1
Q
What is another name for acute confusional state?
A
Delirium or acute organic brain syndrome
2
Q
What percentage of elderly patients admitted to hospital may be affected by acute confusional state?
A
Up to 30%
3
Q
List three predisposing factors for acute confusional state.
A
- Age > 65 years
- Background of dementia
- Significant injury (e.g., hip fracture)
4
Q
What are the precipitating events for acute confusional state?
A
- Infection (particularly urinary tract infections)
- Metabolic issues (e.g., hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration)
- Change of environment
- Significant cardiovascular, respiratory, neurological or endocrine condition
- Severe pain
- Alcohol withdrawal
- Constipation
5
Q
What are common features of acute confusional state?
A
- Memory disturbances (loss of short term > long term)
- Agitation or withdrawal
- Disorientation
- Mood change
- Visual hallucinations
- Disturbed sleep cycle
- Poor attention
6
Q
What is the first step in managing acute confusional state?
A
Treatment of the underlying cause
7
Q
What modification may be necessary in the environment for managing acute confusional state?
A
Modification of the environment
8
Q
What is the first-line pharmacological treatment for acute confusional state if no Parkinson’s disease is present?
A
Haloperidol 0.5 mg
9
Q
According to the 2010 NICE delirium guidelines, which medications are recommended?
A
- Haloperidol
- Olanzapine
10
Q
What is the preferred treatment for patients with Parkinson’s disease experiencing acute confusional state?
A
Lorazepam or an atypical antipsychotic (e.g., quetiapine, clozapine)
11
Q
What should be noted regarding the use of olanzapine for delirium?
A
Olanzapine is no longer recommended for delirium
12
Q
Fill in the blank: Acute confusional state may present with _______ disturbances.
A
memory
13
Q
True or False: Acute confusional state can only be caused by a single precipitating event.
A
False
14
Q
List two metabolic issues that can precipitate acute confusional state.
A
- Hypercalcaemia
- Hypoglycaemia
15
Q
What is a common mood change feature in acute confusional state?
A
Mood change
16
Q
What is a potential effect of polypharmacy in elderly patients regarding acute confusional state?
A
Increased risk of developing acute confusional state
17
Q
What is multimorbidity?
A
The presence of two or more long-term health conditions.
18
Q
What are some examples of long-term health conditions included in multimorbidity?
A
- Defined physical or mental health conditions
- Learning disabilities
- Symptom complexes such as chronic pain
- Sensory impairments
- Alcohol or substance misuse
19
Q
What was the estimated prevalence of multimorbidity in a cohort of 403,985 adults?
A
27.2%.
20
Q
Is the prevalence of multimorbidity higher in males or females?
A
Higher in females.
21
Q
In which age group is combined mental and physical comorbidity more common?
A
Younger adults.
22
Q
What socioeconomic factor is associated with multimorbidity?
A
Socioeconomic deprivation, particularly with mental health disorders.
23
Q
What is the most prevalent disorder that exists comorbidly with other disorders?
A
Hypertension.
24
Q
What are the most common mental health disorders that exist comorbidly with other conditions?
A
- Depression
- Anxiety
25
What are some other conditions found in multimorbidity?
* Chronic pain
* Prostate disorders
* Thyroid disorders
* Coronary artery disease
26
What are some risk factors for multimorbidity?
* Increasing age
* Female sex
* Low socioeconomic status
* Tobacco and alcohol usage
* Lack of physical activity
* Poor nutrition and obesity
27
What are some complications associated with multimorbidity?
* Decreased quality of life and life expectancy
* Increased treatment burden
* Mental health issues
* Polypharmacy
* Negative impact on carers' welfare
28
What is a key goal in managing comorbidity?
Reducing treatment burden and optimising care.
29
What should be established to understand the extent of disease burden in patients with multimorbidity?
* Discuss mental health issues
* Investigate treatment burden
* Assess social circumstances
* Assess health literacy
30
What tool can be used to assess frailty?
The PRISMA-7 questionnaire.
