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41 Cards in this Set
- Front
- Back
Define Osteoporosis
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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 #
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Define Osteopenia
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Low bone mass, defined by a T-score between -1 and -2.5 (T-Score of -1 or higher is normal)
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What is the difference between T-scores and Z-scores? When are Z-scores used?
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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 |
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What is a minimal trauma #/fragility #? |
Fall from standing height leading to a #
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Risk factors for OP (6 broad categories)
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-Age -Genetic (female, white, Asian, FHx) - Lifestyle/nutrition (↓Ca, Cigs, ETOH, eating disorders, amenorrhoea (↑PA), malabsorption, TPN - Med conditions (Endocrine↑PTH, Haem, CT, Renal, GIT, Genetic) - Parent with hip # |
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How + When to measure BMD?
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- 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) |
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Causes of T-score false negatives (higher than it should be)? |
- Osteophytes, vertebral crush #'s, spondylosis ( (Post # →Callous formation, extra bone) - Degenerative changes - Vascular calcifications - Past hip surgery |
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Screening tests for secondary causes of OP? |
- Ca, ALP, Vit D - PTH - TFTs, LFTs - SPEP (Serum Protein Electrophoresis - MM) - Testosterone, SHBG - 8am cortisol - Cr (Renal bone disease) - B12, Folate, Fe |
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Prevention strategies for OP?
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- 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) |
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Rx of OP - When and what?
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- 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) |
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What do you know about Bisphosphonates? (Mechanism, types, regimen, side effects)
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- 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 |
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Bisphosphonates continued...
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Zolendronic acid (Zometa) - IV infusion 4mg, need PBS authority and documented #, >20% loss of vertebral height/fragility #. Can cause Osteonecrosis of the jaw.
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How does Denosumab work?
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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.
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Why do Corticosteroids cause OP?
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- 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 |
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Recommendations for Steroids and OP |
- ↓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 |
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Falls prevalence? % >65yrs? % >80yrs? In hospital or RACF?
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- 30% of people aged >65 fall annually - 50% of people aged >80 fall annually - 2 to 3 fold ↑ falls rates in hospital or RACF |
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Fall definition? (Seriously)
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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 - Sustaining a violent blow - Sudden onset of paralysis - Epileptic seizure |
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Who is "a faller"? (these are getting worse)
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Anybody who has had 2 or more falls in the past 6/12 or an injurious fall
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Falls risk factors?
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-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 |
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What contributes to balance?
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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 |
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Important aspects of taking a falls history?
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- 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 |
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Aspects of physical exam post-fall?
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- 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 |
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Investigations post fall?
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- 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 |
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What is Rhomberg's test and what is it for?
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- For Proprioception - Stand Feet Together Eyes Open, then close eyes. (hold for up to 1min). Positive If balance lost |
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What is Pastors test and what is normal?
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-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 |
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What is a Timed Up and Go test (TUG) and what is normal?
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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 |
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Falls prevention strategies? (9)
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- 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 |
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Delirium definition + Incidence + Prevalence
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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 |
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Delirium signs and symptoms (many) |
- 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 |
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Delirium predisposing factors? (7) |
- ↑Age - Cognitive deficits (Dementia, past ABI) - Polypharmacy - Sensory Impairment (vision+hearing) - Multiple chronic medical conditions - Functional disability - Chronic Renal Impairment |
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Delirium precipitating factors? (there is always one, commonly multiple) (5 broad groups) |
- 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 |
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Medications associated with Delirium? (Hint - Ducking everything) |
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) |
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What is the Confusion Assessment Method? (For Delirium) (4 categories) |
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) |
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Non-pharmacological prevention/management of delirium? |
- 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 |
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Communication strategies when treating someone with delirium? |
- 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 |
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Investigations for Delirium (and why)? (7 + a few possible extras) |
-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 |
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Pharmacological management of Delirium? |
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. |
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Consequences of delirium? |
- 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 |
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Define Dementia |
- 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. |
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Dementia Prevalence? (Age groups) |
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) |
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Define Alzheimer's Dementia |
- 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 |