Exam II Flashcards
1
Q
What are the 4 intentions of the Beers Criteria?
A
Improving the selection of Rx drugs by clinicians and patients
Evaluating patterns of drug use within populations
Educating clinicians and patients on proper drug usage
Evaluating health-outcome, quality of care, cost, and utilization data
2
Q
The goal of the Beers criteria is to improve the care of older adults by reducing their exposure to what?
A
PIMs
Potentially Inappropriate Medications
3
Q
Is the Beers criteria considered a set of hard and fast rules?
A
No. It’s geared toward the practicing clinician, but is not meant to supersede the Dr’s judgement or the patient’s needs.
4
Q
What’s considered to be the best approach to prescribing a medication?
A
A team approach to prescribing, the uses of non-pharmacologic means first, and a care plan that meets the needs specific of the patient (aka don’t just parrot the Beers criteria…use your brain!)
5
Q
What are the 2 ways that drug-drug interactions occur?
A
Pharmokinetic: What the body does to the drug
Pharmodynamic: What the drug does to the body
6
Q
What is the most frequent drug-drug pharmokinetic interaction?
A
P450 (CYP)
7
Q
Which type of drug interaction is related to the pharmocologic activity of interacting drugs and is an amplification or decrease in the therapeutic effects or side-effects of a specific drug?
A
Pharmacodynamic D-D interactions
8
Q
What are the 5 other types of drug-drug interactions?
A
- Drug-disease
- Drug-Food
- Drug-Alcohol
- Drug-Herbal products
- Drug-Nutritional Status
9
Q
What type of reserves decrease with age? Why do you need to take this into consideration when prescribing to the elderly?
A
Cellular, organ, and systems reserves. This means the elderly are not going fit the prototypical model of the medication and its effects.
10
Q
What is an important thing to obtain from a pt before doing any prescribing?
A
A complete medication list. They may be on Meds from various docs
11
Q
What type of drugs should you avoid if there is an equally effective alternative available?
A
Drugs with a narrow therapeutic window
12
Q
Who are the elderly patients that bear a higher risk for drug interactions?
A
Organ transplant pts, HIV pts, and pts with mental or health problems, pts who take lots of rxs, have several co-morbidities, or do not maintain adequate nutrition
13
Q
What are some common causes of falls?
A
Accidental/environmentally related, Gait/balance disorders*, weakness, dizziness, drop attack, confusion, postural hypotension, visual disorders, syncope
14
Q
What is a drop attack?
A
A sudden fall without loss of consciousness or dizziness
15
Q
What are 2 important risk factors that can pre-dispose a pt to falling?
A
Muscle weakness from disease and inactivity and medications (specifically psychoactive meds)
16
Q
What is important to obtain when treating a patient who has fallen?
A
You want to get a full report of the circumstances and symptoms around the time of the fall, reports from witnesses can be helpful
17
Q
What are 3 things you should do when assessing a pt who has fallen?
A
- Look for orthostatic changes in pulse and blood pressure, heart sounds, bruits, neurological signs, etc
- Try to reproduce the events that may have caused the fall (head turn, position changes)
- Asses gait and stability
18
Q
For what 3 conditions is it important to first treat the underlying cause?
A
cardiac, drug side effects, Parkinsons
19
Q
What are some things you can do for pts experiencing orthostatic hypotension?
A
- Sleeping with the head raised can reduce sudden drop in pressure when rising
- Elastic stocking minimize varicose veins pooling
- Increase blood volume with salt
- Mineralocorticoids if the above doesn’t help
20
Q
What can you do for disabilities that don’t respond to Tx?
A
Short-term rehabilitation may improve safety and diminish long-term disability
21
Q
What can you eliminate/add in the home to prevent falls?
A
Eliminate home hazards (rugs, wires, etc) and get proper handrails and grips
22
Q
What can the pt do to prevent falling?
A
the patient should do exercise programs for balance, strength, and endurance training
23
Q
Changes in what 3 physiological systems lead to frailty?
A
Neuromuscular
Neuroendocrine
Immunological
24
Q
What is the key phenotypical component to frailty?
A
Sarcopenia or loss of muscle mass and strength
25
What 4 factors contribute to sarcopenia?
