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rdabolt Geriatrics

WVSOM, Geriatrics, Dr. Knepp, Entire Course Feb-March 2011,

The single most critical issue facing geriatric patients is: Loss of independence
Name 4 skills important to geriatric physicians Must Be: 1. Good at Physical Diagnosis 2. Able to obtain history from patient with failing memory 3. Able to manage multiple advanced diseases in same patient 4. Able to serve as leader of a multidisciplinary team.
When does a physical exam begin? When the physician first lays eyes on the patient.
It is important to remember that although a patient will present with an acute problem, they often have___? multiple interwoven problems.
Geriatric patients often seek help only after ____________? experiencing a significant loss of function.
T or F: Over the next 4 decades, number of geriatric patients in the U.S. is expected to remain the same. False, the number of geriatric patients in the U.S. is expected to double by the year 2050.
What happens to life expectancy as we get older? Why? The age at which we are expected to die increases b/c those with medical problems have already died.
6 Social issues of the elderly: Loss of: 1. Physical endurance 2. Memory-Cognitive ability 3. Earning ability 4. Self care ability 5. Independent living ability 6. Traditional Support Group
Social issues often lead to ________ in the elderly? Depression
A major factor in the loss of the traditional support group in the elderly is __________? the death of friends and family members.
Medicare expects, and Physicians often act as leaders of ____________? Medical support teams for the elderly.
Who/what may comprise a medical support team? Providers of mental and physical needs Physicians Mid-Level Providers Home Health Agencies Ancillary Therapists
Two skills important to geriatric physicians: Leadership Skills Business Skills
What is the average cost per day of nursing home stay? $150 to $200 per day
Who pays for daily living expenses when an elderly person runs out of money? Daily living expenses become the responsibility of the state, and are covered by Medicaid.
At what approximate age does one qualify for Medicare coverage? Age 65
Who pays for the medical bills of an elderly patient? Medicare covers 80% after deductables, and the individual or their private insurance covers 20%.
Which part of Medicare covers inpatient hospital care? Medicare Part A
Which part of Medicare covers skilled nursing home care following acute injury/ illness? Medicare Part A
Which part of Medicare covers Outpatient care? Medicare Part B
Which part of Medicare covers ALL physician charges? Medicare Part B
Which part of Medicare covers a portion of outpatient medication costs? Medicare Part D
What is an important financial consideration when prescribing meds for an elderly patient. The physician should be aware of the patient's Part D Medicare $ limit.
What part of Medicare will pay for a nursing home when rehab will result in an independent level of functioning. Medicare Part A
What is the one situation when Medicare Part A will pay for a nursing home stay. After an acute injury/illness, and when rehab will result in a return to an independent level of functioning.
What Medicare Part pays for all physician charges both at the hospital and at home? Medicare Part B
What Medicare Part pays for: -Surgeons' bill for hip replacement -Rounds to manage meds -Rehab Specialists? Medicare Part B
What percentage of those individuals in the U.S. over age 65 live with non-relatives? 2% of the U.S. population of the age 65 live with non-relatives
Briefly describe an Assisted Living Facility Apartments, patient is still independent.
Who would stay in an Intermediate Care Facility A patient with daily living activity deficits
A patient requiring care from individuals with ___________ would be admitted to a Skilled Care Facility.. Professional licenses for providing such things as Therapy, Nutritional Management, and Medications.
