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TN Gériatrie > 2. Differential Diagnoses of Common Presentations > Flashcards

2. Differential Diagnoses of Common Presentations Flashcards

1
Q

Describe: Frailty (1)

A

clinically-recognizable state of decreased reserve in older adults with increased vulnerability to acute stressors resulting from functional decline across multiple physiologic systems

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2
Q

Describe: Functional decline

A

progressive limitation in the ability to carry out basic functional activities

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3
Q

The Clinical Frailty Scale is shown to predict what?

A

to predict death and need for institution

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4
Q

Describe: Clinical Frailty Scale (9)

A
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5
Q

Describe: Dementia Frailty Scale (3)

A

Degree of frailty corresponds to degree of dementia.

  • Mild Dementia
    • Common symptoms include forgetting details of recent event, though still remembering the event itself. Repeating the same question/story and social withdrawal.
  • Moderate Dementia
    • Recent memory is very impaired, although can remember past life events well. Can do personal care with prompting.
  • Severe Dementia: Cannot do personal care without help.
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6
Q

Describe: Physical Frailty (PF) Phenotype (Fried et al.) (5)

A

Frail = 3 or more criteria; at-risk or pre-frail = 1 or 2 criteria

  1. Shrinking: unintentional weight loss (baseline: >10 lbs or 5% total body weight lost in prior year)
  2. Weakness: grip strength in lowest 20% (by gender, BMI)
  3. Poor endurance: as indicated by self-report of exhaustion
  4. Slowness: walking time/15 feet in slowest 20% (by gender, height)
  5. Low activity: kcals/wk in lowest 20% (males: <383 kcals/wk, females: <270 kcals/wk)
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7
Q

Describe: Cumulative Deficit Approach (Rockwood et al.) (2)

A
  • balance between assets (e.g. health, attitudes, resources, caregiver) and deficits (e.g. illness, disability, dependence, caregiver burden) that determines whether a person can maintain independence in the community
  • Frailty Index = number of deficits present/number of deficits possible
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8
Q
A
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9
Q

Describe: Screening Tool for Frailty (5)

A

FRAIL

  • Fatigue: “Are you fatigued?”
  • Resistance: “By yourself and without aids, do you have any difficulty walking up 10 steps without resting?”
  • Ambulation: “By yourself and without aids, do you have any difficulty walking several hundred yards?”
  • Illnesses: more than five
  • Loss of weight: greater than five percent

Frailty: “Yes” to 3 or more questions

Pre-frailty: “Yes” to 1-2 questions

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10
Q

Name: Etiologies of Frailty (5)

A
  • Physiologic Changes with Aging
  • Immune System
  • Endocrine System
  • Dysregulated Stress Dysregulation of autonomic nervous system
  • Age related changes in renin-angiotensin system and mitochondria likely impact sarcopenia and inflammation
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11
Q

Describe mechanism of this etiology of frailty: Physiologic Changes with Aging (4)

A
  • Sarcopenia (age-related loss of skeletal muscle and strength)
  • decreased mass
  • increased stiffness of organs
  • decreased reserve capacity of systems
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12
Q

Describe mechanism of this etiology of frailty: Immune system (3)

A
  • Elevated levels of circulating interleukin-6, C-reactive protein, white blood cells, and monocytes associated with skeletal muscle decline
  • Elevated clotting markers (factor VIII, fibrinogen, D-dimer) upregulates clotting cascade
  • Chronic inflammation
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13
Q

Describe mechanism of this etiology of frailty: Endocrine system (4)

A

Decreased skeletal muscle mass via:

  • Decreased growth hormone and IGF-1
  • Increased cortisol levels
  • Decreased DHEA-S
  • Decreased 25 (OH) vitamin D
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14
Q

Describe: Comprehensive Geriatric Assessment (5)

