GERI Flashcards
1
Q
UTI is an umbrella term encompassing what dzs?
A
- Asymp Bacteriuria
- cystitis
- Prostatitis
- Pyelonephritis
2
Q
Most common infectious illness in adults > 65 y/o
A
UTI
3
Q
most common pathogens causing UTI
A
enteric gram-negative rods
- E.coli (75-90%)
- Staph saprophyticus(5-15%),
- Klebsiella
- Proteus
- Enterococcus
- Citrobacter spp. (5-10%)
4
Q
discuss dx differences b/w Typical vs Atypical presentations of UTI
A
Typical sx (dysuria, new frequency, etc.): = clinical diagnosis
- UA/culture may be helpful
Atypical sx or sx of upper urinary tract involvement:
- UA w/ Cx with sensitivity
- Remember - + leukocyte esterase or nitrites on dipstick does not rule in a UTI(low specificity),
- useful as a screening tool to rule out UTI
5
Q
T/F
Presence of bacteria on culture does not always equate to a UTI
what is seen on positive UA for UTI
A
TRUE
Presence of bacteria on culture does not always equate to a UTI
- Leukocyte esterase and nitrites(urine dipstick) can be used as a screening tool, but further evaluation needed
6
Q
UTI Tx
Inpatient
Critical illness
Treatment in MDR Outpatients
A
Inpatient
- Cipro or Ceftriaxone
- Followed by TMX-SMX or Augmentin/Cefpodoxime
Critical illness
- Imipenem or Meropenem PLUS Vanco or Linezolid
Treatment in MDR Outpatients
- Ertapenem Followed by Cipro or Levaquin
7
Q
Define Asymptomatic Bacteriuria
A
isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms of urinary tract
8
Q
tx of Asymptomatic Bacteriuria
A
No Tx if not symptomatic!!!
Defer abx tx for 1 week with follow-up(as long as patient not ill)
Women - second specimen should be obtained (within 2 weeks) to confirm growth of the same organism
9
Q
If an asymptomatic women has positove bacteria on urine cx
what should be the next step in tx?
A
second specimen should be obtained (within 2 weeks) to confirm growth of the same organism
10
Q
Select individuals to treat w/ Asymptomatic Bacteriuria
A
Pregnant women – adverse outcomes associated with AB
Urologic Intervention – associated with infectious outcomes
Renal transplant patients
11
Q
what is the Rome IV Criteria used to help dx?
define Rome IV Criteria
A
Constipation / fecal impaction
Rome IV Criteria –> Any 2 of the features:
- Straining
- Lumpy hard stools
- Sensation of incomplete evacuation
- Use of digital maneuvers
- Sensation of anorectal obstruction or blockage with 25% of bowel movements
- ↓ in stool frequency
12
Q
imaging studies to consider for Constipation / Fecal Impaction
A
Sigmoidoscopy/Colonoscopy - Strongly consider in
- alarm symptoms
- or if most recent colonoscopy >10 years ago
Radiopaque marker study
Motility Studies - anal sphincter function at rest and during defecatory maneuvers as well as reflex activation of the pelvic floor
Defecography
Balloon Expulsion Test
13
Q
Tx for Constipation / Fecal Impaction
A
Lifestyle and dietary modification
- ↑ fluid intake , exercise & Fiber (20-25 g/day)
Laxatives
- Bulk forming (Metamucil, Citrucel, FiberCon, Benefiber)
- Osmotic (Miralax, Lactulose, Sorbitol)
