UKMLA: Geriatrics

Alzheimer’s Disease: What is the pathophysiology?

Accumulation of tau tangles and amyloid plaques

Alzheimer’s Disease: What are the risk factors?

• Over 65 y/o (most significant factor is age!!)

• Apolipoprotein E (APOE) gene mutation

• Down syndrome

• FH

• Smoking, bad diet, physical inactivity

• Traumatic brain injury

• Low educational attainment

Alzheimer’s Disease: What are the symptoms?

• Poor memory

• Language impairment

• Poor ability to plan or organise tasks

• Aggressive behaviour

• Hallucinations

• Delusions

• Paranoia

• Unable to recognise places or people

• Loss of motor skills

Alzheimer’s Disease: What is the management?

1. Donepazil OR galantamine (cholinesterase inhibitor)

2. Memantine (NMDA receptor antagonist)

• Low dose rsiperidone for behaviour and psychological symptoms of dementia

Parkinson’s Disease: What presentation is contraindicated with the use of donepazil?

Bradycardia

Constipation: What is the Rome IV criteria?

• Fewer than three bowel movements per week

• Hard stool in more than 25% of bowel movements

• Tenesmus (sense of incomplete evacuation) in more than 25% of bowel movements

• Excessive straining in more than 25% of bowel movements

• A need for manual evacuation of bowel movements

Constipation: What are the risk factors?

• Old age

• Poor nutrition e.g. low fibre

• Inactive

• Medications e.g. CCB

• Female

Constipation: What are the symptoms?

• Less than 3 bowel movements a week

• Tenesmus

• Straining

• Distended abdomen

• Abdominal mass in left/right lower quadrants (stool)

• Rectal bleeding

• Haemorrhoids

• Fissures

• Confusion

Constipation: What are the investigations?

• Faecal immunochemical test (FIT)→ detects hidden blood in stools to check for malignancy

Constipation: Under what circumstances is a constipated patient referred for cancer investigation?

• Constipation with weight loss

• 60 y/o or older

Constipation: What is the management?

Laxatives:

• Ispaghula husk → increase stool bulk

• Senna → short-term relief

• Lactulose→ treats constipation in patients with hepatic encephalopathy

• Enema→ rapid evacuation pre-procedure or examination

• Sodium docusate/macrogol→ treats constipation in patients with anal fissures (stool softener)

Constipation: What are the different MOA for laxatives?

‘BOSS’ mneumonic:

• Bulk-forming→ e.g. isphagul husk

• Osmotic → e.g. lactulose

• Stimulating→ e.g. senna

• Softening→ docusate sodium
  

Haemorrhagic Stroke: What is the pathophysiology?

Bleeding in the brain parenchyma, ventricles or subarachnoid space → raised ICP

Haemorrhagic Stroke: What are the risk factors?

• Old age

• Male

• FH

• Haemophilia

• HTN

• Cocaine use

Haemorrhagic Stroke: What are the symptoms?

• Severe headache

• Altered conscious (drowsy to coma)

• Vomiting

• Weakness

• Visual loss

• Seizures

• HTN

Haemorrhagic Stroke: What are the investigations?

• Blood glucose

• Blood pressure

• ECG

• CT head is key investigation

Haemorrhagic Stroke:

• Refer to neurosurgery

• Reverse coagulation treatments

• IV GTN or labetalol for HTN

• Ensure patient is NBM

Ischaemic Stroke: What is the pathophysiology?

Ischaemic strokes occur due to occlusion or stenosis of the vessels supplying the central nervous system, causing infarction of tissues

Ischaemic Stroke: What is the Bamford classification criteria for a Total Anterior Circulation Stroke?

All 3 of the following:

• Unilateral motor or sensory deficit (or both) affecting at least two of the face, arm and leg

• Higher cerebral dysfunction (e.g. dysphagia, neglect, dyscalculia)

• Homonymous hemianopia

Ischaemic Stroke: What is the Bamford classification criteria for a Partial Anterior Circulation Stroke?

2 out of the following:

• Unilateral motor or sensory deficit (or both) affecting at least two of the face, arm and leg

• Higher cerebral dysfunction (e.g. dysphagia, neglect, dyscalculia)

• Homonymous hemianopia

Ischaemic Stroke: What is the Bamford classification criteria for a Lacunar Stroke?

