Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Geriatrics and Palliative medicine Umaima HuriaaTable of Contents Dementia Delirium Falls in elderly End of Life (EoL) care Parkinsons Deprivation of Liberty Safeguarding Palliative prescribing SBA 1. A 84 year old female patient, is being investigated for dementia. Which of the below is the most common type of dementia in the UK? A) Alzheimers dementia B) Vascular dementia C) Lewy body dementia D) Frontal temporal dementia E) Parkinsons disease dementia SBA 1. A 84 year old female patient, is being investigated for dementia. His wife reports memory has worsened over the past two years. His wife informs you that it started with forgetting words and where he has put items and belongings. His only medications are Atorvostatin and metformin. Blood tests are not remarkable. What is the most common type of dementia in the UK? A) Alzheimers dementia B) Vascular dementia C) Lewy body dementia D) Frontal temporal dementia E) Parkinsons disease dementia SBA 2. Which of the following assessment tools do NICE recommend for the non-specialist setting to aid in diagnosis of dementia? A) Mini mental state exam (MMSE) B) Mental state exam C) Abbreviated mental test score (AMTS) D) 10-point cognitive screener (10-CS) E) General practitioner assessment of cognition (GPCOG) SBA 2. Which of the following assessment tools do NICE recommend for the non-specialist setting to aid in diagnosis of dementia? A) Mini mental state exam (MMSE) B) Mental state exam C) Abbreviated mental test score (AMTS) D) 10-point cognitive screener (10-CS) E) General practitioner assessment of cognition (GPCOG)•OtherScoring •Numberof people affected Dementia pharmacological cognitive screener /6 >70,000 people Investigations item cognitive Mildto Moderate Dementia impairment CRP, MSU, U&E, LFT, FBC, ESR OR glucose, Ca , TFT, B12 OR Rivastigmine Donepezil Bloodscreen forreversible Alzheimers causesand Neuroimaging •Blood/imaging Perfusion hexamethylpropyleneamine oxime Severe Dementia • Mostcommon (HMPAO) single-photon emission computerised cause ofdementia tomography (SPECT) may be used to distinguish 2 line:Memantine (NMDAantagonist by vascularthenwed LBD between Alzheimer's disease, vascular dementia recommended byNICE)inaddition toanAche and frontotemporal dementia. inhibitor Triad ofSymptoms Physio/SALT Cognitive tools 1 Cognitiveimpairment:Causing difficulties Nurse Multi-disciplinary Dr/Mental with memory, language, attention, 10 pointcognitive 6-item cognitive approach: Physical Health orientation and problem solving Screener impairmenttest psychological, 2 socialandspiritual support Psychiatricor Behaviour disturbances Memory impairment Difficultieswith activitiesof daily living Mini-Cognitive Mental 3 screen Health OT eithermajor stroke, Vascular 25%- Brain unrecognisedstrokes damagedue to (multi-infarct)or chronic CVdisease changesin smaller vessels (subcorticaldementia). PREVALENCE BY AGE about15%).Depositionof 160 Lewybody abnormalproteinwithin Hallucinationsfollowed by neuronsin thebrain stem motorsymptoms 140 dementia and neocortex. 120 Types of 100 Onetypeof (lessthan5%).Specific frontotemporaldementia 80 degeneration/atrophyof isPick'sdisease, where dementia Frontotemporal thefrontalandtemporal proteintangles(Pick's lobesof thebrain. bodies)areseen 60 histologically 40 20 Usuallyyoung Presentwith Huntington’s patientswith motor 0 1 2 3 4 5 6 7 8 familyhistory symptoms Age Prevalence SBA 3. A patient is admitted with confusion, impairment of consciousness, hallucinations, high blood pressure and loss of balance. Which of the following point to a diagnosis of delirium rather than dementia? A) Confusion B) Impairment of consciousness C) Loss of balance D) High blood pressure E) Loss of balance SBA 3. A patient is admitted with confusion, impairment of consciousness, hallucinations, high blood pressure and loss of balance. Which of the following point to a diagnosis of delirium rather than dementia? A) Confusion B) Impairment of consciousness C) Loss of balance D) High blood pressure E) Loss of balance SBA 4. A 76 year old patient is admitted for surgical intervention for a hip fracture. On day 3 post-op, the nurses report she has become suddenly quiet, withdrawn and sleepy. Which of the following below best describe this change? A) Confusion B) Depression C) Hypoactive delirium D) Hyperactive delirium E) Behavioural change in the elderly SBA 4. A 76 year old patient is admitted for surgical intervention for a hip fracture. On day 3 post-op, the nurses report she has become suddenly quiet, withdrawn and sleepy. Which of the following below best describe this change? A) Confusion B) Depression C) Hypoactive delirium D) Hyperactive delirium E) Behavioural change in the elderly Delirium Acute confusional state that affects up to 30% of elderly patients apathy and quiet Hypoactive confusion are present Quiet,Withdrawn and and easily missed.This sleepy delirium tywith