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WVSOM -- Geriatrics

What is the definition of Geriatrics? age 55 and up even though literature and medicare says it is 65 and up
When does Medicare pay benefits age 62 for reduced benefits; 65 for full benefits
What are social issues surrounding geriatrics? loss of physical endurance, memory, earn income, care for themselves, independence, support group, and the need to find a new source of support
What kind of approach is needed when caring adequately for geriatric patients? team approach
What are the four types of social agencies able to assist the elderly? private-for-profit; private not for profit; governmental; religious groups
What is Medicare Part a? only covers hospiatl/nursing home charges. covers inpatient hospital care and skilled nursing home care
What does medicare part b cover? outpatient care and all physicisan charges (80%)
What does Medicare part D cover? portion of outpatient medication costs
What is the single most critical issue facing geriatric patients? loss of independence
What are the 5 ADLs? bathing, using bathroom, feeding, transferring, dressing
What happens with the individual cannot financially support themselves? becomes the responsibility of the state Medicaid
who is responsible for the 20% medicare part B doesn't cover? private insurance of the individual
What is a gerontologist? clincal studies of mature adults and aging.
What is senescence aging
What are the three senescence variations? rapid, gradual adn negligible
What is gradual senescence ? slow but persistant. Placental mammals
What is cellular senescence observation of finite number of replications with in vitro studies of human fibroblasts (40-60 replications)
What blocks proliferation of damaged cells? p53 transcriptace
What is the price we pay for protection against tumors? aging
What will help improve health and slow senescence? preventative measures
What is the goal of proper prevention? to define what preventative maintenance will best preserve optimum fucntion
What is the stochastic theroy of aging? accumulation of random damage (random error). free radical damage; lack of dna repairs; somatic mutations from radiation; glycosylation of protiens
What is the neuroendocrine theory of aging? holds that degeneration of the hypothalamic-pituitar-endocrine axis is central to aging as evidenced by hormonal control.
what is immunologic theory of aging? basedon observation of decline of immune system which age.
What is hutchinson-gilford Syndrome? progeria of childhood. median age 12. AMI/CHF major cause of death. due to single base change in DNA sequence of LMNA gene on chromosome 1.
What is werner syndrome progeria of adulthood; median age mid-forties; autosomal recessive trait; gene on chromosome 8 affecting DNA unwinding
What is eye anatomy from external to internal? cornea;angerior chamber; iris forming the pupil; lens; vitreous gel; retina
What is arcus senilis caused by lipid depositis in teh deep layer of the peripheral cornea. NO clincial significatnce with vision
What is cataract? opacification of the lens of the eye
what is the most common eye surgery? cataract
What is the most common eye problem cataracts
What symptoms are seen with cataracts? blurred vision; impaired visual acuity in low ambient light; can significantly impair ability to read adn drive at night
What is seen in physical exam with cataract? will appear as a cloudy lens; usually bilateral; difficult to viualize the retinal structures
What is hyperopic eyes far-sighted
what is myopic near sighted
what is presbyopia increasing stiffness of lens with age
what is the result of presbyopia? inability to accommodate; a degree of hyperopia
What are some eye problems that are non-aging associated? glaucoma; cornea injury due to dry eye syndrome; macular degeneration
what is presbycusis? hearing loss; loss of cochlea and auditory nerve neurons
What is meniere's disease? tinnitius
What do teleomeres have to do with aging? telomere shortening
Why do elderly loose height? intravertebral height decreases; bone mass loss; thoracic kyphosis/cervical lordosis
What happens to GFR with aging? decreases
What is a stage III pressure sore? involves the subcutaneous tissue
