild or absent sensory involvement ## Footnote Symptoms typically start in the legs and progress to the arms.

Answer 65

Acute Motor Axonal Neuropathy (AMAN) ## Footnote AMAN involves an immune attack on the axons of motor nerves.

Answer 66

Immune system attacks axons of motor nerves directly ## Footnote Unlike AIDP, which targets myelin, AMAN targets the axons.

Answer 67

Pure motor weakness without sensory loss, absent reflexes ## Footnote Recovery may take longer than in AIDP due to the nature of axonal damage.

Answer 68

Both motor and sensory axons are affected ## Footnote AMSAN has a worse prognosis due to extensive axonal involvement.

Answer 69

Weakness, sensory loss, absent reflexes ## Footnote Symptoms are more severe and prolonged than in AMAN.

Answer 70

A rare variant of GBS with ophthalmoplegia, ataxia, and areflexia ## Footnote MFS typically starts at the head and face and usually does not involve weakness.

Answer 71

Anti-GQ1b antibodies ## Footnote These antibodies are associated with the pathology of MFS.

Answer 72

Weakness in the neck, face, and arms with normal leg reflexes ## Footnote This variant affects specific muscle groups without impacting leg reflexes.

Answer 73

Overlap with Miller Fisher, includes reduced consciousness and brainstem dysfunction ## Footnote This condition presents symptoms similar to MFS but with additional neurological impairments.

Answer 74

AIDP involves demyelination while AMAN/AMSAN involves axonal degeneration ## Footnote This fundamental difference affects the clinical presentation and recovery.

Answer 75

AIDP is triggered by general infections; AMAN/AMSAN is specifically associated with Campylobacter jejuni ## Footnote The triggers can influence the prevalence of each form in different geographic regions.

Answer 76

Sensory involvement is mild or absent in AIDP; present in AMSAN ## Footnote This distinction helps in the clinical diagnosis of the different forms.

Answer 77

Acute Inflammatory Demyelinating Polyneuropathy (AIDP) ## Footnote Recovery is faster in AIDP because myelin regrows more quickly than axons regenerate.

Answer 78

True ## Footnote Both conditions exhibit absent reflexes in the affected areas.

Answer 79