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All right guys. So I think we could just get started again. Let me know if there's any problem with the screen share or anything like that because um sometimes Zoom um tends to be playing up with us. Um Now I'm Katina, I'm one of the final year medical students slash um F zeros. And um tonight, I'm just gonna be having a quick chat to you about care of the elderly geriatrics or whatever you want to call it. Um It is quite um sort of detailed topic because it entails everything that general medicine entails. And to be honest, majority of general med patients are elderly, but there are a couple of particularities and a couple of things that they like to include in exams from what we've seen along the years and I would take care of the elderly is particularly important for the oy. So we will have a couple of osk points along the way. I have sort of tried to um keep the osk uh points for our ay specific lecture. However, I just included one of the most important aspects for the osk that I think you will have to remember whenever it comes to care of the elderly or any elderly person. Now, you've got my name and my email address there and towards the end of the presentation there is my phone number as well in case you wanna whatsapp me or anything with questions about placement, um, care of the elderly or any other, any other thing. So, without any further, do I think we can get started and again, any questions or anything, put them in the chart or just simply unmute and stop me because I sometimes tend to sort of talk too much and um sort of confuse people. So hopefully we'll keep it nice and straightforward. Starting off with falls and bone health. Then looking a tiny bit of nutrition and just covering uh the basics of what you will need to know in case nutrition comes up as an AUS station for care of the elderly. Then we need to look at a polypharmacy because there is no exam that does not contain a polypharmacy question on care of the elderly or something like what medication has caused these patient's BP to drop whenever they stand up and things like that. Then we'll get into sort of the more medical aspects that are um concerning people over 65 things like stroke or tia. Then we'll look a tiny bit into neuropsychiatry, including dementia delirium and a tiny bit of Parkinson's disease. And lastly, we'll be briefly touching on incontinence because it is once again a problem that mainly affects the elderly and it's um sort of such a multifactorial problem that needs to be discussed. So, starting off with falls and bones, well, this diagram is just showing you the whole etiology of falls and we've got so, so many causes that may be predisposing somebody to have a fall and we always need to keep them in the back of our heads. Maybe not for MCQ S. Although there are a couple of things that might be popping up in MC Qs, but particularly for the Os, whatever, you can easily get a question on um somebody who's fallen and take a false history or take a collateral false history from somebody else. So it's important to have a very, very broad view of what might be predisposing to um falls. Well, obviously, the main sort of problems are with regards to weakness and frailty just because the elderly are gonna have a decreased muscle strength, decreased power and they are just gonna be more unstable on their feet. Then they might have vision defects including cataracts as well as reduced facial acuity. There may be issues with their knees being very, very sore and stiff due to the arthritis. They might have, as we were saying, weak muscles or they might just be having this like deconditioning this fly, fly, fly state, whatever they are just gonna be um sort of struggling on their feet. There may be issues with Parkinson's disease, which obviously affect the patient's capacity to move and to sort of, um, maintain their posture. And that might lead to a fall as well as, um, issues like, um, heart problems which are really, really important to consider. Whenever you talk to somebody about their fall, the environment is also a huge trigger for falls. Probably the main one other than anything else. Whenever people have cluttered homes with poor lightning, they've got a lot of stairs, they've got like very uneven floors. There's many rugs and just a lot of clutter around and they just trip and fall. I was recently hearing about a patient who tripped on their catheter and fell. So it is things like this that might be predisposing them to falls and in terms of the effect of falls because it's always important to look at um sort of the other side of the coin what happens to the patient after they have fallen and it might lead to bruising fractures, even brain hemorrhages. There may be issues with dehydration, pneumonia and death. And if you've been on the words and you've surely seen the amount of patients that come in with unwitnessed falls and then they decondition, deteriorate and they end up in nursing home residents. Um because the fall has been their life changing event that has led to um sort of their health completely deteriorating. Obviously, falls also have a mental impact that would be always nice to highlight in an oy station, things like depression, they lose confidence in their feet and they sort of become housebound bed bound and that just limits all of their activity. Now, in terms of the main investigations that you need to do for falls, um, there are three main key investigations that you need to do. If you always, always for anybody who's fallen, need to check their lung and standing BP. You want to check their ECG to ensure that this is not a cardiac cause. And you also want to be checking their blood glucose to ensure that um, it wasn't a hypoglycemic episode. So always do the um, do a urine dip just to check if there's any infection. Do an E CG. Again, that's a mandatory aspect. Make sure that they are not bradycardic or in any kind of um heart block, check their bloods, including their bone profile, particularly for their calcium, their magnesium, check their thyroid function test and also check their um, liver function test because all of these may be predisposing them to um falling. If there is any sign of injury, any pain, any mobility, make sure to do an X ray and a CT head. If the fall has included um sort of um of, of head injury or if they are on any anticoagulants, maybe you can do like an echocardiogram if you suspect anything to do with their heart. But obviously, that's gonna be something that doesn't happen acutely and also check their medications, um, as they might be one of the worst offenders over here, then make sure to fix the injury. So make sure the patient will be treated adequately. And then suggesting rehab is also great tackle the patient's fears and anxiety. Educate about false prevention and environmental