PEER MENTOR TUTORIAL FOR AGEING

Question 1

Explain your answer

Answer 1

D - Vascular dementia The history of a number of TIAs correlates with vascular dementia - inadequate blood flow can damage and eventually kill areas of brain leading to vascular dementia The stepwise sequence seen in vascular dementia was also present hear as she would remit then have a sudden decline relapse typically seen in vascular dementia

Question 2

What is expressive dysphasia also known as? What does it mean?

Answer 2

It is also known as motor or Broca’s dysphasia It means she can understand the words being said to her but has difficulty in putting words together to make meaning

Question 3

Where is Broca’s area located?

Answer 3

Broca’s area is located in the frontal lobe of the brain

Question 4

What specific sign mentioned here is indicative of dementia?

Answer 4

C - Alzhiemer’s disease The gradual worsening of the condition (forgetfulness) is seen typically in alzheiemers Word finding difficulties is very indicative of dementia

Question 5

What are the three Ws of this condition?

Answer 5

This man has Normal pressure hydrocephalus Typically 3 Ws Wet - urinary incontinence Weird - Dementia / forgetfulness Wobbly - gait disturbances increasing falls likelihood

Question 6

Normal pressure hydrocephalus is different from normal hydrocephalus as it develops over time What type of dementia is it similar to? What disease does the abnormal gait look alike? What age group is typically affect by NPH?

Answer 6

Because it develops gradually over time it resembles Alzhiemer’s dementia The abnormality in gait - shuffling gait resembles Parkinson’s disease Typically those aged above 60 are affected by this disease

Question 7

What is the usual treatment of normal pressure hydrocephalus? What are the other symptoms in Parkinson’s disease?

Answer 7

The treatment is usually a ventriculoperitoneal shunt where excess CSF is drained into the peritoneum Parkinsons also presents with a tremor and bradyinesia

Question 8

What condition does the patient have? and how is it diagnosed? What drug was she put on?

Answer 8

Patient has orthostatic hypotension Diagnosed by carrying out a lying and standing blood pressure Was started on A - atenolol most likely

Question 9

What step in the management of hypertension is BBlockers? How is lying and standing blood pressure carried out?

Answer 9

1st line - ACEi or CCB 2nd line - ACEi or CCB 3rd line - Thiazide 4th line - BBlocker or Alpha 5th line - Spironolactone 1st BP - take after patient has been lying for at least 5 mins 2nd BP - take within one minute of paient standing 3rd BP - take after patient has been standing for 3 minutes

Question 10

What does the change in blood pressure need to be for a diagnosis of orthostatic hypotension?

Answer 10

Systolic blood pressure to drop by 20 or more Diastolic blood pressure to drop by 10 or more

Question 11

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Answer 11

E - simvastatin

Question 12

What drug that this patient is on does simvastatin interact with and how?

Answer 12

Clarithromycin interacts with the simvastatin Macrolide antibiotics inhibit the cytochrome p450 enzyme in the liver which would normally breakdown the statin, therefore the concentration of statin is greatly increased and therefore the side effect of muscle weakness is more likely

Question 13

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Answer 13

D -Spironolactone

Question 14

Why might the patient have generalised muscle weakness? Why can spirnolocatone cause increased potassium? WHat channel does it work on?

Answer 14

In severe cases of hyperkalameia, it can cause muscle weakness - usually only seen above 6.5mmol/l Spirnolactone is a potassium sparing diuretic acting on the collecting ducts by aldosterone mediated sodium excretion and potassium reabsorption

Question 15

Hyperkalaemia is a raised serum potassium level: Mild: K+ = 5.5 - 5.9mmol/L Moderate: K+ = 6.0 - 6.4mmol/L Severe: K+ ≥ 6.5mmol/L or if ECG changes or symptoms present What is given to treat each hyperkalaemia?

Answer 15

Mild Greater than 5.5 = give calcium resonium orally Moderate Greater than 6 - calcium resonium + Dextrose + Insulin Severe Greater than 6.5 - calcium gluconate 10mls, 10% + INsulin 10units ActRapid + 50mls 50% dextrose + Salbutamol nebulsier

Question 16

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Answer 16

Polympharacy - he is on 8 medications Osteoarthritis Angina Type II diabetes (peripheral neuropathy)

Question 17

What is his likely primary mechanism of his fall?

