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DU PA All Geriatrics

Duke PA Everything Geriatric

those with more positive self perceptions of aging lived __ years longer than those with negative self perceptions of aging 7.5
traditionally age __ has been designated as elderly b/c it is the age at which people in industrialized societies generally leave the work force 65
by 2030 __ of the US population will be older than 65 1/5
the healthcare cost per capita for persons aged 65 or older in the US is __ times greater than the costs for those under 65 years 5
what is successful (healthy) aging no debilitating disease/disability, active healthy life until death from "old age", no unwanted features "tooth loss"
the number of people in the US older than 80 years is expected to __ in the years 2000-2030 double from 9.3 million to 19.5 million
currently a 70 year old man can expect to live until age 83
currently a 70 year old woman can expect to live until age __ 85
despite the best genetic makeup and medical care, no one seems to live much beyond __ years 125
challenges of geriatric care normal aging vs pathology, diversity of population, multiple chronic diseases, polypharmacy, diagnosis vs functional status
depression in the elderly is the great __ masquerader
never underestimate the morbid significance of __ vision and hearing loss
care not __ cure: support comfort, function, independance
look for __ in elderly patients, it is always present udiagnosed disease
don't __ for mild conditions overtreat
don't __ for serious conditions undertreat
common diseases of the elderly CAD, stroke, cancer, osteoporosis, arthritis, diabetes, depression
normal aging changes/disease progression (general) increased fat, decreased total body water
obesity in the elderly __ is a disease not a normal part of aging
consequence of increased fat and decreased body water in the elderly drug effects-fat vs water soluble, increased risk for dehydration
how is cost of elder care funded 57% public programs, 25% patient's families, 18% private insurers
3 categories of aging senescence, normal aging, successful aging
refers to the common complex of diseases/impairments that affect many older people, wide spectrum, as people age very differently normal aging
three factors influencing longevity heredity, lifestyle, exposure to environment
four predominant physiologic changes associated with normal aging musculoskeletal, eyes, fat distribution, internal organ changes (cardiac output, renal function)
general change in total body water declines 46-60%
change in muscle mass 30% decrease
change in taste buds 70% decrease
change in cardiac reserve decreased CO
change in max heart rate 195-155 bpm
change in lung vital capacity 17% decrease
change in renal perfusion reduced by 50%
change in cerebral blood flow reduced by 20%
change in bone mineral content reduced by 25-30% in women 10-15% in men
change in brain wt reduced by 7%
change in amount of light reaching the retina diminished by 70%
change in plasma glucocorticoid levels no change
3 body composition changes decrease in lean body mass, increase in fat storage, decrease in total body water
body composition changes can affect drug metabolism
5 musculoskeletal changes loss of bone mass, degenerative joint changes, loss of muscle mass, foot problems, decrease in stature
consequences of musculoskeletal changes leads to fall risks/increasing daily pain
10 common geriatric diseases at 65-74 htn, diabetes, glaucoma, cataract, CAD, osteoarthritis, dermatoses, arrhythmias, lipid disorders, bronchitis
many older people tend to conceal __ and do not seek medical care until the problems become major minor problems
you must not only treat the disease but you must maintain __ function
assessment to identify and manage fixable problems clinical assessment
assessment to maximize independence through human, mechanical, or environmental manipulations functional assessment
a mental state marked by the mingling of ideas w/consequent disturbance of comprehension/understanding, and bewilderment confusion
chronic organic brain syndrome dementia
acute organic brain syndrome, acute confusional state, acute dementia delerium
short term memory loss w/o delirium or dementia (Korsakov's psychosis) amnestic syndrome
patient describes a state of "noisy restlessness" delerium
acute or subacute alteration in mental status. disorder of attention, improvement or normalization of mental function after underlying condition treated delerium
