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Geriatrics > Chapter 8 > Flashcards

Chapter 8 Flashcards

1
Q

How is immobility treatment gauged?

A

By improvement in function

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2
Q

Definition of immobility

A

A limitation in independent, purposeful physical movement; it is a measure of function (or lack of), not a dz

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3
Q

Importance of small improvements

A

Can decrease incidence and severity of complications, and improve function, sense of well being, caregiver burden

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4
Q

Musculoskeletal causes of immobility

A 
Arthritides
Osteoporosis
Fxs (esp hip and femur)
Podiatric problems
Other (e.g., Paget's dz)
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5
Q

Neurological causes of immobility

A 
Stroke
Nl pressure hydrocephalus
Parkinson's dz
Dementia
Other (cerebellar dysfunction, neuropathies)
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6
Q

Cardiovascular causes of immobility

A

CHF (severe- low output/perfusion)
Coronary artery dz (frequent angina)
Peripheral vascular dz (frequent claudication)

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7
Q

Pulmonary causes of immobility

A

COPD (severe)

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8
Q

Sensory factors in immobility

A

Impairment of vision, proprioception, touch

Fear (from instability and fear of falling)

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9
Q

Environmental causes of immobility

A 
Forced immobility (in hospitals and nursing homes)
Inadequate aids for mobility
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10
Q

Other causes of immobility

A

Acute and chronic pain
Malnutrition
Severe systemic illness (e.g., widespread malignancy)
Depression
Deconditioning (after prolonged bed rest from acute illness)
Drug side effects (e.g., antipsychotic-induced rigidity
Apathy, fear of falling, lack of motivation

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11
Q

Skins complications of immobility

A

Pressure ulcers

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12
Q

MS complications of immobility

A

Muscular deconditioning and atrophy
contractures
Bone loss (osteoporosis)

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13
Q

Cardiovascular complications of immobility

A

Deconditioning
Orthostatic hypotension
Venous thrombosis, embolism

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14
Q

Pulmonary complications of immobility

A

Decreased ventilation
Atelectasis
Aspiration pneumonia

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15
Q

GI complications of immobility

A

Anorexia
Constipation
Fecal impaction, incontinence

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16
Q

GU complications of immobility

A

Urinary infection
Urinary retention
Bladder calculi
Incontinence

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17
Q

Metabolic complications of immobility

A

Altered body composition (e.g., decreased plasma volume)
Negative nitrogen balance
Impaired glucose tolerance
Altered drug pharmacokinetics

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18
Q

Psychological complications of immobility

A

Sensory deprivation
Isolation
Delirium
Depression

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19
Q

Hx components in assessment of immobile geriatric pts

A

Medical conditions contributing to immobility
Nature and duration of disabilities causing immobility
Pain
Drugs that can affect mobility
Motivation and other psychological factors
Environment

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20
Q

Two things to check in the start for PE

A

Skin

Cardiopulmonary status

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21
Q

MS examination

A

Muscle tone and strength; symmetry
Joint-ROM; heat; swelling; deformity; erythema; crepitus; mono-poly; large vs small; symmetry
Foot deformities and lesions

22
Q

Neuro exam

A

Focal weakness
Sensory and perceptual eval
Affect, cognition

23
Q

Levels of mobility

A 
Bed mobility
Ability to transfer (bed to chair)
Wheelchair mobility
Standing balance
Gait
Pain with movement
24
Q

General assessment of immobile pts

A

Ascertain pts perceived cause; there is frequently some volitional component, need pt education!
Assess mood and fear (subjective) and affect (objective); fear may be denied, ask caregivers
Assess nutrition, protein, and vit D levels
Pt function with reevaluations

25
Q

Lab assessment

A

ESR- helpful in following pts with PMR; nonspecific (infection, malignancy)
Rheumatoid factor- false positives (rate increases with age); false negatives (esp early in process)
Uric acid- blood levels may support suspicion, but: crystals in synovial required for diagnosis of gout, CPPD
ANA: sensitive for autoimmune dz; positive only 20-30% for RA
Anti-CCP: specific and sensitive for RA

26
Q

Maxims of immobility managment

A

Goal driven (prevention of complication, optimize function and mobility)
Target diseases and disabilities (by diagnosis)
Multispecialty involvement (PT, OT)
Frequent reassessment
Environmental manipulation

27
Q

Algorithm for joint pain

A

Is it joint or periarticular (tendonitis, bursitis) or polymyalgia?
Is it monoarticular (OA) or polyarticular?
Is it inflamed or not?
Is it acute onset, 1st M-T? Think gout
If more muscle than joint, think PMR

28
Q

Monoarticular joint pain

A 
Inflammatory- consider:
-Gout
-CPDD (pseudogout)
-Septic arthritis
Noninflammatory- consider:
-Osteoarthritis
29
Q

Polyarticular joint pain

A

Inflammatory- consider:
-Rheumatoid arthritis
Noninflammatory- consider hx:
-Osteoarthritis

30
Q

What is the most common joint disease?

