1
Q
Define dementia
A
Syndrome of generalized decline of memory, intellect and personality, without impairment of consciousness, leading to functional impairment
2
Q
Irreversible causes of dementia
A
- Alzheimer’s disease
- Fronto-temporal dementia
- Pick’s disease
- Dementia with Lewy bodies
- Parkinson’s disease with dementia
- Huntington’s disease
- Infection (HIV, encephalitis, syphilis, CJD)
- Toxins (alcohol, barbiturates, benzodiazepines)
- Vascular (vascular dementia, multi-infarct dementia, CVD)
- Traumatic head injury
3
Q
Reversible causes of dementia
A
- Normal pressure hydrocephalus
- Intracranial tumours
- Chronic subdural haematoma
- Vitamin deficiency (B12, folic acid, thiamine, nicotinic acid)
- Cushing’s syndrome
- Hypothyroidism
4
Q
Most common types of dementia
A
- ) Alzheimer’s disease (50%)
- ) Vascular dementia (25%)
- ) Dementia with Lewy bodies (15%)
- ) Fronto-temporal dementia (<5%)
5
Q
Name 2 types of cortical dementia
A
Alzheimer’s disease
Frontal-temporal dementia
6
Q
Name 1 type of subcortical dementia
A
Dementia with Lewy bodies
7
Q
Name 1 type of mixed dementia
A
Vascular dementia
8
Q
Features of cortical dementia
A
Severe memory loss Normal mood Early aphasia Normal co-ord Apraxia Normal motor speed
9
Q
Features of subcortical dementia
A
Moderate memory loss Low mood Dyasthria Apathetic Impaired co-ord Slow motor speed
10
Q
Risk factors for Alzheimer’s disease
A
- Advancing age
- Family history
- Genetics
- Down’s syndrome
- Low IQ
- Cerebrovascular disease
- Vascular risk factors
11
Q
Genes associated with early onset AD
A
- Presenilin 1 on chromosome 14
- Presenilin 2 on chromosome 2
- Amyloid precursor protein on chromosome 21
12
Q
Genes associated with late onset AD
A
• ApoE-4 on chromosome 19
–> ApoE-2 is thought to be protective
13
Q
ICD-10 classification of dementia
A
A.) Decline in memory (most evident when learning new information)
B.) Decline in other cognitive abilities, characterized by deterioration in judgement and thinking (e.g. planning and organising) and general processing of information
C.) Preserved awareness of the environment for a period of time long enough to demonstrate
D.) Decline in emotional control or motivation, or a change in social behaviour, manifested by 1 of:
• Emotional lability
• Irritability
• Apathy
• Coarsening of social behaviour
E.) A must be present for >6 months
14
Q
Pathophysiology of Alzheimer’s disease
A
- Degeneration of cholinergic neurons in nucleus basalis of Meynert –> deficiency of acetylcholine
- Neurofibrillary tangles (intracellular)
- Beta-amyloid plaques (extracellular)
- Cortical atrophy (hippocampal)
- Widened sulci
- Enlarged ventricles
15
Q
Clinical presentation of AD - early stages
A
- Memory lapses
- Difficulty finding words
- Forgetting names of people/ places
16
Q
Clinical presentation of AD - intermediate stages
A
- Apraxia
- Confusion
- Language problems
- Difficulty with executive thinking
- Agnosia
17
Q
Clinical presentation of AD - later stages
A
- Disorientation to time and place
- Wandering
- Apathy
- Incontinence
- Eating problems
- Depression
- Agitation
18
Q
Classification of AD
A
- Early onset/ pre-senile: <65 years, familial
* Late onset/ senile: >65 years, sporadic
19
Q
Features of AD brain on MRI
A
- Hippocampal atrophy
* Enlarged ventricles
20
Q
ICD-10 criteria for early onset AD
A
- ) General criteria for dementia met
- ) Age of onset <65
- ) At least 1 of:
- Relatively rapid onset and progression
- Aphasia, agraphia, alexia, acalculia or apraxia
21
Q
ICD-10 criteria for late onset AD
A
- ) General criteria for dementia met
- ) Age of onset >65
- ) At least 1 of:
- Slow, gradual onset and progression
- Predominance of memory impairment over intellectual impairment
22
Q
Define Wernicke’s aphasia/ receptor aphasia/ fluent aphasia
A
Inability to comprehend speech
23
Q
Define Broca’s aphasia/ expressive aphasia
A
Inability to produce language
24
Q
Define aphasia
A
Total loss of language
25
Define dysphasia
Partial loss of language
26
Define apraxia
Inability to carry out previously learned purposeful movements e.g. dressing, unbuttoning shirt
