Topics and Conditions Flashcards
Dementia
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
Hx of prolonged decline (gradual and progressive) in cognition, including memory. Reduced ability to complete IADLs and ADLs. Question cognitive decline, BPSD and impact of (I)ADLs.
Cognitive decline: Memory problems, receptive/expressive dysphasia, apraxia/dyspraxia, disorientation to place/time, impaired exectutive function (planning/problem solving)
Disruption to memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.
BPSD: Fluctuating, psychosis, agitation, emotional lability, depression and anxiety, dishibition, wandering, sleep disturance
Parkinsonism in PD, LBD and late in AD.
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Dementia blood screen: Allows a reversible cause to be ruled out and also provides baseline function results in readiness for treatment commencing
- FBC, U&E, LFTs, lipids, CRP, TFTs
- Ca2+, glucose, B12, folate
- Midstream urine and MC&S - if UTI suspected
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Cognitive assessment: AMT < 8 suggests further assessment is required
- MoCA < 26 suggests impairment
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CT brain
- Visualisation of brain matter to check for degenerative changes or vascular changes indicative of vascular dementia
- NOT diagnostic, only biopsy would allow official diagnosis, but allows for ‘likely X’ to be stated
Aetiological factors
- Genetics: Specific mutations related to subtypes.
- Vascular pathway for vascular dementia e.g Hx of hypertension, diabetes, CVD
- Neurological conditions such as stroke or Parkinson’s disease
- Intellectual disabilty
- Lifestyle
Pathophysiology
Subtype specific - generally, loss of perfusion or interrupted neuronal activity leads to loss of function in the affected area.
Management
Pharmacological
Acetylcholinesterase inhibitors
- Increase synaptic acetylcholine through preventing the breakdown of the NT (donepezil, galantamine and rivastigmine)
- Side effects: Aggression, agitiation, GI, increased production of sweat/saliva/tears (uncommon)
- Contraindications: HR < 60 bpm due to the increased parasympathetic effects causing further deceleration in HR, heart block, severe asthma, severe COPD
Memantine
- NMDA (glutamate) receptor antagonist
- Side effects: GI, dizziness and balance issues, drowsiness
- Cautions: Epilepsy or RFs for seizures, reduced renal function
Lifestyle
- Active lifestyle, balanced diet
- Inform pt that they must notify the DVLA of their diagnosis
Support
- CST: 12 sessions, 1 hour long, range of activities, groups are ‘decline appropriate’, good evidence base for efficacy
- Carer support
- Support groups: Dementia friends
- Consider advance decisions and LPA
Differential diagnosis
- Reversible causes (see dementia screening tests)
- Iatrogenic: Medications (benzodiazepines, anticholingergics, analgesics)
- Depression
- Delirium
- Infective cause e.g. UTI
Delirium
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
Hx suggestive of delirium and ruling out ddx. Collateral may be required.
Enquire about bowel habits and urinary symptoms.
A thorough set of investigations are required to help identify the cause:
- Bloods - FBC, U&Es, LFT, CRP/ESR, Ca2+, B12, folate, TFTs,
- Glucose
- Urianlysis
- CXR
- ECG
AMT < 8 indicates need for further assessment
CAM (confusion assessment method) used to screen for delirium
Acute onset, fluctuating course
Inattention
Disoganised thoughts
Altered consciousness
Aetiology
- Iatrogenic: Medications (corticosteroids, opioids, anticholinergic activity), electrolyte disturbance 2º to medication (SSRI, diuretics, PPIs, ACEi), post-surgery
- Dehydration
- Electrolyte disturbance: Sodium, calcium
- *Constipation
- *Infection: UTI, CAP commonly
- *Organ failure
* indicate the most common causes of delirium
Pathophysiology
Cause specific
Management (following CGA)
Provide a suitable environment for the provision of care - well lit, quiet, private, low stimulation, familiarity
Treatment of identified cause e.g. provision of fluids in dehydration or hypercalcaemia, abx for identified infection
Support and provision of information for family.
