Comorbidities and care for chronically ill Flashcards
What are the care principles in FM
- Continuity of care
- Comprehensiveness of care
- Coordination of care
- Domination of prevention
- Community oriented
- Family - focused
What is palliative care according to WHO?
Is an approach that improves the quality of life of pat and their families facing the problem ass w life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual
How many deaths does GP have per 2000 pats?
20 deaths. Usually from dementia, fruity and decline, cancer, organ failure and acute illness.
What are the principles of cancer pain tx?
- The use of drugs according to WHO analgesic ladder
- Use the rule of watch
- When applicable, give drugs orally
What are the non opioid analgesic drugs used for cancer pain tx?
NSAIDs, metamizole, acetaminophen
Weak opioids used?
Tramadol, codeine, dihydrocodeine, small dose of weak opioids ( morphine, oxycodone, hydromorhone) + drugs from step 1
What are the drugs on step 3?
Strong opioids: morphine, phentanyl, buprenorfine, oxycodone + drugs from step 1
What should you do at every stage/step?
- Treat breakthrough pain
- Control SE of medication (constipation)
- Use co-analgesics and adjuvant Tx
- Consider invasive procedures
- Consider rehab procedures
What are the causes of constipation w cancer?
- hypercalcemia, infiltration and compression of organs
What are the causes of constipation w palliative treatment?
opioids, Nsaids, cholinolytics (TCAd, antiemetics), 5HT3 receptor antagonist, vincristine, diuretics (dehydration and hypokalemia)
What are the causes of constipation w cachexia ?
- Limited physical activity
- Poor nutrition
- Limited fluid intake
- Dehydration from vomiting, polyuria, fever
- General weakness
What are the direct tumor dyspnea causes?
Parenchymal, lymphangitic carcinomatosis, obstruction, superior vena cava sd/obst, tumor microemboli, pleural effusion/tumor, pericardial effusion, ascites/hepatomegaly
What are the indirect tumor dyspnea causes?
Neurologic paraneoplastic sd, cachexia, electrolytes, infection, anemia, pulmonary embolus, aspiration
What is the Norton scale?
Scale for deductible ulcer. W score of 14 or less you have increased risk of deductible ulcer. Measures physical condition (1-4), mental, activity, mobility, incontinence
Nortons physical condition
4 -good
3 - fair
2 - bad
1 - very bad
Norton mental condition
4 - Alert
3 - Apathetic
2 - confused
1 - stuporous
Norton activity
4 - active
3- help with walking
2 - chairbound
1 - bedridden
Norton mobility
4 - full
3 - slightly impaired
2 - very impaired
1 - immobile
Norton incontinence
4 - none
3 - occational
2 - urinary
1 - urinary and fecal
How to prevent deductible ulcer?
- Minimize pressure w frequent change of position
- Special mattress
- Regular inspection and proper skin care
- Proper diet w protein and hydration
- Education of caregivers
What are the type measures in hyperglycemia?
- Random plasma glucose w/o regard to time or last meal (RPG)
- Fasting plasma glucose before breakfast ( FPG)
- Postprandial plasmaa glucose 2h after a meal (PPG)
- Oral glucose tolerance test (OGTT) 2h after a 75g oral glucose drink
- HbA1C reflects mean glucose over 2-3 months
What makes DM unlikely?
Fasting or random glucose <5,5 or OGTT negative
What should you do if fasting glucose is 5,5-6,9 or random btw 5,5-11?
Do OGTT
What should you do if fasting glucose is >7 or random is >11 ?
Retest w FPG. If 7 or more, DM dx can be made. If under 7, do OGTT
Who is at risk for DM after OGTT?
If impaired fasting glucose or impaired glucose tolerance. Retest in 1 year
What is DM?
A disorder of carbohydrate metabolism. A group of diseases characterized by high levels of blood glucose ass w relative or absolute deficiency of insulin resulting from 1) defect in insulin production 2) insulin action 3) both (?).
What are the characteristics of DM?
Chronic hyperglycemia w disturbance of carbohydrate, fat and protein metabolism
What are the overall effects of DM?
Long term damage, dysfunction and value of organs
What is DM 1?
