2. Phase 3a Care of Elderly Question Revision Session
By Sona Mistry Phase 3a
Feedback Form:

3. How the session will work:
Introduction
Exam Techniques & Tips
SBA Question
Answer
Explanation
More QUESTIONS!

4. Exam Techniques and Tips:
SBA Paper:
Always mark an answer – If unsure, Go with your first instinct
Pick up as many clues!
Usually no red herrings
Answer first – then look at Options?
SAQ Paper:
Re-read the question
Move on and come back to questions
Find what works for you!

5. What Topics will be covered?
Osteoporosis
Dementia
Delirium
Pressure sores
Falls
Malnutrition
Comprehensive Geriatric Assessment for Discharge Planning

6. 1. Dementia - Question
A 71 year old woman presents to the GP with a 12-month history of progressive decline in her memory function. She has no other symptoms. Her husband says she now gets lost trying to find the toilet at home. She has previously been fit and well, and physical examination is unremarkable. She scores 23/30 on a mini-mental state examination (MMSE). Select the most appropriate cause of the dementia?
Lewy body dementia
Vascular dementia
Alzheimer’s disease
Picks disease
Normal pressure hydrocephalus

7. 1. Dementia - Answer
A 71 year old woman presents to the GP with a 12-month history of progressive decline in her memory function. She has no other symptoms. Her husband says she now gets lost trying to find the toilet at home. She has previously been fit and well, and physical examination is unremarkable. She scores 23/30 on a mini-mental state examination (MMSE). Select the most appropriate cause of the dementia?
Lewy body dementia
Vascular dementia
Alzheimer’s disease
Picks disease
Normal pressure hydrocephalus

8. 1. Dementia - Explanation
Alzheimer’s disease = most common type of Dementia (followed by Vascular dementia and Lewy body dementia
Global atrophy
Intra-cellular neurofibrillary tangles made from tau protein → disrupt the microtubules in nerves
Extra-cellular beta-amyloid plaques → disrupt nerve communication at synapses
→ causes nerve degeneration
Rx = anticholinesterase inhibitors: donepezil, rivastigmine, galantine
5 A’s of Alzheimer’s:
Amnesia
Aphasia
Apraxia
Agnosia
Apathy
Aphasia – receptive (difficulty comprehending – Wernicke’s) or expressive (difficulty producing language – broca’s)
Apraxia is a deficit in voluntary motor skills. While Alzheimer's is known primarily for affecting cognitive functioning, it also affects the body's physical ability to function. As Alzheimer's progresses, the ability to perform certain activities of daily living such as bathing and getting dressed might decline. Activities such as walking and eating 
Agnosia  - difficulty recognising things or faces
Apathy – lack of motivation – unable to do things themselves

9. 1. Dementia – Other Options
Lewy body dementia
day-to-day fluctuating cognition, visual hallucinations, sleep disturbance, recurrent falls, parkinsonism (TRAP) Which drugs should you NOT prescribe? B
Vascular dementia
No atherosclerotic risk factors, step-wise deterioration in cognition, can get focal neurology, fits, nocturnal confusion C
Alzheimer’s disease D
Picks disease
a type of Frontotemporal dementia – disinhibition, antisocial behaviour, personality changes, knife-blade atrophy E
Normal pressure hydrocephalus
A triad of ‘wet, wacky, wobbly’ – urinary incontinence, dementia, gait disturbance. Due to ↑CSF, but ventricles dilate.
Vascular dementia – multiple cerebral infarcts

10. 1. Dementia – Other questions
Name 3 cognitive assessment tools, other than the MMSE?
2. What is mild cognitive impairment?