Rapid transquilisation if required: IM lorazepam or haloperidol (! AVOID in PD or LBD as worsens motor dysfunction). PO may also be provided, but only is absolutely necessary
Differential diagnosis
- Organic cause: Space occupying lesion
- Substance misuse
- Dementia
- Depression
- Psychiatric condition: Schizophrenia, bipolar disorder
Depression
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies), ddx)
Diagnosis:
Hx of core symptoms (low mood, anhedonia, anergia) +/- cognitive and biological symptoms persisting for > 2 weeks. In the absence of drug/alcohol use, medical condition or bereavement which may be responsible for symptoms.
MSE also suggestive of depression.
Collaterol Hx
Geriatric depression score (GDS) may be used for screening. A score > 5/15 on the GDS-15 suggests depression is likely. Shorter, 4 question version, is also available
Aetiology:
- Genetic
- Environmental: Loneliness, bereavement
- Iatrogenic: 2º to medication (e.g. beta blockers)
- Health related: 2º to long term health condition
Pathophysiology:
Monoamine deficiency (5-HT, NA)
Interplay of genetic, environmental etc
Management:
Pharmacological
- Mild-moderate depression: SSRI
- Generally considered sooner in the eldery, especially if biological symptoms (weight loss etc) are present
- Counsel on side effects (GI disturbance, nausea, increased anxiety in first few weeks of treatment)
- Ensure that medications will not exacerbate co-morbidities e.g. dementia, or increase risk, e.g. falls.
- ECT for severe treatment resistant depression or for life threatening depression
Psychological
- Risk assessment: Specific focus on risk to self (neglect, suicide) and risk from others (elder abuse)
- CBT
- Psychotherapy
- Provide sleep hygiene advice if having difficulty sleeping
Social
- Support groups, age UK
- Provision of means to allow pt to socialise
- Encourage healthy diet and exercise
REVIEW in 4/52
Differential diagnosis:
- Organic cause
- Substance misuse *ALWAYS screen for drug/alcohol misuse
- Dementia
- Delirium
- Bereavement
Continence
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
Hx
- Assess voiding and storage symptoms
- Assess number of day and night time voids
- Assess symptoms to establish type: Stress, urge, mixed, overflow
- Stress: Occurs on coughing, sneezing
- Urge: Sudden need to urinate and increased frequency
- Overflow: Hesitancy even when the urge is present, sudden release, feeling of fullness even after micturition, unexpected high volume micturition
- Assess effect on QoL
- Assess possible causes and risk factors
- Caffiene, alcohol, obesity, obstetric Hx, BPH, smoking
- Medical conditions: Dementia/MCI, diabetes, renal failure, heart failure
- Medications: Alpha 1 - adrenoceptor antagonists, antipsychotics, anticholinergics, anti-parkinsonism drugs, antidepressants, benzodiazepines, beta-adrenoceptor antagonists, diuretics, and hormone replacement therapy.
- Rule out reversible causes - especially UTI
- Check for red flags: Haematuria, dysuria, recurrent UTI, constant leakage (fistula), persitent bladder/urethral pain
3 day bladder diary
- Frequency, volume, fluid (volume and type) intake
Post-void bladder scan
- Residual volume should be < 50 mL or < 100 mL in those over 65
- A residual volume > 300 mL indicates the need for intermittent catheterisation to relieve retention
Urinalysis and MC&S
Further investigation if indicated
Aetiology:
Infection: 2º to UTI
Stress incontinence (inability to maintain urethral pressure > abdominal pressure): Pelvic floor weakness (obstetric), pelvic floor weakening secondary to reduced oestrogen levels, vaginal prolapse, following prosectomy
Urge incontinence (detrusor overactivity): Neurogenic (MS, spina bifida), UTI, 2º to retention
Overflow incontinence: Blockage of the urinary tract (calculi, malignancy, BPH), constipation
Pathophysiology:
Sympathetic branch of the autonomic nervous system mediates the storage phase. Detrusor relaxation and contraction of the internal urethral sphincter.