27
Examples of executive thinking
Problem solving, abstract thinking, reasoning, decision making, judgement, planning, organizing and processing
28
Define agnosia
Impaired recognition of sensory stimuli e.g. object agnosia/ auditory agnosia
29
Define agraphia
Reduced ability to communicate through writing
30
Define alexia
Reduced ability to read
31
Define acalculia
Reduced ability to perform mathematical tasks
32
Investigations for dementia - routine
Routine:
1. ) Blood tests
- FBC (infection, anaemia)
- CRP (infection, inflammation)
- U&E’s (renal disease)
- Calcium (hypercalcaemia)
- LFT’s (alcoholic liver disease)
- Glucose (hypoglycaemia)
- Vitamin B12 and folate (nutritional deficiencies)
- TFT’s (hypothyroidism)
33
Investigations for dementia - non-routine
1. ) Urine dipstick (UTI)
2. ) Chest x-ray (pneumonia, lung tumour)
3. ) Syphilis serology and HIV testing
4. ) Brain imaging (CT – hippocampal atrophy, MRI – posterior circulation vascular pathology, SPECT)
5. ) ECG (if CVD suspected)
6. ) EEG (Fronto-temporal or CJD)
7. ) Lumbar puncture (meningitis or CJD)
8. ) Genetic testing (Huntington’s disease)
9. ) Cognitive assessment
- MMSE
- AMT
- Addenbrooke’s cognitive examination (ACE)
- GPCOG
- MOCA
34
Indications for brain imaging in dementia
- <60 years
- Sudden decline
- High risk of structural pathology
- Focal CNS signs or symptoms (to rule out space-occupying lesions)
- To monitor disease progression
35
Normal MMSE results
25-30
36
Mild MMSE results
21-24
37
Moderate MMSE results
16-20
38
Moderate-severe MMSE results
10-14
39
Severe MMSE results
<10
40
Frontal lobe tests
1. ) Verbal fluency and initiation
2. ) Cognitive estimates
3. ) Clock drawing test
4. ) Similarities
5. ) Motor sequencing
41
Management of dementia
1. ) Supportive treatment (OT input)
2. ) Environmental control measures (motion sensors for wanderers)
3. ) Contact DVLA
4. ) Advance planning
5. ) Social support (support groups)
6. ) Community dementia team involvement
7. ) Acetylcholinesterase inhibitors (for cognition)
- Donepezil
- Galantamine
- Rivastigmine
8. ) N-methyl-D-aspartate (NMDA) receptor antagonist
- Memantine
- -> For moderate/ severe AD when step 3 has failed or is CI
42
Adjunct therapy for dementia
* Antidepressants
* Antipsychotics
* Management of insomnia (trazadone)
43
Mechanism of action of acetylcholinesterase inhibitors
* Act centrally
| * Compensate for depletion of Acetylcholine in cerebral cortex and hippocampus
44
Side effects of acetylcholinesterase inhibitors
- GI disturbances
- Bradycardia
- Muscle spasms
- Extrapyramidal side effects (rivastigmine)
45
Which acetylcholinesterase inhibitor is commonly associated with extrapyramidal side effects?
Rivastigmine
46
Main clinical features of AD
Memory loss
Word finding difficulties
```
Apraxia
Language problems
Executive thinking problems
Apathy
Wandering
Depression
```
47
Main clinical features of VD
Memory loss
Emotional (depression, apathy), personality changes, confusion
Unilateral spastic weakness of limbs or increased tendon reflexes
Extensor plantar response
Pseudobulbar palsy
UMN signs
CVD
48
Main clinical features of DWL
Recurrent visual hallucinations
```
Parkinsonism
Recurrent falls
Syncope
Depression
Severe sensitivity to neuroleptic drugs
```
49
Main clinical features of Mixed Dementia
Ad + VD (memory loss, word finding difficulties)
50
Main clinical features of Huntington's disease
Abnormal choreiform movements of face, hands and shoulders (repetitive and rapid, jerky involuntary movements)
Gait abnormalities
51
Main clinical features of FTD
Disinhibition (e.g. urinating in living room)
Apathy
FH present in 50% of cases
Worsening of social behaviour
Repetitive behaviour
Language problems
52
Main clinical features of Normal pressure hydrocephalus
Triad of dementia (frontal lobe), urinary incontinence and gait disturbance
53
Main clinical features of CJD
Disintegration of all higher cerebral functions
Pyramidal, extrapyramidal and cerebellar neurological signs
54
Define delirium
Acute, transient, global organic disorder of CND functioning resulting in impaired consciousness and attention.
