Common Presentations in Elderly Medicine

What are the intrinsic causes of falls and collapses? (23)

Central nervous disease
Visual impairment
Cognitive impairment
Depression
Postural hypotension
Peripheral neuropathy
Medication including antihypertensives and sedatives
Pain such as arthritis
Parkinsonism's
Muscle weakness
Incontinence
Alcohol
Polypharmacy
Arrhythmias
Bradycardia
Valvular heart disease
Stroke
UTI
Hypoglycaemia
Arthritis
Diffuse atrophy
Ear wax
Vertigo

What are the environmental causes of collapses and falls? (2)

Poor lighting
Uneven walking surfaces

What investigations should be done in collapses and falls? (13)

Basic observations
Lying and standing blood pressure
Urine dipstick
ECG
Cognitive screen
Blood glucose
FBC
U&Es
LFTs
Bone profile
Chest x-ray
CT head
Echo

What are the risk factors for collapses and falls? (11)

Gait problems
Visual problems
Hearing problems
Medications
Alcohol excess
Cognitive impairment
Postural hypotension
Incontinence
Poorly fitting footwear
High blood pressure
Environmental hazards

How do you manage collapses and falls? (3)

Address injuries
Reduce risk factors
Reduce risk of injury such as treating osteoporosis

What are the risk factors for an osteoporotic fracture? (19)

Slender or anorexic
Smoker
Prolonged rest
Old age
Hyperparathyroidism
Steroid use
Vertebral deformity
Early menopause
Cushing's syndrome
Malabsorption
Thyrotoxicosis
Myeloma
Amenorrhoea
Family history of osteoporosis
Primary biliary cirrhosis
Rheumatoid arthritis
Hypogonadism
Past low trauma fracture
Mastocytosis

How do you manage osteoporosis? (7)

Increase dietary calcium
Calcium and vitamin D supplements
Bisphosphonates
Raloxifene
Calcitonin
Recombinant PTH
Strontium ranelate

How do you prevent osteoporosis? (6)

Exercise
Calcium rich diet
Avoid smoking
Avoid excess alcohol
Bisphosphonates for all on steroids
HRT

How do you diagnose osteoporosis? (3)

X-ray after a bone fracture
DEXA scan
Serum calcium, phosphate, and alkaline phosphatase

What is sepsis?

SIRS in the presence of an infection

What is severe sepsis?

Sepsis with evidence of organ hypoperfusion such as hypoxaemia, oliguria, lactic acidosis, or altered cerebral function

What is septic shock?

Severe sepsis with hypotension despite adequate fluid resuscitation or the requirement of vasopressors or inotropes to maintain blood pressure

What is septicaemia?

Was used to define the presence of multiplying bacteria in the blood but has now been replaced by other definitions

What is delirium?

An acute transient and reversible state of confusion

What are the causes of confusion? (13)

Hypoxia
Pain
Infection
Nutrition
Sleepiness
Prescriptions
Constipation
Hypothermia
Pyrexia
Metabolic disturbance
Organ dysfunction
Environmental changes
Drugs

How do you manage confusion? (15)

Identify and treat any underlying cause
Clear communication
Ensure access to glasses, hearing aids, and walking aids
Allow the patient to do what they can for themselves
Control noise levels
Ensure reasonable lighting and temperature
Inform family and carers of any changes and management plans
Consistent care and regular introductions and reminders
Ensure access to orientation reminders such as clocks
Familiar objects present
Involve patients family and friends
Avoid medication where possible
Haloperidol is first line
Benzodiazepines can be used
Assess risk factors for induction or exacerbation of confusion

What are the clinical features of hyperactive delirium? (5)

Agitation
Delusions
Hallucinations
Wandering
Aggression

What are the clinical features of hypoactive delirium? (4)

Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

What investigations should be done in delirium? (8)

U&Es
FBC
ABG
Lumbar puncture
Blood cultures
Malaria film
EEG
MRI

What are the differential diagnoses for delirium? (2)

Anxiety
Primary mental health illness

What are the causes of delirium? (13)

Pain
Psychological state
Infection
Drugs
Alcohol withdrawal and drug withdrawal
Metabolic
Hypoxia
Vascular
Intracranial infection
Head injury
Raised intracranial pressure
Epilepsy
Nutritional deficiencies

How do you manage delirium? (11)

Identify and treat the underlying cause
Reduce the patients distress
Music
Massage
Muscle relaxation
Augment self care
Do not use physical restraints
Find hearing aids and glasses
Nurse in a moderately lit, quiet room
Reassure and orientate to time place and person
Minimise medications

What are the signs of delirium? (8)

Disordered thinking
Euphoria
Language impairment
Illusions, delusions, and hallucinations
Reversal of sleep-awake cycle
Inattention
Unaware or disorientated
Memory deficits

What is an acute kidney injury?