hazards. Try to, um, um sort of encouraging dependence and also try to encourage them to, um, sort of consider the environment they're living in, consider getting a false alarm and all of those um sort of tiny lifestyle changes that might actually make a difference for them. Then false prevention is very, very important, making sure that the episode is not gonna be recurring because obviously with more episodes like this, the higher the risks will be. Um So it's all about assessing their safety. Are they ok to be at home or do they need cars or do they need placement? Involve a geriatrician as well as the pharmacist, ot physiotherapist and social workers. And we did have a station last year in oral case, whatever we had to do a full comprehensive geriatric assessment on a patient who's fallen. And we had to include all of these aspects about her own mobility as well as their baseline and what has happened and how confident they are feeling now and also um look at their bone health, making sure that um the patient, whether they are osteopenic or osteoporotic are reviewed and treated cause the worst thing would be for them to fall again and get a um a fracture on top of that. So, complications of false, probably the most M CQ, the highest YMC Q would be the one about rhabdomyolysis. A long line will be considered any lie longer than two hours. And rhabdomyolysis, which is just a breakdown of the b of the muscle, which releases creatine kinase, a protein found in the muscle cells, it might come back higher than 1000. And that's sort of an indication that rhabdo has um occurred. And as you probably know, um we fear rhabdomyolysis because creatine kinase is quite toxic to the kidneys. And with such high levels, there is no other place in the body where creatine kinase will deposit other than the kidneys. So that might lead to them having an AK I and um become very, very unwell quite rapidly. Now, if a person has been lying for more than two hours, they're surely gonna become dehydrated. They are, they might even get a pressure ulcer cause their skin is quite thin and they are quite frail. They might get hypothermia, they may become delirious and they might even get pneumonia from all of those factors. Now, the two special tests that I wanted to sort of bring to your attention and you won't need to be able to perform them, but it would be nice for you to impress the osk examiners by um mentioning them are the timed up and go and the 3rd, 100 and 80 and these are just two diag drops which are showing you how to perform them. Basically, they do what they say, um, turn 100 and 80 you're just watching the patient turn, stand up and go. It's just stand up without using their arms and then try to go and see how well they perform at those. They are indicators of their baseline and they are really useful in assessing the patients um risk of falls. And um we might pop up in MC Qs or even in um the Os case. Now, going through bone health really, really quickly. This is a very useful table that I have used for my um revision in the previous years, which compares the types of bone disease and the levels of calcium phosphate and alkaline phosphatase and we'll go through the majority of them in turn. However, if you understand the physiology behind that, um you're surely gonna have no problem. So this table would be used for um revision just before exams with no um kind of issue. So in terms of osteoporosis, which is the most common sort of bone disease that the elderly are facing. It simply means a reduction in bone mass with normal mineralization, the bone will look completely normal on X ray. However, the quality of the bone will be um the mass of the bone, the sort of structure of the bone will be quite depleted. Two major risk factors which you might meet in M CQ is our age, the older we get, the more prone we are to this and being female because of the lack of estrogen after menopause. Other very important factors that you should never forget about are steroids and alcohol steroids are massively predisposing even young people um to osteoporosis. And that's why whenever a patient is started on long term steroids, they are gonna be considered for bone protection with bisphosphonates, calcium and Vitamin D immobility and family history are also quite important. However, the main ones to remember will be your age, your gender as well as the steroids and the alcohol. Now, usually women over 65 and men, over 75 are gonna be assessed using the Frax score, which can be done in general practice, which estimates the risk of fragility fracture, a fragility fracture representing a fracture that happens uh whenever the mechanical force is not strong enough to be causing a fracture in a normal person. And the frax score is usually calculated very similar to the Q risk score. So it is a, an online tool that doesn't require any kind of tests. Now, the dexa scan on the other side is the proper x-ray scan which measures the bone mineral density. So it actually checks how much bone mass there is. Um and the T score is gonna be the important number. Again, M CQ alert posed is filled with these questions about um the patient's T score. You may or may not be provided with um an indication in our, in with a diagram that explains them. In our finals, we got the diagram that was telling us um the levels were normal osteopenia and osteoporosis, but it's not um too hard to remember. So anywhere less than minus one, it's normal minus one to minus 2.5 is osteopenia and minus 2.5 or lower is osteoporosis. And if the patient has um a score of minus two and a fracture, that established osteoporosis, which needs treatment. And in terms of management, whenever you're asked about the management of any condition, always start with a non pharmacological management. So, um activity and weight bearing exercise are absolutely fantastic. So, refer the patient to a physiotherapist may be in an a scenario or an M CQ good diet and stopping smoking and alcohol consumption are also very important for tackling these issues before we jump into medication. Then in terms of the pharmacological management, you want to, first of all, check the patient's bone profile, check their Vitamin D and calcium and check if they are depleted in Vitamin D and calcium and replace them if they are inadequate. And you want to be doing that before you start bisphosphonates because the bisphosphonates are working in conjunction with Vitamin D and calcium. And if the patient is depleted in them, bisphosphonates won't be as efficient. Um, no bisphosphonates in terms of sort of the first line will be alendronic acid. And before you decide to change the, before you decide to change, um, the formulation of the drug because the patient cannot tolerate that, try another bisphosphonate and the other medications will be the Nouma Stron um, raloxifene and a couple of other ones. The