55
Types of delirium
1. ) Hypoactive (40%)
2. ) Hyperactive (25%)
3. ) Mixed (35%)
56
Define hypoactive delirium
Lethargy, decreased motor activity, apathy, sleepiness
57
Define hyperactive delirium
Agitation, irritability, restlessness, aggression, hallucinations, delusions
58
Aetiology of delirium
HE IS NOT MAAD
• Hypoxia (resp failure, MI, HF, PE)
• Endocrine (hyper/ hypothyroidism, hyper/ hypoglycaemia, Cushing’s)
• Infection (pneumonia, UTI, encephalitis, meningitis)
• Stroke and other intracranial events (stroke, raised ICP, intracranial haemorrhage, space-occupying lesions, head trauma, epilepsy (post-ictal), intracranial infection)
• Nutritional (decreased thiamine, decreased nicotinic acid, decreased B12)
• Others (severe pain, lost glasses/ hearing aids, relocation, sleep deprivation)
• Theatre (post-op) (anaesthetic, opiates)
• Metabolic (hypoxia, electrolyte disturbance (hyponatraemia), hypoglycaemia, hepatic impairment, renal impairment)
• Abdominal (faecal impaction, malnutrition, urinary retention, bladder catheterization)
• Alcohol (intoxication, withdrawal – delirium tremens)
• Drugs (benzodiazepines, opioids, anticholinergics, anti-parkinsonian medications, steroids)
59
Risk factors for delirium
* Older age >65
* Dementia
* Multiple co-morbidities
* Physical frailty
* Renal impairment
* Male
* Sensory impairment
* Previous episodes
* Recent surgery
* Severe illness e.g. CCF
60
ICD-10 criteria for delirium
1. ) Impairment of consciousness and attention
2. ) Global disturbance in cognition
3. ) Psychomotor disturbance
4. ) Disturbance of sleep-wake cycle
5. ) Emotional disturbances
61
Clinical features of delirium
Mnemonic = DELIRIUM
Acute onset + fluctuating course (worse at night)
• Disordered thinking (slowed, irrational, incoherent thoughts)
• Euphoric, fearful, depressed or angry
• Language impairment (rambling, repetitive, disruptive)
• Illusions, delusions (persecutory or misidentification) and hallucinations (tactile or visual)
• Reversal of sleep-wake pattern (tired during day and hyper-vigilant at night)
• Inattention (inability to focus, clouding of consciousness)
• Unaware/ disoriented (time, place or person)
• Memory deficits
62
Investigations for delirium
1. ) Urinalysis (UTI)
2. ) FBC (infection)
3. ) U&E’s (electrolyte disturbance)
4. ) LFT’s (alcohol, liver disease)
5. ) Calcium (hypercalcaemia)
6. ) Glucose (hypo or hyperglycaemia)
7. ) CRP (infection/ inflammation)
8. ) TFT’s (hyperthyroidism)
9. ) B12, folate, ferritin (deficiencies)
10. ) ECG (ACS, cardiac abnormalities)
11. ) CXR (chest infection)
12. ) Infection screen – blood culture (sepsis) and urine culture (UTI)
13. ) ABG (hypoxia)
14. ) CT head (head injury, intracranial bleed, CVA)
15. ) Lumbar puncture (meningitis)
16. ) EEG (epilepsy)
17. ) Diagnostic questionnaire (diagnosing + monitoring)
- Abbreviated mental test (AMT)
- Confusion assessment method (CAM)
- Mini-mental state examination (MMSE)
63
Confusion assessment method (CAM) tool
1. ) Acute onset and fluctuating course
2. ) Inattention
3. ) Disorganized thinking
4. ) Alteration in consciousness
--> for cognitive impairment, must have 1 + 2 + 3 or 4
64
Abbreviated mental test (AMT) score which would indicate likely cognitive impairment
<8
65
Management of delirium
1. ) Treat underlying cause
2. ) Reassurance and re-orientation
3. ) Provide appropriate environment
- Appropriately lit
- Consistency in care and staff
- Optimize sensory acuity (glasses, clock, calendar)
4. ) Manage disturbed, violent or distressed behaviour
- Oral low dose haloperidol or olanzapine
- Avoid benzodiazepines
- Referral to COTE consultant
66
Define fall
Event that results in a person non-intentionally coming to rest at a lower level
67
Factors influencing frequency of falls - intrinsic
- Maintaining balance
- Muscle strength
- Stable but flexible joints
- Proprioception
- Vision/ eyesight
- Functional peripheral and CNS
68
Factors influencing frequency of falls - extrinsic
- Lighting
- Obstacles
- Presence of grab rails
- Height of steps
- Softness of floor
69
Factors influencing frequency of falls - acute stressors
- Transient dizziness
| - Gust of wind/ nudged
70
Factors influencing severity of fall
* Osteoporosis + increased fracture rates
* Secondary injury (pressure sores, burns, dehydration, hypostatic pneumonia)
* Psychological adverse effects
71
Drugs a/w falls
* Polypharmacy (>4 drugs, any type)
* Benzodiazepines
* Antidepressants
* Antipsychotics
* Opiates
* Diuretics
* Antihypertensives (ACE-inhibitors and alpha blockers)
* Antiarrhythmics
