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Senoir 21-2 > GERI > Flashcards

GERI Flashcards

1
Q

What is the approach to life expectancy in Geri pts

A

> 10 years: Appropriateness of tests and treatments is generally the same as for younger persons.

<10 years: Test choice should be made on ability to improve patients prognosis/quality of life.

Prognosis <12 months: Consider Palliative Care Services

Prognosis <6 months: Consider Hospice Care

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2
Q

What is the “get up and go” test

A

It’s a functional evaluation exam

Record the time that it takes for a patient at risk to get up from a chair, walk 10 feet, and return to the chair. If this takes more than 15 seconds, they have impaired mobility and are at greater risk for a fall.

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3
Q

Intrinsic risk factors for falls

A 
Visual impairment
Postural Hypotension
Medications (Hypnotics, anxiolytics)
Muscle Atrophy
(Vitamin D? 800IU daily)
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4
Q

Primary care screening for impaired vision

A

Near vision: Jaeger card

Far vision: Snellen eye chart

Referal: Optometrist/ Ophthalmologist

Periodic screening is reasonable (DM, glaucoma)

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5
Q

What is the geriatric screening for cognition

A

Mini Cog:
- 3 item recall + clock drawing exercise: 2 minutes

Dementia unlikely if both portions normal.

Patients who fail the mini-cog should be followed up with a more in-depth mental status examination.
-Mini Mental Status Exam (MMSE): 10 minutes

-MOCA; specific: 30 minutes

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6
Q

Screening for depression

A

PHQ 2 screen: 2 questions.

One positive response requires more in depth interview/screening tool. (PHQ 9)

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7
Q

<35 on the mini mental exam =

A

Cognitive impairment

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8
Q

NML value for a Montreal Cognitive Assessment

A

NML: >26

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9
Q

What are the two questions in the PHQ-2

A

“Over the past 2 weeks, have you felt down, depressed, or hopeless?” (depressive mood)

AND

“Over the past 2 weeks, have you felt little interest or pleasure in doing things?” (anhedonia)

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10
Q

Is incontinence a normal part of aging?

A

NO!

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11
Q

What is the screening acronym for incontinence

A

DIAPPERS
(Delirium, Infection, Atrophic Urethritis, Pharmaceuticals, Psychological, Excessive excretion, Restricted mobility, Stool Impaction)

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12
Q

What level of wt loss requires further eval

A

Unintentional weight loss >5% in one month or 10% in 6 months requires further evaluation

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13
Q

Leading cause of vision impairment in the United States

A

Cataracts

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14
Q

A Geri pt presents with blurred yellowed vision, with an increased sensitivity to glare

Suspect

A

Cataracts

S/s: central opacity, diminished red reflex

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15
Q

What are the two types of Age related Macular Degen

A

Non-neovascular (“Dry”) 90%

  • gradual blurring of central vision
  • increased difficulty reading fine print, recognizing faces or seeing street signs.
  • RX: dry AMD specific formulation of antioxidants and zinc in supplements

Neovascular (“Wet”)

  • rapid loss of central vision
  • RX: With prompt recognition and referral to a retinal specialist ophthalmologist, many patients treated with anti-VEGF (vascular endothelial growth factor) intravitreal injections will maintain or even have mildly improved vision
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16
Q

What is the screening for DM retinopathy pts

A

All diabetic patients should have an annual dilated, funduscopic examination

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17
Q

Do we routine screen for Glaucoma ?

A

NO!

USPSTF does not recommend routine screening, if concerned send to optometry for a tonometer

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18
Q

What is the vision loss assoc w/ glaucoma

A

Periphery loss and extends inward

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19
Q

Is hearing loss a NML part of aging?

A

NO!

Hearing loss is independently associated with

  • incident dementia
  • accelerated cognitive decline
  • poorer neurocognitive functioning
  • increased falls
  • gait disturbance
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20
Q

What ABX is associated with hearing loss

A

Aminoglycosides

Gentamicin

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21
Q

Define NMLL cognitive impairment of aging

A

In Normal aging the patient typically:

  • Remembers the information later
  • Has intact learning
  • Any deficits in memory function are subtle, relatively stable over time, and do not cause functional impairment.
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22
Q

Define Mild Cognitive impairment

A

MCI is characterized by:
-subjective cognitive complaints, preferably corroborated by someone else
-evidence of objective cognitive impairment in 1 or more cognitive domains (memory, language, executive function, etc.)
intact functional status.

MCI is a disorder in which cognitive function is below normal limits for that patient’s age! and education! but is not severe enough to qualify as dementia!

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23
Q

What should be ruled out in dementia w/u

A

Delirium and depression

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24
Q

When should we screen pts for dementia

A

The effectiveness of screening asymptomatic patients for dementia is controversial.

However, for patients with a high risk of dementia
(e.g., patients age 80 years and older)
or for those who report memory impairment, screening with a standardized and validated tool is recommended.