What happens with skeletal senescence? decrease in bone mass; decrease bone str; increased risk of fractures
What happens with cartilage aging? decreaed cartilage hydration; reduced condrocytes and proteoglycan get smaller in size
What happens with skeletal muscle aging? decrease muscle mass and strength;
What will increase short-term endurance muscle strength? exercise
what is a stage I decubitus? nonblanchable eyrhtema of intact skin
what is stage II decubitus? superficial ulcer, abrasion, blister or shallow crater
what is stage III pressure sore? full-0thickness skin loss involving subcutanous tissue
Waht is stage IV pressure sore full-thickness injury with damage or necrosis of underlying muscle and joint
what happens to the skin with aging? thinking of epidermis and dermis; atrophy of subcutaneous adipose tissue; decreased fascularity; decreaed oil and sweat production
What does aging of the skin result in? bruising;skin tears; pressure sores; increased skin lesions
Is cancer a normal sign of aging? NO
What does skeletal muscle aging result in as far as daily living? limited ability to climb stairs, rise form chair; increase risk of falling; heat and cold intolerance
What happens with nervous system aging? decreased brain weight, cortical cell count; neuronal loss; declinging neurotransmitter prodction; loss of synaptic receptors
What happens in autonomic aging? inability to increase heart rate; decreased GI motility; bladder incontinence; bowel incontinence; sexual dysfuncttion
What happens in central, motoar and senesory nervous system aging? Inc motor response time; slower psychomotor performance; decreased intellectual performance; decreased complex learning; decreased hourof REM and total sleep
What happens to the heart in aging? myocytes decrease and remaining myocytes hypertrophy. sclerosis and calcifications of the heart valves
How many myocytes has a 70 y/o male lost? 30%
What happens in vascular aging? irregularities in size and shape of endothelial cells; fragmetnaion of elastin; increased lumen diamater, length adn wall thickness; collegen increase; decreased basal and stimulated NO production; increase in pulse pressure
What are teh clincal implications of vascular aging? resting HTN; orthostatic hypotension; blunted heart rate response to stress; S4; sclerotic murmurs
what are aortic stenosis? calcific deposits extend form the cusps into the sinuses of valsalva
What does calcific aoritc stenosis result in ? prevents normal opening of heart valves and result in rheumatic heart disease
What happens with lung aging? lower maixaml expiratory flows; lower difusing capacity; lower pO2 and SpO2; lower respiratory muscle str and endurance; stiffer chest walls; increased lung tissue compliance
What is the respiratory impact due to aging? less exercise capacity; higher susceptibility to pulmonary diseases; higher incidence of respiratory tract infections; use of cough reflex due to decrease ciliary action
What happens in GI tract aging? reduction of post-prandial unger; decreased saliva; delinging dental health; decreased chewing str; decreased olfaction;
What GI physiology does not change? esophageal fucntion persist until very advanced age; gastric emptying of solids; small bowel transit times
What declines in the absorption secretion functions of the GI? gastric prostaglandin; bicarbanate; nonparietal; jejunal lactase; vit D, zinc and calcium absorption
What absorption stays stable in teh GI? intrinsic factor; duodenal glucose; protein digestion; fat absorption; thiamin, B12 and C abosrption; iron abosrption
What are changes of function and structure of the upper GI tract indicative of? result of pathological changes secondary to disease
What changes in renal function? kidney mass and size in 4th decade; progressive delcine in renal fucntion; renal blood flow decrease by 10% per decade; GFR declines; tubular function slowly declines
How does tubular function decline impact geriatric patients? makes them more sensitive to neprhotoxic injury
Progressive renal decline results in ? thickening of basement membrane; mesangial expansion; focal glomerulosclerosis
What are the 7 steps to pharmacology therapy selection? gatehr data; diagnosis etiology; review therapy choices; discuss therapy with patient or care giver; implement plan; evaluate outcome; go back to step 3!
