Ch 14 health issues in older adults

Question 1

delirium

Answer 1

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

Question 2

dementia

Answer 2

slowly/insidious onset, developed impairment of intellectual or cognitive function that is progressive and interefers with normal functioning

Question 3

depression onset

Answer 3

gradual with exacerbation in times of stress

Question 4

delirium memory is…

Answer 4

impaired but variable recall
“mom getting ready for work but she retired 15 years ago”

Question 5

dementia memory is…

Answer 5

memory LOSS for recent events

“dad did not remember he went to daughters wedding last month”

Question 6

depression memory is..

Answer 6

difficulty concentrating, forgetfulness, inattention
KNOWS this is happening

REVERSIBLE once treated (like delirium)

Question 7

delirium, depression, dementia
reversible?

Answer 7

delirium: reversible when illness resolved
depression: reversible with proper tx
dementia: progressive and IRREVERSIBLE

Question 8

delirium, depression, dementia
sleep disturbance?

Answer 8

delirium: “Sun downing” worse at night
depression: poor sleep quality with early morning awakening
dementia: disturbed sleep wake but lacks hr to hr variabliity

Question 9

delirium, depression, dementia
psychomotor:

Answer 9

delirium: hyperkinetic, hypoactive, mixed, or no change
depression: decreased actviity, lethargy, fatigue, lack of motivation
dementia: no changes intil later

Question 10

delirium, depression, dementia
perceptual disturbances

Answer 10

only delirium has (hallucinations)

Question 11

delirium intervention

Answer 11

tx underlying cause, know that infection, meds, fractures are MOST common cause

Question 12

dementia intervention

Answer 12

mild to moderate: cholinesterase inhibitors (donepezil (Aricept), rivastigmine (Exelon)
-mod-severe:

Question 13

dementia speech

Answer 13

incoherent, confused, word searching to sparse speech content

Question 14

Depression intervention

Answer 14

antidepressants (SSRI, SNRI)

Question 15

screening tools for delirium

Answer 15

confusion assessment method (CAM)

Question 16

dementia screening tool

Answer 16

mini mental state exam

Question 17

depression screening tool for older adult

Answer 17

geriatric depression scale

Question 18

if a pt has dementia, consider what diagnosis if there is sudden onset change in mental status?

Answer 18

delirium. often coexists with dementia

Question 19

most common contributers to the cause of delirium

Answer 19

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)

Question 20

if pt has new onset altered mental status change, what labs help rule in/out delirium?

Answer 20

UA C&S (UTI)
CBC with diff (WBC)
serum electrolytes
glucose
BUN/creatinine
Vitamin B12
Thyroid functiont tests
LFT
Depression screening

Question 21

based on pt’s risk factors, new onset of altered mental status/delirium/dementia, want to order what?

Answer 21

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)

Question 22

dementia etiology

Answer 22

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

Question 23

Alzheimer type dementia: mild to moderate care

Answer 23

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)

Question 24

Alzheimer type dementia: moderate to severe

Answer 24

NMDA receptor antagonist memantine (Namenda)
-works on glutamate
-use with cholinesterase inhibitor in early but not later stages

Question 25

other considerations for Alzheimer type dementia

Answer 25

-eval for pain, infection, other clinical conditions in older adults
-treat agitation and depression (40% with dementia have depression = antidepressants)
-

Question 26

when do you give 2nd gen antipsychotics (risperidone)?

Answer 26

-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

Question 27

when do you give 2nd gen antipsychotics (risperidone)?

Answer 27

-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

Question 28

strategies to improve functional performance and reduce problem behavior in dementia

Answer 28

-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

Question 29

when hearing FRAIL, think…

Answer 29

increase risk of falls and delirium

Question 30

frailty syndrome diagnosis

Answer 30

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)

Question 31

frailty syndrome

Answer 31

syndrome of age decline from multiple phsyiologic systemic, increase vulnerability to adverse health outcomes (increase fall risk , delirium, disability)

Question 32

frailty syndrome intervention

Answer 32

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

Question 33

which med class has significant risk of orthostatic hypotension?

Answer 33

Tricyclic antidepressants (TCA)
amitriptyline (Elavil)

Question 34

which med class increase in fall and fracture risk?

Answer 34

sedative-hypnotics
-zolpidem (Ambien)

Question 35

which med class protential to promote fluid retention and minimize effect of many anti-HTN meds?

Answer 35

NSAID
naproxen (Aleve, Anaprox)

Question 36

which med class increase risk for hypOnatremia, esp when sued with diuretic?

Answer 36

SSRI (sertraline, Zoloft)

Question 37

which med class have significant systemic anticholinergic effects when compared to other meds?

Answer 37

anticholinergics - oxybutynin (Ditropan)

Question 38

which med class have significant systemic anticholinergic effects when compared to other meds?

Answer 38

anticholinergics - oxybutynin (Ditropan)

Question 39

dizziness common causes

Answer 39

circulatory (orthostatic)
neurologic (parkinsons)
meds
anxiety
hypoglycemia
hyperthermia
dehydration

Question 40

vertigo causes

Answer 40

usu inner ear disturbances or neurological
-inflammation of inner ear
menierie’s dz
head trauma
stroke
multiple sclerosis
tumors
migraines

Question 41

syncope causes

Answer 41

neurologic (fear, pain, anxiety)
situational (cough, defecation)
cardiac (cardiomyopathy, outlfow obstruction, dysrhythmia)

Question 42

peripheral artery disease (PAD) presentation

Answer 42

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

Question 43

PAD diagnosis

Answer 43

ankle brachial index value < 0.9
doppler US or MRI for blood flow

Question 44

PAD tx

Answer 44

lifestyle mod (no smoking, exercise, weight loss if overweight)
control BP, cholesterol, sguars
antiplatelets

cilostazol and pentoxifylline to reduce PAD sx’s
vascular surgery

Question 45

venous insufficiency presentation

Answer 45

burning, swelling, throbbing, cramping, aching, heaviness in legs
-restless legs and leg fatigue
-telangiectasis (spider veins)

Question 46

venous insufficiency etiology

Answer 46

congenital absence or damage to venous valves = reflux via superficial veins
thrombus formation = valve failure

Question 47

venous insufficiency diagnosis

Answer 47

PE of leg veins
-duplex ultrasound = flow

Question 48

venous insufficiency tx

Answer 48

exercise, weight loss
-compression stockings for swelling
-sclerotherapy, ablation

Question 49

peripheral neuropathy

Answer 49

gradual onset numbness, tingling in hands and feet
burning pain, sharp electric like pain
muscle weakness, extreme sensitivity to touch

Question 50

peripheral neuropathy etiology

Answer 50

damage to nerves in peripheral system
#1: diabetes, trauma, infections, toxins

Question 51

peripheral neuropathy diagnosis

Answer 51

nerve function test (electromyography) or nerve biopsy
-full medical hx & physical to find underlying reason

Question 52

peripheral neuropathy tx

Answer 52

-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

Question 53

peripheral neuropathy tx

Answer 53

-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