Like the Mini mental status exam

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25
Q

What is the rate of decline for Alzheimer’s on the MMSE

A

3 points of decline per year

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26
Q

What is the rate of decline for moderate cognitive impairment on the MMSE

A

Decline of 1 point per year

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27
Q

Which is more sensitive for detecting Cognitive impairment

The MMSE or the MoCA (Montreal)

A

Montreal

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28
Q

Specific labs to R/o causes of dementia

A

Specific (high index of suspicion):

  • Vit B12
  • TSH
  • Calcium levels
  • ETOH
  • evaluation of CSF
  • Drug levels
  • toxicology screen
  • RPR (latent syphilis)
  • HIV.
Imaging:
MRI or CT to rule out treatable causes of dementia:
-subdural hematoma
- normal pressure hydrocephalus, -tumor
-vascular dementia
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29
Q

What is the key finding that should alert the provider to possible underlying depression in the dementia pt

A

Patient’s memory complaints that are disproportional to objective deficits should alert a provider to the possibility of depression

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30
Q

What is the classic triad of Alzheimer’s

A

Memory impairment: manifested by difficulty learning and recalling information
(especially new information)

Visuospatial disorientation; getting lost

Progressive language impairment

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31
Q

Do Alzheimer’s pt have insight to their deficits?

A

No

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32
Q

What are the features of Lewy Body dementia

A

Parkinsonism (Bradykinesia)

Fluctuant Cognitive Impairment

Hallucinations
(but are aware of them)

REM sleep disorder
(Thrashing, punching, kicking)

Syncope and falls are common

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33
Q

What defines vascular dementia

A

SUDDEN ONSET of dementia!

Hx of or evidence of cerebrovascular dz (Series of strokes)

Stepwise decline

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34
Q

What is PICKS dz

A

Young pt dementia
(Younger than 50) !

Changes in personality and behaviors

Changes in food preference

Early loss of social awareness

Compulsive and repetitive behaviors

OFTEN MISSDX AS PSYCH D/o

+Progressive aphasia and semantic dementia

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35
Q

What is the mainstay tx for AD

A

Cholinesterase Inhibitors (ChEIs)

  • Donepezil
  • rivastigmine
  • galantamine
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36
Q

What are the ADE Of Cholinesterase Inhibitors

A

Side effects: GI distress
(nausea, vomiting, diarrhea), syncope, bradycardia

Slow titration (8-12 weeks) to prevent.

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37
Q

How do you know Cholinesterase Inhibitors are working

A

Stable or improved MMSE or MOCA scores over 6–12 months suggests the drug may be effective

->Continued indefinitely

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38
Q

What is the role of memantine

A

NMDA antagonist
FDA approved for Mod/Severe Alzheimer’s Disease.

Typically added to ChEI when dementia reaches moderate severity.

Side effects: Headache

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39
Q

What are the tx for Vascualr dementia

A

No specific drug therapies

Treat risk factors of stroke:
HLD, smoking, DM, Atrial Fibrillation.

HTN treatment is somewhat controversial
->Permissive HTN ( SBP 150s) may be better for cognitive function!

ChEIs and memantine may be of benefit in VaD

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40
Q

What Rx have the best evidence of effectiveness for treating dementia

A

Antipsychotics
(Olanzapine/risperidone).
->Best evidence of effectiveness.

BLACK BOX WARNING (increased risk of mortality and cerebrovascular events and tardive dyskinesia in patients with dementia).
->Risk vs Benefit discussion.

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41
Q

What SSRI can be used to tx dementia

A

Citalopram

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42
Q

When counseling a pt with dementia

What medications should you advise the pt to avoid

A

Gingko Biloba
NSAIDS
Estrogens
Vitamin E

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43
Q

What does SIGECAPS stand for

A

Helps DDX MDD

  1. must be present x 2 weeks
S-sleep 
I-interest
G-Guilt 
E-Energy 
C-Concentration
A-Appetite
P-Phsycomotor 
S-SI/HI
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44
Q

Tx for MDD in Geri Pts

A

SSRI, SNRI, TCAs, or Mirtazapine

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45
Q

Side effects of SSRI: Citalopram

A

QT prolongation/torsade de pointes (max dose 20mg).

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46
Q

ADE of SSRI: Fluoxetine

A

LONG half life, inhibition of P-450 System.

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47
Q

What class of Rx is venlafaxine, and duloxetine

A

SNRI

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48
Q

What Rx class are amitryptyline and imipramine and Doxepin

A

TCAs

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49
Q

What is the role of mirtazapine

A

Stimulant of appetite in a depressed pt

ADE: Insomina

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50
Q

What is the approach of Depression Rx for Geri pts specifically

A

Start at ½ normal dose and titrate up to reduce side effects

Older patients frequently undertreated
(provider fails to titrate).

Can at times take 8-12 weeks to see full effect.

If side effects tolerable and no benefit: Titrate.

At therapeutic w/o response: switch or “AUGMENT” with additional agent.

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51
Q

ADE of SSRIs in Geri pts

A

May increased BP
Increased risk of falls (on Beers list)

May increase bleeding risk with anticoagulants

Hyponatremia

Beware Serotonin syndrome  includes AMS (HA, confusion, agitation)
Autonomic hyperactivity (diaphoresis, HTN, tachycardia, nausea, diarrhea)

neuromuscular abnormalities (tremor, myoclonus, hyperreflexia)

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52
Q

What are the ADE of TCAs in Geri

A

(lethal in overdose)

Orthostatic hypotension, arrhythmias

Cognitive impairment (anticholinergic effect)

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53
Q

What is the approach to Dc MDD rx

A

Continue regimen 6 months if S/s resolve

High risk of relapse: 1-2 years vs indefinitely

D/C? – taper down over 3 month period.

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54
Q

When should MDD Geri pts be referred

A

Concomitant Mania/psychosis

No response to 2 medicines

SI risk factors
->hx of SI, drug/alcohol abuse, severe anxiety/stress, SI plan, access to firearms/lethal means
(stockpiled medications).

