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All right. So let's get started. I'm sure more people will keep joining as, as we go on. Um So welcome guys to this teaching thing session on everything you need to know about growing old or geriatrics is presented by myself and Priya who's here. Um And we'll try and keep it to an hour, although, so we're using med all to do to do this teaching series. Um because I mean, there's lots of advantages of it, but one of the things is that you can't unmute yourselves to talk. We do have some interactive stuff, there's some SBA S in involved. So please try and take part in those. Um And then there might be some points where we ask you just to put, put some, some information in the chart or whatever, answer some questions in the chat. So please do do that and that will make it a lot more engaging and a lot better learning experience as well. So, yeah, let's get into it. All right. So just first of all teaching things, um it's run by medical students mainly for medical students. Uh We run weekly tutorials, we focus on a presentation and then try and teach some diagnostic technique as well. Um It's all, all our information is reviewed by doctors so that it's all accurate. Uh, and we have your email addresses so we'll keep sending the, uh, the, the, the weekly events to you. Um, so, yeah, let's get going with the presentation. So we're gonna start off the way we're going to split this, er, presentation up is by looking, first of all at Frailty and Falls, um having a look at the CgA the Comprehensive Geriatric Assessment, then we're going to be, then we'll go on to look a bit more about falls and then we'll talk about uh um geriatric mental health. So things like delirium dementia, things like that. So we'll start off what is frailty? Um This is er, if um anyone wants to stick in the chart very quickly. Um What, what is frailty? Any ideas? Right? Just give me like a couple of words. I know it's uh it's annoying to type out full definitions and sentences and things like that. While you're all doing that, I'll just show you the British Geriatric Society definition of frailty. So, frailty is a distinctive health state related to the aging process in which multiple body systems gradually lose their, built in built reserves side. Um It's important to, to say that frailty, what it does is it makes our patients more susceptible to external stressors so they become less resilient. However, having said that um people can very much and often they do become old without becoming frail. So there's a way that there's a, there's a score that we use to measure frailty called the Rockwood frailty score. And this is a good indicator. So just remember that just because someone's old doesn't necessarily mean that they're frail. Cool. So we've got our geriatric giants. Uh These are some big factors which play a play a role in contributing to a patient's royalty. So they are immobility, instability, incontinence, and intellectual decline. So all of these are things that are really contributing to frailty. Um and it's important to remember that it might be a combination of these factors or all of them, which are making our patient more frail. Um So immobility, they're not able to move around, they'll have muscle wasting, things like that. Instability, more susceptible to falls incontinence is a big marker and intellectual decline with age that also makes you more susceptible to a variety of different things. So this is the Rockwood frailty scale which we use. Uh it's important to note the frailty. Number one, it can fluctuate. Er and number two, the Rockwood frailty scale is only appli applicable for patients who are over 65 years old or those with a learning disability. Um So uh we have um grade one people who are very fit, grade two people who are well with no active disease symptoms, but probably less active than grade one and grade three, managing well, uh, with controlled medical problems. Grade four. So they're vulnerable but not dependent on others, but their symptoms might limit their activities. Grade five means, um, they're mildly frail, so evidence slowing. Um, and they struggle a little bit moderately frail. Uh, they need help with all outside activities. Er, and with looking after their home, number seven is severely frail, so they're completely dependent for their care. Er, and eight is very severely frail, completely dependent. Um And this is when the approaching end of life and nine is terminally ill. So that's the Rockwood frailty scale that we can use to grade someone's frailty. Um Now I'm going to talk about the Comprehensive Geriatric Assessment because this ties in really nicely with frailty. This is really important for AK you will be asked to do a CgA or there's a good chance that you'll be asked to do a CgA in an OSK exam. Um And it's also a good thing to remember when assessing the kind of social side, social history of an older person. So that's very good. So there's four parts of our CgA, medical, functional mood and cognition and carers. There's a few extra questions on top of these four domains that we need to make sure that we ask. But these are the four domains that we cover when we're doing our CgA. All right, just keep those in your head and try and remember them. So first of all, we're going to take a full medical history from our patient. Let's say we've got our elderly patient in front of us. They've come in for a review. So we need a full medical history. If they've come in for a reason, they'll have a presenting complaint and history of presenting complaint. Obviously, if they haven't, then they won't. Um, we need a full past medical history, including their surgeries. We need their medication history because medication in the elderly is really important. There's lots about deprescribing things with BP. You might have to take BP, reducing medications off things like that. And we also want to double check the allergies, then do a family history and a social history. Now, the social history, the CgA is basically a really big social history or it contains a really big social history. But things that we want to ask in this part of the social history is smoking or smoking habits in the past, drinking