Bariatrics and Geriatrics Flashcards
Obesity is a modifiable morbidity and mortality risk factor only second to smoking
Risk Factors for developing obesity
- sedentary lifestyle
- High glycemic diet
- Environmental and lifestyle factors: smoking cessation, stress, history of abuse
- Medications that increase appetite or food cravings
- Genetic or familial predisposiiton
- Underlying illness (e.g. hypothyroidism, polycystic ovary syndrome, Cushing’s syndrome, Prader-Willi syndrome)
Anatomic Physiologic Changes with Obesity – Cardiac
Cardiomyopathy (e.g. heart failure)
Abnormal ventricular remodeling (e.g. hypertrophy)
Atrial fibrillation
Dysrhythmias
Anatomic Physiologic Changes with Obesity – Pulmonary
Asthma
Obstructive sleep apnea
Hypoventilation syndrome
Anatomic Physiologic Changes with Obesity – Kidneys
Decreased renal perfusion
Anatomic Physiologic Changes with Obesity – Genitourinary
Urinary incontinence
Infertility
Anatomic Physiologic Changes with Obesity – Integumentary
Infection
Hyperkeratosis
Acanthosis nigricans
Anatomic Physiologic Changes with Obesity – Vascular
Increased total blood volume
Altered stroke volume and cardiac output
Hypertension
Venous insufficiency
Varicosities
Anatomic Physiologic Changes with Obesity – Muscuoloskeletal
Osteoarthritis
Altered mobility patterns
Anatomic Physiologic Changes with Obesity – Adipose tissue
Increased production of adipokines (e.g. leptin, interleukin-6, angiotensinogen)
Anatomic Physiologic Changes with Obesity – Liver
Non-alcoholic fatty liver disease (NAFLD)
Non-alcoholic steatohepatitis
Anatomic Physiologic Changes with Obesity – Pancreas
Insulin resistance
DM 2
BMI
- Body Mass Index - estimates individuals body fat percentage and weight related health risks based on using height and weight.
- Limitation - very muscular may be labeled as obese when they are not
<18.5 = underweight
18.5-24.9 = desirable weight
25-29 = overweight
> 30 = obese
Peripheral fat distribution
- pear shape (gluteofemoral obesity) more common in women….associated with lower relative risk factor than central obesity
- Central fat distribution (apple shape or abdominal obesity) higher correlated with significant risk factors such as CVD and DM2.
Waist Circumference
Better measure predictors of DM and cardiovascular risks than BMI
> 40 inches – males
36 inches – females
considered to be indicative of central obesity.
Waist to hip ratio has also been found to show positive correlation to obesity related risk of death and disease.
Bariatric Interventions - Medical Management
- physician monitoring for access for education or program referral which may assist in weight loss goals
- if not wanting to loose weight – physician then is more focused on medial management of the co-morbidities
Bariatric Interventions - Behavioral Therapy
- some degree of psychological influence leads to obesity so addressing these can help improve long-term outcomes
- Behavioral therapy individualized or support – stimulus control, goal setting and problem solving, social support, and/or strategies to improve self monitoring of dietary intake and physical activity
- Pts hoping to undergo bariatric surgery are requires typically to participate in some form of behavioral counseling prior to sx.
Bariatric Interventions - Increased Activity
- Increased activity levels essential for long term management
- increased activity for first 6 months of weight loss journey shown to significantly impact weight reduction.
- Pt education and support to reduce frustration
- Advised to begin increasing activity level with gentle modes such as walking or swimming
- Target 30 mins daily (divided as needed)
Bariatric Interventions - Dietary Modification
- 500-1000 kcal/day reduction in dietary intake — 1-2 pound weight loss per week
- Reduction in carbs and overall calories are equally important (than just restricting fat)
Bariatric Interventions - Pharmacology
- Appetite suppressants - reduce feeling of hunger or increase feelings of fullness
- Lipase inhibitors – decrease body’s ability to absorb dietary fats.
