1
Q
what to take into account in assessment of falls
A
- falls history
- gait, mobility, balance and muscle weakness
- osteoporosis risk
- perceived functional ability and fear relating to falling
- visual impairement
- cognitive impairment and near exam
- urinary incontinence
- home hazards
- cardio exam
- meds review
2
Q
who gets osteoporosis assessment
A
-all women > 65
-all men > 75
-all people over 50 if:
- previous fragility fracture
current/frequent use of glucocorticoids
- history of falls
- FH hip fracture
-other causes of secondary osteoporosis (hyperthyroidism, chronic kidney/liver disease, rheumatoid arthritis, eating disorders, lithium, chemotherapy)
-low BMI
-smoker
- alcohol intake > 14 units/week
3
Q
prevention of osteoporosis
A
medication:
- bisphosphonates (alendrotnic acid or IV)
- HRT
lifestyle: - stop smoking cut down on alcohol - exercise - vit D and calcium (if depleted)
4
Q
how do you assess risk of osteoporosis
A
FRAX (predicts 10y risk % of fracture)
DEXA scan
5
Q
aetiology of falls
A
DAME
DRUGS (antihypertensives, sedatives, opioids, psychotropics, beta blockers)
AGEING (vision changes, cognitive decline, gait, osteoarthritis)
MEDICAL (cardiac, neuro, cataracts)
ENVRONMENT (walking aids, footwear, home hazards)
6
Q
risk factors for delirium
A
- > 65 years
- cognitive impairement/dementia
- current hip fracture
- severe illness
- frailty
- sensory inpairement
7
Q
clinical presentation of delirium
A
- cognitive function (worsening concentration, reduced movement, confusion)
- perception (visual/auditory hallucinations)
- physical function (reduced mobility, reduced movement, changes in appetite*, restlessness, agitation, sleep disturbances)
- social behaviour (lack of cooperation, withdrawal*, alteration in communication, mood and/or attitude)
- hypoactive delirium
8
Q
interventions to prevent delirium
A
- familiarity (people, places)
- reorientated people (lighting, clocks, family)
- adress dehydration and constipation
- assess hypoxia
- address immobility
- adress pain
- adress poor nutrition
- adress sensory impairement
- good sleep patterns/sleep hygiene
- adress polypharmacy
9
Q
diagnosis of delirium
A
- clinical assessment (DSM-V criteria/CAM/CAM-ICU)
- quick cognitive assessment (AMTS10/AMT4)
- all 4 of the following must be present: 1. acute onset, 2. disturbances of consciousness, 3. impaired cognition or perceptual disturbances, 4. clinical evidence of acute general medical condition, intoxication or substance withdrawal
10
Q
managing delirium
A
- manage underlying cause
- effective communication and reorientation (involve family/friends/same MDT)
- if distressed: verbal/nonverbal techniques to deescalate, short term haloperidol/olanzepine
11
Q
causes of delirium
A
PINCH ME Pain Infection Nutrition (B12/folate/hypothyroidism/hypoglycaemia/hypercalcaemia) Constipation Hydration Medication Environment change
12
Q
difference between delirium and dementia
A
delirium: acute, fluctuating, reversible, clouding of consciousness, psychomotor disturbances, disturbance of sleep, hallucinations (visual)
dementia: slow, irreversible, no clouding of consciousness, functional impairment
13
Q
stroke mimics
A
hypoglycaemia seizures sepsis syncope space occupying lesions
14
Q
Bamford classification of strokes (location)
A
- TACS (large cortical stroke ACA/MCA)
- PACS (partial cortical stroke MCA/ACA)
- POCS (posterior circulation)
- LACS (lacunar: subcortical stroke due to small vessel disease)
- Weber syndrome (Ipsilateral iii palsy, contra lateral weakness)
15
Q
diagnostic criteria for TACS
A
- unilateral weakness/sensory of face, arm and leg +
- homonymous hemianopia +
- higher cerebral dysfunction (dysphagia, visuospatial i.e. inattention)
16
Q
diagnostic criteria for PACS
A
2 of the following:
- unilateral weakness/sensory of face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphagia, visuospatial)
17
Q
diagnostic criteria for POCS
A
1 of the following:
- cerebellar or brainstem dysfunction
- loss of consciousness
- isolated homonymous hemianopia
18
Q
diagnostic criteria for LACS
A
1 of the following:
- unilateral weakness/sensory of face and arm, arm and leg or of all 3
- pure sensory stroke
- ataxic hemiparesis
19
Q
classification of stokes (aetiology)
A
- ischemic (+ haemorrhage transformation)
- haemorrhage
- subarachnoid haemorrhage
- cerebral venous thrombosis
20
Q
aetiology of ischemic stroke
A
- thrombus (atheroma)
- emboli (AF, calcium from heart, bacterial vegetation)
- systemic hypo perfusion (systemic hypotension: arterial dissection, cardiac arrest)
- cerebral venous sinus thrombosis
- small vessel disease
21
Q
aetiology of intracranial haemorrhage
A
- hypertension
- aneurysm
- cerebral arteriovenous malformations
- cerebral amyloid angiopathy
- brain tumour blood vessel bleed
- drugs
- trauma
- bleeding disorders
22
Q
symptoms of intracranial haemorrhage
A
- sudden onset headache