depression.d gitation, delusions and Hyperactive disorientation are Agitated, restless and prominent and it can sometimes agressive delirium beschizophrenia. Mixed patients vary from Patient will move in hhyperactiveo and hypoactive phase subtype DSM-V can be used for criteria of delirium 4AT screening tool Pathophysiology Hypoxaemia /metabolic Systemicicytokineion/High derangement Activation of Primemicroglia Global impairment of cerebral metabolism Increase cytokinelevels Decrease synthesisand release ofneurotransmitters Neurotransmitter imbalance/ Disruption of synaptic communication Delirium 4-ATbedsideassessmenttool Main Risk factors • Risk factors: are factors that make a The4ATisabedsidetoolfordeliriumassessmentthatiseasy andquicktoadministerwithnospecial trainingrequired –so person more likely to develop a recommended for clinical useinmultipleinternational guidelinesand pathways. condition The4ATfacilitates rapid screening basedonfoureasyto • Precipitating factors are the assessitems: •Alertness; immediate cause of the •AMT4(AbbreviatedMentalTest -4) •Attention; disease/pathology •Acutechangeorfluctuatingcourse. • Frail, hip fracture, severe illness and Items1-3 are rated on observationofthepatient duringthe sourcesaboutthepatient,e.g.,fromtheassessor,othereral pre-existing dementia/cognitive clinical staff,carers, filenotesetc. Risk factors: impairment Mnemonic DELIRIUM SBA 6. A 82 year old patient is admitted falling a fall and long lie at home. Which of the following drugs is most likely the cause of her fall? A) Naproxen B) Amlodipine C) Bisphosphonates D) Zopiclone E) Aspirin SBA 6. A 82 year old patient is admitted falling a fall and long lie at home. Which of the following drugs is most likely the cause of her fall? A) Naproxen B) Amlodipine C) Bisphosphonates D) Zopiclone E) Aspirin SBA 7. A 82 year old patient is being investigated following a fall. Which of the following describes the expected findings in sympathotonic orthostatic hypotension? A) Drop in BP, no change in HR B) Drop in BP, drop in HR C) Drop in BP, increase HR D) Increase in BP, no change in HR E) Increase in BP, drop in HR SBA 7. A 82 year old patient is being investigated following a fall. Which of the following describes the expected findings in sympathotonic orthostatic hypotension? A) Drop in BP, no change in HR B) Drop in BP, drop in HR C) Drop in BP, increase HR D) Increase in BP, no change in HR E) Increase in BP, drop in HRFalls History Getting up from lying/sitting (postural hypotension?) Before Any pre-syncopal symptoms e.g. From the toilet (vasovagal?) How is their general health? Any feeling dizzy, light-headed, In the middle of walking infective symptoms (e.g. dysuria, palpitations? (arrhythmia?) cough, cellulitis?) Turning their head (carotid sinus the fall hypersensitivity?) Wheretheyable toput outtheir Dotheyrememberfalling? Was thereanyLOC? handstopreventinjury? During Was itwitnessed? Aretheyabletodescribethe •A fracturedwrist where theyhavetried to Ifso, obtain adetailedcollateral mechanismofthefall? •A significanthead (e.g.blackeye) isconsistent history this isnot thesame asremembering’ suchLOC(likely sudden onset – e.g.arrhythmia) Ibeensomeloss ofconsciousness adefinitemechanicalreasonfor the priortothe fall. the fall (LOC) fall! Rapidlyrecoveringorientationis in Weretheyabletomobilise Anylimb jerkimply seizure?aecalincontinenceto keepingwith noLOC,or syncopal fall?endentlyfollowingthe After Some myoclonicjerkingfollowinga syncopal episode episode is notuintothissodonotreadtoomuch • implies apost-ictalstateandess thelookoutfor bonyinjuries.Patient Were theywell-oriented following thefall? potentialseizureas cause willmovein betweenhyperactive Rapidly rLOC,orsyncopalepisodeis in keepingwith no andhypoactivephase the fallFalls causes Lower limb muscle weakness Incontinence Blood tests: >65 Vision problems Have a fear of falling FBC,U&E,CRP,LFTs,Clotting History Balance/gait disturbances Depression ofinfectionasacauseoffall (diabetes, rheumatoid arthritis Postural hypotension aswellasCTheadtoruleout and Parkinson's disease etc) APsychoactive drugslimbs heamatoma Polypharmacy (4+ medications) Cognitive impairment Examination : Pulse(Regular or irregular), PMH: diabetes, HTN, epilepsy, BP:Alwaystry to obtain3 postural (lyingto standingBP readings). previousfalls Lastly,murmurs todifferentiate betweencausesoffalls. Medications: Benzodiazepines,Antipsychotics,Opiates, Anticonvulsants,Codeine.Medications that causes postural hypotension:antidepressants&betablockers Orthostatic hypotension Symptoms Sympathotonic orthostatic hypotension: drop BP and HR increase (hypovolaemia, medications, prolonged Causes: bed rest) -Diabetes • Aympathotonic orthostatic hypotension: drop in BP -Neurodegenerative disease and no HR increase (diabetic autonomic neuropathies, parkinsons) -Someone with hypertension • Postural tachycardia syndrome: HR increase after prolonged standing -Alpha-blockers AKA postural