* Anticonvulsants
* Skeletal muscle relaxants (baclofen, tizanidine)
* Hypoglycaemics (glibenclamide, insulin)
72
Adverse drug effects a/w falls
Psychoactive, systemic hypotension, cerebral hypoperfusion
73
Investigations for falls
1. ) Bloods
- FBC
- B12, folate
- Vitamin D (common deficiency that when rectified, reduces chance of falls)
- U, C + E
- Glucose
- Calcium
- Phosphate
- TFT
2. ) ECG
3. ) 24-hour ECG
4. ) Echocardiogram
5. ) Head-up table testing (HUTT) for unexplained syncope, normal resting ECG and no structural heart disease)
74
Measures to reduce fall frequency
1. ) Drug review
2. ) Treat orthostatic hypotension
3. ) Strength and balance training
4. ) Walking aids
5. ) Environmental assessment and modification
6. ) Vision – ensure appropriate glasses
7. ) Reduce stressors
75
Measures to reduce adverse consequences of falls
1. ) Osteoporosis detection and treatment
2. ) Teach patients how to get up (physio)
3. ) Alarms (pull cords in rooms, city wide alarms)
4. ) Supervision
5. ) Change of accommodation
76
Measures to prevent falls in hospital
1. ) Treat infection, dehydration and delirium
2. ) Stop incriminated drugs
3. ) Provide good quality footwear and walking aid
4. ) Provide good lighting and bedside commode
5. ) Keep a call bell close to hand
77
General causes of falls
1. ) Syncope/ presyncope
2. ) Balance and disequilibrium
3. ) Dizziness
4. ) Drop attacks
5. ) Orthostatic (postural) hypotension
6. ) Postprandial hypotension
7. ) Carotid sinus syndrome
78
The 3 components of balance
1. ) Input
2. ) Assimilation
3. ) Output
79
Mechanism of balance - input
```
• Peripheral input
- Peripheral nerves --> proprioception
- Mechanoreceptors in joints
--> this information is relayed via POSTERIOR COLUMN of spinal cord to the CNS
• Eyes
- Visual cues
• Ears
- Otolithic organs (utricle and saccule) --> static head position
- Semi-circular canals --> head movement
- Auditory cues
```
80
Mechanism of balance - assimilation
Information Is gathered and assessed in the BRAIN STEM and CEREBELLUM
81
Mechanism of balance - output
• Eyes
- Steady gaze during head movements (vestibulo-ocular reflex)
• Cortex and cord
- Controls postural (antigravity) muscles
82
Disorders that may cause disequilibrium
1. ) Neuropathy (peripheral nerves)
2. ) Decreased visual acuity
3. ) Cataracts/ glaucoma
4. ) Decreased hearing
5. ) Reduced vestibular function
6. ) Degenerative joint disease (arthritis)
7. ) Slowing of CNS processing
8. ) Weak postural muscles (inactivity, disease, medication)
83
Management of disequilibrium
1. ) Optimize function of each system
2. ) Review medication
3. ) Treat underlying conditions
4. ) Work on prevention
- Alter environment e.g. improve lighting
- Develop safer ways to mobilize, increase strength, stamina and balance (physio)
5. ) Persistent falls --> refer to falls clinic
84
Define dizziness
When the brain is unable to know where it is in space generates a sensation of dizziness
85
Define vertigo
The hallucination of rotatory motion either of the patient with respect to the environment or the environment with respect to the patient.
86
Aetiology of dizziness
1. ) Benign paroxysmal positional vertigo
2. ) Labyrinthitis
3. ) Posterior circulation stroke
4. ) Orthostatic hypotension
5. ) Carotid sinus hypersensitivity
6. ) Vertebrobasilar insufficiency
7. ) Cervical spondylosis
8. ) Anxiety and depression
87
Define drop attack
Fall with no prodrome, no loss of consciousness and rapid recovery
88
Aetiology of drop attacks
1. ) Cardiac arrythmia
2. ) Carotid sinus syndrome
3. ) Orthostatic hypotension
4. ) Vasovagal syndrome
5. ) Vertebrobasilar insufficiency
6. ) Weak legs (e.g. cauda equina syndrome)
89
Define vertebrobasilar insufficiency (VBI)
Collection of symptoms caused by transient compromise of the vertebrobasilar circulation.
90
Clinical presentation of vertebrobasilar insufficiency (VBI)
* Abrupt onset, recurrent dizziness or vertigo
* N+V
* Ataxia
* Visual disruption (diplopia, nystagmus)
* Dysarthria
* Limb paraesthesia
91
Aetiology of vertebrobasilar insufficiency (VBI)
* Atherosclerosis of vertebral or basilar arteries
* Vertebral artery compression by cervical spine osteophytes
* Obstructing tumour
92
Diagnosing VBI
1. ) Mainly history
2. ) Cervical spine X-ray
3. ) CT brain
4. ) MR angiography
93
Treatment for VBI
1. ) Vascular secondary prevention measures
2. ) Vessel stenting
3. ) Limiting neck movements
4. ) Soft collars
94
Define orthostatic (postural) hypotension
Fall in BP of >20mmHg systolic or >10mmHg diastolic on standing from supine.