Nutrition
Hormonal
Metabolic
Immunological
26
What are the 5 other phenotypical factors of frailty>
```
Anorexia
Osteoporosis
Fatigue
Risk of falls
Poor physical health.
```
27
What are 2 measures of frailty?
Sarcopenia and the Fried Frailty Model
27
What are 2 measures of frailty?
Sarcopenia and the Fried Frailty Model
28
What are the 5 components of the Fried Frailty Model? *WWELS)
1. Weight Loss
2. Weakness
3. Exhaustion
4. Low Energy Expenditure
6. Slowness
28
What are the 5 components of the Fried Frailty Model? *WWELS)
1. Weight Loss
2. Weakness
3. Exhaustion
4. Low Energy Expenditure
6. Slowness
29
How much weight loss is considered to be a factor for frailty?
Self-reported >4.5 kg
| or recorded loss of > or = to 5%/year
29
How much weight loss is considered to be a factor for frailty?
Self-reported >4.5 kg
| or recorded loss of > or = to 5%/year
30
What energy expenditure is a factor for frailty?
Women: <383 kcal/week
30
What energy expenditure is a factor for frailty?
Women: <383 kcal/week
31
How do you measure slowness?
Standardized cut-off times for a 15 ft walk, adjusted for sex and height
31
How do you measure slowness?
Standardized cut-off times for a 15 ft walk, adjusted for sex and height
32
How do you measure weakness?
Grip strength
32
How do you measure weakness?
Grip strength
33
What are some indications for measuring bone mineral density in persons over 50 years of age?
Over 65, Fragility fracture after age 40, Prolonged use of glucocorticoids or other high risk meds, parental hip fracture, vertebral fracture or osteopenia, current smoking, high alcohol intake, low body weigh, major weight loess, or RA
33
What are some indications for measuring bone mineral density in persons over 50 years of age?
Over 65, Fragility fracture after age 40, Prolonged use of glucocorticoids or other high risk meds, parental hip fracture, vertebral fracture or osteopenia, current smoking, high alcohol intake, low body weigh, major weight loess, or RA
34
What is an example of an anti-resporptive agent?
Bisphosphonates, Receptor activator for nuclear factor κ B [RANK] ligand inhibitor, Selective estrogen receptor modulator, Hormone therapy, Calcitonin)
34
What is an example of an anti-resporptive agent?
Bisphosphonates, Receptor activator for nuclear factor κ B [RANK] ligand inhibitor, Selective estrogen receptor modulator, Hormone therapy, Calcitonin)
35
What is an example of a bone-forming agent?
Teriparatide
35
What is an example of a bone-forming agent?
Teriparatide
36
In general, pharmacotherapy reduces the risk of vertebral fracture by ___________, depending on the agent and level of adherence
30-70%
36
In general, pharmacotherapy reduces the risk of vertebral fracture by ___________, depending on the agent and level of adherence
30-70%
37
What 2 drugs may decrease the pain associated with vertebral fractures?
Teriparatide and calcitonin
37
What 2 drugs may decrease the pain associated with vertebral fractures?
Teriparatide and calcitonin
38
What are the first line Rxs for menopausal women with osteoporosis?
Alendronate, risedronate, zoledronic acid, and denosumab
38
What are the first line Rxs for menopausal women with osteoporosis?
Alendronate, risedronate, zoledronic acid, and denosumab
39
What are the first line Rx for menopausal women with osteoporosis to prevent vertebral fxs?
Raloxifene
39
What are the first line Rx for menopausal women with osteoporosis to prevent vertebral fxs?
Raloxifene
40
What is the 1st line therapy for women with osteoporosis that also require Tx for vasomotor Sx?
Hormone therapy 1st line therapy for prevention of hip, non-vertebral, and vertebral fractures
40
What is the 1st line therapy for women with osteoporosis that also require Tx for vasomotor Sx?
Hormone therapy 1st line therapy for prevention of hip, non-vertebral, and vertebral fractures
41
What is the 1st line therapy for menopausal women who are intolerant of first line therapies?
Calcitonin or etidronate for prevention of vertebral fractures
41
What is the 1st line therapy for menopausal women who are intolerant of first line therapies?