A
  • includes:
    • Past Medical History, Medications, Allergies, Social History, Function, Physical Exam, and Geriatric Review of Systems (cognition, mood, sleep, pain, nutrition, falls, continence, vision/ hearing, skin, and safety)
  • interdisciplinary primary care
  • pharmaceutical care and medication optimization
  • management of geriatric syndromes (e.g. falls, cognitive impairment, incontinence)
  • caregiver support
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15
Q

Define: Delirium (2)

A
  • acute and potentially reversible disturbance in cognition, attention, or level of consciousness
  • screened using the Confusion Assessment Method: delirium likely if 1 + 2 and either 3 or 4 are present
    • 1: acute onset and fluctuating course
    • 2: inattention
    • 3: disorganized thinking
    • 4: altered level of consciousness
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16
Q

Name Differential Diagnosis of Delirum (3)

A

3Ds (dementia, delirium, depression) can present with overlapping cognitive changes

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17
Q

Describe work-up of delirium (4)

A

work-up is not universal, and depends on possible causes based on history and physical exam:

  • Drugs: medication review
  • Infection, Infarction, Inflammation: CBC, urinalysis, urine culture, blood culture, chest x-ray, ECG/ troponin
  • Metabolic: basic and extended electrolytes, Vit B12, TSH, LFT, toxicology screen
  • Structural: neurologic exam, CT head
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18
Q

Describe: Delirium Prevention in Elderly (6)

A
  • ensure optimal vision and hearing to support orientation (e.g. appropriate eyewear and hearing aids)
  • provide adequate nutrition and hydration (up in chair to eat and drink whenever feasible)
  • encourage regular mobilization to build and maintain strength, balance, and endurance
  • avoid unnecessary medications and monitor for drug interactions
  • avoid bladder catheterization
  • ensure adequate sleep at night and wakefulness during the day
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19
Q

Describe use of antipsychotics for treatment of delirium (1)

A

There is no evidence that antipsychotics shorten the course of delirium, reduce mortality risks, or improve quality of life in hospitalized patients

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20
Q

Describe: Dementia

  • Onset
  • Duration
  • Natural History
  • Level of Consciousness
  • Attention
  • Orientation
  • Behaviour
  • Psychomotor
  • Sleep-Wake Cycle
  • Mood and Affect
  • Cognition
  • Memory Loss
A
  • Onset: Gradual or step-wise decline
  • Duration: Months to years
  • Natural History: Progressive, usually irreversible
  • Level of Consciousness: Normal
  • Attention: Intact initially
  • Orientation: Intact initially
  • Behaviour: Disinhibition, loss of ADL/ IADLs, personality change
  • Psychomotor: Normal
  • Sleep-Wake Cycle:
  • Mood and Affect: Fragmented sleep at night
  • Cognition: Labile but not usually anxious
  • Memory Loss: Decreased executive function, paucity of thought
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21
Q

Describe: Delirum

  • Onset
  • Duration
  • Natural History
  • Level of Consciousness
  • Attention
  • Orientation
  • Behaviour
  • Psychomotor
  • Sleep-Wake Cycle
  • Mood and Affect
  • Cognition
  • Memory Loss
A
  • Onset: Acute (hours to days)
  • Duration: Days to weeks
  • Natural History:
    • Fluctuating, reversible
    • High mobidity/mortality in very old
  • Level of Consciousness: Fluctuating
  • Attention: Impaired, difficulty concentrating
  • Orientation: Impaired, fluctuates
  • Behaviour: Severe agitation/retardation
  • Psychomotor: Fluctuates between extremes
  • Sleep-Wake Cycle: Reversed sleep-wake cycle
  • Mood and Affect: Anxious, irritable, fluctuating
  • Cognition: Fluctuation preceded by mood changes
  • Memory Loss: Marked short-term
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22
Q

