REVISION

Question 1

Which body cells do not divide and therefore have to last a lifetime?

Answer 1

Neurons
Renal cells
Myocardial cells

Question 2

What are the big ‘I’s in care of the elderly?

Answer 2

Important presenting complaints which need to be considered
Instability
Incontinence (new)
Immobility
Intellectual changes
Inability to look after SLE

Question 3

What is polypharmacy?

Answer 3

The use of multiple drugs, normally >4

Question 4

Pharmacokinetics = what the body does to the drug

Answer 4

Pharmacokinetics = what the drug does to the body

Question 5

Give some differences in the physiology of elderly patients which may affect drug distribution and action

Answer 5

1) Delayed gastric emptying
2) More fat, less lean tissue
3) Reduced liver and renal function
4) Reduced plasma albumi

Question 6

START and STOPP criteria

Answer 6

STOPP = screening tool of older peoples prescriptions
START = screening tool to alert doctors to the right treatment

Question 7

Which drug is used for delirium tremendous e.g. alcohol withdrawal

Answer 7

Chlordiazepoxide

The dose depends on the severity of drinking

Question 8

Elderly patient with failing vision develops vivid visual hallucinations. Most likely diagnosis?

Answer 8

Charles-Bonnet syndrome

important that people are normally aware that they are hallucinating

Question 9

Management of a patient with COPD who is still symptomatic on a SABA/ SAMA

Answer 9

FEV1 >50 = LABA or LAMA

FEV1 <50 = LABA + ICS (or LAMA)

Question 10

Main differential for bilateral Hilary lymphadenopathy

Answer 10

TB or sarcoid

Question 11

Define delirium

Answer 11

Transient, reversible decline in cognitive function, that is acute and fluctuating and occurs in the presence of an acute illness
Loads of causes including infection, stroke, head injury, pain and emotional distress

Question 12

Neurotransmitters involved in delerium?

Answer 12

Low ACh
Dopamine excess

Classically causes reversal of sleep wake cycle, clouding of consciousness, hallucinations, lucid intervals,delusions etc

Question 13

What is the confusion assessment method?

Answer 13

A diagnostic algorithm used in the assessment of delerium.
4 components
1) Acute onset and fluctuating course
2) Inattention
3) Disorganised thinking
4) altered conscious level 

Needs features 1+2 and 3 or 4 to be diagnosed

Question 14

Define dementia

Answer 14

A syndrome of acquired, chronic, global impairment of higher brain function in an alert patient which interferes with there ability to cope with daily living

Question 15

Features of normal pressure hydrocephalus

Answer 15

1) Incontinence
2) Gait disturbance
3) Dementia

Dementia may benefit from shunting

Question 16

What is the first feature of Alzheimer’s disease?

Answer 16

Usually impaired short term memory

Remember
My - memory
Old - orientation 
Granny - grasp e.g. difficulty planning and with executive functions
Converses - communication 
Pretty - personality changes
Badly - behaviour changes

Question 17

Investigations in a patient with suspected dementia

Answer 17

FBC, UE, LFT, calcium TFT, B12 and folate
ECG
Consider CT

Question 18

Pathology features of alzheimers

Answer 18

Amyloid plaques

Neurofibrillary plaques from tau protein

Question 19

Which gene is associated with alzheimers?

Answer 19

APOE e4

Question 20

What are the 4 alzheimers drugs?

Answer 20

1) Donepezil
2) Galantamine
3) Rivastigmine
(All AChE inhibitor)

4) Memantine (only for severe disease)
A N methyl-D aspartame receptor antagonist

Question 21

Which drugs should be used in a patient with severe Alzheimers?

Answer 21

Memantine (a N methyl D aspartame receptor antagonist)

Question 22

What are the cut offs for diagnosing Alzheimers using MMSE?

Answer 22

MMSE is out of 30

Mild = 21-26
Moderate = 10-20
Severe = <10

Question 23

Which group of patients should you always avoid giving anti-psychotic drugs in?

Answer 23

Levy body dementia
(if you have too, use quetiapine)

Rivastigmine and L-dopa can help symptoms)

Question 24

Best anti-psychotic drug in levy body dementia?

Answer 24

Quetiapine

Question 25

List some features of fronto-temporal dementia?

Answer 25

Impaired executive function e.g. cannot problem solve/ plan Social disinhibition - ‘private things in public’ Compulsive behaviour e.g eating Loss of empathy SSRIs may be useful - ACHe worsen symptoms Important that memory and orientation are well preserved

Question 26

What is the SPLATT pnuemonic for assessing falls?

