Geriatrics: Final (based strongly around objectives)
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| T/F: Glucose tolerance is higher in geriatrics | False, Glucose INtolerance is higher
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| 2 ways DM may be Dx in geriatrics? | Fasting glucose >126 mg/dL OR A1c >6.5
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| Difference in screening for DM in USPSTF and ADA | ADA recommends screening every 3 years; USPSTF doesn't recommend unless HTN or hyperlipidemia
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| A1c goal of DM? | <7% in those healthy and functioning well
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| 4 main management points for DM in geriatrics | 1) Diet 2) Exercise 3) Wt loss 4) Medications
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| 4 main medications used for DM in geriatrics: MOA and adverse | 1) Sulfonylureas: increase insulin secretion, wt gain, hypoglycemia; 2) Acarbose: inhibits SI glucosidases, flatulance; 3) Metformin: inhibits glucose production, wt loss, acidosis, exacerbates CHF (first line in overweight); 4) Thiazolidinediones
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| Hyperglycemia (>600), hyperosmolarity, dehydration, all w/o significant ketoacidosis | HONK or Hyperosmolar non-ketotic coma or HHS
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| T/F: T3, T4, free T4, TSH should all be normal in geriatrics | True
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| Fatigue, memory complaints, depression, wt gain, high TSH | Hypothyroidism
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| Increased TSH, normal T4, normal free T3 | Subclinical hypothyroidism
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| lethargy, stupor, delirium, coma, hypothermia, delayed DTRs, Respiratory failure | Myxedema Crisis: severe Sx hypothyroidism
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| What else should a pt be tested for with the following Sx: CHF, stroke, infection, weight loss, anorexia, Afib, tachyarrhythmias, psychiatric sx | Hyperthyroidism
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| "Bones (less Ca), Stones (more Ca), Abdominal Groans and Psychiatric moans" | Hyperparathyroidism
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| Occult blood testing, diverticulosis. TIBC? Iron? Ferritin? Retic? RBC indices? | Iron deficiency; Increased TIBC, Low iron, Low ferritin, Low retic, hypochromic, microcytic anemia
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| Poor intake, loss of intrinsic factor, malabsorptive GI conditions. Indices? Tx: | Vitamin B12 or Folate Deficiency. Macrocytotic hypersegmented neutrophils. Tx: B12 and Folate IM
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| Most frequent cause of death due to infection | Pneumonia
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| What general type of infections are more common in elderly compared to younger adults | Gram negative infections
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| Why do 50% of infective endocarditis cases occur in older adults? | Predisposition from atherosclerotic and degenerative valve disease, as well as prosthetic valves
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| What 3 things do elderly have (or not have) that impairs temperature regulation? | 1) Impaired temp perception 2) Diminished sweating w/ heat 3) Altered vasoconstrictor response to cold
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| Fatigue, apathy, slurred speech, confusion, bradycardia, arrhythmias, hypotension, slow reflexes, V fib, areflexia, apnea | Hypothermia
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| Dizziness, N/V, HA, CNS dysfunction, psychosis, delirium | Hyperthermia
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| Opacifiation of the lens, problems w/ night driving, reading road signs, difficulty w/fine print or glare. RF (4)? Tx? | Senile Cataract; RF: age, UV light, smoking, DM. Tx: surgery
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| Optic nerve damage and loss of peripheral, then central. Pathophys? Tx? (acute and chronic) | Glaucoma; P: Increased IOP Tx: Acute: Ophthalmology consult stat; Chronic: Opthalmic drops
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| Loss of central vision and is most common cause of legal blindness. 2 types? RFs (4)? Dx? Tx? | Macular Degeneration; Types: Atrophic: progressive bilateral and moderate. Neovascular: rapid, severe, unilateral. RF: smoking, low intake of anti-oxidants, obesity, high sun exposure. Dx: Dilated fundus exam and slit lamp microscope. Tx: Anti-oxidants
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| Hard exudates, aneurysms and abnormal growth of blood vessels on fundoscopy. Tx? | Diabetic Retinopathy; Tx: laser photocoagulation
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| loss of ability of eye to focus on near objects (accommodation) | Presbyopia
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| Eardrum thickens, ear canals thin, cochlea hair cells lost, basilar membrane stiffens, CN 8 degeneration, atrophic changes in temporal auditory cortex in brain | Changes to auditory system as we age
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| Conductive pathophysiologies for hearing loss (name 2 for each of the 2 parts of the ear they occur) | Conductive: External ear: cerumen, foreign body, squamous cell carcinoma, otitis externa. Middle ear: otosclerosis, cholesteatoma, TM perforation, middle ear effusion, immunologic diseases.