Describe: Depression

  • Onset
  • Duration
  • Natural History
  • Level of Consciousness
  • Attention
  • Orientation
  • Behaviour
  • Psychomotor
  • Sleep-Wake Cycle
  • Mood and Affect
  • Cognition
  • Memory Loss
A
  • Onset: Subacute (weeks to months)
  • Duration: Variable
  • Natural History: Recurrent, usually reversible
  • Level of Consciousness: Normal
  • Attention: -
  • Orientation: Intact
  • Behaviour: Importuning, self-harm/ suicide
  • Psychomotor: Slowing
  • Sleep-Wake Cycle: Early morning awakening
  • Mood and Affect: Depressed, stable
  • Cognition: Concentration impaired
  • Memory Loss: Short-term
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23
Q

Define: Falls (2)

A
  • an event resulting in a person coming to rest inadvertently on a lower level
  • other than as a consequence of sudden paralysis, epileptic seizure, or overwhelming external force
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24
Q

Describe epidemiology: Falls (5)

A
  • 30-40% of people >65 yr old and ~50% of people >80 yr old fall each year
  • equally common between men and women, but more likely to result in injury in women and death in men
  • falls are the leading cause of death from injury in persons ≥65 yr
  • 25% associated with serious injuries (e.g. hip fracture, head injury, bruises, laceration)
  • between 25-75% do not recover to previous level of ADL function after injurious falls
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25
Q

Name etiologies of falls (3)

A
  • intrinsic factors
  • extrinsic factors
  • situational factors
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26
Q

Name etiologies of falls: Intrinsic factors (3)

A
  • age-related changes and diseases associated with aging:
    • musculoskeletal (arthritis, muscle weakness)
    • sensory (visual, proprioceptive, vestibular)
    • cognitive (depression, dementia, delirium, anxiety)
    • cardiovascular (CAD, arrhythmia, MI, low BP)
    • neurologic (stroke, decreased LOC, gait disturbances/ataxia)
    • metabolic (glucose, electrolytes)
  • orthostatic/syncopal
  • acute illness, exacerbation of chronic illness
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27
Q

Name etiologies of falls: Extrinsic factors (2)

A
  • environmental (e.g. home layout, slippery surfaces, overcrowding, new environments)
  • side effects of medications, polypharmacy (>4 medications), and substance abuse (e.g. alcohol)
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28
Q

Name etiologies of falls: Situational factors (2)

A
  • activities (e.g. rushing to the toilet, walking while distracted)
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29
Q

Describe history: Falls (7)

A
  • previous falls and/or gait instability
  • inquire about intrinsic, extrinsic and situational factors
  • associated symptoms
  • loss of consciousness
  • medication and alcohol use
  • change in medications
  • have a witness present if possible for interview
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30
Q

Describe physical exam: Falls (8)

A
  • orthostatic blood pressure
  • cardiac
  • visual acuity
  • examination of feet and footwear
  • Performance-Oriented Assessment of Mobility
  • Timed Up-and-Go Test
  • musculoskeletal
  • neurologic
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31
Q

Describe investigations: Falls (3)

A
  • comprehensive geriatric assessment to identify all potential causes
  • CBC, electrolytes, BUN, creatinine, glucose, Ca2+, TSH, B12, urinalysis, cardiac enzymes, ECG, CT head (as directed by history and physical), coagulation profile
  • bone densitometry (DEXA) for osteoporosis screening in all women and men >65 yr old
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32
Q

Describe interventions: Falls (8)

A
  • multidisciplinary, multifactorial, health, and environmental risk factor assessment and intervention programs in the community
  • muscle strengthening, balance retraining (e.g. Tai Chi), and group exercise programs
  • home hazard assessment and modification (e.g. remove loose rugs and tripping hazards, add shower bars and stair railing, improve lighting)
  • prescription of vitamin D 1000 IU daily if vitamin D stores are low
  • tapering or gradual discontinuation of psychotropic medication
  • postural hypotension, heart rate, and rhythm abnormalities management
  • eyesight (cataract surgery) and footwear optimization
  • compression socks if venous stasis edema
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33
Q

Name: Key Clinical History Findings in Falls Evaluation (6)