Nouma is a monoclonal antibody and it's quite an expensive drug. So that's why it's kept a sort of third line. Um but bisphosphonates have been around for a while and they are very good at tackling these issues. Um Make sure, you know, the side effects the contraindications and sort of the main red flags for bisphosphonates for your oy because they might be quite a high yield um topic. So, always remember the way they are supposed to be taking it, the side effects they need to watch out for. And um sort of remember about the medication gap and the fact that they need to be reviewed after five years on the drug, then our next stop will be osteomalacia, which is gonna be decreased bone mineralization due to Vitamin D deficiency. So these are gonna be just a poorly manufactured bones in my head. They are just gonna be the sort of jellylike bones, they are not gonna be well formed and they are not gonna be um sort of mineralized enough. It's usually caused by a lack of sunlight, dietary chronic renal failure or malabsorption of Vitamin D and it features bone pain because the bones are not strong enough to hold the patient's um body and posture properly. There is gonna be muscle weakness and muscle aches again because the patient doesn't have a good enough skeletal structure may present with fatigue and also proximal myopathy and the waddling gait. And these are things to look out for in um MC Qs and try to ascertain. Why does this patient have a Vitamin D deficiency? And usually it will be patients who are housebound. People who are um homebound need to always be on Vitamin D replacement therapy. Or it could be somebody who lives in sort of a very, very cold country where they don't see the sun too often. Or it might just be somebody with a darker skin tone, for example. And then it's really important to investigate these with the bone profile, the bone profile. It just gives you the Vitamin D the calcium, the magnesium. So it tells you everything about the patient's bone health and sometimes a bone biopsy can be performed and you're gonna see these wide osteoid seems I haven't seen it too often in MC Qs, but a good buzzword to remember, treatment will be Vitamin D and calcium and sort of encourage dietary changes, exposure to sunlight and um tackle the other comorbidities. Then we've got Paget's disease of the bone, which is quite a common M CQ question from what I've seen on pasted. It's um caused by or characterized by uncontrolled bone turnover, which is an increase in osteoclast. The ones that they just the bone and the decrease in osteoblast um uh sorry, an increase in osteoblast activity, it's bone that it gets continuously destroyed and reformed. However, given this sort of very, very fast turnover, the bone won't have enough time to mature and be qualitative enough. There is gonna be bone quantity but not bone quality. And classically, the most common MCI scenario will be an old male with bone pain and isolated rise in ap calcium, Vitamin D phosphate will all be normal. It's only gonna be the AP that gets rise that just that um that rises, just explain the fact that the patient has sort of a cut bone turnover happening. It will be leading to the bowing of the tibia and bossing of the skull. It's that pepper pot skull appearance that might be um seen on x-rays. It may lead to deafness due to cranial nerve aid compression whenever it happens in the skull and the x-ray will show mixed le and sclerotic lesions. Again, just due to this increased bone turnover management will be with bisphosphonates which are gonna be calming the bone down. And in terms of MC QS, the key complications will be deafness because of that involvement with cranial nerve, um with cranial nerve, um eight and uh bones and uh bone sarcoma just because it might the the rapid activity of the bone might trigger a malignant process. Then very, very briefly touching upon nutrition, which is obviously important in any age range. However, the elderly are particularly prone to malnutrition and nutritional deficiencies. So there is a high risk of malnutrition due to poor functional and cognitive um due to poor functional and cognitive um residual function, it leads to increased frailty and poor health outcomes. And usually they are described as having the tea and toast diet. So again, not that much M CQ sort of um ill on these, however, very important to have in mind for your oy, just whenever you're thinking about any elderly patient, it's a very important functional indicator. If you see the old frail, tiny almost tactic, 90 year old, you're gonna think surely they're not, they don't have a very good baseline. And for the case, I just want you to draw your attention. I thought it would be nice to just put it on the slide over here. The mas score as far as I remember for our logbook last year, we had to do a mass score with one of the dieticians on the ward. And I think that was a very useful activity because it gets you thinking it is a proform up. You just need to follow what they say. Um maybe try to sort of remember for your sys what sort of a severe malnutrition means and what sort of the cut or severe weight loss is um considered to be. And then you just need to um sort of check whether they are low risk, medium risk or high risk whenever you need to intervene. Now, getting on to the drugs, which again, um are really, really important for um care of the elderly and for geriatrics. And um you're gonna see a lot of these questions in your s as well as in um the PSA next year. These are a couple of tables that I have found useful during my revision cause I like the thing that they put everything together. Things that cause postural hypo hypotension are all the BP medications usually. So, ranging from your diuretics, ace inhibitors, beta blockers, even antidepressants, LDOPA. So, parkinsonian medications, anticholinergics, we hate anticholinergic medication in ca care of the elderly and also nitrates because they drop your BP. And, um, for an elderly person with some, um, sort of autonomic impairment, it might prove a very, very hard tobacco. Then we've got um, a couple of medications which are associated with falls due to other mechanisms other than um, postural hypotension, things like benzos because they cause sedation. Again. Another drug that we try to avoid using in the elderly as much as we can cause it really, really damages their functional, the, their functional status and type psychotics just because of their drowsiness and their, um, um sort of tiredness side effect opiates again cause they cause drowsiness, anticonvulsants codeine digoxin. Uh these are all quite nasty drugs even in the young people. Um not even to say about the sort of elderly who are frail and quite naive to all of these drugs. And over here, um I've included a table that contains the drugs with a high anticholinergic burden. Again, um, if