predisposing factors for delerium decreased sensory function, sensory deprivation, sleep deprivation, immobilization, transfer to new environment, psychological disturbances, males, >3 new meds
10 common causes of dementia metabolic disorders, infections, decreased CO, stroke, drugs, intoxication, hypo/hyperthermia, acute psychoses, transfer to unfamiliar surroundings, fecal impaction/urinary retention
chronic deterioration of mental function sufficiently severe to interfere with daily living dementia
onset of delerium acute
onset of dementia insidious
course of delerium fluctuating
course of dementia generally stable
duration of delerium hours to weeks
duration of dementia months to years
awareness in delerium reduced
awareness in dementia clear
attention in delerium hypo/hyper alert
attention in dementia usually normal
orientation in delerium mistakes familiar/unfamiliar
memory in delerium immediate/recent impaired
memory in dementia recent > remote impaired
thinking in delerium disorganized
thinking in dementia impoverished
perception in delerium illusions/hallucinations
perception in dementia usually normal
speech in delerium incoherent/hesitant/slow/rapid
speech in dementia word finding difficulty
sleep wake in delerium always disrupted
sleep wake in dementia often fragmented
illness/toxicity in delerium either or both present
illness/toxicity in dementia often absent
tertiary syphillis can cause __ dementia
prevalence of dementia over age 65 5-10% have some level of dementia
how is Alzheimer's diagnosed clinical diagnosis of exclusion. post-mort-neurofibrillary tangles, plaques
Alzheimer's generally presents in the __ decade of life 7-8th
mean survival associated with Alzheimer's 8-10 years
DSMIV TR criteria for dementia of the Alzheimer's type memory impairment and at least 1 of (aphasia, apraxia, agnosia, disturbance in executive function or occupational functioning) deficits do not occure exclusively during a delerium
__% of older adults in primary care settings suffer from depression 37
mild stage of Alzheimer's symptoms suble and often undetected, decline of short term memory
moderate stage of Alzheimer's language abilities and ability to think abstractly and exercise judgment impaired(personality changes), decline of visual and spatial skills
severe stage of Alzheimer's loss of long term memory, problems sleeping, weak, unable to walk or talk, incontinent, completely dependant on the caregiver
is emotional lability more common in primary degenerative dementia or vascular dementia vascular
are focal neuro signs/hx of stroke/TIA more common in primary degenerative dementia or vascular dementia vascular
is hypertension/hx more common in primary degenerative dementia or vascular dementia vascular
Vascular dementia occurs more in __ men
normal memory loss "forgetfulness" associated with aging, doesn't cause impairment, not progressive benign senescent forgetfulness
important aspects of patient history when evaluating dementia active medical problems, list drugs, cardiovascular and neurological, characterize the symptoms, assess the social situation, ask about special problems
who has the highest rate of suicide older white males
important aspects of PE when evaluating dementia BP,cardiovascular, neurologic, Folstein MMSE
mangagement of dementia cholinesterase inhibitors, treat underlying medical conditions, physical and mental activity, use memory aids, good nutrition, manage complications, provide ongoing care, patient and family education, social service info, family counseling
therapeutic effect of cholinesterase inhibitors best for mild-moderate dementia, shown to slow progression
therapeutic use of NMDA antagonist more for moderate-severe, shown to slow decline in function
is delerium preventable yes, provide humane care, adequate light, warmth, familiar staff
three important apsects of health assessment history, review of systems, physical exam
seven important history aspects continence, abuse, pain, cognition, relationship, sensory changes, compensation(covering, confabulation)
strategies for taking a history of elderly patient environment (quiet/private), communication, dates, verbal (lower, slower), nonverbal communication, validate and verify, "have we met before", the red pajama question
purpose of PE in elderly patients establish baseline, evaluate new S&S, monitor chronic illness
timed "get up and go" get out of chair, walk 10 feet, turn around, walk 10 feet sit down