A

`Osteoarthritis

The major cause of knee and hip pain in the elderly

31
Q

Characteristics of OA

A

Cartilage destruction
Osteophyte formation
Loss of joint space (in wt-bearing joints)
Insidious, brief morning stiffness, crepitus
Usually 1 or few joints, not polyarthritis

32
Q

Dx of OA

A

X-ray
Wt-bearing film shows narrowed joint space;
U/s, MRI more accurate, comprehensive, but more expensive

33
Q

Tx of OA

A

Nonpharm- wt loss, PT, exercise, ice, heat
Pharm- APAP, NSAIDs, intra-articular steroids, glucosamine +/- chondroitin controversial, visco-supplementation (intra-articular injections of hyaluronan or hyaluronic acid polymers)
Surgical: joint replacement, arthroscopy
Vit D, glucosamine, chondroitin of doubtful benefit

34
Q

What is helpful in diagnosing other arthritides?

A 
Synovial fluid analysis
Joint X-ray
ESR
H/h (anemia in RA and PR)
Anti-CCP
RF
35
Q

Onset of RA

A

Usually age 20-40, but may have new onset of RA in elderly (20% of all cases)

36
Q

What RA affects

A 
PIP (ulnar deviation)
MCP
Wrist
Elbow
Shoulder
TMJ
C-spine
Hip
Knee
Ankle
MTP
37
Q

Characteristics of OA

A 
Inflammatory
Polyarticular
With symmetry
Joint synovitis
Prolonged morning stiffness
38
Q

Lab findings in OA

A

RF usually, but not always, elevated, esp early

39
Q

Diagnostic criteria for RA

A 
Must have 5 of 7, 1st 4 continuous for >6 wks
Morning stiffness (1 hr or more)
Arthritis of 3 or more joints with swelling or fluid
Swelling of 1 or more wrist, PIP, MCP joints
Symmetrical joint swelling
Positive serum RF
Rheumatoid nodules (sub-Q, hands, fingers, knuckles, elbows)
X-ray: erosions, decalcification in affected joints
40
Q

Labs in RA

A 
H/h frequently normochromic, normocytic anemia, thrombocytosis
ESR, CRP elevated: not specific
RF sensitivity only 70-80%
Anti-CCP sensitive; specificity >90%
ANA not sensitive; shows autoimmune SLE
41
Q

Radiography of RA

A

Plain films of hands, wrists, feet initially
Lack of bony remodeling, symmetric joint space narrowing
Cortical bone erosions: indistinct margins, dot-dash pattern of cortical loss
Periarticular osteopenia

42
Q

RA tx goals

A

Control pain
Maximize functional status
Modify disease
Advanced age doesn’t necessarily preclude use of DMARDS

43
Q

RA management

A

Think both symptomatic management and dz-modifying
Don’t wait to start DMARDs (N-B first) 1st 2-3 mos
DMARDs from different classes additive
Refer to rheumatologist if ongoing active disease > 3 mos maximal therapy
Use steroids only for brief flare sx; but low dose c-s effective, and better than NSAIDs
Think med-induced gastritis; PPIs, surveillance, caution in Hep C, or liver dz
Screen for latent TB if using TNF inhibitors

44
Q

When is PMR most common?

A

Older women

45
Q

What is PMR associated with?

A

Temporal arteritis, esp when ESR >75 mm/h
Untreated, can lead to blindness
Biopsy the temporal artery; treat aggressively

46
Q

Prognosis of PMR

A

Tends to be self-limited 1-2 yrs

47
Q

Lab findings of PMR

A

Increased ESR

Anti-CCP usually neg

48
Q

Dx of PMR

A

Clinical; immediate response to corticosteroids confirms

49
Q

Findings of PMR

A 
Prolonged morning stiffness
Wt loss
Fever
Muscle pain
Symmetry
Hip
Shoulders
50
Q

Tx of PMR

A

Prednisone 10-20 mg/day

Most will need Rx for >2 yrs then taper off; may relapse

51
Q

Inflammatory vs Noninflammatory

A

All newly inflamed joints with significant effusion should be tapped, cultured (with Gram stain) to r/o infection, a cause of osteomyelitis, joint destruction
OA usually not associated with inflammatory response, RA and PMR always are

52
Q

First line treatments for OA, RA, PMR

A

OA: NSAIDs or other anti-inflammatories
RA: DMARDs
PMR: steroids

Geriatrics (2 decks)

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