you really want to impress your markers in the Os, try to mention the calculating the anticholinergic burden. It is an online calculator, but these are a couple of drugs that you're c being sort of um really, really um insisted on by geriatricians, things like um oxybutynin amitriptyline just because of their uh promethazine, um just because of their anticholinergic effects, which are gonna be um sort of inhibiting the patient's autonomic response and it might be quite troublesome in somebody who's anyway, um has a, has a poor baseline. Then we've got other drugs which are important to remember for patients traMADol again, quite dangerous in the elderly. We tend not to not to use it. Things like Mirtazepine again, codeine, um Warfarin and things like that. And the there are various reasons why we don't really like those drugs. Now, in terms of um the worst offenders. And I would say if there is one slide that I would advise to sort of print off or make note of it would be this one because they are so, so common in questions, the postural hypotension ones, we've gone through them, the culprits for falling are the benzos, the antipsychotics and the opiates, um digoxin can be quite toxic. However, not many patients are on it anymore and the ones who are on it are gonna be the elderly. So keep an eye out for that, especially if your patient. Um Inosi has digoxin prescribed under cardex. Then in terms of a couple of side effects which are sort of to be noticed is the leg swelling with amLODIPine hypotension with beta blockers, ace inhibitors, calcium channel blockers, hyponatremia with PPI SSRI S and diuretics always keep that in mind because um we fear hyponatremia in the elderly confusion. Again, important to realize the risk of warfarin in the elderly because it causes an increased response and also a higher bleeding risk. We've got the benzodiazepines, the anticholinergics and we'll briefly touched upon um oxybutynin in the incontinence part, it is very good for incontinence. However, it comes with a nasty side effect. So it's always about the risk versus benefit um reduction. And we've got this wonderful drug called Mirabegron, which is a beta three agonist, which could be an alternative to anticholinergics such as oxybutynin um in the setting of incontinence. However, it's not widely used at the minute because apparently it's not that um um sort of effective. And it's really important to remember that Myron is contraindicated if they are severely hypertensive because it can cause a malignant hypertension crisis that might lead to an acute stroke or M I because it is a beta three agonist and not to bore you with too much physiology. But I just think it's quite important to remember this cause I have seen this in a couple of M CQ questions. So um a lot of things ha change in the elderly physiology and mostly everything goes down. They are gonna get less plasma proteins. So there is gonna be less binding of drugs to plasma proteins, More free drugs in the plasma means an accumulation of toxic drugs, the binding of drugs to red blood cells will again be decreasing. The patient's body composition is gonna be sort of um changing just because they are gonna become smaller mic, they're not gonna be as um sort of thick and well as before the apparent volume, volume of distribution in which the drug is dissolved will be decreasing and um regional blood flow and tissue permeability may be decreasing as well. There, um glomerular filtration rate will be decreasing. So there are gonna be delays in um getting the blood, getting the drug out of the body and that might lead to higher concentrations. So that's why we need to be careful about elderly, particularly if they've got a longstanding renal impairment as well. And a couple of um drugs also, um a couple of patients are more sensitive to particular drugs such as Nitrazepam and Warfarin and that's to do with um tissue sensitivity, no moving on to stroke and tia which again is one of the high yield, mandatory sort of topics for care of the elderly. And in terms of stroke, we've got mainly two types of stroke. We've got the ischemic stroke, which is the more common, one usually associated with af and any other general cardiovascular risk factors that might lead to the blockage of a vessel. Then we've got the hemorrhagic stroke, which is likely less common. It's much worse because it is a bleed in the brain. And um it may lead to leaking of vessels. And the risk factors for that are people who are anticoagulants, people who've got very, very high risk of false people with like alcohol dependency and stuff like that as well as people with um arteriovenous malformations, um hypertension because malignant hypertension may basically penetrate through the blood vessels and just break them and also age. Um Now, one thing that I took me a while to realize is that a subarachnoid hemorrhage is considered to be a stroke as well like a hemorrhagic stroke. So, an interesting thing to, to keep in mind. Now, in terms of signs and symptoms, you probably are aware that there is gonna be motor weakness and loss of sensation, visual field defects and speech problems. So, we've got those like three cardinal um Oxford Bamford criteria, which are gonna be um crucial to recognize. And then if the patient is um presenting with a hemorrhagic stroke, they will be getting headaches, nausea and vomiting and decreased level of consciousness. And it, it is because there is gonna be some degree of meningism in there because the blood um leaking into the brain will be um annoying the meninges, irritating them. And that's why the patient will present with more acute um symptoms. And this is the Bamford stroke classification, which is absolutely crucial to remember. We've got the TB Lox and Fox. Um and there's basically three criteria that we need to remember and keep following, we've got the weakness. There is the hemianopia and also the higher ce um cerebral dysfunction. The way I think about it is just by using the um sort of fast pneumonic. So you look at their face for weakness. Um You think about their speech and then you also look at their eyes to make sure that they have no sensory dysfunction. And if they've got all three of them, they've got a total anterior circulation stroke, a partial circulation stroke will just be containing two of those criteria. So the patient may have only hemianopia and weakness with no um higher cognitive dysfunction or they might have cognitive dysfunction and hemianopia or neglect, but they won't have any um sort of um muscle issues. So it just has to be two of that two of those criteria. And the lacunar stroke is just a tiny um stroke happening in one particular area which is very well localized and it's only gonna contain one of the following. So it could be a pure sensory stroke or they just lose one type of sensation in one particular