A

SPLATT

  • Symptoms
  • Previous falls
  • Location of falls
  • Activity at the time of fall
  • Time of fall
  • Trauma
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34
Q

Describe: Impact of Medication Classes on Falls Risk in Geriatrics (Odds Ratios) ()

A
  • Antidepressants (1.68)
  • Neuroleptics/Antipsychotics (1.59)
  • Benzodiazepines (1.57)
  • Sedatives/ Hypnotics (1.47)
  • Antihypertensive agents (1.24)
  • NSAIDs (1.21)
  • Diuretics (1.07)
  • Φ1-blockers (1.01)
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35
Q

Define: Malnutrition (3)

A
  • no uniformly accepted definition of malnutrition in older adults. Some commonly used definitions include the following:
    • involuntary weight loss (community: ≥2% over 1 mo, >10 lbs over 6 mo, or ≥4% over 1 yr; nursing home: ≥5% over 1 mo, ≥10% over 180 d)
    • hypoalbuminemia (community: ≤38 g/L; hospital: ≤35 g/L), hypocholesterolemia (<4.1 mmol/L)
    • other features include: insufficient energy intake, loss of muscle mass, fluid accumulation (e.g. edema), loss of subcutaneous fat, decreased hand-grip function
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36
Q

Describe etiology: Malnutrition (6)

A

nutritional

  • decreased assimilation: impaired transit, maldigestion, malabsorption
  • decreased intake: financial, psychiatric (depression), cognitive deficits, anorexia associated with chronic disease, functional deficits (e.g. difficulty shopping, preparing meals or feeding oneself due to functional impairment)
  • stress: acute or chronic illness/infection, chronic inflammation, abdominal pain
  • mechanical: dental problems, dysphagia
  • age-related changes: appetite dysregulation, decreased thirst
  • mixed: increased energy demands (e.g. hyperthyroidism), abnormal metabolism, protein-losing enteropathy
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37
Q

Describe history: Malnutrition (7)

A
  • weight loss in 6 mo prior to examination
  • recent or chronic illness
  • constitutional symptoms (e.g. recent weight loss)
  • dietary intake in relation to usual pattern
  • depression, GI symptoms (anorexia, nausea, vomiting, diarrhea)
  • functional disability: impaired ADLs and IADLs
  • social factors: economic barriers, dental problems, and living situation (e.g. living alone)
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38
Q

Describe physical exam: Malnutrition (5)

A
  • BMI <23.5 in males, <22 in females should raise concern
  • muscle wasting, temporal wasting, presence of triceps skin fold
  • loss of subcutaneous fat
  • ankle or sacral edema, ascites
  • assess cognition
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39
Q

Describe investigations: Malnutrition (2)

A
  • CBC, electrolytes, Ca2+/albumin, Mg2+, PO43–, creatinine, LFTs (INR, bilirubin), B12, folate, TSH, lipid profile
  • if indicated by assessment, can consider urinalysis, ESR, CXR
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40
Q

Describe tx: Malnutrition (3)

A
  • direct treatment at underlying causes
  • dietary modification: high calorie foods, oral nutritional supplementation: patient specific meal replacement products (e.g. Ensure™, Glucerna™, Nepro™), vitamins/minerals (e.g. B12, calcium, vitamin D)
  • referral: speech language pathologist, nutritionist
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41
Q

Name: Etiology of Malnutrition in the Elderly (13)

A

MEALS ON WHEELS

  • Medications
  • Emotional problems
  • Anorexia
  • Late-life paranoia
  • Swallowing disorders
  • Oral problems
  • Nosocomial infections
  • Wandering/dementia related activity
  • Hyperthyroid/Hypercalcemia/ Hypoadrenalism
  • Enteric disorders
  • Eating problems
  • Low-salt/Low-fat diet
  • Stones
42
Q

Define: Constipation (5)

A

Rome IV Diagnostic Criteria:

  • straining
  • hard stools
  • sensation of incomplete evacuation
  • use of digital maneuvers, and/or sensation of anorectal obstruction/blockage with 25% of bowel movements and <3 bowel movements per wk.
  • The criteria must be fulfilled for the last 3 mo with symptom onset ≥ 6 mo prior to diagnosis
43
Q

Describe epidemiology: Constipation (2)

A
  • chronic constipation increases with age (up to 1/3 of patients >65 yr experience constipation and 1/2 of patients >80 yr)
  • in the elderly, chronic constipation may present as fecal impaction
44
Q

Describe pathophysiology: Constipation (2)

A
  • impaired rectal sensation (increased rectal distention required to stimulate the urge to defecate)
  • colorectal dysmotility
45
Q

Describe tx: Constipation (5)

A
  • non-pharmacological
    • increase fibre intake (note: bulking agents, e.g. psyllium, Metamucil, may worsen constipation)
    • ensure adequate fluid intake
    • increase physical activity
  • pharmacological
    • discourage chronic laxative use
    • review medication regime, reduce dosages or substitute
46
Q

Name: Common Causes of Constipation in the Geriatric Population include (6)

A
  • Primary impaired colonic and anorectal function
  • Drugs
  • Diet (dehydration, low fibre “tea and toast” diet)
  • Colo-anorectal disorders (cancer, masses, stenosis, strictures)
  • Neurologic (stroke, dementia, Parkinson’s, autonomic neuropathy)
  • Psychiatric (depression, anxiety)
47
Q

Name: Drugs Associated with Constipation (7)

A
  • OTC (antihistamines, NSAIDs)
  • Opioids
  • Psychotropic (antipsychotics, TCAs)
  • Anticholinergics
  • Calcium channel blockers
  • Diuretics
  • Supplements (iron or calcium)
48
Q

Describe: Treatment algorithm for the management of chronic constipation in the elderly (Figure)

A
49
Q

Define: Fecal incontinence (3)

A
  • involuntary or inappropriate passing of feces that impacts social functioning or hygiene
  • severity can range from unintentional flatus to the complete evacuation of bowel contents
  • there are three subtypes:
    1. passive incontinence: involuntary discharge of stool or gas without awareness
    2. urge incontinence: discharge of fecal matter in spite of active attempts to retain bowel contents
    3. fecal seepage: leakage of stool following otherwise normal evacuation
50
Q

Describe epidemiology: Fecal incontinence (3)

A

the incidence of fecal incontinence differs by setting:

  • community (17-36%)
  • hospital (16%)
  • nursing home (33-65%)
51
Q

Name risk factors: Fecal incontinence (7)

A
  • constipation
  • age >80 yr
  • female sex
  • urinary incontinence
  • impaired mobility
  • dementia
  • neurologic disease
52
Q

Name etiologies: Fecal incontinence (8)

A
  • physiological changes with age >80 yr (e.g. decreased external sphincter strength, decreased resting tone of internal sphincter, weakened anal squeeze, increased rectal compliance, and impaired anal sensation)
  • trauma (e.g. vaginal delivery, pudendal nerve damage, cauda equina)
  • iatrogenic
    • surgical (e.g. anorectal surgery, lateral internal sphincterotomy, hemorrhoidectomy, colorectal resection)
    • radiation (e.g. pelvic radiation)
  • neurogenic (e.g. neuropathy, stroke, MS, diabetic neuropathy)
  • anorectal/colorectal diseases (e.g. rectal prolapse, hemorrhoids, IBD, rectocele, cancer)
  • medication (e.g. laxative, anticholinergics, antidepressants, caffeine, muscle relaxants)
  • cognitive (e.g. dementia, willful soiling with psychosis)
  • constipation/fecal impaction
53
Q

Describe investigations (if cause not apparent from history and physical): Fecal incontinence (5)

A
  • differentiate true incontinence from frequency and urgency (e.g. IBS, IBD)
  • stool studies
  • endorectal ultrasound
  • colonoscopy, sigmoidoscopy, anoscopy
  • anorectal manometry/functional testing
54
Q
A
55
Q