What percentage of U.S. deaths results from heart disease? 25.4%
What percentage of U.S. deaths results from Cancer? 23.2%
What percentage of U.S. deaths results from Cerebrovascular Diseases? 5.6%
What percentage of U.S deaths results from Chronic Lower Respiratory Diseases? 5.3%
What percentage of U.S. deaths results from Accidents (unintentional injuries)? 5.1%
What percentage of U.S. deaths results from Alzheimer's Disease? 3.1%
What percentage of U.S. deaths results from Diabetes Melitus? 2.9%
What percentage of U.S. deaths results from Influenza and Pneumonia? 2.2%
What percentage of U.S. deaths results from Nephritis? 1.9%
What percentage of U.S. deaths results from Septicemia? 1.4%
What is the single most critical issue facing geriatric patients? Loss of Independence
Medicare Part _____ covers the cost of outpatient medical care? Medicare Part B
True or False, Senescence in humans may be due to telomere shortening? True
True or False, Senescence is unavoidable? True
Name the single most critical issue facing geriatric patients. Loss of Independence
Mdicare Part B covers? 80% of outpatient physician charges
Name 7 socaial issues of the elderly 1. Loss of physical endurance 2. Loss of momory and cognitive skills 3. Loss of earning ability 4. Loss of self care ability 5. Loss of independence 6. Loss of support group 7.Need to develop new support source
Daily support of the elderly comes from___________? Family friends, social support
Medical support of the elderly comes from_____________? Physicians, mid level providers, home health agencies, ancillary providers
Physicians in elderly care often fill the role of___________? Team Leader
When an elderly daily living expense budget is gone, who becomes responsible for paying the bills? Medicaid
At what age does medicare begin to cover medical expenses? Age 65
Medicare will cover what % of the cost after yearly deductibles are met? 80%
What is covered by Medicare Part A? Inpatient hospital care and skilled nursing home care following injury/illness
What is covered by Medicare Part B? Outpatient care and all physician charges.
What is covered by Medicare Part D? A portion of the outpatient medication costs.
The #1 and #2 causes of death among the elderly are________? 1. Heart Disease 2. Cancer
Another Term for aging? Senescence
Senescence occurs in__________? Multicellular organisms that undergo somatic cell differentiation
What is rapid senescence? Deterioration after maturation or reproduction
What is gradual senescence? Slow, persistent senescence
Name the theory of aging that states: aging is caused by accumulation of random damage. Stochastic (Random Error) Theory
Name the theory of aging that attributes aging to degradation of the hypothalamic-pituitary-endocrine axis. (growth-pubery-menopause) Neuroendocrine Theory
Name the aging attributes aging to deminished T-cell response, increased infection risk, and autoimmune problems. Immunologic Theory
Name the cause of aging related to a finite number of cellular replications. Cellular (replicative) senescence
Name the non-coding DNA sequences which grow shorter on the end of each chromosome with each replication. telomeres
What enzyme maintains telomere length? Telomerase
________ blocks proliferation of damaged cells, and resists cancer. p53 proliferation factor
An autopsy was done on a patient who had progeria at an age of 12 and died of AMI/CHF. It was found that it was due to a single base change in the DNA sequence of the lamin A (LMNA) gene on chromosome 1. What is the most likely diagnosis? chromosome 1. What is the most likely diagnosis? Hutchinson-Gilford Syndrome
A female died in her mid-forties and had progeria from her adulthood. The condition she had was an autosomal recessive trait and it was caused by gene on chromosome 8 and is thought to be involved with DNA unwinding. What is the diagnosis? Werner Syndrome
What condition of the eye is caused by lipid deposits in the deep layer of the peripheral cornea? Arcus senilis
(True/False) Arcus senilis is correlated with high blood cholesterol and is clinically significant with vision False X2
Opacification of the lense of the eye is called __________? A cataract
From what does opacification of the eye occur? Accumulation of cellular debris thought to be due in part by glycosylation of protein
What is the function of the lense? If focuses light on the retina.
