4 - Presentation Of Disease Flashcards
What is the most important element in making a diagnosis in the geriatric patient?
History
May be challenging to completely obtain
Barriers to eliciting a helpful hx
Cultural / language Education / life experiences Fear of loss of autonomy Fear of pain, financial costs Hearing and vision difficulties Depression and apathy Misunderstanding the significance of sxs
What might a caregiver or provider overlook when seeking a cause of sxs?
Reversible causes (medication use)
Name some examples of normal physiologic changes which may mask dz presentation
Masked hypoglycemia
Decreased tendency to sweat
Diminished HR response in stress
Infection - what normal response may be blunted in geri’s?
Blunted or absent fever
Fever in infection as it relates to mortality?
Fever = more favorable prognosis
Normo- or hypothermic = shittier prognosis
Is neck stiffness a reliable sign of meningitis in geri’s?
No, they’re necks are usually hurting and fucked up anyway
Possible Features of urosepsis
Delirium
Hypo- or normothermia
New-onset incontinence
Low WBC count
Why is pneumonia frequently missed in geri’s?
Afebrile in many cases
May have severe infx but not actually appear ill
Appendicitis in geri’s
Very high mortality 2/2 diminished immunocompetency / atypical presentation
What is the major cause of death 2/2 influenza?
Pneumonia
90% of influenza deaths occur in people over 65
Uncommon complications of influenza vaccine
Gullain-Barre
Anaphylaxis
Local reaction
Amantadine
Influenza A only
Inexpensive
No longer recommended for prophylaxis
Frequent GI and CNS SE’s
Oseltamivir
Tamiflu
Prophylaxis OR txt
Expensive but preferred for geri’s
Criteria for influenza “epidemic” in nursing home
3 or more pts with a fever to 101*F AND flu-like sxs within three days
Management of NH flu epidemic
Isolate the sick
Encourage staff to stay home if ill
Vaccinate any susceptible patients (who should already be vaccinated, anyway)
Consider anti-viral prophylaxis
TB
You already know it
A large percentage of geri’s admitted to NH’s are anergic to TB skin testing and at risk of developing primary infx
Sxs of CA
New weight loss
Increasing fatigue
Recent change in taste
Decreased appetite
HA
AMS
Spine pain (mets)
Pathologic fx (hypercalcemia 2/2 PTH-like hormone secreted by tumor)
Anemia
Dysphagia
Hematemesis
Melena
New-onset persistent ABD pain in women and/or postmenopausal bleeding
2nd MCC of death WW?
Stroke
Majority of strokes are which type?
Ischemic
Consequences of stroke?
90% have residual effects
30% are veggies
What is a significant contributor to loss of ADL’s and IADL’s?
Vision loss
Who is at increased risk for glaucoma?
Blacks
(+) FHx
Long-term ‘roids
Screen for macular degeneration with:
Amsler grid
Sxs of hypothyroid?
Dry skin
Alopecia
Diminished reflexes
Cold intolerance
Decreased max HR
Arthritic complaints
Which is more common - multinodular goiter or Graves dz?
Goiter
What drug may cause hyperthyroidism?
Amiodarone
Contains iodine and may cause iodine excess
What is apathetic hyperthyroidism?
Depressed, withdrawn, unanimated appearance
Txt for thyroid dz?
Start low, go slow
Levothyroxine - initial dose 12.5 - 25mcg/day
Thyroid dz presentation in geri’s vs. younger persons?
Physical signs may be different
Classic eye findings are less common
Tremor - may be a benign finding
Management of hyperthyroid in geri’s?
Usually radioactive iodine ablation and/or antithyroid drugs
How will MI present in geri?
More likely to present WITHOUT chest pain!
Asymptomatic myocardial ischemia is more frequently found on ECG
If you see conduction defects on geri’s ECG, you must worry about:
Onset of coronary artery dz
MC symptom of ACS in patient’s over 80 yrs?
SOB
What may be the presenting symptom in a geriatric patient after an MI?