31
What does the STOPP/START screening tool help identify?
* STOPP identifies medications where the risk outweighs the benefits
* START suggests medications that may provide additional benefits
32
Fill in the blank: Tobacco and alcohol usage are _______ for multimorbidity.
[risk factors]
33
True or False: Mental health issues are not a concern for those with multimorbidity.
False.
34
What should be included in an individualized management plan for multimorbidity?
* Actions to be taken
* Goals
* Prioritized healthcare appointments
* Anticipated changes
* Areas of importance to the patient
35
What is the recommendation for reviewing medications in patients over 65?
A yearly review of all medications.
36
What is a 'bisphosphonate holiday'?
A discussion about stopping bisphosphonates after 3 years due to lack of consistent evidence of continued benefits.
37
What is Lewy body dementia?
An increasingly recognised cause of dementia, accounting for up to 20% of cases.
38
What is the characteristic pathological feature of Lewy body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
39
What is the relationship between Parkinson's disease and Lewy body dementia?
Complicated; dementia is often seen in Parkinson's disease, and up to 40% of Alzheimer's patients have Lewy bodies.
40
What are the features of Lewy body dementia?
* Progressive cognitive impairment
* Occurs before parkinsonism
* Fluctuating cognition
* Early impairments in attention and executive function
* Parkinsonism
* Visual hallucinations
41
How does the cognitive impairment in Lewy body dementia differ from Alzheimer's disease?
Early impairments in attention and executive function rather than just memory loss.
42
What is the typical progression of symptoms in Lewy body dementia?
Cognitive impairment typically occurs before parkinsonism, with both features usually occurring within a year of each other.
43
What is the diagnostic method for Lewy body dementia?
Usually clinical; single-photon emission computed tomography (SPECT) is increasingly used.
44
What is the commercially known name for SPECT used in diagnosing Lewy body dementia?
DaTscan.
45
What is the sensitivity and specificity of SPECT in diagnosing Lewy body dementia?
Sensitivity is around 90% and specificity is 100%.
46
What types of medications can be used in the management of Lewy body dementia?
* Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
* Memantine
47
What should be avoided in the management of Lewy body dementia?
Neuroleptics should be avoided due to extreme sensitivity and risk of irreversible parkinsonism.
48
True or False: Patients with Lewy body dementia can tolerate neuroleptics well.
False.
49
Fill in the blank: The radioisotope used in DaTscan is _______.
[123-I FP-CIT]
50
What is the mechanism of action of haloperidol?
dopamine antagonist. It exerts its effects by blocking dopamine receptors in the brain, particularly the D2 subtype of dopamine receptors.
51
What is an important part of a falls risk assessment in the elderly?
Lying/standing blood pressure
52
How is lying/standing blood pressure measured?
After 5 minutes of lying down, then after the first minute of standing, then after the third minute of standing
53
What is orthostatic hypotension?
A condition diagnosed by specific drops in blood pressure upon standing
54
What drop in systolic BP indicates orthostatic hypotension?
A drop in systolic BP of 20mmHg or more (with or without symptoms)
55
What systolic BP threshold indicates orthostatic hypotension regardless of the drop amount?
A drop to below 90mmHg on standing
56
What drop in diastolic BP can indicate orthostatic hypotension?
A drop in diastolic BP of 10mmHg with symptoms
57
True or False: A drop in diastolic BP is clinically as significant as a drop in systolic BP.
False
58
What percentage of elderly people living in the community fall every year?
Around one-third
## Footnote
This statistic highlights the prevalence of falls among the elderly population.
59
What are the three components involved in normal gait?
* The neurological system - basal ganglia and cortical basal ganglia loop
* The musculoskeletal system
* Effective processing of the senses (sight, sound, sensation)
## Footnote
These components are crucial for maintaining balance and preventing falls.
60
List three risk factors for falling in the elderly.
* Lower limb muscle weakness
* Vision problems
* Balance/gait disturbances
## Footnote
Other factors include polypharmacy, incontinence, and age over 65.