their past occupation and recreational drugs. Now, I know it might feel really weird asking 80 year old Doris to use recreational drugs, but at least for the sake of acies, it's really important. And also in real life, you don't know what a person's past might have involved. Um And so it is always good to ask what, what can be a good way of going about. It is saying this might feel like a bit of a strange question, but it's something that we have to ask everyone and then be like, mm, have you ever used recreational drugs at all? And that's, that might be a good way of going around that. Cool. All right, then. So then we move on to the functional assessment. This is the next part of the CgA. Um The way I like to do this is to visualize the person in front of you. All right. So here I've tried to put some, there's some A I images of an older person going about his day. Um But literally visualize that person waking up in the morning. Uh So the way I would introduce this to the patient when asking them about it is saying, so now I'm going to ask you about your daily activities just to see how you're getting on at home. So I'm going to run through some of the activities that you might be doing. And I just want you to tell me, are you OK with doing them? Do you need a bit of help or, or, or anything like that or do you struggle with them? So we're gonna start off. How are you waking up in the morning? Are you able to get out of bed? All right. That's great. How are you, do you dress yourself? Are you able to dress yourself? How do you find doing buttons, things like that, then going to the toilet? Are you able to go to the toilet by yourself. Do you need any assistance? Do you need assistance in the shower? Things like that while I'm talking about going to the toilet and things like that? I like to check continent incontinence. Remember it's one of our geriatric giants. So we want to double check. Are they continent of urine and of feces? All right then. Ok. What would an older person do next in the day? Um Do you have stairs in your house? Are you able to go down and up the stairs by yourself? Ok. What else do you do? What's next? Do you cook breakfast? Are you able to cook for yourself? What kind of meals do you eat? Do you eat? Uh what, what's your diet like? Um Then what else might an older person do? Um You could ask them, what do you generally do with your day? You could ask them? Are you able to go out by yourself? And if not, how do you go out? Do you, do you have some kind of assistance things like that or do you not go out at all? Um Yeah, so that, that kind of covers the functional assessment. Uh Remember we need to ask as well about less stability. Do you feel stable on your feet? Um What kind of footwear do you wear? So maybe they wear slippers, maybe they wear shoes, maybe they don't wear anything, maybe they're susceptible to falling. Um We mentioned the incontinence. Uh We need to ask them about their home environment. So that includes, do you have any walking aids, any rails that you hold onto at home? And then we also need to check their vision and hearing. All right. So those are the kind of parts of the functional assessment, the easiest way of going about it is visualizing your older person waking up in the morning and running through each activity that they do and say, are you able to do this? Cool. Next we come to carers. So we need to double check how many carers this person's having if any. Um and we need to check who they are and how they're getting on. Are they able to cope with the caring needs? Do they require more carers? Do they require less carers? How's it going? So yeah, ask them, do you have regular carers or is it family or none at all? You need to ask them what kind of things the carers are doing at home? You need to ask, are they coping? And that's important, especially for family members so often, what you'll find is an older person might be being cared for by a family member. Um But that family member because of the share responsibility of it um might be struggling to cope. So you just need to double check on that person. Um And this is a good place to when you're double checking on that person saying, how is it, do you need extra help is all. So to say, how are you doing? Because you need to double check um the the the ability of the carer to provide that care. So for example, when I've been in GP practice before, um there'll be an older person who comes in with their son, for example, and although the older person is doing really well and really happy, the son is having a really tough time or the daughter is having a really tough time caring for that parent. And so you need to say, hold on a second, are you OK? Do we need to have a chat about things like mental health, how you're coping strategies, whatever. So I really check on the camera uh and then there's always uh do you need increased care? So regular care of things like that coming in, uh we come to mood and cognition. Uh This is another one of the important, the geriatric giants. So that is er intellectual decline is our geriatric giant. So this checks on that. So you can ask either the older person or the carer any changes in mood. How are you feeling? Are you feeling lonely? Are you OK? Um Cognition level. So does it go up and down or is it, is it fairly stable then one thing you need to check and this is probably from the carer that you need to check it is risky behaviors. So are they, do you find them wondering and not knowing where they are. Are they leaving the cooker on? Are they leaving the door unlocked? Things like that are risky behaviors that might indicate that increased care is required. Then we also want to ask about their social support network. So do you have any friends? Do you have any people that you keep in contact with family locally? Whatever and also safeguarding concerns? Remember that it's not just I think often when we think of safeguarding, we think of Children, but remember that older people can also be vulnerable. And so we need to think about safeguarding with them. If you have any concerns, then escalate it as you see fit. Um But yeah, and last, last thing, the CgA is basically pulling together all of the patients cash. We're