Ch15: Gerontology Flashcards
etiology of delirium
typically precipitated by an acute underlying illness
some underlying cause
onset of delirium
sudden state of rapid changes in cognition or mental status, over hours to days
memory loss in dementia most commonly affects [proximal vs. distant] events
loss of memory for recent, proximal events
“sundowning” or progressive worsening as the day progresses: delirium or dementia
delirium
expected change in psychomotor activity in delirium
- 25% hyperkinetic/ hyperactive
- 25% hypoactive
- 35% mixed
- 15% no change
delirium or dementia: speech content is incoherent, confused, with a wide variety of often inappropriately-used words such as misnamed persons or items
delirium
delirium or dementia: in earlier stages, marked by word-searching and progressing to sparse speech content. may be mute in later disease
dementia
delirium or dementia: marked perceptual disturbances, including hallucinations
delirium
no perceptual disturbances in dementia until later on in the disease
DELIRIUMS mnemonic for causes of delirium
D - drugs E - emotional or electrolyte disturbance L - low oxygen, lack of drugs I - infection R - retention (urinary or fecal), reduced sensory input I - ictal or post-ictal state U - undernutrition M - metabolic or myocardial problems S - subdural hematoma
most common electrolyte disturbance in older adults
hyponatremia
aging kidneys tend to waste sodium and hang on to potassium
also, we prescribe a lot of salt-depleting drugs to older adults like diuretics
problematic drugs in older adults that can cause delirium
- TCAs (anticholinergic effects)
- 1st gen antihistamines, e.g., diphenhydramine (anticholinergic effects)
- doxepin (anticholinergic effects; used for anx/dep)
- OAB medications e.g., oxybutynin (anticholinergic effects)
- 1st and 2nd gen antipsychotics
- opioids/opiates
- benzodiazepines
- alcohol
most common cause of delirium in elderly adults (2)
INFECTION
- UTI (MOST common)
- CAP pneumonia (distant second)
how does an older adult present with UTI (2)
- new onset AMS/confusion
- new onset wetting/incontinence
delirium s/t hypoxemia can occur in these (4) conditions
- CAP pneumonia
- COPD exacerbation
- MI
- PE
reduced sensory input examples that can cause delirium in elderly adults
- loss of eyeglasses
- loss of hearing aids
- hearing loss
(4) nutrition issues in elderly adult that can contribute to delirium
- dehydration
- protein/calorie malnutrition
- vitamin B12 deficiency
- folate deficiency
new onset confusion and new onset SOB in elderly adult, consider this on your differential….
myocardial infarction
subdural hematomas can be a result of even minor head trauma for older adults, due to a combination of (2)
- brain atrophy
- fragile blood vessels
most common (2) causes of delirium in elderly adults (generally)
- infections
2. medications
% of dementias that are Alzheimer-type
50-80%
% of dementias that are vascular (multi-infarct) dementia
20%
% of dementias that are Parkinson’s disease
5%
approximately 30% of people with Alzheimer-type dementia also have …..
vascular dementia
rare dementia type marked by intense hallucinations and behavior change
Lewy Body dementia
lab tests in evaluation of the person with new onset altered mental status
DEFINITELY:
- URINALYSIS with urine culture & sensitivity (most important one)
- CMP (electrolytes [especially Na and Ca] and kidney function, liver function)
- serum glucose
- serum vitamin B12
- serum folate
- TSH
- CBC with WBC differential
- ECG (could reveal ACS)
- RPR/VDRL syphilis testing (r/o neurosyphilis)
BY RISK FACTORS:
- brain imaging (CT vs. MRI; particularly useful if there was a head injury)
- toxic screen (concern for substance use)
- chest xray (if RR is up, suspected pneumonia)
- ESR (inflammation)
- HIV
(4) medications that can be considered to slow the decline mild-moderate (early) Alzheimer’s dementia
- cholinesterase inhibitors (eg., donepezil [Aricept], rivastigmine [Exelon], galantamine [Razadyne] have a clear though minor and time-limited benefit by increasing availability of acetylcholine
- memantine (Namenda), an NMDA receptor antagonist that exerts effect on glutamate, helpful in combination with cholinesterase inhibitor
- vitamin E 1,000 IU BID
- selegiline 5mg BID (no added benefit to using selegiline AND vitamin E, just choose one)
medication class: donepezil (Aricept)
cholinesterase inhibitors –> increase availability of acetylcholine
medication class: rivastigmine (Exelon)
cholinesterase inhibitors –> increase availability of acetylcholine
medication class: galantamine (Razadyne)
cholinesterase inhibitors –> increase availability of acetylcholine
why are the benefits of cholinesterase inhibitors time-limited in the treatment of dementia?
