Duke PA Everything Geriatric
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| those with more positive self perceptions of aging lived __ years longer than those with negative self perceptions of aging | 7.5
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| 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
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| by 2030 __ of the US population will be older than 65 | 1/5
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| 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
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| what is successful (healthy) aging | no debilitating disease/disability, active healthy life until death from "old age", no unwanted features "tooth loss"
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| 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
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| currently a 70 year old man can expect to live until age | 83
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| currently a 70 year old woman can expect to live until age __ | 85
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| despite the best genetic makeup and medical care, no one seems to live much beyond __ years | 125
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| challenges of geriatric care | normal aging vs pathology, diversity of population, multiple chronic diseases, polypharmacy, diagnosis vs functional status
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| depression in the elderly is the great __ | masquerader
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| never underestimate the morbid significance of __ | vision and hearing loss
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| care not __ | cure: support comfort, function, independance
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| look for __ in elderly patients, it is always present | udiagnosed disease
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| don't __ for mild conditions | overtreat
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| don't __ for serious conditions | undertreat
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| common diseases of the elderly | CAD, stroke, cancer, osteoporosis, arthritis, diabetes, depression
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| normal aging changes/disease progression (general) | increased fat, decreased total body water
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| obesity in the elderly __ | is a disease not a normal part of aging
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| consequence of increased fat and decreased body water in the elderly | drug effects-fat vs water soluble, increased risk for dehydration
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| how is cost of elder care funded | 57% public programs, 25% patient's families, 18% private insurers
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| 3 categories of aging | senescence, normal aging, successful aging
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| refers to the common complex of diseases/impairments that affect many older people, wide spectrum, as people age very differently | normal aging
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| three factors influencing longevity | heredity, lifestyle, exposure to environment
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| four predominant physiologic changes associated with normal aging | musculoskeletal, eyes, fat distribution, internal organ changes (cardiac output, renal function)
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| general change in total body water | declines 46-60%
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| change in muscle mass | 30% decrease
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| change in taste buds | 70% decrease
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| change in cardiac reserve | decreased CO
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| change in max heart rate | 195-155 bpm
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| change in lung vital capacity | 17% decrease
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| change in renal perfusion | reduced by 50%
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| change in cerebral blood flow | reduced by 20%
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| change in bone mineral content | reduced by 25-30% in women 10-15% in men
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| change in brain wt | reduced by 7%
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| change in amount of light reaching the retina | diminished by 70%
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| change in plasma glucocorticoid levels | no change
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| 3 body composition changes | decrease in lean body mass, increase in fat storage, decrease in total body water
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| body composition changes can affect | drug metabolism
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| 5 musculoskeletal changes | loss of bone mass, degenerative joint changes, loss of muscle mass, foot problems, decrease in stature
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| consequences of musculoskeletal changes | leads to fall risks/increasing daily pain
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| 10 common geriatric diseases at 65-74 | htn, diabetes, glaucoma, cataract, CAD, osteoarthritis, dermatoses, arrhythmias, lipid disorders, bronchitis
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| many older people tend to conceal __ and do not seek medical care until the problems become major | minor problems
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| you must not only treat the disease but you must maintain __ | function
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| assessment to identify and manage fixable problems | clinical assessment
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| assessment to maximize independence through human, mechanical, or environmental manipulations | functional assessment
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| a mental state marked by the mingling of ideas w/consequent disturbance of comprehension/understanding, and bewilderment | confusion
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| chronic organic brain syndrome | dementia
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| acute organic brain syndrome, acute confusional state, acute dementia | delerium
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| short term memory loss w/o delirium or dementia (Korsakov's psychosis) | amnestic syndrome
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| patient describes a state of "noisy restlessness" | delerium
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| acute or subacute alteration in mental status. disorder of attention, improvement or normalization of mental function after underlying condition treated | delerium
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| predisposing factors for delerium | decreased sensory function, sensory deprivation, sleep deprivation, immobilization, transfer to new environment, psychological disturbances, males, >3 new meds
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| 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
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| chronic deterioration of mental function sufficiently severe to interfere with daily living | dementia
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| onset of delerium | acute