Delirium
Delirium has a super-broad differential
What does a geri patient presenting to acute care with vague, atypical sxs have until ruled out?
Coronary ischemia / infarction
Do ECG
Get enzymes
RISK FACTORS SIMILAR TO YOUNGER PATIENTS
Is being old a contraindication to thrombolytics in the setting of ACS?
Nope
Minimal management for ACS (if not contraindicated)
ASA 81mg daily
ACEI
BB
Statin
Causes of CHF
Obstruction (valve dz)
Myocardial failure
Impaired filling
Volume overload
CHF is most commonly associated with:
Prolonged systolic HTN
Sxs of CHF include:
SOB DOE Weight gain Lower leg edema Fatigue S3 or S4 Coarse-wet inspiratory rales in the lower lung fields
NYHA CHF categories
I (Mild) - no limitation on physical activity
II (Mild) - slight limitation of physical activity
III (moderate) - marked limitation of physical activity
IV (severe) - unable to carry out any physical activity without discomfort
Preferred test for evaluation of LV function?
Echocardiography
Note: cardiac cath remains “Gold Standard” although not necessarily for elderly
Obstructive lesions of CHF may require:
Surgical intervention
Therapy for systolic CHF:
Afterload reduction: ACEI’s
Volume overload: diuretics
Digoxin: reduces frequency of CHF exacerbations
Beta-blockers should be prescribed unless contraindicated
What is the MC valvular disorder in the elderly?
Mitral regurgitation
Txt for mitral regurg:
Mild - nothing
Mod-severe - ACEI’s
Acute, severe MR w/ pulmonary edema = poor prognosis
Mitral stenosis is associated with:
Rheumatic fever
Sxs of mitral stenosis include:
New onset a-fib or CHF sxs
What medical prophylaxis will patients with persistent a-fib or a-fib with clot risks receive?
Warfarin
Txt for aortic insufficiency?
Control HTN
Txt dyslipidemias
In order to:
Decrease risk of aortic root aneurysms and aortic dissection
Is aortic stenosis common in geri’s?
Yup - affects 20% of people over 80yrs
Sxs of aortic stenosis
Exertional angina
Dizziness / syncope
Dyspnea
All patients with new-onset a-fib should get:
An echo
Also, r/o hyperthyroidism and electrolyte imbalance
Therapy for a-fib includes
Rate/rhythms control and thrombolytic therapy
Are frequent PVC’s in geri’s with NO underlying cardiac disease associate with increased mortality?
Nope - i guess it’s just a thing that happens as our hearts get older…. i’d still work it up, tho
Predisposing factors for PAD:
Age, sex, heredity
Smoking, high cholesterol, HTN, physical inactivity, obese, DM
The presence of PAD increased risk for:
Cardiac and cerebrovascular morbidity and mortality
Sxs of PAD:
Claudication
Non-healing lower extremity ulcers or gangrene
- Most or caused by microtrauma
- presence of PAD increases risk of pressure ulcers
Skin cool to touch, dry, shiny, alopecia
Diminished or absent pedal pulses
How to screen for PAD?
ABI
Txt of PAD:
Risk factor reduction
Exercise rehab
Daily ASA or clopidogrel (or cilostazol)
Percutaneous angioplasty
Surgery (bypass)
Sxs of chronic venous insufficiency
Edema, usually around the ankle and sparing the dorsum of the foot
Ache, heaviness, or tightness of the lower extremities
Varicosities
Skin warm, dry, bluish-red hue
Painless stasis ulcers
Dx of chronic venous insufficiency?
Clinical
Can utilize venous duplex ultrasonography, as well
Txt for chronic venous insufficiency
Compression stockings
Ulcer care
Weight loss
Exercise
Good foot and nail care
Avoid prolonged sitting or standing
Asthma
Under-dx’d and under-txt’d in geri’s
Why? Breathlessness often attributed to “old age”
Same therapy as in young people
What is the one-year mortality after a COPD exacerbation in persons over 65?
