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-there has been a decline in the percentage of older adults reporting functional limitations, from 49% in 1990 to 41% in 2010, even though up to   56% report at least one chronic condition.  
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obesity may increase future levels of disability, especially in   African American and Hispanic adults aged 60 to 69 years.  
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New paradigms also highlight the importance of shifting assessment to geriatric syndromes that fall outside traditional disease models but are strongly linked to   activities of daily living (ADLs).  
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Geriatric syndromes are present in almost 50% of older adults and include   cognitive impairment, falls, incontinence, low body mass index (BMI), dizziness, impaired vision and hearing—  
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In aging, decreased cutaneous vasoconstriction and sweat production can impair responses to   heat  
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declines in thirst may delay recovery from dehydration; and the physiologic drops in maximum cardiac output, left ventricular filling, and maximum heart rate may impair the response to   shock.  
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In Western societies, systolic blood pressure tends to   rise with aging.  
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The aorta and large arteries stiffen and become atherosclerotic. As the aorta becomes less distensible, a given stroke volume causes a greater rise in systolic blood pressure   systolic hypertension with a widened pulse pressure (PP) often ensue (systolic-diastolic >40)  
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In older adults, resting heart rate remains   unchanged  
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There are declines in the pacemaker cells of the sinoatrial node and the maximal heart rate   which affect the response to exercise and physiologic stress.  
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Rhythm changes=   syncope  
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There may be purple patches or macules, termed   actinic purpura  
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The pupils become smaller, making it more difficult to examine the ocular fundi. The pupils may also become slightly irregular but   should continue to respond to light and show the near reaction  
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Visual acuity remains fairly constant between ages 20 and 50 years. It diminishes gradually until   approximately 70 years and then more rapidly.  
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Near vision begins to blur noticeably for virtually everyone, the lens gradually loses elasticity, with progressive loss of accommodation and the ability to focus on nearby objects   Ensuing presbyopia usually becomes noticeable during the fifth decade.  
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When a person fails to hear the higher tones of words but still hears lower tones, words sound distorted and difficult to understand, especially in noisy environments   presbycusis, becomes increasingly evident, usually after age 50 years.  
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Cervical lymph nodes harder to feel but   submandibular are easier  
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There is a decrease in arterial pO2, but the   O2 saturation normally remains above 90%.  
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Lengthening and tortuosity of the aorta and its branches occasionally result in   kinking or buckling of the carotid artery low in the neck, especially on the right. The resulting pulsatile mass, occurring chiefly in women with hypertension, may be mistaken for a carotid aneurysm—a true dilatation of the artery.  
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A tortuous aorta occasionally raises the pressure in the   jugular veins on the left side of the neck by impairing their drainage within the thorax.  
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Myocardial contraction is less responsive to stimulation from   β-adrenergic catecholamines.  
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There is a modest drop in resting heart rate, but a significant drop in the   maximum heart rate during exercise. Although heart rate drops, stroke volume increases, so cardiac output is maintained.  
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Diastolic dysfunction arises from decreased   early diastolic filling and greater dependence on atrial contraction. There is increased myocardial stiffness, notably in the left ventricle, which also hypertrophies.  
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Risk of heart failure increases with loss of atrial contraction and onset of atrial fibrillation due to   decreased ventricular filling.  
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A physiologic third heart sound, commonly heard in children and young adults, may persist as late as age   40 years, especially in women.  
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After age 40 years, however, an S3 strongly suggests   heart failure from volume overload of the left ventricle in conditions like heart failure and valvular heart disease (e.g., mitral regurgitation).  
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a fourth heart sound is seldom heard in young adults other than well conditioned athletes. An S4 can often suggest   decreased ventricular compliance and impaired ventricular filling.  
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Middle-aged and older adults commonly have which type of murmur?   a systolic aortic murmur.  
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In most older adults, the process of fibrosis and calcification, known as aortic sclerosis, does not impede   blood flow. In some, the aortic valve leaflets become calcified and immobile= aortic stenosis and outflow obstruction.  
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A brisk carotid upstroke can help distinguish aortic sclerosis from aortic stenosis, which has a delayed carotid upstroke   but clinically distinguishing these conditions is difficult. Both carry increased risk for cardiovascular morbidity and mortality.  