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| onset of dementia | insidious
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| course of delerium | fluctuating
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| course of dementia | generally stable
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| duration of delerium | hours to weeks
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| duration of dementia | months to years
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| awareness in delerium | reduced
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| awareness in dementia | clear
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| attention in delerium | hypo/hyper alert
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| attention in dementia | usually normal
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| orientation in delerium | mistakes familiar/unfamiliar
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| memory in delerium | immediate/recent impaired
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| memory in dementia | recent > remote impaired
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| thinking in delerium | disorganized
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| thinking in dementia | impoverished
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| perception in delerium | illusions/hallucinations
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| perception in dementia | usually normal
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| speech in delerium | incoherent/hesitant/slow/rapid
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| speech in dementia | word finding difficulty
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| sleep wake in delerium | always disrupted
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| sleep wake in dementia | often fragmented
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| illness/toxicity in delerium | either or both present
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| illness/toxicity in dementia | often absent
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| tertiary syphillis can cause __ | dementia
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| prevalence of dementia over age 65 | 5-10% have some level of dementia
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| how is Alzheimer's diagnosed | clinical diagnosis of exclusion. post-mort-neurofibrillary tangles, plaques
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| Alzheimer's generally presents in the __ decade of life | 7-8th
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| mean survival associated with Alzheimer's | 8-10 years
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| 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
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| __% of older adults in primary care settings suffer from depression | 37
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| mild stage of Alzheimer's | symptoms suble and often undetected, decline of short term memory
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| moderate stage of Alzheimer's | language abilities and ability to think abstractly and exercise judgment impaired(personality changes), decline of visual and spatial skills
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| severe stage of Alzheimer's | loss of long term memory, problems sleeping, weak, unable to walk or talk, incontinent, completely dependant on the caregiver
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| is emotional lability more common in primary degenerative dementia or vascular dementia | vascular
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| are focal neuro signs/hx of stroke/TIA more common in primary degenerative dementia or vascular dementia | vascular
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| is hypertension/hx more common in primary degenerative dementia or vascular dementia | vascular
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| Vascular dementia occurs more in __ | men
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| normal memory loss "forgetfulness" associated with aging, doesn't cause impairment, not progressive | benign senescent forgetfulness
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| 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
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| who has the highest rate of suicide | older white males
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| important aspects of PE when evaluating dementia | BP,cardiovascular, neurologic, Folstein MMSE
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| 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
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| therapeutic effect of cholinesterase inhibitors | best for mild-moderate dementia, shown to slow progression
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| therapeutic use of NMDA antagonist | more for moderate-severe, shown to slow decline in function
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| is delerium preventable | yes, provide humane care, adequate light, warmth, familiar staff
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| three important apsects of health assessment | history, review of systems, physical exam
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| seven important history aspects | continence, abuse, pain, cognition, relationship, sensory changes, compensation(covering, confabulation)
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| 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
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| purpose of PE in elderly patients | establish baseline, evaluate new S&S, monitor chronic illness
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| timed "get up and go" | get out of chair, walk 10 feet, turn around, walk 10 feet sit down
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| timed get up and go of 10 seconds or less | low risk of fall
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| timed get up and go of 11-19 seconds | low to moderate of fall
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| timed get up and go of 20-29 seconds | moderate to high of fall
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| timed get up and go of 30+ seconds | high risk of fall
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| 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
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| standardized tools for congnitive assessment | MMSE, Clock drawing, fluency testing, parable interpretation, judgment, observation, concerns of others
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| 3 components of functional assessment | physical abilities, cognitive abilities, environmental fit
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| 7 activities of daily living (ADL's) | eating, bathing, grooming, dressing, walking, transferring, toileting
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| 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
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| 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
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| choosing preventative measures should be guided by __ | patients general condition
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| 1/10 people diagnosed with AIDS in the US is older than __ | 50
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| 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