61
True or False: Individuals with 4 or more risk factors have up to a 78% chance of falling.
True
## Footnote
This statistic underlines the importance of identifying and managing risk factors.
62
What is the ideal approach for assessing falls risk in patients?
All patients should be screened for falls risk
## Footnote
This is particularly important when patients are in a hospital or home setting.
63
What key history details should be established when assessing a patient who has fallen?
* Where was the patient when they fell?
* When did they fall?
* Did anyone else see the patient fall?
* What happened during the fall?
* Why do they think they fell?
* Have they fallen before?
## Footnote
Collecting this information helps to understand the circumstances of the fall.
64
Fill in the blank: Reviewing a patient's _______ is crucial to reduce the chances of falling again.
[medication]
## Footnote
Patients on more than four medications are at a higher risk of falling.
65
Name two types of medications associated with postural hypotension.
* Nitrates
* Diuretics
## Footnote
These medications can increase the risk of falls due to their effects on blood pressure.
66
What should be included in the assessment of a patient who has fallen?
A full A to E approach and assessment of all systems
## Footnote
This thorough assessment helps rule out the cause of the fall.
67
List three bedside tests to consider during the investigation of falls.
* Basic observations
* Blood pressure
* Blood glucose
## Footnote
These tests provide initial information about the patient's condition.
68
What is the 'Turn 180° test' used for?
To assess individuals at risk of falling
## Footnote
This test evaluates balance and mobility.
69
What criteria should patients over 65 meet to receive a multidisciplinary assessment?
* >2 falls in the last 12 months
* A fall that requires medical treatment
* Poor performance on the 'Turn 180° test' or 'Timed up and Go test'
## Footnote
These criteria help identify those who need more comprehensive evaluation.
70
Individuals who fall but do not meet assessment criteria should be reviewed how often?
Annually
## Footnote
They should also receive written information on falls.
71
What is Lewy body dementia?
An increasingly recognised cause of dementia, accounting for up to 20% of cases.
72
What is the characteristic pathological feature of Lewy body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
73
What is the relationship between Parkinson's disease and Lewy body dementia?
Complicated; dementia is often seen in Parkinson's disease, and up to 40% of Alzheimer's patients have Lewy bodies.
74
What are the features of Lewy body dementia?
* Progressive cognitive impairment
* Occurs before parkinsonism
* Fluctuating cognition
* Early impairments in attention and executive function
* Parkinsonism
* Visual hallucinations
75
How does the cognitive impairment in Lewy body dementia differ from Alzheimer's disease?
Early impairments in attention and executive function rather than just memory loss.
76
What is the typical progression of symptoms in Lewy body dementia?
Cognitive impairment typically occurs before parkinsonism, with both features usually occurring within a year of each other.
77
What is the diagnostic method for Lewy body dementia?
Usually clinical; single-photon emission computed tomography (SPECT) is increasingly used.
78
What is the commercially known name for SPECT used in diagnosing Lewy body dementia?
DaTscan.
79
What is the sensitivity and specificity of SPECT in diagnosing Lewy body dementia?
Sensitivity is around 90% and specificity is 100%.
80
What types of medications can be used in the management of Lewy body dementia?
* Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
* Memantine
81
What should be avoided in the management of Lewy body dementia?
Neuroleptics should be avoided due to extreme sensitivity and risk of irreversible parkinsonism.
82
True or False: Patients with Lewy body dementia can tolerate neuroleptics well.
False.
83
Fill in the blank: The radioisotope used in DaTscan is _______.
[123-I FP-CIT]
84
What is frontotemporal lobar degeneration (FTLD)?
The third most common type of cortical dementia after Alzheimer's and Lewy body dementia.
85
What are the three recognised types of FTLD?
* Frontotemporal dementia (Pick's disease)
* Progressive non fluent aphasia (chronic progressive aphasia, CPA)
* Semantic dementia
86
What are common features of frontotemporal lobar dementias?