hypotension. Drop in BP (over 10- 20mmHg) within 3 minutes of standing. End of LifeCare Treatment • Physical, emotional, social, and spiritual support for patients and their families • Pain and symptom control to help patients be as comfortable as possible Fludrocortisone • Care in the hours, days, or months before a person dies • care and where to dies wishes about where to receive or midodrine • Support for families, carers, and other people who are important to the patient SBA 8. A 70 year old woman presents to clinic with concerns about slowed gait and frequent falls over the past few months. Her daughter notes that her handwriting has looked quite shaky as well, worse with the right hand. According to NICE, which of the following is required to officially diagnose the most likely differential? A) Neurological examination B) Full history and examination findings only C) Dopamine active transporter (DaT) scan D)123-I-FP-CIT single photon emission computed tomography (SPECT) E) Tissue biopsy SBA 8. A 70 year old woman presents to clinic with concerns about slowed gait and frequent falls over the past few months. Her daughter notes that her handwriting has looked quite shaky as well, worse with the right hand. According to NICE, which of the following is required to officially diagnose the most likely differential? A) Neurological examination B) Full history and examination findings only C) Dopamine active transporter (DaT) scan D)123-I-FP-CIT single photon emission computed tomography (SPECT) E) Tissue biopsyDegeneration of Dopamine producing neurons in Pathophysiology substantia nigra Impaired extrapyramidal tract controlling Low Dopamineproduction LowActivation ofdirectbasal Disruptsthe balance between dopamineand & ganglia pathway acetylcholineinthe basal ganglia Lowinhibition of indirect ganglia pathway Loss of MotorControl which can Impaired extrapyramidal tract HighGPI output HighSNRI controlling lead to tremor, rigidity and output Akinesia Bradykinesia, Impaired regulation of hypokinesia muscle tone Shuffling gait Pill rollingtremor Cogwheelrigidity leadpipe rigidity immediately apparent, may be induced byf not months of the year backwards. It is absentrecite during activity - eg, tipping water from cup to cup. •Rigidity presents as an RestingTremor Bradykinesia presents as a slowness of increase in resistance to voluntary movement and reduced automatic movements. It is particularly passive movement that can whilst walking. It can also be seen as a produce a characteristic flexed progressive reduction in the amplitude posture in many patients. It of repetitive movements - eg, asking may be increased by asking the patient to repeatedly oppose middle finger and thumb. Patients may the patient to perform an still retain the ability to move quickly in action in the opposite limb an emergency situation Parkinson Disease Diagnosis Bradykinesia Rigidity nosisof Parkinson Diag ism Muscular Postural Instability, Rigidity not caused r 4-6 Hz by visualor E ri resting cerebellar x e tremor dysfunction u +v L-dopainduced History of s i chorea&visual repeated o e hallucinations strokes n o r P UnilateralSx, rest Oculogyric t i tremor, Persistent crises r ro asymmetry Neuroleptic ai pu Cerebellar treatmentat S signs, onsetof autonomic symptoms involvement air etir c n oi sul cx E SBA 9. A 72 year old woman is having a medication review. You notice she was prescribed levodopa alongside entacapone. What best describes the mechanism of action of entacapone? A) Increase dopamine uptake in central nervous system B) Decrease dopamine breakdown by monoamine oxidase B C) Mimic the action of dopamine by stimulating relevant receptors D) Mimic the action of dopamine by blocking relevant receptors E) Decrease dopamine breakdown by catechol-O- methyl- transferase SBA 9. A 72 year old woman is having a medication review. You notice she was prescribed levodopa alongside entacapone. What best describes the mechanism of action of entacapone? A) Increase dopamine uptake in central nervous system B) Decrease dopamine breakdown by monoamine oxidase B C) Mimic the action of dopamine by stimulating relevant receptors D) Mimic the action of dopamine by blocking relevant receptors E) Decrease dopamine breakdown by catechol-O- methyl- transferase SBA 10. You are reviewing a patient with Parkinson’s disease in the ward after she was hospitalized for delirium. Her concerned partner reports that she has developed a penchant for gambling and seems to have experienced quite the ‘shift in personality’. What medication will you be most concerned about? A) Amantadine B) Glyropyrrolate C) Levodopa D) Pramipexole E) Seligiline SBA 10. You are reviewing a patient with Parkinson’s disease in the ward after she was hospitalized for delirium. Her concerned partner reports that she has developed a penchant for gambling and seems to have experienced quite the ‘shift in personality’. What medication will you be most concerned