Geriatrics

Front 1

Define Osteoporosis

Back 1

A reduction of bone mass (or density) or the presence of a fragility fracture/minimal trauma fracture. 2.5 or more standard deviations below the mean (T-score of -2.5 or lower). Accompanied by deterioration in the architecture of the skeleton, leading to a markedly increased risk of #

Front 2

Define Osteopenia

Back 2

Low bone mass, defined by a T-score between -1 and -2.5 (T-Score of -1 or higher is normal)

Front 3

What is the difference between T-scores and Z-scores? When are Z-scores used?

Back 3

T-score = Number of SD from the mean BMD of an adult aged 30yrs.
Z-Score = Number of SD from the age and sex matched mean BMD. Used to assess patients younger than 50yrs (Z-score less than -2 should prompt investigation for underlying cause of bone deficit

Front 4

What is a minimal trauma #/fragility #?

Back 4

Fall from standing height leading to a #

Front 5

Risk factors for OP (6 broad categories)

Back 5

-Age

-Genetic (female, white, Asian, FHx)
- Hormonal (premature/surgical menopause)

- Lifestyle/nutrition (↓Ca, Cigs, ETOH, eating disorders, amenorrhoea (↑PA), malabsorption, TPN
- Meds (Steroids (5mg or more for >3/12=Rx), Anticonvulsants (phenytoin, NaVal), heparin

- Med conditions (Endocrine↑PTH, Haem, CT, Renal, GIT, Genetic)

- Parent with hip #

Front 6

How + When to measure BMD?

Back 6

- Bone mineral densitometry = Dual Energy X-ray Absorptiometry (DEXA) - measures bone mass in all areas

- Indicated if one or more risk factors (Free DEXA every 2 yrs over 70, Younger if on LTCS)

Front 7

Causes of T-score false negatives (higher than it should be)?

Back 7

- Osteophytes, vertebral crush #'s, spondylosis (

(Post # →Callous formation, extra bone)

- Degenerative changes

- Vascular calcifications

- Past hip surgery

Front 8

Screening tests for secondary causes of OP?

Back 8

- Ca, ALP, Vit D

- PTH

- TFTs, LFTs

- SPEP (Serum Protein Electrophoresis - MM)

- Testosterone, SHBG

- 8am cortisol

- Cr (Renal bone disease)

- B12, Folate, Fe

Front 9

Prevention strategies for OP?

Back 9

- Able to cease LTCS or Antiepileptics?

- Adequate Ca and vitamin intake

- Exercise (30min wt bearing or resistance at least 4x/wk)

- Smoking cessation

- Limited ETOH and Coffee

- Fall prevention

- Meds (Bisphosphonates, Raloxifene)

Front 10

Rx of OP - When and what?

Back 10

- Recommended for women with a T-score <-2 without RF's (<-1.5 with RF's and >70yo)

- Should include prevention and lifestyle (exercise, don't chew darts, limit imbibing)

- Ca (1.2g) and Vit D (800-1000IU)

- Meds - Bisphosphonates (Alendronate (Fosamax), risedronate (Actonel), zolendronic acid), Raloxifene, Teriparatide, Denosumab (Prolia)

Front 11

What do you know about Bisphosphonates? (Mechanism, types, regimen, side effects)

Back 11

- Should be given if on Antiepileptics/LTCS

- Disrupt OC formation and apoptosis of OC

- Remain in skeleton for years, efficacy lasts

Alendronate (Fosamax) - Weekly 70mg/monthly 140mg, need creatinine clearance 50%. Sit upright + take on empty stomach (oesophageal erosion)

Risedronate (Actonel) - 5mg, better in CS induced OP

Front 12

Bisphosphonates continued...

Back 12

Zolendronic acid (Zometa) - IV infusion 4mg, need PBS authority and documented #, >20% loss of vertebral height/fragility #. Can cause Osteonecrosis of the jaw.

Front 13

How does Denosumab work?

Back 13

Fully human monoclonal antibody binds RANK-Ligand, prevents interaction of RANKL with its receptor RANK on OCs and OC precursors, reversibly inhibits OC-mediated bone resorption.

Front 14

Why do Corticosteroids cause OP?

Back 14

- Inhibits osteoblast function/apoptosis/↓precursors

- ↓Ca absorption from GIT, ↑urinary losses (secondary hyperPTH

- ↓Adrenal androgens

- Most common form of seconday OP

- Bone loss very rapid - 20% 1st yr,

- 30-50% # risk if Rx for >6/12

Front 15

Recommendations for Steroids and OP

Back 15

- ↓possible dose, ↓possible duration (ST ↑dose better than continuous ↓dose)

- Alternative therapy used whenever possible

- Topical or inhaled preferred

- Budesonide the preferred inhaled CS

- Encourage preventative measures (30min exercise, ↓Cigs, ↓ETOH, Falls prevention

- Ca + Vit D, risedronate

Front 16

Falls prevalence? % >65yrs? % >80yrs? In hospital or RACF?