95
Precipitating factors for postural hypotension
* During exercise
* At night-time
* After meals
* In a warm environment
* When coughing
* Post-defecation
* Post-micturition
96
Aetiology of postural hypotension
1. ) Drugs (vasodilators, diuretics, negative inotropes, negative chronotropes, antidepressants, antipsychotics, opiates, levodopa, alcohol)
2. ) Chronic hypertension (reduces baroreflex sensitivity and LV compliance)
3. ) Volume depletion (dehydration, acute haemorrhage)
4. ) Sepsis (vasodilation)
5. ) Autonomic failure (diabetic, Parkinson’s disease)
6. ) Prolonged bed rest
7. ) Adrenal insufficiency
8. ) Raised intrathoracic pressure
97
Treatment of postural hypotension
1. ) Treat cause
2. ) Stop, reduce or substitute drugs incrementally
3. ) Reduce consequences of falls
4. ) Modify behaviour (stand slowly and stepwise, lie at prodrome)
5. ) Supplement with IV fluids
6. ) Consider starting fludrocortisone, alpha blockers or desmopressin if above fails
7. ) Full length compression stockings
8. ) Head-up tilt to bed
9. ) Caffeine or NSAIDs
10. ) Erythropoietin or octreotide
98
Define postprandial hypotension
Fall in BP of >20mmHg within 75 minutes of meals
99
Investigation for postprandial hypotension
1. ) Measure BP before meals
2. ) Measure BP 30 mins post-meal
3. ) Measure BP 60 mins post-meal
100
Treatment for postprandial hypotension
1. ) Avoid hypotensive drugs and alcohol with meals
2. ) Lie down or sit after meals
3. ) Reduce osmotic load of meals (small, frequent meals, low simple carbs, high fibre/ water content)
101
Define carotid sinus syndrome (CSS)
Episodic, symptomatic bradycardia +/or hypotension due to a hypersensitive carotid baroreceptor reflex, resulting in syncope or near syncope.
102
Precipitating factors for CSS
* Neck turning
* Tight collars
* Straining (coughing, micturition, defecation)
* Meals (post-prandial)
* Prolonged standing
103
Subtypes of CSS
1. ) Cardioinhibitory (sinus pause of >3 seconds)
2. ) Vasodepressor (BP fall >50mmHg)
3. ) Mixed
104
Diagnosing CSS
All 3 of the factors below must be present:
1. ) Unexplained attributable symptoms
2. ) Sinus pause of >3 seconds OR systolic BP fall of >50mmHG in response to 5 seconds of carotid sinus massage
3. ) Symptoms are reproduced by carotid sinus massage
105
Treatment of CSS
1. ) Stop aggravating drugs where possible
2. ) AV sequential pacing for cardioinhibitory CSS
3. ) Increase circulating volume with fludrocortisone or midodrine (for vasodepressor CSS)
106
Components of falls clinic
1. ) Focuses on identifying and reducing syncope by performing:
- Medication review
- Tilt table testing
- Arrythmia detection (ECG/ pulse)
2. ) More in-depth cardiovascular evaluation
107
Staff involved in falls clinic
* Nurses
* Occupational therapists
* Physiotherapists
108
Falls clinic referral criteria
* Recurrent falls (>2)
* Loss of consciousness, syncope or near syncope
* Injury e.g. fracture/ facial injury
* Polypharmacy (>4 drugs)
109
Define frailty
Reduced physiological reserve resulting in adverse outcomes following minor stressor events e.g. infection, fall or change in environment.
110
2 types of classification of frailty
1. ) Phenotype (Fried)
| 2. ) Cumulative deficit (e-FI, CFS)
111
Main risk factor for frailty
Age
112
Fried criteria for classifying frailty
```
Frailty defined as >3 of:
• Unintentional weight loss
• Self-reported exhaustion
• Weakness
• Slow walking speed
• Low physical activity
```
Pre-frail = 2 or less
113
Outcome of being classified as 'frail'
Increased incidence of falls, worsening mobility or ADL disability, hospitalisation and death.