From what is the lens of the eye made? Water and Protein
Cataract causes______________vision, and impaired____________in low light conditions. Blurred Vision; Acuity
How does a cataract appear during a physical exam? Bilaterally cloudy lenses
What condition of the eye occurs due to increasing stiffness of the lens, and causes loss of accomodation, and hperopia Presbyopia
What nutrients are helpful in treating age related macular degeneration? Antioxidants (Vitamins C,and E, beta carotene, zinc oxide)
Age related loss of cochlea and auditory nerve neurons causes_______? Presbycusis
Two reasons the elderly become shorter increased cervical lordosis and increased thoracic kyphosis
What happens to the bones in the elderly and how does this endanger their lives? Decreased bone mass and bone strength. It increases risk of fractures
In an elderly with sex steroid deficiency, the life span of what cells decreases? What cells has its life span increase? Life span of osteoclasts increases and the life span of osteoblasts decreases
There is decreased cartilage _______ in the elderly hydration
The proteoglycans in the elderly....? (3 things) The proteoglycans in the elderly....? Do not decrease in quantity Become smaller in size Have increased cross-linking
The chondrocytes in the elderly?(2 things) Reduced proliferation Reduced metabolic activity
Which skin layers get thinner with aging? Dermis and Epidermis
What skin related tissue atrophies during aging allowing veins and bruises to become more visable? Subcutaneous adipose tissue
During aging,_______ and ________ production decrease? Oil and Sweat
Decreased vascularity in the elderly results in_______? More bruising
Name 3 problems that occur more frequently in the skin of the elderly. 1. Bruising 2. Pressure Sores 3. Skin Tears
___________ is a skin lesion common among elderly. Eczema
A stage ______ pressure sore shows nonblanching erythema of intact skin Stage I
A stage _______ pressure sore shows superficial ulcer, abrasion, blister or shallow crater. Stage II
A stage _______ pressure sore shows full thickness skin loss involving subcutaneous tissue, but not underlying fascia. Stage III
A stage ____ pressure sore is a full thickness injury involving damage or necrosis of underlying muscle, bone, tendon or joint. Stage IV
What causes a pressure sore? Vascular compromise causing cell death
During autonomic aging, there is an inability to increase _______, decreased ____ motility, _____ and _____ incontinence Heart rate, GI, bladder and bowel
there is increased ____ ____ time, slower ______ performance, decreased ______ performance, and decreased hour of _____ motor response, psychomotor, intellectual, REM
________ of the aortic valve may be a result of ______ heart disease calcification, rheumatic
In the heart of the elderly, the number of remaining ________ decreases and results in _______ myocytes, hypertrophy
In the elderly, the parasympathetic neurons decreases hence use of _____ has less effect on heart rate atropine
Upon auscultation of the elderly heart, there will be frequent findings of ___ and _______. S4 and sclerotic murmurs
In the elderly heart, there is a ______ heart rate response to stress blunted
6 Activities of Daily Living? 6 Activities of Daily Living? 1. Bathing 2. Continence 3. Dressing 4. Feeding 5. Toileting 6. Transferring
Name a commonly used screening exam for cognitive function? Folstein Mini Mental Status Exam (MMSE)
What is a good screening exam for balance? Rhomberg Test
Name two parts of the eye exam. Rosenbaum Vision card and complete physical exam of eye (cornea, lens, retina)
3 things you can do for a hearing exam? hearing screen, whisper test, audiometric testing
The type of malnutrition that is very common in elderly? protein calorie
etiology of malnutrition (name 3)? dementia, dysphagia, polypharmacy
For what two impairments should you screen in cases of polypharmacy? Liver and renal
Continence issues are more common in women because of what two things? Pelvic floor dysfunction and urethral anatomy
Male urinary incontinence is often related to? Benign Prostate Hypertrophy (BPH)
Cardiovascular Disease Predisposing Aging Factors (name 4) +increased vascular stiffness +impaired ventricular filling +impaired cardiac output with stress +degeneration of the conduction system
Common diagnosis of CV disease (name 3) +systolic hypertension +orthostatic hyptension +atherosclerosis
Deficits in atherosclerotic disease +any neurologic presentation +hemiplegia +dysphagia +aspiration pneumonia
Name 3 types of infarction in cerebral atherosclerotic disease thrombotic, embolic, hemorrhagic
Name two presentations in coronary atherosclerotic disease +acute MI +acute and chronic ischemia