looking at that medical side, but then we're also looking at a very holistic, we're doing it very holistically. Um So once you've got all of that information, you're comfortable with how this person is doing, you've built a full picture of their day, what they're doing, whatever, then you can come up with a plan. So for example, it will include, we'll get an occupational therapist or physiotherapist out to review you looking at putting more rails, for example, in your house or giving you a Zimmer frame or more carers, whatever it is and then we'll rebook the patient in uh to see how they're improving or declining. Um As well included in there. Sorry, I forgot to mention, uh, Medicaid. Oh, maybe I didn't forget to mention. No, I didn't forget to mention. But medication review, uh, is, is important as well. If they're having falls and things like that, you wanna, you wanna make sure that there's no meds causing that. But, yeah, so that is, that is all I have to say about CgA S, er, and that's very Ocu that, er, there's a good chance that that could come up. So just, uh, just be aware of that stuff, we'll move on now to falls and prayers covering this. Can you, can you quickly go back to the cognition page? So, just something to be aware of when it comes to changes in mood in elderly patients specifically is something that can be a, as well is a patient who has a change in behavior and more that they're not taking medications as they would usually. Um, and this actually becomes more of like a station assessing their low mood. Um, so we had this last year where it was a patient who wasn't taking his antihypertensives, his, uh, his BP was through the roof and when you assess them and you're thinking like, why is this person not taking their medication? Especially in an elderly patient? Thinking about low mood is a really important one, particularly in elderly because grief is a massive factor as well to consider. Um, so, yeah, that's just something to be aware of when it comes to Aussies and this kind of particular CgA. Ok. Can you go forward? Ok. So go back things. So falls are really, really common when it comes to the elderly and falls related to injuries as well. Um, so if you are on the Geriatric ward, it's something that you're going to see very often. Um, any ideas about how much falls cost the NHS in a year, just put it in the chart. It's a very high number. Oh, no. Ok. Um Well, it costs the NHS about 2.3 billion a year and I think it's something like one person falls every second. Um So obviously it has a lot of like healthcare costs to it. Um But on the actual person itself, it costs a lot for them. So it causes so much distress, it can cause pain, it can cause injury, obviously, and also this loss of confidence. So, um generally those who have already fallen are more likely to fall again because of this loss of confidence. Um So it has a huge impact on people. Um and generally people aged 65 and older are at the highest risk of falling. Um So something like 30% of people older than 65 and 50% of people aged over 80 fall at least once a year. Um So t you next slide. So any ideas about what risk factors might make an older person more likely to fall. So, if you just put it in the chart, if you want to type. Bye. Ok, we'll give it a minute and if it all just move on. Yeah, that's fine. Just be one. Oh, medications. Yes. Antihypertensive. Yeah, exactly. Perfect. Uh, she can you go next slide? So there are loads and loads of different causes of why, um, a patient, an older person would be more likely to fall. So thinking about muscle weakness and wasting vision problems is really common as well, especially in the elderly, balancing gait disturbances. So thinking about balancing gait disturbances, we're looking more at things like Parkinson's um diabetes, um stroke. So basically neuropathy secondary to something else, sorry about noise in the background. Um OK. And yeah, so polypharmacy. So mm elderly people on are on so many medications usually um some of which are just completely unnecessary and will actually make them more likely to fall incontinence is obviously very common as well. Postural hypertensions. This could be due to many different things. Um antihypertensives being on too many of them is one of those obviously um arthritis. So someone being in so much pain, um if they're getting up and they're in a lot of pain, they're more likely to stumble, cognitive impairment and syncope. So it's there are so many causes as you can see. Um So when we take a history, it's really important to go into as much detail as we can so we can try and think about what would be my potential differential here and why they've fallen. Excellent. OK. So we're gonna go through a case now. So um this is a very uh osk kind of situation we had this in our osk last year. So you're an F one on the ward and you're called by a nurse to help with a 86 year old Maggie who has fallen unwitnessed onto the floor. So any ideas of what you're going to do in terms of assessing this patient? Yep. Perfect. A two assessment. So that's definitely gonna be your go to assessment as well for any of this. Um This is how we had in our, in our A as well. Trey. Can you click? Yeah. So a reassessment and it's really important to call for help as soon as possible. So especially if you think there is hemodynamic compromise or if there's a potential trauma here in terms of in an ACY and how we did in ours, the patient was on the floor, like the actual actor was on the floor. It's really important not to move them. They are probably in a lot of pain. We don't know exactly how the fall has happened and if there is a potential c spine injury here, we don't want to be moving them just yet. So if the patient is on the floor as they were in our making sure you're getting down to the level of the patient don't be standing over them. Um When you talk to them, assess them from their level, um It makes them feel a lot more comfortable. Um And it'll just help you so much more with your assessment of them. Um Obviously this would make, this would involve making sure they're actually conscious in the first place as well. Um And then obviously call for help as soon as possible if you're worried at all about