Back 16

- 30% of people aged >65 fall annually

- 50% of people aged >80 fall annually

- 2 to 3 fold ↑ falls rates in hospital or RACF

Front 17

Fall definition? (Seriously)

Back 17

An event which results in a person coming to rest inadvertently on the ground or other lower level, other than as a consequence of the following
- Loss of consciousness

- Sustaining a violent blow

- Sudden onset of paralysis

- Epileptic seizure

Front 18

Who is "a faller"? (these are getting worse)

Back 18

Anybody who has had 2 or more falls in the past 6/12 or an injurious fall

Front 19

Falls risk factors?

Back 19

-previous fall, fear of falling

- frailty (sarcopenia, malnutrition), dependent with ADLs

- lower extremity weakness

- Balance problems

- joint instability and pain (OA)

- Cognitive impairment

- polypharmacy, psychotropic drug use

- Othorstatic hypotension, dizziness

Front 20

What contributes to balance?

Back 20

Highly complex, involves sensory input (vision, postural control of BP and vestibular function), central processing at multiple levels and an effector response via the peripheral nervous system and musculoskeletal system

Front 21

Important aspects of taking a falls history?

Back 21

- Circumstances of fall (activity, location, walking aid, footwear, time of day, lighting, eyewear, warning symptoms, LOC)

- Previous falls/near falls

- observer history

- fear of falling

- impact on lifestyle

- injuries/complications

-ability to get up post-fall

Front 22

Aspects of physical exam post-fall?

Back 22

- MSK (feet, ankles, knees, hips)

- Neuro (power, balance, gait)

- Vision

- Postural BP+HR (Lying and stand at 1+2mins)

- Gait and balance Ax (TUG, Pastors, Rhombergs)

- Ax of feet and footwear

Front 23

Investigations post fall?

Back 23

- No standard set, Ax determines Ix

- Vit D, Ca/PO4, FBE, U&E, Glucose common.

- X-Ray if indicated on assessment (pain, deformity, loss of function)

- BMD scan as an Outpatient if indicated

Front 24

What is Rhomberg's test and what is it for?

Back 24

- For Proprioception

- Stand Feet Together Eyes Open, then close eyes. (hold for up to 1min). Positive If balance lost

Front 25

What is Pastors test and what is normal?

Back 25

-Test for Dynamic balance reactions in response to external perturbation.

- Stand behind pt, brief tug backwards on shoulders. Warn pt prior to tug, ask them to try and stay standing.

- Grading = 1- Sways, no step.

2- one step,

3- two or more steps, stays upright,

4- two or more steps, then falls.

5- 'Timber' reaction. 1 or 2 is normal

Front 26

What is a Timed Up and Go test (TUG) and what is normal?

Back 26

Using usual footwear and gait aid, starting seated in a chair with arms. On 'Go', rise from chair and walk 3m, turn and return to chair and sit down.

- Normal in older ppl is <10s

Front 27

Falls prevention strategies? (9)

Back 27

- Strength, Balance, Gait, T/F training

- Vit D + Ca

- Medication r/v (withdraw Benzos - slowly)

- Vision testing + Cataract surgery

- Home hazard assessment and modification

- Footwear modifications, Hip protectors

- Education ++++++

- Fall alert cards and bracelets

Front 28

Delirium definition + Incidence + Prevalence

Back 28

Syndrome characterised by the rapid onset of altered consciousness and cognition. Typically fluctuates and is usually temporary. Includes both hyperactive and hypoactive forms (+mixed), the latter is under-recognised and often leads to poorer prognosis.

Prevalence = 10-30% of elderly pts admitted

Incidence = up to 56% in elderly hospital pts

Front 29

Delirium signs and symptoms (many)

Back 29

- Irritable, bewildered, angry or evasive, agitated

- Fluctuating consciousness (drowsy, lethargic, easily distracted, disoriented, repeated qns)

- Disorganised thinking (impaired decisions/difficulty executing simple tasks, poor judgement & insight, Delusions - 30%, paranoid, rambling/incoherent speech)

- Visual hallucinations - night

- Sleep-wake cycle reversed

Front 30

Delirium predisposing factors? (7)

Back 30

- ↑Age

- Cognitive deficits (Dementia, past ABI)

- Polypharmacy

- Sensory Impairment (vision+hearing)

- Multiple chronic medical conditions

- Functional disability

- Chronic Renal Impairment

Front 31

Delirium precipitating factors? (there is always one, commonly multiple) (5 broad groups)

Back 31

- Severe acute illness (Infection, Electrolyte/acid base disturbance, hypoxia/hypercapnia, hepatic/renal failure, hypoglycaemia, stroke)