A significant deterioration in renal function that occurs over hours or days

How do you detect an acute kidney injury?

Rising plasma urea and creatinine

What causes an acute kidney injury? (5)

Severe illness
Sepsis
Trauma
Surgery
Nephrotoxic drugs

What bloods should be done in an acute kidney injury? (14)

U&Es
FBC
Clotting
Creatine kinase
ESR
CRP
ABG
Blood cultures
Hepatitis serology if dialysis is considered
Serum immunoglobulins
Electrophoresis
Complement levels
Autoantibodies
ASOT

What other investigations should be done in an acute kidney injury? (5)

Urine dipstick
Urine MC&S
Chest x-ray
ECG
Renal ultrasound

How do you manage acute kidney injury? (9)

Treat the cause
Stop any nephrotoxic drugs
Urgent renal ultrasound
Basic observations
Fluid balance
Weight chart
Aim for normal calorie intake
Treat complications
Dialysis if indicated

What are the complications of an acute kidney injury? (4)

Hyperkalaemia
ECG changes
Pulmonary oedema
Bleeding

What are the indications for dialysis in acute kidney injury? (5)

Refractory pulmonary oedema
Persistent hyperkalaemia
Severe metabolic acidosis
Uraemic encephalopathy
Uraemic pericarditis

What are the pre-renal causes of acute kidney injury? (7)

Hypovolaemia
Sepsis
Congestive cardiac failure
Liver cirrhosis
Renal artery stenosis
NSAIDs
ACE inhibitors

What are the vascular causes of acute tubular necrosis which causes an AKI? (8)

Vasculitis
Malignant hypertension
Cholesterol emboli
Haemolytic uraemic syndrome
Thrombotic thrombocytopenic purpura
Glomerulonephritis
Interstitial nephritis
Hepatorenal syndrome

What are the nephrotoxic causes of acute tubular necrosis which causes an AKI? (5)

Drugs
Radiological contrast
Uric acid crystals
Haemoglobinuria in rhabdomyolysis
Myeloma

What is a stroke?

The result of ischaemic infarction or bleeding into parts of the brain that manifests as a rapid onset of focal CNS signs and symptoms

What is the presentation of a brainstem infarct? (4)

Wide range of effects
Quadriplegia
Disturbance of gaze and vision
Locked in syndrome

What is the presentation of a cerebral hemisphere infarct? (5)

Contralateral hemiplegia - initially spastic and then spastic
Contralateral sensory loss
Homonymous hemianopia
Dysphasia
Visuo-spatial deficit

What is the presentation of a lacunar infarct? (2)

Pure motor, pure sensory, mixed motor and sensory signs or ataxia
Intact cognition and consciousness

What is a lacunar infarct?

Small infarcts around the basal ganglia, internal capsule, thalamus, and pons

What investigations should be done in a stroke to exclude a preventable cause? (17)

Basic observations
Chest x-ray
CT head
ECG
Carotid doppler
FBC
Platelets
ESR
U&Es
Lipids
Sickling test
Blood glucose
Syphilis serology
Endocarditis tests
Echo
Clotting
Carotid angiography

What are the causes of stroke? (5)

Thrombosis in situ
Heart emboli
Atherothromboembolism
CNS bleeds
Failure of cerebral autoregulation of blood flow

What are the rare causes of a stroke? (3)

Sudden blood pressure drop by more than 40mmHg
Vasculitis
Venous sinus thrombosis

What are the causes of a stroke in young patients? (5)

Thrombophilia
Vasculitis
Subarachnoid haemorrhage
Venous sinus thrombosis
Carotid artery dissection

What are the risk factors for a stroke? (12)

High blood pressure
Smoking
Diabetes mellitus
Heart disease
Peripheral vascular disease
Past TIA
High packed cell volume
Carotid bruit
Oral contraceptive pill
Hyperlipidaemia
Alcoholism
Increased clotting

What are the methods of primary prevention for a stroke? (3)

Control risk factors
Regular exercise
Lifelong anticoagulation if indicated

What are the methods of secondary prevention for a stroke? (3)

Control risk factors
Reduce blood pressure and cholesterol at any level
Aspirin or warfarin in embolic stroke

What is the acute management for a stroke? (2)

Aspirin
Thrombectomy if indicated

How do you rehabilitate a stroke patient? (11)

Ideally with a specialist team
Assess swallow
Avoid NG tubes
Take care when lifting patients to avoid damage to their shoulders
Ensure good bladder and bowel care
Avoid early catheterisation
Position the patient to avoid spasticity
Start physiotherapy early
Anti-depressants in emotional lability
Screen for depression
Test perceptual function, spatial ability, apraxia, and agnosia

What is dysphasia?