* Onset before 65
* Insidious onset
* Relatively preserved memory and visuospatial skills
* Personality change and social conduct problems
87
What is the most common type of FTLD?
Frontotemporal dementia (Pick's disease).
88
What characterises Pick's disease?
* Personality change
* Impaired social conduct
* Hyperorality
* Disinhibition
* Increased appetite
* Perseveration behaviours
89
What is characteristic of the atrophy seen in Pick's disease?
Focal gyral atrophy with a knife-blade appearance.
90
What macroscopic changes are seen in Pick's disease?
Atrophy of the frontal and temporal lobes.
91
What are the microscopic changes in Pick's disease?
* Pick bodies - spherical aggregations of tau protein (silver-staining)
* Gliosis
* Neurofibrillary tangles
* Senile plaques
92
What does NICE recommend regarding the use of AChE inhibitors or memantine in frontotemporal dementia?
They do not recommend their use.
93
What is the chief factor in progressive non fluent aphasia (CPA)?
Non fluent speech.
94
What characterises the speech in CPA?
Short utterances that are agrammatic, with relatively preserved comprehension.
95
How is speech characterised in semantic dementia?
Fluent but empty speech that conveys little meaning.
96
In semantic dementia, how does memory for recent events compare to remote events?
Memory is better for recent events rather than remote events.
97
What is the Abbreviated Mental Test Score (AMTS)?
A 10-point screening tool to assess cognitive function and detect potential dementia, delirium, or other cognitive impairments in elderly patients.
## Footnote
Developed in 1972.
98
How many questions are included in the AMTS?
10 questions.
99
What does each correct answer in the AMTS score?
1 point.
100
Which of the following is NOT a question in the AMTS?
- What is your age?
- Can you name three colors?
- What is the year?
- Count backwards from 20 down to 1.
Can you name three colors?
101
What does a score of 0-3 on the AMTS suggest?
Severe cognitive impairment.
102
What does a score of 4-7 on the AMTS suggest?
Moderate cognitive impairment.
103
What does a score of 8 and above on the AMTS suggest?
Normal cognitive function.
104
Fill in the blank: The AMTS is a useful screening tool in _______ and emergency settings.
hospital
105
What type of patients is the AMTS primarily used for?
Elderly patients.
106
List three areas tested by the AMTS.
* Age
* Orientation
* Memory
* Calculation
107
True or False: The AMTS includes questions about personal history.
False.
108
What is one of the questions asked in the AMTS regarding recognition?
Can you recognize two people?
109
What is the purpose of the AMTS?
To quickly assess cognitive function and detect potential cognitive impairments.
110
What are pressure ulcers?
Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age.
111
Where do pressure ulcers typically develop?
Over bony prominences such as the sacrum or heel.
112
What are some factors that predispose to the development of pressure ulcers?
* Malnourishment
* Incontinence (urinary and faecal)
* Lack of mobility
* Pain (leads to a reduction in mobility)
113
What is the Waterlow score used for?
To screen for patients who are at risk of developing pressure areas.
114
What factors are included in the Waterlow score?
* Body mass index
* Nutritional status
* Skin type
* Mobility
* Continence
115
What is Grade 1 in the European Pressure Ulcer Advisory Panel classification?
Non-blanchable erythema of intact skin. Discolouration, warmth, oedema, induration or hardness may also be indicators.
116
What characterizes a Grade 2 pressure ulcer?
Partial thickness skin loss involving epidermis or dermis, presenting as an abrasion or blister.
117
What defines a Grade 3 pressure ulcer?
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
118
What is the definition of a Grade 4 pressure ulcer?
Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss.
119
What is the recommended environment for ulcer healing?
A moist wound environment encourages ulcer healing.
120
Which dressings may help facilitate ulcer healing?
* Hydrocolloid dressings
* Hydrogels
121
What should be discouraged in the management of pressure ulcers?
The use of soap should be discouraged to avoid drying the wound.
122
Should wound swabs be done routinely for pressure ulcers?
No, as the vast majority of pressure ulcers are colonised with bacteria.