- Stimulant (Senna or Bisacodyl)
Stool softeners
- Glycerin and bisacodyl suppositories
- Enemas (tap water or soapsuds)
Colonic secretagogues
- Lubiprostone (Amitiza) –> Chloride channels – secreting chloride and water into the lumen
- Linaclotide(Linzess) –> Stimulates intestinal fluid secretion and transit
Opioid Antagonists
- Methylnatrexone SubQ
- Naloxegol(Movantik)
14
Q
list tx for Constipation / Fecal Impaction
Colonic secretagogues
Opioid Antagonists
A
Colonic secretagogues
- Lubiprostone (Amitiza) –> Chloride channels – secreting chloride and water into the lumen
- Linaclotide(Linzess) –> Stimulates intestinal fluid secretion and transit
Opioid Antagonists
- Methylnatrexone SubQ
- Naloxegol(Movantik)
15
Q
Fecal Impaction Management
A
- Disimpaction –> In the absence of perforation and if safe to do
- Warm water enema –> if above fails
- Once Disimpacted –> begin bowel regimen w/ PO polyethylene glycol (MiralaX)
16
Q
Define watery vs inflammatory diarrhea
list common pathogens responsible
A
Watery Diarrhea – usually large volume, abdominal bloating, none or minimal bleeding
- Norovirus most common ID’d cause*
- C. diff (Clostridoides)
- C. perfringens
- Giardia and Cryptosporidium
Inflammatory Diarrhea – usually involves fevers, significant abdominal pain, bloody or mucoid diarrhea
- Salmonella(2nd most common cause*),
- Campylobacter, Shigella, Yersinia
- EHEC/STEC
17
Q
differentiate b/w acute and chronic diarrhea
A
Acute - <14 days
Chronic - >14 days
18
Q
Dx of acute diarrhea
A
Stool cultures (usually includes E.coli, Salmonella, Campylobacter)
_endoscopic evaluatio_n –> if concern for IBD, no clinical improvement or worsening (rare)
19
Q
you should ALWAYS wait for stool cx in diarrhea pt before initiating abx bc???
A
Risk of hemolytic anemia syndrome & C. Diff
- E.coli – NO TX (risk of HUS!!!)
- Campylobacter – azithromycin
- Salmonella – ciprofloxacin or Azithromycin
20
Q
ABx tx of diarrhea
E.coli –
Campylobacter –
Salmonella –
A
E.coli – NO TX (risk of HUS!!!)
Campylobacter – azithromycin (inflam)
Salmonella – ciprofloxacin or Azithromycin (inflam)
21
Q
define Hemolytic Uremic Syndrome(HUS)
timeline?
dx triad?
A
complication of E.coli infection associated with antibiotic use
- Nonimmune-mediated hemolytic anemia
- Thrombocytopenia
- Thrombotic microangiopathy
- Acute kidney injury
occurs b/w 5-13 days of diarrhea
Diagnostic Triad:
- Hemolytic anemia (<30%)
- Thrombocytopenia (<150,000)
- ↑ Creatinine than ULN for pt age
22
Q
Dx of chronic diarrhea
A
Stool cultures, Cdiff, Ova and Parasite
Check Electrolytes, celiac serologies, TSH
R/O lactose intolerance – Lactose breath hydrogen test (↑20 is positive)
Lactulose breath test - SIBO (↑20 is positive)
Fecal elastase (Pancreatic insufficiency)
Review Medications
Flex sig/colonoscopy - (if – cx)
23
Q
Lactose / Lactulose breath test is used to dx what dz?
what value is +??
A
Chronic diarrhea
lactulose -SIBO (↑20 is positive)
24
Q
in chronic diarrhea Flex sig/colonoscopy is indicated when?
A
negative cx
25
Fecal elastase is used to dx?
what does it indicate?