Deficits in coronary atherosclerotic disease Congestive heart failure and exertional agina
Name 4 presentations in peripheral vascular diseas +claudication +infarction +aneurysmal disease +ischemic bowel disease
3 Problems associated with peripheral vascular disease +exertion ischemic pain +reduced endurance +sudden death
5 Presentations in venous insuffiency +brown discoloration of skin +leathery skin +cellulitis +dependat edema +DVT
5 Examples of conduction system disease in the elderly +atrial fibrillation +complete heart block +PVC +tachy-brady syndrome +sinus bradycardia
aortic stenosis in the elderly can produce? congestive heart failure
All valves in the heart in the elderly are susceptible to what two things? stenosis or insufficiency
3 most common types of cancer deaths in the male lung&bronchus, prostate, colon
3 most common cancer deaths in the female lung&bronchus, breast, colon
What is a thrombtic stroke? Stroke that forms around atherosclerotic plaques
What is an embolic stroke? A blockage of an artery by an embolus (a travelling particle or debris in the arterial bloodstream originating from elsewhere)
4 Treatment goals for elderly patients with diabetes mellitus? +control blood pressure +control lipids +keep HgbA1c < 7.0 +smoking cessation
4 major complications in diabetes mellitus +neuropathy +peripheral vascular disease +retinopathy, macular degeneration, cataracts +nephropathy
2 common causes of death of elderly patients with major comorbidity? influenza and pneumonia
What is an important preventative measures of influenza and pneumonia? Immunization
(True or False) Dementia is not part of the aging process True
Diagnostic criteria of dementia Impairment of memory plus one of following (aphasia, apraxia, agnosia, impaired executive function) severe enough to interfere with daily functioning
Most common type of dementia? Alzheimer's Disease
2 microscopic pathological changes associated with Alzheimer's Disease? +Extracellular deposition of amyloid-beta protein producing neuritic plaques +Development of neurofibrillary tangles
What are gross pathological characteristics of a brain with Alzheimer's Disease? narrowed gyri and widened sulci
AD patients have reduced production of __________ and excessive _________ stimulation choline acetyltransferase (acetylcholine synthesis); NMDA receptor
Excessive stimulation by glutamate in AD can lead to what 2 things? cell toxicity and cell death
What class of drug blocks glutamate from stimulating the neuron and slow the progression of moderate to advance AD? NMDA receptor antagonist
What have been suspected of causing neuron toxicity and cell death? Oxidants
DSM-IV TR diagnostic criteria for Alzheimer's Disease Impairment of recent memory, gradual onset and continued decline of cognitive ability and at least one of the following (aphasia, apraxia, agnosia)
Second most common cause of dementia? Dementia with Lewy Bodies (DLB)
Dementia with Lewy Bodies is most common in what sex? Males
What are Lewy Bodies? Lewy Bodies, AKA: Lipofuscin, are round, eosinophilic, intracytoplasmic inclusions in the nuclei of neurons
Where are Lewy Bodies located? substantia nigra
Diagnostic criteria of dementia with Lewy Bodies Dementia criteria plus at least 2 of 3 following clinical features (cognitive fluctuations, visual hallucinations, parkinsonism
In Dementia with Lewy Bodies, what symptom precedes the other? cognitive impairment often precedes memory loss
In Lewy Body treatment, what is the first choice? nonpharmacological therapy
What treatment in Dementia with Lewy Bodies is used for cholinergic deficits though not approved? cholinesterase inhibitors
What therapy for Dementia with Lewy Bodies should be avoided but if unavoidable, be used only atypicals? Neuroleptic therapy
Parkinson's symptoms should be treated preferably with what drug rather than what? levodopa rather than dopamine agonist
Most notable diagnostic criteria(s) of vascular dementia? onset with a stroke and slow improvement following acute onset; medical history consistent with arterial disease or cardiovascular disease risk factors
Treatments for vascular dementia? Treatments for vascular dementia? control risk factors and underlying disease processes; may respond well to rehab efforts
Current criteria for PDD (Parkinson's Disease with Dementia)? motor symptoms occur at least 1 year prior to the cognitive symptoms
PDD patients are more susceptible to _______ side effects of Parkinson's Disease medications neuropsychiatric
In treating PDD, consider using _____, use ______ if needed cholinesterase inhibitors; atypical antipsychotic meds
Functional gait rely on what three systems? sensory, central, and MSK systems
Sensory impairment in gait related systems lead to? Significant loss of function, and falls.