Describe management of fecal incontinence: physiological changes with age (6)

A
  • medication management (anti-motility agents (e.g. loperamide)
  • diet/ bulking agents for loose stool)
  • increase fluid intake
  • biofeedback
  • retraining of pelvic floor muscles
  • surgery
56
Q

Describe management of fecal incontinence: trauma (1)

A
  • direct surgical repair or augmentation of the sphincters
57
Q

Describe management of fecal incontinence: iatrogenic (2)

A
  • surgical repair
  • artificial sphincters
58
Q

Describe management of fecal incontinence: neurogenic (5)

A
  • medication management
  • abdominal massage
  • digital stimulation for dysfunction
  • biofeedback and behavioural training
  • prevent autonomic dysreflexia in spinal injury
59
Q

Describe management of fecal incontinence: anorectal/colorectal diseases (2)

A
  • treat underlying cause (optimize IBD medications)
  • surgical (e.g. mass removal, prolapse repair, hemorrhoid removal, colostomy)
60
Q

Describe management of fecal incontinence: medication-related causes (2)

A
  • stop laxatives, lower dose or discontinue any other offending agents
  • cognitive: regular defecation program in patients with dementia, psychiatric consult (optimize medications and cognitive function)
61
Q

Describe management of fecal incontinence: constipation/fecal impaction (4)

A
  • disimpaction
  • prevent impaction
  • enema
  • or rectal irrigation
62
Q

Name Transient Causes of Fecal Incontinence (6)

A

DIAPERS

  • Delirium
  • Infection
  • Atrophic urethritis/vaginitis
  • Pharmaceuticals
  • Excessive urine output
  • Restricted mobility
  • Stool impaction
63
Q

Define: Urinary incontinence (2)

A
  • complaint of any involuntary loss of urine
  • there are 4 subtypes:
    • stress incontinence
    • urge incontinence
    • overflow incontinence
    • functional incontinence
64
Q

Define: Stress incontinence (1)

A

leakage associated with physical strain

65
Q

Define: Urge incontinence (1)

A

leakage associated with strong urge to urinate

66
Q

Define: overflow incontinence (1)

A

leakage associated with poor bladder emptying

67
Q

Define: functional incontinence (1)

A

leakage due to illness or disability not related to the urinary tract

##

68
Q

Describe epidemiology: Urinary incontinence (3)

A
  • 15-30% prevalence dwelling in community and at least 50% of institutionalized seniors
  • morbidity: cellulitis, pressure ulcers, urinary tract infections, falls with fractures, sleep deprivation, social withdrawal, depression, sexual dysfunction
  • not associated with increased mortality
69
Q

Name risk factors: Urinary incontinence (8)

A
  • impaired mobility
  • falls
  • medications
  • depression
  • TIA/stroke
  • dementia
  • CHF
  • obesity
70
Q

Name etiologies: Urinary incontinence (8)

A
  • physiologic changes with age: decreased bladder capacity
  • genitourinary diseases (e.g. cystitis, urethritis, benign prostatic hyperplasia)
  • neurogenic (e.g. cauda equina syndrome, stroke, MS)
  • iatrogenic: prostate surgery
  • trauma: pelvic trauma, traumatic spinal cord injury
  • drugs (e.g. alcohol, loop diuretics, sedative hypnotics, GABAergic agents)
  • cognitive (e.g. dementia, depression)
  • functional impairment (e.g. arthritis, poor vision)
71
Q

Describe investigations: Urinary incontinence (1)

A
  • urinalysis and culture
72
Q

Describe management: Urinary incontinence (6)

A
  • lifestyle modification: avoid excessive fluid intake and alcohol
  • pharmacologic: β-adrenergic agonists to reduce involuntary bladder contractions
  • physiologic changes with age:
    • pelvic muscle exercises
    • bladder training
    • biofeedback
  • genitourinary diseases: treat underlying cause (empiric antimicrobial treatment for cystitis, α blockers/5-α reductase inhibitors for benign prostatic hyperplasia)
  • functional impairment: incontinence pads, environmental modification, personal assistance
  • cognitive: referral to incontinence program if needed
73
Q