Answer 17

Likely to be postural hypotension - can see the lying and standing BP has reduced systolic by greater than 20

Question 18

c. What medications classes in general are most associated with an increased risk of falls?

Answer 18

Anti-cholinergics Anti-hypertensives Neuroleptics Opiates Hypoglycaemics - Sulfonylureas or Insulin

Question 19

d. What is the single greatest evidence based change to reduce Mr Smith’s future risk of falls?

Answer 19

Strength and balance training classes 3x per week for 12 weeks

Question 20

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Answer 20

The 4AT test Alertness AMT4 (Abbreviated mental test 4) Attention - name the months backwards Acute change or fluctuating course - change in cognition or alertness

Question 21

Is the 4At test or CAM tests used for rapid initial assessment of delirium and cognitive impairment?

Answer 21

The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment.

Question 22

What score on the 4 AT test is suggestive of delirium? Is it diagnostic?

Answer 22

Score of 4 or more is indicative but not diagnostic of delirium

Question 23

b. List 5 predisposing and 5 precipitating factors for the development of delirium

Answer 23

Predisposin Dementia, age, polympharmacy, sensory impairments, co-morbidities Precipitating - constipation, infection, post-operative, dehydration, electrolyte imbalances

Question 24

Give an example of a drug that cause constipation?

Answer 24

Opiates cause constipation

Question 25

c. What simple interventions should be put in place as part of the treatment of delirium?

Answer 25

Probably find out the causative cause of the delirium and treat that Then get family involved so the patient can see familiar faces Side room where there is less noise and lights

Question 26

Unfortunately despite treatment, the patient remains confused and has become aggressive towards staff and other patients. Assuming other interventions have failed, what medication can be prescribed? At what dose also?

Answer 26

Prescribe haloperidol - start at 0.25mg dose(anti-psychotic)

Question 27

In which conditions can haloperidol medication not be prescribed and what can be used as an alternative?

Answer 27

Parkinsons and Lewy body dementia - use quetiapine If alcohol or benzodiazepine withdrawl causing the delirium then use benzodiazpeine - lorazepam

Question 28

Why cant haloperidol be used in Parkinsons?

Answer 28

Haloperidol can block dopamine receptors in the CNS further worsening the parkinsons

Question 29

Mrs Smith, a 79 year old woman has been diagnosed with metastatic breast cancer and it is decided she is suitable for palliative care only. Like any other cause of pain, an appropriate approach to treatment of cancer related pain is the WHO Pain Ladder. a. Outline the steps of the WHO Pain Ladder with an example of a medication at each level.

Answer 29

Step 1 - Non-opioid (eg paracetamol) +/- Adjuvant (eg NSAID)

Step 2 - Weak opioid (eg codeine) + Non opioid +/- Adjuvant

Step 3 - Strong opioid (eg morphine) +/- Non opioid +/- Adjuvant

Question 30

. Over the coming weeks, Mrs Smith is in increasing pain and the GP decides it is necessary to prescribe oral morphine as required in the form of oromorph. What side effects can be anticipated with a prescription of morphine and should the patient be warned about?

Answer 30

Constipation, nausea& vomiting, hallucinations and respiratory depression are signs of opioid toxicity

Question 31

You review Mrs Smith’s pain control and decide it is now necessary to prescribe her regular oral morphine via morphine sulphate tablets. Mrs Smith has been using her oromorph 5mg around 6 times a day in 24 hours. Calculate her conversion to the regular oral morphine and her necessary breakthrough dose. What drugs are usually prescribed alongside morphine due to side effects?

Answer 31

total intake was 30mg So give 15mg BD as MST Give 5mg PRN as Oramorph (1/6th of faily dose) Usually a laxative and an anti-emetic

Question 32

What anti-emetic is usually given for morphine sickness and when cant it be given?

Answer 32

Usually give metoclopramide Cant give in Parkinsons as it can worsen the condition

Question 33

What are symptoms of opioid toxicity and what is the management? . Mrs Smith is thought to be reaching the end of her life and the decision is made to commence her on a syringe driver for pain relief. How is oral morphine converted to subcutaneous morphine as administered via a syringe driver?

Answer 33

Respiratory depression and hallucinations Prescribe naloxone for opioid toxicity Oral morphine dose is halved when converting to continuous subcutaneous infusion (CSCI) EG if taken 15mg BD orally, convert to 15mg in syringe driver over 24 hours