Changes in Sensation & Function in the Elderly Flashcards
what do older patients rely on more to determine foot placemement rather than using proprioception
Vision
what are motor performance deficits in older people due to
dysfunction of central and peripheral nervous system as well as neuromuscular system
What is included in motor performance deficits
coordination difficulty
increased variability of movement
slowing of movement
difficulties with balance and gait
If a older patient has slower information processing, what else can it affect
Motor performance
What is oropharyngeal dysphagia
AKA transfer dysphagia
-refers to initiation of swallow
transfer of food bolus from hypopharynx to esophagus
What is esophageal dysphagia
difficulty passing food to the stomach through the body of the esophagus
what can cause swallowing difficulties
mechanical obstruction and altered motor function
common in elderly
on average, how many times does a person swallow per day
600 times / day
What cranial nerves are involved in the oral phase of swallowing
CN V (trigeminal)
CN VII (facial)
CN XII (hypoglossal)
What cranial nerves are involved in the pharyngeal phase of swallowing
CN V (trigeminal)
CN X (vagus)
CN XI (accessory
CN XII (hypoglossal)
At what age goes the brain begin to shrink?
30-40 years old, rate of decreasing size ramps up by age 60
what part of the brain changes with age?
decrease in white matter (myelinated nerve fibers)
this slows cognitive processing and reduces cognitive function
What is the decrease in dopamine transmission in older people correlated with
increased anterior-posterior sway - impaired balance
fine motor control
working memory and executive function
What is the ‘compensation hypothesis’
healthy older adults can perform complex motor tasks automatically (like younger peers), they appear to require additional brain activity to perform at the same level as young adults
What interentions can we use to help prevent motor deficits
Exercise, exercise, motor training, pharmceuticals, exercise
What are the most common chronic health problem in older patients
HTN and arthritis
Hearing
Who usually experiences greating hearing loss at an earlier onset?
Men
What are normal conversation frequencies for hearing
500 to 3,000 Hz at 45 to 60 dB
how is hearing loss classified
Conduction or sensorinueral
what is the cause of conductive HL
problems in external or middle ear
what is the cause of SNHL
problems converting mechanical vibrations to electical potential in the cochlea and/or in auditory nerve transmissionto the brain
What are risk factors for age-related HL
genetics/fhx
noise exposure
regular exposure to 85 dB or more
drug use
chemicals
male
DM, renal failure, atherosclerosis, immunosuppression, head injury
meds
tobacco use
vitamin intake
What are the screening tests for HL
whispered voice
Single question - 90% self report
screening version of the Hearing Handicap Inventory
Audioscopy
what does unilateral hearing loss suggest
local pathology, obstruction or idiopathic sudden SNHL
What does a rapid onset of HL suggest
possible perforation of TM, trauma or idiopathic sudden SNHL
What is idiopathic Sudden SNHL (isSNHL)
develops in less than 72 hoursl usually unilat
sound is ‘harsh and distorted’, accompanied by aural fullness
emergency and requires prompt referral
MRI with Gadolinium is recommended
what is the most common cause of conductive HL
cerumen impaction
how can we treat cerumen impaction
curetting, HOH-based solution, warm water irrigation, prescription cerumenolytics
what is vision loss in older population associated with
increased fall risk, loss of independecne, depression, increased all-cause mortality
how is low vision defined
central visual acuity of 20/70 or worse in better-seeing eye with best correction or total visual field loss of 140 degrees
how is legal blindness defined
Cental visual acuity of 20/200 or worse in better sing eye with best correction or a visual field of 20 degrees or less
What are major causes of severe vision loss and blindness in older adults
age-related macular degeneration
ocular complications of DM
Glaucoma
age-related cataracts
What are risk factors for macular degeneration
smoking, obesity, untreated HTN, age, female, fhx, sun exposure
What is the treatment of macular degeneration
vitamin supplements
vascular endothelial growth factor inhibitors - injections used for ‘wet’ MD
what does glaucoma cause
progressive damage to optic nerve, leading to visual field loss and irreversible blindness
how is glaucoma diagnosed
measurement of IOP in conjuction with optic disc eval and automated visual field test
what is the treatment of glaucoma
medicated eyedrops to decrease IOP
laser trabeculplasty for primary open-angle glaucoma
what is assessed with age-related cataracts
red reflex
what are risk factors for accelerated cataract formation
UV light exposure
smoking
what is the treatment of cataracts
no treatment needed
surgery is the only effective treatment
what causes peripheral neuropathies
m/c is idiopathic
followed by DM
what is the medial survival time after dementia diagnosis
4.5 years
what is the greatest risk for dementia
older age
What is the diagnosis criteria for dementia
‘major neurocognitive disoers’ require deomnstation of significant cognitive decline in atleaset one of the following domains:
- complex attention
- executive function
- language
- learning and memory
- perceptual-motor
- social cognition
decline must be based on both subjective and objective findigns, and interfere with IADLs
What are examples of IADLs
(Instrumental Activities of Daily Living)
managing finances
managing transportation
shopping and meal prep
house clearning/maintenance
managing communication
managing meds
what are the cognitive domains of dementia
complex attention
executive function
language
learning and memory
perceptual-motor
social cognition
What is the screening tools used for dementia
mini-cog, MMSE, MoCA
What is included in the mini-cog
- 3 word reptition
- clock-drawing
- 3 word recall
requires < 5 min to complete
When are MMSE and MoCA completed
for patient who have a positive Mini-cog
MMSE is most commonly used
What is the definition of delirium
acute, flunctuating syndrome of altered attention, awareness and cognition precipitated by an underlying condition or event in vulnerable persons
AKA ‘AMS’, ‘acute confusional state’, ‘sundowning’, ‘encephalopathy’, ‘acute organic brain syndrome’
what is delirium associated with for immediate and long-term outcomes
increased fall risk
lengthened hospital stay
increase hospital costs
increased duration of mechanical vent
increased degree of cognitive impairment
long-term facility placement
mortality
what are the subtypes of delirium
hypoactive
hyperactive
mixed
what are behaviors seen with hyperactive delirium
(atleast three ofthe following)
hypervigilance, restlessness, fast/loud speach, irritability, comativeness, impatience, swearing, singing, laughing, etx.