Bariatric Interventions - Bariatric Surgery
- pre-operatively pts must meet number of requirements to be surgical candidate
- BMI >40 (or 35 with other co-morbidities
- evidence that other weight loss interventions have been largely unsuccessful
- Most common restrictive procedure is the least invasive (Laparoscopic gastric banding (lap band)
- low risk of complications
- can be adjusted or removed as needed
- however the risk of both post-operative and long-term complications is high
Which of the following would a therapist have to be the most concerned about when treating a patient with anorexia nervosa?
muscle weakness
vital sign instability
fatigue
poor posture
vital sign instability
Although all options are things that a therapist should be monitoring during physical therapy sessions, vital sign instability is of the highest concern. This can include orthostatic hypotension, irregular pulse, bradycardia, and hypothermia which can lead to cardiac arrest. Profound heart abnormalities have been observed during exercise with this population that can result in sudden death.
When treating a patient with bulimia nervosa, what would be most important for a therapist to discern?
previous exercise experience
how often the patient binges and purges
use of vomit-inducing agents
presence of body dysmorphia
use of vomit-inducing agents
It would be most important to discern if the patient with bulimia nervosa has used vomit-inducing agents, especially ipecac, and how often. Repeated use of ipecac can cause toxic levels in the body that produce myopathy. Myopathy presents with arm or leg weakness or can directly affect the heart.
Female athlete triad
describe the interrelationship of energy availability, menstrual function, and bone density. The disordered eating behavior leads to a low body fat percentage which then leads to amenorrhea. Amenorrhea affects hormone levels in the body which affects bone mineral density.
Abnormal lipid droplets in nonfat cells such as the heart, pancreas, liver, and skeletal muscle is known as:
ectopic fat
Ectopic fat is common with obesity. With obesity, fat cells become insulin-resistant and lose the ability to store calories. As a result, fat is stored in the skeletal muscles and organs as ectopic fat. This can result in skeletal muscle cell death which decreases lean body mass and is associated with low muscle strength and impaired physical function.
Which of the following would be considered a genetic risk factor for developing childhood obesity?
lack of exercise
low family income
phenylketonuria
Prader-Willi syndrome
Prader-Willi syndrome
Prader-Willi syndrome is a genetic condition that causes excessive hunger, intellectual disability, and other pathologic changes. Lack of exercise and low family income are associated with an increased risk of childhood obesity, however, are not genetic risk factors. Phenylketonuria is an inherited disease, however, it is not a risk factor for child obesity.
Which of the following conditions might be mistaken for gluteofemoral obesity?
type 2 diabetes
abdominal obesity
renal failure
lipedema
lipedema
Lipedema is a condition that causes symmetrical swelling typically in the lower extremities of females. This type of distribution is similar to that observed in patients with gluteofemoral obesity.
Gerontology
- Study of aging in older adults
- women will outlive men and make up the greatest percentage of adults over 85.
Optimal Aging
- capacity to function across many domains (physical, functional, cognitive, emotional, social, and spiritual) to one’s satisfaction despite one’s medical conditions.
Age-Related Changes Impacting the Musculoskeletal
- Type Ilb fibers are enervated and remaining motor units hypertrophy
- Approximately 10% decline in strength per decade, especially during the sixth and seventh decades
- Decreased muscle mass (sarcopenia)
- Decreased velocity of muscular contraction
- Decreased cross-sectional area of type II muscle fibers
- Decreased ability to perform forceful and alternating movements
- Increased muscular fat infiltration
- Decreased skeletal bone mass after the fourth decade
- Women have lower bone mass compared to men
- Women experience the greatest level of bone mass loss following menopause
- Decreased articular cartilage thickness
- Increased collagen stiffness due to cross linkage between fibers
Age-Related Changes Impacting the Neuromuscular and Nervous system
• Decreased brain volume with an increased ventricular size
• Decreased peripheral nerve conduction velocity
• Decreased reaction speed
Age-Related Changes Impacting the Cardiovascular and Pulmonary systems
- Decreased myocyte density with increased myocyte volume
*Decreased sinoatrial node pacemaker cells - Increased cardiac afterload
- Decreased sensitivity to beta-adrenergic stimulation
- Increased calcification and fibrosis of heart valves
- Increased vascular tone leading to increased systolic blood pressure
- Decreased arterial elasticity and compliance
- Increased mucosal thickening in combination with decreased mucosal transport
- Increased physiological “dead space”
*Decreased inspiratory muscle strength - Decreased FEVI
- Increased residual volume following maximal expiration
Age-Related Changes Impacting the Integumentary System
- Decreased fever response
- Decreased autonomic regulation of thermoregulatory responses
- Decreased vascularity, thickness, and elasticity of the dermis
- Increased pain threshold
- Decreased subcutaneous adipose tissue
- Decreased sensory perception
Age-Related Changes Impacting the Metabolic and Endocrine System
- Decreased insulin sensitivity
- Decreased hepatic insulin release control
- Decreased sensitivity to beta-adrenergic stimulation
Age-Related Changes Impacting the Gastrointestinal System
- Decreased energy metabolism
- Decreased drug metabolism
- Increased risk of adverse side effects from medications
- Decreased gastric acid production
- Decreased bowel mobility
Age-Related Changes Impacting the Genitourinary System
• Prostate enlargement
• Increased incontinence
• Decreased kidney function and filtration rate
• Decreased bladder capacity
Hearing and Aging
- progressive loss of hearing (presbycusis) after 4th decade.