Musculoskeletal impairment in gaitlead to? weakness and joint impairment
Central nervous system impairment in gait lead to___________? Deminished postural reflexes, increased central processing time, decreased step length, decreased step velocity
What are the environmental aspects related to falls? poor lighting, loose carpets, lack of bathroom safety equipment
In a history evaluation of patients with falls, you would look for? (HINT: CATASTROPHE) Caregiver&Housing / Alchohol / Treatment (Meds) / Affect (Depression) / Syncope / Teetering (Dizziness) / Recent Illness / Ocular Problems / Pain with Mobility / Hearing / Environmental Hazards
In a physical exam in patient with falls, you would look for? (Hint: I HATE FALLING) Inflammation of Joints / Hypotension / Auditory and Visual Exam / Tremor / Equilibrium and Balance (Rhomberg) / Foot Probs/ Arrhythmia or Valvular Disease / Leg length diff (osteo exam) / Lack of conditioning / Illness / Nutritional Status / Gait Probs
Describe vertigo Think of dizziness, remember how it feels as you get off the circus ride!
What are syncope and presyncope? Actual loss of consciousness Presyncope is the feeling right before fainting
What is Hypotension's relationship to syncope? It is the physiological cause of Syncope and Presyncope
To what etiology is dysequilibrium related? Usually related to neuromuscular etiologies
8 Causes of vertigo? Benign positional vertigo Cerebral vascular disease Acute labyrinthitis Vestibular neuronitis Otits media Drug toxicities Meniere’s Disease Acoustic neuroma
4 Causes of presyncope/syncope? Orthostatic Hypotension Cardiac arrhythmias Congestive Heart Failure Vasovagal episodes
5 Causes of dysequilibrium? Neuromuscular diseases Stroke Cerebellar Diseases Physical Deconditioning Neurosensory deficits, Eg. -Vision problems -Proprioception
In evaluating falls, what must you rule out quickly? Life threatening conditions
Definition of orthostatic hypotension? A fall in Systolic Blood Pressure of at least 20 mm Hg or to less than 90 mm Hg when moving from a supine to standing position.
What is optimum medical care? -Doing the right thing -For the right reason -At the right time
What is the right reason? The correct diagnosis
Primary prevention in geriatrics? Examples? Prevent disease from happening (immunization/no smoking/ exercise/ nutrition / accident prevention)
Secondary prevention in geriatrics? Examples? Screen to detect disease while still treatable (cancer)
Tertiary prevention in geriatrics? Example? Is intended to slow the disease process. Eg. Rehabilitation
Name the screening criteria for secondary prevention? +Must be condition that significantly effects morbidity or mortality +Condition must be treatable +Early detection must reduce morbidity or mortality +Incidence and treatment outcomes should justify the cost of the screening
In screening the elderly population, yield can be higher due to? higher incidence of disease
In screening the elderly population, what aspect of life tend to outweigh the other? quality of life tends to outweigh length of life
Screening decisions become ______ decisions rather than _______ based decisions individualized; population
What types of screening become most important? secondary and tertiary screening take on more importance than primary screening
Ethical questions to consider in geriatrics 1. Is patient competent to understand their medical condition. 2. Can patient understand risks and benefits of Tx. 3. Can patient tell us their decisions on treatment options 4. What if other significant individuals disagree with the patient’s wishes?
Essential elements of competence in the elderly -Intact long and short term memory -Sensory ability intact to receive new information -Cognitive ability to process the information -Confirmation of a decision when presented with the same information on a second occasion.
Patients can dictate, in advance, _____________ in case they become incompetent. The care they want
What is a living will? a specific document tested in law that defines the patient wishes in the event of a Terminal Illness or Persistent Vegetative State that has no reasonable hope of recovery
Chronic vegetative state is a result of? ischemic cerebral event
Patients in chronic vegetative state may show___________? reflexive neurological activity
Patients in chronic vegetative state often exhibit ______ cycles sleep/wake
Health care power of attorney (HCPOA) is a legal document which___________? designates another individual to make health care decision if the patient is not competent or able to make the decisions.