how should we workup delirium
older persons with delirium require basic workup: CBC, CMP, UA, EKG
CT head is recommended if new neuro deficits, hx head trauma or fever associated iwth encephalopathy
How is delirium managed
prevention is key
avoid constipation/dehydration, assess hypoxia, assess for and treat infection, promote good sleep patterns, supplementation between meals, continually assess for verbal and non-verbal signs of pain
pharmacotherapy reserved for patient who are a threat to their own safety or others saftety (haloperidol)
what are the most common psychiatric problems among older adults
depression and anxiety
what are risk factors for anxiety/depression
female
unmarried (esp. for men)
lower income
having functional limitations
believing in an external locus of control
fhx of depression/anxiety
death of a partner
what is the first line pharmacotherapy for MDD
SSRIs
what is short and disturbed sleep associated with
poor cognitive and health outcomes
what defines apnea
repetitive events while asleep of complete cessation of airflow lsting at least 10 seconds
What is classicially associated with OSA
obesity
what is CSA
central sleep apnea
due to defect in central control of breathing (no respiratory effort) - classically associated with HF
What is Cheynes-Stokes respiration
alternating between hypo- and hyper-ventilation
what is the gold standard testing for OSA or CSA
polysomnography - sleep testing
HSAT (home sleep apnea test) - challenging for some older adults to place sensors
what is the first line managmeent of OSA
positive airway pressure therapy (CPAP)
What is PLMS
periodic leg movements in sleep
- atleast 4 cycles or sterotyped movements in a row
What is PLMD
periodic limb movement disorder
-diagnosis requires 15 PLMS per house, causes sleep disturbance
requires sleep study for dx
cause unknown
what is circadian rhythm
24 hour biological rhythms that govern hormone secretion, core body temp and sleep-wake cycle
what is the suprachiasmatic nucleus (SCN)
internal circadian pacemaker
what drives sleep-wake cycles
melatonin secretion
what is the treatment of circadian rhythm disorders
appropriately timed bright light therapy
can augment with melatonin
increased daytime activity
quiet environment and dark room at night, cooler temps
what is the definition of insomnia
inability to FALL asleep and/or
inability to STAY asleep and/or
waking up TOO EARLY
-has a negative impact on QOL
what medical problems are associated with Insomnia
HTN
CAD
arthritis
lung disease
GERD
CVA and neurodegenerative d/o
what are the treatment options for restless leg
iron supplementation if needed (often IV)
dopamine agonists - ropinirole, pramipexole
calcium channel ligands - gabapentin, pregabalin
what is the best tool for evaluating circadian rhythm disorders
comprehensive sleep hisotry
(official sleep study not generally needed)
what is the first line management for insomnia
CBT
(sleep diary for 2 weeks)
what are the pharmacologic managements for insomnia
benzodiazephines(Tiazolam, temazepam, lorazepam) - increase risk of falls/confusion
non-benzos (zolpidem, zaleplon) - concern for sleep eating/driving
melatonin receptor agonists (ramelton)
Dual orexin receport agnoists (DORA) - Lemborexant and Suvorexant
what is ETOH effect on sleep
creates feeling of relaxation and sleepiness but interferes with sleep length and quality
What vitamins/minerals need to be increased in patients > 70 yo
Calcium (1200mg/day) and vitamin D (800 IU/day)
what are medical causes of unintentional weight loss
malignancy
CHF
COPD
malabsorption
dementia
endocrine (DM, hyperthryoidism)
end stage liver or renal failure
poor dentition, poorly fitting or lack of dentures
What are psychological causes of unintentional weight loss
depression, dementia, bereavement, anxiety, parinoia
what medication classes can affect appetite and olfactory/taste sensation
antidepressants
anti-inflammatories
anti HTN, cardiac meds
lipid lowering meds
antihistamines
antimicrobials
antineoplastics
bronchodilators or other asthma meds
muscle relaxants
parkinsonism meds
anticonvulsants
vasodilators
