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Geri Midterm

Geriatrics: Midterm

What is a hallmark of normal aging? Poorer adaption to external stress than they once had
T/F: Elderly have decreased sensitivity to narcotics False, increased sensitivity
T/F: Elderly have a decreased GFR True
T/F: Elderly have increased incidence of thyroid disease? True
Central focus of Geriatric Assessment Functional abilities
What age group is the fastest growing segment of the US population (yes, it is Geriatrics duh, give me a age in years and a subset). What percentage of all health care does this cost? >65 fastest growing segment in US population and >85 yo fastest subset of population. 1/3 of all health expenditures
T/F: May not have pain w/ MIs and will have normal resting pulse and CO that does not increase w/ exercise True
What happens to renal function as we age? GFR and blood flow decrease, but creatinine may be normal since there is less production
What happens to blood sugars as we age? Normal fasting blood sugar, but inability to handle glucose load
T/F: Systolic BP decreases as we age False, one of the few things that increases (most everything else in the body decreases, atrophies or loses)
Other that SBP, what else increases with age (Hint: reproductive system)? Prostate tissue!
3 other things that increase in the elderly body 1) lens size of the eye 2) cerumen in the ears 3) Fibrosis of thyroid
4 things we want to look at for the Geriatric Primary Care role: 1) Clinical assessment 2) Chronic illnesses 3) Geriatric syndromes 4) resources to optimize function and QoL (quality of life)
4 elements of Comprehensive Geriatric Assessment 1) Physical 2) Psychological 3) Socio-economic 4) Function
Why does cognitive impairment and depression go overlooked? Providers mistake them for being normal signs of aging
3 essential ways to assess function status of elderly? 1) Ability to walk into exam room 2) Ability to get up and down from being seated 3) Dressing/undressing
ADL or IADL required to maintain independent living? What does the other measure? IADL (Instrumental Activities of Daily Living. ADL measures basic self-care
What are a few specific things to enhance communication w/ elderly? (just name a few as there are 9) Allow time. Avoid distractions. Sit face-to-face with patient. Maintain eye contact. Listen. Speak clearly; loud enough for patient to hear. Provide information systematically. Simplify instructions. Give the patient opportunity to ask questions.
T/F: Therapeutic window decreases as toxic response and age increase True
T/F: WBCs will be even higher in an elderly patient with an infection False, may not be elevated at all w/ infection. Conversely, patient may be septic and ASx. Crazy old people!
Abnormal presentation of diabetes in elderly May not see the classic "polys" (polyuria, polydipsia, polyphagia)
Goal of chronic disease mamagement (2) 1) Prevent catastrophes 2) Palliative care
Probably the most important preventable problem for Geriatrics: Iatrogenesis
T/F: Leading causes of death mirror the actual causes of death, which are modifiable True
Give an example of a leading cause of death and its modifiable actual cause of death: Heart disease from Tobacco use (this is just ONE of many examples)
How often is diabetes screening recommended for those over 45 yo? Every 3 years
T/F: Statin therapy is not recommended for those over 70 yo False, Recommended for those INCLUDING over 70 yo
When is abdominal aortic aneurysm screening recommended and for who? Men 65-75 yo who have EVER smoked
What lifestyle preventions are recommended for elderly? (6) 1) Diet 2) Tobacco 3) Exercise 4) Cognitive Activity 5) Social Activity 6) Napping
Which screening test for elderly aren't necessary? BMI, BP, Lipids, Glucose, TSH, Cancer, Depression, Dementia, Cognition, Vision, Hearing Dementia
How often should a high-functioning elderly women over 75 get a mammogram? Over 50? Every 2 years
When do you stop PSAs for men? >75 yo
When can you stop pap smears for women w/ history of normal pap smears and are at low risk? >70 yo
What 3 tests are not routinely recommended for elderly? 1) Asymptomatic bacteriuria 2) TSH 3) Hemochromatosis
When can elderly stop getting colonoscopys? >85 yo
Confusion in an older adult? Impaired cognitive function
Acute disorder associated w/ acute illness, drugs, environment Delirium
Slowly progressive impairment of cognitive function Dementia
Dementia or Delirium? Changing levels Delirum
Dementia or Delirium? Hallucinations Delirium
Dementia or Delirium? No acute illness Dementia
Dementia or Delirium? No change in attention span Dementia
Dementia, depression, renal insufficiency, Hx alcohol abuse, Hx of age, male Predisposing factors of delirium
Medications, immobilization, restraints, dehydration, alcohol withdrawal, pain, emotional stress, sleep deprivation Precipitating factors of delirium
