Geriatrics: Midterm
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| What is a hallmark of normal aging? | Poorer adaption to external stress than they once had
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| T/F: Elderly have decreased sensitivity to narcotics | False, increased sensitivity
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| T/F: Elderly have a decreased GFR | True
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| T/F: Elderly have increased incidence of thyroid disease? | True
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| Central focus of Geriatric Assessment | Functional abilities
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| 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
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| T/F: May not have pain w/ MIs and will have normal resting pulse and CO that does not increase w/ exercise | True
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| What happens to renal function as we age? | GFR and blood flow decrease, but creatinine may be normal since there is less production
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| What happens to blood sugars as we age? | Normal fasting blood sugar, but inability to handle glucose load
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| 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)
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| Other that SBP, what else increases with age (Hint: reproductive system)? | Prostate tissue!
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| 3 other things that increase in the elderly body | 1) lens size of the eye 2) cerumen in the ears 3) Fibrosis of thyroid
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| 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)
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| 4 elements of Comprehensive Geriatric Assessment | 1) Physical 2) Psychological 3) Socio-economic 4) Function
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| Why does cognitive impairment and depression go overlooked? | Providers mistake them for being normal signs of aging
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| 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
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| ADL or IADL required to maintain independent living? What does the other measure? | IADL (Instrumental Activities of Daily Living. ADL measures basic self-care
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| 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.
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| T/F: Therapeutic window decreases as toxic response and age increase | True
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| 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!
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| Abnormal presentation of diabetes in elderly | May not see the classic "polys" (polyuria, polydipsia, polyphagia)
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| Goal of chronic disease mamagement (2) | 1) Prevent catastrophes 2) Palliative care
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| Probably the most important preventable problem for Geriatrics: | Iatrogenesis
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| T/F: Leading causes of death mirror the actual causes of death, which are modifiable | True
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| 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)
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| How often is diabetes screening recommended for those over 45 yo? | Every 3 years
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| T/F: Statin therapy is not recommended for those over 70 yo | False, Recommended for those INCLUDING over 70 yo
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| When is abdominal aortic aneurysm screening recommended and for who? | Men 65-75 yo who have EVER smoked
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| What lifestyle preventions are recommended for elderly? (6) | 1) Diet 2) Tobacco 3) Exercise 4) Cognitive Activity 5) Social Activity 6) Napping
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| Which screening test for elderly aren't necessary? BMI, BP, Lipids, Glucose, TSH, Cancer, Depression, Dementia, Cognition, Vision, Hearing | Dementia
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| How often should a high-functioning elderly women over 75 get a mammogram? Over 50? | Every 2 years
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| When do you stop PSAs for men? | >75 yo
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| When can you stop pap smears for women w/ history of normal pap smears and are at low risk? | >70 yo
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| What 3 tests are not routinely recommended for elderly? | 1) Asymptomatic bacteriuria 2) TSH 3) Hemochromatosis
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| When can elderly stop getting colonoscopys? | >85 yo
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| Confusion in an older adult? | Impaired cognitive function
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| Acute disorder associated w/ acute illness, drugs, environment | Delirium
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| Slowly progressive impairment of cognitive function | Dementia
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| Dementia or Delirium? Changing levels | Delirum
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| Dementia or Delirium? Hallucinations | Delirium
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| Dementia or Delirium? No acute illness | Dementia
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| Dementia or Delirium? No change in attention span | Dementia
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| Dementia, depression, renal insufficiency, Hx alcohol abuse, Hx of age, male | Predisposing factors of delirium
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| Medications, immobilization, restraints, dehydration, alcohol withdrawal, pain, emotional stress, sleep deprivation | Precipitating factors of delirium
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| T/F: Can have a high vulnerability with a less noxious insult or a low vulnerability with a noxious insult | True
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| 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)
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| What is the CAM? | Confusion Assessment Method
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| Gradual progressing course w/ no disturbance of consciousness | Dementia
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| 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
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| Dementia or Delirium? Difficulty learning/retaining, handling complex tasks, reasoning, spatial ability, language, behavior | Dementia
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| DSM-IV for Dementia | Memory impairment w/ 1 or more of the following Aphasia, Apraxia, Agnosia, Executive functiong
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| Most common cause of dementia, progressive cognitive/behavioral deficits. Sx: memory loss, confusion, impairment. Biggest risk factor? | Alzheimers; age
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| Neuropathology of Alzheimers | amyloid plaques and neurofibrillary tangles
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| Step-wise decline of dementia | Vascular/Multi-Infarct
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| Early decline in social interpersonal conduct and language skills, later to lose memory Sx, early impairment. | Frontotemporal Dementia
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| Fluctuating cognitive Sx, recurrrent hallucinations, syncope, visuospatial/construtional impairment on cognitive testing | Dementia w/ Lewy Bodys
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| Management of Dementia | Optimize function, ID/manage behavior, ongoing care, patient/family education. Therapy, regular appointments, avoid drugs that worsen cognitive function, treat comorbidities
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| 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)
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| Family Hx, previous Hx, medical illness, memory loss, losses, social isolation, neurotransmission changes | Factors predisposing to depression
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| Depression accounts for 25% of what? What are risk factors for it? | suicides; male, white protestant, divorced/widowed, blue collar, alcoholism
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| 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
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| What distinguishes presentation in older folks? | Somatic complaints (poor health, constipation etc), and impairment of memory/cognitive functions
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| CP, SOB, bowel/bladder issues, HA, memory disturbances, fatigue, weakness, anorexia, wt loss, anxiety, apathy | All physical Sx that can represent depression
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| Anti-hypertensives, narcotics, anti-parkinson meds, cardiac mdes, hypoglycemics, sedatives, anti-psychotics, alcohol, chemo | Meds that can all contribute to depression
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| Malignancy, COPD, CHF, MI, infections, incontinence, dehydration | all illnesses that can be associated with depressive Sx
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| Depressive syndrome w/in 2-3 months of a death? Some differences w/depression | Bereavement; preoccupation w/ worthlessness, prolonged functional impairment
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| CAGE questionnaire | Cut down? Annoy you? Guilty? Eye-opener?
