Ch 14 health issues in older adults Flashcards
delirium
abrupt onset, state of rapid changes in brain function reflected in confusion, changes in cognition, activity and LOC, usu caused by acute illness or similar trigger
dementia
slowly/insidious onset, developed impairment of intellectual or cognitive function that is progressive and interefers with normal functioning
depression onset
gradual with exacerbation in times of stress
delirium memory is…
impaired but variable recall
“mom getting ready for work but she retired 15 years ago”
dementia memory is…
memory LOSS for recent events
“dad did not remember he went to daughters wedding last month”
depression memory is..
difficulty concentrating, forgetfulness, inattention
KNOWS this is happening
REVERSIBLE once treated (like delirium)
delirium, depression, dementia
reversible?
delirium: reversible when illness resolved
depression: reversible with proper tx
dementia: progressive and IRREVERSIBLE
delirium, depression, dementia
sleep disturbance?
delirium: “Sun downing” worse at night
depression: poor sleep quality with early morning awakening
dementia: disturbed sleep wake but lacks hr to hr variabliity
delirium, depression, dementia
psychomotor:
delirium: hyperkinetic, hypoactive, mixed, or no change
depression: decreased actviity, lethargy, fatigue, lack of motivation
dementia: no changes intil later
delirium, depression, dementia
perceptual disturbances
only delirium has (hallucinations)
delirium intervention
tx underlying cause, know that infection, meds, fractures are MOST common cause
dementia intervention
mild to moderate: cholinesterase inhibitors (donepezil (Aricept), rivastigmine (Exelon)
-mod-severe:
dementia speech
incoherent, confused, word searching to sparse speech content
Depression intervention
antidepressants (SSRI, SNRI)
screening tools for delirium
confusion assessment method (CAM)
dementia screening tool
mini mental state exam
depression screening tool for older adult
geriatric depression scale
if a pt has dementia, consider what diagnosis if there is sudden onset change in mental status?
delirium. often coexists with dementia
most common contributers to the cause of delirium
D.E.L.I.R.I.UM.S.
- Drugs: NEW med added or dose adjusted (TCA, 1st gen antihistamines), 1 & 2nd antipsychotics, opioids, opiates, benzos, alcohol
-Emotional/Electrolyte disturbacnes (depression, grief/loss), electrolyte disturbances (hyponatremia most common)
-Low PO2/lack of drugs (hypoxemia from CAP, COPD, MI, PE);
Lack of drugs (alcohol etc)
-Infection (#1 UTI, #2 CAP)
-Retention/reduced sensory input:urinary or fecal retention (reduced senosry input (loss glasses, hearing aids)
-Ictal or postictal state (alcohol withdrawal)
-Undernutrition (protein/calorie malnutrition, vitamin B12 or folate deficiency, dehydration
-Metabolic/Myocardial problems (poor DM, hypo/hyperthyroidism), MI, HF, dysrhythmia
-Subdural hematoma (minor head trauma, brain atrophy, fragile blood vessels)
if pt has new onset altered mental status change, what labs help rule in/out delirium?
UA C&S (UTI)
CBC with diff (WBC)
serum electrolytes
glucose
BUN/creatinine
Vitamin B12
Thyroid functiont tests
LFT
Depression screening
based on pt’s risk factors, new onset of altered mental status/delirium/dementia, want to order what?
brain imaging (CT vs MRI)
PET scan
toxic screen
CXR (for tachypnea)
ESR
HIV
RPR/VDRL (syphilis testing)
ECG (ACS)
genetic testing (APOE genotyping, others)
dementia etiology
50-80%: alzheimer type
20%: vascular Multip-infarct) dementia
5%: parkinson disease
other: HIV, dialysis encephalopathy, neurosyphilis, normal pressure hydrocephalus, Pick’s disease, Lewybody disease, frontotemporal dementia
Alzheimer type dementia: mild to moderate care
slow the decline: give vitamin E 1,000 units BID or selegiline 5 mg BID
mild-mod: use cholinesterase inhibitors (increase Ach availability) helps TEMPORARILY but not long term since it needs healthy neurons to work
Donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne)
Alzheimer type dementia: moderate to severe
NMDA receptor antagonist memantine (Namenda)
-works on glutamate
-use with cholinesterase inhibitor in early but not later stages
other considerations for Alzheimer type dementia
-eval for pain, infection, other clinical conditions in older adults
-treat agitation and depression (40% with dementia have depression = antidepressants)
-
when do you give 2nd gen antipsychotics (risperidone)?