Parasympathetic branch mediates micturition. Contraction of the detrusor muscle and relation of of internal urethral sphincter.
Somatic mediated relaxation of the external urethral sphincter via the pudendal nerve
Management:
Stress incontinence
1st line:
Lifestyle modifications: Reduced caffiene/alcohol intake, weight loss, smoking cessation,
Pelvic floor exercises: 3 months of supervised exercise. At least 8 pelvic floor contractions x3 a day
2nd line:
Surgical intervention - urethral sling etc
3rd line:
Pharmacological: SSRI - duloxetine, only if prefered to surgery
Urge incontinence
1st line:
Lifestyle modifications: Reduction in caffiene/alcohol intake, smoking cessation
Bladder retraining (e.g. double voiding, increasing time between voiding) and pelvic floor exercises
2nd line:
Pharmacological: Anti-muscarinics
Oxybutynin, tolterodine, or darifenacin
Side-effects: Incontinence 2º to retention, dry mouth, blurred vision, constipation
Intravaginal oestrogen can help those with vaginal atrophy
3rd line:
Detrusor botulinum injection
Sacral nerve stimulation
Osteoporosis
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
A condition characterised by low bone mass and structual deterioration. May have symptoms of wedge fracture - pain, kyphosis.
Hx of fall with fragility fracture
DEXA scan reveals low BMD, with a T-score of - 2.5 or below (at least 2 SD below the reference point) (non age-grouped)
Aetiology:
- Risk factors: BMI <18.5, smoking, increasing age, female gender, low peak bone mass, immobility, post-menopausal, FHx, corticosteroid use, anticonvulsants, prolonged heparin use
- Causes of seconary osteoporosis: RA, hyperthyroidism, hyperparathyroidism, premature menopause, chronic malabsorption, chronic liver disease
Pathophysiology:
Imbalance in bone remodelling, with increased osteoclast activity. Bone is resorbed in an attempt to increase calcium levels.
Management:
Lifestyle changes: Smoking cessation, reduce alcohol intake, balance diet, regular exercise (combination of strength, balance, endurance, flexbility training)
Assessment of 10-year fracture risk using FRAX
Whole spine X-ray to assess for non-symptomatic fractures
Pharmacological
1st line - Bisphosphonates: Inhibit osteoclast activity
Require adminstration on an empty stomach, full glass of water and to remain upright for half an hour due to risk of dyspepsia.
Usually taken for 3 years before reviewing risk:benefit.
Side effects: Jaw osteonecrosis (jaw pain and poorly healing ulcers), atypical femoral fractures e.g. intertrochantic (sudden onset hip pain), dyspepsia
Monitoring: C-terminal telopeptide levels can be used to monitor adherance. Levels should decrease, showing reduced bone turnover.
Monoclonal antibody: RANKL receptor antagonist
Side effects: Atypical femoral fractures, osteonecrosis of the jaw
SERMs:
Raloxifene: Act as agonist in bone. Antagonist in breast tissue. Indicated for use in vertebral osteoporosis.
Side effects: Increased thromboembolism risk
Synthetic PTH: Teripertide. Indicated for use in vertebral osteoporosis.
Side effects: Hypercalcaemia
Supplementation of vitamin D and calcium
Rehabilitation following fractures
Falls
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
Thorough Hx, collateral Hx if possible
Exclude stroke, seziure and trauma as the cause.