Insulin dependent DM. Beta cell destruction leading to absolute insulin deficiency. Little or no endogenous secretion of insulin. Require insulin Tx. It is the more severe type. Prevalence is highest in young persons, although onset can occur in any age.
What are the risk factors of DM1?
- Autoimmune disease 2. Genetic 3. Environmental factors (?)
What are the circulating autoantibodies in DM1?
GAD65, ICA
Subacute presentation on DM1
- Polyuria, polydipsia
- loss of weight
- fatigue and weakness
- pruritus
- parasthesia
- visual disturbance
How is severe acute prestentation of DM1?
- Dehydration
- N/V
- abd pain
- circulatory collapse
- stupor and coma
what is late onset DM1?
- About half of pat w type one are dx after 18
- autoimmune process may differ and is slower
- often mistaken for type 2 , may make up 10-30% of individuals w type 2
- oral agents are usually ineffective, insulin tx is eventually required
What is DM2?
- Non- insulin dependent DM, (NIIDM)
- From predominantly insulin resistance w relative insulin deficiency to predominantly an insulin secretory defect w insulin resistance
- mature onset
- insulin is still produced
- ass w obesity
What are clinical presentation of DM2?
- Many are asymptomatic
- sx are often mild and gradual: thirst, polyuria and loss of weight developing over several months
- susceptible to skin Staph inf
- increased mortality from atherosclerotic complications
- candida vaginitis
- balanitis
What is pre-diabetes?
- increased risk for developing DM, impaired fasting glucose or impaired glucose tolerance
- weightless and increased physical activity can prevent/delay diabetes and may return to normal blood glucose levels
- have increased risk of AE (HD and stroke)
How can you prevent DM if preDM?
- lifestyle change: diet and exercise 2,5h/week
- metformin, reduce risk of DM in pat w IGT by 31% over 3y. Most effective among younger heavier people
Finding DM
- 25-30% are undiagnosed
- true onset may be 7-12y before clinical recognition
- 25% have evidence of microvascular complication on Dx
- early intervention w diet and lifestyle amongst risk group is preventative and worthwile
What are the problems ass w DM?
- mortality from CHD x 5 higher
- mortality from CVA (cerebrovascular accident) x 3 higher
- leading cause of renal failure
- leading cause of blindness in working age
- 2nd most common cause of lower limb amputation
What is the strategy for weight loss in DM?
- decrease intake of calories by 500 per day
- increased physical activity, increase insulin sensitivity and aid in weight mx, 45-60min 5x week
- monitor weight at least once a week
- recommend keeping a food diary
physical activity in DM
- low risk of hypoglycemia in patient on diet and oral drugs
- adjusted to general activity, health, preferences
- moderate intensity: 1) brisk walking 2) swimming 3) jogging
- weight maintenance: 30 min per day at least 5 x week
- weight reduction: 60 min per day
- use of pedometer to measure number of steps
- can benefit insulin sensitivity, BP and blood lipid control
What is the basal bolus insulin concept?
- Basal insulin: controls glucose production btw meals and overnight, nearly constant levels, 50% of daily needs
- Bolus insulin: mealtime or prandial, limits hyperglycemia after meals, immediate rise and sharp peak at 1h post meal. 10-20% of total daily insulin requirement at each meal
What is ideal insulin replacement tx?
Each component should come from a different insulin w a specific profile
what is the tx of DM2?
- prediabetes : lifestyle
- onset of sx and dx: metformin
What can you use in DM2 after metformin treatment for a while?
alpha glucosidase inhibitor, glitazones, secretagogues, insulin
What are the microvascular complications in DM?
- Eye: retinopathy, cataract, glaucoma, blindness
- Kidney: nephropathy, microalbuminuria, gross albumin uria, kidney failure
- Nerves: neuropathy , peripheral, autonomic, amputation
What should you monitor of microvascular complications in DM?
- Eyes: visual acuity, ophthalmoscopy, retinal photography
- kidney: serum creatinin, GFR, ACR (urine albumin/ creatinine ratio)
- nerves: gastroparesis, erectile dysfunction, bladder emptying problems, foot neuropathy (ulcer)
What are the macrovascular complications in DM?
