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Geriatrics > FINAL > Flashcards

FINAL Flashcards

1
Q

Functional level

A

-eval how pts problems and living environment leads to -> functional disability and diminished quality of life - @ every visit!
-majority live independently !!
-IADLs and ADLs
-eval different domains: medical, cognitive, psychological, social (living situation), physical
-increase in active life expectancy! -> do as much as they possibly can

-Use functional status as baseline
-Guides recommendations for exercises, PT, adaptive devices for impairments -> sitting down exercise, balance
-Consider home evaluation for impaired
-Potential marker of caregiver stress
-Useful for evaluating risk of & need for placement

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2
Q

ADLs vs IADLS

A

-need to be able to do these to live independently
-Bathing
-Dressing
-Toileting
-Transfers
-Continence
-Feeding- use utensils to feed themselves

-if you cant do these it doesnt mean you cant live independently
-Using telephone
-Shopping
-Food preparation
-Housekeeping
-Laundry
-Transportation
-Medications- can be delivered
-Managing money

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3
Q

geriatric syndromes

A

-Cognitive and Behavioral Disorders:
-Confusion
-Dementia
-Delirium
-Depression

-Frailty
-Falls & Gait disorders- every visit! -> beginning of the end
-Urinary incontinence
-Medication management- polypharmacy

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4
Q

acute care for elders- ACE

A

-specific area in hospital made for elderly
-design- non slip, lighting, etc
-goals- mobility, cognitive
-stakeholders- pt, family, provider, hospital
-impact- lower readmission, shorter stay

-how it works:
-prepared environment
-interdisciplinary team

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5
Q

physiological changes

A

-decreases in muscle mass and strength
-Deterioration and drying of joint cartilage
-bone density
-exercise capacity
-respiratory function
-thirst and nutrition
-ability to mount effective immune responses
-more vulnerable to periods of bedrest and inactivity, external temperature fluctuations, and complications from common infectious diseases

-Atrophy of muscle that line endocardium
-Atherosclerosis
-Increased systolic BP
-Decreased compliance of LV
-Decreased # of pacemaker cells
-Decreased sensitivity of baroreceptors

-Decline in nerves and nerve fibers
-Atrophy of brain and increase in cranial dead space

-LAST TO BE AFFECTED -> RESPIRATORY
-Decreased lung tissue elasticity
-Thoracic wall calcification
-Cilia atrophy
-decrease respiratory muscle -> Aspiration

-Loss of dermal and epidermal thickness
-Atrophy of sweat glands
-Decreased vascularity
-Collagen cross-linking
-Loss of subcutaneous fat

-Decreased liver size
-Less cholesterol stabilization
-atrophy of salivary and taste
-Decreased muscle in bowel
-Decreased HCL
-Decreased ca abs

Decline in number of functioning nephrons
Decreased bladder muscle tone
Atrophy of cervical and uterine walls

-Decreased rod and cone function
-Decreased speed of EOM
-Increased IOP
-Increased lens size and yellowing
-Decreased tears

Loss of auditory neurons
Loss of hearing from high to low frequency
Increased cerumen
Angiosclerosis of ear

-bitter and sour tastes remain

Decreased thermoregulation
Decreased febrile response
Decreased basal metabolic rate

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6
Q

screener

A

-vision- >20/40 on snellen chart
-hearing- cant hear 1,000 or 2,000
-TUG > 10s (10 ft)
-urinary incontinence- have you lost urine in past year -> have you 6 times
-nutrition- 10 lbs in 6 mo or <100 lbs
-memory- 3 item recall after 1 minute
-depression
-physical disability- 6 diff questions

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7
Q

why do we age?