Aetiology:
- Consider 3 ‘types’ of fall:
- Fall due to acute illness
- Single fall
- Recurrent falls
- Functional
- Secondary to an impairment caused by a medical condition: Diabetes, CKD, CVD
- Age-related: Visual changes, orthostatic hypotension
Pathophysiology:
Management:
- Investigations: *Looking to identify cause and assess risk of recurrent falls*
- Examination: Neurological, visual assessment
- Abbreviated mental test
- Bloods: FBC, CRP, U&Es, LFTs, Ca2+/bone profile
- Infection ‘screen’: Urinalysis, CXR
- ECG
- Lying and standing BP
- Tilt table test (for investigation of syncope. May be performed +/- carotid massage if carotid sinus hypersensitivity is suspected)
- Imaging as required e.g. CT head, pelvic X-ray
- Assess risk of recurrent falls
- Timed up and go test (> 12 seconds is indicative of increased risk)
- Investigations for osteoporosis: FRAX score, bone profile, DEXA
- MDT APPROACH REQUIRED
- Treatment/resolution of causation
- Medication review - especially in polypharmacy
- Environmental adaptations following OT and physio input e.g. ramps, handles, walking frame
- Rehabilitation to aid muscle strength and balance
- Provision of a care package if appropriate
Differential diagnosis
- Consider elder abuse
- Orthostatic hypotension: Occuring on standing, dizziness, lying and standing BP reveals drop
- Syncope: Fall following long stand/distressing event, ‘prodromal’ symptoms present, whilst on the toilet/straining
- Cardiovascular cause: AF/arrythmia, heart block, hypotension
- Functional: Poor vision, environmental hazard
- Secondary to incontinence
- Hypoglyaemia in diabetes
Parkinsonism and movement disorders
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis: Predominantly a clinical diagnosis.
CT brain may be used to look for cerebral ischaemia in patients suspected to have vascular Parkinsonism.
DATscan may be used to distinguish between idiopathic Parkinson’s disease and other causes of Parkinsonism if there is uncertainty.
Dopaminergic treatment may be commenced and response monitored, allowing for the specific subtype to be identified - as drug treatments for motor symptoms are only effective in idiopathic Parkinson’s disease.
Aetiology:
Conditions which cause Parkinsonism (bradykinesia, tremor, rigidity, postural instability)
- (Idiopathic) Parkinson’s disease
- Lewy body dementia
- Vascular dementia
- Drug induced Parkinsonism
- Progressive supranuclear palsy (PSP) - consequential of accumulation of neurofibrillary tangles. Causes problems with balance, movement, vision, speech and swallowing.
- Multi-system atrophy (MSA)1 - consequential of alpha-synuclein accumulation
- Benign essential tremor may also be considered amongst the list of differentials for pts presenting with a tremor.
*Consider ‘characteristics’ which may allow these conditions to be excluded according to pt symptoms e.g. uni/bilateral tremor
Pathophysiology:
Parkinson’s sees degeneration of the substantia nigra. With reduced dopaminergic activity the functioning of the basal ganglia is disrupted.
Management:
1: Symptoms of autonomic failure that may be seen in MSA include fainting spells and problems with heart rate, erectile dysfunction, and bladder control. Motor impairments (loss of or limited muscle control or movement, or limited mobility) may include tremor, rigidity, and/or loss of muscle coordination as well as difficulties with speech and gait (the way a person walks).
Pressure ulcers
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Diagnosis:
Visual inspection and staging of ulcers.
Consider the presence of risk factors and look to minimise development, such as through regular turning and use of pressure relieving devices e.g. mattress.
The Braden score may be used to calculate the risk of pressure ulcer development in patients. The score determines the appropriate *SSKIN bundle of care for the patient.
Aetiology:
Pressure and shear forces on the skin occlude small vessels supplying the skin. Reduced supply of oxygen and nutrients to the tissues.