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55
Q

What are the essential tools to use to evaluate Rx excretion in GEri pts

A

ESSENTIAL to make GFR-related dosage adjustments

Use MDRD or CKD-EPI and not Cockcroft-Gault

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56
Q

Rsk factors for increased ADE in Geri pts (RX)

A

Risk factors for ADRs include:

  • Increasing age
  • Gender (women)
  • Small body size
  • Duration of therapy
  • Poor compliance with therapy
  • Underlying disease states
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57
Q

Beers list

A

1st gen antihistamines

Digoxin >0.125 mg/day

TCAs (amitryptyline)

Antipsychotics (unless pt is a risk to others)

Benzos

Zolpidem and Eszopiclone
(Similar to Benzos)

Testosterone (men)

Glyburide, and chlopropamide
(DM drugs)

Meperidine (neurotoxicity)

Non selective NSAIDS

Skeletal Muscle Relaxants

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58
Q

What is the STOPP criteria

A

Screening Tool of Older Persons’ Prescriptions

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59
Q

What is the stopp criteria for Loop Diuretics

A

Stop:

Leg elevations and stockings more appropriate

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60
Q

STOPP criteria for diltiazem or verapamil

A

MAy worsen HF

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61
Q

STOPP criteria for Aspirin for Afib

A

No benifits

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62
Q

STOP criteria for Acetylcholinesterase inhibitors (eg donepezil) with history of persistent bradycardia, heart block, recurrent unexplained syncope, or concurrent treatment with drugs that reduce heart rate

A

Risk of cardiac conduction failure, syncope, injury

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63
Q

STOP criteria for SSRIs with HypoNA+

A

Risk of exacerbating or precipitating hyponatremia

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64
Q

STOP criteria for Drugs likely to cause constipation (e.g., antimuscarinic/anticholinergic drugs, oral iron, opioids, verapamil, aluminum antacids) in patients with chronic constipation where nonconstipating alternatives are available

A
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65
Q

STOP criteria for Bladder antimuscarinic drugs with dementia or cognitive impairment

A

Risk of increased confusion, agitation

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66
Q

When to use anticoagulants in Geri

A

Anticoagulants in the presence of chronic atrial fibrillation

(Not aspirin)

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67
Q

When to use antiplatlet tx in Geri

A

Antiplatelet therapy with a documented history of coronary, cerebral, or peripheral vascular disease

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68
Q

When to use ACEI in Geri

A

Angiotensin-converting enzyme (ACE) inhibitor in heart failure with reduced ejection fraction and/or documented coronary artery disease

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69
Q

When to use B2 agonists in Geri

A

Regular inhaled β2-agonist or antimuscarinic bronchodilator for mild to moderate asthma or chronic obstructive pulmonary disease

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70
Q

When to use L-Dopa in Geri

A

L-DOPA (levodopa) or dopamine agonist in idiopathic Parkinson disease with functional impairment and resultant disability

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71
Q

When to use Antidepressants in Geri

A

Antidepressant (other than tricyclic antidepressant) in the presence of persistent major depressive symptoms

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72
Q

When to use PPI in Geri

A

Proton pump inhibitor with severe gastroesophageal reflux disease or peptic stricture requiring dilatation

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73
Q

When to use Bisphosphonates in Geri

A

Bisphosphonates, vitamin D, and calcium in patients taking long-term systemic corticosteroid therapy

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74
Q

What is the recommendation for AAA screening

A

USPSTF recommends that men between the ages of 65 and 75 with any current or past history of smoking undergo a one time screening for AAA with an abdominal ultrasound.

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75
Q

Recommended screening for falls

A

Annually

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76
Q

Recommended screen for depression

A

Annually

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77
Q

Recommended screen for nutrition

A

Wt at each visit

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78
Q

Recommended screening for vision

A

Initial the q2yrs

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79
Q

Recommended IMRs in the Geri population

A

Influenza yearly

Pneumococcal one after age 65

Tetanus booster every q10yrs

Herpes zoster: two shots after age 50

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80
Q

Recommended screening for DM

A

Initially if hypertension, hyperlipidemia, or obese, and then every 3 years

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81
Q

Recommended screening for osteoporosis

A

Initially women >65 years, consider men >70 years

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82
Q

Recommended screening for HLD

A

Initial than q5yrs

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83
Q

Recommended screening for HTN

A

Initial then pts driven

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84
Q

recommended screening for Aortic Aneurysm

A

Once in men age 65–75 years who ever smoked

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85
Q

recommended screening breast cancer

A

Mammo q2yrs

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86
Q

Recommended screening for colorectal cancer

A

Fecal immunochemical test (FIT) annually or colonoscopy q 10 years

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87
Q

Recommended screening for cervical cancer up to what age

A

65

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88
Q

Recommended screening for lung cancer

A

Annually (age 50–80 with 20-pack-year smoking or quit in past 15 years)

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89
Q

What are the 2 phases of Cerebrovascular Dz

A
  1. Acute triage: Noncontrast brain CT, MRI, EKG, cardiac markers, CBC, CMP, INR

Uncertainty: Lumbar puncture, ABG, toxicology screen, blood alcohol.

  1. Investigations into etiology after stroke is established as the diagnosis
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90
Q

What is a lacunae stroke

A

Ischemic stroke from small vessel occlusion

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91
Q

Exclusion criteria for TPA for INR and aPTT

A

Great than 1.7 INR and greater than 15 seconds aPTT

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92
Q

Should BP be dropped rapidly in ischemia stroke

A

Avoid rapid reduction in acute ischemic stroke (helps maintain perfusion to ischemic brain tissue).

