SCE Revision Course Geriatric Medicine & Other

Transcription

1 SCE Revision Course Geriatric Medicine & Other

2 Geriatric Medicine: what the curriculum says you should know Physiology of ageing Atypical presentations: the Geriatric Giants Falls and fragility fractures Syncope* Dizziness Funny turns (TIA/seizure)* Delirium* Dementia* Incontinence Hypothermia Polypharmacy Parkinson s Disease Malnutrition Leg and pressure ulcers Rehabilitation and Intermediate Care *including any relevant legal aspects e.g. mental capacity and driving (England/Wales)

3 What s in Other? (These are all in the curriculum) Allergy & immunology Dermatology Clinical genetics Mental health Legal framework for practice (UK 4 countries) Public health Quality & safety (e.g. improvement science) Diagnostic test interpretation

4 Question 1 A 75-year-old woman was admitted following a fall and a Colles fracture. During a falls assessment she complained of recent balance problems and brief vertigo whenever she looked up. Her past medical history comprised hypertension, angina and diet controlled diabetes for which she was taking aspirin 75mg daily and amlodipine 10mg daily. On examination, her gait and balance was normal. The rest of the physical examination was normal. A lying and standing blood pressure showed no postural drop. What is the most likely reason for her fall?

5 A. Acoustic neuroma B. Benign positional vertigo C. Cervical spondylosis D. Mechanical fall E. Vertebrobasilar insufficiency

6 A. Acoustic neuroma B. Benign positional vertigo C. Cervical spondylosis D. Mechanical fall E. Vertebrobasilar insufficiency

7 Falls in older people NICE Clinical Guideline 161: assessment and prevention of falls in older people (Jul 2013) NICE Clinical Guideline 146: osteoporosis: assessing risk of fragility fractures (Aug 2012) Assess fracture risk in: Previous fragility fracture History of falls (Guideline lists others as well) FRAX or Qfracture plus other risks +/- DXA scan

8 There is no such thing as a mechanical fall in older people (and always remember their bones!)

9 Question 2 An 80-year-old man was admitted after an episode of transient loss of consciousness. He did not injure himself and recovered quickly. This has happened 6 times in the last 18 months, always while standing or walking. His past medical history included diet controlled diabetes, hypertension and benign prostatic hypertrophy for which he was taking ramipril, bendroflumethiazide and tamsulosin. On examination, there was nothing abnormal to find. His lying and standing blood pressure showed no postural drop. His blood results and 12-lead ECG were normal. What is the next best step in management?

10 A. Ambulatory blood pressure monitoring B. Ambulatory ECG C. Capillary glucose measurement during symptoms D. Carotid sinus massage E. Tilt test

11 A. Ambulatory blood pressure monitoring B. Ambulatory ECG C. Capillary glucose measurement during symptoms D. Carotid sinus massage E. Tilt test

12 Collapse?cause transient loss of consciousness Due to acute illness Treat illness Syncope Initial evaluation Not syncope: Seizure Hypoglycaemia Intoxication etc % of cases Obvious cause: treat Unexplained: Divide in to those with structural heart disease and those without

13 Unexplained: Divide in to those with structural heart disease and those without Structural heart disease: Always investigate Cardiac investigations Ambulatory ECG Echo (Exercise test) (Electrophysiology) (Other) No heart disease: Do not investigate a single episode Investigate recurrent episodes NICE guideline CSM if aged 60+ Ambulatory ECG (ILR in this case) No tilt testing! ESC guideline CSM if aged >40* Tilt test ILR

14 Question 3 An 80-year-old man with dementia was admitted to an English hospital with increased confusion thought to be due to a recent change in medication. His wife was no longer able to look after him at home. He had been wandering up and down the ward and repeatedly attempting to leave. He was amenable to distraction from the nursing staff some of the time but became aggressive if he was contradicted or manhandled. There was no evidence of any acute illness and his blood results, 12-lead ECG and CT of the head were all normal. What is the next best step in management?

15 A. Detain under Common Law B. Detain under the Mental Capacity Act C. Detain under Section 5(2) of the Mental Health Act D. Detain under an emergency Deprivation of Liberty (DOL) order E. Discharge back to his usual environment

16 A. Detain under Common Law B. Detain under the Mental Capacity Act C. Detain under Section 5(2) of the Mental Health Act D. Detain under an emergency Deprivation of Liberty (DOL) order E. Discharge back to his usual environment

17 Delirium A clinician s brief guide to the Mental Capacity Act 2 nd Ed. Brindle et al. RCPsych Publications, (NB: England & Wales) NICE Clinical Guideline 103 delirium: prevention, diagnosis and management (Jul 2010)