50% (yikes)
Txt for COPD patients with resting hypoxemia
O2
Pharm therapy for COPD in geri’s?
Same as young people EXCEPT: AVOID THEOPHYLLINE
Who to screen for Vitamin B-12 deficiency?
Any older adult who is frail, has characteristic changes in RBC and WBC with or without anemia, peripheral neuropathy, gait disorder, or unexplained neuropsychiatric sxs
Appendicitis in geri’s
High mortality rate
Bowel perf -> peritonitis and gangrene
Severe pain not likely unless appendix perfs
In some cases of geriatric appendicitis, your only sxs might be:
Low-grade fever an generalized abdominal pain
PUD in geri’s
Many cases present with bleeding and perforation
Classic evidence of perf such as sudden pain and rigidity may NOT occur
Acute cholecystitis in geri’s?
Half of them won’t have abdominal tenderness and peritoneal inflammation
They’ll often be afebrile with normal WBC’s, even with acute cholecystitis
Then at surgery, they’ll discover gangrene and per
PE findings for constipation
Vague, diffuse abdominal discomfort
Possibly palpable stool in LLQ
No findings consistent with acute abdomen
Rectal exam - hard stool in vault, guaiac negative
Meds that can cause constipation
Opioids
Antacids
CCB’s
Diuretics
Iron supplements
Anticholinergics
Management of constipation
Hydrate
Exercise
Take advantage of “morning gastrocolic reflex”
Increase dietary fiber
Stool softeners: colace
Laxatives: lactulose or sorbitol
Titrate to achieve a BM every day or every other day
Disimpaction / enemas may be required initially
Medication causes of acute renal failure?
Aminoglycosides
NSAIDs
ACEI’s
Hyperkalemia is a common complication
By age 80, what percentage of men have BPH?
About 80%
Ddx for BPH includes:
Cystitis
Bladder CA
Bladder stone
Prostate CA
What tests should be performed in men with possible BPH?
DRE
UA
Renal function tests
Txt for BPH
Alpha-1A blockers (tamsulosin, alfuzosin)
5-alpha reductase inhibitors (dutasteride, finasteride)
Surgery: TUIP, TURP, prostatectomy
Is urinary incontinence a normal event in the aging process?
Nope
Etiologies of urinary incontinence?
Prior pregnancy / childbirth
Pulmonary disease with cough
Obesity
UTI’s
Neurologic disorders (parkinson’s, DM)
Cognitive and functional impairments
Subtypes of urinary incontinence:
Total - pt loses urine in all positions at all times - could be associated with fistulas
Stress - increased abdominal pressure, pelvic floor laxity
Urge - overactive bladder
Overflow - 2/2 chronic retention (i.e. BPH or urethral strictures)
Transient urinary incontinence causes: DIAPPERS
Delirium Infection Atrophic vaginitis / urethritis Pharm Psych Excess fluid output (many factors) Restricted mobility Stool impaction
Findings in osteoarthritis include:
Thinning and fissuring of articular cartilage that occurs with aging, osteophytes and joint effusion may be present
Initial therapy for osteoarthritis includes:
APA (1g up to 4x daily)
May use NSAID but beware of increased risk for GI bleed
Txt for gout
Indomethacin is NOT well-tolerated in the elderly
Another NSAID or prednisone are alternative therapies
Giant cell arteritis
We already know this one, nothing new here. Txt with steroids.
Actinic keratosis
Precursor to squamous cell CA (SCC)
Face, lips, ears, forearms, dorsal aspect of the hands, lesions are scaly, rough, and adherent
2/2 excess sun exposure
Txt for actinic keratosis
Cryotherapy
Imiquimod or fluorouracil
Txt for basal or squamous cell CA:
Electrodesiccation and curettage, or excision
Malignant melanoma
Incidence and mortality continue to rise in elderly
Txt options are limited, highlighting need for increased patient education and prevention
Why couldnt the bicycle stand up on its own?
It was two tired