T/F: Can have a high vulnerability with a less noxious insult or a low vulnerability with a noxious insult True
Management process of delirium? 1) Dx w/ H/P and labs 2) Evaluate potential causes especially life threatening 3) Manage Sx (socialization, reorientation, sleep protocol, haldol for psychosis, benzos for alcohol withdrawal)
What is the CAM? Confusion Assessment Method
Gradual progressing course w/ no disturbance of consciousness Dementia
Subjective memory or executive function complaint with objective deficit in one or more cognitive areas and NO functional impairment. Tx? Mild Cognitive Impairment; No Tx
Dementia or Delirium? Difficulty learning/retaining, handling complex tasks, reasoning, spatial ability, language, behavior Dementia
DSM-IV for Dementia Memory impairment w/ 1 or more of the following Aphasia, Apraxia, Agnosia, Executive functiong
Most common cause of dementia, progressive cognitive/behavioral deficits. Sx: memory loss, confusion, impairment. Biggest risk factor? Alzheimers; age
Neuropathology of Alzheimers amyloid plaques and neurofibrillary tangles
Step-wise decline of dementia Vascular/Multi-Infarct
Early decline in social interpersonal conduct and language skills, later to lose memory Sx, early impairment. Frontotemporal Dementia
Fluctuating cognitive Sx, recurrrent hallucinations, syncope, visuospatial/construtional impairment on cognitive testing Dementia w/ Lewy Bodys
Management of Dementia Optimize function, ID/manage behavior, ongoing care, patient/family education. Therapy, regular appointments, avoid drugs that worsen cognitive function, treat comorbidities
Meds for Alzheimer's disease (one for mild to severe and the other for moderate to severe) Donepezil (cholinesterase inhibitor) (mild to severe) and Memantine (NMDA receptor blocker for moderate to severe)
Family Hx, previous Hx, medical illness, memory loss, losses, social isolation, neurotransmission changes Factors predisposing to depression
Depression accounts for 25% of what? What are risk factors for it? suicides; male, white protestant, divorced/widowed, blue collar, alcoholism
SIG E CAPS? What is this for? Sleep problems, Interest decreased, Guilt, Energy decreased, Concentration difficulties, Appetite disturbances, Psychomotor retardation, Suicidal thoughts; This helps Dx depression in YOUNGER people
What distinguishes presentation in older folks? Somatic complaints (poor health, constipation etc), and impairment of memory/cognitive functions
CP, SOB, bowel/bladder issues, HA, memory disturbances, fatigue, weakness, anorexia, wt loss, anxiety, apathy All physical Sx that can represent depression
Anti-hypertensives, narcotics, anti-parkinson meds, cardiac mdes, hypoglycemics, sedatives, anti-psychotics, alcohol, chemo Meds that can all contribute to depression
Malignancy, COPD, CHF, MI, infections, incontinence, dehydration all illnesses that can be associated with depressive Sx
Depressive syndrome w/in 2-3 months of a death? Some differences w/depression Bereavement; preoccupation w/ worthlessness, prolonged functional impairment
CAGE questionnaire Cut down? Annoy you? Guilty? Eye-opener?
SBIRT Screening, Brief Intervention Referral to Treatment
Can cause and present as anxiety or depression Insomnia
Chronic pain, GERD, nocturia, dyspnea Conditions interfering w/ sleep
Best screening for depression? One that is more used? One most used for elders? Beck Depression Inventory best, Zung Depression Scale shorter, Geriatric Depression Scale most used for elders
Management of Depression (4); potential side effects? CBT or Cognitive Behavior Therapy, medications (SSRIs [hyponatremia, SIADH, HTN), exercise, ECT
What is a anti-depressant that helps with urinary incontinence and chronic pain? Cymbalta (duloxetine)
What anti-depressant can cause wt gain? Mirtazapine (Remeron is trade name)
Prevalence of urinary incontinence 1/3 women and higher in nursing homes, 15% in men
coordinated balance between cortex and the spinal cord sympathetic and parasympathetic systems Structural components of normal micturition
YTI/ atrophic vaginitis/urethritis, stool impaction, increased urine production, impaired mobility All contribute to incontinence
DRIP. What is this used for? Delirium, Restricted mobility, Infection, Polyuria; potentially reversible conditions leading to incontinence
Diuretics, TCAs, anti-cholinergics, anti-psychotics, narcotics, alpha blockers, alpha agonists Meds contributing to incontinence
Pelvic floor laxity, associated w/ cough/obesity. Small amounts lost. Stress incontinence
Detrusor hyperactivity=involuntary bladder contractions. Larger volumes Urge incontinence
Anatomic or neurogenic obstruction (like BPH), small amounts of urine. Post-void residual. Overflow incontinence
What is mixed incontinence elements of urge and stress incontinence
Evaluation of incontinence lab studies, renal ultrasound
How do you treat asymptomatic bacteriuria? Usually don't because screening is not recommended!