them. Um We are not going to go into so much detail about the A two assessment. Yeah, exactly. Find some information, background information from the nurse as well. Um We're not going to go into so much detail about the A two assessment in this session. We are doing a session in January where we'll go in a lot more depth um and going through different scenarios for A two es. Um So yeah, sign up to that session and we'll go in much more detail for that. Um Yeah, in terms of patients who are on the floor, there are usually guidelines per hospital in terms of moving them. Um So it'd be involving other teams as well in terms of moving that patient. Um again, next slide. Ok. So Maggie is now stabilized and is complaining of hip pain. Um So you give her some painkillers in the meantime, you take a history to find out how she fell. Any ideas of how you might structure your history um and specific questions that you might ask. So this is thinking, not just uh this is just a general's false, false history really and the structure that you would do for a false history. No. So the way that we would generally structure falls history is thinking, yeah, exactly. So before, during and after the fall and what happened? So straight next slide. So thinking about before the fall itself. So what were they doing when the fall actually happened? So this was a really good way of determining is this maybe a mechanical fall? Were they getting up when they um were when they fell themselves? Were they dizzy when this, when it first started happening? Um Did they stand up quite suddenly? Has this ever happened before? Hydration and nutrition is an important one as well? Thinking were they eating at all or have they eaten at all before it happened? Um So we're thinking like is this potentially hyperglycemia if they are diabetic? Um Yes, next one. So during the fall is probably gonna give you a lot of information as well. So, um again, this will tell you, help you determine. Is this a mechanical fall? So did they trip over any at all? Do they remember falling? Um or they were, were they awake, were they conscious when it happened? Did they lose consciousness? Anyone around them to witness this fall? Um which will give you a collateral history. Um Was there any any incontinence, um, any trauma, any tongue biting. Um, these are all key aspects to ask anyone who's gone through a fall itself next and finally after the fall, um, thinking about how long were they on the floor for? So, especially if it was an un witness fall, if they live alone. Um, if they were lying on the floor for a very long time, we're going to be thinking about potential complications of the fall and the long line. Um And how long it was before they were found um as well. So this will just complicate things a lot more obviously in terms of their treatments, but it's really important to um ask them, um thinking about drowsiness, any ideas about why we might be thinking about drowsiness afterwards and what might it suggest go back and what it might suggest? That's fine. So we're thinking more about the post actal phase. So especially if someone is quite drowsy afterwards, it might suggest that they had um an epileptic seizure. Um And so this is obviously going to, yeah, exactly. Post ex or state. So this would also help us narrow down our differentials. Basically, taking an in depth false history is really important because it will help us narrow things down a little bit. Um Yeah, next slide. So in terms of the rest of the falls history, so we're thinking about past medical history, anything that might make them more at risk of a fall itself medication reviews. So, like I said, it's most elderly people come on a very, very long list of medications which haven't been reviewed in a very long time. So generally, whilst they're in hospital reviewing them is really important, we can help reduce, um, some of the medications they're on. Think about maybe if any of those have caused the fall itself, um, particularly with postural hypertension. Um, and yeah, so there are different criteria that we can use in terms of medication reviews. So there's a stop start criteria which we look at in terms of stopping and starting medications. Um and how useful they actually are for this patient, especially in the elderly. Uh social history is also really important as well. So this is going back to our CgA again. So thinking besides thinking about like alcohol use, drug use, um smoking and everything, we're thinking about the social history in terms of how mobile is this patient usually. So we're thinking like if we aren't needing to um do surgery on this patient, are they going to be? How mobile are they going to be? How um how are they going to cope with the recovery, uh recoveries? Um And how much support do they have at home as well. So especially if they live at home and they're not very mobile is going to change how we manage the patient. Ok. Next slide. So yeah, strictured approach is really key here. So thinking about from the bedside, there are loads of investigations that we're going to be doing. Um, especially if we don't know what the reason for the fall is itself. So, um, ECGS is one important one to rule out cardiac causes and lying, standing BP, if they are able to stand up, that is, is also really important to go for, um, timed up and go test. So this is basically seeing how long it takes for them to stand up from sitting and it'll help determine like is this person in pain when there, if there's potential like arthritic causes of their um falls as well? Um Blood is also really important. So we're going to um we're going to do initial set of bloods. So thinking about FP CSU LFT S um bone profile clotting screens. Um and thinking like is this person potentially at risk of bleeding, um especially if they've had a fall with some trauma. Um And obviously an X ray for the trauma as well. Another thing that's not included on here but is CT scans are really important. Um especially if the fall was unwitnessed, you do need to do a CT scan um just to be to rule out any sort of head injury. Ok. So um an SBA let me send it. So Maggie undergoes a pelvic x-ray which shows an intraocular uh neck or feur fracture, undergoes a hemi