organ or part of their body might be a pure motor stroke, whatever they just lose sensa. Um mo motor function in one particular limb or one particular part of the body could be a sensory motor stroke or some um atoxic hemiparesis. And the posterior circulation syndrome usually involves cranial nerve palsies and also issues with um the cerebellum. Basically, everything that happens at the back of your brain from the ponto me junction um downwards. Now, the main things that I would say try to remember would be that for the anterior circulation strokes. If it is the anterior cerebral artery, the lower limb is affected more than the upper limb. So the upper limb will be spared. If it's a middle cerebral artery, the upper limb will be affected more than the lower limb. Um There's unfortunately, or I couldn't find any easy way to remember these. I've just tried to memorize them cause um they are very, very frequent on FMD. I can't remember if they were that frequent in the queens and c but be prepared for that. And if you're um doing FMED or ques meed or whatever, you're gonna see that there's many other syndromes like Weber's lateral Medullary syndrome, lateral bone time syndrome. I would not um worry too much about them. Maybe if you've got time and brain space. Yes. Do try to memorize them or make some sort of sense of them, but they are very unlikely to be, um, high yield. Cause in the end your mcs will be to make sure that you're gonna be a safe as one, not a specialist, um, neuro, uh, neurologist. Now, in terms of investigations for, um, stroke, always, always go for the non contrast head ct scan. That's the first thing and the quicker you get that done, the higher the chance of um the patient feeling be getting better. And it's all about ruling out hemorrhage because what we do to treat an ischemic stroke will either be thrombolysis or you know, loading them with aspirin and so on. And we do not want to cause even more bleeding if they're already bleeding and then ischemic stroke will be um defined by low density in the gray and white matter. There is gonna be a loss of that gray white differentiation. Basically, it just will look fuzzy on the um CT scan or there might be that hyperdense artery sign, which is also I think called the malignant or middle um um middle cerebral artery sign or something like that. And in terms of primary management, always keep this in mind, load them with aspirin, 300 mg and then thrombolysis within 4.5 hours of the onset of stroke. It's usually out the place or any other tissue plasminase and activators or thrombectomy. Usually they like combining in questions, at least combined thrombolysis with thrombectomy because apparently it leads to better outcomes. Um and thrombectomy can be done within 24 hours, but the patient need to be needs to be quite well, um quite well and quite um sort of with a good functional baseline because they are basically gonna go and track the thrombus uh with a device down the patient's arteries. Now, a couple of points that I would say are quite important to be aware of. Um are a couple of the contraindications for thrombolytic treatment. Now, you've got all of the relative ones over there. However, the main ones to remember are the absolute ones, the sort of complete red flags that would put you off thrombolysis um in any patient. So, if they had a recent intracranial hemorrhage, obviously, you wouldn't wanna thrombolism them to get even more blood into the hemorrhage if they've got structural cerebral vascular lesions, if they've got an active intracranial neoplasm, because the neoplastic tissue may be more prone to bleeding if they've had an is ischemic stroke within three months. And that's again because they might be bleeding into the infarction, whether they've got um a significant head injury or facial trauma, recent, recent intracranial or spinal surgery, severe um um hypertension and one of the relative one that keeps coming up in questions is uh whether they had an internal bleeding in the past 2 to 4 weeks and whether they had a um recent surgery in the past three weeks. So again, um, these are some important things to keep in mind about thrombolysis. I've seen them coming up in questions. They might be sort of, um, asos cases as well. So keep them in mind and never, ever forget about the non-contrast HEP CT scan. It is the thing that is always gonna keep you safe and the sooner it's done, the better it's gonna be so reiterating the management for stroke in terms of secondary prevention, you start, you keep them on the high dose aspirin for two weeks and then you swap the aspirin to clopidogrel, 75 mg and if not tolerated or contraindicated, then you can give them aspirin and dipyridamol. And if aspirin not tolerated or contraindicated for various reasons, you can keep them on modified release dipyridamol, which is another platelet inhibitor. As with any sort of cardiovascular disease, you want to keep them on high dose atorvastatin, 80 mg treat their comorbidities and perform a car, a carotid endarterectomy if they've got more than 70% stenosis on carotid ultrasound. Um and the percentages for that vary. I've seen 75 in some guidelines, I've seen 70 in others. So um probably as this is sort of a gray area, they may not be using the exact percentage in um in your MC QS. Other important management aspects to sort of mention neuros case would be a safe swallow test with um um speech and language therapy and avoiding hypoglycemia. Again, we want to keep them normoglycemic or a tiny bit on the hyper side because that's um more helpful for the brain to be healing. And you want to investigate further for the cause of the stroke. Do an E CG on the patient, do an echo on the patient. Um do act angiogram or an MRI angiogram. Now, the sort of less um acute phase of stroke is a tia, a transient ischemic ischemic um attack, which keeps all the clinical features um as the stroke. However, they will be resolving usually within 24 hours and there is gonna be no evidence on imaging of any kind of ischemia. The immediate management will be 300 mg of aspirin unless there is a bleeding disorder or they are taking an anticoagulant already. Um if they're already on aspirin or if the aspirin is contraindicated for any other reason. And specialist review needs to be done immediately if they've got a crescendo ti A. So more than two ti A s in 48 hours, if they have any cardioembolic um issues such as sort of um af that may be predisposing to um a thrombus in the heart or any known severe carotid stenosis, they need to be seen within 24 hours if the TI A was in the last seven days and within seven days, if the TI A was more than seven days ago and in my head, it was very hard to sort of, um, think about these. But basically, again, a very rough explanation, they managed to survive for the previous seven days after the Tia Tia A, they're