Impairment of language caused by brain damage

What should you assess in dysphasia? (4)

Comprehension
Repetition
Naming
Reading and writing

What are the features of conduction aphasia? (3)

Traffic between Broca's and Wernicke's areas is interrupted
Repetition is impaired
Comprehension and fluency are not as affected

What are the features of nominal dysphasia? (3)

Objects cannot be named
Other aspects of speech are normal
Issue is in the posterior dominant temporoparietal lobe

What are the features of Wernicke's posterior dysphasia? (5)

Empty, fluid speech
Phonetic and semantic paraphrasia's
Patient is unaware of errors
Reading, writing, and comprehension are all impaired
Replies are inappropriate
Issue is in the posterior superior dominant temporal lobe

What are the features of Broca's anterior dysphasia? (5)

Non-fluent speech produced through a lot of effort and frustration
Words are often malformed such as spoot instead of spoon
Reading and writing are impaired but comprehension is relatively intact
Patients understand the questions and attempt to answer meaningfully
Issue is in the infero-lateral dominant frontal lobe

What is dysphagia?

Difficulty swallowing

What are the types of cause of dysphagia? (4)

Oral
Pharyngeal
Oesophageal
Neurological

What investigations should be done in dysphagia? (6)

Upper GI endoscopy and biopsy
ENT referral if pharyngeal cause suspected
FBC
U&Es
Chest x-ray
Barium swallow

What is the presentation of dysphagia? (9)

Progressive worsening of swallow
Difficulty making the swallowing motion
Odynophagia
Intermittent, constant, or progressive
Neck bulging or gurgling on drinking
Cachexia
Anaemia
Supraclavicular lymph nodes palpable
Signs of systemic disease

What are the mechanical causes of dysphagia? (4)

Malignant stricture
Benign stricture
Extrinsic pressure
Pharyngeal pouch

What are the motility disorders that cause dysphagia? (9)

Achalasia
Diffuse oesophageal spasm
Systemic sclerosis
Myasthenia gravis
Bulbar palsy
Pseudobulbar palsy
Syringobulbia
Bulbar poliomyelitis
Chagas disease

What are the other causes of dysphagia? (4)

Reflux oesophagitis
Infective oesophagitis
Global hystericus
Stroke

What is a tremor?

A rhythmic oscillation of limbs, trunk, head, or tongue

What are the features of an intention tremor? (3)

Worse on movement
Seen in cerebellar disease
No effective management

What are the features of a resting tremor? (4)

Worst at rest
Includes Parkinsonism's
Usually a slow tremor
Typically pill rolling

What are the features of a postural tremor? (5)

Worst if arms are outstretched
Typically a rapid tremor
May be exaggerated physiological tremor such as from anxiety, hyperthyroidism, alcohol, or drugs
Can be due to brain damage
Can be benign

What are the diagnostic features of Parkinson's disease? (4)

Tremor
Rigidity
Bradykinesia
Loss of postural reflexes

What causes Parkinson's disease?

Degeneration of substantia nigra dopaminergic neurones

How do you manage Parkinson's disease? (8)

MDT approach
Formal exercises for posture and mental strength
Disability and cognition assessments regularly
Dopaminergic drugs
Dopaminergic agonists
Anticholinergics for motor symptoms
Antimuscarinics for motor symptoms
Modafinil for daytime sleepiness

What are the neuropsychiatric complications of Parkinson's disease? (2)

Psychosis
Dementia

How do you manage the neuropsychiatric complications of Parkinson's disease? (4)

Tricyclic antidepressants
SSRIs
Atypical antipsychotics
Cholinesterase inhibitors

What are the rare causes of Parkinson's disease? (5)

Vascular events
Orthostatic hypertension and atonic bladder
Dementia and vertebral gaze paralysis due to supranuclear palsy
Kayser-Fleisher ring due to Wilson's disease
Apraxic gait due to hydrocephalus

How do you manage drug induced Parkinson's disease?