arthroplasty and given good POSTOP pain management, she's able to stand So yeah, the SP should be up on your screen. Mm. Ok. Um, ok, we move on. So the answer is e it's 20 next fight. Sure. Ok, thanks. Yeah, so it's 20. So um, postural hypertension is when you have a drop of 20 in systolic or 10 in diastolic and it's usually within three minutes of standing from sitting or lying position. So in terms of managing this, we're gonna be looking at the medications. Um, do you prescribing any hypertensive medications? Um, anything else that might be causing postural hypertension, making sure this patient is adequately tolerated as well. Um And there are other pharmaco pharmacological interventions that we could also consider as well. But starting from very conservative management before we start on anything else? Ok. And what are fragility fractures? Any definitions, any features of them? Yeah, exactly. So it's um basically a result of low, what we call low energy trauma. So this is like falls from standing height or anything less than that as well. And it's usually a sign of an underlying osteoporosis. Um So we've got the risk factors of osteoporosis over there as well. So, um increasing age, obviously. So we're, we're focusing on the elderly female sex, most likely menopausal, um steroid use, uh smoking alcohol, previous fractures, um rheumatological conditions, which is also very common in elderly anyway. Um And yeah, parental, I didn't know about parental history of hip fractures and then um those with uh low BMI as well. Next question, next slide. So we've got another SBA which I will send uh sorry just to add as well on that point, fragility fractures are usually fractures of the girdle or the long bones as well. So for example, if you fall from a standing height and you fracture your finger, that's not a fragility fracture. If you fracture your femur, for example, or your humerus or a rib, then that is, it's all right. That's fine. Yeah, that's a good point to think. Um OK, so Maggie's uh fractured kno is a fragility fracture. How do we manage her? Probable um osteoporosis? Ok. So it looks like we're mostly between two answers, whether to start bisphosphonates immediately or check bloods first. So usually we would check. So this patient, Maggie is 86 years old. So she's above 75. So we would consider bisphosphonates for her or not consider we would give her bisphosphonates um with a fragility fracture. The reason we're checking blood verse is because we're thinking about looking at her calcium and to be Vitamin D levels, making sure that they're within range. Um Before we start the medication, um any ideas about how bisphosphonates actually work? This is quite a common osk situation. Uh OSK scenario as well is um a patient who has had a fragility fracture, you're gonna be prescribing them bisphosphonates and counseling, counseling them on the use of bisphosphonates. And just another thing to add, sorry Um if the person has a low calcium or Vitamin D we replace that first and then start them on bisphosphonates, which is the reason uh stimulation of osteoblasts and inhibition of osteoclasts. Yeah, exactly. So you're inhibiting, so, bisphosphonates inhibit osteoclast activity. Um So you're reducing osteoclast recruitment and increasing um the osteoclast apoptosis. Um So this is basically just helping reduce that breakdown of the bone itself. Um So, in situations, you obviously usually have to in any situation with bisphosphonates, you need to counsel them on the side effects of it. Um So, one of the very common side effects of bisphosphonates is esophageal reactions, esophageal discomfort. So, when taking it, it's really important that you take it 30 minutes before food and you stay upright to help reduce this and also because of the poor absorption of bisphosphonates themselves as well. One of the more rarer side effects is osteonecrosis of the jaw. So, this is something to be aware of when someone has um is on bisphosphonates and comes in with something like jaw pain. Um consider osteonecrosis. Um and also atypical stress fractures are also sometimes seen with um bisphosphonate use as well. Um Anything else to add to cool. So success, she started um she's now stable following the operation and recovering well, her calcium and vitamin vitamin D were within within range. So you start her on long term bisphosphonates. Um Yeah. Any questions about any of that? Ok. Would you move on. Cool. All right then. So it's back to me to cover the last bit, which is psychiatry in the elderly. What I'm going to do is I'm going to send the feedback form just in case in the chart, just in case anyone needs to head off or anything like that. But we're still well within time and we will be done by, by seven. Um, ok, so psychiatry in the elderly. Um, so what are we going to cover? What, what kind of psychiatric conditions can affect older people? Well, it's a whole range of things all the way from dementia, depression, delirium to things like drugs and alcohol, which is also really important to remember in the elderly just because they're older doesn't mean they don't use drugs, they don't drink whatever it is. Um There's other conditions as well or other situations to consider like when a doll might be required, which we're not going to cover that directly in this presentation. But basically just a quick summary is a doll is a deprivation of liberties. Um And it, it basically the patient doesn't have capacity. So what Doles is put in place? Um And it basically means that they no longer have the liberty to make full decisions about their treatment. Um So they can't leave hospital and things like that. However, it only applies to someone who is already in hospital. That's the important thing to remember about adults. It can't be someone at home. You can't apply adults to them. It's only applicable if that patient is already in hospital. Cool. Right. Let's get going. First of all, with, back to Maggie. Poor old Maggie. Um, she's been getting more confused and distressed on the ward. She's pulling out a cannula, she's throwing things at the nurses. She's got Parkinson's disease as well in her history. You find out the nursing staff aren't able to calm her down. Er, you've got