A

-genomic instability -> spontaneous mutation
-telomere attrition -> shortened

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8
Q

cancer screenings

A

-breast and colorectal- >75 or >65 with < 10yrs left

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9
Q

cognitive impairment / dementia

A

-Impairment in 2+:
-memory
-executive function- math, planning,
-language- word searching
-visuospatial function- getting lost
-personality/behavior

-SOCIAL or OCCUPATIONAL impairment -> ADLs
-decline from previous
-not 2/2 delirium or psychiatric disorder -> r/o depression

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10
Q

diff types of dementia

A

-mild cognitive impairment:
-measurable by screening
-at least 1 -> memory, executive function, language, visuospatial function, personality/behavior

-alzheimers:
-memory and learning deficit
-ADLs affected (social/occupational)
-gradual and progressive
-possible atrophy on imaging

-vascular dementia
-sudden / stepwise
-subcortical/cortical ischemia on MRI

-LEWY BODY DEMENTIA:
-hallucination
-REM sleep behavior
-gradual
-parkinsonism

-FRONTOTEMPORAL DEMENTIA:
-<65yo
-gradual
-no motor sx
-atrophy in frontotemporal lobes

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11
Q

cognitive exam

A

-Mini-cog- recall and clock
-MMSE- 0-30
-MoCA
-‘Bedside’ Cognitive assessment
-Confusion Assessment Method (CAM)- change from baseline, inattention, LOC, disorganized thinking

-Lab findings- hypercalcemia, B12, thyroid, heavy metals
-Imaging- tumors, subdural, normal pressure hydrocephalus

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12
Q

caregiver: dementia

A

-maintain familiarity and routines
-decrease # of choices- lay out clothes

-tell; dont ask- dementia pts have apathy -> dont agree with anything
-ex. its time to go to dinner (instead of do you want dinner)
-use positive terms- come with me (instead of dont go there)

-understand they cant -> not they wont -> they arnt being stubborn, learn the limitations -> you cant teach
-dont try logic or reason

-always keep goals in mind- pick and choose battles

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13
Q

pharm tx for dementia

A

-haloperidol
-risperidone
-olanzapine
-trazodone
-citalopram
-divalproex sodium

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14
Q

delirium

A

-Acute, transient, reversible
-fluctuating attention, cognition, and consciousness level
-Precipitating factors -> Any disorder or drug
-Clinical dx with labs and imaging

-Drugs
-Electrolytes
-Lack of drugs- withdrawal
-Infection- respiratory, skin, urinary
-Reduced sensory/motor- bed bound
-Intracranial
-Urinary, fecal
-Myocardial
-Surgery

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15
Q

depression

A

-Somatic > mood complaints in elderly

-depressed mood or anhedonia for 2+ weeks
-3-4+ (total of 5+ symptoms):
-insomnia or hypersomnia,
-worthlessness or excessive guilt,
-fatigue
-diminished ability to think/concentrate,
-appetite or wt loss
-psychomotor agitation or retardation,
-thoughts of suicide

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16
Q

5 Ms

A

-Mind- cognitive, capacity (decisions), delirium, agitation, dementia, depression
-Mobility- functional (ADLs), fall risk, ambulation -> gait and balance assess
-Medications- reconciliation @ every visit, eliminate meds
-Multimorbidity- hospitalization risks, frailty, prognosis, atypical presentations (temp), aging physiology, sensory impairment, urinary incontinence, transition of care, health equity
-Matters most- spiritual, priorities, palliative, advance care

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17
Q

MMSE-2

A

-short (16) version- no referral
-long versions (90)- ceiling effect
-language translations
-no motor component of the comprehension portion now
-reading, writing, drawing- same

-count backward by 7s
-point to body parts not objects

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18
Q

falls

A

->1 fall in past year or fall with injury or gait/balance problem -> increase fall risk
-leading cause of death >65yo
-PRESENTING sx of illness
-screening is annual - if fall within the year -> eval -> if 2 falls within year or gait/balance problem -> multifactorial falls and risk assess
-train gait with ambulatory devices
-hx and TUG are annual screenings

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19
Q

fall risk factors

A

-biggest risk = previous falls
-MODIFIABLE:
-visual acuity
-home environment- extrinsic
-foot wear- extrinsic
-psychotropic drugs or 4+ drugs -> modify
-balance impairment
-muscle strength
-urinary incontinence

-Intrinsic:
-decrease proprioception
-decrease baroreflex -> ortho hypo
-functional problem- ADLs
->80yo
-female
-cognitive impairment
-arthritis
-diabetes
-pain
-low BMI