Main management of incontinence Modifcations of fluid, caffeine, meds, pelvic muscle exercises, scheduled toileting
Tx of stress incontinence kegals, wt loss, alpha agonists (increase sphincter control)
Tx of urge incontinence kegals, bladder training, bladder relaxants
Tx of overflow incontinence surgical removal of obstruction
Meds for BPH 5-alpha reductase inhibitor (finasteride/Proscar), alpha blockers (tamsulosin/Flomax)
Laxative overuse, dementia, stroke, spinal cord disease, colorectal disorders causes of fecal incontinence
immobility, colorectal disorders/tumor, depression, drugs, diabetic autonomic neuropathy causes of constipation
Management of constipation ID cause, fluid and fiber, probiotics, improved mobility, timing (gastrocolic reflex), meds: milk of magnesia (osmotic cathartics), stool softners, bulk forming agents, enemas
Prolonged bed rest, hypovolemia, impaired venous return, post-prandial causes of hypotension (orthostatic)
Throw rugs, frayed carpets, wires, pets common environmental hazards that contribute to falls
2 huge factors associated w/ falls at nursing home residents 1) recent admission (new environment) 2) polypharmacy
Circumstances surrounding the fall, premonitory or associated Sx, LOC Hx of falls
CATASTROPHE; what is this for? Caregiver, Alcohol, Treatment, Affect, Syncope, Teetering, Recent illness, Ocular problems, Pain, Hearing, Environmental hazards; for a history after a fall
Key aspect of dizziness history Distinguish between vertigo and lightheadedness
sensation of movement/spinning; usually vestibular origin; may be cervical origin Vertigo
unsteadiness or imbalance primarily involving the lower extremities/ trunk; pt may feel that they are about to fall; disorders of proprioceptive system, musculoskeletal weakness, or cerebellar disease Dysequilibrium
feeling of lightheadedness/faintness or the sensation that one is about to pass out; due to hypoperfusion of the brain; cardiovascular causes (including vasovagal disorders) Presyncope
2% to 8% of older patients with dizziness Triad of recurrent episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss Meniere's Disease
Sudden-onset, episodic vertigo, often associated with N/V, precipitated by changes in the position of the head. Causes: idiopathic, head injury, viral labyrinthitis. Assessment: Dix-Hallpike test Tx: Epley’s manuever. Benign Paroxysmal Positional Vertigo
benign tumor of Cranial N 8; tinnitus, unilateral sensorineural hearing loss, feeling unsteady (CT scan shows) Acoustic Neuroma
may cause dizziness along with diplopia, dysarthria, numbness, weakness (be especially suspicious in pt with DM/vascular risk factors with acute onset dizziness) TIA/Stroke in vertebrobasilar distribution
I HATE FALLING; What is it used for? Inflammation, Hypotension, Auditory/visual abnormalities, Tremor, Equilibrium, Foot problems, Arrhythmia, Leg length discrepancy, Lack of conditioning, Illness, Nutritional status, Gait disturbance, used to memorize PE for falls
Test for gait and falling Get Up and Go Test
Management of elderly patients with instability or falls Assess and treat injury, treat underlying conditions, prevent falls, provide PT and education, alter the environment
Management of dizziness; what should be avoided? anti-histimines and benzodiazepines (avoid scopolamine, and anti-cholinergic, due to side effects in elderly), diuretics, PT
MSK disorders, neuro disorders, CV/Pulmonary disorders Causes of Immobility
Pressure ulcers, MSK contractures, CV deconditioning, psychological Some complications of immobility
Wt loss, PT, strength training, heat/ice, acupuncture, exercise, NSAIDs, joint replacement management of arthritis
Management of bicipital tendonitis, olecranon and trochanteric bursitis PT, steroid injection
T/F: 5-8x increased risk for mortality in first year after hip fracture True :(
Management of Parkinson's Disease Meds (increasing dopamine level), surgery, exercise/PT
Any lesion caused by unrelieved pressure that results in damage to underlying soft tissue when the tissue is compressed between a bony prominence and external surface over a prolonged period of time Pressure Ulcer
Intrinsic (4) and extrinsic (3) RF for pressure sores I: poor nutritional status, immobility, low body mass, moisture, poor circulation. E: direct pressure, shear force, friction
Persistent erythema of intact skin; often over bony prominence; may be red/blue/purple in dark skin (persistent, unblanchable redness Stage 1
Full-thickness skin ulcer extending through subcutaneous fat. This may extend down to but not through the underlying fascia. May have undermining Stage 3
Extension of ulcer through deep fascia, so that bone is visible at base of ulcer. Undermining and sinus tracts may be present as well as osteomyelitis. Stage 4
Partial-thickness skin loss involving epidermis, dermis, or both. Superficial ulcer that presents as an abrasion or blister Stage 2
ID those at risk, skin care (clean and dry), nutrition, decrease pressure and friction, avoid bedrest and sedation Prevention of pressure ulcers
Tx of pressure ulcers (5) Cleansing/warm NS or water, dressings, debridement of stage 3 or 4, IV ABX if stage 3 or 4 and infected, pain management
____ in older persons is commonly underdiagnosed and undertreated despite the availability of many assessment tools and effective therapies Pain
First line for pain in elderly Acetaminophen
Neuropathic pain Tx; also how does it feel? TCAs, anti-convulsants, opioids. Tingling, burning, shocklike pain
Chronic pain Tx (4) TCAs, SSRIs/SNRIs, corticosteroids, anticonvulsants
Leading cause of death worldwide, most common cause for hospitalization Cardiovascular disease
4 physiologic changes that occur with aging with the heart 1) decreased ability to raise HR 2) slight decrease in CO 3) hypertrophy 4) diastolic dysfunction (impaired filling)
T/F: 67% of people >60 yo hypertensive True!
