multisystem

Question 1

Diagnosis criteria for delirium

Answer 1

CAM criteria
* must have:
1. acute onset and fluctuating Course
2. inAttention
* and one of the below Mental presentation:
1. disorganised thinking
2. altered level of consciousness

.

Question 2

causes of delirium

Answer 2

Drugs (narcotics, sedatives, alcohol)
Eyes and ears dysfunction => sensory isolation
Low O2
Infection (sepsis, meningitis)
Retention (urine, faeces)
Ictal (seizure, stroke, headache)
Underhydration, undernutrtion
Metabolic (electrolyte disturbances, hypoglycaemia)

other causes: kidney or liver failure

Question 3

forms of delirium

Answer 3

• HYPERactive/agitated delirium:
  a/w alcohol intoxication/withdrawl
• mixed
• HYPOactive delirium:
  most common, commonly misdiagnosed or missed,
  a/w metabolic conditions (e.g. liver/renal failure)

Question 4

status epilepticus

Answer 4

• 1 seizure > 5 min
• ≥ 2 seizures w/ incomplete resolution

Question 5

management of patients with seizure

Answer 5

• before 5 mins:
  leave brain to stop on its own
  1. put patient in left lateral position
  => prevent aspiration
  2. give supplemental O2 if needed
  <- lack of O2 is one cause
  3. check glucose and give IV dextrose if needed
  <- hypoglycaemia is most rapidly reversibly cause of seizures
• after 5 mins:
  drugs to treat status epilepticus
  1. IV benzodiazepines (e.g. lorazepam/diazepam)
  2. if no IV access, give rectal

Question 6

benign essential tremor:
* includes which types of tremor?
* causes

Answer 6

• includes action tremors
  (occurs w/ ANY movements)
  and postural tremors
  (occurs when maintaining a POSITION)
• causes: lack of sleep, caffeine, stress

Question 7

should IV thiamine be given before or after IV dextrose

e.g. in patients w/ hypoglycaemic crisis, patients w/ epilepsy, etc

Answer 7

IV thiamine
-> bcos it is vit B1
and is a required cofactor for several key enzymes in aerobic glucose metabolism
=> giving glucose w/o thiamine is useless and can even trigger acute Wernicke encephalopathy

Question 8

what is Parkinson’s Plus Syndrome

Answer 8

degeneration in brain areas NOT limited to substantia nigra
(e.g.

vs PD/idiopathic Parkinson = degeneration of dopaminergic neurons in substantia nigra only

Question 9

how does Parkinson’s Plus Syndromes
compare to PD which is
1. > 50 y/o
2. usually asymmetrical
3. gradual, slow progression
4. well controlled by levodopa)

Answer 9

1. < 50 y/o
2. symmetrical
3. rapid progression
4. poor response to Levodopa

Question 10

what other syndromes does PPS present with

Answer 10

• multisystems atrophy (MSA):
  autonomic nervous system failure
• Lewy-Body Dementia
• progressive supranuclear palsy:
  vertical gaze palsy (inability to look down)
• corticobasal generation:
  present w/ both basal signs (parkinsonism) and cortical signs (e.g. apraxia, cortical sensory loss)

Question 11

should you try to lower or raise BP during acute management of an ischaemic stroke

Answer 11

a. if not giving thrombolytic drugs:
allow it to rise up to 220/120
* high BP is protective mechanism
* as results in higher pressure gradient
* blood can push through collateral vessels
and supply brain tissue which are still alive

b. if giving thrombolytic drugs:
allow it to rise up but < 185/110
* high BP + thrombolysis may result in intracerebral haemorrhage
* as ischaemia from clot has resulted in vessels being structurally damged alr
* forcing high pressure blood into it results in rupture

Question 12

what does each of these
in the funding of healthcare for older people do

Answer 12

• medisave: compulsory savings in central provident fund (CPF)
• medishield: catastrophic medical insurance
• medifund: for low income grp
• eldershield: long term disability insurance

Question 13

what is normal in terms of cognitive ability of elderly:
* decrease in executive function
* significant cognitive decline
* decrease in psychomotor speed

Answer 13

• decrease in executive function + psychomotor speed
  = normal ageing
• significant cognitive decline = marker for disease

Question 14

features that distinguish delirium from dementia

Answer 14

• time course:
  delirium: acute (hours to days)
  dementia: progressive (months to years)
• level of consciousness:
  delirium: fluctuating
  dementia: stable
• attentiion
  delirium: INattention
  dementia: usually preserved until very late stages

Question 15

important aspects to note when taking history of patient who fell

Answer 15

• detailed history on falls
  (location,
  activity BEFORE, ability to get up AFTER,
  history of previous falls in past year)
• what precipitated the fall
  (usually acute illness, thus ask abt cough, fever, chest pain, seizure, …)
• medications
  (check ADRs + DDIs, any recent change in meds, whether taking meds regularly)
• brief functional + cognitive history
  (caregiver, physical envt, function PRIOR to fall)

Question 16

which drug has the highest impact on increasing fall risk

Answer 16

antipsychotics

Question 17

factors in elderly that predispose them to falls

Answer 17

• AGE: increased postural sway
  & slower righting reflex
  & unstable gait
• poor VISION: e.g. cataracts, glaucoma
• INACTIVITY
  -> muscle hypotrophy and weakness
  => impaired strength and balance
• chronic conditions: e.g. knee OA,
  DM resulting in peripheral neuropathy
• POLYPHARMACY
  => increse risk of ADRs
• acute exacerbations: hypotension, hypoglycaemia
• ENVT: poor lighting, flooring

Question 18

PE that should be down for patients who fell

Answer 18

• visual acuity
  <- fundoscopy
• BP
• CNS examination (UL + LL)
• CVS examination
• screen for mental status

Question 19

what issues must be addressed to prevent further falls before patient can be dischaged home

Answer 19

• assess underlying risk factor causing the fall
• opthalmology review
• provide necessary walking aids to improve gait stability
• modification of home envt
• assess rehabilitative potential and thus arrange step-down care services accordingly
• arrange for home visit by occupational therapist