probably not that such high risk. So, um, we can just see them in the next seven days. However, if, uh we had, if we're still sort of in the warm period and we catch them in the first seven days, we want to see them as ap and critical information to give in an AK is advising them not to drive until they have been seen. Many patients come to the tia a clinic driving and they're like, no, no, no, I'm not gonna drive, I'm gonna leave here with a taxi but they hold the keys in their hands and they're surely gonna go drive. It is advisable and you always need to document in your notes that you've advised them not to drive. Um, in terms of investigations, you can do an MRI that is gonna be a bit more detailed and it's gonna show the sort of areas with uh vague signs of ischemia um and an urgent carotid Doppler or an E CG and echo to look for the source of that thrombus that has blocked their artery in their brain and the secondary ma ma management will be starting them on aspirin or clopidogrel and um tackling all of their cardiovascular um cardiovascular issues. And this is the most important osk that I could not help myself but include over here and it is all about the telephone consultation of someone having a stroke. We had this as a station last year and um, you never know what else might be coming up. And I think the same sort of rationale applies to any acute condition that you are dealing with over the phone. The key here is to call the ambulance as soon as you recognize it is a potential stroke and it is gonna be you calling the ambulance. You're not gonna tell the patient, by the way, call the ambulance, you can just tell them, ok, just stay on the line. I'm gonna ring the ambulance for you or ask the practice manager to ring the ambulance while you're on the phone to the patient after you've gotten that out of the way and you know, help is coming. You can take a typical history targeting the key symptoms and important to ask about their meds. Don't let them take any non-essential medications, especially any antiplatelets or anticoagulants because there's always gonna be um, an extra member of the family or some sort of a distractor who's gonna be he or she hasn't taken um, their aspirin today. Will they take it? So, really important to tackle that. I remember our patient in our oy was asking if they could go upstairs and pack some clothes for the hospital and I was like, no, no, no, you stay where you are, the paramedics will be helping you. It's important to also tell them again if one of your sleep in your oy, that, um, you know, make sure that if there's somebody else with you in the house, they open the door, um, to let the paramedics come in and just all of these preparations, however, don't get the patient to do any of them. Ask. Um, you know, sometimes you may be asked to briefly interpret the CT scan and say whether it's an ischemic or hemorrhagic stroke. And it's gonna be pretty obvious the CT scans they are providing are usually quite good and quite clear. And if you know the history already, you're gonna figure out what's happening. Um Sometimes they, you might get an examination of a patient having a stroke and trying to get the moderate sensory weakness or the hormonin was hemianopia. But that would be more of a sensory and um moderate neurological examination. Also make sure you are familiar with the N I HSS stroke scale. I know it was part of our local last year, unsure about this year. But if you are not or whenever you're approaching your OSC, make sure to have a look through it and actually try to sort of if you're on placement at the minute, try to steal one from the hospital. Um Each don't want I understood has its own sort of pro performer for that, but it's important to be familiar with those things cause I remember right before my kids, I've looked through one and I was like, hm, that sounds a bit like interesting and some things you may not be that familiar with. So just take a bit of time looking through that they might, there have been previous patients in the past where they've asked you to um complete sort of a part of the scale, not the whole N HSS stroke scale. Um and then interpret your findings. So it is useful to have a look at it just to be familiar with it. And um, yeah, you may only be asked to do a part of it, not the whole thing. Now, as we are approaching sort of um the end of the talk, we are gonna have a chat about neuropsychiatry where I've included Parkinson's, um and all the dementia and delirium and we'll be starting with delirium, which we've had a station in um our final zone um with a patient becoming delirious and we had to run through causes and sort of try to ascertain what was wrong with them. There's four cardinal criteria. There has to be an acute cognitive impairment. It could be on the sort of uh on top of a previous cognitive impairment, but it has to be an acute change in their condition. They will have disordered thinking, they will have inattention, they are simply unable to orientate themselves to anything and they will have fluctuating consciousness again. Another key one for M CQ is cause dementia does not present with fluctuating consciousness. The diagnosis needs to include uh the acute cognitive impairment and their disordered thinking and inattention or the fluctuating consciousness. Not everybody ticks all the boxes but majority will have a blister of them. There could be hypoactive delirium which apparently is the worst that being recognized because the patient is just not gonna be acting out and they are just gonna be um lying there, not eating, not drinking. So it's really important to keep an eye out for those patients hyperactive delirium. Whenever they might even become sort of agitated, angry, they might be wandering around the world, the word and uh might be causing some trouble. And there might also be mixed faces of delirium whenever they are hypoactive in the morning and then hyperactive at night in terms of the poor outcomes of delirium. Obviously, people who already have some mental cognitive impairment are at a higher risk of poor outcomes. Um However, it's um also important to mention that usually patients who develop delirium in hospital have a one third chance of um being left over with some residual cognitive impairment. One third will continue to be sort of delirious uh for up to six months and one third will be back to sort of normal function after the, the um delirium has been reversed. The causes are absolutely crucial to remember and very, very um widely explored into questions and that's the pinch me, pneumonic pain, infection, nutrition, constipation, hydration, medication and the environment that low stimulus environment. You want to notice them in a quiet side room with familiar faces around. You want to make sure your or uh orienting them um to the place they are, make sure to repeat where