- difficulty differentiating between sounds
- Working with them:
- reduce background noise, speak loudly and slowly, and pronounce works carefully
- attempt to communicate in lower frequency range since older adults can distinguish lower frequencies better than higher frequencies.
- Tinnitus is also common
Vision and Aging
- Visual impairment increases drastically after 75 y/o.
- Visual acuity, visual field, and peripheral vision all decrease
- pupils decrease and less responsive to changes in light (make it harder to see in the light)
- increase in amount of time to accommodate to brighter or darker environment (increased risk of falling when navigating stairs or uneven surfaces)
- Common eye disease with aging: cataracts, glaucoma, macular degeneration, and diabetic retinopathy.
Taste and Smell with Aging
- number and size of taste buds decrease resulting in decreased sensitivity to all five tastes
- Less saliva is produced – causes dry mouth – decreases taste sensitivity.
Touch and Aging
- decreased sensitivity to a variety of sensation including touch, pain, vibration, pressure, proprioception, and temperature.
- makes prone to injury
- decrease in somatosensattion contributes to balance impairments
Memory and Aging
most common cognitive impairment that is associated with aging. Memory is made up of numerous constructs, and only some of the facets of memory are affected by aging.
Short-term memory is affected, and as a result older adults may have difficulty recalling information they have just learned. This is exacerbated by trying to remember more complex or lengthy memories. Working memory also declines in older age. This is the memory type where individuals use relevant information while in the middle of an activity (e.g., remembering items on a shopping list while shopping). Episodic memory (i.e., personally experienced events) tends to be affected to a greater degree than semantic memory (i.e., knowledge of facts) or procedural memory (ie, performance of skills).
Attention and Aging
Older adults demonstrate significant loss of divided attention, which is the ability to process two or more sources of information at the sume time. This is known as dual-tasking and a deficit in this ability can be associated with a greater risk for falls in older adults. They also show a decreased ability to switch their attention between two different tasks. However, other forms of attention do not show a decline with age, such as sustained attention (i.e. maintaining attention over a long period of time on a single task and selective attention (i.e., the ability to disregard sources of information that are irrelevant to the task).
Intelligence and Aging
With increasing age, intelligence declines though this construct is difficult to study due to generational differences. General intelligence begins to decline sometime between the 50s and 70s.
Crystalized intelligence, which is the accumulation of knowledge and skills, has the tendency to be maintained, or even improve, as an individual ages. However, fluid intelligence, which is the speed and ability to reason and problem solve, begins to decline.
Mild Cognitive Impairment
Mild cognitive impairment (MCI) is defined as having lower than expected cognitive performance when compared to others in the age group. It generally does not interfere with activities of dally living. Having MCI does not infer that an individual will progress towards developing dementia.
Dementia
Dementia is a process of cognitive decline that eventually influences the individual’s ability to participate in daily activities.
Difficulty comprehending language, impaired problem solving, behavioral disturbances, and memory deficits are all commonly associated with dementia. Alzheimer’s disease, a progressive form of dementia, is found largely in older adults. The incidence of dementia is shown to increase with age.