11. 1. Dementia – Other questions
What other cognitive assessment tools may be used?
Addenbrookes cognitive examination-III (ACE-III)
Montreal cognitive assessment (MoCA)
Abbreviated mental test score (AMT)
6-Item cognitive impairment test (6CIT)
General practitioner assessment of cognition (GPCOG)
2. What is mild cognitive impairment?
Cognitive impairment but minimal impairment of ADL’s

12. 2. Delirium - Question
A 77 year old woman is found by her carers confused and disorientated. She is usually lucid. The carers notice she has been incontinent of urine.
Define Delirium? Name the 2 types? (3 marks)
Name 5 causes of Delirium? (5 marks)
Name 5 investigations which are part of the Delirium screen? (5 marks)
Name 3 supportive methods of Management? (3 marks)
What medical treatment can be used to manage delirium? (2 marks)
The patient recovers and is medically fit. What are the next steps in management? Who is involved? (4 marks)

13. 2. Delirium - Answers
Delirium = acute, transient, reversible state of fluctuating impairment of consciousness, cognition, and perception
Hyperactive = agitation, inappropriate behaviour, hallucinations
Hypoactive = lethargy, reduced concentration
Drug use, e.g. anticholinergics, opioids, steroids, benzodiazipines
Electrolyte abnormalities, e.g. ↓/↑ Na+, ↑Ca2+,↓Glucose, ↑urea
Lack of drug (withdrawal),
Infection, e.g. UTI or pneumonia
Reduced sensory input (blind, deaf)
Intracranial problems (stroke, post-Ictal, meningitis, subdural haematoma)
Urinary retention and constipation
Malnutrition, e.g. thiamine, nicotinic acid, B12 deficiency
Delusion:
A fixed belief, held with conviction
Usually false
Cannot be altered with evidence / proof
Is inappropriate according to the social / cultural norm

14. 2. Delirium Screen Bloods: FBC (WCC for infection, anaemia, MCV)
U&Es (urea, AKI or Na+, K+)
LFT (liver failure, or alcohol abuse)
blood glucose
TFTs (hypothyroid)
↑Ca2+ (bones stones, groans, psychic moans)
haematinics (B12 and folate)
INR (Warfarin, bleeding risk)
Septic Screen
urine dipstick
chest X-ray
blood cultures
ECG
Malaria films
Lumbar Puncture
EEG
CT / MRI

15. 2. Delirium Management
Supportive management: alter environment → help with reorientation
Clocks and calendars
Side room
Sleep hygiene – discourage napping
Adequate lighting
Continuity of care
Access to hearing aids / glasses
Medical treatment: (Try to Avoid)
IM haloperidol (antipsychotic)
benzodiazepines

16. 2. Delirium – Assessment - *EXAM*
Complete a full Comprehensive Geriatric Assessment for Discharge Planning?
Medical Assessment – Problem list (diagnosis and treatment), co-morbid conditions & disease severity, Medication review - doctor / consultant
Functional Assessment – ADL, gait, balance - occupational therapist, physiotherapist
Psychological Assessment – cognition, mood - nurse, psychiatrist
Social assessment – care resources, finances - social worker
Environmental assessment – home safety

17. 3. Osteoporosis - Question
A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?
Spinal X-rays
MRI scan
Full blood count, bone and liver biochemistry blood tests
Vitamin D levels
DEXA scan

18. 3. Osteoporosis - Answer
A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?
Spinal X-rays
MRI scan
Full blood count, bone and liver biochemistry blood tests
Vitamin D levels
DEXA scan

19. 3. Osteoporosis - Explanation
Osteoporosis = ↓bone mineral density (BMD), ↑ bone fragility → fractures
Osteopenia = precursor to osteoporosis
Osteomalacia = softening of bones, due to impaired bone metabolism from inadequate levels of Ca2+, PO43- and Vitamin D
DEXA = Dual-Energy X-ray Absorptiometry
WHO osteoporosis criteria (T score)
>1 BMD is better than reference
0 to -1 = normal
-1 to -2.5 = osteopenia – give lifestyle measures
≤ -2.5 = osteoporosis
T score - number of standard deviations the patients’ bone mineral density differs from the population average for a young healthy adult.
the bone mineral density of more than 2.5 standard deviations below that of the average for a young healthy adult).

