Geriatrics formative test answers with explanation.

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Q1. Regarding Benign Essential tremor

• Worse on action

• Often inherited (autosomal dominant)

• Improved by alcohol and beta blockers

• May have head nodding (titubation)

• Can also have vocal tremor

2Five marks

• http://youtu.be/sf1N0Zf5IqA

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Q2.Regarding Parkinson’s Disease

• Tremor usually asymmetrical (but still bilateral)

• Rest tremor

• Tremor unaffected by alcohol

• Treatment should begin when the patient and clinician are ready no danger in delaying

• MRI is not helpful in diagnosis but may sometimes be used if other neurological disorders are suspected

4Five marks

Q3 Regarding Delirium

• High prevalence in hospitalised elderly (15-60%) depending on ward type

• Fluctuation in conscious level is very common and helps diagnosis

• People with sensory impairment are more at risk

• Sedative drugs should be used as for patient and staff safety when other methods have failed. They may well worsen the delirium

• Symptoms are often worse at night

5Five marks

Q4 Depression • Memory loss more rapidly progressing

• Patient complains about poor memory

• May do well in cognitive tests or answer don’t know (apathy)

• On probing or giving clues patients may remember

• The opposite tends to be true in dementia.

• Dementia may have more behavioural features and there may be loss of ability to self care and incontinence which would be very unlikely in depression

6One mark

Q5 Assessing delirium

• The best diagnostic tool is the CAM (confusion assessment method)

• Other cognitive tests (AMT, MMSE) may trigger you to consider delirium

7Two marks

Q6 Depression • Memory loss more rapidly progressing

• Patient complains about poor memory

• May do well in cognitive tests or answer don’t know (apathy)

• On probing or giving clues patients may remember

• The opposite tends to be true in dementia.

• Dementia may have more behavioural features and there may be loss of ability to self care and incontinence

8Two marks

Q9 Falls risk assessment tools• Get up and Go or TUG (timed up and go)

• Quick, simple bedside assessment of walking

• http://www.youtube.com/watch?v=s0nqzvt9JSs

9One mark

Q 10 High Ck• Muscle necrosis (rhabdomyolysis) due to prolonged pressure releases

myoglobin which can accumulate in the renal tissues

• Creatine kinase is released by damaged muscle levels above 5 times normal indicated rhabdomyolysis

• Patients can get renal failure, disseminated intravascular coagulation and low calcium

Long Lie• Pressure areas,

• rhabdomyolysis,

• fear of not being found,

• hypothermia,

• stasis pneumonia

• DVT

10Four marks

Q11 Falls Investigations

• BASIC TESTS

• Lying and standing blood pressure

• Urine Dip

• ECG

• Assessment of walking (eg Up and Go)

• Appropriate xrays may be needed

• Assess vision

CT heads, tilt table testing and 24hr ECG tapes only in specific cases

11Three marks

Q12 Taking an oral bisphosphonate

• May be daily or weekly preparations but weekly generally used as studies have shown increased compliance.

• Tablets swallowed whole with plenty of water• Sat upright or stood upright• On an empty stomach (including no milky drinks)• No breakfast or other medications for at least half an hour (two hours for

risedronate) after• Remain upright for half an hour post dose.

• COMPLIANCE can be a BIG issue!

12One mark

Q 14 Falls Risk factors from the case

• Increasing age and frailty level

• Living alone

• Cognitive Impairment

• Previous fall

• Women tend to fall more than men

• Visual impairment

• Home hazards

• Use of walking aid

• Fear of falling

• Acute illness

• Knee pain

13Eight marks available

Q 15 Functional rating scale

• Barthel Index • Ten item scale looking at daily functioning

• Mainly ADL and mobility

• Used as a baseline level

• Can be used to show acute deterioration (compared with Barthel a while ago)

• Can be used to demonstrate rehabilitation success

• Higher scores more independent patients

14One mark

Q 16 Pneumonia Severity scoring

• Confusion • New onset AMT less or equal to

8

• Urea• Greater than 7

• Respiratory Rate• Greater or equal to 30/min

• Blood pressure• Less than 90 systolic or 60 diastolic

• 65 • Age 65 or over

• Risk of death at 30 days

• You would be unlikely to be asked these exact figures

0 0-0.7%

1 1

2 3%

3 17%

4 41%

5 57%

15One mark

Q 17 Falls intervention.

• Only way to stop falls is to stop movement!

• We may be able to reduce the frequency and possibly impact of the fall

• Strength and Balance Training has convincing evidence

16One mark

Q 19 Stroke

• If present within 4 and half hours consider thrombolysis if not contraindicated.

• Need to urgently contact the stroke team to organise this

17One mark

Venous about 70% of ulcers

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Q21 Leg ulceration

• Venous leg ulcers common in the elderly (70-90% of all leg ulcers)

• Appearance of “inverted champagne bottle” legs

• Generally medially located

• Painless (unless infected)

• Antibiotics only rarely indicated

• Skin biopsy only needed if prolonged non healing or worsening with treatment

• Treated with compression bandaging after arterial Doppler to exclude concomitant arterial disease

19One mark

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Q22 Vulnerable adults

• All trusts must have a policy for safeguarding

• Generally you should refer if any index of suspicion to the Protection of Vulnerable Adult team

• Other appropriate responses may be to speak to social services or if more serious the police

• If in doubt about a home or nursing environment admit the patient to hospital as a place of safety

21One mark

Q 24 Isaacs Geriatric Giants

• Immobility

• Instability (falls)

• Incontinence

• Impaired memory/Intellectual impairment

• Elderly patient commonly present with one, some or all of these

22One mark

Q25 Pressure area Risk Assessment Tool

• Waterlow• Takes into account Nutritional status• Skin Type• Acute illnesses• Degree of immobility• Sex and Age• Continence

• Gives advice about how to manage risk

• Like all risk assessment tools there can be interater variability which reduces reliability

23One mark

Q 27 Pressure areas Categories

1. Non Blanching Erythema

2. Partial thickness. • Broken skin shallow ulcer. Not eroding deeper. Blisters generally category 2

3. Full thickness skin loss. • Deep ulcer may see subcutaneous fat but not bone, muscle or tendon.

4. Full thickness tissue loss.• Exposed bone, tendon or muscle

• Eschar

• May be undermining/tunnelling

24One mark

Q27 Stress Incontinence

• Small volumes leak during coughing, laughing

• Associated with pelvic floor weakness (obstetric history in females)

• Treatment • Rigid adherence to pelvic floor exercises

• Duloxetine (SNRI)

• Surgery (colposuspension, tension free vaginal tape)

25One mark

Q 28 Overactive bladder syndrome

• Frequent and precipitant voiding

• Nocturnal incontinence

• Feeling of Urgency can leak small volume

• Treatment• Bladder retraining

• Regular toileting

• Anti-muscarinic drugs

26One mark

First key principle mental capacity act

• Presumption of capacity

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