Answer 26

``` S = symptoms P = previous falls L = location A = activity e.g. standing, peeing, hanging out washing T = time e.g. first thing, after tablets etc T = trauma? ```

Question 27

List some common drugs that can cause falls?

Answer 27

1) Anti-hypertensive e.g. diuretics, CCB —> can cause postural hypotension 2) opiates/ benzodiazepines —> cause drowsiness 3) Ant-psychotics —> extra-pyramidal side effects 4) Anti-depressants, especially TCA —> slow central processing

Question 28

How do you check for postural hypotension?

Answer 28

Measure BP lying and after standing for 3 minutes | A drop of >10mmg diastolic and >20 systolic is significant

Question 29

Baseline investigations for a patient who falls?

Answer 29

FBC, TFT, B12 | ECG

Question 30

Consequences of a long lie (>1 hour)

Answer 30

Hypothermia (if outside/ unseated room) Pressure sores Rhabdomyolysis Death (its a very bad prognostic indicator)

Question 31

List a good differential for a dizzy patient

Answer 31

1) ENT = BPPV, Acoustic neuroma, Labyrinthitis, meniere’s 2) Cardio = hypotension, syncope, arrhythmias 3) Drugs 4) CNS - vertebro-basilar syndrome/ cerebellar disease

Question 32

Trabecular bone is spongy bone

Answer 32

Cortisol bone is the hard outer bone

Question 33

What tests should be done to exclude secondary causes of osteoporosis?

Answer 33

FBC, LFT, UE, ESR, serum immunoglobulins and urinary Bence Jones proteins to exclude myeloma Calcium TFT

Question 34

How do bisphosphonates work?

Answer 34

They bind to hydroxyapatite within the bone which inhibits osteoclast recruitment and therefore bone respiration

Question 35

Which drug can be used to increase bone density?

Answer 35

Teriparatide Given by daily sub-cut injection in people with severe disease who are not tolerant of bisphosphonate Very expensive

Question 36

Which bone drug is given by 3 monthly injection?

Answer 36

Denosumab | A monoclonal antibody against RANKL

Question 37

What is osteomalacia?

Answer 37

Reduced calcification due to vitamin D deficiency E.g. there is a normal amount of bone but it is very weak Features include fractures, skeletal pain, muscle weakness and waddling gait Alk phos will be high, Ca and phosphate low

Question 38

What is Paget’s disease of bone?

Answer 38

An increase in bone tunorver, producing expanded but weakened bone. Usually the skull, pelvis, spine and femur that is affected Bone pain or nerve entrapment may be the presenting feature - often the 8th nerve

Question 39

Alk phos and calcium are high in patients with Pagets

Answer 39

Remember that many will be asymptomatic and diagnosed with finding of raised Alk phos for other reasons Treatment is usually with risedronate (a bisphosphonate)

Question 40

What is the Sestamibi scan?

Answer 40

A technetium scan used in the detection of a parathyroid adenoma e.g. in primary hyperparathyroidism- used to determine anatomy pre-surgery

Question 41

List 5 causes of hypercalcaemia in older patients

Answer 41

1) Primary hyperparathyroidism 2) Hypercalcaemia of malignancy 3) Renal disease 4) Myeloma 5) drug induced e.g. thiazides, lithium and vit D

Question 42

What is the CHA2DS2-Vasc score?

Answer 42

``` Calculates the risk of stroke in patient with AF E.G. age, sex, CHF, HT, previous stroke DM etc 0 = low risk 1 = low-moderate e.g. consider aspirin 2+ = high —> warfarin ```

Question 43

Remember that amarousis fugax is a type of TIA

Answer 43

Remember that amarousis fugax is a type of TIA

Question 44

What is the ABCD2 score?

Answer 44

A tool used to calculate the risk of stroke after a TIA Age BP Clinical features e.g. unilateral weakness (2), speech disturbance (1) Duration <10 min (0), <1 hour (1), >1hr (2) DM?

Question 45

Total anterior circulation infarct

Answer 45

Middle coronary artery occluded - very bad prognosis All 3: 1) Higher cortical dysfunction e.g. dysphasia 2) hemianopia 3) Motor/ sensory defect in 2 out of face, arm and leg

Question 46

Partial anterior circulation infarct

Answer 46

2/3 of TACI symptoms E.g. hemianopia, executive dysfunction and motor/ sensory deficit Branch of MCA or ACA, reasonable outcome but very high chance of recurrence

Question 47

Features of lacunar infarct

Answer 47

Occlusion of deep perforating arteries, often with good recovery ``` Any 1 of: Motor deficit Sensory deficit Hemiparesis Ataxia ```

Question 48

Features of posterior circulation infarct

Answer 48

Any one of: Homonymous hemianopia Brain stem signs Cerebellar dysfunction Good recovery but also high recurrence rate

Question 49

Remember that vertigo can be a feature of a cerebellar stroke

Answer 49

Other signs are a focal neurological deficit, ataxia and nystagmus

Question 50

Which drugs should be used in the managment of a SAH?

Answer 50

Nimidopine (dyhydropirodine CCB) | Codeine for analgesia

Question 51

Aspirin is given in ALL ischaemic stroke patients

Answer 51

300mg acutely and then 75mg daily for at least the first 2 weeks

Question 52

Indications for thrombolysis in stroke?

Answer 52

Main one is within 4.5 hours of symptom onset | Also no haemorrhaging stroke, no previous stroke within 3 months and not on anticoagulation

Question 53

Secondary prevention in stroke patients?

Answer 53

1) Lifestyle - smoking, diet, salt and alcohol 2) Anti-platelet e.g. clopidogrel 75mg 3) Statin 4) BP

Question 54

What are the 6 features of dependence?

Answer 54

1) Strong desire to use substance 2) Withdrawal if not using 3) Tolerance 4) Lack on interest in other things’ 5) Using despite harm 6) difficulty controlling substance use

Question 55

What is the main side effect/ risk of MAOI?

Answer 55

Mono-amine oxidase inhibitors e.g. moclobemide, hydrazine and phelzine can cause drug reactions and potentially fatal hypertensive crisis Patients must limit tyramine in their diet —> liver, alcohol etc due to the risk of crisis Patients should carry a card around - being on a MAOI affects dose of drugs e.g. adrenaline

Question 56

What is the CGA?

Answer 56

Comprehensive geriatric assessment, gold standard assessment of older people. Fast, effective and should be used

Question 57

How is tone and reflexes in PD?

Answer 57

``` Tone = increased Reflexes = normal ```

Question 58

For BPH, alpha blockers have an effect within a few days

Answer 58

5 alpha reductase inhibitors e.g. finestaride take several weeks -

Question 59

Treatment of delirium

Answer 59

Treat cause, orientation and good nursing Oral haloperidol may be required Avoid benzos as they worsen delirium