about? A) Amantadine B) Glyropyrrolate C) Levodopa D) Pramipexole Beware dopamine agonists E) Seligiline (pramipexole, rotigitine)• Multiple • Progressive pharmacological Parkinson’s System Supranuclear atrophy Palsy InitialDrugTreatment Characterisedby Investigations mayalsopresentwithpgazewith initially symptoms,oftenwithproblemslookingup apoor ortemporaryanddownon request, Sinimet/Medapor + Levodopa responsetolevodopdifficulty in following OR Functional MRI therapy. objectsup anddown. Functional CT MonoamineOxidase OR DopamineAgonist Mimicsparkinsonism: Inhibitors Alien hand accumulationof syndrome, abthebrain.Itisin For patient who fail to respond to therapeutic Apraxia and progressiveovertime doses of L-dopa administered for 12 weeks. MRI Adjuvant therapy Aphasia acognitionandep, behaviour scanning is needed to exclude rate secondary cause • Cortico-basal and extensive sub cortical vascular pathology Patientswho develop dyskinesiaor motor fluctuations degeneration • Lewybody despiteoptimallevodopatherapyshouldbeoffered achoice dementia of non-ergoticdopamine-receptoragonists(pramipexole, Functional MRI and CT imaging are useful research ropinirole, rotigotine),monoamine oxidaseBinhibitorsor tools. COMTinhibitors PalliativeAim: OcugyloricCrisis(Acute Dystonia and Tardive Dyskinesia) To allow patientsto diewith dignityina Facial Protrusionof the 1 supportiveenvironment Grimacing/Involuntar Physio/SALT y upward eye tongue,Smacking movements To refer - Referral maybe needed to social movement 2 services/decide with the patient and family Facial Nurse Multi-disciplinaryDr/Mental whether referral isappropriate Dyskinesia/Involuntary approach: Physical Health Laryngeal spasm psychological, movement of the socialandspiritual To treat any symptomsappropriatelyand tongue support 3 considerwithdrawal or reduction indrugs NOT prescribein one placeif the above Sxoccur Mental Health OT NMS vs Oculogyric crisis Oculogyric Neuroleptic Malignant Syndrome Crisis Acute dystonic reaction causing rigidity in extraocular Beware neuroleptic malignant syndrome in any muscles - beware of other dystonic reactions and EPSE patient withdrawn from or starting new • Known precipitants: neuroleptics (such as haloperidol, antipsychotics - can also result from missing or chlorpromazine, fluphenazine, olanzapine), delaying levodopa dose carbamazepine, chloroquine, cisplatin, diazoxide, • “Lead pipe rigidity” seen as opposed to cogwheel levodopa, lithium, metoclopramide, lurasidone, domperidone, nifedipine, pemoline, phencyclidine ("PCP"), reserpine, cetirizine, post encephalitic PD Management - offer ergot-derived dopamine Sign - paroxysmal conjugate upward deviation of eyeball agonists and/or dantrolene in hyperthermia, stop Management -IM antimuscarinic procyclidine, benztropine antipsychotics, push IV fluids to avoid renal • Conduct further meuromuscular testing to assess failure breathing, swallow, speech, range of movement Parkinson’s Medications AdvancedParkinson’sdisease AlternativeMedicine Alternativemedicine • To reduce risk of QT • Intestinal gel containing co- • Offer apomorphine prolongation, assess cardiac careldopa or continuous hydrochloride as intermittent risk factors and ECG monitoring subcutaneous infusion of injections or continuous and to ensure that the benefits foslevodopa with foscarbidopa subcutaneous infusions. outweighs the risks when may be used to treat advanced • To control nausea and initiating treatment. levodopa-responsive vomiting, domperidone started Parkinson's disease with severe two days before apomorphine • Consider a cholinesterase motor fluctuations and therapy, and then discontinued inhibitor for people with severe hyperkinesia or dyskinesia as soon as possible. Parkinson's disease dementia. • Consider memantine for people with Parkinson's disease dementia, only if cholinesterase inhibitors are not tolerated or are contraindicated. • [NICE Guidelines Parkinson’s Disease in Adults 2017] Parkinson’s Medications DDC inhibitors COMT inhibitors -Carbidopa (Central) COMT HighDopamine inhibitor availability Amantadine Dopamine L-Dopa L-Dopa Dopamine DopamineReceptor MAO-Binhibitors COMTinhibitors (peripheral) - Selegiline DopamineAgonist Tolcapone - Rasagiline MAO-B –Bromocriptine Entacapone /Ropinirole inhibitor Blood-Brain barrier SBA 11. An 80 year old woman presents to A/E with persistent growing tremors, twitching of the fingers, and involuntary grinding of the jaw over the past 2 weeks. Her eyes keep rolling up. She has a past medical history of stroke, schizophrenia, cancer for which she was on chemotherapy, and hay fever. Her current medications include aspirin, domperidone, quetiapine, and oral antihistamines. What is the likely cause of her presentation? A) Quetiapine B) Domperidone C) Neuroleptic malignant syndrome D) Serotonin syndrome E) Taking antihistamines and domperidone concurrently SBA 11. An 80 year old woman presents to A/E with persistent growing tremors, twitching of