a set of obs which show she's got a normal temperature. Her heart rate is 100 and five BP, 1 38/78. And she's, er, saturating at 95% on rumor, her blood glucose is five. So which of the following, er, is the most appropriate immediate management for Maggie if you just put it in the pole? So are we going to give her immediate release? Carbidopa Levodopa, OLANZapine, LORazepam Amitriptyline or some Haloperidol? Yeah. So, right, for a few more answers. It doesn't matter if you get it wrong, just give it a go. Um, and we'll go through it. Cool. Oh, big range of big range of artists. Um, all right then. So this patient uh oh, ok. Now we cover the answer here. The correct answer is uh LORazepam. So well on to the person who said LORazepam. Ah, so we know that this patient has Parkinson's disease and that is key in this. So let's go through each of each of the things. So, um immediate release, Carbidopa levodopa, it doesn't sound like from the history. It doesn't sound like she's got bradykinesia or Parkinsonian symptoms, things like throwing things around and um and pulling out a cannon that doesn't, doesn't really sell Murray Parkinsonian. So we're not thinking that she's necessarily um dopamine deficient at the moment. So we probably, she's probably on a maintenance dose of um Cocala dope or something like that. So, chances are the, the, the reason for this isn't the lack of dopamine. So, a is not correct OLANZapine antipsychotic, which isn't from my experience used um for, for calming patients down. LORazepam is the correct answer. Amitriptyline is a um uh pain, pain relief, er, neuropathic pain relief and TCA. Um So basically, we're down to LORazepam and haloperidol, right. In most cases, we would give haloperidol to patients uh to calm them down if they're uh very uh distressed um on the ward. However, in the presence of a Parkinson's disease, we cannot give Haloperidol because it's a dopamine antagonist. Um and it's going to reduce the amount of dopamine in the body and that's going to really worsen parkinsonian symptoms. So we can't give them haloperidol and therefore we have to give them LORazepam and LORazepam is a benzodiazepine. So we can get that. Uh and it's not going to interfere with their dopamine levels. All right. I hope that makes sense. Any questions. Just uh type it in the chart and let me know. Um So to assess we now need to assess her confusional state and think about what might be going on. So this patient, she's had a fall, she's in the hospital, what? She's had an operation as well. Can anyone tell me just put it in the chart? What, what do you think might be going on? Why is she in this state where she's needing LORazepam to sedate her and to stop her uh being so distressed. I knew I did. If not, it's OK. Uh Yeah. So the answer is not take, I needed to sneeze and then didn't come. All right. Uh Maggie most likely, although we can't say for sure. Uh has delirium. Yeah. Thank you. She has uh delirium. Most likely, we can't say for certain. And therefore we need a screening tool to tell us. Does Maggie have delirium or is there something else going on? All right. So the tool that we use to assess an acute confusional state in an older person is called the four at and it's the screening tool for delirium. So basically, we can see whether the patient that has delirium or whether there's another cause something like dementia or something like that going on. So how do we do the four at? This is another very oscopy thing this could come up very easily. So, um the first thing we look at is alertness. Um The second parameter um is the A MT four So it's just four questions. Um your age, your date of birth, the main name of the hospital or where they are. Uh And the current year. All right. So that's to uh uh assess their cognition. Um Then we're going to check their attention. So ask them to say the month of the year backwards. And then the last component of the 40 is whether they have an acute change or a fluctuating course. All right. So if this is changing, if one day they're scoring more and one day they're scoring less, it is much more likely that they have delirium and that's where a lot of the points are allocated. All right. So a score of four or above suggests that there's probably delirium 1 to 3 is possible cognitive impairment and zero is not right. So Maggie score seven on the 480. So we suspect that she's suffering for delirium. We've already kind of thought about one and we haven't really. So what might be causing her delirium? Let's go through that. Um So sorry, this is another summary slide. So delirium is an acute transient change in attention and cognition. So the key there is it's transient um and it's fluctuating. So there's something that we need to identify, which is making this older person er delirious and we need to identify it and fix it and get them back to their baseline. So it can involve in altered consciousness and you can have hyper or hypo active or mixed states of delirium. Um and sometimes you can get abnormal perceptions as well. So, moving on, um there's an acronym that we need to remember called Pinch Me. These are the causes of delirium. Uh So we have pain uh infection, nutrition, constipation, hydration, medication and the environment. So, first of all, pain Maggie has had uh an operation. There's a chance that she could be in pain that could be causing her delirium infection. Again, she's had an operation. Um she could have an infection which is causing it nutrition, hopefully she's been eating. Ok. And hopefully that's being monitored by the nurses constipation. We need to ask about that hydration as well. Look at fluid balance chart, look at urine output, things like that medication, just do a medication review and environment. A lot of older people if they're put in a new environment, which they don't recognize they can become delirious. And what hospitals do to help that um is putting some key identifier about a patient on the wall behind them. So for example, things that they like or whatever, so that if that patient is delirious, then you can kind of call on those things to make them a bit more comfortable and that should help as well as that. Having familiar people around family around is