123
When should systemic antibiotics be considered for pressure ulcers?
On a clinical basis, for example, evidence of surrounding cellulitis.
124
Who should be considered for referral in the management of pressure ulcers?
The tissue viability nurse.
125
What surgical intervention may be beneficial for selected wounds?
Surgical debridement.
126
What is Alzheimer's disease?
A progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK
127
What does NICE recommend for non-pharmacological management of Alzheimer's disease?
Offering a range of activities to promote wellbeing that are tailored to the person's preference
128
What type of therapy does NICE recommend for patients with mild and moderate dementia?
Group cognitive stimulation therapy
129
Name two other non-pharmacological options for managing Alzheimer's disease.
* Group reminiscence therapy
* Cognitive rehabilitation
130
What significant update did NICE make to its dementia guidelines in 2018?
The inclusion of three acetylcholinesterase inhibitors as options for managing mild to moderate Alzheimer's disease
131
List the three acetylcholinesterase inhibitors recommended by NICE.
* Donepezil
* Galantamine
* Rivastigmine
132
What is memantine and when is it recommended for use?
An NMDA receptor antagonist recommended as a second-line treatment for moderate Alzheimer's in specific situations
133
In which situations is memantine recommended for use?
* For patients with moderate Alzheimer's who are intolerant of acetylcholinesterase inhibitors
* As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's
* Monotherapy in severe Alzheimer's
134
Does NICE recommend antidepressants for mild to moderate depression in patients with dementia?
No, they do not recommend antidepressants
135
Under what conditions should antipsychotics be used in dementia patients?
Only for patients at risk of harming themselves or others, or when agitation, hallucinations, or delusions cause severe distress
136
What is a contraindication for the use of Donepezil?
Relatively contraindicated in patients with bradycardia
137
What is a common adverse effect of Donepezil?
Insomnia
138
What is the correct answer concerning the subtype of delirium that is characterized by being withdrawn and lethargic?
Hypoactive delirium
## Footnote
Hypoactive delirium is often less recognized compared to hyperactive delirium.
139
How many subtypes of delirium are there?
Three subtypes: hyperactive, hypoactive, and mixed
## Footnote
Each subtype presents different symptoms and behaviors.
140
Which subtype of delirium is commonly well acquainted by people?
Hyperactive delirium
## Footnote
Hyperactive delirium features more visible symptoms such as agitation.
141
List the symptoms of hypoactive delirium.
* Withdrawn
* Lethargic
* Slow to respond
## Footnote
These symptoms can make hypoactive delirium harder to detect.
142
What are extrapyramidal symptoms (EPS)?
Movement disorders caused by disruptions to the brain's extrapyramidal system
143
What is the most common cause of EPS?
Medications like antipsychotics
144
List some symptoms of extrapyramidal symptoms (EPS).
* Muscle stiffness
* Tremors
* Restlessness (akathisia)
* Involuntary muscle spasms (dystonia)
* Uncontrolled repetitive movements (tardive dyskinesia)
145
True or False: EPS can only occur due to physical injuries to the brain.
False
146
Fill in the blank: EPS are often a side effect of _______.
antipsychotics
147
What type of movement disorder is characterized by muscle stiffness?
Muscle stiffness is a symptom of extrapyramidal symptoms (EPS)
148
What is akathisia?
Restlessness
149
What does dystonia refer to in the context of EPS?
Involuntary muscle spasms
150
What is tardive dyskinesia?
Uncontrolled repetitive movements
151
How can Lewy body dementia be differentiated from idiopathic Parkinson's disease dementia?
By the time of onset of dementia compared to the motor symptoms
152
What are some overlapping features of Parkinson's disease dementia (PDD) and dementia with Lewy bodies (DLB)?
* Tremors
* Rigidity
* Postural instability
* Fluctuating cognition
* Hallucinations
153
When is Parkinson's disease dementia (PDD) diagnosed?