the fingers, and involuntary grinding of the jaw over the past 2 weeks. Her eyes keep rolling up. She has a past medical history of stroke, schizophrenia, cancer for which she was on chemotherapy, and hay fever. Her current medications include aspirin, domperidone, quetiapine, and oral antihistamines. What is the likely cause of her presentation? A) Quetiapine B) Domperidone C) Neuroleptic malignant syndrome D) Serotonin syndrome E) Taking antihistamines and domperidone concurrently Medication Reviews in Elderly “Many hypnotics with long half-lives Beware of prescribing have hangover effects, including • Dopamine (D2) antagonists: haloperidol, metaclopromide, drowsiness, unsteady gait, slurred speech, and confusion. Hypnotics with prochlorperazine, domperidone short half-lives should be used. Short • Antipsychotics - phenothiazines and butyrophenones courses of hypnotics are useful for • Benzodiazepines - lorazepam (unless PD patient in delirium) helping a patient through an acute Refer to STOPP (Screening Tool of Older Persons' potentially illnes but avoid dependence. Benzodiazepines impair balance, which inappropriate Prescriptions) and START (Screening Tool to Alert to can result in falls.” Right Treatment), as markedly changed pharmacokinetics increases risks of over-concentration, renal failure, slow gastric motility, and “Diuretics are overprescribed in old age and should not be used on a long-term delirium. Consider lower maintenance doses of: basis to treat simple gravitational • Digoxin oedema which will usually respond to • Warfarin increased movement, raising the legs, • Lithium and support stockings. A few days of diuretic treatment may speed the • NSAIDs clearing of the oedema but it should rarely need continued drug therapy.” Read further on Cockcroft and Gault formula for creatinine clearance and assessing anticholinergic burden. SBA 12. A patient attends PD clinic with concerns about increased sleepiness during the daytime, which heavily impacts their activities. They are on levodopa with co-beneldopa. They deny hallucinations, impulsive behaviour, dizziness, or other symptoms suggesting complications of PD. What is the best medication to prescribe for their daytime somnolence? A) Increase dose of levodopa B) Clonazepam C) Rotigitine D) Vitamin supplements E) Modafinil SBA 12. A patient attends PD clinic with concerns about increased sleepiness during the daytime, which heavily impacts their activities. They are on levodopa with co-beneldopa. They deny hallucinations, impulsive behaviour, dizziness, or other symptoms suggesting complications of PD. What is the best medication to prescribe for their daytime somnolence? A) Increase dose of levodopa B) Clonazepam C) Rotigitine D) Vitamin supplements E) ModafinilManaging Non-Motor Complications Complication Reason Medication Side Effects Daytime Daytime somnolence (often due to MODAFINIL Review every year somnolence levodopa therapy) Often due to autonomic symptoms of PD MYDODRINE Orthostatic Check BP frequently, especially in hypotension or dopaminergic therapy, HYDROCHLORIDE (1rst line), falls anticholinergics, antidepressants FLUDROCORTISONE Extension of day-time motor symptoms Levodopa or oral selegiline Inform of risk of impulse disorder Nocturnal akinesia or end-dose deterioration first line, rotigitine with all dopaminergic therapy Hallucinations and/or delusions due to Lower doses needed for PD patients Psychosis enhanced dopaminergic activity in the QUIETIAPINE, CLOZAPINE than others frontal lobe REM sleep behaviour Due to damage to pons controlling Beware melatonin in patients who disorder muscle paralysis in usual REM sleep CLONAZEPAM, MELATONIN forget frequently! SBA 13. A 70 year old woman is brought into the general practice by her worried daughter. She has been more forgetful over the past year, on some days more than others, and seems to struggle to keep her focus on simple daily activities and conversations. Her daughter is also worried as she occasionally states she is talking to their dog whilst apparently talking alone, although they have never had any pets. Over the past month, she has also developed a tremor that prevents her from writing. Currently, the patient is talking to you clearly and able to understand instructions. Before examining her, what is the most likely diagnosis you’d be concerned about? A) Parkinson’s disease B) Hyperactive delirium C) Lewy body dementia D) Alzheimer’s dementia E) Vascular dementia SBA 13. A 70 year old woman is brought into the general practice by her worried daughter. She has been more forgetful over the past year, on some days more than others, and seems to struggle to keep her focus on simple daily activities and conversations. Her daughter is also worried as she occasionally states she is talking to their dog whilst apparently talking alone, although they have never had any pets. Over the past month, she has also developed a tremor that prevents her from