Gerries

Question 1

RFs of falls

Answer 1

• Lower limb muscle weakness
• Vision problems
• Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
• Polypharmacy (4+ medications)
• Incontinence
• > 65
• Have a fear of falling
• Depression
• Postural hypotension
• Arthritis in lower limbs
• Psychoactive drugs
• Cognitive impairment

Question 2

It is important to establish the following from the history in a falls pt

Answer 2

Where was the patient when they fell?
When did they fall + how long did they lie for?
Did anyone else see the patient fall? (collateral history)
What happened? Were there any associated features before/during/after
Why do they think they fell?
Have they fallen before?
Systems review
Past medical history (especially issues related to balance/sight/gait)
Social history - including level of independence and how they mobilise.

Question 3

how would you assess a falls pt

Answer 3

an A-E assessment
make sure you fully expose the pt especially on their back for bruising and bleeding.

Question 4

typical presentation of lewy body dementia

Answer 4

• fluctuating cognition
• visual halLEWcinations
• in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
• parkinsonism usually within a year of cognition sx.

Question 5

normal pressure hydrocephalus features

Answer 5

• NPH presents with the classic triad of gait disturbance, urinary incontinence, and dementia, with gait changes usually appearing first.
  
  • wet wacky and wobbly
• The cognitive symptoms in NPH tend to involve attention and executive function.

Question 6

acronym for delirium

Answer 6

PINCH ME
* pain
* infection
* nutrition
* constipation
* hydration,
* metabolism
* environmental changes

Question 7

types of delirium

Answer 7

• Hyperactivedelirium: associated withagitationorhallucinations, ↑ psychomotor activity + restlessness.
• Hypoactivedelirium: associated withlethargy,reduced responsiveness, activityandconcentration
• Mixeddelirium with symptoms and signs ofboth hyper- andhypoactive delirium

Question 8

Mx of delirium

Answer 8

1. Correction of precipitating factors
2. Non-pharmacological/Reorientation strategies: such as easily visible and accurate clocks and calendars, good lighting, access to hearing aids + glasses, regular sleep-wake cycle.
3. V. agitated pts or those that are a danger to themselves or others may be sedated using haloperidol 1st line or lorazepam 2nd line [OR 1st for pts with parkinsons]

Question 9

Alzheimer’s disease management

Answer 9

• 1st line = Acetylcholinesterase inhibitor: rivastigmine, donepezil or galantamine.
• 2nd line = Memantine: NMDA antagonist. Monotherapy if ↑ is not tolerated or dual therapy in moderate – severe cases
• Non- pharmacological Mx - given to all pts:
  
  • Supportive management: cognitive stimulation therapies
  • Care plans

Question 10

pressure ulcers:
- risk assessment tool
- grading system

Answer 10

• The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.

Question 11

pressure ulcer Mx

Answer 11

• a moist wound environment encourages ulcer healing.
  
  • hydrocolloid dressings and hydrogels may help facilitate this
  • the use of soap should be discouraged to avoid drying the wound
• wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
• consider referral to the tissue viability nurse
• surgical debridement may be beneficial for selected wounds

Question 12

In a new diagnosis of Alzheimer’s disease, it is important to review and potentially stop medications that may worsen cognition or increase adverse effects. Key drug classes to consider include:

Answer 12

• Anticholinergic drugs: These impair cholinergic neurotransmission, worsening cognitive symptoms. Examples include: Bladder antimuscarinics, TCAs and 1st gen antihistamines
• Benzodiazepines and other sedative-hypnotics: Increase risk of sedation, falls, confusion, and delirium.
• Opioids: Can cause sedation and cognitive impairment; use cautiously if necessary.
• Antipsychotics: Should be avoided unless absolutely indicated for behavioural symptoms due to increased risk of stroke and mortality in dementia.
• Drugs causing orthostatic hypotension: Such as some antihypertensives (e.g., alpha-blockers), which increase fall risk.
  *

Question 13

CT head findings of alzheimer’s

Answer 13

widespread cerebral atrophy mainly involving the cortex and hippocampus

Question 14

CT head findings of frontotemporal dementia

Answer 14

Atrophy of the frontal and temporal lobes

Question 15

advanced directive vs advanced statement

Answer 15

Question 16

advanced directive AKA a living will

1. what is it
2. what does it include
3. how long does it last
4. what is needed for it to be valid
5. T/F legal advice must be sought for this
6. what invalidates it
7. can it be overridden? if yes - when? if no why not?
8. role of relatives
9. limitations of an advanced directive

Answer 16

1. A legally binding document outlining what medical treatment a patient would not want in the future, if they lacked capacity.
2. It specifies which treatments you refuse, helping to guide healthcare professionals and family members.
3. do not have a legal expiration date and remain valid indefinitely unless the pt specifically revokes or changes them.
4. -Signed
   -Witnessed if you want to refuse life-sustaining treatment
   -It is not felt to have been signed under duress
   -There is no doubt about the patient’s state of mind at time of signing
5. No
6. if it is deemed to have been done under duress or harrasment is involved. also if pt changes their mind.
7. no it is legally binding, unless pt with capacity changes their mind.
8. Relatives have no legal rights to rescind or modify a valid advance decision.
9. The patient cannot specify which treatments they would want, only those they would not want.

Question 17

Lasting power of attorney

1. what is it
2. who can be appointed
3. types

Answer 17

1. A third party is appointed (in advance) to make decisions on the patient’s behalf should they lose capacity.
2. The third party may be one person or more than one person.
   
   • If the latter, they can be appointed to act together (‘jointly’); or so that each can make decisions alone (‘jointly and severally’).
   • The third party may be a relative/friend or legal advocate.
3. There are two types of lasting power of attorney: 1)health + welfare and 2)property and finance affairs:
   
   4. For decisions regarding health and only takes effect if the patient loses capacity. they only have the right to refuse offered medical treatments, not to choose which treatments to have. they can make decisions as if they are the pt, including:
      
      • Daily routine
      • Medical care
      • Moving into a care home
      • Refusing life-saving treatment
   5. For decisions regarding finances, bills, pensions, and selling property. Can take effect immediately with patient’s consent

Question 18

Mx of hiccups in palliative care

Answer 18

Hiccups in palliative care - chlorpromazine or haloperidol

Question 19

alzheimers key presentations

Answer 19

5A’s:

1. Anomia,
2. Apraxia,
3. Agnosia,
4. Amnesia,
5. Aphasia

Question 20

end of life care talking points

Answer 20

• increasing burden of treatment and diminishing returns
• ceilings of care
• DNACPR
• wishes for dying at home or in hospital
• signposting to spiritual care,
• alternative therapies,
• management of pain,
• mental health support,
• palliative care and end of life care.
• Advance directives