timed get up and go of 10 seconds or less low risk of fall
timed get up and go of 11-19 seconds low to moderate of fall
timed get up and go of 20-29 seconds moderate to high of fall
timed get up and go of 30+ seconds high risk of fall
6 strategies of PE of elderly patient slow, prioritize, assess both sides non-tender, sensory function, minimize ups and downs, if not goin to do anything with the findings then don't do it
standardized tools for congnitive assessment MMSE, Clock drawing, fluency testing, parable interpretation, judgment, observation, concerns of others
3 components of functional assessment physical abilities, cognitive abilities, environmental fit
7 activities of daily living (ADL's) eating, bathing, grooming, dressing, walking, transferring, toileting
8 instrumental Activities of Daily Living (IADL's) ability to use the telephone, shopping, food prep, housekeeping, laundry, driving a car, medication management, money management
positive physical approach come from the front, go slow, get to the side, get low, offer you hand, call out the name, wait for response
choosing preventative measures should be guided by __ patients general condition
1/10 people diagnosed with AIDS in the US is older than __ 50
healthy elderly patient minimal or no chronic disease and are functionally independant, primary and secondayr prevention of disease and prevention of frailty are the most beneficial measures for this group. maintianing and preserving function
frail elderly patient severe chronic disease, functionally dependant, loss of physiologic reserve, frequently hospitalized and institutionalized. prevention of accidents and iatrogenic complications
11 primary preventative strategies for older adults influenza vacc, pneumococcal vacc, tetanus vacc, blood pressure, exercise, cholesterol, sodium, social support, environment, seat belts
10 secondary preventative strategies for older adults pap smear, breast exam, self breast exam, mammography, hypothyroidism, depression, vision, hearing, oral cavity, TB
4 tertiary prevention strategies for older adults assessment, foot care, dental care, toileting efforts
USPSTF screening recommendations for osteoporosis all women 65+
__% of women >50 have osteopenia 40
__ of women >50 have osteoporosis 7
what is a T score a measure (in SDs) below the young adult mean value for bone mineral density
WHO T-score for osteoporosis vs. National Osteoporosis Foundation 2.5 vs 2.0
12 risk factors for osteoporosis age, low body wt or BMI, not on ERT, white/asian, hx of fracture, family hx, low physical activity, smoking, excessive EtOH or caffeine, low calcium/vit D, medication use
prevention of osteoporosis calcium, vit D and weight-bearing excercise, consider women and men, drugss (fosamax)
leading cause of death for all age 65+ heart disease
wt loss for obese patients will reduce __ cardiovascular load and assist in management of DM and HTN
cholesterol lowering drug treatment __ years decrease risk of CHD by 30% in people with high total cholesterol or average colesterol and low HDL-C 5-7
all patients (regardless of lipid level shoud be counseled about dietary mods, regular physical activity, avoiding tobacco, maintaining a healthy wt
treatment of HTN in the elderly significantly reduces cardiac mortality, reduces rates of fatal and nonfatal endpoints for stroke, CHD, and CVD
JNC VII recommendations for HTN treatment wt reduction, physical activity and medical treatment
National Stroke Association recommendations for BP screening at every office visit and self monitor BP at home
most important preventable problem associated with treatment iatrogenesis-the more aggressive the treatment the greater the chance of an adverse effect (polypharmacy)
therapeutic window as the response to therapy decreases the susceptibility to toxic side effects increases, space between therapeutic dose and toxic dose narrows with age
risks associated with hospitalization medial errors, risks of bed rest, infection, delerium, sundowning, falls, dependancy, nursing home placement
disturbacne of consciousness in conjunction with reduced ability to focus, sustain or shift attention delerium
involuntary loss of urine on a regular basis urinary incontinence
__ million adults suffer with a form of urinary incontinence 12
4 consequences of urinary incontinence psychological, physical, social, economic