20
Q

fall screening: performance oriented mobility assessment

A
21
Q

fall prevention

A

-vision tests, vestibular, neuro -> specialist
-gait, balance, exercise program -> rehab
-med modify

-postural hypotension tx -> drop in systolic >20:
-caffeine for postprandial hypotension
-midodrine
-fludrocortisone

-environmental mod
-cardiovascular tx- ECG, echo
-footwear
-assistive devices
-neurologic -> imaging /tx, reflexes
-bone density
-BMP- dehydration, hypoglycemia
-CBC- anemia
-vitamin D- 51-70yo -> 600IU; >70 800U

22
Q

meds that can cause fall

A

-AChei
-antiarrhythmics
-anticholinergics
-anticonvulsants
-antidepressents
-antihistamines
-antihypertensives
-antipsychotics
-benzos
-diuretics
-insulin and oral hypoglycemics
-narcotics
-NSAIDs
-sedative hypnotics
-glucocorticoids

23
Q

urinary incontinence

A

-need cognition
-age, female, cognitive impairment, GU surgery, obesity, impaired mobility
-F>M until 80 -> M=F
-underreported -> poor quality of life -> depression
-U/A + culture, med rev, diary, post-voidal residual (PVR) -> refer to uro
-increase FALL risk
-pressure injury, less sleep, hydronephrosis

-URGENCY (UI)- MC
-idiopathic, neurologic (stroke/parkinson), stones, infection, tumor, irritants
-detrusor over active/contracted

-STRESS (SUI)-
-physical- cough, sneeze
-failure of urethral sphincter closure, low pelvic support, prostate surgery
-trauma, atrophic vaginitis

-MIXED (MUI)

24
Q

transient causes of incontinence

A

-Delirium
-Infection/illness
-Atrophic vaginitis
-Pharm- anticholinergics, diuretics, EtOH, narcotics, sedatives
-Psychological
-Excess urinary output- drugs, BPH, inflation, hyperglycemia, CHF
-Restricted mobility
-Stool impacting

25
Q

meds that can contribute UTI

A

-ANTICHOLINERGICS
-antihistamines
-antimuscarinics
-antispasmodics
-antipsychotics
-antiparkinson
-muscle relaxers
-tricyclic antidepressants

-diuretics
-sedative hypnotics
-benzos
-opioids
-alpha agonist- sphincter constriction
-alpha antagonist- sphincter relaxation
-CCB- decrease bladder contraction

26
Q

urinary incontinence tx

A

-URGE
-anticholinergics- oxybutynin, tolterodine -> S/E: dry eyes and mouth, constipation, headache, dizziness, orthostatic BP, confusion
-estrogen
-beta 3 agonist (mirabegron)
-bladder retraining
-fluid management
-timed voids

-STRESS
-pelvic floor muscle exercise
-surgery

-OVERFLOW
-relief of obstruction
-alpha blockers- BPH - tamsulosin
-catheter for 3-4 weeks if retention -> alpha blocker

-cognitive impairment
-prompted voiding
-habit training
-bladder retraining
-fluid intake

27
Q

pressure ulcer

A

-RF- maceration, immobility, incontinence, decrease perfusion, age, AMS, low albumin, dry skin, low wt, poor nutrition, hx of ulcer, fracture
-MC- sacrum, heels, trochanteric
-MC- orthopedics and ICU
-intense full careful skin exam prior to admission -> document
-high protein diet -> healing

28
Q

stages of ulcer

A

-STAGE 1:
-non-blanchable red
-pain, firm/soft, warm/cool

-STAGE 2: PARTIAL THICKNESS:
-partial loss of dermis
-shallow -> intact or open
-serum or serosanginous filled blister
-no sloughing or bruising

-STAGE 3: FULL THICKNESS SKIN:
-subcutaneous tissue visible (not bone, tendon muscle)
-slough present but doesnt obscure
-can be shallow- nose, ear, occiput (head), malleolus- no adipose

-STAGE 4: FULL THICKNESS TISSUE:
-exposed bone, tendon, muscle
-slough or eschar
-undermining and tunneling
-osteomyelitis/osteitis