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| SBIRT | Screening, Brief Intervention Referral to Treatment
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| Can cause and present as anxiety or depression | Insomnia
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| Chronic pain, GERD, nocturia, dyspnea | Conditions interfering w/ sleep
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| 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
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| Management of Depression (4); potential side effects? | CBT or Cognitive Behavior Therapy, medications (SSRIs [hyponatremia, SIADH, HTN), exercise, ECT
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| What is a anti-depressant that helps with urinary incontinence and chronic pain? | Cymbalta (duloxetine)
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| What anti-depressant can cause wt gain? | Mirtazapine (Remeron is trade name)
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| Prevalence of urinary incontinence | 1/3 women and higher in nursing homes, 15% in men
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| coordinated balance between cortex and the spinal cord sympathetic and parasympathetic systems | Structural components of normal micturition
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| YTI/ atrophic vaginitis/urethritis, stool impaction, increased urine production, impaired mobility | All contribute to incontinence
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| DRIP. What is this used for? | Delirium, Restricted mobility, Infection, Polyuria; potentially reversible conditions leading to incontinence
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| Diuretics, TCAs, anti-cholinergics, anti-psychotics, narcotics, alpha blockers, alpha agonists | Meds contributing to incontinence
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| Pelvic floor laxity, associated w/ cough/obesity. Small amounts lost. | Stress incontinence
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| Detrusor hyperactivity=involuntary bladder contractions. Larger volumes | Urge incontinence
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| Anatomic or neurogenic obstruction (like BPH), small amounts of urine. Post-void residual. | Overflow incontinence
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| What is mixed incontinence | elements of urge and stress incontinence
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| Evaluation of incontinence | lab studies, renal ultrasound
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| How do you treat asymptomatic bacteriuria? | Usually don't because screening is not recommended!
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| Main management of incontinence | Modifcations of fluid, caffeine, meds, pelvic muscle exercises, scheduled toileting
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| Tx of stress incontinence | kegals, wt loss, alpha agonists (increase sphincter control)
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| Tx of urge incontinence | kegals, bladder training, bladder relaxants
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| Tx of overflow incontinence | surgical removal of obstruction
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| Meds for BPH | 5-alpha reductase inhibitor (finasteride/Proscar), alpha blockers (tamsulosin/Flomax)
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| Laxative overuse, dementia, stroke, spinal cord disease, colorectal disorders | causes of fecal incontinence
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| immobility, colorectal disorders/tumor, depression, drugs, diabetic autonomic neuropathy | causes of constipation
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| 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
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| Prolonged bed rest, hypovolemia, impaired venous return, post-prandial | causes of hypotension (orthostatic)
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| Throw rugs, frayed carpets, wires, pets | common environmental hazards that contribute to falls
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| 2 huge factors associated w/ falls at nursing home residents | 1) recent admission (new environment) 2) polypharmacy
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| Circumstances surrounding the fall, premonitory or associated Sx, LOC | Hx of falls
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| 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
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| Key aspect of dizziness history | Distinguish between vertigo and lightheadedness
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| sensation of movement/spinning; usually vestibular origin; may be cervical origin | Vertigo
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| 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
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| 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
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| 2% to 8% of older patients with dizziness Triad of recurrent episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss | Meniere's Disease
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| 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
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| benign tumor of Cranial N 8; tinnitus, unilateral sensorineural hearing loss, feeling unsteady (CT scan shows) | Acoustic Neuroma
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| 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
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| 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
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| Test for gait and falling | Get Up and Go Test
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| Management of elderly patients with instability or falls | Assess and treat injury, treat underlying conditions, prevent falls, provide PT and education, alter the environment
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| Management of dizziness; what should be avoided? | anti-histimines and benzodiazepines (avoid scopolamine, and anti-cholinergic, due to side effects in elderly), diuretics, PT
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| MSK disorders, neuro disorders, CV/Pulmonary disorders | Causes of Immobility
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| Pressure ulcers, MSK contractures, CV deconditioning, psychological | Some complications of immobility
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| Wt loss, PT, strength training, heat/ice, acupuncture, exercise, NSAIDs, joint replacement | management of arthritis
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| Management of bicipital tendonitis, olecranon and trochanteric bursitis | PT, steroid injection
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| T/F: 5-8x increased risk for mortality in first year after hip fracture | True :(