Name complications of immobility (7)

A
  • cardiovascular: orthostatic hypotension, venous thrombosis, embolism
  • respiratory: decreased ventilation, atelectasis, pneumonia
  • gastrointestinal: anorexia, constipation, incontinence, dehydration, malnutrition
  • genitourinary: infection, urinary retention, bladder calculi, incontinence
  • musculoskeletal: atrophy, contractures, bone loss
  • skin: pressure ulcers
  • psychological: sensory deprivation, delirium, depression
74
Q

Define: Pressure Ulcers (1)

A
  • any lesion caused by unrelieved pressure resulting in damage of underlying tissue; usually develops over bony prominences
75
Q

Name risk factors: Pressure Ulcers (12)

A
  • extrinsic:
    • friction
    • pressure
    • shear force
  • intrinsic:
    • immobility
    • malnutrition
    • moisture
    • sensory loss
  • geriatric:
    • age-related skin changes
    • bed-bound
    • cognitive impairment
    • chronic illness
    • use of anti-hypertensive medications
76
Q

Describe pressure Ulcers: Stage 1 (2)

A
  • Changes include skin temperature, tissue consistency or sensation
  • An area of persistent erythema in lightly pigmented, intact skin; in darker skin, it may appear red, blue or purple
77
Q

Describe pressure Ulcers: Stage 2 (2)

A
  • Partial thickness skin loss involving the epidermis, dermis or both
  • The ulcer is superficial and presents as an abrasion, blister or shallow crater
78
Q

Describe pressure Ulcers: Stage 3 (2)

A
  • Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia
  • Presents as a deep crater with or without undermining of adjacent tissue
79
Q

Describe pressure Ulcers: Stage 4 (2)

A
  • Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
  • May have associated undermining and/or sinus tracts
80
Q

Describe prevention: Pressure Ulcers (3)

A
  • pressure reduction
    • frequent repositioning
    • pressure-reducing devices (static, dynamic)
  • maintaining nutrition, encouraging mobility and managing incontinence
  • use validated pressure injury risk assessment tools on admission for those identified to be at risk for skin breakdown (Canadian Association of Wound Care, 2018)
81
Q

Describe tx: Pressure Ulcers (11)

A
  • optimize nutritional status
  • minimize pressure on wound
  • analgesia
  • all ulcers with necrosis warrant debridement (mechanical, enzymatic and autolytic are non-urgent forms of debridement, whereas sharp debridement is performed urgently due to risk for sepsis or cellulitis)
  • dressing application (exudate absorbing, barrier products to reduce friction)
  • maintain moist wound environment to enable re-epithelialization
  • treatment of wound infections (topical gentamicin, silver sulfadiazine, mupirocin)
  • diabetic foot ulcers: offloading with removable cast walker (e.g. aircast boot), orthopedic shoes and orthotics
  • swab wounds not demonstrating clinical improvement for C&S; biopsy chronic wounds to rule out malignancy
  • referral to Wound Care
  • consider other treatment options
    • negative pressure wound therapy/vacuum-assisted closure
    • biological agents: application of fibroblast growth factor, platelet-derived growth factor to wound
    • non-contact normothermic wound therapy
    • electrotherapy
82
Q

Name different hazards of hospitalization (12)

A
  • Malnutrition
  • Urinary Incontinence
  • Depression
  • Adverse Drug Event
  • Confusion/Delirium
  • Pressure Ulcers
  • Infection
  • Falls
  • Hypotension/Dehydration
  • Diminished Aerobic Capacity/ Loss of Muscle Strength/ Contractures
  • Decreased Respiratory Function
  • Functional Decline
83
Q

Describe recommendations for this hazard of hospitalization: Malnutrition (4)

