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Ge ra ricsMe dicine DeliveDr.Ashlin Nourolahi-OskouiDisclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.LearningOutcomes •Falls •Delirium •Dementia •SBAsFalls OSCE Scenario You are a junior doctor working in ED. An 82-year-old female patientpresents following an unwitnessed fall at home.Please take a historyandexamine this patient. What questions should youask? Which investigations are important?History of PresentingComplaint • Before After oWhat were theydoing oHow did theyget up? beforehand? oHowlong on the floor for? oCan theyremember? oContinence? oSymptoms? Now • During oSystem review oHowdid they fall? oHead injury? oLOC? oDo they knowif it was witnessed?Past MedicalHistory DrugHistory • Past falls? Antihypertensives • Cognitive impairment? Sedatives • Dementia diagnosis? Diuretics • CVS conditions? Antidepressants Anticholinergic burden • Posturalhypotension? Steroids • Parkinsons disease? Anticoagulants Compliant with antiepileptics? • Sensory impairment? • Diabetes? Others • Epilepsy?SocialHistory • What type of house? • Stairs? - stair lift, rails? • Toilet upstairs or downstairs? • Who they live with? • POC? • Independent of ADLs? • Alcohol,smoking? • Pendent Alarm?Examination • CVS oHeart rate - Irregular? Weak? oMurmur – ESM? oBP- Lying and standing • Resp • Abdo o constipated? Enlarged bladder? • Neuro o Evidence of stroke? Neuropathy? Cerebellar signs? Assess gaitWhatinvestigationswouldyourequest?What investigationswould yourequest? • Bedside o Obs, L+S BP , BM o ECG o Urine MCS,bladder scan o PR • Bloods o FBC,UE, LFT, BP ,CRP, Coags o Confusion screen • CXR • CT head o lower threshold especially ifon anticoagsManagement • MDT review • 1:1 nursing ifconfused • Non-slipsocks • Medication review • POC • Home adjustments • Falls clinicOSCE scenario 85-year-old malepatientpresentsto the acutemedicalunitwitha UTI. Overnightshe becomesagitated,restlessanddoesn't sleep.Hehas visualhallucinations. Heisn'torientated totime,place orperson. PMH:HTN,CKD3 DH: Amlodipine, atorvastatin What isthemost likelydiagnosis: • Schizophrenia • Dementia • Delirium • Charles BonnetSyndrome • BipolardisorderWhat is delirium? • Delirium (sometimes called'acuteconfusional state') isanacute, fluctuating syndromeofencephalopathy causing disturbed consciousness, attention, cognition, andperception • Behaviour changes • Altered cognition • Inattention • Disorganised thought • Altered perception - hallucinations 30% • Altered physical– hypoorhyperactive • Altered social behaviour • Altered consciousnessCauses of Delirium Risk factors of Causesof Delirium Delirium • Pain >65 • Infection Previous episodes Dementia • Nutrition Hip fracture • Constipation Severe concurrent illness • Hydration • Medication • EnvironmentWhat screeningtools canbeused?CAM A positive or negative result depends on four criteria: 1. Acute onset and fluctuating course • Determined by collateral history or repeated clinic assessment 2. Inattention • Counting from 20-1 is a simple (if blunt) test for this 3. Disorganised thinking 4. Altered levels of consciousness The CAM is positive for the presence of delirium if both features 1 and 2 are present, with at least one of 3 or 4. • Age AMTS • Currenttime(to thenearest hour) • Recall:Askthepatienttorememberan address(e.g. 42 WestStreet) • Currentyear • Currentlocation • Recognisetwopeople • Dateof birth • Yearsof the first world war • Nameof thecurrentmonarch • Countsequentially backwardsfrom20to1 • A scoreof lessthan8inthe AMTS implies the presence ofcognitiveimpairmentInvestigations • Urinedip/MCS • FBC • UE • CRP • LFT • Bone profile • VitB12,folate • TFT • CXR • Bladder scan • CT head • CulturesManagement • Treat underlying cause • Reviewmedications • Optimise comorbidity management • Clocks visible • Continuity of care • Encourage visits • Encourage mobilisation • Normalise sleep-wake cycleDrugtreatment Onlyusedif a harm to themselvesor others. If alcoholwithdrawal start GMAWS Haloperidol 0.5-2mg PO/SC/IM UnlessPD, DLB, alcohol withdrawalQR codeforfeedbackDementia Dementiaisirreversible, progressivedecline andimpairmentof more language,personality,emotion). Thisoccurswithout impairment of consciousness.Causes • Alzheimer's • Vascular • Lewybody • Frontotemporal • Huntingdon's • Priondisease/CJD • Tumours • HIV, Syphilis • ParkinsonsdiseaseAlzheimer's • Progresssteadily over time. • Thehistologicalfeaturesare beta- Management amyloid oMemory clinic plaques andneurofibrillary oAcetylcholinesteraseinhibitors tangles (bundlesoffilaments within oNMDA-R inhibitors protein).mostly madefrom tau • many functionsandabilities can be impacteduponandeventually lost. • Themostcommonpresenting symptom is memory loss, with evidence ofvarying changesin orientation.soning, speechand • Global cortical atrophy Vascular • Syndrome of cognitive impairment caused byischaemia or haemorrhage secondaryto cerebrovascular disease. • Risk factors: oStroke, TIA, AF, HTN,DM, Hyperlipidaemia, smoker, coronary heart disease • Stepwise deterioration of cognition over months-years. • Onsetof dementia within 3 months following stroke • No specific managementLewyBodyDementia • Fluctuating cognition • Visualhallucinations • REM sleep behaviour disorder • ≥1 symptomof parkinsonism (dementia develops before this) • in substantianigra, paralimbic and neocorticalstructuresons • In contrast to alzheimers oEarly impairment to attention andexecutivefunction ratherthan memory oFluctuating cognition • Clinicaldiagnosis (may be SPECT scan) • Mx: AChEi,memantine,avoid neurolepticsFrontotemporalDementia • Behaviour variant oPersonality changes - apathy oBehaviour disturbed- socially/sexually • Primary progressive aphasia variant • Language difficulties e.g.,apraxia, problems naming things • No speicifc mx oAvoid AChEi andmemantine.SBA1 was referred to memory clinic. They were diagnosed with AD. Whichand medication should you consider stopping? 1. Apixaban 2. Alendronic acid 3. Aspirin 4. Simvastatin 5. AmitriptylineSBA1 1. Apixaban 2. Alendronic acid 3. Aspirin 4. Simvastatin 5. Amitriptyline TCAs in dementia can worsen cognition.SBA2 80M attends memory clinic. PMH: HTN, hyperlipidaemia. Used to smoke 20 cigarettes per day. He had a previously stable congition but his wife happened. He has no visual symptoms. What is the most likely diagnosis?has 1. Vascular dementia 2. LBD 3. PD 4. FTD 5. ADSBA2 1. Vascular dementia 2. LBD 3. PD 4. FTD 5. AD Stepwise deterioration. Risk factors present.SBA3 Elderly male patient diagnosed with alzheimers dementia. Has been started on donepezil. Which are relative contrindications to donepezil? 1. Bradycardia 2. eGFR 60 3. Mild Alzheimer's dementia 4. Sick sinus syndrome 5. Vascular dementiaSBA3 1. Bradycardia 2. eGFR 60 3. Mild Alzheimer's dementia 4. Sick sinus syndrome 5. Vascular dementiaSBA 4 80M attends GP . He has been having issues with memory, periods of confusion and sleepiness for over a year. He has recently noted a resting tremor in his hand. What is the most liekly diagnosis? 1. AD 2. LBD 3. Parkinons dementia 4. Vascular dementia 5. Mild cognitive impairmentSBA 4 1. AD 2. LBD 3. Parkinon's dementia 4. Vascular dementia 5. Mild cognitive impairmentSBA5 85F admitted with delirium secondary to CAP . Despite IV Abx she is agitated and aggressive. You consider prescribing haloperidol. When should you not prescribe this medication? 1. Depression 2. Benign essential tremor 3. Parkinson's disease 4. Alzheimer's 5. EpilepsySBA5 85F admitted with delirium secondary to CAP . Despite IV Abx she is agitated and aggressive. You consider prescribing haloperidol. When should you not prescribe this medication? 1. Depression 2. Benign essential tremor 3. Parkinson's disease 4. Alzheimer's 5. EpilepsySBA6 of cognitive impairment presents with a tremor and shuffling gait. They have also lost control of their bladder and are incontinent of urine. Which is a likely diagnosis? 1. Alzheimer's dementia 2. Lewy body dementia 3. Epilepsy 4. Normal pressure hydrocephalus 5. Huntington's diseaseNormal Pressure Hydrocephalus Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. Ventricular dilatation present in the absence of raised CSF (normalpressure on LP). Causes: idiopathic, SAH, meningitis, head injury, or malignancy. Triad of Parkinsonian gait, urinary incontinence, and dementia On CTimaging, there will be ventricular enlargement, which is in excess to sulcal atrophy and periventricular lucency. The mainstay of treatment is through surgical insertion of a CSFshunt.FOR FEEDBACK AND QUERIES: Email @ info@bidasw.com