Calcitonin or etidronate for prevention of vertebral fractures
42
What are the Rxs for men requiring Tx of osteoporosis?
Alendronate, risedronate, and zoledronic acid 1st line therapies for prevention of fractures
42
What are the Rxs for men requiring Tx of osteoporosis?
Alendronate, risedronate, and zoledronic acid 1st line therapies for prevention of fractures
43
What is the one thing you do NOT want to give men with osteoporosis?
Do NOT give testosterone
43
What is the one thing you do NOT want to give men with osteoporosis?
Do NOT give testosterone
44
What are the adverse effects of high-dose Ca++ supplements?
Increase risk of renal calculi and CV events
44
What are the adverse effects of high-dose Ca++ supplements?
Increase risk of renal calculi and CV events
45
What are the adverse effects of bisphosphates?
Self-limited flu-like symptoms (especially after 1st dose of zoledronic acid by infusion 10% pts)
45
What are the adverse effects of bisphosphates?
Self-limited flu-like symptoms (especially after 1st dose of zoledronic acid by infusion 10% pts)
46
What are the adverse effects of Denosumab?
Increased risk of cellulitis
46
What are the adverse effects of Denosumab?
Increased risk of cellulitis
47
What are the adverse effects of Raloxifene and Hormonal therapy?
Increase risk of thromboembolic events (including PE)
47
What are the adverse effects of Raloxifene and Hormonal therapy?
Increase risk of thromboembolic events (including PE)
48
What are the adverse effects of Teriparatide?
Hypercalciuria and hypercalcemia
48
What are the adverse effects of Teriparatide?
Hypercalciuria and hypercalcemia
49
What are the really weird side effects of bisphosphonates?
Osteonecrosis of the jaw
(Area if exposed alveolar bone in mandible/maxilla not healing after 8 weeks)
Atypical fractures of the femur
(Occur subtrochanteric or diaphyseal regions)
Esophageal CA
Atrial Fibrillation
49
What are the really weird side effects of bisphosphonates?
Osteonecrosis of the jaw
(Area if exposed alveolar bone in mandible/maxilla not healing after 8 weeks)
Atypical fractures of the femur
(Occur subtrochanteric or diaphyseal regions)
Esophageal CA
Atrial Fibrillation
50
Given all the weird side effects, when is it appropriate to use bisphosphonates?
Generally, for patients with a high 10-year fracture risk the benefits of pharmacologic therapy far outweigh the potential risks
50
Given all the weird side effects, when is it appropriate to use bisphosphonates?
Generally, for patients with a high 10-year fracture risk the benefits of pharmacologic therapy far outweigh the potential risks
51
What are the criteria that make a pt at high-risk for fx?
10- year fracture risk > 20% OR
Prior fragility fracture of hip or spine OR
>1 Fragility fracture
51
What are the criteria that make a pt at high-risk for fx?
10- year fracture risk > 20% OR
Prior fragility fracture of hip or spine OR
>1 Fragility fracture
52
What is the Tx strategy for a high risk pt?
Offer pharmacologic therapy
| If patient undergoing treatment, repeat measurement of bone mineral density performed 1-3 years
52
What is the Tx strategy for a high risk pt?
Offer pharmacologic therapy
| If patient undergoing treatment, repeat measurement of bone mineral density performed 1-3 years
53
What are the criteria that make a pt at moderate risk for fx?
10-year fracture risk 10%-20%
Look at additional risk factors and patient preference, maybe pharmacologic therapy
Repeat bone mineral density after 1-3 years to monitor for rapid bone loss
53
What are the criteria that make a pt at moderate risk for fx?
10-year fracture risk 10%-20%
Look at additional risk factors and patient preference, maybe pharmacologic therapy
Repeat bone mineral density after 1-3 years to monitor for rapid bone loss
54
What are the criteria that make a pt at low risk for fx?
10-year fracture risk <10%
Pharmacologic therapy usually not needed Lifestyle changes (exercise, fall prevention, optimized Ca and Vit D intake, stop smoking)
Testing interval for bone mineral density of 5-10 years may be sufficient
54
What are the criteria that make a pt at low risk for fx?