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Calcification of the mitral valve annulus, or valve ring, impedes normal valve closure during   systole, causing the systolic murmur of mitral regurgitation- may become pathologic as V/O increases in the left ventricle.  
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The peripheral arteries tend to lengthen, become tortuous, and feel   harder and less resilient.  
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There is increased arterial stiffness and decreased endothelial function. The trophic changes of the skin, nails, and hair discussed earlier occur   independently, although they may accompany arterial disease.  
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Although arterial and venous disorders, especially atherosclerosis, are more common in older adults, these are   not normal changes of aging.  
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after age 70 years, the temporal arteries may develop giant cell, or temporal, arteritis, leading to   loss of vision in 15% of patients and headache and jaw claudication.  
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androgen dependent proliferation of prostate epithelial and stromal tissue BPH begins in   he third decade, continues to the seventh decade, then appears to plateau  
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Sarcopenia is the loss of lean body mass and strength with aging    strength training  
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Unlike parkinsonian tremors, benign tremors are   slightly faster and disappear at rest, and there is no associated muscle rigidity  
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Older adults frequently lose some or all vibration sense in the   feet and ankles (but not in the fingers or over the shins).  
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Less commonly, position sense   may diminish or disappear.  
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The gag reflex may be   decreased or absent.  
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Abdominal reflexes may   diminish or disappear.  
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Ankle reflexes may be   symmetrically decreased or absent, even when reinforced- knee reflexes are similarly affected d/t musculoskeletal changes in the feet, the plantar responses become less obvious and more difficult to interpret.  
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If there are associated abnormal neurologic findings, or if atrophy and reflex changes are asymmetric   search for an explanation other than aging.  
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Older patients having a myocardial infarction are less likely to report   chest pain; symptoms of atypical or no chest pain, shortness of breath, palpitations, syncope, and confusion are more common  
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Older patients with hyperthyroidism and hypothyroidism have   fewer s/s- 1/3 hyperthyroidism present with fatigue, weight loss, and tachycardia instead of classic heat intolerance, sweating, and hyperreflexia & atrial fibrillation.  
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Hyperthyroidism increases the risk of   osteoporosis, and, in affected women, the risk of hip and vertebral fractures increases X3  
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hypothyroidism is most commonly caused by   autoimmune thyroiditis (Hashimoto thyroiditis); fatigue, weakness, constipation, dry skin, and cold intolerance are often attributed to other conditions, medication side effects, or aging.  
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Geriatric syndromes are strongly linked to   functional decline. Examples include dizziness, as well as functional impairment, frailty, delirium, depression, cognitive impairment, falls, and urinary incontinence.  
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The ETHIC(S) mnemonic helps clinicians escape the pitfalls of   group-labeling by expanding individual history taking to include Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, and Spirituality.  
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drug–drug interactions- consult the   Beers criteria  
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Hospitalized older adults- risk factors for a/e meds   >4 comorbid conditions, Heart or renal failure, liver dz, ● ≥80 yo ● polypharmacy >8 ● warfarin, insulins, oral antiplatelet agents, oral hypoglycemic● hx drug rx● Hyperlipidemia ● inc WBC● antidiabetic agents ● LOS ≥  
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Geriatric syndrome   Frailty- wt loss, exhaustion, weakness, slowness, and low physical activity; broader definition includes mood, cognition, and incontinence.  
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Osteoporotic Fractures   wt loss > 5% over 3 years, inability to do five chair stands, self-reported exhaustion.  
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“Do you often feel sad or depressed?” has a sensitivity of   69% and specificity of 90%  
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“Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”   100% sensitive and 77% specific.  
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Dementia is “an acquired condition that is characterized by a decline in   at least two cognitive domains (loss of memory, attention, language, visuospatial or executive functioning) that is severe enough to affect social or occupational functioning.  
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Age-related Cognitive Decline ● This diagnosis is suggested by   mild forgetfulness, difficulty remembering names, mildly reduced concentration. ● S/s are sporadic and do not affect daily function.  
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Mild Cognitive Impairment (MCI) -Daily function is preserved, but modest cognitive decline in one or more cognitive domains   (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) Alertness and attention is preserved (unlike delirium). ● Other dementias are unlikely  
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Vascular dementia is suggested by   vascular risk factors or cerebrovascular disease causing cognitive impairment- decline in executive function, w/onset of cerebrovascular event, but consider this dementia -gait changes and focal findings.  