- LOC
- nausea
- vomitting
- delirium
- focal/generalised seizures
23
Q
what steps in rapid recognition of stroke
A
exclude hypoglycaemia
use ROSIER to exclude stroke mimics
perform CT
24
Q
In what cases do you perform a non enhanced CT for stroke enquiry
A
- indications for thrombolysis/thrombectomy
- on aanticoag treatment
- known bleeding tendency
- depressive level of consciousness (GCS<13)
- unexplained progressive fluctuation symptoms
- papilloedema, neck stiffness or fever
- severe headache at onset of stroke symptoms
25
management of ischemic stroke
RULE OUT INTRACRANIAL HAEMORRHAGE
- alteplase (w/in 4.5 hours)
- thrombecomy (w/in 6 hours and if in proximal anterior circulation)
- IF can't alteplase or thrombectomy: Aspirin 300 mg ASAP for 2w + clopidogrel lifetime
- lifestyle and risk factor management
26
long term anti platelet treatment for stroke:
- 24h post alteplase (after CT scan): aspirin 300mg for 2 weeks
- at 2 weeks: stop aspirin, start clopidogrel 75mg OR reduce aspirin (75mg) and add modified release dipyridamole 200mg
27
management of intracranial haemorrhage
- reverse DOAC or warfarin (prothrombin complex or vit K)
- bring BP 130-140 mmHg systolic
- potential surgery
28
complications of strokes
- residual weakness
- post stroke pain
- dysphasia
- hemorragia transforamtion
- vascular dementia
- autonomic dysfunction
- dysphagia/aspiration pneumonia
- incontinence
- depression/anxiety
- loss of independence
29
when do you consider carotid endartectomy
carotid stenosis > 50% symptomatic or > 70% asymptomatic
30
symptoms of acute lower limb ischema
5 Ps
- pain
- pallor
- parasthesia
- paralysis
- perishing cold
31
signs of acute lower limb ischemia
- cold limb
- mottling or marbling skin
- diminished/absent pulses
- sensation and movement reduced
- development of compartment syndrome with pain in calf on compression
32
clinical features of TIA
Transient: full recovery within 24h
ischemic: are symptoms similar to stroke
attack: sudden onset?
has the symptoms spread (if so, TIA unlikely)
33
risk factors for TIA
- vascular :
hypertension, smoking diabetes, PVD, IHD
-thrombotic:
AF, carotid stenosis, contraceptive pill, clotting disorders, polycythaemia
34
TIA mimics and how to differentiate them
```
- syncope
TIA no TLoC
- atypical seizure
followed by postictal state, repetitive and stereotypical, Todd's paresis
- migraine
headache, symptoms evolve over time
- temporal artritis
temporal artsy tenderness, jaw claudication visual impairment
- retinal haemorrhage or detachment
unilateral visual loss
- hypoglycaemia
- labyrinthine disorders
presenting with vertigo
```
35
initial management of TIA
- aspirin 300mg daily
- referral to specialist within 24h of onset
- CT/MRI
36
secondary management of TIA
- manage aortic stenosis, AF, hypertension, hyperlipidaemia, diabetes etc
- clopidogrel 75mg (first line)
modified release dipyridamole+ aspirin (second line)
37
what scoring system for AF
```
CHADS2VASC
age
sex
CHF
hypertension
stroke/TIA/thromboembolism
vascular disease
diabetes
```
38
causes of TIA
embolus from plaque rupture (carotid stenosis) or from thrombus in heart (AF)
39
what scoring systems for strokes
NIH
ROSIER (distinguish between acute stroke ad mimics)
GCS
40
tremor differential diagnosis
```
Parkinsonism
essential tremor
cerebellar tremor
hyperthyroidism
drug induced
```
41
symptoms/signs of PD
TRAP
resting tremor, rigidity, akinesia, postural instability
non movement: anosmia, GIT problems, REM sleep behaviour disorder, prominent pain, micrographia
behavioural impairment: cognitive disturbances, impulsive behaviour, depression, anxiety, fatigue
42
clinical diagnosis of PD
- bradykinesia + one of the following: rigidity, ring tremor, postural instability
- unilateral onset and persistent asymmetry
- good levodopa response
43
pathophysiology of PD
Lewy body in substantial nigra pars compacta (causing death of cells and loss of dopamine)
44
prognosis of PD
13 year average survival
45
aetiology of PD
>60years old: usually idiopathic
<40: young onset: genetic component
most common in men,, whites
46
pharmacological treatments of PD
first line: levodopa, dopamine agonists, MAO-B inhibitors
adjuvant treatment: levodopa + dopamine agonists, MAO-B inhibitors, COMT inhibitors
47
non motor symptoms management in PD
- depression: antidepressants
- impulse control disorders: reduce dopaminergic therapy
- dementia: cholinesterase inhibitor
- sleep disorder: modafinil, clonzepam, melatonin
- orthostatic hypotension: midodrine
- psychotic symptoms: reduce dopaminergic therapy, clozapine
- constipation: laxatives
48
causes of parkinsonism
- idiopathic PD
- drug induced (symmetrical bradykinesia, history of drugs)
- vascular (step wise progression, symmetrical)
- dementia with Lewy Bodies (fluctuating cognitive impairment, visual hallucinations)
- PSP
- MSA
49
history of progressive supra nuclear palsy
- rapid progression