Many forms have a section where patients can leave directives about decisions such as: These are called: Advanced Directives -Hospitalization -IV medications -IV hydration -Gastric feeding tubes -Ventilator support -CPR
Many forms exist to allow patients to specify if they wish Cardiopulmonary Resuscitation in the event of cardiac or respiratory arrest. What is this form called? Do Not Resuscitate (DNR) Order
3 DNR Variations? NO CPR under any circumstances. -No intubation, but CPR and electroshock is OK. -Medications and CPR only
Orange Card? Used in WV homes: Confirms patient’s DNR order
POST form: POST stands for: Physicians Orders for Scope of Treatment
What do patients want as they approach death? (1-7) 1.kept clean 2.free of pain 3.free of anxiety 4.free of shortness of breath 5.comfortable with their nurse 6.have someone to listen to them 7.Maintain their dignity
What is one of the most important things we can do to relieve anxiety? Communicate with the patient. Let them know what to expect, while maintaining a sense of humor.
True or False: Physical touch is reassuring to dieing patients? True.
True or false: Dieing patients want the chance to say goodbye to important people. True
9. More things a patient wants as they approach death: 1.share time with close friends 2.feel prepared to die 3.not die alone 4.remember personal accomplishments 5.put Tx preferences in writing 6.name a decision maker 7.have financial affairs in order 8.Family presence 9.know family is prepared
True or False: A person facing death wants to resolve unfinished business with friends and family? True
What do dieing people want from their physicians? (5 things) 1. receive care from personal physician 2.physician to know the whole person 3.physician who's comfortable talking about it 4.able to discuss their fears 5.Can be trusted
5 stages of grief/dying according to Elisabeth Kubler-Ross, MD 1.Denieal 2.Anger 3.Bargaining 4.Depression 5.Acceptance
True or False: It is okay to ask a person facing death about their life, accomplishments, and their personal affairs. True
When asking about advance directives it is important to do so_____________? While the patient is still competent.
True or Fals: The person who holds the medical and financial power of attorney, are usually one and the same? False, they are often two different people
True or False: Pallative care is a new specialty with its own fellowships and boards? True
During which Kubler-Ross stage of dying is it best to ask about important issues? Acceptance
See slide #12 in the Palliative care lecture. Know the difference b/w Decarebrate and Decorticate postures. See slide #12 in the Palliative care lecture. Know the difference b/w Decarebrate and Decorticate postures.
Name 4 etiologies of Neurological problems. 1. Infarction 2. Ischemia 3. Toxins 4. Pressure from: Injury (contusion,inflammation) and Metastatic Tumors
Name 3 etiologies of cardiac problems. 1.Primary ischemic heart disease 2.Myocarditis both infectious and autoimmune 3.Secondary to pulmonary hypoxia
Name 5 symptoms of Congestive Heart Failure. 1.Short of breath due to pulmonary edema 2.Chest pain due to ischemia 3.Claudication 4.Mottled skin from peripheral ischemia 5. Pressure sores
Name 4 Pulmonary Etiologies 1.COPD 2.Pulmonary Fibrosis 3.Pneumonias 4.Lung Tumor
Name 6 signs of Pulmonary Etiologies 1.Cough 2.Shortness of Breath 3.Systemic effects of hypoxia 4.Hypercapnea (too much Co2) 5.Cheyne-Stokes Respiration 6.Apnea
Name 4 signs of Hpercapnea (too much Co2) 1.Numbness 2.Virtigo 3.Presyncope 4.Seizures
Name 6 Gastrointestinal Etiologies 1.Esophageal Cancer 2.Pancreatic Cancer 3.Hepatic Cancer-Metastatic more common 4.Colon Cancer 5.Rectal Cancer 6.Unresectable bowel obstruction or ischemia
Signs of Esophogeal Cancer Pain, unable to swallow
Signs of pancreatic cancer Pain, weight loss
Signs of Hepatic Cancer Jaundice, itching, nausea
Signs of Colon/Rectal Cancer Pain, colostomy, metastatic disease common
Signs of Unresectable bowel obstruction or ischemia Bowel decompression with nasogastric tube or percutaneous drains
Does a total obstruction of the GI tract prevent the stomach from secreting? No, this often results in vomiting and trouble eating, so an NG tube is often used to remove gastric secretions.