because they require live neurons to work on and sadly there is neuronal loss as dementia progresses?
preferred SSRI (1) for elderly adults with dementia and depression (2)
- escitalopram (Lexapro)
lowest potential for drug-drug interactions
% of folks with dementia who also have depression
40%
(1) medication class that can be used to treat agitation or psychosis in an elderly adult with dementia, once environmental manipulation has failed
2nd generation antipsychotics, e.g., risperidone
priority risk of prescribing a 2nd gen antipsychotics for the elderly adult with agitation or psychosis
increased risk of stroke and cardiovascular events, must weigh the risks and benefits
(2) most common side effects of cholinesterase inhibitors
nausea, diarrhea
BBW on 2nd gen antipsychotics in the elderly adult
increased risk of death
increased risk appears to be 1.6-1.7x that of those taking placebo
risk appears to be s/t cardiovascular and infectious complications
(2) strongly recommended interventions for improving urinary incontinence in elderly adults
- scheduled toileting
- prompted voiding
potential anticholinergic effects of select medications in elderly adults
- dry mouth
- dry skin
- blurred vision
- urinary retention
overdose / toxicity symptoms…
- sedation
- agitation
- tachycardia
- hyperpnea
- mydriasis
- flushing
- psychosis
- seizure
- coma
- hyperthermia
who is most at risk for urinary retention when taking an anticholinergic
elderly men with BPH
(2) rhyming mnemonics for anticholinergic side effects
Dry as a bone, Red as a beet, Mad as a hatter, Hot as a hare
Cant see
Cant pee
Cant spit
Cant shit
frailty refers to a syndrome of age-related decline across multiple physiologic systems and characterized by increased vulnerability to adverse outcomes, including increased risk of … (3)
- FALLS
- delirium
- disability
(5) components of frailty screening scale
3 or more of the following:
- unintentional weight loss (>10 lbs)
- exhaustion (self reported)
- low physical activity
- slowness (TGUG test)
- weakness (grip strength)
(4) evidence-based interventions for managing frailty
- regular physical activity/exercise including resistance training and aerobics
- calorie and protein support
- vitamin D supplementation
- reduction in polypharmacy
what is the only (1) anti hypertensive medication class whose effect is not blunted by taking NSAIDs
calcium channel blockers
if you put an older adult on an SSRI, recheck their _______ 1 month after starting
serum sodium
risk for hyponatremia
why are sedative-hypnotics on the Beer’s List
increase in fall/fracture risk
why are TCAs on the Beer’s List
significant risk of orthostatic hypotension
why are NSAIDs on the Beer’s List
potential to promote fluid retention and minimize effect of many antihypertensive medications
why are SSRIs on the Beer’s List
increased risk for hyponatremia, especially when used with a diuretic
underlying etiologies to consider for a fall with syncope
- vasovagal syncope (fear, pain, anxiety, prolonged standing, warmth, nausea, sweating)
- vasovagal response during cough, defecation, micturition, swallowing
- cardiac outflow tract obstruction in hypertrophic cardiomyopathy, valvular stenosis (especially aortic stenosis), aortic dissection, dysrhythmia, QT-prolonging medications (e.g., macrolides, fluoroquinolones, 2nd gen antipsychotics),AV heart block
- dehydration
- medications that can cause orthostatic hypotension (e.g., TCA, alpha blockers, CCBs, clonidine, diuretics, alcohol, PDE-5 inhibitors)
(3) medication classes that can prolong QT interval
- macrolide antibiotics (e.g., azithromycin, clarithromycin)
- fluoroquinolones (e.g., levofloxacin)
- 2nd generation antipsychotics
common medications that can cause orthostatic hypotension in the elderly
- TCAs (e.g., amitriptyline)
- alpha blockers
- calcium channel blockers
- clonidine (alpha agonist)
- diuretics
- alcohol
- PDE5 inhibitor (e.g., sildenafil)
angina/ischemia of the calves
intermittent claudication
dx: diminished bilateral pedal pulses, thinning of the BLE skin, hairless BLE, cold feet
PAD - arterial (e.g., atherosclerosis)
dx: hyperpigmentation of the BLE with bilateral ankle edema
PVD - venous
dx: diminished sensory perceptions and abnormal monofilament examination to the BLE
peripheral neuropathy
how to diagnose PAD
ankle-brachial index (ABI), ABI <0.9
doppler US can be used to assess blood flow
treadmill test can evaluate severity of symptoms
arteriogram can be ordered to identify blocked arteries (specialist?)
how to diagnose PVD
venous doppler US can be used to assess blood flow in the veins and eliminate other causes (e.g., a blood clot, DVT)
sclerotherapy is a treatment for PAD or PVD?