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93
Q

What is the MGMT for Acute ischemic stroke

A

IV tPA
->3 hours of symptom onset.

Can be extended up to 4.5hr (patients <80 y/o). BP <185/110

Intra-arterial thrombolysis or mechanical thrombectomy.
->Carefully selected patients.

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94
Q

What is the 1st Line anti platelet tx in non-cardioemboic stroke

A

Aspirin
Clopidogrel
Aspirin and dipyridamole

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95
Q

What is the threshold for a Carotid endarectomy

A

Carotid Stenosis- Carotid Endartectomy (CEA) effective when >70-90% stenotic

may benefit if >50% but balance with risks

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96
Q

What is the time frame of tiA

A

brief episode of neurologic dysfunction caused by focal brain, spinal or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction.

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97
Q

What is the MGMT for coronary Dz

A

Anti-platelet
Statin
B blocker
ACE/ARB: HFrEF

98
Q

A Geri pt presetns with Exertional dyspnea, fatigue, orthopnea, lower extremity swelling.

Think

A

HF

99
Q

What is the tx for HFrEF

A 
HFrEF: <40%. 
->Beta blocker and Neprilsyn inhibitor (Sacubitril-valsartan- first line) 
or  
ACE/ARB, mineralocorticoid antagonist 
(Spirinolactone/Eperenone) for EF <35%.

Cardiac resynchronization: EF <35%. Biventricular pacing.

100
Q

What is the tx for HFpEF

A

Aggressive management of HTN
NA restriction
Loop diuretics

101
Q

What is the sodium and fluid restriction for HF pts

A

Sodium limit: 2g daily.
Fluid limit: 1-1.5L daily.
Daily weights.

102
Q

What are the comments of a CHAD2VASc score

A

CHA2DS2VASc >2:

(CHF, HTN, Age>75 (2), DM, Stroke, Vasc dz, 65-74)

103
Q

What is the Tx for Tachyarythmmias in Geri

A

1) Anticoagulation.
2) Rate vs Rhythm Control.
(BB) -> Cardioversion, Radiofrequency ablation, Watchman.

104
Q

What does the HASBLED score predict

A

score estimates risk of bleeding, history of falls does not increase score

105
Q

Stage I HTN

A

Stage 1 HTN : Systolic between 130-139 or diastolic between 80-89

106
Q

Four common conditions in older patients complicate diagnosis/management HTN

A

“White coat hypertension”, orthostatic hypotension, post prandial hypotension, pseudohypertension.

107
Q

most common indication for major cardiac surgery in older adults after coronary bypass surgery

A

Aortic Stenosis

108
Q

How do you DDX PAD vs spinal stenosis

A

PAD: Leg discomfort with ambulation, rest pain, non-healing ulcers, gangrene

(distinguish from spinal stenosis- worse with standing/walking, better sitting/knees to chest)

109
Q

What is the Rx for PAD/VTE

A

Cilostazol

General: Good skin/foot care. Podiatry (DM). Daily foot inspection. PT

Reduction of CVD: Anti-platelet, high intensity statin. HTN mgmt., DM mgmt., tobacco cessation.

110
Q

What is the MGMT for VTE

A

Massive PE- Thrombolysis

DOAC or Heparin/VKA compression stockings

Treatment length estimate is for minimum of 3 months if a discrete cause, 6-12 months if no cause.

111
Q

A geri pt with an unprovoked VTE

Think

A

CANCER

112
Q

What does HASBLED score stand for

A

HTN

Abdominal Liver or Kidney Dysfunction

Stroke

Bleeding

Labile INRs

Elderly >65

Drugs or Alcohol

Score greater than 2 consider risk

113
Q

What is the only approved anti Xa inhibitor approved in older pts with renal failure

A

only enoxaparin has approved dose reduction in older patients with renal impairment

114
Q

What is the tx for chronic Venus insufficiency

A

Treatment:
Conservative: weight loss, Skin/ulcer care, foot/nail care, leg elevation, compression stockings, PT, diuretics, Laser ablation.

115
Q

Ulcers from chronic venous insufficiency appear where

A

Severe disease presents with ulceration typically located above the medial malleolus.

116
Q

Ulcers from arterial insufficiency appear where

A

Over the toes, foot and heals

117
Q

Which is painful

Venous or arterial insufficiency

A

Arterial

118
Q

MGMT for acute COPD exacerbation

A
  1. Beta agonist (albuterol)
  2. Anticholinergic (Ipatropium)
  3. Prednisone
  4. NIPPV
  5. ABX
119
Q

Dx for chronic bronchitis

A

Chronic bronchitis: Cough and sputum for at least 3 months during 2 consecutive years

120
Q

Tx for Chronic COPD

A

: SABA prn (albuterol)
(mild symptoms, up to 2 puffs bid).

LABA/Inhaled corticosteroids, (formoterol/ Budesonide )

Anticholinergics ( Ipatropium)

Pulmonary Rehab.

Oxygen: for patients with resting SpO2 <88% Room air

121
Q

Late onset asthma is assoc with

A

Obesity and Tobacco

122
Q

What is the recommendation from the CDC for Geri pts with asthma

A

The CDC recommends patients 65 years of age or older receive both pneumococcal conjugate vaccine-13 and pneumococcal polysaccharide vaccine-23 to decrease risk of pneumonia.