• Pure motor stroke

• Pure sensory stroke

• Sensori-motor stroke

• Ataxic hemiparesis

• Dysarthria-clumsy hand syndrome

Ischaemic Stroke: What is the Bamford classification criteria for a Posterior Circulation Stroke?

• Cerebellar dysfunction

• Conjugate eye movement disorder

• Bilateral motor and/or sensory deficit

• Ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit

• Isolated homonymous visual field defect

Ischaemic Stroke: What are the symptoms?

• Cerebellar dysfunction

• Conjugate eye movement disorder

• Bilateral motor and/or sensory deficit

• Ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit

• Isolated homonymous visual field defect

Ischaemic Stroke: What are the investigations?

• Bloods

• Hb1Ac and blood glucose

• Lipid profile

• CT to rule out haemorrhage

• Carotid Doppler to identify stenosis

• Echo to identify embolism

Ischaemic Stroke: What is the management?

• Refer to SALT for dysphasia

• NG tube and feeding within 24 hours

• Physiotherapy

• Thrombolysis with alteplase within 4.5 hours onset

• Aspirin 300mg → for 2 weeks!!

• Switch to 75mg clopidofrel

• Thromboectomy

Lewy-Body Dementia: What is the pathophysiology?

Deposits of alpha-synuclein protein that form Lewy bodies

Lewy-Body Dementia: What are the clinical features?

• Changes in attention

• Parkinsonism→ rigidity, bradykinesia, postural instability

• Visual hallucinations

If cognitive impairement and Parkinsonism develops within one year of each other, it is likely LBD.

Lewy-Body Dementia: What are the investigations?

• Dopamine transporter scan (DAT)

• Electroencephaalography scan (EEG)

Lewy-Body Dementia: How common is it?

1. Alzheimer’s

2. Vascular dementia

3. Lewy-body dementia

Parkinson’s Disease: What are the clinical features?

• Bradykinesia

• Asymmetric 3-5Hz "pill-rolling" resting tremor

• Rigidity

• Gait→ small, shuffling steps

• Constipation

• Olfactory issues

• Depression, anxiety and hallucinations

Parkinson’s Disease: What is the pathophysiology?

• It is believed to result from the accumulation of "Lewy bodies", intracellular inclusions primarily composed of misfolded alpha synuclein.

• These bodies form and lead to neuronal death in the dopaminergic cells of the substantia nigra of the basal ganglia, thereby causing the characteristic symptoms.

Parkinson’s Disease: What excludes a diagnosis?

An absolute failure to respond to 1-1.5g of levodopa daily almost excludes a diagnosis of idiopathic Parkinson's disease.

Parkinson’s Disease: What is the management?

1. Levodopa

2. Can combine with carbidopa

3. Dopamine agonists

4. Selegiline (MAO-B inhibitor)

Parkinson’s Disease: Levadopa can cause nausea. Which anti-emetic can be prescribed to manage this?

Domperidone

Parkinson’s Disease: What side effect is as associated with short-term use of levodopa?

Abnormal dreams

Parkinson’s Disease: What side effect is as associated with long-term use of levodopa?

End of dose deterioration (by the end of a dose, there is not enough levodopa and symptoms return)

Vascular Dementia: What is the cause?

Ischaemic or haemorrhagic stroke

Vascular Dementia: What are the risk factors?

• HTN

• Diabetes

• Hyperlipidaemia

• Smoking

• AF

Vascular Dementia: What are the symptoms?

• Visual disturbance

• Sensory or motor issues

• Poor attention and concentration

• Seizures

• Memory loss

• Occurs over several months to years

• Patient may have PMH of stroke

Vascular Dementia: What is frontotemporal dementia?

Prominent changes in personality and behavior or language difficulties with relative sparing of memory.

Vascular Dementia: What is the hallmark of diagnosis via MRI?

White matter and infarcts

Vascular Dementia: What is the management?

• Address underlying risk factors/causes

• Music/art therapy

• Donepazil or memantine if they have Parkinson’s too or dementia with lewy bodies