20. 3. Osteoporosis - Other OptionsA
Spinal X-rays
Useful to assess vertebral crush fractures, but cannot assess the extent of osteoporosis. Low sensitivity and specificity B
MRI scan
Not used to assess osteoporosis C
FBC, bone and liver blood tests
Bone profile in osteoporosis (Ca2+, PO43-, Alk Phos) is normal. Bloods can help identify cause / risk factors for osteoporosis D
Vitamin D levels
Low Vitamin D levels contribute to osteoporosis, but cannot assess extent of osteoporosis E
DEXA scan
Vascular dementia – multiple cerebral infarcts

21. 3. Osteoporosis – Risk Factors
Name 5 risk factors for osteoporosis (SHATTERED) Steroids (>5mg/day) Hyperthyroidism, hyperparathyroidism, hypocalcaemia Alcohol / tobacco Thin (BMI < 22) Testosterone ↓ (antiandrogens) Early menopause – oestrogen deficiency Renal or liver failure Erosive / Inflammatory bowel disease Dietary intake (↓Ca2+, malabsorption, diabetes type I)
Drugs?
T score - number of standard deviations the patients’ bone mineral density differs from the population average for a young healthy adult.
the bone mineral density of more than 2.5 standard deviations below that of the average for a young healthy adult).
PPI omeprazole – reduce stomach acid and reduce ca absorption from the stomach
Renal osteodystrophy has been classically described to be the result of hyperparathyroidism secondary to hyperphosphatemia combined with hypocalcemia, both of which are due to decreased excretion of phosphate by the damaged kidney.
Low activated vitamin D3 levels are a result of the damaged kidneys' inability to convert vitamin D3 into its active form, calcitriol, and result in further hypocalcaemia. High levels of fibroblast growth factor 23 seem now to be the most important cause of decreased calcitriol levels in CKD patients.

22. The Parathyroid Gland
4 parathyroid glands on the posterior surface of the thyroid
Increases osteoclast activity – releasing calcium and phosphate from bones
Increases calcium reabsorption but decreases phosphate reapsorption from the kidneys
Active vitamin D production is increased – increases calcium absorption from the gut and decreases phosphate
Increases Ca2+ Resorption
Increases Ca2+ Reabsorption
Increases Ca2+ Absorption
The Peer Teaching Society is not liable for false or misleading information…

23. Vitamin D Synthesis
UV Sunlight
Dietary Vitamin D
25-hydroxylase
1-hydroxylase
PTH
1,25 hydroxy vitamin D (1,25-(OH)2D) → ↑ Ca2+ absorption from gut

24. 3. Osteoporosis – Treatment
Conservative – Life style changes - ↓ risk factors - weight-bearing exercises - fall prevention – balance exercises - home assessment
Medical Treatment - Bisphosphonates e.g. Alendronate – Instructions to patient? Side effects? - Strontium Ranelate – similar Ca2+ structure – forms bone - Raloxifene (SERM) – agonist in bone, antagonist in breast - Calcitonin – reduce pain after fractures - Denosumab – Monoclonal to RANK Ligand, SC twice yearly
Reduce risk factors – stop smoking, alcohol, weight, calcium Vitamin D supplements
Swollow pills with plenty of water, remaining upright, 30 mins before eating SE: oesophageal ulcers, jaw osteonecrosis, photosensitivity, GI upset
RANKL activate osteoclasts

25. 4. Falls - Question
An 81 year old woman was found collapsed at home following a fall. She is shown to have a raised urea, creatinine and potassium. Her urine is dark red in colour. It has been estimated that she was lying on the floor for at least 24 hours before being found? Define syncope? (2 marks)
Name 5 causes of collapse? (5 marks)
Name 5 risk factors for recurrent falls? (5 marks)
What is the most likely cause of the patients acute kidney injury (AKI)? (1 mark)
What causes the urine to be dark red? (1 mark)

26. 4. Falls – Cause of Collapse
Syncope = temporary loss of consciousness, characterised by - fast onset - short duration - spontaneous recovery (due to hypo perfusion of the brain)
Neuro
CVS
Drugs
Other