- Medications+++ (usually new added)

- Surgery & anaesthetics (↓BP)

- Substance withdrawal (ETOH, Benzos)

- Environmental (poor sleep, IDC, Pain and discomfort-constipation, unfamiliar environment, immobilisation, restraint use

Front 32

Medications associated with Delirium? (Hint - Ducking everything)

Back 32

Benzos (diaz), Antiparkinsons (Levadopa), Anti-Ds (TCAs, SSRIs), Antipsych (Haloperidol), Anticonvulsants (Phenytoin), Lithium, Antiarrhythmics (Amiodarone, digoxin), AntHTNs (Atenolol, nifedipine), H2RAs (Ranitidine), CS (Pred), Opiates (Morphine, codeine, Oxy), NSAIDs (Naproxen), OTC+Herbal (Pseudo, St John's Wort), AntiHistamines, Antispasmodics (Belladonna)

Front 33

What is the Confusion Assessment Method? (For Delirium) (4 categories)

Back 33

1+2 and either 3 or 4

1. Acute onset and fluctuation (Collateral Hx, △Mental status from baseline)

2. Inattention (Ax ability to focus, distractibility, following convo, answering qns. Formal testing with repetition of a phrase, counting backwards.

3. Disorganised thinking (Incoherent, rambling, irrelevant convo, unclear/illogical flow of ideas, unpredictable subject changes

4. Altered level of Consciousness (Alert v hyper-alert, lethargic (drowsy, easily aroused), or in stupor (difficult to arouse), or coma (unrousable)

Front 34

Non-pharmacological prevention/management of delirium?

Back 34

- Early Ax, correct dehydration

- R/v precipitating factors, Rx medical conditions, Med Mx

- Trained MDT (multicomponent intervention), involve family, communication important

- Environmental strategies (Clock and calendar, verbal reminders, isolated room with familiar possessions, avoid staff changes, avoid sensory deprivation and overload, avoid benzo's+antipsych, minimise sensory impairment, minimise immobilising devices (IDC, drips), encourage self-care

Front 35

Communication strategies when treating someone with delirium?

Back 35

- Cognitive Impairment Identifier (CII) end of bed card

- Introduce yourself

- Maintain eye contact

- Calm & matter of fact

- Involve carers

- Short & simple sentences, one instruction at a time

- Allow time for responses, Repeat questions, Avoid offering choices

Front 36

Investigations for Delirium (and why)?

(7 + a few possible extras)

Back 36

-FBP (anaemia, infection)

- U&E (Metabolic/renal problems)

- Glucose (hypo/hyperglycaemia)

- Calcium (Hypercalcaemia)

- LFTs (Hepatic failure, metastases, infection)

- Urinalysis + MSU (UTI)

- CXR (Resp infection, heart failure)

Consider - ECG, Cardiac enzymes, blood cultures, TFTs, ABGs, B12+Folate, Head CT, Lx Puncture, EEG

Front 37

Pharmacological management of Delirium?

Back 37

Mild-Mod - Haloperidol 0.5mg bid, up to 3mg (If prolonged, Risperidone 0.5mg bid /Olanzapine 2.5mg nocte)

Mod - initial dose repeated every 4hrs until response, then cont with bid dose as above.

Severe with agitation/aggression - Haloperidol 0.25mg IM, wait 30min, then 0.5mg, 1mg, 2.5mg, 5mg every 30min up to total of 10mg. If no response, midazolam 1.25mg IM, wait 30min, 2.5mg.

Front 38

Consequences of delirium?

Back 38

- Increases risk of advert outcomes (↑LOS, cognitive & Fx decline, need for nursing home admission, possible mortality)

- Rates of falls, incontinence and pressure sores are tripled in hospital pts with delirium.

- Developing delirium in hospital increases relative risk of mortality at 2 years to 1.82

Front 39

Define Dementia

Back 39

- A disease of the brain causing a state characterised by a decline in memory and cognitive function, impairing social and/or occupational functioning

- Deficits do not occur exclusively during the course of delirium.

- Most common presentation is a progressive disorder associated with alterations in personality, behaviour, judgement and ADL's.

Front 40

Dementia Prevalence? (Age groups)

Back 40

60-65 yrs = 1%

65-70 yrs = 2%

70-75 yrs = 4%

75-80 yrs = 8%

80-85 yrs = 16%

85 yrs + = 32%

From Prof Flicker (Rough guide he said)

Front 41

Define Alzheimer's Dementia

Back 41

- Degenerative neurological condition causing a marked deterioration and dysfunction of the regions of the brain essential for cognition.

- Characterised by neurofibrillary tangles, neuritic plaques and amyloid deposition in those plaques.

- No single cause identified, rare familial dominant mutations, Down's syndrome.

- ↑Risk with Age >60, ApoE4 Gene on Chrom 19