Eval of HTN BP in both arms, wt, funduscopic exam, abdominal bruit, lab tests (U/A, electrolytes, Ca, TSH, ECG, GFR)
T/F: people over 85 should not be treated for HTN False, Relatively healthy older persons at any age should be treated
What should you start with with stage 1 HTN? Lifestyle modifications!!!
Firstline DOC in elderly for HTN? Low-dose thiazide diuretic
Firstline DOC if you needed renal protection, have DM or CHF in HTN ACEI
Choice of drug post-MI in HTN or w/ heart failure, CAD, tachyarrhythmias, or essential tremor. Avoid w/ bradycardia BBs
Low cost, effective in systolic HTN Thiazide diuretics
Angioedema and cough, less effective in AAs, but good for LV systolic dysfucntion and CHF. Can cause hyperkalemia. HTN ACEI
Use if ACEI cough is too much, superior to BBs for HTN and LVH ARBs
Good second line therapy, in addition to thiazide diuretic for HTN CCBs (calcium channel blockers)
Useful in males w/ BPH, but can cause orthostatic/postural hypotension Alpha blockers
Most common type of stroke? Ischemic!
Most fatal type of stroke? Hemorrhagic!
Tx for ischemic stroke, chronic? tPA w/in 3- 4.5 hours of onset of ischemic. Chronic: control HTN, lipids, glucose, arrhythmias, platelets
Principles of Stroke Rehabilitation Initiation of rehab early is advised. Most neurological return occurs during 1st month while little occurs beyond 3rd month.
Acute phase of stroke rehab avoid complications like pressure sores, contractures, phlebitis, PE, fecal impaction by changing position every 2 hours
Later phase of stroke rehab ADL training, ambulation training, muscle reeducation exercises
Coronary Artery Disease (CAD): RF, Tx HTN major RF; Tx: nitroglycerin, ASA, BBs
What procedures associated w/ CAD carry higher risk in elderly? (3) Interventional therapy, CABG, percutaneous procedures
What presenting Sx are different in the elderly w/ a MI? (4) Confusion/delirium, rapid deterioration of health, dizziness/syncope, anxiety
Prevalence of valvular heart disease in elderly? common, especially >75 yo; Degenerative changes and lipid deposition
Fatigue, syncope, CP, SOV, CHF, crescendo-decrescendo systolic murmur radiating to supraclavicular area. Dx? Aortic stenosis; Dx: Echo
Arrhythmias especially blocks, AFib, stroke, CHF, endocarditis, apical holo-systolic murmur radiating to axilla. Dx? Calcified mitral annulus with mitral regurgitation; Dx: Echo
Tx of AFib in elderly including prevention Prevention: ACEI, ARB, BBs reduce risk. Tx: Cardioversion, anti-coagulation, rate control w/ CCBs or BBs, Digoxin if CHF.
Tx of Sick Sinus Syndrome Medical therapy ineffective; Pacemaker may be required to alleviate Sx, especially if anti-arrythmics are ineffective or intolerable
Change in sleep pattern, confusion/delirium, anxiety, fatigue, decreased appetite. Cardiomegaly, S3, basilar crackles, JVD, hepatomegaly BNP > 400pg/mL; Dx? Presentation of CHF in older adults; Dx: Echo to evaluate ejection fraction
Tx of systolic CHF (poor EF) (5) Diuretics, ACEI/ARB, BBs, Aldosterone blockers, digoxin
Tx of diastolic CHF (preserved EF) focuses on treating HTN and volume status; Diuretics for edema/congestion
Intermittent claudication, leg fatigue, difficulty walking, atypical leg pain, decreased pulses, hair loss, palor of color, ulcers; PE? Peripheral Arterial Disease (PAD); PE: Ankle-Brachial Index (ABI)
Tx of PAD/PV(ascular)D RF modification (smoking cessation, lowering lipids, controlling HTN and DM, exercise etc.), Foot care, Anti-platelet therapy, Revas
Created by: crward88



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