If a patient had a Parkinson's disease diagnosis for at least 1 year
154
What is the likelihood of a patient with 8 years of motor symptoms developing Parkinson's disease dementia?
More likely to have PDD
155
Why is the differentiation between PDD and DLB important?
The management of PDD and DLB varies massively
156
What is the mainstay of treatment for Parkinson's disease dementia (PDD)?
Levodopa
157
What is the drug of choice for dementia with Lewy bodies (DLB)?
Rivastigmine
158
True or False: Levodopa may be used in DLB if there are significant motor symptoms.
True
159
Fill in the blank: PDD is diagnosed if a patient has had motor symptoms ongoing for _______.
at least 1 year
160
Fill in the blank: The differentiation between PDD and DLB is crucial because the _______ varies significantly.
management
161
What typically occurs before parkinsonism?
Cognitive symptoms
## Footnote
Both features usually occur within a year of each other.
162
In Parkinson's disease, when do motor symptoms typically present in relation to cognitive symptoms?
At least one year before cognitive symptoms.
163
True or False: In Parkinson's disease, motor and cognitive symptoms occur simultaneously.
False
## Footnote
Motor symptoms precede cognitive symptoms by at least a year.
164
Fill in the blank: In contrast to parkinsonism, Parkinson's disease shows motor symptoms presenting at least _______ before cognitive symptoms.
one year
165
What is neuroleptic malignant syndrome?
A rare but life-threatening reaction to antipsychotics or drugs that block dopamine effects
## Footnote
It is characterized by severe symptoms that require immediate medical attention.
166
What are the symptoms of neuroleptic malignant syndrome?
Symptoms include:
* High fever
* Confusion
* Rigid muscles
* Variable blood pressure
* Sweating
* Fast heart rate
## Footnote
These symptoms can vary in severity and require prompt diagnosis and treatment.
167
True or False: Neuroleptic malignant syndrome can occur in response to any medication.
False
## Footnote
It specifically occurs in response to antipsychotics or other dopamine-blocking drugs.
168
Fill in the blank: Neuroleptic malignant syndrome is often associated with _______.
[antipsychotics]
## Footnote
Antipsychotic medications are the primary class of drugs linked to this syndrome.
169
What is **Alzheimer's disease** primarily characterized as?
A progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK
## Footnote
Alzheimer's disease is the most common cause of dementia.
170
What does **NICE** recommend for non-pharmacological management of Alzheimer's disease?
* A range of activities to promote wellbeing tailored to the person's preference
* Group cognitive stimulation therapy for patients with mild and moderate dementia
* Group reminiscence therapy
* Cognitive rehabilitation
## Footnote
These activities aim to enhance the quality of life for patients.
171
What are the **three acetylcholinesterase inhibitors** recommended by NICE for managing mild to moderate Alzheimer's disease?
* Donepezil
* Galantamine
* Rivastigmine
## Footnote
These medications help improve symptoms related to memory and cognition.
172
What is **memantine** classified as in the treatment of Alzheimer's disease?
An NMDA receptor antagonist, considered a 'second-line' treatment
## Footnote
It is used in specific situations for moderate to severe Alzheimer's.
173
In what situations does NICE recommend the use of **memantine**?
* For patients with moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
* As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's
* Monotherapy in severe Alzheimer's
## Footnote
Memantine is used when first-line treatments are not suitable.
174
What does NICE say about the use of **antidepressants** for mild to moderate depression in patients with dementia?
NICE does not recommend their use
## Footnote
This is due to concerns about efficacy and safety in this population.
175
Under what circumstances should **antipsychotics** be used in dementia patients?
* Patients at risk of harming themselves or others
* When agitation, hallucinations, or delusions cause severe distress
## Footnote
Antipsychotics should be used cautiously due to potential side effects.
176
What is a **contraindication** for the use of **donepezil**?
Bradycardia
## Footnote
This medication can exacerbate heart rate issues.
177
What is a common **adverse effect** of donepezil?
Insomnia
## Footnote
Patients should be monitored for sleep disturbances while on this medication.
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