-UNSTAGEABLE/UNCLASSIFIED:
-full tissue loss obscured by slough
-slough- yellow, tan, gray, green, brown
-eschar- tan, brown, black
-dont remove eschar if stable

-SUSPECTED DEEP TISSUE INJURY:
-purple or maroon
-blood filled blister
-painful, firm, mushy, boggy, warm/cool
-thin blister, thin eschar can evolve

29
Q

pressure ulcer tx

A

-heels- moisturize, hydrocolloid dressing over reactive hyperemia, socks, pillow, cornstarch
-turn every 2 hours
-foam mattress overlay, static flotation overlay (air or water), gel mattress, alternating air mattress overlay, low-air-loss bed, air-fluidized bed
-nutrition
-debridement
-surgery
-wet to dry saline dressing

30
Q

frailty

A

-3+:
-wt loss- >10lb in year or >5%
-exhaustion
-activity low- depends on kcal
-kinetic slowdown (slow walking)- depends on ht
-strength loss (grip, weakness)- depends on BMI

-latent phase- not apparent in absense of stressors
-early stages of weakness, slow gait, physical activity
-end-stage- high risk short term mortality
-adverse outcomes- falls, fractures, hospitalization, chemo, surgery, hemodialysis, disability, dependency, mortality

-frality is midpoint btwn independence and death

31
Q

frailty exam and prevention

A

-ADLs and IADLs
-identify stressors- extremes of heat/cold, depression, meds, surgery, hospital, illness
-check wt - >10lb in year or >5%
-labs- albumin, vit D, B12, folate, magnesium, ca, TSH, CBC, phosphate

-aerobics, strength training with weights!!!, and flexibility+balance
-low fats, low Na, high Ca, high fiber
-low alcohol, high vitamins

32
Q

failure to thrive (FTT)

A

-weak appetite nutrition in peril
-wt loss
-appetite low
-nutrition
-inactivity
-psych (depression, dehydration, immune, low cholesterol)

-worsening of physical frailty -> compounded by cognitive impairment and/or functional disability
-closer to full dependence and death
-4 syndromes predictive of ADR in FTT -> impaired physical function, malnutrition, depression, cognitive impairment

33
Q

elder abuse

A

-patronizing ageism- infatilization
-neglect- no food, meds, care
-financial abuse
-risks for elder- chronic disorder, functional impairment, AMS, social isolation
-risk for caregiver- substance abuse, psychiatric disorder, hx of violence, stress, dependence on victim
-many ED visits for exacerbations of a chronic ds despite care plan resources
-refusal of at home care or to leave pt

-refer to services for pt and caregiver, money management program, helplines, shelters, teams to coordinate
-Adult day care, respite programs, and home health care

34
Q

pharm

A

-use combo products
-any sx in elderly is a SE until proved otherwise

-ABSORPTION
-decrease HCL, high pH, longer gastric emptying-> decrease absorption
-loss of fat -> topicals increased

-METABOLISM
-long term exposure to environment toxin, alcohol, health, nutrition
-decrease liver mass, kidneys -> dec metabolism
-low protein levels -> inc serum drugs
-idiosyncratic rxn

-EXCRETION
-decrease nephrons -> GFR -> longer drug half life
-more SE, toxicity

-DISTRIBUTION
-decrease CO and circulation

35
Q

ADRs

A

-type A- expected exaggerated physiologic effects of drug
-type B- less common -> idiosyncratic effects, ex. anaphylaxis, dyscarias, toxicity

-polypharmacy is primary reason for ADRs -> DDIs

-ask open ended questions about ADRs at follow up and annuals

36
Q

beers criteria

A

-antipsychotics in pts with parkinsons complicated by psychosis -> quetiapine, clozapine, pimavanserin can be used with caution
-AVOID rivaroxaban and dabigatranbc of higher bleeding risk than warfarin and other direct oral anticoagulants
-AVOID tramadol -> hyponatremia from SIADH secretion
-AVOID opioids with benzos or gabapentinoids -> respiratory depression