writing. Currently, the patient is talking to you clearly and able to understand instructions. Before examining her, what is the most likely diagnosis you’d be concerned about? A) Parkinson’s disease B) Hyperactive delirium C) Lewy body dementia D) Alzheimer’s dementia E) Vascular dementia SBA 14. A 62 year old man comes to neurology clinic complaining of akinesia in the right side of his body that initially started last year over the course of 3 months, and progressing to the left since. He has had trouble coordinating himself whilst moving things with his hands, writing, and even pouring himself tea. Sometimes he feels his right hand is not his own, due to the pronounced involuntary twitching he experiences. He was started on levodopa last time he had seen a doctor, which had no benefit. What is the likely diagnosis for this patient? A) Corticobasal degeneration B) Multiple system atrophy C) Progressive supranuclear palsy D) Motor neuron disease E)Parkinson’s Disease SBA 14. A 62 year old man comes to neurology clinic complaining of akinesia in the right side of his body that initially started last year over the course of 3 months, and progressing to the left since. He has had trouble coordinating himself whilst moving things with his hands, writing, and even pouring himself tea. Sometimes he feels his right hand is not his own, due to the pronounced involuntary twitching he experiences. He was started on levodopa last time he had seen a doctor, which had no benefit. What is the likely diagnosis for this patient? A) Corticobasal degeneration B) Multiple system atrophy C) Progressive supranuclear palsy D) Motor neuron disease E)Parkinson’s Disease Parkinson’s Plus Syndromes Corticobasal degeneration Progressive Supranuclear Palsy Characterised by progressive nerve (Steele-Richardson-Olszewski syndrome) Sudden onset extrapyramidal/axial rigidity cell loss and atrophy of multiple areas along nigrostriatum. with paralysis of eye movement, marked by restriction of voluntary eye movements in Symptoms are usually gradual over vertical plane (up, down or both). Progresses year, unilateral and involve arms - ‘alien limb syndrome’ with observable to instability and frequent falls, pseudo- bulbar swallowing, speech difficulties. involuntary involvement. Classical ‘diagnostic’ findings No definite diagnostic criteria - consider if levodopa unresponsive and • Restricted vertical saccadic movements in not similar to other syndromes a supranuclear pattern (‘reading’). • Visuo-spatial impairment Multiple System Atrophy Curvilinear path on downward saccades (previously Shy-Drager syndrome) (‘round-the-houses’ sign) • Apraxia • Dysphagia Rigidity and autonomic features • Slow saccades (tip: compare vertical to more prominent at onset, tremor is horizontal saccades). ‘Round-the- houses’ are seen with saccadic rare and levodopa response is poor. movements on command to target. Only intervention is to maintain postural BP, avoid diuretics and hypotensive, etc. SBA 15. You are bleeped on the ward for a 72-year-old woman with metastatic liver cancer presenting with worsening nausea and vomiting. Her symptoms are associated with early satiety, abdominal distension, and a history of delayed gastric emptying. Her current medications include opioids for pain management, and imaging has ruled out bowel obstruction. What is the most appropriate therapy for this patient? A) Metoclopramide B) Ondansetron C) Cyclizine D) Dexamethasone E)Lorazepam SBA 15. You are bleeped on the ward for a 72-year-old woman with metastatic liver cancer presenting with worsening nausea and vomiting. Her symptoms are associated with early satiety, abdominal distension, and a history of delayed gastric emptying. Her current medications include opioids for pain management, and imaging has ruled out bowel obstruction. What is the most appropriate therapy for this patient? A) Metoclopramide B) Ondansetron C) Cyclizine D) Dexamethasone E)Lorazepam Indications for Anti-Emesis Therapy Reduced gastric motility Raised ICICP Chemical Disturbances Reduced gastric motility Chemical Disturbances Causes: hyponatraemia, hypercalcaemia, Causes: intracranial tumours, chemotherapy, opioids Causes: opioids, GI cancers, ileus, haematoma neuromuscular disease Management : Chemical disturbance Treatment: Cyclizine first line, should be corrected first, naloxone for Treatment: D2 receptor antagonist opioid overdose (domperidone) and/or joint 5-HT4 dexamethasone can also be used receptor antagonists Radiotherapy can be considered if due Ondansetron, haloperidol and/or to cranial tumours/metastases levomepromazine (metoclopramide) Vestibular Visceral Cortical (psychosomatic) Vestibular Visce l Cortical (ps chosomatic) Causes: activation of acetylcholine Causes: constipation, oral candidiasis Causes: anxiety, fear, pain and histamine (H1) receptors, due to motion or base of skull tumours Treatment: Cyclizine and Treatment: GABA-inhibition Treatment: cyclizine as a