Aging Flashcards
Comprehensive Geriatric Assessment (CGA) consists of…
Physical health. Mental health Functional status Social functioning Environment
Benefits of CGA
Decreased nursing facility admission Decreased medication use Decreased mortality Decreased annual medical care costs Increase diagnostic accuracy Improved independence
marijuana withdrawal syndrome sx
Headaches Chills Irritability Anxiety Depression Shakiness Fever
Factors to look out for in the elderly
Social factors- Living arrangements
Nutrition- vulnerable to inadequate nutrition (loneliness, depression,medical disorders
Environmental- Identify SAFETY RISKS (home visit) – lighting, loose mats, kitchen storage
Sleep- spend less time in deep sleep
transition between sleep and waking up is often abrupt
Factors to look out for in the elderly cont
vision- Glare from lights at night- cataract
Eye pain– glaucoma, temporal arteritis
hearing- acoustic neuroma, wax,Paget’s disease,
GIT- hypothyroidism, dehydration,hypokalemia
Be Wary of Abuse and Neglect- Dominates interview, won’t leave, won’t let patient talk
Preparing for death- Instructions given by patients for their future treatment should they become incompetent to consent to, or refuse, such treatment
Laboratory tests done in Comprehensive Geriatric Assessment
Serum cholesterol
Blood glucose – glucose intolerance increases with aging
Heamoglobin
Vitamin b12-Rx IMI (beware of folate supplementation before correcting b12)
Thyroid function tests
In the 6 min walking test
One-time measure of functional status
Use it to guide recommendations for exercises,
Physical Therapy, adaptive devices for impairments,
driving.
Get up and go test
only valid for patients not using an assisted device
Get up and walk 3m, and return to chair
Preventive Interventions for healthy aging
Screening
Immunizations
counseling
Preventative measures towards healthy aging
Longer life
Reduced disability
Improved mental health
Lower health care costs
What would you screen for in elderly patients
Alcohol misuse Blood pressure Breast Cervical Colorectal Depression Osteoporosis
Malignancy screening
Pap smear
Mammography
For colorectal cancer, either colonoscopy every 10
years, an annual fecal occult blood test, or
sigmoidoscopy every 5 years
immunizations to be done in the elderly
influenza
pneumoccocal
zoster
theories of aging
programmed change theories- Developmental-genetic theories or telomore shortening
stochastic theories- Somatic Mutation and
Mitochondrial/Oxidation Theories
Stochastic theories
Damage to vital cell molecules from an accumulation of random events or from environmental agents or influences
skin changes in elderyly
Reduction in pappillary body in menopause, vascular loops decrease, collagen begins to interlace
Skin becomes drier, more wrinkled, stores more lipofuscin (yellow pigment)
Neural degeneration
Deposits of lipofuscin (oxidised lipids)
Retraction of dendrites – neurons die
Neurofibrillary tangles – twisted strands of insoluble TAU proteins
Fluid fills the spaces
Alzheimer’s disease
– increased stimulus-response time, – mild confusion – decrease in language skills – also learning ability and abstract thinking and reasonable judgement decrease
Genetics of inherited 3-5% of Alzheimers
Mutations in gene 21 (Downs’)- Codes for APP (amyloid precursor protein)
Mutations in genes 14 and 1- Code for presenilin 1&2
what does Estrogen increases in the brain
– choline acetyl transferase
– cholinergic neuron survival
– axonal sprouting
– dendrite spine formation
Endocrine disorders as a cause of mental illness in the aged
– Hyper/ Hypothyroidism - depression
– Addison’s - delirium
– Pheochromocytoma – panic attacks
– Diabetes mellitus – cognitive impairment and depression
– Hyperprolactinaemia – decreased libido and impotence
presbyopia
long-sightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age
presbyacusis
age related hearing loss
Progressive loss of hair cells on basilar membrane and loss of elasticity of tympanic and basilar membranes leads to (sometimes pronounced) hearing loss
Circulatory and Respiratory changes in old age
Circ- Systolic and diastolic blood pressure rise with age
Diminished response to beta-adrenergic stimulation
Diminished baroreceptor sensitivity
Diminished SA node automaticity
Resp- Diminished lung elasticity
Increased chest wall stiffness
GIT changes in old age
• Reduced saliva production, with swallowing difficulties
• Decreased hepatic function
• Decreased gastric acidity, with loss of intrinsic factor
secretion
• Reduced area of absorption in small intestines
• Decreased colonic motility
• Decreased rectal function – impaired defecation
Renal system changes in old age
• Sclerosis of glomerular vessels
• Thickening of glomerular basement membrane which leads to
1. Fall in renal plasma flow (50%)
2. Reduced GFR (50%)
3. Decreased capacity to compensate for disturbing
influences, i.e. to concentrate or dilute urine, to adapt to pH changes
Endocrine changes in old age
- Decreased thyroxine production and clearance
- ADH increases in the day but decreases at night – NB nocturia!!