123
Q

A geri pt presents with Velcro-like/”rice crispy”-like rales; lymphadenopathy, hepatosplenomegaly, uveitis, and skin rashes in sarcoidosis; right heart failure with lower extremity edema.

Think

A

ILD

124
Q

Honeycombing on CT

Think

A

ILD

125
Q

Pulm HTN groups

A

Group 1: Pulm arterial HTN

Group 2: HTN 2/2 Left HDz

Group 3: HTN 2/2 Lung Dz

Group 4: HTN 2/2 embolism

Group 5: Mulitfactorial

126
Q

How do you Dx Pulm HTN

A

echocardiogram: estimated systolic pulmonary arterial pressure of 35 to 40 mm Hg (usually higher in older adults) is suggestive of pulmonary hypertension

right cardiac catheterization if suspicious for pulmonary arterial hypertension.

127
Q

What are sisters Mary Joseph’s nodes

A

PERIumbilical lymphadenopathy seen in pancreatic cancer

128
Q

What are typically the only S/s of appendicitis in geri pts

A

In some cases, a low grade fever and general abdominal pain are the ONLY symptoms

129
Q

A geri pt presents with absent bowel sounds, tenderness and rigid dirty

Think

A

Peritonitis

Hypotension and cardiovascular collapse will occur if untreated or the cause is not identified and treated rapidly

130
Q

How does cholecystisis present in geri pts

A

Abdominal tenderness and peritoneal inflammation is absent in > 50% of patients

Normothermia and a normal WBC count are found in a significant number of elderly patients

Gangrene and perforation are commonly discovered at surgery

131
Q

What are the alarm features of dysphasia in geri pts

A

Alarm features such as unintentional weight loss, anemia, and odynophagia should be solicited and warrant endoscopy for evaluation.

132
Q

MGMT for dysphagia

A

Behavior modification (eating/swallowing)

Balloon dilatation

Medications
-> PPI, H2

133
Q

How does PUD present in Geri Pts

A

Perforation is more common in geriatric population and less likely to have significant pain and/or abdominal rigidity

Chronic PUD can present with symptoms of gastric outlet obstruction (early satiety, nausea, vomiting), anemia and possible melena

134
Q

Acute vs chronic diarrhea

A

Acute diarrhea is defined as symptom duration for ≤4 weeks, whereas chronic diarrhea occurs when persistent for >4 weeks

135
Q

A pt presents with painless hematochezia

What is the next step

A

(may require inpatient management in elderly)

136
Q

Should we use docusate for constipation

A

NO (lol)

Use methylcellulose

137
Q

MGMT for Constipation

A

BIG 3: FLUID – FIBER - FITNESS

Take advantage of “morning gastrocolic reflex”

138
Q

Grade A recommendation for Constipation

A

Psyllium (Metamucil) & Methyl cellulose (Citrucel)

139
Q

What is the threshold for dis impaction in Geri pts

A

Pain, bloating, 5 or more days without a BM, or no longer eating

140
Q

What is the age to begin colorectal screening

A

NLT than 50

141
Q

When can colorectal screening be stopped

A

Guidelines recommend that patients may stop screening at age 75 or when life expectancy is <10 years if:
->up to date with screening & negative prior screening tests

142
Q

What is the acute vs chronic tx for hypoNA+

A

Acute (< 48 hrs) – 3% hypertonic saline

Chronic (> 48 hrs or unknown) – -slow correction

->Prevent Osmotic Demyelination Syndrome
(formerly Central Pontine Myelinolysis)
->Water restriction, demococycline

143
Q

Acute vs Chronic Tx for HYPO NA+

A

Acute (< 48 hrs) – 3% hypertonic saline

Chronic (> 48 hrs or unknown) – ->slow correction

  • > Prevent Osmotic Demyelination Syndrome (formerly Central Pontine Myelinolysis)
  • > Water restriction, demococycline
144
Q

What is the acute vs chronic tx for Hyper Na+

A

Acute (< 48 hrs) – hypotonic solutions (0.5% saline)

Chronic (> 48 hrs or unknown) – slow correction

145
Q

Dx for CKD in Geri

A

Abnormal urinalysis
(proteinuria, hematuria)

or

Structural abnormality
(by ultrasound)

or
GFR < 60 mL/min

For ≥ 3 months

146
Q

Mod-Severe CKD

A

Gfr30-59 : Moderate

GFR 15-29: Severe

<15 super severe

147
Q

HTN goal in pts with CKD

A

Less than 130/80

ACEI/ARBS are first line in pts with Protineuria to a goal of <0.2 Ratio

148
Q

LDL goal in Geri pts

A

Less than 100 mg/dl

149
Q

MGMT of CKD in GEri Pts

A

ACE/ARB to slow progression of proteinuria and CVD

Potentiates hyperkalemia
repeat serum creatinine & potassium in one week

Consider a statin
Diuretics to avoid fluid overload

150
Q

What is the Threshold to treat Subclincal Hypothyroidism

A

Subclinical hypothyroidism: TSH 5-10, normal T4

RX: If symptomatic, or TSH >10

151
Q

What is the tx to sub clinical hyperthyroidism

A

Medication induced?
-> Decrease Levothyroxine.