first-line, Refractory vestibular causes with levomepromazine are first-line, anti- (lorazepam) or cyclizine cholinergics (hyoscine) can be useful metoclopramide or prochlorperazine Atypical antipsychotics (olanzapine or risperidone) in refractory cases SBA 16. An 80-year-old woman with advanced liver cancer and bone metastases is reviewed in clinic. She takes 30 mg of modified-release oral morphine twice daily but has to take her 10 mg breakthrough morphine very frequently - up to 3 times a day. Upon further discussion, it is decided that her total daily modified-release morphine dose will be increased by 50%. Which option is the best breakthrough treatment for this patient? A) 15 mg of oral immediate release morphine B) 15 mg of oral modified release morphine C) 15 mg of subcutaneous immediate release morphine D) 30 mg of oral immediate release morphine E)30 mg of oral modified release morphine SBA 16. An 80-year-old woman with advanced liver cancer and bone metastases is reviewed in clinic. She takes 30 mg of modified-release oral morphine twice daily but has to take her 10 mg breakthrough morphine very frequently - up to 3 times a day. Upon further discussion, it is decided that her total daily modified-release morphine dose will be increased by 50%. Which option is the best breakthrough treatment for this patient? A) 15 mg of oral immediate release morphine B) 15 mg of oral modified release morphine C) 15 mg of subcutaneous immediate release morphine D) 30 mg of oral immediate release morphine E)30 mg of oral modified release morphine SBA 17. A 56-year-old patient with pancreatic cancer is being managed on the palliative ward, he requires analgesia for pain - he has already got paracetamol, ibuprofen and codeine prescribed regularly. His bloods from that morning are back, his renal function tests show: What would be the most appropriate analgesia to prescribe for this patient? Na+ 140 mmol/L (135 - 145) K+ 3.6 mmol/L (3.5 - 5.0) A) Diamorphine Bicarbonate 24 mmol/L (22 - 29) B) Dihydrocodeine Urea 6.0 mmol/L (2.0 - 7.0) C) Morphine D) Dexamethasone Creatinine 153 µmol/L (55 - 120) E)Oxycodone 44 eGFR ml/min/1.73m2 SBA 17. A 56-year-old patient with pancreatic cancer is being managed on the palliative ward, he requires analgesia for pain - he has already got paracetamol, ibuprofen and codeine prescribed regularly. His bloods from that morning are back, his renal function tests show: What would be the most appropriate analgesia to prescribe for this patient? Na+ 140 mmol/L (135 - 145) K+ 3.6 mmol/L (3.5 - 5.0) A) Diamorphine Bicarbonate 24 mmol/L (22 - 29) B) Dihydrocodeine Urea 6.0 mmol/L (2.0 - 7.0) C) Morphine D) Dexamethasone Creatinine 153 µmol/L (55 - 120) E)Oxycodone 44 eGFR ml/min/1.73m2 NICE Guidelines for Analgesia • In opioid-naive patients - offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain • if no comorbidities, use 20-30mg of nodified release tablets a day with 5mg oral morphine solution as required for breakthrough pain. • oral modified-release morphine should be used in preference to transdermal patches • laxatives should be prescribed for all patients initiating strong opioids • patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered • drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered SIGN issued guidances • the breakthrough dose of morphine is one-sixth the daily dose of morphine • all patients who receive opioids should be prescribed a laxative • opioids should be used with caution in patients with chronic kidney disease ⚬ oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment ⚬ if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred • metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy SBA 18. A 70 year old man with metastatic lung cancer is referred to the palliative care team for end of life care. Currently, he takes 10mg oral morphine daily which effectively controls his pain. However, he has had difficulty swallowing, so anticipatory medications are prescribed in a syringe driver. How much daily subcutaneous morphine needs to be given? A) 15 mg B) 6.7 mg C) 3 mg D) 5 mg E)10 mg SBA 18. A 70 year old man with metastatic lung cancer is referred to the palliative care team for end of life care. Currently, he takes 10mg oral morphine daily which effectively controls his pain. However, he has had difficulty swallowing, so anticipatory medications are prescribed in a syringe driver. How much daily subcutaneous morphine needs to be given? A) 15 mg B) 6.7 mg C) 3 mg D) 5 mg E)10 mg Pharmacy Conversions • For patients already on opioids with poorly managed pain, increase their next dose by 30-50% of their total Conversion From To original dose factor • Oral oxycodone is twice as strong as oral morphine, but the current BNF uses a conversion rate of 1.5 Subcutaneous Oral morphine morphine Divide by 2 • Transdermal fentanyl 12 microgram patch = 30 mg oral morphine daily • Transdermal buprenorphine 10 microgram patch = 24 Oral morphine