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| Sensorineural pathophysiologies for hearing loss (name 2 or 3) | Presbycusis, noise, ototoxic meds, acoustic neuroma (benign brain tumor essentially), Meniere’s disease (hearing loss, tinnitus, vertigo triad), vascular disease
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| progressive sensorineural hearing loss associated with aging due to combination of factors including peripheral, brainstem and cortical functions | Presbycusis
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| What are some ototoxic medications? (3) | aminoglycoside antibiotics, ASA, high dose loop diuretics
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| Management for hearing loss? | Refer to audiology for amplification therapy and aural rehab
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| 1) Obtain attention 2) Eliminate background noise 3) Ensure they can see lips 4) Speak slowly and clearly 5) Speak toward better ear 6) Change phrasing if not understood initially 7) Spell words or write down | 7 ways to improve communication w/ hearing impaired
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| Eval (8) and Tx (5) for polyneuropathy (Just be able to recall a few) | Eval: electrodiagnostic tests, CBC, ESR, TSH, glucose, B12, ANA, HIV. Tx: avoid EtOH, DM control, Duloxetine, PT, foot care
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| prescribing drugs to treat side effects of drugs they are already on | Prescribing cascade
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| % of non-adherence in older adults | 50%
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| details potentially inappropriate medications for older adults as well as drug–drug and drug– disease interactions that should be avoided or used with caution | Beers Criteria
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| What is one of the most frequent causes of hospital admission in elderly? | Adverse drug reactions
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| Effects of NSAIDs in older patients: (1) | Want to avoid chronic use, COMPLETELY avoid Indomethacin and Ketorolac. Increased GI bleeding/PUD
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| Effects of Narcotics in older patients: (2) | AVOID: meperidine or demerol as they may cause neurotoxicity (seizures). Other cause constipation
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| Effects of ABX in older patients: 1 that is possible with any and 2 specific ABX | Diarrhea possible w/ any. Nitrofurantoin: pulmonary toxicity; Amnioglycosides: renal failure and hearing loss
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| Effects of 1st gen antihistamines in older patients: (2) | 1) Highly anticholinergic (aging brain more sensitive) so confusion, dry mouth, constipation. 2) Reduced clearance. Generally avoid
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| Effects of anti-parkinson drugs in older patients: (4) | Dopaminergic: Nausea, delirium, hallucinations, orthostatic HypoTN
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| Effects of anti-cholinergics in older patients: (6) | flushing, dry skin and mucous membranes, mydriasis, decreased GI motility (constipation), confusion, urine retention. “red as a beet, dry as a bone, blind as a bat, hot as a hare, mad as a hatter”
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| Effects of Benzodiazepines in older patients: (5) | increased risk of cognitive impairment, delirium, falls, fractures, MVCs. Increase sensitivity. Good for seizure and ETOH withdrawal. Bad for insomnia, agitation or delirium.
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| Effects of CV drugs in older patients: (2) | Increased hypotension, myopathy w/ statins
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| Effects of TCAs in older patients: (3) | Avoid; Highly anticholinergic, sedation, orthostatic hypotension
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| Effects of muscle relaxants in older patients: (1) | Avoid; anticholinergic effects
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| Elderly effect on absorption | no major clinical implications!