PVD
(4) interventions for someone with symptomatic PAD (e.g., intermittent claudication)
- management of their CVD risk factors (e.g., smoking cessation, physical activity, weight loss, BP or cholesterol medications)
- referral to a vascular surgeon for consult to improve blood flow
- oral cilostazol (Plental) or pentoxifylline can reduce symptoms, however increases risk for heart failure
- aspirin can be used to prevent blood clots
classic presentation of PAD
leg pain and numbness during activities (intermittent claudication), persistent infections or sores on the legs and feet; skin may be pale or bluish color
some patients may be asymptomatic
classic presentation of PVD/venous insufficiency
burning, swelling, throbbing, cramping, aching, and heaviness in the legs
restless legs and leg fatigue
telangiectasias (spider veins)
etiology of PAD
systemic build-up of plaque in the arteries, limits blood flow (usually observed in the legs).
smoking is the main risk factor.
other factors include age, high blood pressure, high cholesterol, diabetes)
risk factors for PAD (5)
- SMOKING!!!
- age
- high BP
- high cholesterol
- diabetes
etiology of PVD/venous insufficiency
congenital absence of, or damage to, venous valves resulting in reflux through the superficial veins
thrombus formation can also cause valve failure
interventions for someone with PVD/venous insufficiency (3)
- lifestyle (physical activity, weight loss)
- compression stockings to reduce swelling
- referral to specialist as they can do sclerotherapy or ablation to remove the refluxing superficial veins
classic presentation of peripheral neuropathy
gradual onset of numbness and tingling in the hands and feet, burning pain, sharp electric-like pain, muscle weakness, extreme sensitivity to touch
etiology of peripheral neuropathy
damage to the nerves extending to the peripheral system
diabetes is the most common cause, others include traumatic injury, infection, and toxin exposure
how do you diagnose peripheral neuropathy
nerve function test (electromyography)
interventions for someone with peripheral neuropathy (5)
- NSAIDs for pain
- anti-seizure (e.g., gabapentin) and antidepressant (e.g., amitriptyline) medications
- lidocaine patch
- TENs unit
- opioids (all other treatments fail)
make sure tap water is set to temperature below ____ to prevent burns
<120F (48.9C)
would take 5 minutes of exposure to 120F temp water to cause a third-degree burn, 2 seconds if 150F
memory loss the disrupts daily life: how to differentiate possible dementia from age-related memory changes?
age-related = sometimes forgetting names or appointments but remembers this information later
dementia = forgetting especially recently-learned information, forgetting important dates or events, asking for the same information over and over, reliance on memory aids (e.g., notes, family) for things they could formerly handle independently
planning and problem solving problems: how to differentiate possible dementia from age-related memory changes?
age-related = making occasional errors when balancing a checkbook or similar tasks
dementia = change in ability to develop or follow a plan or to work with numbers, trouble following a familiar recipe, trouble keeping track of monthly bills, difficulty concentrating, taking longer to do things than in the past
difficulty completing familiar tasks at work or home: how to differentiate possible dementia from age-related memory changes?
age-related = occasionally needing help to perform a task such as settings on a microwave or how to record a TV show
dementia = difficulty completing typical daily tasks like driving to a familiar location, managing a budget, or trouble remembering the rules to a familiar game
confusion with place or time: how to differentiate possible dementia from age-related memory changes?
age-related = occasionally getting the date or day of the week wrong, but correcting this later
dementia = losing track of dates, seasons, and overall passage of time, trouble understanding something if it is not happening immediately, may forget where they are or how they got there
trouble understanding visual images or spatial relationships: how to differentiate possible dementia from age-related memory changes?
age-related = visual changes consistent with cataracts or age-related macular degeneration
dementia = difficulty reading, judging distance, color discrimination, contrast, altered perception (e.g., not recognizing self in mirror)
new problems with words in speaking or writing: how to differentiate possible dementia from age-related memory changes?
age-related = occasional word-finding difficulties
dementia = trouble following or joining a conversation, often stopping in the middle of a conversation not sure of how to continue, repeating parts of the conversation, struggling with vocabulary and word recall, developing new ways to describe an item because they cannot remember the word
misplacing things or trouble retracing steps: how to differentiate possible dementia from age-related memory changes?
age-related = misplacing an item from time to time, such as a pair of glasses, with the ability to retrace steps to locate the item
dementia = placing items in unusual places such as shoes in the fridge, repeatedly misplacing items, accusing others of stealing the misplaced item
> 50% of mild cognitive impairment that will progress to dementia within ______
5 years
risk is doubled with comorbid depression
average life-span is _____ after a diagnosis of Alzheimer’s dementia
6-9 years