What is the plan for medication (6) consider all medications indicated; review risks; consider ability to afford meds; finalize specific medication choice; schedule follow up; follow up meeting
What happens in the follow up meeting for medicine? review for efficacy, adverse reactions, exacerbaion of co-morbidities, new/improved therapies; if any problems adjust dose or restart process
How do we select and dose a medication? personal knowledge; reference; avoid allergies, contraindications, adverse outcomes; review previous therapy success; consider cost/compliance
What are abosprtion considerations when perscribing a medication? decreased absorption of meds that need a more acidic environment for absorption
What are some acidic drugs that may be absorbed slower? ketoconazole; fluconazole; tetracycline
What is creatine clearance? [(140-age)(kg)(.85 IF FEMALE)] / [72 x serum Cr]
What is the distribution of hydrophillic drugs in geriatrics? increased concentrations if no dose adjustement; ex: EtOH and digoxin
What will distribution of lipohilic drugs be like in geriatrics? lower and have longer half lives; e.g. benzos
What is distribution like for protein bound drugs? higher serum concentrations (less bound) due to decreased albumin; e.g. dig, warfarin, theophyline
How does metabolism in geriatrics affect pharmachology? hepatic mass and blood flow are decreased so drugs metabolied by first pass Phase I reactions will be available in higher concnetrations ane exibit longer half life
What are 2 drugs unaffected by metabolism adn age isoniazid and lorazepam because they are phase II reactions
How is excretion measured? serum Cr and calculation of effective GFR... NEVER rely on serum Cr alone
What are risk factors for adverse drug reactions? age, polypharmacy, female, lower body weight, hepatic/renal insufficiency, hx of previous reactions
What are the drugs to avoid? benzos, barbituates, analgesics, muscle releaxants, antiemetics, anithistamines, antidepressents, antispasmotics, cardiovascular
What benzo should be avoided? valium
What barbituate should be avoided? phenobarbital
what analgesics should be avoided? demerol and darvocet
what muscle relaxants should be avoided? cyclobenzaprine (flexiril)
What antiemetics should be avoided? metoclopramide (reglan)
What antihistamines shoudl be avoid? first generation like diphenhydramine
what antidepressents should be avoided? amitriptyline (eleavil)
what antispasmotics shoudl be avoided? (antichlinergics) belladonna
What cardiovascular drugs should be avoided? digoxin
What drugs shoudl be avoided with DM? beta blockers
what drugs should be avoided in COPD patients? beta blockers; sedatives/hypnotics; opiates
What drugs should be avoided with asthma? beta blockers
what drugs should be avoided with ulcers? NSAID, ASA, corticosteroids
what drugs should be avoided with clotting disorders? ASA, NSAID and corticosteroids
What drugs should be avoided with BPH? anticholinergics, muscle relaxants
What drugs should be avoided with constipation? iron
What drugs should be avoided with arrhythmia? TCA
What drugs should be avoided with insomnia? decongestants
What drugs should be avoided with cgnitive dysfunction? anticholinergics, antihistamines, TCA
What should be avoided with osteoporosis? corticosteroids
does warfarin does need to be increased in patients with liver disease? needs to be decreased
the average patietn over 65 will fil how many prescriptions per year? 12
what is optimal pharmocotherapy? identify all meds; communicate; keep list of meds; minimize prescriptions (eliminate polypharmacy); use pill box; avoid mes with common acvers reactions; keep accurate renal function records
What are some major cardiovascualr diseases seen in elderly? HTN; orthostatid hypotension; atherosclerosis
What diseases occur with coronary atherosclerosis? acute MI; acute and chronic ischemia; deficits (CHF adn exertional angina)
What diseases occur with cerebral atherosclerosis? thrombotic infarction; embolic infarction; hemorrhagic infaction; transient ischemic attacks
What deficits are seen with cerebral atherosclerosis? any neurologic presentation possible; hemiplegia; dysphagia; aspiration pneumonia
What are the diseases that occur with peripheral vascular disease? claudication; infarction; aneurismal disease; ischemic bowel disease
What deficits are seen with PVD? exertional ischemic pain; reduced endurance; sudden death
What is seen with venous insufficiency? brown discoloration; leathery skin; cellulitis; dependant edema; DVT
What are some conduction system diseases? A-Fib; complete heart block; PVC; tachy brady syndrome (sick sinus); sinus bradycardia
what is treatment of bradycardia? pacemaker
What is the common cause of death in patients with major co-morbidity? influenza and pneumonia
What does increased vascular stiffness result in? systolic HTN
What does impaired ventricular filling result in? diastolic dysfunction
What does impaired cardiac output with stress result in? decreased response to beta-adernergic stimulation
What does degeneration of the conduction system result in? predisposes to arrhythmias
What is the most diagnosed male cancer? prostate, lung and colon
What are the 3 most estimated US cancer cases? breast, lung, uterine
How many ischmic strokes per year? 400,000
How many hermorrhagic strokes per year? 100,000
What are ischimc strokes? thromobit and embolic
What are thrombotic strokes? blood clot; cerebral arteries
what are ebolic strokes? fatty deposit; found in common carotid
what is hemorrhagic stroke? bleeding in brain and subarachnoid space
what is most common DM in geriatrics? Type II
Is DKA common in geriatrics? rare due to prsence of at least a small amount of insulin
What is hyposmolar non-keotoic coma? happens do to dehydraion in Type II diabetics with a chornic BS of 500-100.