__ innervation maintains tone in the bladder floor somatic
6 requirments for continence bladder must be able to store urine, bladder must effectively empty, ability to use toilet, adequate cognitive ability, motivation, absence of environmental barriers to toilet
posterior urethral angle (90-100 degrees) is reduced secondary to birth, anterior vaginal surgery or prolapse of urogenital structures pelvic prolapse- may cause incontinence
reduction of what hormone may cause urinary incontinence in women estrogen
neurological causes of urinary incontinence suprasacral lesions, sacral spinal lesions, UMN lesions, dementia
anatomical changes of GU tract associated with aging bladder capacity reduced (by 40% in 90yo), residual urine increases, decreased bladder outlet/urethral resistance, increased laxity of pelvic structures secondary to decreased estrogen, increased size of prostate
does normal aging cause incontinence no
reversible causes of urinary incontinence (DIAPERS) delerium, infection, atrophic urethritis/vaginitis, pharmaceuticals, psychological, excessive urine output, restricted mobility, stool impaction
6 meds that may be associated with urinary incontinence diuretics, sedatives/antidepressants, narcotics, antihistamines, calcium channel blockers
4 categories of urinary incontinence stress, urge, overflow, functional
involuntary loss of urine concomitantly w/ increased intra-abdominal pressure sufficient to overcome urethral pressure w/o and associated bladder contraction. bladder neck descends below midportion of symphysis pubis. failure to store urine stress incontinence
4 causes of stress incontinence weak pelvic muscle, internal organ prolapse, urethral hypermobility, intrinsic sphincter deficiency
3 symptoms of stress incontinence loss of small amount of urine with a cough or sneeze, laughing or changing of position. no leakage when supine. sensation of heaviness in the pelvic region
6 treatments for stress incontinence topical estrogens (atrophic vaginitis), phenylpropanolamine (increased urethral resistance), kegel exercises, biofeedback, wt loss if obese, surgical interventions (sling procedure, anterior vaginal repair)
involuntary loss of urine preceded by the strong feeling of having to void but without sufficient warning. due to hyper reflexia or sphincter dysfunction. failure to store urine urge incontinence
4 symptoms of urge incontinence the need to void comes too quickly to reach the toilet. loss of large amount of urine. frequent voiding. loss of urine with the sound of water running or waiting to use the toilet
4 treatments of urge incontinence restrict fluids after 6:00pm, meds rather than surgery, blader relaxants (antispasmodics, anticholinergics). antibiotics/antiseptic meds
the continuous or persistant urine loss throughout the day due to chronic urinary retention-usually a small amount. failure to empty bladder overflow incontinence
4 causes of overflow incontinence anatomical obstruction (enlarged prostate, urethral strictures, cystocele, stool obstruction). a contractile bladder secondary to DM. Neurogenic bladder secondary to spinal cord injury or MS. anticholinergic meds
4 symptoms of overflow incontinence report of incomplete emptying of bladder. dribbling of urine. painful abdomen. unaware of urine loss.
treatment for overflow incontinence alpha blockers/reductase inhibitors. resection of prostate. balloon dilation of the urethra. crede maneuver. scheduled toileting. suprapubic catheterization. intermittent catheterization (keep bladder amount <400cc)
related to factors outside the urinary tract-an ability to toilet due to cognitive impairment or physical disabilities, psychological problems or environmental barriers functional incontinence
treatment of functional incontinence reschedule meds, decrease use of hypnotics/EtOH, avoid anticholinergics, provide easy access to toilet. easy to remove clothing, convenient toilets, bedside comode/urinal. scheduled toileting. prompt toileting
further assessment that may be indicated urinalysis, culture and sensitivities, PVR, cystometry
4 indications for indwelling catheter urinary retention causing symptomatic infections, renal dysfunction, persistent overflow incontinencecomfort care for terminally ill patientsshort term for pressure ulcers or skin wounds contaminated by urineinability to adequately turn/change pt
3 risks/problems w/ urinary catheters can cause chronic bacteriuria, bladder stones, bladder cancers.iatrogenic hypospadiasoverdistention of the bladder
Created by: bwyche