-Bupropion, pseudoephedrine, vasodilators, and caffeine are removed from the list -> good!
-For pts with dementia, histamine H2 receptor antagonists removed -> need an alt to PPI which cause c diff and fracture

37
Q

drug recommendations

A

-nonbenzo sedative hypnotics -> zolpidem, eszopiclone, zaleplon -> AVOID in delirium
-alpha blockers and clonidine -> orthostatic hypotension risk
-AVOID digoxin- not the best for afib or HF
-sliding scale insulin -> hypoglycemia risk
-AVOID metoclopramide for longer than 12 weeks

38
Q

managing meds for elderly

A

-brown bag review- have them bring the bottles in
-interprofessional care- diff people rx same med
-identify prescribing cascade
-harm vs benefit
-discontinue regimen
-combo products or long acting form for pts taking >5 meds -> less pill burden
-observed therapy- watch them take it
-non pharm therapy

39
Q

decisional capacity

A

-test thought and communication
-mental status exam
-attention, memory, reasoning, reality orientation, language
-state the nature of procedure, reasons for procedure, alternatives, and risks back to you in their own words

-take in info, understand, make informed decision
-independence
-mental skills for ADLs
-Ability to use logic and calculate
-Ability and “flexibility” to turn attention from 1 task to another
-Executive functions

-competence is a legal term- judge

40
Q

consent

A

-nature of procedure
-reason for procedure or consequence of not
-consequences of doing procedure
-risks
-alternatives- offer coordinated, symptom-directed services such as palliative care early in the disease process -> Curative to palliative options
-be able to express an opinion
-demonstrate reasoning process for the choice they made
-need a witness
-document
-power of attorney - documented legal gaurdian
-dont use negative terminology

41
Q

evaluation decision capacity

A

-eval without meds
-fully awake
-try multiple times
-sit pt up
-eval with family member present
-maintain communication with family

42
Q

clinicians role in decision

A

-to patient - make sure pt understands
-to subspecialist - what are the harm and benefits
-to health care team - what else can be offer to pt

-make sure pt wants to know prognosis or not
-be realistic
-explain quality of life with treatments
-Conflicts may arise when pt. wants ‘medically futile’ Rx -> tx that does no good

43
Q

end of life: advance directives

A

-DNR- CPR, IV fluid or nutrition

-DNI- intubate

-living will- removes burden from family, friends, physician

-health care proxy- 2 witness, legal document

-durable power of attorney- signed, dated, witness, notarized, copied, distributed -> for finances -> best to choose 2 diff people (1 for health and 1 for finance) - legal doc

-palliative care- still get antibx, nutrition, pain meds, radiation -> sign and witnessed in the living will (pt can change their mind)

-organ donation

-life sustaining equipment- dialysis, ventilator

44
Q

MOLST

A

-signed by PA or doctor in collab with pt or health care proxy
-usually less than a year to live, terminal, incapacitate

-1. Prepare for discussion-Understand pts health status, prognosis & ability to consent * Retrieve completed Advance Directives * Determine decision-maker & PHL legal requirements
-2. Determine what pt/family know
-3. Explore goals, hopes and expectations
-4. Suggest realistic goals
-5. Respond empathetically
-6. Use MOLST to guide choices & finalize pt wishes * Shared, informed medical decision-making and conflict resolution
-7. Complete and sign MOLST * Follow PHL and document conversation
-8. Review and revise periodically

45
Q

palliative vs hospice

A

PALLIATIVE
-can be anytime (not terminal)
-can be alongside curative or life prolonging tx

HOSPICE
-terminal
-6mo or less
-no curative tx
-usually at home

46
Q

FHCDA- family health care decisions act

A

-physician, NP, or PA must identify & notify a person from highest priority who is reasonably available, willing, & competent to serve as surrogate decision-maker
-person can designate any other person on list to be surrogate, provided no one in a class higher in priority than the person designated objects

-pts guardian authorized to decide about health care under Mental Hygiene Law Article 81
-spouse, if not legally separated from pt, or domestic partner
-Pts son or daughter, age 18+
-Pts parent
-Pts brother or sister, age 18+
-Pts actively involved close friend, age 18+

Geriatrics (10 decks)

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