27. 4. Falls – Risk factors
Motor problems: - gait or balance impairment - muscle weakness
Sensory impairment: - vision problems - peripheral neuropathy - vestibular dysfunction
Cognitive or mood impairment: - dementia - delirium - depression
Orthostatic hypotension
Poly-pharmacy / Medications: - benzodiazipines - antipsychotics - antihypertensives - NSAIDs
Alcohol / drugs
Environmental Hazards: - poor lighting - loose rugs - clutter
Incontinence
Fear of falling

28. 4. Falls - Answer
An 81 year old woman was found collapsed at home following a fall. She is shown to have a raised urea, creatinine and potassium. Her urine is dark red in colour. It has been estimated that she was lying on the floor for at least 24 hours before being found?
Rhabdomyolysis – skeletal muscle breaks down due to traumatic, chemical or metabolic injury. Common causes = crush injuries, prolonged immobilisation following a fall, prolonged seizure activity, hyperthermia, neuroleptic malignant syndrome.
Muscle breakdown causes – ↑ potassium, phosphate, myoglobin and creatine kinase
Myoglobin is harmful to kidneys → acute tubular necrosis
Raised potassium – increases risk of arrhythmias → Do ECG
Management – supportive, IV fluids, correction of electrolytes, renal replacement therapy

29. 4. Hyperkalaemia ECG changes: Peaked T waves Prolonged PR segment
Loss of p waves
Broad QRS
ST elevation
Sine wave pattern
Ventricular fibrillation
Management: C BIG K DRop
Calcium gluconate - cardioprotective
Bicarbonates Insulin drives K+ intracellularly Glucose
Kayexalate – binds K+ in the GI tract
Diuretics - if kidneys ✓
Renal – Dialysis - if kidneys ×

30. 5. Pressure Ulcers - Question
Define Ulcer? (1 mark)
Name 3 risk factors for a Pressure Ulcer? (3 marks)
What score is used to assess the risk of developing a pressure ulcer? (1 mark)
Name 3 ways of preventing a pressure ulcer? (3 marks)
break in the skin or mucous membrane which fails to heal
Cause pain and infection – sepsis
Important in stroke victims with quadriplegia and comatose patients
Preventing pressure ulcers?
Barrier creams
Pressure redistribution and friction reduction (e.g. special foam mattresses, heel support, cushions)
Repositioning (every 6 hours in normal risk; every 4 hours in high risk)
Regular skin assessment:
Check for areas of pain or discomfort
Skin integrity at pressure areas
Colour changes
Variations in heat, firmness and moisture (e.g. incontinence, oedema, dry, inflamed skin)

31. 5. Pressure Ulcers - Answers
Ulcer - break in the skin or mucous membrane which fails to heal
Pressure Ulcer = caused by pressure or shear force over bony prominence
Risk Factors:
IMMOBILITY – bed bound
Poor nutrition
Incontinence
Multiple comorbidities
Smoking
Dehydration
Waterlow score – assess risk of developing a pressure ulcer
Preventing pressure ulcers?
Barrier creams
Pressure redistribution - special foam mattresses
Repositioning
Regular skin assessment
Cause pain and infection – sepsis
Important in stroke victims with quadriplegia and comatose patients
Preventing pressure ulcers?
Barrier creams
Pressure redistribution and friction reduction (e.g. special foam mattresses, heel support, cushions)
Repositioning (every 6 hours in normal risk; every 4 hours in high risk)
Regular skin assessment:
Check for areas of pain or discomfort
Skin integrity at pressure areas
Colour changes
Variations in heat, firmness and moisture (e.g. incontinence, oedema, dry, inflamed skin)

32. Summary + Resources
Check your knowledge with questions, fill in the gaps!
Questions taken from app – Prep4Finals (has lots of questions by-topic)
450 SBA Specialities questions is a good book
Learn Buzzwords -
And GOOD LUCK !
any questions to: more than happy to help :)
Please fill in the Feedback form