114
e-FI (electronic frailty index)
Uses existing information within the electronic primary health care record to identify populations of people aged >65 who may be living with varying degrees of frailty
115
Define polypharmacy
Use of multiple medications (usually >5)
116
Risks of polypharmacy
* More chance of drug interactions
* Increased frequency of drug interactions
* These interactions may increase or decrease effectiveness of one drug
117
Aetiology of polypharmacy
* Multiple people involved in care
* Older people often have multiple conditions requiring medication
* Inappropriate medication reconciliation upon discharge from hospital
118
Components of mental capacity
1. ) Understand information given to them
2. ) Retain this information
3. ) Weigh up this information
4. ) Communicate their decision
119
Pathology of urinary incontinence
* Reduced bladder capacity
* Increased residual volume
* Diminished bladder contractile function
* Reduced ability to postpone voiding
* Increased frequency of uninhibited bladder contractions
* Atrophy of vagina and urethra
* Loss of pelvic floor and urethral sphincter musculature
* Hypertrophy of prostate
120
How comorbidity can precipitate urinary incontinence
* Reduced mobility
* Medications affecting urinary tract, conscious state (sedatives) or ability to get to the toilet promptly (antihypertensives causing postural drop)
* Increased constipation
* Impaired cognition
121
Reversible causes of urinary incontinence
* UTI
* Delirium
* Drugs (diuretics)
* Constipation
* Polyuria
* Urethral irritability
* Prolapse
* Bladder stones and tumours
122
Irreversible (but treatable) causes of urinary incontinence
• BPH
• Overactive bladder syndrome
• Stress incontinence
Fistula between bladder and vagina
123
Urgency symptoms of urinary incontinence
* Frequent (>8 times/day)
* Strong urge
* Decreased time to reach toilet
124
Stress symptoms of urinary incontinence
• Small volume leaks during coughing/ laughing/ lifting/ exercise
125
Obstructive symptoms of urinary incontinence
* Poor stream
* Hesitancy
* Intermittent flow
126
Investigations for urinary incontinence
1. ) Establish symptoms:
- Urgency
- Stress symptoms
- Obstructive symptoms
2. ) Bladder diary
3. ) Vaginal, rectal and neurological examination
4. ) Urinalysis and midstream urine
5. ) Blood tests
6. ) Cytology and cystoscopy if haematuria present
7. ) Urodynamics if incontinence cannot be explained/ not responding to treatment
127
Normal residual volume - young people
1-3mL of urine post-micturition
128
Normal residual volume - elderly people
Up to 100mL
129
Aetiology of raised residual volume
* BPH, carcinoma
* Urethral stricture
* Bladder diverticulum
* Large urinary cystocele
* Pelvic organ prolapses
* Hypocontractile detrusor
* Neurological disease (MS, Parkinson’s, spinal cord, disc disease, disc herniation)
* Bladder tumour
* Drugs e.g. tricyclic antidepressants, anticholinergics
130
Management of urinary incontinence
1.) Bladder retraining (gradually increasing time between voiding)
2.) Regular toileting (going toilet every 2-4 hours)
3.) Pelvic floor exercises
4.) Bladder stabilizing drugs (anticholinergics a.k.a. antimuscarinics)
- Tolterodine
- Solifenacin
- Trospium chloride
- Oxybutynin
5.) Surgery
Female:
- Tension-free vaginal tape (TVT)
- Colo suspension
Male:
- TURP for outflow tract obstruction
6.) Anti-androgens (for BPH)
- Finasteride
7.) Alpha blockers
- Doxazosin
- Tamsulosin
8.) Double micturition (patient repeats voiding)
9.) Intermittent catheterization
10.) Synthetic vasopressin (for nocturnal frequency)
131
Indications for catheter
* Symptomatic urinary retention
* Obstructing outflow a/w deteriorating renal function/ hydronephrosis
* AKI for output monitoring
* Intensive care
* Sacral pressure sore with incontinence
132
Choosing a catheter
* Long-term catheters should be silicone, silastic or silver-impregnated
* Catheter size should be as small as possible
* Should be changed at least every 3 months
* Can use catheter valve instead of a drainage bag
* If duration is likely to be >1 year, consider suprapubic placement
133
Complications a/w catheter
1. ) Blocked catheter
2. ) Bypassing (leakage of urine past catheter)
3. ) Catheter infection
- -> All catheters become colonized after a few days and therefore all catheter urine will dipstick positive
134
Indications for treating catheter infection with antibiotics
- Fever
- Malaise
- Delirium
- Pain
- Abnormal inflammatory markers
135
Risk associated with treating catheter infection with antibiotics
Promotion of resistant organisms
136
Define faecal incontinence
Involuntary passage of faeces in inappropriate circumstances
137
4 components of maintaining normal faecal continence
1. ) Sigmo-rectal sphincter
2. ) Ano-rectal angle
3. ) Anal sphincters
4. ) Ano-rectal sensation
138
Role of sigmo-rectal sphincter
* Rectum is usually empty
| * Faces into rectum --> initiates rectal contraction and anal relaxation
139
Role of ano-rectal angle
• The pubo-rectalis sling maintains an acute angle between rectum and anus --> prevents passage of stool into anal canal
140
Role of anal sphincters
* External sphincter = striated, voluntary muscle
| * Internal sphincter = smooth muscle
141
Role of ano-rectal sensation
• Sensation in the anus and rectum is usually sensitive enough to distinguish between gas and faeces
142
Aetiology of faecal incontinence
```
• Faecal impaction (most common)
• Disorders of anal sphincter and lower rectum
- Sphincter laxity
- Severe haemorrhoids
- Rectal prolapse
- Tumours
- Constipation
• Faecal urgency
• Constipation
• Diarrhoea
• Disorders of neurological control of ano-rectal muscle and sphincter (e.g. LMN lesions, spinal cord lesions, cognitive impairment)
```
143
Clinical features of constipation
* Not being able to open bowels
* Feeling of rectal fullness
* Constant seepage of semi-liquid faeces suggests impaction
* Soiling without being aware suggests neuropathy
144
Examinations for constipation
* Inspect anus
* Rectal examination
* Abdominal and neurological examination
145
Investigations for constipation
* Abdominal x-ray
| * Investigation of anal sphincter tone and neurological control of rectum and anus
146
Pathophysiology of faecal impaction
1. ) Faeces passes from sigmoid
2. ) Produces sensation of rectal fullness and desire to defecate (gastro-colic reflex)
3. ) If ignored, sensation gradually habituates, and rectum fills up with progressively harder faeces.