- supra nuclear gaze palsy
- early postural instability and falls
- axial rigidity (hyperextended neck)
- pseudo bulbar palsy (similar to Bell's)
- poor response to levodopa
50
symptoms of parkinsonism
bradykinesia
rigidity
tremor
51
6 categories of elder abuse
```
physical
sexual
financial
psychology
neglect
racial/cultural
```
52
how do you assess the risk factors for elder abuse
- factors relating to based person
- factors relating to perpetrator
- relationship between both
- environmental factors
53
what is NHS continuating healthcare
free care outside of hospital arranged and payed by NHS
criteria: :
- similar to comprehensive geriatric assessment (high (A), medium (B) and low (C) need)
reviewed every 3 months
54
pressure ulcers classification by grade
- grade 1: non-blanchable erythema of intact skin (discolouration, warm, induration or hardness of skin)
- grade 2: partial-thickness skin loss, involving epidermis, dermis or both. ulcer is superficial and presents clinically as abrasion or blister
- grade 3: full-thickeners skin loss involving damage to or necrosis to subcutaneous tissue and may extend down to (but not through) underlying fascia
- grade 4: extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full thickness skin loss
55
what scoring system do you use for risk of developing pressure ulcers
waterlow score
56
main factors leading to pressure ulcers
interface pressure
shear
friction
moisture
57
def Todd's paresis
focal weakness in a part or all of the body after seizure, usually subsides after 48h
58
def frailty fracture
low energy fracture (fall from standing height or less)
59
DEXA scan T scores diagnosis
compared to average value for young healthy person of the same race and sex as the patient
T>-1: normal
T: -1.1 to -2.4: osteopenia (low bone density)
T
60
risk factors for fragility fractures
- osteoporosis
- non compliant coeliac disease
- breast cancer
- smoking and alcohol
- drugs (SSRIS, omeprazole, steroid use, solace, anti epileptics)
- age and gender
- early menopause, late menarche
- rheumatoid arthritis
- immobility
61
def of frailty
small insult can cause disproportionate change in health state
62
frequent clinical presentations of frailty
- non specific (extreme fatigue, unexplained weight loss, frequent infections)
- falls
- delirium/acute confusion
- fluctuating disability
63
fried's phenotype model of frailty
- weight loss
- self reported exhaustion
- low energy expenditure
- slow gait speed
- weak grip strength
considered frail if have at least 3 of the variables
64
steps of polypharmacy review in geriatrics
1. what matters to the patient
2. identify essential therapy
3. does the patient take necessary drug therapy
4. are the therapeutic objectives being achieved
5. any risk of sSE/ADRs
6. is the drug therapy cost effective
7. is the patient willing and able to take drug therapy as intended?
65
what are the 6 domains of medication review
```
aims
need
effectiveness
safety
cost effectiveness
patient centeredness
```
66
Essential tremor presentation
- slow progression + inherited
- postural and worse on movement
- affects writing and fine movement
- bilateral
- coarse
- yes-yes head titubation
- jaw and leg tremor may be present
- improvement with alcohol use and beta blockers
- worse with anxiety, salbutamol
67
tremors worse at rest
parkinsonism
68
tremors worse on movement
```
essential tremor
hyperthyroidism
dystonic tremor
drug induced
exaggerated physiological tremor
```
69
intention tremors
cerebellar disorders
70
presentation of multiple system atrophy
- parkinsonisms
- autonomic dysfunction
- cerebellar signs
(does not respond to levodopa)
71
what are the 6 key elements in assessing patients for malnutrition and treatment for it
1. risk of malnutrition
2. why is pathophysiology of dysphagia
3. any indication for artificial nutrition?
4. how will you manage risk of malnutrition
5. apply 4 principles of medical ethics
6. who else needs to be involved
72
what are indications for artificial feeding
- mechanical dysphagia due to obstruction
- neurological dysphagia where prospect of recovery
- inability to eat due to global neurological damage (with prospect of recovery)
- nutritional requirements are increased due to malapsortion
- for essential meds delivery
73
symptoms of oropharyngeal dysphagia
- choking
- aspiration pneumonia
- nasal regurg
74
symptoms of oesophageal dysphagia
- pain
| - food getting stuck k
75
what are the different elements of advanced care planning
- advanced decisions (legally binding, refuse treatment, DNR, ceiling of care)
- advanced statements (not legally binding, wishes of how to be treated)
- lasting power of attorney (finances and health)
76
investigations in stroke/TIA
- full neuro exam/NIHSS
- BP, ECG, glucose
- head CT
- carotid stenosis
- bloods: FBC, clotting, glucose, lipids
Year 4
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