really helpful as well. So uh why does she have deli? So her operation was three days ago, her pain is well managed with opiates, there's no fever or, um, and her urine culture is negative. So, chances are she doesn't have infection. She's been eating and drinking. Well. So, uh, nutrition isn't the, let's see, nutrition isn't the cause of her delirium. So we ruled out the first three. Uh, she's been urinating normally but her bowel charts show that she hasn't opened her bowels since three days before her operation or no, since before her operation, which was three days ago. So chances are she's constipated um secondary to the opiates that she's on the opiate medication. So, what are we gonna do? Uh She's constipated caused by the opiates. So, what we're gonna do is what we can't get rid of the opiates really because she's had an operation, she'll be in a lot of pain. So we're going to give her some laxatives, right? Moving on dementia. Um So dementia is an umbrella term used to describe all of these different, different things. So you can have Alzheimer's disease, vascular dementia, Lewy body, dementia, frontotemporal dementia. I'm going to run through each of them fairly quickly. Um Just to give a nice overview of each, right? So, um remember that delirium and dementia can present in a very similar way. So that's why our 480 is really useful because it can help us to rule out delirium. So then we know that our patient, there's a chance that they have dementia. All right. So, first of all, our patient um comes in and we need to take a history, a memory loss history. So what's important with a memory loss, history is actually a collateral history because from a son or daughter or spouse or whatever it is because that person, if they've got memory loss, we don't know if they'll be giving necessarily completely accurate information. It depends on the type of memory loss and stuff, of course. Um So collateral history is really important. We need to think about the onset of the memory loss. So was it, did it come on all of a sudden and they, they, they suddenly lost all their memory or has it been going on for some time? Uh associations, the time course of it exacerbations and the severity of the memory loss, then you're gonna take a general past medical history, drug history, family history. Um, you're going to assess the social, social situation and functional impact and risk, assess and safeguarding, safeguarding again, really important, especially if they've got memory loss, cognitive dysfunction. These patients are going to be extra vulnerable. So you really need to make sure that they're safe. This kind of the last bit is kind of more CgA kind of stuff. So you can perform a full CgA on these patients as well. So, uh dementia screen bloods, patient attends the memory loss clinic. Um, the patient attends with memory loss er, to your clinic. What investigations would you like to request? Are there any key investigations you can think of, um, just put them in the chat, please. It doesn't matter if they're wrong, if they're right, whatever it is, just put it in the chat and, uh, we'll, we'll go through it. I'm gonna go through it because I'm aware that we've only got about five minutes left. Um, so, uh, what we're going to do is we've got a dementia screen blood that we need to take. So we're going to rule out organic causes. So we're gonna do just for baseline, a full blood count using these LFT S. Remember, uh, that calcium uh can cause remember, stones, bones growths, thrown psychiatric undertones. Um, so we need to rule out uh cal calcium as a cause. We're gonna look at T FT ST FT S er, like er, thyroid function can affect memory and things like that. HBA one C B12 and FOLATE because all of these things are related to neuro. Then we're going to look at HIV and syphilis. Serological tests. Remember that those can both affect the brain HIV more through other things like Toxo and stuff and syphilis can directly affect. Then we're gonna review the medications thinking about side effects from polypharmacy. Then we're gonna look at the other causes. So the first thing we do is we exclude delirium. Um, and remember that dementia puts a patient at risk of delirium as well. Er, consider sight and hearing tracts, er, and monitor them over time. Er, and then we're gonna also screen for alcohol excess. Remember that's important. Um, and we might consider some neuroimaging. So, a CT or MRI to check for space occupying lesions, uh, normal pressure hydrocephalus. Remember that's w wacky wobbly. Um, and, yeah, so we'll, we'll do all those things. Right. So, let's talk about Alzheimer's disease. Um, this is the commonest, er, form of dementia. Um, and 5 50% of all cases of dementia. Alzheimer's um 5% of them are genetically associated. They are autosomal dominant in 5% of cases. Um The risk increases with age, it's a slow progression. You're going to get memory problems and cognitive disturbance. Remember that it's also associated with Down Syndrome. So, patients with Down Syndrome will experience Alzheimer's disease a lot earlier than others. Uh The five A S, what are the five A S uh that patients with Alzheimer's disease can suffer from? These are anomia, apraxia, agnosia, amnesia and aphasia. All right, we're going to uh so in terms of the pathophysiology of it, we're gonna find uh amyloid blocks and neurofibrillary tangles tau proteins. Um and on imaging, when we do our MRI we'll see volume loss and atrophy. Um and a pet scan could show some amyloids. So if you see the image you've just got really big uh really, really severe atrophy of the uh of one side of the brain. Ok. Moving on vascular dementia. So the second comminis type um So, 20% of cases is basically just mini strokes in the small vessels of the brain. Um and the key to diagnosis is a step wise deterioration. So if someone's at their baseline drops and then levels out and then drops again and so on. Um so you get memory problems that can have focal neurology. Uh and on CT RM MRI, they'll show areas of ischemia and small vessel disease. And remember, these guys will probably have uh quite a strong cardiovascular history as well. Frontotemporal lobe, uh dementia pigs disease is a type of subtype of