-if environmental manipuatlion fails to eliminate agitation/psychosis
-discuss with pt and loved ones BEFORE pt can’t contribute anymore
-**med a/s with increased stroke risk and cardiovascular events
when do you give 2nd gen antipsychotics (risperidone)?
-if environmental manipuatlion fails to eliminate agitation/psychosis
-discuss with pt and loved ones BEFORE pt can’t contribute anymore
-**BUT it is a/s with increased stroke risk and cardiovascular events
strategies to improve functional performance and reduce problem behavior in dementia
-scheduled toileting, prompted voiding to reduce urinary incontinence
-graded assistance, practice, positive reinforcement to increase functional independence
-music (during meals and bathing)
-walking, light exercise
when hearing FRAIL, think…
increase risk of falls and delirium
frailty syndrome diagnosis
3 or more of:
-unintent weight loss (~10lb) or >5% body weight
-muscle weakness (reduced grip strength)
-physical slowness
-poor endurance (feeling exhausted)
-low physical activity (questionnaire)
frailty syndrome
syndrome of age decline from multiple phsyiologic systemic, increase vulnerability to adverse health outcomes (increase fall risk , delirium, disability)
frailty syndrome intervention
1: treat underlying cause to avoid frailty (a typically irreversible condition)
-regular exercise (resistance and aerobic)
-caloric and protein support
-vitamin D
-reduction of polypharmacy
which med class has significant risk of orthostatic hypotension?
Tricyclic antidepressants (TCA)
amitriptyline (Elavil)
which med class increase in fall and fracture risk?
sedative-hypnotics
-zolpidem (Ambien)
which med class protential to promote fluid retention and minimize effect of many anti-HTN meds?
NSAID
naproxen (Aleve, Anaprox)
which med class increase risk for hypOnatremia, esp when sued with diuretic?
SSRI (sertraline, Zoloft)
which med class have significant systemic anticholinergic effects when compared to other meds?
anticholinergics - oxybutynin (Ditropan)
which med class have significant systemic anticholinergic effects when compared to other meds?
anticholinergics - oxybutynin (Ditropan)
dizziness common causes
circulatory (orthostatic)
neurologic (parkinsons)
meds
anxiety
hypoglycemia
hyperthermia
dehydration
vertigo causes
usu inner ear disturbances or neurological
-inflammation of inner ear
menierie’s dz
head trauma
stroke
multiple sclerosis
tumors
migraines
syncope causes
neurologic (fear, pain, anxiety)
situational (cough, defecation)
cardiac (cardiomyopathy, outlfow obstruction, dysrhythmia)
peripheral artery disease (PAD) presentation
plaque build up in arms/legs causing intermittent claudication (leg pain/numbness during activities)
-persistent infections/sores on leg/feet
-pale or bluish color to skin
-some asx
-smoking #1
PAD diagnosis
ankle brachial index value < 0.9
doppler US or MRI for blood flow
PAD tx
lifestyle mod (no smoking, exercise, weight loss if overweight)
control BP, cholesterol, sguars
antiplatelets
cilostazol and pentoxifylline to reduce PAD sx’s
vascular surgery
venous insufficiency presentation
burning, swelling, throbbing, cramping, aching, heaviness in legs
-restless legs and leg fatigue
-telangiectasis (spider veins)
venous insufficiency etiology
congenital absence or damage to venous valves = reflux via superficial veins
thrombus formation = valve failure
venous insufficiency diagnosis
PE of leg veins
-duplex ultrasound = flow
venous insufficiency tx
exercise, weight loss
-compression stockings for swelling
-sclerotherapy, ablation
peripheral neuropathy
gradual onset numbness, tingling in hands and feet
burning pain, sharp electric like pain
muscle weakness, extreme sensitivity to touch
peripheral neuropathy etiology
damage to nerves in peripheral system
#1: diabetes, trauma, infections, toxins
peripheral neuropathy diagnosis
nerve function test (electromyography) or nerve biopsy
-full medical hx & physical to find underlying reason
peripheral neuropathy tx
-NSAID for mild pain
-antiseizure, antidepresssant (duloxetine, venlafaxine, gabapentin)
-lidocaine patch
-opioids (when other meds fail)
-transcutaneous electrical nerve stimulation (TENS) helps with sx’s
peripheral neuropathy tx
-NSAID for mild pain
-antiseizure, antidepresssant (duloxetine, venlafaxine, gabapentin)
-lidocaine patch
-opioids (when other meds fail)
-transcutaneous electrical nerve stimulation (TENS) helps with sx’s