they are, who they are, make sure to um ensure that they've got their hearing aids glasses that they are sort of up and bright and sort of stimulated. It's really, really important. And in terms of management, the first key would be to reverse the cause. Give them pain relief if they are um in pain, give them in uh like antibiotics. If they've got an infection, give them good food for them. If they are sort of lacking nutrition, give them laxatives and make sure they're well hydrated. It's so easy to help a patient. You're not gonna completely stop them from being delirious, but you're surely gonna be causing the discomfort. And um I do vividly remember a couple of patients um who were just very distressed and were starting to climb out of their bed whenever their pad was wet. So it is things like this that might be triggering them to become agitated and becoming agitated is quite dangerous for themselves. Now, if they do happen to present the risk to themselves or to others, LORazepam or haloperidol, um can be indicated. U usually you need to be careful and again, it's a very common question. Haloperidol. You need to be careful in Parkinson disease or lung QT. Uh Usually whenever, before you administer somebody ha haloperidol, you want to have an E CG done recently or done on the spot. However, um only we know how tough it is to get an E CG in a patient who is um severely agitated. But again, haloperidol, it is first line but make sure they've not, they don't have Parkinson's or they um do not have a long QT because it is an anti um it is a dopamine receptor blocker. No dementia is something that you've probably covered in psych as well. But it's part of the old age psychiatry. It is a global impairment of cerebral function in absence of a reversible cause and always like it should always be on the tip of your um tongue to do a dementia screen consisting of of FB CU ne LFT S bone profile, blood glucose TF TSB 12 and folate and neuroimaging. And you're doing all of that in order to rule out any possible cause of disease, any possible reversible cause. And if all of those are normal, then you can diagnose dementia. The types of dementia that we we're gonna go through are Alzheimer's vascular Lewy body and Parkinson's disease, dementia and the frontotemporal dementia. And it's really easy to distinguish between them. If you remember a couple of keywords about them really important to also cast an eye on um the mini mental screen test and the Aden Brooks cognitive examination, just to be aware of sort of what they look like just in case you're asked to perform them in an sy same with delirium. Always remember the 480 delirium screen, which is a very easy four step test. Um That sort of helps you determine or like it's trying to standardize the diagnosis of delirium. So Alzheimer's disease is whenever we've got the beta amyloid plaques, which are gonna be depositing in the brain, the hippocampus. Again, another high yield uh plasma question is affected first, um particularly the temporal lobe, it is a progressive decline and the risk factors are age, family history. Um head trauma, there is the APO E four gene and the mutations in A PP or presni which may be predisposing to Alzheimer's the management in terms of first line is the acetylcholinesterase inhibitors, things like Donepezil rivastigmine, galanthamine. Obviously, if there are acetylcholinesterase inhibitors, they are gonna come with the side effects of increased um acetylcholine. So they will come with nausea, vomiting and diarrhea and Donepezil will be particularly indicated, contraindicated in bradycardia. Second line and sort of the one that we use for um more severe dementia will be an MDA antagonist and they are not gonna be there to reverse the, the dementia, but they are thought to be adding at least like six months of um better cognitive function and to sort of um don't make the decline as aggressive n non pharmacological um interventions are also quite um good for dementia. And we've got group cognitive stimulation, cognitive rehab and reminiscence therapy. And the reviews need to be done every um half year just because they need to know whether the treatments are working. If they are not, there's no point on um there's no point with the on for the patient to be um to be on them. Now, vascular dementia is the one that goes stepwise and always the patient will be a vasculopath, they will be smoking, they will have had an M I or a stroke. Vascular dementia is basically multiple lacunar strokes which are leading to a sudden um stepwise decline in their cognitive function. If a part of your brain suddenly becomes um um ischemic and infarcted, there's obviously gonna be a change in your cognitive function and personality risk factors are all the vascular risk factors, stroke, tiaa f diabetes, hypertension, smoking, obesity, it is a vascular disease. It's a mini stroke management will be to control cardio vac uh cardiovascular risk factors. And there's no um um sort of role for any uh dementia drugs just because it is again, uh tiny infarcts in the brain. Then Lewy body dementia, as the name implies, it will be containing these aain inclusions called Lewy bodies. And this is the one where ca classically the cognition may fluctuate. They are gonna get the visual hallucinations and the cognitive impairment will be there at least a year before Parkinson is that's why we call it Lewy body dementia, not Parkinson's disease dementia. In terms of the diagnosis, it's usually a clinical diagnosis, but sometimes you might be doing this um spec scan, which is a very fancy dopamine um scan, which can be used and we might want to use acetylcholinesterase inhibitors and memantine. However, they are not um too efficient and it's important for these people to avoid haloperidol and uh the neuroleptics because again, it is a dementia that is associated with a lack of dopamine. And then we've got the Parkinson's disease dementia, which is the one that occurs at least one year after the parkinsonian symptoms. Uh while if it's classified as Lewy body dementia when it is before or within one year of onset. So, again, it's just a matter of um the timings in terms of frontotemporal dementia. This is the one that unfortunately manifest in the young people. It's got an early onset of less than 65 and it leads to personality changes and social contact problems because our personality is well embedded into our front and um into our uh frontal and temporal bones, uh bones, um parts of the brain uh lobes. And hence, if there is a disease that attacks those there are gonna be massive changes in personality memory won't be effective. Memory is to do with the limbic system, the hippocampus. So, not much to do with the memory. However, um, they are gonna be undergoing quite severe personality changes in terms of the imaging. Um, there's gonna be focal, um gyral