Add an antimuscarinic such as procyclidine

What are the general causes of constipation? (9)

Poor diet
Inadequate fluid intake
Dehydration
Immobility or lack of exercise
Irritable bowel syndrome
Old age
Post-operative pain
Hospital environment
Poor toilet facilities

What are the anorectal disease causes of constipation? (3)

Anal fissure
Anal stricture
Rectal prolapse

What are the intestinal obstruction causes of constipation? (5)

Colorectal carcinoma
Strictures such as in Crohn's disease
Pelvic mass
Diverticulosis
Pseudo-obstruction

What are the metabolic or endocrine causes of constipation? (5)

Hypercalcaemia
Hypothyroidism
Hypokalaemia
Porphyria
Lead poisoning

What are the drug causes of constipation? (3)

Opiate analgesics
Anticholinergics
Iron

What are the neuromuscular causes of constipation? (4)

Spinal or pelvic nerve injury
Aganglionosis
Systemic sclerosis
Diabetic neuropathy

What are the other causes of constipation? (4)

Chronic laxative abuse
Idiopathic slow transit
Idiopathic megacolon or megarectum
Psychological

What investigations should be done in constipation? (7)

FBC
U&Es
Calcium
TFTs
Sigmoidoscopy and biopsy
Barium enema
Colonoscopy

How do you manage constipation? (7)

Treat the cause
Advise good fluid intake
Exercise
Bulking agents
Stimulant laxatives
Stool softeners
Osmotic laxatives

What are the pharmacological causes of constipation? (9)

Antibiotics
PPIs
Cimetidine
Propranolol
Cytotoxic drugs
NSAIDs
Digoxin
Alcohol
Laxative abuse

What are the non-GI medical causes of diarrhoea? (4)

Thyrotoxicosis
Autoimmune neuropathy
Addison's disease
Carcinoid syndrome

What are the common causes of diarrhoea? (7)

Gastroenteritis
Irritable bowel syndrome
Drugs
Colorectal cancer
Ulcerative colitis
Crohn's disease
Coeliac disease

What are the uncommon causes of diarrhoea? (10)

Microscopic colitis
Chronic pancreatitis
Bile salt malabsorption
Thyrotoxicosis
Laxative abuse
Lactose intolerance
Ileal or gastric resection
Overflow diarrhoea
Bacterial overgrowth
Pseudomembranous colitis

What are the rare causes of diarrhoea? (10)

Autonomic neuropathy
Addison's disease
Ischaemic colitis
Amyloidosis
Tropical sprue
Gastrinoma
VIPoma
Carcinoid syndrome
Medullary thyroid cancer
Pellagra

What investigations should be done in diarrhoea? (14)

FBC
U&Es
ESR
CRP
TSH
Faecal occult blood
Coeliac serology
Stool microbiology
Faecal fat excretion
C-hiolein breath test
Rigid sigmoidoscopy
Colonoscopy
Barium enema
Small bowel radiography

How do you manage diarrhoea? (4)

Treat the cause
Oral rehydration
Codeine phosphate or loperamide
Avoid antibiotics

What should you check for in urinary incontinence? (5)

UTI
Diabetes mellitus
Diuretic use
Faecal impaction
U&E derangement

How do you manage stress incontinence? (5)

Pelvic floor exercises
Ring pessary
Duloxetine
Burch colposuspension
Vaginal tape

How do you manage urge incontinence? (4)

Incontinence chart
Maximise access to toilet
Keep bladder volume low
Drugs for night time incontinence

What are the causes of faecal incontinence? (4)

Rectal prolapse
Tumour
Sphincter laxity
Severe piles

What is jaundice?

Yellow pigmentation of skin, sclerae, and mucosa due to increased plasma bilirubin.

What causes pre-hepatic jaundice?

Increased bilirubin production, decreased liver uptake, or decreased conjugation meaning that increased unconjugated bilirubin enters the blood. It is not soluble so cannot enter the urine causing unconjugated hyperbilirubinemia

What are the causes of pre-hepatic jaundice? (4)

Physiological causes
Haemolysis
Dyserythropoeisis
Glucuronyl transferase deficiency

What are the causes of drug induced cholestasis? (6)

Antibiotics
Anabolic steroids
Oral contraceptives
Sulfonylureas
Chlorpromazine
Gold

Wat are the causes of drug induced haemolysis? (2)

Antimalarials
Dapscine

What are the causes of drug induced hepatitis? (6)

Paracetamol
Anti-TB
Statins
Sodium valproate
Monoamine oxidase inhibitors
Halothane

What at happens in hepatocellular jaundice?

Hepatocyte damage normally with some cholestasis

What are the causes of hepatocellular jaundice? (19)

Hepatitis
Cirrhosis
CMV
EDV
Drugs
Alcoholic hepatitis
Liver metastases
Liver abscess
Haemochromatosis
Autoimmune hepatitis
Septicaemia
Leptospirosis
Alpha-1 antitrypsin deficiency
Budd-Chiari
Wilson's disease
Failure to excrete conjugated bilirubin
Right heart failure
Toxins
Fungi