Ch 14 health issues in older adults Flashcards by Darlena Thach

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

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dementia

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

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depression onset

gradual with exacerbation in times of stress

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delirium memory is…

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

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dementia memory is…

memory LOSS for recent events

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

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depression memory is..

difficulty concentrating, forgetfulness, inattention
KNOWS this is happening

REVERSIBLE once treated (like delirium)

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delirium, depression, dementia
reversible?

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

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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

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delirium, depression, dementia
psychomotor:

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

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delirium, depression, dementia
perceptual disturbances

only delirium has (hallucinations)

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delirium intervention

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

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dementia intervention

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

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dementia speech

incoherent, confused, word searching to sparse speech content

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Depression intervention

antidepressants (SSRI, SNRI)

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screening tools for delirium

confusion assessment method (CAM)

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dementia screening tool

mini mental state exam

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depression screening tool for older adult

geriatric depression scale

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

delirium. often coexists with dementia

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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)

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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

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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)

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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