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| Elderly effect on distribution (3) | decreased total body water, lean body mass and serum albumin
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| Elderly effect on liver metabolism (2) | decreased in liver blood flow, enzyme activity and inducibility
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| Elderly effect on renal (3) | Decreased renal blood flow, GFR, tubular secretion
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| Key principles for Rxing to older patients (6) | 1) start low, go slow 2) review med list every visit 3) D/C unnecessary 4) Don't start 2 new drugs at same time 5) Consider non-pharm Tx 6) Simplify dosing schedule
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| What are 2nd generation anti-psychotics associated w/ in older pts (2) | Increased mortality and wt gain
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| Hospital Services Insurance, almost everyone over 65 eligible | Medicare part A
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| Based on need and poverty; no fee to patients | Medicaid
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| optional managed care program “Medicare Advantage” | Medicare part C
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| Outpatient services, but no dental, routine eye or hearing coverage | Medicare part B
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| Covers medications and is elective | Medicare part D
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| T/F: You cannot combine Medicare and Medicaid | False, you can; (low income who are disabled and cannot work that are over 65+)
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| Home and community based services including: homemaker, home-delivered meals, home health aides, transportation, legal services, counseling. Available to all over 60 regardless of income but for low income, isolated and minorities | Title III of Older Americans Act
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| Safe and supportive environment, restore and maintain highest level of independence, preserve autonomy, maximize quality of life, provide rehab, medical, nursing, psychosocial care, comfort/dignity to term. ill, prevent acute medical illness | Goals of Nursing Home care
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| Improve documentation, systematic approach to screening health maintenance, preventive practices, use of NPs and PAs, use of practice guidelines and QI activities | Strategies to Improve Medical Care in Nursing Homes
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| 5 basic ethical principles | 1) Autonomy 2) Beneficence 3) Nonmaleficence 4) Justice 5) Fidelity
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| Right to control one’s destiny, exert one’s will | Autonomy
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| The duty to do good for others, to help them directly, and to avoid harm | Beneficence
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| Doing no harm and avoiding negligence that leads to harm | Nonmaleficence
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| Nondiscrimination and duty to treat fairly and distributing resources fairly | Justice
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| Duty to keep promises | Fidelity
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| Assisting patients to think about their priorities, beliefs, and values and how they want to be cared for (chronic illnesses as well as end of life) | Advance Care Planning
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| accompany patients through all health care setting transitions to ensure wishes are known and respected | Advanced Directives
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| CPR, ventilator, IV hydration, Artificial nutrition, Blood transfusions, Organ donation, Medical devices, Transfer to hospital for aggressive intervention, Funeral/burial arrangements | Topics to address for Advance Care Planning
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| understanding information provided including risks and benefits, applying it to one’s own situation, reasoning and making choices | Decision-making capacity
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| T/F: Clock drawing test and executive interview appropriate to determine decision-making capacity | False, NO screening tests appropriate fo determine decision-making capacity. These do focus on executive function.
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| Diminishing capacity to manage stress with risk of poor physical health and function | Frailty
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| Limited life expectancy aprox 6 months or less | Hospice
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| symptom management, relief from suffering and improving quality of life | Palliative Care
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| How does frailty impact prognosis? | Death usually due to multiple comorbidities and frailty
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| Gold standard Tx for dyspnea in palliative care? | Opioids
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| Typical Tx of cough in palliative care? | Opioids
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| Excessive secretions in palliative care? | Anticholinergics
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| What Tx might you consider w/ fatigue? | SSRI
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| Tx for anxiety/drepssion | SSRI
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| Assessment and Tx of pain | A: Pain rating scale; Tx: non-pharmacologic Tx, acetaminophen is DOC,opioid if severe. Adjuvant meds: NSAIDs, Corticos
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| Physical, sexual or psychological abuse, neglect (including self-neglect), abandonment and financial exploitation of an older person by another person or entity | Elder abuse
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| Lower caregiver stress, knowing family history, knowing financial situation | Opportunities to prevent elder mistreatment
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| Soiled or disrepaired clothing, poor hygiene, compromised skin integrity, malnutrition, anxiety w/ caregiver, patterned bruising at various stages of healing, lacerations on face, unexplained injuries requiring ED visit, delays in Tx | Signs of abuse, neglect, abandonment
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