Most commonly seen on bony prominences (as per image)
Presence of risk factors: Reduced mobility, sensory impairment, malnutrition, dehydration, obesity, cognitive impairment, urinary and faecal incontinence
Pathophysiology:
Management:
Stage dependent management
General management:
- Analgesia: PO
- Frequent patient repositioning to relieve pressure on sores
- Assessment of sores and regular dressing changes
- Application of emollient to at risk areas - particularly if incontinent
- Pressure relieving mattresses and cushions
- Debride dead and necrotic tissue
- Abx if indicated ?osteomyelitis
Stage 3 and 4 sores
- Involvement of TVN (tissue viabilty nurse)
- Surgical debridement may be required
- Topical antimicrobials (silver, honey, iodine-impregnated dressings) may be used
- IV antibiotics should be reserved for instances of systemic sepsis or osteomyelitis
* SSKIN: Support surface, Skin assessment, Keep moving, Incontinence and moisture, Nutrition and hydration
Cerebrovascular disease and stroke
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Outline the Bamford classification
Diagnosis:
Sudden onset focal neurological deficit, presumed to be of vascular origin.
Assessment of deficit allows for the Bamford Classification to be applied.
Aetiology:
Presence of risk factors: Hypertension, smoking, high fat diet, PAD, FHx, Hx of TIA, arrythmias (AF)
Pathophysiology:
Ischaemic (80%) - vascular occlusion leads to tissue necrosis. The region affected determines the deficit.
Haemorrhagic (20%)
Management:
- Initial assessment of deficit
- Ongoing monitoring of vital signs - especially blood pressure
- If TIA is suspected provide 300mg aspirin
- Continue for 2/52 after symptom onset
- !Offer PPI if previous aspirin-associated dyspepsia is reported
- CT head (within 1 hour)
- Specifically, CT contrast angiography to assess for haemorrhage
- Thrombolysis for ischaemic stroke - if onset of symptoms is within 4.5 hours of presentation
- Mechanical thrombectomy for ischaemic stroke - if onset of symptoms is within 24 hours of presentation
- Must be performed within 6 hours of symptom onset
- Indicated for ischaemic stroke in which there is confirmed occlusion of the proximal anterior circulation on CTA/MRA
- Carotid doppler in TIA
- Carotid endarterectomy or stenting for secondary prevention
- Assessment of swallow by SALT on admission
- Assessment of mobility by physio and OT
Pharmacological management at discharge
- Antiplatelet therapy: Clopidogrel 75mg OD
- Indicated in TIA without paroxysmal or permanent AF
- Antihypertensive agent: Systolic target of 130 mmHg
- Statin: High dose atorvastatin (80mg) - should be initiated at least 48hrs following stroke
- Anticoagulant therapy for patients with AF - deferred for at least 14 days following ischaemic stroke
- Lifestyle advice at discharge
- Smoking and alcohol intake cessation
- Encourage balanced diet and exercise
Nutritional issues
(Describe / define the diagnosis, multi-factorial aetiological factors, pathophysiology and management (including health promotion, prevention and recovery strategies)
Adequate nutrition → ability to fight infecion and respond to rehabilitation
Most common micronutrient deficiencies:
- Vitamin D - Proximal myopathy, bone pain, fracture risk
- Vitamin C - Gingivitis, increased bruising
- Iron, folate, B12 - Anaemia
Diagnosis
May be identified by use of a risk assessment tool e.g. MUST - high risk, score > 2 → dietetic input and close monitoring, medium risk score of 1 → monitored with food charts for 3 days and then decision made
Aetiology
- General function: Poverty, social isolation
- Cognitive impairment
- Swallowing
- Dentition
- Medication e.g. dry mouth due to anticholinergics, altered taste due to sedatives, candidiasis due to antibiotics
Management
Medication: Consider stopping digoxin, psychotropics, theophylline
Emotions: Depression
Anorexia/alcoholism
Late life paranoia
Swallowing problems
Oral and dental disorders
No money (poverty)
Wandering (dementia)
Hyperthyroidism/hyperparathyroidism
Enteric problems: Malabsorptive conditions
Eating problems
Low-salt/cholesterol diet
Social problems
MUST Refeeding syndrome Frailty, osteoporosis, dehydration as a consequence