- Heart: CAD, coronary sd, MI, CHF
- brain: cerebrovascular disease, TIA, CVA, cognitive impairment
- extremities: peripheral vascular disease, ulceration, gangrene, amputation
- survival in DM depends on macrovascular complications
How to monitor macrovascular complications in DM?
- Exercise ECG if cardiac sx or abnormal ECG
- peripheral / carotid vascular disease
- Multiple risk factors
- plans to begin vigorous exercise program
How to assess outcomes
= HbA1C
- reflects mean glucose over 2-3 months
- aberrant values w variant Hb or blood disorders
- target level < 7% ( 6-8%) = 42 mol
- frequency of testing: w values at target every 6 m, w/o target or tx changes = every 3m
What is the definition of having comorbidities?
At least 2 chronic diseases. Average is 4-5 diagnoses. > 65y, 80% have at least 1 disease
What is the life expectancy of a geriatric patient based upon?
On their health and function. Evaluation can help health professionals set priorities in making decisions about the health care needs of this group of patient.
HT among >65y
Very common, 60-80%.
HT is a major risk factor for
coronary heart disease. Tx decrease 59% in mortality from stroke and 50% from CHD
What is the recommended screening for HT
Every 1-2 y
What is the initial mx of HT?
- Routine tests
- Non-pharmacological tx
What are the non modifiable risk factors of ischemic heart disease?
- age, 45 or over in male, 55 or over in female
- male sex
- family history of CHD
- personal history of CHD
- low birth weight
What are the modifiable (by lifestyle) risk factors of icd?
- diet: cholesterol, saturated fat, calories
- smoking
- obesity
- sedentary lifestyle
What are the modifieable by pharmacology + lifestyle risk factors of IHD?
- high BP
- increased LDL
- decreased HDL
- increased triglycerides
- thrombogenic factors
- DM
How can you dx CAD?
- ECG
- exercise stress test
- echocardiography
- perfusion scintigraphy of the heart
- angiography (invasive)
When should you start w risk assessment in IHD?
- begin at age 20
- positive family history of CHD, regularly updated
What should you do in risk assessment of IHD?
- smoking status
- diet
- alcohol intake
- physical activity
What is the assessment scale for evaluating risk for CVD?
- SCORE: Systematic COronary Risk Evaluation
- use age + cholesterol level + smoking status + gender + systolic BP
- 10 year risk of fatal CVD in population of high risk
What is atherogenic dyslipidemia?
- increased total cholesterol, LDL and TG + decreased HDL
When is screening and tx justified in atherogenic dyslipidemia?
For pat w increased risk of CHD more than 10% in 10 years. Pat w HT + impaired lipid economy benefit from Tx w hypolipemics
What may decreased visual acuity by cataract increase the risk for ?
Increase the risk for falling and is a predictor of mortality in elderly
How may cataract surgery influence?
Improves cognitive functions (?), decrease the rate of depression and improve quality of life
What is early intervention of vision disorders ass w?
Ass w the dx of macular degeneration
What is associated with hearing loss in elderly?
Ass w occurrence of depression, social isolation and low self esteem
What is the standard reference of hearing screening?
Audiometric test
What is ass w depression in elderly?
- Suicide rate in geriatric population is almost twice as high compared to general population
- Highest indicator is for caucasian men > 85y (?), initially present in the POS (?) because of somatic complaints
- recommended screening pat w severe chronic illness or incidents or death in the family
What is ass w elderly and vaccinations?
- Over 90% of deaths from influenza is over 60y
- Pneumococcal pneumonia is an important cause of morbidity and mortality in the elderly. Pneumovaccine Prevenar 23 & 13 should be given to pat > 65y
- Tetanus prophylaxis w wounds
What is the rationale for prescribing meds w comorbidities?
- SE can result in increased morbidity and high rate of hospitalization in older patient
- Meds should be tailored to the individual pat, together w assessment of renal function (GFR) and liver
- Lists of drugs should be reviewed and updated periodically. Focus on indications for use and SE
- One drug should not be used to treat the SE of another
- Meds should be given within a rational Tx plan