What are treatment goals of DM patietns? control BP; control lipids; keep HgbA1c < 7.0; smoking cessation
What are teh major complications of DM? PVD; nuropathy; retinopahty, macrualr degenration, cataracts; nephropathy
How is a patient treated when focusing on quality of life? focus on the disease producing the highest mortality.
What usually precedes end-of-life? significant loss of function adn quality of life
What is leading causes of death among US adults aged 65 and older? heart disease; cancer; stroke
What is dementia? impairment of memory plus one of the following: aphasia; apraxia; agnosia
What is the differential diagnosis for Alzheimer's? 80% of all dementias; extracellular depostition of amyloid-beta protein producing neuritic plaques; development of neurofibrillary tangles; ultimately results in neuronal death; can only be detected at autopsy; narrowed gyri and widened sulci
What physiological impairments contribute to AD? reduced cerebreal production of chline acetyltransferase; leades to decrease in ACh syntheiss and excessive NMDA
What is used in Alzheimer treatment? cholinesterase inhibitior; NMDA receptor antagonis; antioxidant tehrapy
What are examples of cholinesterate inhibitors? tacrine; donepezil
what is an example of NMDA? memantine
What are the features of vascular dementia? infarcts on CT or MRI imaging; neuro exam with focal deficits; deterioration in discreet steps; onset with a stroke; slow improvement following acute onset; medcial history consistent with arterial disease
how do you treat vascular dementia? control underlying disease processes and risk factors; HTN, DM, valvular/caraotid atherosclerosis; a fib; lipid disorders
How is lewy body dementia different from parkinsons dementia with lewy bodies first then parkinsonian tremors second
How is demential with lewy body treated? nonpharmacological tehrapy first choice; parkinson's symptoms treated with levodopa rather than dopamine agonists
How is lewy body dementia diagnosed? dementia criteria PLUS at least tow of the following: cognitive fluctuations; fvisual hallucinations; parkinsonism
How is parkinson's treated? cholinsteratse inhibitors; treat motor parkinsonism symptoms same as for conventinal parkinsons disease
What are the clincal features of frontotemporal dementia? gradual behavioral change and language dysfunction; characterized by focal atrophy of the frontal and temporal lobes; occurs between 35 and 75
What is reversible dementia? delirium
How is delirium diagnosed? medical history; can be induced by medication, EtOH, metabolic disorders, depression, CNS neoplasm;
what is MMSE? mini mental status exam? series of questions, writings and a diagram drawing which can be easily scored with a maximum of 30 points
what is normal mini mental exam? 26-30
what is mild deficit in mini mental exam? 20-25
What is a moderate deficit in mini mental? 10-19
What is severe deficit in mini mental exam? < 10
what is a fall? an unintentional positional change that results in a person coming to rest on the ground, floor or other lower level
What are falls an indicator of? functional decline
What sensory impairments cause falls? vestibular function; tatile sensation; proprioception; visual acuity (light adaptation
What are intrinsic reasons for falls? age;female; vit d def; lower ext weakness; poor grop str; balance disorder; podiatric problem; visual defecit; low gait speed; incontinence; depression; hypotension; hemeplegia; perifpheral neuropathy; fear of falling
What are environmental reasons for falls? poor lighting; loose carpets; lack of bathroom safety equipment
How do you do a Hx for falls? CATASTROPHE
What does catastrophe stand for? caregive/housing; alcohol; treatements; affect (depression); syncopy; teetering; recetn illness; ocular problems; pain with mobility; hearing; environment
What medications shoudl be reviewed with falls? benzos; antidepressants; antiemetics; anticholinergics; antiHTN; NSAID; hypoglycemic agents; antipsychotics
What is acronym for physical exam for fallign? IHATEFALLING
what does IHATEFALLING stand for? Inflammation of joints; hypotension; auditory/visual exam; tremor; equilibriumand balance; foot problems; arrhythmia/valvular disease; leg length; lack of conditioning; illness; nutritional status; gait disturbance
what lab work is done with fallign? vit D; intact PTH; serum B12/folate; electrolytes; thyroid; drug levels