18 NICE Clinical Guideline 103 Admission to hospital Risk factors? Age >65; cognitive impairment/dementia; hip fracture; severe illness YES NO At risk YES Change in risk factors? Not at risk Are there any indicators of delirium? NB carers or relatives may report these: RECENT changes in cognitive function, behaviour, perception or physical function? NO Daily observations for indicators of delirium PLUS delirium prevention strategies YES Clinical assessment: short CAM and AMT Delirium diagnosed?* YES Record in hospital and primary care notes. TREATMENT*

19 Simplified diagnostic criteria: the short Confusion Assessment Method (CAM) Criteria 1. Acute onset and fluctuating course (Is there an acute change in mental state? Did this fluctuate during the past day?) 2. Inattention (Is the patient easily distracted or does he have difficulty keeping track of what is being said?) Inattention can also be detected by asking for the days of the week to be recited backwards 3. Disorganised thinking (Is the patient s speech disorganised, incoherent, rambling, irrelevant, unclear/illogical or unpredictable switching between subjects?) 4. Altered level of consciousness (Is the patient vigilant (hyper-alert) or lethargic/drowsy?) Present? Y / N Y / N Y / N Y / N either 3 or 4 must be present to diagnose delirium.

20 3 sub-types of delirium Hyperactive (think: meerkat) Hypoactive (think: in bed and carphology ) Mixed Hypoactive delirium more likely to go unrecognised and thus has a worse outcome

21 Delirium has serious complications Studies show delirium is associated with poor outcomes. People who develop delirium are more likely to: Stay in hospital or critical care for longer Have an increased incidence of dementia Have more hospital-acquired complications eg falls, pressure ulcers Be admitted to long term care Die* (mortality among hospitalised patients is 22-76%, as high as MI or sepsis. One-year mortality 35-40%)

22 Question 4 An independent 88-year-old man was admitted with chest pain and diagnosed with angina. He had a past medical history of ischaemic heart disease, gout and hypertension. He was taking ramipril 10mg daily, aspirin 75mg daily, bisoprolol 5mg daily, allopurinol 200mg daily, and atorvastatin 40mg at night. On examination, his vital signs, including a lying and standing blood pressure, were normal. His blood results and a 12-lead ECG were also normal. He asked his doctor to review his medication as he felt he was taking too many tablets. Which of his regular medications should be stopped?

23 A. Allopurinol B. Aspirin C. Atorvastatin D. Bisoprolol E. Ramipril

24 A. Allopurinol B. Aspirin C. Atorvastatin D. Bisoprolol E. Ramipril Evidence that statins offer no benefit in this age group.

25 Question 5 A 24-year-old woman developed difficulty breathing and swelling of her tongue and lips within 30 minutes after ingesting penicillin which she had been prescribed by her GP. She was treated for anaphylaxis in the Emergency Department and documented as having an allergy to penicillin. She started to improve quickly. A blood mast cell tryptase level was sent to the lab. At what time should this blood test be repeated?

26 A. 2 hours later B. 4 hours later C. 6 hours later D. 8 hours later E. 12 hours later

27 A. 2 hours later B. 4 hours later C. 6 hours later D. 8 hours later E. 12 hours later After suspected anaphylaxis in adults, a mast cell tryptase sample should be sent as soon as possible after emergency treatment has started, and a second sample ideally within 1-2 hours (but no later than 4 hours) from the onset of symptoms. NICE CG134. Anaphylaxis: assessment and referral after emergency treatment, 2011.

28 Question 6 A 24-year-old woman developed difficulty breathing and swelling of her tongue and lips within 30 minutes after ingesting penicillin which she had been prescribed by her GP. She was treated for anaphylaxis in the Emergency Department and documented as having an allergy to penicillin. She started to improve quickly. She was reviewed on the Acute Medical Unit two hours later. For how long should she be observed?

29 A. No further observation required B. Up to 4 hours C. Up to 6 hours D. Up to 12 hours E. Up to 24 hours

30 A. No further observation required B. Up to 4 hours C. Up to 6 hours D. Up to 12 hours E. Up to 24 hours NICE CG134: Patients should be observed for 6-12 after onset of symptoms, depending on their response to emergency treatment. Not NICE: Biphasic reactions are more likely to occur when people have ingested the allergen and a longer period of observation should be considered here.

31 Question 7 A 21-year-old student was admitted with headache, fever, nausea and vomiting and was diagnosed with meningitis. A lumbar puncture was performed and his cerebrospinal fluid microscopy revealed Gram negative diplococci. He lived in a flat with other students. What treatment should his flatmates be given?

32 A. Azithromycin B. Benzylpenicillin C. Ceftriaxone D. Ciprofloxacin E. Rifampicin

33 A. Azithromycin B. Benzylpenicillin C. Ceftriaxone D. Ciprofloxacin E. Rifampicin Public Health England. Meningococcal disease: guidance on public health management, last updated Ciprofloxacin is the preferred choice (500mg po stat dose adults). Rifampicin is also licensed but has disadvantages.

34 Questions