COTE Peer Teaching

Question 1

List 6 possible causes of falls in elderly people.

Answer 1

• Drugs (sedatives, alcohol)
• MSK eg. OA of hip
• Syncope (vasovagal, cardiogenic, arrhythmias)
• Stroke / TIA
• Hypoglycaemia
• Visual impairment
• Dementia
• Poor environment

Question 2

What are the 3 main features of Parkinson’s?

Answer 2

• Tremor
• Bradykinesia
• Rigidity (lead-pipe; cog wheel)

Question 3

List 3 differential features of a Parkinsonian tremor.

Answer 3

• Slow (pill-rolling)
• Worse at rest
• Asymmetrical
• Reduced on distraction
• Reduced on movement

Question 4

What is the underlying pathophysiology of Parkinson’s?

Answer 4

Loss of dopaminergic neurons in the substantia nigra.

Question 5

What class of drugs is normally combined with L-Dopa to prevent peripheral side effects? (re: Parkinson’s).

Answer 5

L - Dopa Decarboxylase inhibitor (Carbidopa or Benserazide)

Question 6

Name 3 complications of L-dopa therapy (re: Parkinson’s patients).

Answer 6

• Postural hypotension on starting treatment
• Confusion
• Hallucinations
• L-dopa induced dyskinesias
• On-off effect: fluctuations in motor performance between normal function (on) and restricted mobility (off).
• Shortening duration of action of each dose (i.e. end-dose deterioration, where dyskinesias become more prominent at the end of the duration of action.

Question 7

A patient presents with confusion. What should you ask about in their history?

Answer 7

• Premorbid personality
• PMHx
• Medications
• Social circumstances
• Any past similar episodes

Question 8

Describe ‘dementia’.

Answer 8

• Chronic illness
• Progressive course
• Preserved attention
• Consciousness preserved
• Irreversible
• No underlying medical cause

Question 9

Describe ‘delirium’.

Answer 9

• Acute onset
• Fluctuating course
• Inattention
• Altered level of consciousness
• Usually reversible
• Associated with underlying medical cause

Question 10

What causes delirium?

Answer 10

‘DELIRiUM’

• Drug use (introduction, dose adjustments)
• Electrolyte and physiological abnormalities
• Lack of drug (withdrawal)
• Infection
• Reduced sensory input (blind, deaf, changing environment)
• Intracranial problems (stroke, post-octal, meningitis, subdural haemorrhage)
• Urinary retention + faecal impaction
• Myocardial (MI, Arrhythmia, HF)

Question 11

How would you manage a patient with delirium?

Answer 11

• Treat the cause
• Manage environment
• Soft lighting
• Clocks and calendars
• Sleep hygiene (promote night time sleep)
• Avoid multiple rooms / ward moves
• Minimise provocation

Question 12

Give a summary of ‘Vascular Dementia’.

Answer 12

• Step-wise progression

- Caused by problems with the blood supply to brain

Question 13

Give a summary of ‘Alzheimer’s Dementia’.

Answer 13

• Most common type of dementia
• Progressive
• Loss of ability to learn, process and retain new information

Question 14

What would a patient with Alzheimer’s’ brain look like on CT / MRI?

Answer 14

Atrophic :(

Question 15

What is the pathophysiology of Alzheimer’s?

Answer 15

• Neurofibrillary tangles
• Loss of neurons
• Aggregation of beta-amyloid plaques

Question 16

What is the management for Alzheimer’s?

Answer 16

• Supportive
• AChE inhibitors
• Memantine

Question 17

What is a ‘Comprehensive Geriatric Assessment’ designed to do?

Answer 17

• Identify health problems + establish a management plan in older patients with frailty.

Question 18

What domains does a ‘Comprehensive Geriatric Assessment’ take into account?

Answer 18

• Physical health
• Mental health
• Social aspects
• Functional aspects
• Environment

Question 19

Who might be involved in the Comprehensive Geriatric Assessment team?

Answer 19

• Geriatrician
• Nurses
• Pharmacist
• OT
• Physio
• SALT
• Dietitian
• Social worker
  etc

Question 20

What are the complications of a long lie following a fall?

Answer 20

• Pressure ulcers
• Dehydration
• Rhabdomyolysis

Question 21

What investigations should you do if you suspect / see a pressure ulcer on admission?

Answer 21

• CRP, ESR
• WCC
• Swabs
• Blood cultures
• X-ray for bone involvement

Question 22

How would you manage a pressure ulcer?

Answer 22

• Antibiotics
• Wound dressing
• Pain relief
• Debridement if grade 3/4

Question 23

Define ‘osteoporosis’.

Answer 23

Decreased bone mineral density due to imbalance between remodelling and resorption

Question 24

List some risk factors for osteoporosis.

Answer 24

• Smoking
• Early menopause
• Steroid use
• Underweight
• Inactivity
• Alcohol
• ALL ELDERLY PEOPLE

Question 25

Which fractures are most common in people with osteoporosis?

Answer 25

- Spinal - Hip - NOF

Question 26

How is osteoporosis diagnosed?

Answer 26

DEXA scan

Question 27

What does the 'FRAX' score assess?

Answer 27

The risk of a 10 year fragility fracture

Question 28

How is osteoporosis managed?

Answer 28

Bisphosphonates

Question 29

How might a patient present if they have Vitamin C deficiency?

Answer 29

- Bleeding from gums | - Extensive bruising on legs (unrelated to falls)

Question 30

How might Vitamin C deficiency be managed?

Answer 30

- Correct the deficiency -> MDT approach to malnourishment

Question 31

How is Nutritional Status assessed?

Answer 31

- Using the 'MUST' screening tool | - > Malnutrition Universal Screening tool

Question 32

What is 'Refeeding Syndrome'?

Answer 32

- Metabolic disturbances as a result of reinstating nutrition to patients who are starved / severely malnourished.

Question 33

List some biochemical features of refeeding syndrome.

Answer 33

- Hypophosphataemia - Hypokalaemia - Thiamine deficiency - Abnormal glucose metabolism

Question 34

List some complications of 'Refeeding syndrome'.

Answer 34

- Cardiac arrhythmias - Convulsions - Cardiac failure

Question 35

How should you manage / treat 'Refeeding syndrome?'

Answer 35

- Monitor blood biochemistry | - Commence re-feeding with guidelines

Question 36

What are the four 'I's of Geriatric Giants?

Answer 36

- Immobility - Incontinence - Incompetence - Impaired homeostasis