4. ) Incontinence past anal sphincter is likely
5. ) Impaction of hard faecal material causes partial obstruction, stasis, irritation of mucosa with excessive mucus production and spurious diarrhoea
6. ) Emptying colon normally prevents spurious diarrhoea, urgency and permits normal colonic motility and habit to be restored
147
Treatment options for neurogenic faecal incontinence
1. ) Toilet at appropriate times (+/- suppository) if patients have a regular habit
2. ) Arrange for planned evacuation by administering a constipating agent e.g. loperamide + phosphate enema 2-3 times weekly
3. ) Provide suitable protective clothing if both of the above are not appropriate/ fail
148
Treatment options for overflow faecal incontinence
1. ) Rehydration, regular meals, help with toileting
2. ) Phosphate enema administered 1 or 2 times a day until rectum is empty
3. ) Complete colonic washout (using bowel prep e.g. Picolax)
4. ) Manual evacuation of faeces
5. ) Laxatives
- Softening laxative = lactulose
- Stimulant laxative = senna
6. ) Extra fibre in diet for prophylaxis
149
Clinical presentation of acute urinary retention
* Inability to urinate
* Pain, often severe, in lower abdomen
* Urgent need to urinate
* Swelling of lower abdomen
150
Clinical presentation of chronic urinary retention
* Inability to completely empty bladder
* Frequent urination in small amounts
* Difficulty starting the flow of urine – hesitancy
* Poor stream
* Urgent need to urinate but with little success
* Feeling the need to urinate after finishing urination
* Leaking urine without any warning or urge
* Lower abdominal pain or discomfort
151
Pathology of urinary retention
1. ) Blockage, preventing urine from leaving bladder or urethra
2. ) Bladder not strong enough to expel all of the urine
152
Aetiology of blockage of urine flow
* Enlarged prostate
* BPH
* Urethral stricture
* Scar tissue in bladder neck
* Pelvic organ prolapse – cystocele and rectocele
* Renal calculi
* Constipation
* Pelvic mass
* Tight pelvic floor muscles
* Infections – UTI, STI, prostatitis
* Trauma to pelvis, urethra or penis
153
Aetiology of underachieve bladder
1. ) Neurological problems
- MS
- Parkinson's
- AD
- Stroke
2. ) Drugs
- alpha-adrenergic agonists
- anticholinergics
3. ) Surgery
4. ) Weak bladder muscles
- Age
- Pregnancy
154
Treatment of urinary retention
```
• Catheter
• 5-alpha reductase inhibitors
- E.g. finasteride
- For BPH
• Alpha-blockers
- E.g. tamsulosin, doxazosin
- For BPH
• Antibiotics for infection
• Cystoscopy
• Laser therapy
• Vaginal pessary
• Surgery
```
155
Define osteoporosis
Reduction in bone bass and disruption of bone architecture, resulting in increased bone fragility and fracture risk
156
Pathology of osteoporosis
Resorption (bone breakdown by osteoclasts) > deposition (bone formation by osteoblasts)
157
Risk factors for increased bone loss
* Menopause
* Smoking
* Alcohol
* Low BMI
* Hyperthyroidism
* Hyperparathyroidism
* Hypoandrogenism (men)
* Kidney failure
* Immobility
* Steroids
* Phenytoin
* Long-term heparin
* Ciclosporin
158
Clinical presentation of osteoporosis
‘Osteoporosis’ is asymptomatic --> it’s the FRACTURES that cause the problem.
• Wrist fracture
• Femoral neck fracture
• Crush fracture of vertebral body
• Wedging of vertebrae (progressive kyphosis – Dowager’s hump)
159
Diagnosing osteoporosis
1. ) Bloods (calcium, phosphate and ALP should be normal)
- If calcium or ALP raised, consider metastases or Paget’s disease
2. ) X-ray
3. ) DEXA scan – measures bone density (gold-standard)
- -> T-score: average (young adult mean value)
- -> Z score: accounts for age/ sex/ weight
160
Normal T score
> -1 SD
161
Osteopenia T score
-2.5 SD - -1 SD
162
Osteoporosis T score
< -2/5 SD
163
Severe osteoporosis T score
< -2/5 SD + fracture
164
Primary prevention of osteoporosis
* Diet
* Exercise
* Stop smoking
* Reduce alcohol
* For steroid users, prophylactic bisphosphonate should be given
165
Management of osteoporosis
1. ) Oral calcium and vitamin D
2. ) First line = bisphosphonates e.g. Alendronate
3. ) Second line = strontium ranelate (S/E diarrhoea, vomiting and VTE)
4. ) Third line = teriparatide
166
Management of non-operative fractures
1. ) Control pain
- Heat
- TENS
- Calcitonin
- Vertebroplasty
- Short course of NSAIDs
2. ) Encourage mobility and independence
3. ) Consider mechanism of fall and reduce risk of this reoccurring
4. ) Consider prophylactic heparin
5. ) Consider osteoporosis treatment
6. ) Maintain contact with orthopaedic colleagues
- Advise on when to replace/ remove plasters, how much exercise and what type of exercise to do etc.