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| Management of Parkinson's Disease | Meds (increasing dopamine level), surgery, exercise/PT
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| 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
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| 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
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| Persistent erythema of intact skin; often over bony prominence; may be red/blue/purple in dark skin (persistent, unblanchable redness | Stage 1
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| Full-thickness skin ulcer extending through subcutaneous fat. This may extend down to but not through the underlying fascia. May have undermining | Stage 3
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| 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
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| Partial-thickness skin loss involving epidermis, dermis, or both. Superficial ulcer that presents as an abrasion or blister | Stage 2
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| ID those at risk, skin care (clean and dry), nutrition, decrease pressure and friction, avoid bedrest and sedation | Prevention of pressure ulcers
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| 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
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| ____ in older persons is commonly underdiagnosed and undertreated despite the availability of many assessment tools and effective therapies | Pain
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| First line for pain in elderly | Acetaminophen
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| Neuropathic pain Tx; also how does it feel? | TCAs, anti-convulsants, opioids. Tingling, burning, shocklike pain
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| Chronic pain Tx (4) | TCAs, SSRIs/SNRIs, corticosteroids, anticonvulsants
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| Leading cause of death worldwide, most common cause for hospitalization | Cardiovascular disease
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| 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)
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| T/F: 67% of people >60 yo hypertensive | True!
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| Eval of HTN | BP in both arms, wt, funduscopic exam, abdominal bruit, lab tests (U/A, electrolytes, Ca, TSH, ECG, GFR)
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| T/F: people over 85 should not be treated for HTN | False, Relatively healthy older persons at any age should be treated
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| What should you start with with stage 1 HTN? | Lifestyle modifications!!!
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| Firstline DOC in elderly for HTN? | Low-dose thiazide diuretic
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| Firstline DOC if you needed renal protection, have DM or CHF in HTN | ACEI
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| Choice of drug post-MI in HTN or w/ heart failure, CAD, tachyarrhythmias, or essential tremor. Avoid w/ bradycardia | BBs
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| Low cost, effective in systolic HTN | Thiazide diuretics
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| Angioedema and cough, less effective in AAs, but good for LV systolic dysfucntion and CHF. Can cause hyperkalemia. HTN | ACEI
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| Use if ACEI cough is too much, superior to BBs for HTN and LVH | ARBs
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| Good second line therapy, in addition to thiazide diuretic for HTN | CCBs (calcium channel blockers)
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| Useful in males w/ BPH, but can cause orthostatic/postural hypotension | Alpha blockers
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| Most common type of stroke? | Ischemic!
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| Most fatal type of stroke? | Hemorrhagic!
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| Tx for ischemic stroke, chronic? | tPA w/in 3- 4.5 hours of onset of ischemic. Chronic: control HTN, lipids, glucose, arrhythmias, platelets
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| Principles of Stroke Rehabilitation | Initiation of rehab early is advised. Most neurological return occurs during 1st month while little occurs beyond 3rd month.
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| Acute phase of stroke rehab | avoid complications like pressure sores, contractures, phlebitis, PE, fecal impaction by changing position every 2 hours
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| Later phase of stroke rehab | ADL training, ambulation training, muscle reeducation exercises
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| Coronary Artery Disease (CAD): RF, Tx | HTN major RF; Tx: nitroglycerin, ASA, BBs
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| What procedures associated w/ CAD carry higher risk in elderly? (3) | Interventional therapy, CABG, percutaneous procedures
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| What presenting Sx are different in the elderly w/ a MI? (4) | Confusion/delirium, rapid deterioration of health, dizziness/syncope, anxiety
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| Prevalence of valvular heart disease in elderly? | common, especially >75 yo; Degenerative changes and lipid deposition
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| Fatigue, syncope, CP, SOV, CHF, crescendo-decrescendo systolic murmur radiating to supraclavicular area. Dx? | Aortic stenosis; Dx: Echo
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| Arrhythmias especially blocks, AFib, stroke, CHF, endocarditis, apical holo-systolic murmur radiating to axilla. Dx? | Calcified mitral annulus with mitral regurgitation; Dx: Echo
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| 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.
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| Tx of Sick Sinus Syndrome | Medical therapy ineffective; Pacemaker may be required to alleviate Sx, especially if anti-arrythmics are ineffective or intolerable
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| 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
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| Tx of systolic CHF (poor EF) (5) | Diuretics, ACEI/ARB, BBs, Aldosterone blockers, digoxin
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| Tx of diastolic CHF (preserved EF) | focuses on treating HTN and volume status; Diuretics for edema/congestion
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| 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)
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| Tx of PAD/PV(ascular)D | RF modification (smoking cessation, lowering lipids, controlling HTN and DM, exercise etc.), Foot care, Anti-platelet therapy, Revas
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