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| frail elderly patient | severe chronic disease, functionally dependant, loss of physiologic reserve, frequently hospitalized and institutionalized. prevention of accidents and iatrogenic complications
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| 11 primary preventative strategies for older adults | influenza vacc, pneumococcal vacc, tetanus vacc, blood pressure, exercise, cholesterol, sodium, social support, environment, seat belts
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| 10 secondary preventative strategies for older adults | pap smear, breast exam, self breast exam, mammography, hypothyroidism, depression, vision, hearing, oral cavity, TB
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| 4 tertiary prevention strategies for older adults | assessment, foot care, dental care, toileting efforts
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| USPSTF screening recommendations for osteoporosis | all women 65+
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| __% of women >50 have osteopenia | 40
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| __ of women >50 have osteoporosis | 7
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| what is a T score | a measure (in SDs) below the young adult mean value for bone mineral density
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| WHO T-score for osteoporosis vs. National Osteoporosis Foundation | 2.5 vs 2.0
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| 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
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| prevention of osteoporosis | calcium, vit D and weight-bearing excercise, consider women and men, drugss (fosamax)
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| leading cause of death for all age 65+ | heart disease
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| wt loss for obese patients will reduce __ | cardiovascular load and assist in management of DM and HTN
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| 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
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| all patients (regardless of lipid level shoud be counseled about | dietary mods, regular physical activity, avoiding tobacco, maintaining a healthy wt
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| treatment of HTN in the elderly significantly reduces | cardiac mortality, reduces rates of fatal and nonfatal endpoints for stroke, CHD, and CVD
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| JNC VII recommendations for HTN treatment | wt reduction, physical activity and medical treatment
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| National Stroke Association recommendations for BP screening | at every office visit and self monitor BP at home
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| most important preventable problem associated with treatment | iatrogenesis-the more aggressive the treatment the greater the chance of an adverse effect (polypharmacy)
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| 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
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| risks associated with hospitalization | medial errors, risks of bed rest, infection, delerium, sundowning, falls, dependancy, nursing home placement
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| disturbacne of consciousness in conjunction with reduced ability to focus, sustain or shift attention | delerium
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| involuntary loss of urine on a regular basis | urinary incontinence
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| __ million adults suffer with a form of urinary incontinence | 12
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| 4 consequences of urinary incontinence | psychological, physical, social, economic
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| __ innervation maintains tone in the bladder floor | somatic
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| 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
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| posterior urethral angle (90-100 degrees) is reduced secondary to birth, anterior vaginal surgery or prolapse of urogenital structures | pelvic prolapse- may cause incontinence
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| reduction of what hormone may cause urinary incontinence in women | estrogen
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| neurological causes of urinary incontinence | suprasacral lesions, sacral spinal lesions, UMN lesions, dementia
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| 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
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| does normal aging cause incontinence | no
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| reversible causes of urinary incontinence (DIAPERS) | delerium, infection, atrophic urethritis/vaginitis, pharmaceuticals, psychological, excessive urine output, restricted mobility, stool impaction
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| 6 meds that may be associated with urinary incontinence | diuretics, sedatives/antidepressants, narcotics, antihistamines, calcium channel blockers
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| 4 categories of urinary incontinence | stress, urge, overflow, functional
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| 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
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| 4 causes of stress incontinence | weak pelvic muscle, internal organ prolapse, urethral hypermobility, intrinsic sphincter deficiency
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| 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
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| 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)
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| 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
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| 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
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| 4 treatments of urge incontinence | restrict fluids after 6:00pm, meds rather than surgery, blader relaxants (antispasmodics, anticholinergics). antibiotics/antiseptic meds
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| the continuous or persistant urine loss throughout the day due to chronic urinary retention-usually a small amount. failure to empty bladder | overflow incontinence
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| 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
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| 4 symptoms of overflow incontinence | report of incomplete emptying of bladder. dribbling of urine. painful abdomen. unaware of urine loss.
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| 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)
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| 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
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| 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
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| further assessment that may be indicated | urinalysis, culture and sensitivities, PVR, cystometry
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| 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
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| 3 risks/problems w/ urinary catheters | can cause chronic bacteriuria, bladder stones, bladder cancers.iatrogenic hypospadiasoverdistention of the bladder
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