- DHEA decreases a lot: replacement betters mood and muscle mass and strength (in men)
- Vitamin D absorption and activation decreases
- Cholecystokinin increases – satiating effect with aging
- Dynorphin (opioid peptide) and neuropeptide Y decline with aging - satiation
factors in incontinence
Bladder factors: underactive detrusor
detrusor/sphincter
Factors affecting our ability to cope with the bladder:
impaired mental function
mobility and dexterity problems
Urethral Factors: incompetent urethral closure
weakness of pelvic floor muscles
Risk factors for Stress Urinary incontinence
Increasing parity, probably related to obstetrical trauma
Increased intra-abdominal pressure- medical factor/environmental factors
Pelvic floor trauma and denervation injury- non-/obstetric trauma
Hormonal status and estrogen deficiency
Connective tissue disorders
drugs that cause Urinary incontinence
Sedative hypnotics Diuretics Anticholingeric agents (Antihistamines, Antispasmodics Andrenergic agents Calcium channel blockers
surgeries and dz that cause Urinary incontinence
Abdominoperineal resection
Radical hysterectomy
Polio (almost always recovers)
Lumbar disc disease
Meningomyelocele
Sexual changes in older women
↓ Vaginal lubrication
↓ elasticity of the vaginal walls
↑ Plateau phase
Sexual changes in older men
More time to get an erection Testicles may not elevate that high Longer time to orgasm and ejaculation Increase in the length of the refractory period Incr Plateau stage with age
Differences between female and male menopause
Female
Abrupt & Complete lost of ovarian function
Marked reduction in Estrogen and Progesterone
Peri- and postmenopausal women
Male
No abrupt or incomplete lost of testicular function
Gradual reduction in Testosterone
No peri- and postmenopausal men
Vaginismus
when the muscles of a woman’s vagina squeeze or spasm when something is entering it
Most frequent adverse drug reactions in
elderly persons
– Bleeding due to oral anticoagulants,
– Hypoglycaemia from diabetes treatment
– Gastric complications from NSAIDs
Elderly patients and drug sensitivity
less sensitve to- beta blockers
more sensitvive - warfarin , opioids and benzodiazepines
Water soluble drugs eg
atenolol propranolol hydrochlorothiazide lithium cimetidine
highly protein drugs eg
salicylates phenytoin warfarin, sulphonamides theophylline)
Drugs requiring phase I metabolism
TCA
antipsychotic drugs
diazepam
calcium channel blockers
Appropriate prescribing in the elderly requires
Formulating a therapeutic goal
Drugs should be initiated at low doses (50%)
Long acting agents should be avoided.
Drug regimens should be kept simple and reviewed frequently
5 eg of Drugs that should often be avoided for elderly patients
carisoprodoli chlorzoxazone cyclobenzaprine metaxalone methocarbamol (all are muscle relaxant)
Drugs that should ALWAYS be avoided for elderly
patients include barbiturates, flurazepam, meprobamate,
chlorpropamide, meperidine, pentazocine, trimethobenzamide, belladonna alkaloids, dicyclomine, hyoscyamine,
and propantheline
Cardiac glycosides
class of organic compounds that increase the output force of the heart and increase its rate of contractions by acting on the cellular sodium-potassium ATPase pump
potentially inappropriate drugs based on condition
heart failure- drugs containing Na
HT- pseudoephedrine, diet pills
gastric/duodenal ulcer- NSAIDS, aspirin
blood clotting disorder or anticoagulant Rx- NSAIDS, aspirin
bladder flowe obstruction- anticholinergics, H1 blockers
insomenia- decongestants
cognitive impairment- anticholinergics
chrionic constipation- anticholinergics
urinary incontinence Rx
Conservative treatment (lifestyle interventions and bladder retraining)
Physiotherapy
Drug therapy–Antimuscarimes, estrogens
Surgery- Anterior colporrhaphy, Colposuspension
Procidentia
the falling down of an organ from its normal anatomical position
Vaginal vault prolapse
a condition in which the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina
spinal stenosis
Back/buttock pain
Worse on walking downhill, improves on sitting/leaning forward.
Numbness/parasthesia
osteophyte
a bony projection associated with the degeneration of cartilage at joints
joints most commonly affected by osteoarthritis
neck, spine, fingers, thumbs, hips, knees, or toes
Heberden’s and Bouchard’s nodes
H- bony growths that develop on distal interphalangeal joints
B- hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints
Crystal Arthropathy
Gout-increased uric acid- Diuretic use (important risk factor in females)
Psuedogout- Calcium crystals deposition, Commonly affects Wrist/knee
patients with which types of cancers can develop and RA like picture
breast GI Lung ovarian lymphoproliferative
hypertrophic osteoarthropathy
Paraneoplastic manifestation that causes RA like sx
Acute/severe/burning bone pain
clubbing of the fingers and toes
periostitis of long bones
Rheumatoid arthritis-like syndrome
Paraneoplastic manifestation that causes RA like sx
explosive onset RF
asymmetric polyarthritis(lower limbs)
Poorly responsive to Rx (steroids, biologics, NSAIDs, DMARDs)
Lupus-like syndrome
Paraneoplastic manifestation that causes RA like sx
Poly- serositis
Raynaud’s phenomenon
antinuclear antibodies
Inflammatory myopathies
Paraneoplastic manifestation that causes RA like sx
Onset > 50
Dermatomyositis look for underlying malignancy
Paraneoplastic vasculitis
Paraneoplastic manifestation that causes RA like sx
chronic unexplained vasculitis
rapidly progressive digital gangrene
Cutaneous leukocytoclastic vasculitis-most frequent
Seen more so in lymphoproliferative disorders
Polymyalgia Rheumatica
Paraneoplastic manifestation that causes RA like sx
Discomfort/stiffness- shoulders and pelvic girdle Fatigue Weight loss anemia of chronic disease elevated erythrocyte sedimentation rate
atypical heart sx of elderly
dyspnoea diarrhoea fatigue N&V syncope confusion dizziness
cardiovascular effects on aging
decr B adrenergic and baroreceptor responsiveness
impaired sinus node fx
impaired endothelia
incr vascular and myocardial stiffness
morphological changes in heart
lipid, lipofucin and amyloid deposits
thicken and stiffening of aortic and mitral leaflets and pericardium
incr cardiac fat and fibrous connective tissue
tortuosity of coronary aa and incr in nr and size of collaterals brances
morphological changes in heart CONT
decr density of B1 receptors
reduction in sensitivity of catecholamines