what tests are done with falls? ecg; holor monitor; bone density imaging; brain imaging
What interventions are done with falls? exercise; environment change; medication adjustment; gait training; physical therapy; nutritional status; hip protector; bed alamr; wander alarm; timed toileting
What is syncope? actual loss of consciousness
what is presyncope? feellign right before fainting
what can cause syncope? orthostatic hypotension; cardiac arrhythhmia; chf; vasovagal episodes
what is dysequilibrium? related to Neuromuscular etilogies; neurosensory deficits in visiona nd proprioception
What is vertigo? specific dizziness which has a major symptom of balance disorder; acute labryinthitis; cerbral vascular disease; otitis media
what is orthostatic hypotension fall in systolic BP of at least 20mmHg or to less than 90 mmHg when moving from a supine to standing position. record pulse at each position as well nothing rate adn regularity
What are teh Geriatric 3 R's prevention
What is primary prevention? prevent disease form happening
what is secondary prevention? screen to detect disease while treatable
what is best prevention? primary + secondary prevention
what is tertiary prevention? slowing teh disease process
what is elderly patient's role in screenign? may misudnerstand aging from disease adn not make informed decision; may be put off by cost of tests; may be put off by fear of test;
what is competence? intact long and short term memory; sensory ability intact to recevie new information; cognitive ability to process information; confirmation of a decision when presented with teh same information on a second occasion
in the elderly patient secondary and tertiary screen take on more importance than primary screening. TRUE OR FALSE true
what is physician role in screening offer screening based on evidenced based research; deliver screening, not just focus on diagnosis and treatment;
what is a living will? a specific document tested in law tha defines the patient wishes in the event of a terminal illness or persistant vegatative state that has no reasonalbe hope of a recovery
what are advanced directives/ patient can define what care they want if they become incompetent
what is a chronic vegetative state require hydration adn nutrition intervention to maintain life; may show reflexes; often exhibit sleep/wake cycles
what is a HCPOA? legal document which designates another individual to make health care decision if the patient is not competent or able to make teh decisions
what is a DNR? allow patients to specifyif they wish CPR int eh event of cardiac or respiratoyr arrest
Waht are DNR variations? NO cpr; no intubation; etc
what do pateints want as they approach death? maintain their dignity; to feel prepared to die; have physical touch; presence of family; have financial affairs in order
what is the stages of grief? denial; anger; bargaining; depression; acceptance
What is the common course of death? sleepy lethargic; obtudned; semicomatose; comatose; death
what is uncommon course of death? restless; confused; tremulous; hallucinations; delirium; myoclonic jerks; seizures; semicomatose; comatose; death
What are 3 types of pain? somatic; visceral; neuropathic
what is somatic pain? muscle; localized but dull, aching, throbbing
what is visceral pain? poorly localized; internal organs
what is neuropathic pain? severe, burning, stabbing; nerve compression, ischemia or infection
what is the therapy of pain? right drug; right half life; right dose for volume of distribution; treat side affects; take advantage of adverse reactions
how do you treat SOB? oxygen; diuresis; anxiety management; opiod management
what is comfort management? anausea/emesis; anorexia; starvation vs cachexia; delirium; constipation; seizures; muscle spams/restless leg sydroms
what finanical assistance programs are available at the end of life? medicare covers the cost of equipment, medications, aned part time staff but does not cover the cost of housing and meals or fulltime staff. physician must certify life expectancey of six months or less
what is physicisan role after death? presence at time of death; pronouncing death; support the family;visitation/wake; answer questions; complete death certificate
what is hospice patietn may stay in the place of their choosing assuming support is available; nursing visists to monitor and deliver care; can visits to maintain hygiene and provide equipment
Created by: Todd Jamrose Todd Jamrose