Subcutaneous Divide by 3 diamorphine mg oral morphine daily. Conversion Oral morphine Oral oxycodone Divide by 1.5-2 From To factor Subcutaneous Oral oxycodone diamorphine Divide by 1.5 Oral codeine Oral morphine Divide by 10 this has previously been stated as 5 Oral tramadol Oral morphine Divide by 10** but the current version of the BNF states a conversion of 10 SBA 19. You are an F1 doctor on the palliative care center asked to review a 93 year old man with advanced prostate cancer and bone metastases. The patient has been delirious lately and sleeping often, as he is approaching final days of life. His family have noticed that he seems to be making rattling sounds while he sleeps. The patient has granted his daughter lasting power of attorney for both health and finance. What is the best course of action? A) Inform the family of the cause and offer a CPAP machine B) Consider prescribing glycopyrronium bromide C) Inform the family of the cause and consider prescribing hyoscine hydrobromide D) Inform the family of the cause and consider prescribing hyoscine butylbromide E)Refuse to prescribe SBA 19. You are an F1 doctor on the palliative care center asked to review a 93 year old man with advanced prostate cancer and bone metastases. The patient has been delirious lately and sleeping often, as he is approaching final days of life. His family have noticed that he seems to be making rattling sounds while he sleeps. The patient has granted his daughter lasting power of attorney for both health and finance. What is the best course of action? A) Inform the family of the cause and offer a CPAP machine B) Consider prescribing glycopyrronium bromide C) Inform the family of the cause and consider prescribing hyoscine hydrobromide D) Inform the family of the cause and consider prescribing hyoscine butylbromide E)Refuse to prescribe Anticipatory Prescribing Secretions Anti-emetics Hyoscine butylbromide 20mg Most commonly SC. Do not repeat within 1- Haloperidol 0.5 – 1.5mg SC. hour, maximum dose 120mg Do not repeat within 4 hours, in 24 hours maximum dose 3mg in 24 hours. Hyoscine hydrobromide (BNF doesn’t have preference - Analgesia butylbromide less sedative) Morphine sulphate 1 – Consider glycopyrronium 2.5mg SC. Do not repeat bromide within 1-hour, maximum 4 doses in 24 hours If reduced renal function Agitation (eGFR <50): Oxycodone 1 Midazolam 2.5 – 5mg – 2 mg SC. Do not repeat within 1-hour, maximum 4 SC. Do not repeat within 1 hour, maximum 4 doses in 24 hours doses in 24 hours. SBA 20. You are an F1 doctor teaching medical students about syringe drivers, particularly for polypharmacy patients. Most medications are safe for use together in syringe drivers, except for? A) Glycopyrronium hydrobromide B) Morphine and cyclizine C) Diamorphine only D) Cyclizine and haloperidol E)Cyclizine and diamorphine SBA 20. You are an F1 doctor teaching medical students about syringe drivers, particularly for polypharmacy patients. Most medications are safe for use together in syringe drivers, except for? A) Glycopyrronium hydrobromide B) Morphine and cyclizine C) Diamorphine only D) Cyclizine and haloperidol E)Cyclizine and diamorphine Deprivation of Liberties Now called LIBERTY PROTECTION SAFEGUARIDNG - BMA 2022 • Occurs where someone is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements. • During provision of care to adults who may temporarily or permanently lack relevant decision-making capacity, it may be necessary to treat them in circumstances that amount to a deprivation of liberty • Care or treatment amounting to deprivation of liberty • Identifying/ authorising deprivation of liberty should not substitute for does not mean that it is inappropriate. It means only that it reaches a certain threshold of restriction and or impede the delivery of highest standard of care. • The focus of decision-making must remain the best interests of the authorisation is required. patient. • Nothing in the MCA (mental capacity act) or DoLS (deprivation of liberty safeguards) is designed to prevent timely and appropriate medical treatment. In an emergency, treatment must not be delayed for the purposes of identifying whether a deprivation of liberty has taken place, or seeking its authorisation. SBA 22. The supervisory body must arrange a series of assessments when it receives a DoLS request for authorisation. What assessments does this not include? A) 4AT delirium assessment B) Age assessment C) Mental health assessment D) Mental capacity assessment E)No refusals assessment SBA 22. The supervisory body must arrange a series of assessments when it receives a DoLS request for authorisation. What assessments does this not include? These assessments are made by A) 4AT delirium assessment qualified healthcare B) Age assessment professionals on request of the C) Mental health assessment supervisory body, including: E)No refusals assessmentsment capacity, best interests, eligibility and no refusals.Thank You Any questions?