Are oral medications helpful with a bowel obstruction? No
Renal Falure can often lead to: (3 things) 1. End stage renal disease 2. End stage heart faiure 3. Primary renal tumors
3 Signs/Symptoms of renal failure 1.Elevated BUN and Cratinine 2.Uremic coma 3.Fluid retention, electrolyte impalances
Uremic coma causes: Depression of our mental status and pain perception.
From what should a terminal patient be free? Free of: Pain Shortness of Breath Anxiety Nausea Constipation Prssure Sores Hunger or Thirst
3 types of pain? Somatic Visceral Neuropathic
Describe Somatic Pain and causes Localized, dull, aching, throbbing Muscle-ischemia, sprains Bone-fractures, tumors
Describe Visceral Pain and causes Poorly Localized-Squeezing, pressure internal organs-ischemia, inflammation, obstructions
Describe Neuropathic Pain and causes Severe, burning, stabbing Nerve compression-Vertebral Disc Prolapse Nerve ischemia or tumor infiltration Infection-Herpes Zoster Neuralgia, Trigeminal neuralgia
Of the three types of pain, which is the toughest one to deal with? Neuropathic, because nothing really makes it better
How can pain be effectively managed? With the: Right Drug Right 1/2 life Right dose for Volume of Distribution and by treating any side-effects
True or False: Sedation and anti-anxiety side effects of medications can be helpful. True, and they should be taken advantage of.
3 ways we treat pain Treat underlying cause Choose Effective Pharmaceuticals Choose Effective Routs of Administration
The first choice for pain medication should be: Acetaminophen
When should a trans-dermal drug patch not be used? On mottled skin. It won't be effectively delivered.
Are benzodiazapines a good choice for managing pain in patients with shortness of breath. No, it causes respiratory depression.
How do we treat feelings of shortness of breath in terminal patients? Oxygen Diuresis Anxiety Management Opiod Management, Eg. Morphine
A big side effect of narcotics, which must be addressed is______________? Constipation, for this we use a lot of laxatives
Will Medicare pay for Hospice? Yes
True or False: Hospice provides 24/7 in-home care, housing meals, and full time staff at the expense of Mediare. False, Medicare will pay for Hospice care, but Hospice only provides daily nurse and CNA visits. Not food or housing
How does one qualify for Hospice care? A physician must determine that they have only six months to live.
6 Stages of the common clinical course of death? 1.Sleepy 2.Lethargic 3.Obtunded= dull, or blunted 4.Semicomatose 5.Comatose 6.Death
10 Stages of the uncommon clinical course of death: 1. Restless 2.Confused 3.Tremulous 4.Hallucinations 5.Delirium 6.Myoclonic Jerks 7.Seizures 8.Semicomatose 9.Comatose 10.Death
True or False: Patients may only receive hospice care in their own home? False, they may receive hospice care in the place of their chosing. Home, Nursing Home, Hospice Home, Family or Friend's Home
What is a CNA's function in Hospice care? Maintains Hygiene
Know the things that affect the Mini-Mental Status Exam. See the graph in the lectures. Know the things that affect the Mini-Mental Status Exam. See the graph in the lectures.
Describe the point for listening to an Aortic Murmur. 2nd intercostal space, right sternal border
Describe the Physician's Role after Death Pronounce the death Support the family by calling, attending the visitation/wake, and acknowledging the death at the next encounter. Answer questions Complete the Death Certificate.
True or False: Warfarin dos will need to be increased in patients with liver disease? False, it may need to be decreased.
The average patient over the age of 65 will fill prescriptions for _____ number of drugs per year. 12
What must a physician do after prescribing meds? Make sure the patient returns in order to evaluate the outcome.
What must a physician consider when presecribing drugs? Consider all medications that are indicated for the diagnosis. Review the risks. Consider the patients' ability to afford the meds.