Delirium
Delirium is different from dementia in that it is a transient state of fluctuating cognitive abilities. Memory, orientation, and arousal may all be affected. The condition is commonly experienced after a hospitalization, post-surgically, during the course of an untreated medical condition or as a side effect of certain medications.
While the symptoms of delirium can mimic other conditions (e.g., dementia), it is important to consider that the patient’s cognitive status may change from day to day. Daily orientation and cognitive evaluations are key components of skilled geriatric physical therapy. Risk factors for developing delirium include age greater than 70, having a diminished cognitive status, depression, and alcohol abuse.
Pharmacokinetics
study of what happens to the drug once it is in the human body
Pharmacodynamics
study of how a drug exerts its therapeutic effects on the body at the cellular or organ level.
Advance directives:
- Documents that are completed by a patient prior to the onset of an liness that dictate how the patent wants their end-of-lite care to be carried out.
*Advance directives are important since illness may take away a patient’s ability to communicate their wishes concerning their own health care as they get older.
*A durable power of attorney and a living will are two types of advance directives.
Do not resuscitate (DNR):
- A medical order written by a doctor that documents a patient’s wishes to not be resuscitated with cardiopulmonary resuscitation (CPR) if they stop breathing or their heart stops beating.
- This order only applies to CPR;
- it does not apply to the administration of medication or other health care treatments.
Durable power of attorney:
A legal document in which a patient authorizes another person to make their health care decisions when the patient can no longer make their own decisions.
Hospice:
- A form of palliative care for terminally ill patients who have a limited life expectancy that focuses on the management of their pain and other symptoms as well as the acceptance of their own death.
- The goal of hospice care is to allow the patient to remain in their home as they near death, though there are inpatient facilities that provide these services as well.
Living will:
A legal document in which a patient dictates their preferences for health care treatment, which becomes especially important if the patient becomes terminally ill and can no longer express their wishes.
Palliative care:
An approach to a patient’s care (typically patients with serious illnesses) that aims to relieve their pain and suffering, as well as address any psychological, social, and spiritual problems, with the goal of improving the patient’s quality of life.
Older adults and medication considerations
- more predisposed to side effects as the half-life is extended.
- kidneys have the diminished ability to excrete drugs from the body – medications active for longer periods of time (so dosages need to be adjusted)
*
What increases cardiovascularly with age?
Blood pressure
(cardiac output, resting heart rate, venous return all decrease)
Which of the following aspects of pharmacokinetics is negatively affected in older adults due to the decrease in renal blood flow?
- absorption
- distribution
- metabolism
- excretion
Excretion
Which lung volume usually increases with age?
Residual volume
A decrease in intestinal motility with increasing age would most likely result in which of the following conditions?
diverticulosis and constipation
As a person ages, loss of motility (i.e., peristalsis) begins in the esophagus and continues throughout the digestive tract. Intestinal motility issues are common (especially in the large intestine) and lead to an increased incidence of constipation and diverticulosis.
Which type of incontinence is common in older adults and is associated with an overactive detrusor muscle?
stress incontinence
overflow incontinence
urge incontinence
functional incontinence
urge incontinence
Sensation associated with the need to urinate is often delayed or nonexistent in older adults, which results in an increased incidence of incontinence. Certain medical conditions (e.g., Alzheimer’s, Parkinson’s disease) result in detrusor muscle instability, which leads to an overactive bladder and urge incontinence.
Which type of memory that declines with age is defined by the use of relevant information while in the middle of an activity (e.g., remembering items on a shopping list while shopping)?
episodic memory
procedural memory
semantic memory
working memory
working memory
Working memory (i.e., use of relevant information while in the middle of an activity) declines in older age. Episodic memory (i.e., personally experienced events) tends to be affected to a greater degree than semantic memory (i.e., knowledge of facts) or procedural memory (i.e., performance of skills).
Which of the following pharmacokinetic parameters would be most influenced by decreased acidity in the stomach and slower emptying times associated with aging?
absorption
distribution
metabolism
excretion
absorption
Absorption refers to the movement of a drug into the bloodstream. Decreased acidity in the stomach, along with slower emptying times and decreased motility can alter the absorption of a drug.
What cardiovascular function will decline with bed rest?
- decreased stroke volume
- decreased cardiac output
- decreased maximal oxygen consumption