atrophy with knife blade, knife blade appearance and that's gonna be fix disease. It's usually quite obvious in the, um, CT S that I've seen in exam questions that there is a problem at the front and only at the front you're gonna see a massive sort of um, deterioration in there. And dementia drugs are not gonna be used. Then um Parkinson's disease is again, another quite common disease that you might see in your exams. We had Parkinson's disease as one of our um real patient on Soy's Hospital Day. Oy today of this year, Parkinson's disease is a degeneration of the dopaminergic neurons in the substantia agra. So it has to do with dopamine. Less dopamine means more acu colon will stimulate unwanted movements. And there is the triad of the resting tremor. The asymmetrical pill rolling tremor, which is improving with voluntary movement. The rigidity will be led by becoming cogwheel. When there is a superimposed tremor, they are gonna be very rigid. It is gonna be just like the class knife rigidity whenever it's really, really hard to um sort of unbend, their to straighten their arms or their wrists. And they're also gonna have bradykinesia, they are gonna have the shuffling gait, the reduced arm swing and um the slow turning. And it's also important to recognize their hypomenia, their masklike fishes and also the fact that they will be struggling with mental health and with um sleep disturbance, their sleep is gonna be severely um agitated and usually it will be the partner that actually um complains of that in terms of differentials. Um essential tremor is a good differential to be excluding and that usually is uh bilateral. It is gonna be present nonstop, particularly on movement and alcohol, alcohol will be improving it. Um It may be, there might be drug induced parkinsonism particularly by the antipsychotics which block dopamine or there might be a couple of Parkinson's plus syndromes such as multisystem atrophy, whatever their um um autonomic system is not working properly or um um progressive supranuclear palsy in terms of management of Parkinson's, it's always, always important to remember that their medication is critical medication and you've probably seen on placement on the card is some um red stickers that say critical meds. Those are the medications that never should be stopped. No matter if the patient is nil by mouth, there should be alternative ways for the medication to be delivered and always will be given on time. Um Levodopa is one of the main um management therapies and that's basically dopamine. We usually take it with a decarboxylase inhibitor to prevent the metabolism of the dopamine in the peripheral tissues to allow it to get into the brain. And there are a couple of problems with it in terms of usually patients get used to it and at some point during their, the progress of their disease, they won't be benefiting from it anymore. So we try to sort of either combine it with a dopa mono agonist at the start or we try to save it for later. If the patient is quite young, we try to start their treatment with other medications and only revert to levodopa whenever, um, they get older or they're uncontrollable side effects of levodopa would be dry mouth, palpitations, psychosis and dyskinesia. And then we've got dopamine receptor agonists such as bromocriptine carline, which are associated with pulmonary and retroperitoneal fibrosis. Um Don't forget about the dopamine receptor agonist because the, the way I think about it, they cause a mini psychosis just because they are gonna be pushing off the dopamine levels in the patient's brain. So they will get sleep attacks and they might get hallucinations and they will get IU impulse control disorders. So always safety net them about gambling, impulsivity, hypersexuality and risky behavior in general safety net. Both them and their sort of family members and just a couple of dementia mimics. We've got subdural hematoma, which is sort of delayed confusion following a fall and you get the crescent shape on ct metabolic disturbance such as B12 b12 folate deficiency, hypothyroidism, wernickes encephalopathy as well. And, and the um hydrocephalus where they get cognitive impairment, incontinence gait disturbance and it's sorted with a VP shunt and lastly we've got incontinence, which is a really, really troublesome issue in the elderly, um which is predisposing them to false pressure, ulcers. It's got severe social implications and also comes with psychological issues. There might be stress, incontinence, urge incontinence, mixed incontinence overflow or neurogenic. And men are usually more likely to have overflow due to their benign prostatic hyperplasia. Now, the management would be conservative, reducing caffeine losing weight, treating um cough. If they've got a chronic cough, we want to do urodynamic studies if we can't find a cause with um sort of following their bladder diary. And um for urge incontinence, we want to use anticholinergics like oxybutynin or Myr for stress, we need to use accessories such as DULoxetine or estrogen. In case there is a case of atrophic vaginitis. Uh We want to refer the patient to ot and physio for sort of bladder retraining and for pelvic floor exercises. And we need to be sort of aware of what might, what might be causing a transient incontinence. So things like delirium infection, um psychological aspects, excessive urinary output. Have we started the patient on furosemide in hospital? Well, that's probably why they have become incontinent. And here we've got a couple of MC Qs that I'm gonna probably let you um sort of look at in the, in your free time. They try to cover the majority of things that we've discussed and that I believe are quite important. Now, um if you've got any questions, you can either put them in the chart. Now, if I would be able to see the chart. There we go. I've got it there or if not, you can just take my email address or my phone number or just contact us by the peer group chats. Um I'm also one of the peer share coordinators in the Belfast trust. So if you've got any kind of issues at any point, feel free to let us know, feel free to let us know if you want more support from us or if there's anything else that we can do sort of in the next couple of weeks to help you out. So I think that's me. I'll just hang around for a couple more um minutes just to see if you've got any questions or anything like that. All right. And now I've got a quick feedback link. I forgot about that. Uh I've got a quick feedback link to put in the chart if you um don't mind filling that in and that's how you're gonna get the slides as well. Um So that's just the feedback link into the chart now. And if you follow that link and share it with your friends, um, if they want to get the, get the slides, that's absolutely fine. All right. Thank you very much guys. Hopefully it's been um useful.