A
  • No dietary restrictions (except diabetes)
  • assistance
  • dentures if necessary
  • sitting in a chair to eat
84
Q

Describe recommendations for this hazard of hospitalization: Urinary Incontinence (3)

A
  • Medication review
  • remove environmental barriers
  • discontinue use of catheter
85
Q

Describe recommendations for this hazard of hospitalization: Depression (1)

A

Routine screening

86
Q

Describe recommendations for this hazard of hospitalization: Adverse Drug Event (1)

A

Medication review

87
Q

Describe recommendations for this hazard of hospitalization: Confusion/Delirium (7)

A
  • Orientation
  • visual and hearing aids
  • volume repletion
  • noise reduction
  • early mobilization
  • medication review
  • remove restraints
88
Q

Describe recommendations for this hazard of hospitalization: Pressure Ulcers (3)

A
  • Low-resistance mattress
  • daily inspection
  • repositioning every 2 h
89
Q

Describe recommendations for this hazard of hospitalization: Infection (4)

A
  • Early mobilization
  • remove unnecessary IV lines
  • catheters
  • NG tubes
90
Q

Describe recommendations for this hazard of hospitalization: Falls (5)

A
  • Appropriate footwear
  • assistive devices
  • early mobilization
  • remove restraints
  • medication review
91
Q

Describe recommendations for this hazard of hospitalization: Hypotension/Dehydration (1)

A

Early recognition and repletion (ideally oral rehydration, if possible)

92
Q

Describe recommendations for this hazard of hospitalization: Diminished Aerobic Capacity/ Loss of Muscle Strength/ Contractures (1)

A

Early mobilization

93
Q

Describe recommendations for this hazard of hospitalization: Decreased Respiratory Function (1)

A

Incentive spirometry, physiotherapy

94
Q

Describe recommendations for this hazard of hospitalization: Functional Decline (3)

A
  • Structured exercise
  • progressive resistance training
  • walking programs
95
Q

Define: Elder Abuse (2)

A
  • includes physical abuse, sexual abuse, emotional/psychological abuse, financial exploitation and neglect
  • elder abuse is a criminal offence under the Criminal Code of Canada and in most U.S. states
96
Q

Describe Epidemiology: Elder Abuse (3)

A
  • in Canada in 2013, almost 3000 seniors were victims of family violence. The perpetrators of family violence against seniors were identified to be their grown child (43% of cases) and their spouses (28% of the cases)
  • in older adults aged ≥60 yr, elder abuse is estimated to occur in 10% of patients
  • insufficient evidence to include/exclude screening in the Periodic Health Exam
97
Q

Name risk factors: Elder Abuse (7)

A
  • Situational Factors: Social
  • Victim Characteristics
    • ​Physical or emotional dependence on caregiver
    • Lack of close family ties
    • History of family violence
    • Dementia or recent deterioration in health
  • Perpetrator Characteristics
    • ​Related to victim
    • Dependency on older adult (e.g. financial dependency)
98
Q

Name the most common cause of sensorineural hearing loss

A

Presbycusis

99
Q

Define: Presbycusis (1)

A

sensorineural hearing loss associated with aging (starting in 5th and 6th decades)

100
Q

Name etiologies: Presbycusis (4)

A
  • hair cell degeneration
  • age-related degeneration of basilar membrane, possibly genetic etiology
  • cochlear neuron damage
  • ischemia of inner ear
101
Q

Describe clinical features: Presbycusis (4)

A
  • progressive, bilateral hearing loss initially at high frequencies, then middle frequencies
  • loss of discrimination of speech, especially with back ground noise present–patients describe people as mumbling
  • recruitment phenomenon: inability to tolerate loud sounds
  • tinnitus
102
Q

Describe tx: Presbycusis (2)

A
  • hearing aid if patient has difficulty functioning, hearing loss > 30-35 dB, and good speech discrimination
  • ± lip reading, auditory training, auditory aids (door bell and phone lights)

TN Gériatrie (6 decks)

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