10-year fracture risk <10%
Pharmacologic therapy usually not needed Lifestyle changes (exercise, fall prevention, optimized Ca and Vit D intake, stop smoking)
Testing interval for bone mineral density of 5-10 years may be sufficient
55
Hospital-PCP communication can be improved by doing what with the discharge summary?
Making it clear and concise (standardized format) and hand-delivering it the day of discharge
56
The current JCAHO performance standard requires that discharge summaries be completed w/in_______ ________ but this isn’t sufficient from a patient safety perspective and doesn’t meet the needs of primary care physicians and patients
30 Days
57
Errors related to discontinuity of care due to primary care physicians not receiving discharge summaries in a timely manner or receiving discharge summaries lacking pertinent information, are associated w/ a significantly higher risk of what?
Readmission
58
About ______ of pts. have test results that return after they’ve been discharged and their physicians are usually unaware of these results, even though about _____ of them require some action
40%, 10%
59
What is elder maltreatment?
an act or omission that results in harm or threatened harm to the health or welfare of an elderly person.
60
What is physical abuse?
An act carried out with the intention of causing physical pain.
61
What are some examples of physical abuse?
Includes slapping, blunt force trauma, bites, pinching, traumatic alopecia, burns and scalds, force feeding, overmedication, under-medication, improper medication, and improper use of physical restraints.
62
What are some indicators of accidental trauma?
abrasions and contusions over bony prominences and long bone and vertebral fractures.
63
What are some indicators that are considered worrisome?
Injuries to inner thigh, top of feet, inner ankle, inner wrists, palms and soles, pinna, posterior neck, mastoid region, face, head, and axilla.
64
What is the most common cause of death in elder abuse?
Subdural hemorrhage
65
What does a Stage 4 pressure ulcer look like?
Full-thickness tissue lost with exposed bone, tendon, or muscle; slough or escar may be present in some parts of the wound bed. Often includes undermining and tunneling
66
What are the 5 mimickers of elder abuse?
Skin findings, bleeding, fractures, malnutrition, and anogenital findings.
67
What are some common locations of Fx that are NOT worrisome?
Femoral neck, proximal humerus, and vertebrae. Ribs can break from CPR.
68
What are some common changes in women that can mimic urogenital abuse?
postmenopausal bleeding, uterine prolapse, and infections
69
Use of what Rx can mimic anogential abuse/contact burn in men?
Tetracycline
70
What conditions cause anal fissure that can mimic sexual abuse?
IBD/Constipation
71
Senile purpura, steroid purpura, Cushing syndrome, Fixed drug reactions, and bleeding disorders secondary to medications can mimic what type of abuse?
Contusion
72
DM, Malabsorption, UTI, perineal excoriation, dehydration secondary to medications, vaginitis, constipation, poor would healing, and IBD can all mimic what type of abuse?
Neglect/Starvation
73
Fragile photo aged skin can mimic what type of abuse?
Laceration
74
Fracture from osteoporosis can mimic what type of abuse?
Inflicted Fx or blunt force trauma (BFT)
75
Cystocele, uterine prolapse, fixed drug reactions, decreased anal sphincter tone, perineal excoriation, Vaginitis, Lichen sclerosis, Constipation, and IBD can all mimic what type of abuse?
Sexual
76
Fracture from osteoporosis, bleeding disorders secondary to meds, subdural hemorrhage, contact dermatitis, and allergic runs can mimic which type of abuse?
Blunt Force Trauam
77
Fixed drug reactions, contact dermatitis, and toxic epidermal necrolysis can all mimic which type of abuse?
Burn/Scald
78
Elevated drug levels secondary to decreased renal clearance can mimic what type of abuse?
Chemical restraint
79
Describe active vs. passive neglect
Active neglect caregiver intentionally fails to meet his/her obligations toward an elder
Passive neglect unintentional failure to meet obligations toward elder
80
Name the 6 main types of abuse
1. Physical
2. Sexual
3. Neglect
4. Psychological
5. Financial/material exploitation
6. Violation of rights
81
What is does the typical abuse victim look like?