167
Normal capillary pressure
24-35 mmHg
168
Define pressure sore
Skin necrosis due to pressure-induced ischaemia
169
Common locations of pressure sores
* Sacrum
* Heels
* Over greater trochanters
* Shoulders
170
Grading of pressure sores - 0
Skin hyperaemia
171
Grading of pressure sores - I
Non-blanching erythema
172
Grading of pressure sores - II
Broken skin or blistering (epidermis +/- dermis only)
173
Grading of pressure sores - III
Ulcer down to subcutaneous fat
174
Grading of pressure sores - IV
Ulcer down to bone, tendon or joint
175
Risk factors for developing a pressure sore
* Age
* Immobility (esp. postoperative)
* Extremes of BMI
* Malnutrition
* Dehydration
* Incontinence
* Neurological damage
* Sedative drugs
* Vascular impairment
176
Score used to assess patient's risk of pressure sores
Waterlow score
177
Pathophysiology of pressure sores
2 hours of tissue ischaemia --> development of an ulcer
Mechanisms:
1.) Pressure >35mmHg -> compress and cause ischaemia (heels common)
2.) Shear -> skin pulled away from fixed axial skeleton -> capillaries can be kinked or torn (sacrum common)
3.) Friction -> rubbing skin decreases integrity -> crumbs in bed, drip sets and debris between patient and sheets (elbows and heels common)
4.) Moisture -> sweat, urine and faeces cause maceration and decrease skin integrity
178
Management of pressure sores
1. ) Prevention
2. ) Turning and handling (e.g. 2-hourly turns)
3. ) Pressure-reliving devices
4. ) Promote healing environment
- Nutrition
- Manage incontinence
- Good glycaemia control for DM patients
- Correct anaemia
5. ) Debridement (dead tissue removed with scalpel)
6. ) Dressings
7. ) Swab ulcer and prescribe antibiotics
- -> consider osteomyelitis if bone is exposed
179
Microorganisms commonly found in pressure ulcers
* Bacteroides (gram –‘ve)
* Enterococci and staphylococci e.g. MRSA (gram +’ve)
* Yeasts
180
Define compression mononeuropathy
Nerves are compressed against bone and become damaged
181
Pathophysiology of compression mononeuropathy
Nerve compressed against bone --> demyelination injury (neuropraxia) --> resolves spontaneously within 2-12 weeks
182
Risk factors for compression mononeuropathy
* Alcohol
* Diabetes
* Malnutrition
* Period of immobility on a hard surface
183
Common site of radial nerve compression
Upper arm/ armpit
184
Common site of ulnar nerve compression
Elbow
185
Common site of common peroneal nerve compression
Knee
186
Common site of sciatic nerve compression
Buttock/ thigh
187
Clinical presentation of radial nerve compression
Motor: Wrist drop
Finger extension weakness
Sensory: Small area of numbness at base of thumb
188
Clinical presentation of ulnar nerve compression
Motor: Little and ring finger flexors and finger abduction and adduction
Sensory: Little and ring finger
189
Clinical presentation of common peroneal nerve compression
Motor: Foot drop
Failure of foot eversion and toe extension
Sensory: Lateral calf and top of foot
190
Clinical presentation of sciatic nerve compression
Motor: Knee flexors + peroneal signs
Sensory: Posterior thigh plus peroneal signs
191
Define rhabdomyolysis
Prolonged pressure (e.g. post-fall) --> muscle necrosis --> releases myoglobin
High levels of myoglobin = nephrotoxic --> tubule obstruction with acute renal failure
192
Diagnosing rhabdomyolysis
CK levels at least 5x normal
May also have:
• Coca-Cola urine, hyperkalaemia, hypocalcaemia or acute pressure sores
193
Management of rhabdomyolysis
1. ) Aggressive rehydration
2. ) Monitor urine output and U&E’s
3. ) Review medication (statins)
Medicine Phase 3a
flashcards
Decks in class (18)
# Cards
-
OBSTETRICS - 1311
-
GYNAECOLOGY - 1289
-
PSYCHIATRY - 1197
-
PSYCHIATRY - 2259
-
PSYCHIATRY - 3152
-
NEUROLOGY - 1a225
-
NEUROLOGY - 1b37
-
NEUROLOGY - 2172
-
PAEDIATRICS - 1225
-
PAEDIATRICS - 2196
-
PAEDIATRICS - 3149
-
PAEDIATRICS - 4165
-
PAEDIATRICS - 5103
-
PAEDIATRICS - 6231
-
GERIATRICS - 1193
-
NEUROLOGY - anatomy and physiology82
-
OBSTETRICS - anatomy and physiology66
-
GYNAECOLOGY - anatomy and physiology99