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Lewy body disease is suggested by evidence of   parkinsonism. Visual hallucinations, delusions, and gait d/o- EPS at times, fluctuating mental status, sensitivity to antipsychotic medications.  
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Frontotemporal lobar degeneration is suggested by   prominent behavioral or language disorders, impulsivity, aggression, and apathy, excessive eating and drinking-may occur before age 60 years.  
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10-Minute Geriatric Screener   3 important areas-cognitive, psychosocial, and physical function. It includes vision, hearing, and questions about urinary incontinence, an often hidden source of social isolation and distress.  
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To identify incontinence pneumonic■ DIAPERS:   Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart failure, Restricted mobility, and Stool impaction  
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To identify incontinence pneumonic ■ DDRRIIPP:   Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, Inflammation, Polyuria, and Psychogenic  
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Joint National Committee (JNC8) recommends blood pressure targets of   ≤150/90 but notes that if tx results in SBP <140 and is okay treatment does not need to be adjusted.  
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those aged 80 years and older, other experts cite studies showing that blood pressure targets of   140 -<150/70 - 80 appear optimal for notable reductions in stroke, cardiovascular events, and all-cause mortality  
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A red reflex is seen with   cataracts At +10 diopters, a cataract appears white  
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isolated systolic hypertension and a widened PP are cardiac risk factors, prompting a search for   left ventricular hypertrophy (LVH).  
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A tortuous atherosclerotic aorta can raise pressure in the   left jugular veins by impairing emptying into the right atrium, also kinking of carotid artery low in the neck on right, can be mistaken for a carotid aneurysm.  
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A sustained PMI is present in   LVH; a diffuse PMI and an S3 signal left ventricular dilatation from heart failure or cardiomyopathy.  
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An S4 often accompanies   hypertension.  
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A systolic crescendo–decrescendo murmur in the second right interspace suggests   aortic sclerosis or aortic stenosis= increased risk of cardiovascular disease and death  
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A harsh holosystolic murmur at the apex radiating to the axilla suggests   mitral regurgitation, the most common murmur in older adults.  
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Abdominal bruits are suspicious for   atherosclerotic vascular disease.  
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A widened aorta of ≥3 cm and pulsatile mass occur in   abdominal aortic aneurysm, especially in older male smokers.  
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Probable AD, based on DSM-5 criteria, consists of   evidence of a causative genetic mutation from family history or genetic testing, or the presence of cognitive decline in two or more cognitive domains, with all three features  
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AD features   (1) decline in memory/learning & @least one cognitive (2) steady progressive decline in cognition (3) no evidence of mixed etiology from other neurodegenerative, cerebrovascular, mental, or systemic disease.  
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Possible AD is diagnosed when the patient meets all three criteria by evidence from genetic testing or when family history is absent   Alertness and attention is preserved, Other dementias are unlikely AD  
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AD Memory difficulties may take the form of   repeating questions, losing objects, confusion when performing tasks (shopping). Later stages- impaired judgment, disorientation progressing to aphasia, apraxia, left–right confusion, dependence of IADLs. Psychosis and agitation  
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Carotid bruits can occur in   aortic stenosis. The presence of bruits from carotid stenosis increases risk of ipsilateral stroke.  
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A sustained PMI is present in   LVH; a diffuse PMI and an S3 signal left ventricular dilatation from heart failure or cardiomyopathy  
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An S4 often accompanies   hypertension.  
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A systolic crescendo–decrescendo murmur in the second right interspace suggests   aortic sclerosis or aortic stenosis- Both are associated with an increased risk of cardiovascular disease and death  
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A harsh holosystolic murmur at the apex radiating to the axilla suggests   mitral regurgitation, the most common murmur in older adults.  
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Benign masses include   condylomata, fibromas, leiomyomas, and sebaceous cysts. Bulges and Swellings of the Vulva, Vagina, and Urethra  
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Erythema with satellite lesions results from   Candida infection; erythema with ulceration or a necrotic center =vulvar carcinoma. Multifocal reddened lesions w/white scaling plaques occur in extramammary Paget disease, a form of intraepithelial adenocarcinoma.  