frontotemporal lobe dementia that was a mouthful. So that's about 10% of cases. It starts early. All right. Um and it's got an insidious onset and a gradual progression. What happens uh patients become disinhibited so they start gambling, they might become hypersexual things like that. Um And it's, this condition has a stronger genetic association. Um And you're gonna see on imaging atrophy of the frontal and temporal lobes. Um key to this is er you might get something called knife edge atrophy. This basically refers to the extreme and global thinning of the gyri in the cerebral cortex um seen in the frontal and temporal lobe. And that's more specific to picks disease is pick's disease. You can also get picks bodies which are in intracellular neurofibrillary fibrillary tangles composed of abnormal tau proteins. Uh they're different to the ones that you find in Alzheimer's disease. Um And they stain differently as well. Uh They're more straight and fibrous. So that's just some extra, extra information for you guys if you're interested in Hot Star. Next we have Lewy body dementia. This is the third commonest. Um it's progressive with daily fluctuations of lucidity, you get er memory problems and Lily put li li hallucinations, er what are these? These are basically, you see humans, animals, whatever it is in your environment, but they can be of uh smaller size. Um Although the hallucinations vary from person to person, you can get some Parkinson's features. So things like bradykinesia trauma and rigidity. Um and you see as the names are just Lewy bodies in the cerebral cortex. The imaging is pretty nonspecific for this one. Um So as also neuronal inclusion bodies can also be found in diseases like Parkinson's disease and Lewy body dementia as well. So it's in both of them, the inclusion bodies are nuclear or cytoplasmic aggregates of sustainable substances, especially proteins. Um And as a bonus, uh more information, these cytoplasmic inclusion bodies can be found with several certain viral infections as well. So things like rabies and smallpox, you can see these inclusion bodies um that look like Lewy body dementia, but they might not be cool, few more, few more points to cover. Uh I know it's seven o'clock so we'll finish very soon. Um So er a normal grief reaction. This is uh a very a thing that they really like testing in, in SBA questions. Er so manifests often or can do as hallucinations of the deceased person. Um These are normal within the first six months of the event. Uh things that or, or symptoms can be uh emotional numbness, ps of grief and guilt, hallucinations of the deceased person. Um When someone has a normal grief reaction, what's key is just monitoring them for signs of depression um and suggesting some conservative interventions. So, good sleep hygiene, healthy eating exercise, things like that. Next up, we have alcohol withdrawal. So this is the uh a classic person who's come in alcohol withdrawal, that'll have seizures within the 1st 48 hours. Um and then major withdrawals later and your delirium tremens kicks in after 48 hours. Then Charles Bonnet syndrome is basically um simple or complex visual hallucinations that happen because you have a visual impairment. Um So for example, macular degeneration, if both eyes are affected, um they, they can start hallucinating. Uh and last of all, we have depression. So in older people, especially that can present with a global memory loss with a short history, a history that's much shorter than dementia. So it comes on quickly, depression. In older people, it comes on quickly, the memory loss will come on very quickly. Um There'll be other symptoms like weight loss or sleep disturbance, things like that. Um The patient might be worried about their poor memory as well. Usually in dementia, the patient isn't really aware, they don't know what they've forgotten. Um, the patient uh will need AM M SE and the score can be variable depending on the day. Um, but yeah, essentially it's global memory loss that comes on very suddenly and that's how you differentiate, differentiate it with dementias. Cool. All right, then, er, this is one of the last slides. Now, I think. So we'll just, er, do this question and then, uh, I will, uh, let you guys go. So your f one covering the night shift on the co board. Um, and, uh, Charlotte's 87 year old woman being treated for a neck fire fracture. She's ready for discharge in the morning. It bleeds right after by one of the nurses who says Charlotte is talking, waving her hands in the air. She says that she's playing with the rabbits deer and doesn't appear distressed. Which element of her medical history is the most likely cause of this presentation. Is it an untreated uti a bilateral dry age related macular degeneration, rheumatoid arthritis, liver cirrhosis or epilepsy? So, the correct answer is actually bilateral dry age related macular degeneration. This is Charles Bonnet Syndrome. This is Charles Bonnet syndrome and it's caused by a patient with bilateral vision problems and they have hallucinations because of it. It's probably not an untreated uti because, uh, delirium is less likely to, to present with hallucinations and also the patient isn't distressed. They're not confused per se they're just, er, having hallucinations. And so that is why, um, it's not that rheumatoid arthritis can't really be that liver cirrhosis, I guess there's an element of maybe a ha hepatic encephalopathy or something. But in terms of the question, that is the most likely answer is bilateral, dry age related macular degeneration. All right then. Ok. Um, so that's everything. Um, please do fill out the feedback form. Um I'll send it again in the chart now. Um And yeah, that's that, that's everything. Uh Thank you guys for coming. Any questions, stick them in the chat. I'll hang around for a couple of minutes. Um And yeah, we'll keep sending you these events and please keep signing up and coming along because it's, it's, it's good to teach and good to good to uh good to learn about these things. So, thank you very much. No. Yeah, this is all recorded as well. So it, it should go up on our page on me. All right. If there aren't any questions I'm going to stop, I should know. Thank you Iron.