RX: Iodine-131 ablation

152
Q

What is the MGMT for symptomatic hypothyroidsm

A 
Primary: High TSH, low t4
->Rx: “low and slow” 
Start at 12.5 (cardiac hx)- 25 mcg,
 f/u q4-6wks. 
End: Euthyroid w/o SE

Secondary: Low TSH, low t4
(brain tumor?)
->Myxedema Coma- alteration of cognition, lethargy, seizures, psychosis, confusion
Refer to SRGRY

153
Q

What is the tx for hyper calcemia

Stones, bones, groans, overtones

A

NS

Bisphosphonates

Steroids

Calcitonin

Parathyroidectomy

Dialysis

154
Q

Primary Hyperparathyroidism

A

common disorder in post menopausal women
->50% no
or minimal symptoms- incidental hypercalcemia found on routine labs
usually from an adenoma- tx surgery

Stones, bones, groans, and moans/ psychiatric overtones

155
Q

Secondary Hyperparathyroidism

A

Due to hypocalcemia from renal failure, vit D insufficiency, malabsorption, bisphosphonates/lasix

156
Q

Typical cause of Cushing Syndrome in Geri’s

A

usually iatrogenic

->Iatrogenic, ACTH neoplasm (small cell lung/carcinoid)
Cushing disease less common

Establish hypercortisolemia

157
Q

W/u for finding an incidentaloma

A

Should be evaluated for excess cortisol, aldosterone, and catecholamine production

158
Q

MUDPILES

A

Methanol

Uremia

Diabetic Ketoacidosis

Paraldehyde

Iron, Isonazid

Lactic Acidosis

Ethylene Glycol

Salicylates

159
Q

Dx for DM

A

Hemoglobin A1c ≥6.5
or
Fasting (no caloric intake for ≥8 hours) ->plasma glucose ≥126 mg/dL (7.0 mmol/L),
or
Symptoms of hyperglycemia plus random plasma glucose ≥200 mg/dL (11.1 mmol/L),
or
2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test .

160
Q

Treatment goal for DM Geri pts

A

RX: Patient guided. <7 for younger and healthy.

Short life expectancy <8-9

161
Q

What are the Thresholds for anemia

A

<13g/dL in men; <12g/dL in women

162
Q

Work up for central lung cancer

A

Sputum Cytology

Bronch Biopsy

163
Q

W/u for peripheral lung cancer

A

CT guided transthoracic biopsy

164
Q

Recommendations for screening lung cancer

A

annual screening for lung cancer with low-dose CT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years

165
Q

Screening for Breast cancer

A

Biennial screening mammo for age 50-74

166
Q

Screening for colorectal cancer

A

q10 yr C-scope up to 75 (q5 for high risk)

167
Q

Tx duration of prostatitis

A

4-6 weeks

Use TMPX/SMX or Fluoroquinolones

168
Q

MGMT for UTIs

A

1st Line: TMP/SMX, nitrofurantoin

2nd Line (allergy/resistance): ->Fluoroquinolones

Duration: Female: 3-5 days; 10-14 days male or female with severe symptoms-> (pyelonephritis).

169
Q

What is the criteria to Dx UTI in a pt with a urinary catheter

A

Fever >100 or an increase in 1.5*F over baseline

New CVA tenderness

Rigors

New onset of delirium

170
Q

What is the criteria for Dx of UTI without a catheter

A

Acute dysuria

Fever >100*

+ Urgerncy, Frequency, supapubic pain, gross hematuria, CVA tenderness, Urinary incontinence

171
Q

Threshold for transudative effusion

A

Pleural: serum protien <0.5
Plearal:seurm LDH <0.6

172
Q

Prevention of RTI in Geri pts

A

Yearly influenza vaccine. Pneumococcal vaccine. COVID

173
Q

Tx for influenza

A

Oseltamivir (Tamiflu)

72hrs or if Severe

174
Q

MGMT for PNA

A

CAP: Macrolide (azithromycin) or doxycycline.

Comorbidities (chronic lung or renal disease, DM):
->Respiratory quinolone or beta-lactam plus macrolide.

Hospital Acquired and skilled nursing acquired:
->IV abx (Vanc, Pip-tazo, etc).

CURB 65 or Pneumonia Severity Index for disposition/mortality estimation

175
Q

MGMT for PNA pt with renal dz

A

Respiratory quinolone or beta-lactam plus macrolide.

Floxacin+Azithromycin

176
Q

What is the most common health care assoc diarrhea

A

C. difficile - most common health-care associated diarrhea

Volume repletion and stop inciting antibiotics

Rx: Oral Vancomycin or Fidaxomicin
->Avoid metronidazole in frail or >65 years

Hand hygiene key in prevention

177
Q

What are the ABX for Staph and Strep MSSA and MRSA

A

Strep/MSSA: 1st generation cephalosporin, dicloxacillin

Staph: MRSA?; Clindamycin; Doxycycline, TMP-SMX

178
Q

Rash q with target like lesions

A

Erythema multiforme

179
Q

A new mole in a Geri pt

A

Benign Nevi uncommon: New mole should be suspicious for malignancy

180
Q

Tx for SKs

A

Remember stuck on papules

Rx: Cryotherapy or curettage

181
Q

MGMT for stasis dermatitis

A

DDx: Pigmented purpuric dermatosis, contact dermatitis

RX: Leg elevation, compression stockings.
Class 5 steroids BID for plaques. ->Diuretics for edema

182
Q

Tx for Zoster and post herpetic neuralgia

A

Zoster Rx: Anti-viral.
(acyclovir, valacyclovir), within 48 -72hrs of rash onset.
Dermatome heals in 3-4 weeks.

Post Herpetic Neuralgia.
Rx: Gabapentin, Tylenol, topical lidocaine

183
Q

Tx for Scabies

A

Permethrin 5% cream
Or oral ivermectin 0.2mg/kg
->Class 1 steroid bid for pruritus, 3-4 weeks.