75-80 white woman who is socially isolated and lives within a close proximity to her abused
82
What are some factors what put elders at risk for abuse?
```
Cognitive impairment
Dementia
Physical impairment
Functional debility
Incontinence
Provocative actions of the elder
Guilt
Fear of nursing home placement
Fear of retaliation
```
83
What is the name of the scale to grade pressure ulcers?
Braden Scale
84
What does a score of 6-9 indicate?
Very high risk of developing pressure ulcers
85
What does a score of 19-23 indicate?
No risk of developing pressure ulcers
86
What are the areas assessed in the Braden Scale?
Sensory perception (1-4), Moisture (1-4), Activity (1-4), Mobility (1-4), Nurtirtion (1-4), and Friction and Shear (1-3)
87
What causes pressure ulcers?
Caused by unrelieved pressure applied with great force over a short period (or with less force over a longer period) that disrupts blood supply to the capillary network, impedes blood flow and deprives tissues of oxygen and nutrients
88
The _________ pressure must be greater than ________ pressure to cause inflow impairment and resultant local ischemia and tissue damage
External; Capillary
89
What does a suspected deep tissue injury look like?
Purple or maroon localized area of discolored, intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure/shear; tissue may be painful, firm, mushy, boggy, or warmer or cooler compared to adjacent tissue
90
What does a Stage 1 pressure ulcer look like?
Intact skin with non-blanchable redness of localized area, usually over a boney prominence, dark pigmented skin may not have visible blanching, and the affected area may differ from the surrounding area. The affected tissue may be painful, firm, soft, or warm or cool compared to surrounding tissue
91
What does a Stage 2 pressure ulcer look like?
Partial thickness loss of dermis appearing as a shallow, open ulcer with a pink-red wound bed without slough; may also appear as an intact or open/rupture serum-filled blister
92
What does a Stage 3 pressure ulcer look like?
Full-thickness tissue lost, sub cut. fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
93
What does a Stage 4 pressure ulcer look like?
Full-thickness tissue lost with exp
94
What does an Unstageable pressure ulcer look like?
Full-thickness tissue loss with the bast of the ulcer covered by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black) on wound bed
95
How do you manage a clean, Stage I ulcer w/o cellulitis?
Protective dressings, as needed
96
How do you manage a clean, Stage II ulcer w/o cellulitis?
Moist dressing (transparent film) + Cleanse wound
97
How do you manage a clean, Stage III/IV ulcer w/o cellulitis?
Apply moist to absorbent dressing (hydrogel, foam, alginate); Sx consult, cleanse wound at each dressing
98
How do you manage a clean, Stage III/IV ulcer w/o cellulitis if it has not improved after 14 days or if you have a clean ulcer with cellulitis?
Use topical antibiotics; apply moist to absorbent dressing, cleanse wound
99
How do you manage a clean, Stage III/IV ulcer w/o cellulitis if it has not improved after 2- weeks or if you have a clean ulcer with cellulitis that has not improved in 2-4 weeks?
Tissue culture for osteomyelitis
100
How do you Tx osteomyelitis or a clean ulcer with advancing cellulitis and systemic infection?
Systemic antibiotics; apply moist to absorbent dressing, cleanse wound
101
How do you Tx a Stage III/IV necrotic ulcer?
Perform debridement; apply moist to absorbent dressing and clean wound
102
What kind of debridement do you perform if advancing cellulitis or sepsis is present?
Sharp
103
What kind of debridement do you perform if it is non urgent?
Autolytic, enzymatic, mechanical
104
When is debriding necrotic tissue NOT recommended?
Not recommended for heel ulcers that have stable, dry eschar without edema, erythema, fluctuance, or drainage
105
What are the basic components of wound care?
```
Release or reduce the pressure on the skin
Debriding necrotic tissue
Cleansing the wound
Managing bacterial load and colonization
Selecting a wound dressing
Pain assessment should be completed
```
106
What is palliative care?
Palliative care aims to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through specific knowledge and skills, including communication with patients and family members; management of pain and other symptom; psychosocial, spiritual, and bereavement support; and coordination of an array of medical and social services.
107
What is the fundamental goal when treating terminally ill pts?
Relief of pain and Sx
