Geriatrics

Question 1

The maintenance dose of digoxin is often lower in 80yo cf 40 yo - which age-related change is responsible for this difference?

Answer 1

Decreased renal clearance

Question 2

What is frailty?

Answer 2

A state of vulnerability due to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime

Phenotype
3 or more of:
- unintentional weight loss
- self-reported exhaustion
- low energy expenditure
- slow gait speed
- weak grip strength

Frailty index
- tipping point of 0.67

Question 3

Which treatment has the best evidence for managing frailty in elderly men?

Answer 3

Physical activity

Question 4

What is the most effective intervention to reduce the risk of falling in community-dwelling older persons?

Answer 4

Exercise programs

Question 5

What is the most effective intervention to reduce the risk of falling in hospitalised older persons?

Answer 5

Multifactorial interventions (maybe but evidence not strong)

Question 6

Which class of medications is most consistently assoc with falls?

Answer 6

Benzodiazepines

Question 7

What are the 4 criteria in the Confusion Assessment Method (CAM) for delirium?

Answer 7

Acute and fluctuating course
Inattention
Disorganised thinking
Altered level of consciousness

Question 8

What is the most likely precipitating factor for delirium in older people?

Answer 8

Infection

Question 9

What is Mild Cognitive Impairment (or Minor neurocognitive disorder)?

Answer 9

Varied group with cognitive changes (eg memory) that exceed what is expected for an individual at a particular age but have NO social or functional impairment in ADLs or iADLs

Question 10

What is the best predictor of conversion of mild cognitive impairment to dementia?

Answer 10

Abnormal neuropsych testing - (the greater severity and range of deficits the greater the risk; esp poor memory)

Age also key factor

Imaging/biomarkers not yet validated/shown consistent results

Question 11

What tx reduces the risk of progression of MCI to Alzheimer’s

Answer 11

Nil - we don’t have a anti-progression treatment

Question 12

Neurofibrillary tangles are typically seen in what type of dementia?

Answer 12

Alzheimer’s disease

Question 13

What is the benefit of ACh inhibitors in mild-mod dementia?

Answer 13

Improvement in neurocognitive function (MMSE increased by ~2 or slowed decline)

Question 14

What is the role of Aducanumab and Lecanemab in Alzheimers?

Answer 14

Both are human monoclonal antibodies directed at soluble amyloid beta or soluble protofibrils

Studies show strong biological efficacy (ie reduced amyloid burden on PET by 60-80%) but only modest clinical benefits (ie may slow decline in cognition in some px) and expensive + treatment regimens involved and only 5-20% of px in real world would be eligible

Risk of infusion reactions and amyloid-related imaging abnormalities (ARIA-E (edema/effusions) and ARIA-H (haemorrhagea)

Question 15

What is the pathology of Frontotemporal dementia?

Answer 15

Heterogenous

Tau
TDP-43
Other proteins

Question 16

What are the subtypes of frontotemporal dementia?

Answer 16

Behavioural variant
Primary progressive Aphasia - semantic
Primary progressive aphasia - non-fluent
Logopaenic variant (AD aetiology that mimics FTD)

Question 17

What are the key features of behavioural variant FTD (bvFTD)?

Answer 17

Most common FTD
Character change
Breakdown in social behaviour (eg disinhibited or apathetic)
Loss of empathy
Neglect self-care
Repetitive behaviours
Dietary change - gluttonous/sweet food preference
Frontal features eg impulsive, poor judgement

50% due to Tau, 50% due to TDP-43

Assoc with MND in 15-20%

Question 18

What are the key features of Primary Progressive Aphasia (Semantic)?

Answer 18

Difficulty remembering words or using wrong words
Asking what words mean
Prominent naming disorder
Impaired word comprehension
Difficulty recognising faces and things
Narrowed behavioural repertoire

But intact, fluent speech
Preserved perception and spatial skills/tasks
Good autobiographical memory

Usually physically well, rare MND
TDP-43 - ~100%

Question 19

What are the key features of Primary Progressive Aphasia (non-fluent)?

Answer 19

Difficulty in expressing language
anomia
agrammatism
apraxia of speech
memory problems are limited to verbal memory (remembering what they were told)
limb apraxia
usually physically well with high degree of functional independence
Occ asymmetric limb rigidity, rarely MND

Tau 70%, TDP-43 30%

Question 20

Which clinical feature may make you suspect DLB rather than AD?

Answer 20

Visual hallucinations

Question 21

What is the pathology in DLB?

Answer 21

Synucleinopathy

Eosinophilic intracytoplasmic inclusions containing alpha-synuclein in deep cortex (esp anterior frontal, temporal lobes, cingulate gyrus and insula)

Question 22

What are the key clinical features of DLB?

Answer 22

Dementia with attentional, visuospatial and executive dysfunction
Cognitive fluctuation
Visual hallucinations
REM sleep disorder (often predates rest)
Parkinsonism
Sensitivity to antipsychotic medication

Question 23

What biomarkers may fit with DLB?

Answer 23

Reduced basal ganglia dopamine in DaT SPECT scan

REM sleep without atonia on sleep study

Question 24

What drugs may cause urinary incontinence?

Answer 24

Alpha blockers eg prazosin, labetalol
Caffeine
Alcohol
Diuretics
Sedatives
Acetycholinesterase inhibitors eg donepezil
Anticholinergics eg TCAs, antihistamines
Antipsychotic meds
CCB
SSRI

Question 25

How does mirabegron work?

Answer 25

beta-3 adrenoreceptor agonist - relaxes bladder muscle during the storage phase of micturition, increasing bladder capacity

Question 26

What are the contraindications to Mirabegron treatment?

Answer 26

Severe / uncontrolled HTN Renal impairment eGFR <30 CYP3A4 inhibitors esp if moderate hepatic or renal impairment

Question 27

What are the main side effects of Mirabegron?

Answer 27

Hypertension Nasopharyngitis UTI Less commonly headache, tachycardia, rash, urticaria, angioedema, leukocytoclastic vasculitis

Question 28

What are the advantages or disadvantages of Mirabegron for urinary incontinence?

Answer 28

Adv Should have less cholinergic / cognitive effects cf oxybutynin or solifenacin Disadvantages Cost, not PBS-subsidised so ~$75per month HTN

Question 29

What is the hallmark of Primary Progressive Aphasia?

Answer 29

Early and progressive language disturbance leading to functional impairment with relatively preserved memory and other neurocognitive function

Question 30

Primary Progressive Aphasia implies neuro degeneration in which part of the brain?

Answer 30

The language-dominant hemisphere E.g. Speech apraxia = left inferior frontal gyrus and posterior fronto-insula.

Question 31

What feature distinguishes non-fluent aphasia from the other two forms of PPA?

Answer 31

Difficulty articulating speech - speech is often effortful and halting with inconsistent speech-sound errors, distortions and incorrect grammar Can test at bedside by asking patient to say caterpillar repeatedly

Question 32

What distinguishes logopaenic variant of PPA from other subtypes?

Answer 32

Firstly is assoc with AD not FTD Secondly, deficits tend to involve impaired single-word retrieval and repetition with errors in speech and naming, but with spared single-word comprehension and object knowledge, spared motor speech, and absence of agrammatism. Whilst speech may be slow, unlike nonfluent PPA it is due to word-finding pauses rather than difficulties with articulation or speech apraxia