All clothes worn within 2 days of treatment, towels, and bedsheets should be machine washed in hot water or dry cleaned

184
Q

Geri pt with sandpaper texture skin

What is the Dx and Tx

A

AKs

Tx: Cryotherapy, or ‘field’ treatment with imiquimod (Aldara) 
or fluorouracil (Effudex)
185
Q

MGMT for BCC and SCC

A

Excision

186
Q

ABCDE for Malignant melanoma

A

asymmetry, border irregularity, color variegation, diameter >6 mm and an evolving lesion

187
Q

Screen for sleep D/o

A

Polysomnography.
AHI >30 per hour denotes severe OSA,

16–30 per hour that of moderate OSA,

5–15 per hour for mild OSA

188
Q

What should be ruled out in pts with periodic leg movement D/o in sleep

A

Iron deficiency anemia

189
Q

DDx for lower urinary tract symptoms

A

Prostatitis
malignancy
bladder stone
medication side effect (anticholinergic/urinary retention) UTI

190
Q

Obstrucive Urinary S/s

A

Hesitancy*

Decreased force and caliber of stream*

Sensation of incomplete bladder emptying

Double voiding

Straining to urinate

Post-void dribbling

191
Q

S/s of irritative urinary tract d/o

A

Frequency*
Urgency*
Nocturia*
Dysuria

192
Q

MGMT for BPH

A 
Alpha blockers
 (prazosin/doxazosin/terazosin)

Alpha-1a blockers
(tamsulosin/alfuzosin)

5-alpha reductase
(finasteride)
->Reduces PSA by 1/2

Surgery: Transurethral resection of the prostate (TURP), Transurethral incision of the prostate (TUIP )

193
Q

What is the NSAID of choice for pain in Geri pts

A

Diclofenac Gel

194
Q

MGMT to Gout

A

Acute: Colchicine, NSAIDs, Steroids.

Chronic: Allopurinol/febuxostat (xanthine oxidate inhibitors), probenecid (uricosuric).

195
Q

MGMT for CPPD/ Pseduo Gout

A

Rx: NSAIDs, colchicine, steroids.

196
Q

MGMT for Polymyalgia Rheumatica

A

RX: Steroids.

197
Q

Dx for Polymyalgia Rheumatica

A

One month of bilateral aching shoulders/proximal arms/hips.

Worse in AM, up to 1hr.

Neg RF/joint erosions.
Elevated ESR/CRP

198
Q

MGMT for RA

A

NSAIDs, DMARDs, steroids

199
Q

Red flags for Osteoporosis Fx

A

Hx

Use of steroids

Older age 75

Recent trauma

200
Q

Acute, subacute and chronic back pain

A

acute (lasts less than 4 weeks)

subacute
(lasts between 4 and 12 weeks)

chronic (lasts longer than 3 months).

201
Q

S/s of Lumbar spinal stenosis

A

Lumbar spinal stenosis- radiates to legs, worse with standing/walking

202
Q

ASAP referral criteria for Lower Back Pain

A

Indications for ASAP referral to a surgeon include cauda equina syndrome, suspected cord compression, and progressive or severe neurologic deficits.

203
Q

Tx for Giant Cell

A

Get a ESR or CRP

Then treat with Prednisone

204
Q

A pt presents with falls

What is the red flags for syncope

A

history of loss of consciousness with the fall

unexplained non-accidental fall

recurrent falls despite adherence to a multi-factorial targeted treatment program

205
Q

MC sites for pressure ulcers

A 
Iliac crests
Sacrum
Greater trochanters
Ischial tuberosity
Lateral malleoli
206
Q

Optimal order for pressure ulcer prevention

A

q2 turns

Bedridden patients should have there head positioned no more than 30 degrees or maintained at the lowest level needed to prevent complications to prevent shearing of the skin.

207
Q

Stage 1 ulcer

A

non-blanching erythema of intact skin

Warmth, edema, and induration are also indicators, particularly on persons with dark skin

208
Q

Stage 2 ulcer

A

partial thickness involving the epidermis and dermis, superficial

Appears as a blister or abrasion

209
Q

Stage 3 ulcer

A

full thickness, deep crater involving necrosis of subcutaneous tissue that may extend to the underlying fascia

210
Q

Stage 4 ulcer

A

tissue necrosis and destruction that includes damage to bone, muscle, and/or supporting structures with or without full thickness skin loss

211
Q

Documentation for Ulcers

A 
Size
Location
Eschar and granulation tissue
Exudate
Odor
Sinus Tracts
Signs of infection

Undermining: Separation of skin/mucosa from the stroma, it can stretched over the defect of wound

Staging (I-IV)

212
Q

Tx for stage 1-2 ulcers

A

Only clean with normal saline.

Apply a protective, transparent dressing

Avoid “skin cleaners” or antiseptics (destroys granulation tissue).

Remove necrotic tissue
->Ulcers with stable, dry eschar do not need debridement, if there are no signs of infection.

213
Q

MGMT for Stage 3-4 ulcers

A

Prolonged and expensive treatment by irrigation, debridement of necrotic tissue, healing by secondary intention, appropriate dressings, or surgical closure

Perform mechanical, enzymatic, autolytic debridement

Maintain appropriate wound moisture and remove excessive external moisture

Wound care nursing

214
Q

What is the Tx for cellulitis, osteomyelitis, bacteremia, or sepsis 2/2 to ulcers

A

Topical antibiotic should be considered if no healing is achieved after 14 days of conservative interventions (Silver Sulfadiazine)

May need surgical debridement, as appropriate

Systemic antibiotic are used with advanced cellulitis, osteomyelitis or systemic infection.