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The thin patchy atrophic white plaques of lichen sclerosus   may be precancerous  
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Estrogen-stimulated cervical mucus with ferning is seen in   use of hormone replacement therapy, endometrial hyperplasia, and estrogen-producing tumors.  
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Mobility of the cervix is restricted with   inflammation, malignancy, or surgical adhesion.  
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Enlarging uterine fibroids, or leiomyomas, can be normal or   malignant leiomyosarcoma; ovarian masses or enlargement are seen in ovarian cancer.  
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Rectal masses are found in   colorectal cancer.  
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Examples of age-related abnormalities include   unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, snout and grasp reflexes, ↓ toe vibratory sense.  
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several of the most common features of Parkinson disease   Tremor, Rigidity, Akinesia, and Postural instability, or TRAP- Also bradykinesia, the most characteristic clinical sign, micrographia, shuffling “freezing” gait, difficulty rising from a chair.  
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Memory impairment in delirium vs dementia   Immediate and recent memory impaired vs Recent memory and new learning especially impaired  
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Test- frailty   Characterized by age-related, lack of adaptive physiological capacity occurring by an age-identifiable illness- three elements: Weight loss of more than 5% over 3 years, Inability to do five chair stands, Self-reported exhaustion.  
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Palliative care   Takes into consideration well-being for both Patients & Families: Physical, Mental, Social, Spiritual  
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Dementia and cognition definition   Definition- “An acquired condition that is characterized by a decline in at least two cognitive domains & affects social or occupational functioning: Memory, Attention, Language, Visuospatial (Executive Function)  
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Influenza-Tri/Quadrivalent -Adults 50+   once a year  
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Pneumococcal- PVC 13-Adults 65+   at least 1x  
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Zoster Vaccine-Adults 60+   or younger if they have CVD, pulmonary disease, DM, immunosupressed, immunocompromised, caregivers, high dose steroids  
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Tdap-60 + /every   10 yrs  
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Breast CA-Mammography   Annually at age 40-75 ACOG  
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Cervical CA-PAP-   Over age 65 USPSTF & ACOG recommends against screening unless the pt has had a recent abnormal pap.  
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Colorectal CA-Colonscopy   Every q 10 years or sigmoidoscopy every 5 yrs w/FOBTs. Recommends against routine screening for those 76-85 due to poor net benefit. Do not screen if life expectancy is less than 10 yrs.  
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Prostate CA-PSA   USPSTF & AAFP-Against all use of the PSA citing harm>benefit.  
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Lung CA-   Low-Dose CT-USPSTF & AAFP recommend the use of LD CT for patients with a 30-pack/yr smoking hx or those who have quit within the past 15 years.  
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Skin CA-Whole-Body Skin Exam-   Both USPSTF & AAFP given no recommendation for routine screening.  
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PHQ2   2 questions- Question 1- Sensitivity 69% Specificity 90%- Combined-Sensitivity 100% and 77% Specificity  
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Dementia is an umbrella term for what?   Alzheimer’s, Vascular Dementia, Frontotemporal Dementia, Dementia with Lewy Bodies, Parkinson w/dementia, Dementia of Mixed Etiology  
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You’re more likely to get dementia if   1st degree relative has it  
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Mild cognitive impairment   decline in Memory, attention, Language, Visuospatial (Executive Function)- daily fx is okay  
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Alzheimer’s criteria   >2 Memory, Attention, Language, Visuospatial (Executive Function) plus ↓memory & learning,Steady, progressive ↓ in cognition w/o other cause or mixed etiology from another neurodegenerative , CV, mental, or systemic dz.  
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Dementia and sleep   lose night and day perception- sleep fragmented  
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MMSE s&s   Best-91% Sensitivity & 86% Specificity  
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Function   economic, environmental, cognitive, medical, affective, social support, spirituality  
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orthostatic B/P changes   <20 systolic or <10 diastolic?  
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Normal Aging Changes   Unequal pupil size, ↓arm swing, Spontaneous movements, ↑ leg rigidity, Gait abnormality, ↓ toe vibratory sense  
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10-Minute Geriatric Screener   Vision-Visual Acuity 20/60on Snellen, Hearing-Cannot hear Whisper voice either ear. Audiometry if done. Leg Mobility-Scored 9 seconds on Timed Get-Up & Go Test. Urinary Incontinence-no self wetted in 20/30 days.  
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