What 3 risks must be considered when prescribing meds? Allergies Adverse Reactions Coexisting medical conditions
What should a physician do about 2 weeks after prescribing a thiazide diuretic? Check for Hyperkalemia
What patient data is important to consider when prescribing meds? Age Weight Renal Function
True or False: We loose nephrons as we age? True, this affects renal function, thus dose.
What should always be done with zero order drugs, and those that are highly toxic? A serum concentration check
What must be considered when prescribing a trans-dermal patch? Is the blood flow at the site of administration compromised?
Define: Health Literacy The level at which a patient or their caregiver is able to understand medical topics
What must a physician consider when explaining medical topics to a patient or caregiver? Their "Health Literacy".
True or False: A physicain should never refer to a Physicans' Desk Reference or any other resource in front of the patient? False, Using a PDR in front of the patient builds confidence/trust, so long as the physician explains that they are trying to be thorough.
7 factors involved in selecting and dosing of meds. 1.Personal Knowledge 2.References-PDR-Epocrates 3.Allergies 4.Metabolic Contraindications 5.Adverse outcomes 6.Review previous therapy success 7. Consider cost/compliance
Name the 4 Geriatric Metabolic Considerations. 1.Absorption 2.Distribution 3.Matabolism 4.Excretion
Name the two routs of drug excretion. Hepatic Renal
Define achlorhydria. Low levels of stomach acid, or low production of stomach acid.
Name 3 factors that affect a patients drug absorption ability. 1.Achlorydria (Stomach acid level) 2.Decreased splanchnic blood flw 3.Decreased GI motility
Name an indicator of decreased muscle mass. Decreased albumin levels
What does a decrease in albumin, thus a decrease in muscle mass suggest about adipose tissue? That it has increased.
How does a decrease in lean body mass, and total body water, accompanied by an increase in body fat affect volume of distribution of hydrophilic drugs? It decreases the volume of distribution of hydrophilic drugs.
How does a decrease in lean body mass, and total body water, accompanied by an increase in body fat affect volume of distribution of lipophilic drugs? It increases the volume of distribution of lipophilic drugs
How does a decrease in lean body mass, and total body water, accompanied by an increase in body fat affect the concentration of hydrophilic drugs? Hydrophilic drugs will exist at higher concentrations if the dose is not adjusted.
How does a decrease in lean body mass, and total body water, accompanied by an increase in body fat affect concentration and half life of lipophilic drugs? Lipophilic drugs will exist at lower concentrations, but will have a longer half life. So might need a bigger dose, but it will last longer.
How does a decrease in lean body mass, and total body water, accompanied by an increase in body fat affect protein bound drugs? Protein bound drugs will have a higher serum concentration, because less will be bound.
Name an important consideration when using beta blockers, nitrates, calcium channel blockers, and tricyclic anti depressants in a patient with decreased liver function. They may cause a complete heart block because they are not cleared as quickly.
Name a common problem with staten drug use. Statens often irritate the liver and decrease its funcion.
What markers are used to identify decreased liver function? Transaminases, and biliruben.
True or False: Renal function declines with age. True
Name the 5 serum markers used to assess renal function. 1.Creatinine(Preferable) 2.Potassium 3.BUN 4.Albumin 5.Glucose
True or False: Serum Creatine alone is a good indicator of GFR. False, never rely on Creatinine alone. Always do the math.
What is the metabolite of protein breakdown? Creatine
Creatinine Clearance Formula There WILL be a test question about this!!!! CrCl= (140-age)(Wt.in Kg)(.85 if female)/(72 x Serum Cr) There WILL be a test question about this!!!!
Convert Lbs to Kg Lbs/2.2=Kg
At what Creatinine Clearance value should a patient be referred to a nephrologist. 30 or less.
Drugs to avoid Benzodiazepines Barbituates Analgesics Muscle Relaxants Antiemetics Antihistamines Antidepressants-incl.St. Johns Wort Antispasmotics Cardiovascular
See Tables 6-1 and 6-2 in the Geriatrics Text Book See Tables 6-1 and 6-2 in the Geriatrics Text Book
Created by: rdabolt