Pending culture, antibiotic should cover MRSA, anaerobes, enterococci and gram negative bacteria

215
Q

Causes of Urge incontinence

A

Detrusor over activity
Idiopathic or associated with neurologic disorders
(e.g., stroke, multiple sclerosis, Parkinson disease)
bladder irritants
stones
infection or tumors.

216
Q

Causes of stress incontinence

A

Failure of the urethral sphincter mechanisms, insufficient pelvic support in women, or prostate surgery in men.

217
Q

MGMT for urge incontinence

A

Anticholinergics

218
Q

MGMT for stress incontinence

A

Topical estrogen

219
Q

MGMT for overflow incontinence

A

Alpha Adrenergic blockers

220
Q

MGMT for atonic bladder 2/2 stroke or severe DM neuropathy

A

intermittent catheter

221
Q

DIAPPERS

A

Delerium

Infection

A trophic Vaginitis

Pharm

Psych

Excess UOP

Restricted mobility

Stool impaction

222
Q

What should be R/o in Urinary Incontinence

A

r/o CHF, neuro/mental status, prostate/penis, pelvic, perineum

Do cough stress test

Post Void residual

223
Q

What are the PCM recommendations for incontinence

A

Kegel (pelvic floor strengthening) exercises

Reducing caffeinated beverages

Reducing total fluid intake

Weight loss

Compression stockings instead of diuretics

Consider PT/increase mobility training

224
Q

Rx for Urge incontinence

A

Estrogen
Oxybutynin
Mirabegron

225
Q

Rx for overflow incontinence

A

alpha blockers (Doxazosin)
5-a reductase inhibitors (finasteride)
catheter, surgery

226
Q

MGMT for osteoporosis

A

Nonpharmacologic
-> Weight loss, exercise, PT, heat and cold

Pharmacologic
-> Acetaminophen: Initial

NSAIDs: Prescribed if inadequate response to acetaminophen

Oral NSAIDSs: ADVERSE EFFECTS! Consider topical NSAIDs first

227
Q

Type I and Type II oestoporosis

A

Type I: post menopausal

Type II: advanced age, lack of zinc or calcium

228
Q

W/u for osteoporosis

A 
CBC
CMP (inc LFT)
Phosphate
PTH
25-hydroxy vitamin D
Consider 24 hr urine Ca
229
Q

Test for multiple myeloma (2nd cause of osteoporosis)

A

Serum and Urine protine electrophoresis and free light chains

230
Q

What is the Screening for Osteoporosis

A

Per USPSTF:
DEXA for females 65 > y/o

Results interpretation:
Normal: BMD within one SD of young adult (T score greater than -1.0)

Osteopenia: BMD within 1 and 2.5 SD below a young normal adult (T score -1 to -2.5)

Osteoporosis: T score less than -2.5.

231
Q

MGMT for osteoporosis

A

Bisphosphonates (dronates)

HRT

Raloxifene
(Increased risk of VTE, hot flashes, cramps)

Calcitonin

Denosumab

Teripoaratide

Romosozumab

232
Q

What is the CAM w/u for delerium

A

Acute onset + Inattention

Or
Disorganized thinking + AMS

233
Q

Specific test to w/u delerium

A 
Thyroid Function Tests
Vit B12
Drug levels
toxicology screen
ABG
blood cultures
 cortisol levels
evaluation of CSF
UA/Urine Culture
234
Q

MGMT for delerium

A

Non-pharmacologic
->Sleep Protocol ; Sleep wake cycle
Avoid sedatives; Avoid restraints
Volume repletion
Frequent re-orientation
Taper and/or discontinue unnecessary Medications
->Beers Criteria (TCAs, anticholinergics, etc.)

Pharmacologic
->Last resort
Haldol, Olanzapine, Quetiapine, Risperidone, Benzodiazepines.

235
Q

4 criteria for Parkinson’s dz

A
  1. Resting tremor
  2. Bradykinesia
  3. Muscular rigidity
  4. Postural instability
236
Q

dopaminergic cell loss of substantia nigra

A

Parkinson’s

237
Q

Red flags for 2ndary Parkinson’s

A

Think of secondary causes when certain red flags are seen

  • > symmetric presentation
  • > lack of tremor
  • > and/or atypical features that are rarely seen early in PD

Lack of response to higher doses of dopaminergic medications should alert clinician to likelihood of secondary PD

238
Q

2 MC causes of 2nd Parkinson’s

A

Vascular: From chronic ischemic damage/multiple infarcts

Drug induced: Anti-emetics and antipsychotics (dopamine receptor blocking agents)

239
Q

Are anti HTN needed in pts with Parkinson’s Dz

A

Reduce medications as possible (antihypertensives no longer needed as PD progresses),

240
Q

How do we treat Depression in Parkinson’s

A

SSRIs 1st line. Followed by SNRIs

241
Q

MGMT for Parkinson’s

A

Levodopa is the drug of choice in patients >70 years

 dopamine agonists
 (pramipexole and ropinirole), amantadine, and anticholinergics are poorly tolerated in this age group

Dopamine agonists: Pramipexole, ropinirole (1st line if age<70)

242
Q

MGMT for essential tremor

A

Beta blockers

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