chronic diarrhea
Fecal elastase (Pancreatic insufficiency
26
tx of chronic diarrhea - general measures
General Measures
* Antidiarrheals - Loperamide
* Cholestyramine
* Fiber supplementation
* Supportive care – ↑ PO fluid intake and maintain nutrition
27
# Define Microscopic colitis(Lymphocytic colitis or collagenous colitis)
what age group does it affect
type of chronic diarrhea
**4-9 loose stools per day**
chronic, intermittent
relapses are common (approximately 30 to 60 percent)
occurs in middle-aged and elderly adults
not assoc. with an ↑ risk of colorectal cancer
28
Dx of Microscopic colitis(Lymphocytic colitis or collagenous colitis)
Colonoscopy via biopsy – mucosa usually grossly normal
* Proximal biopsies are best as the severity of histologic changes decline in the distal colon
29
tx of Microscopic colitis(Lymphocytic colitis or collagenous colitis)
Antidiarrheals – loperamide
Glucocorticoids – Budesonide
Cholestyramine
Bismuth subsalicylate –limited data
30
Treat underlying issue in chronic diarrhea
Microscopic colitis
celiac disease
pancreatic insufficiency
lactose intolerance
SIBO
Budesonide in _Microscopic colitis_
Gluten avoidance in _celiac disease_
Lactose avoidance or use of Lactaid in l_actose intolerance_
Pancreatic enzyme supplementation (Lipase 30,000 to 90,000 USP per meal) in _pancreatic insufficiency_
Empiric antibiotics (Xifaxan ) in _SIBO_
31
T/F
Tx diarrhea caused by E. coli
FALSE
NO - risk of HUS
32
describe the 4 normal phases of sleep
**Stage 1 “Drifting off” (10-25 mins)**
* period between awake and sleep
**Stage 2 “ Light Sleep” (4hrs per night)**
* body still on alert, most wake up during stage 2, power naps.
* When we consolidate our memories.
**Stage 3 “Deep Sleep” (2 hrs per night)**
* Rest and Recovery.
* HR and Breathing slows down.
* Closest we get to hibernation.
**Stage 4 “REM” Rapid Eye Movements**.
* Vivid dreams
**Stage 1--\> 4 , then cycle 2,3,4**
33
what is important to ask elderly when discussing sleep disorders
* Are you experiencing restlessness before falling asleep?
* Do you feel refreshed upon waking?
* How long does it take fall asleep?
When discussing sleep disorders important to ask:
* Psychiatric history: depression, anxiety
* Recent stressors Caffeine, alcohol, smoking
* Increase in MVA’s
* Increase in use in sedatives = increase in falls
34
differentiate b/w primary & secondary sleeo disorders
List examples of each
**Primary sleep disorders:**
* Breathing
* insomnia
* sleep wake disturbances
* restless legs
* periodic limb movement
**Secondary sleep disorders** related to comorbid conditions:
* Nocturia
* Orthopnea (CHF)
* chronic pain syndromes
* pulmonary disorders
35
List the 4 types of insomnia:
1. Difficulty falling asleep
2. Mid sleep awakening
3. Early morning awakening
4. Nonrestorative sleep
36
duration of sx in insomia
Transient / acute -
Short term/subacute –
Chronic
Duration of symptoms:
Transient / acute - \<1 wk
Short term/subacute – 1wk -3mo
Chronic \> 3 mo
37
Polysomnography is indicated to help dx?
is not indicated for regular evaluation of insomnia:)
Dx REM sleep disorders & sleep apnea
38
nonpharm tx of insomnia
**Sleep hygiene**
* Regular wake up times
* Limit daytime napping
* Avoid excess pm fluids to avoid nocturia
* minimize noise, ambient temperature
**Behavioral therapy**: Used for trouble falling asleep and mid sleep arousals
* Cognitive interventions, relaxation techniques
**Bright light therapy**: Sunlight / light boxes help with circadian rhythms
39
pharmacologic treatment of insomnia
**BZD** – intermittent low dose
* _short actin_g (midozalam, triazolam)--\> rebound insomnia ↑ risk of fall, hallucinations
* _Long-acting_ (lorazepam) carryover effects --\> Habit forming, longer half life
**Non-BZD Sleep aids**
* _Trazadone_ (less hallucinations & fall risk),
* _Zolpidem_ (Ambien)
40
discuss the pros and cons od short vs long acting bzd in insomnia
**short acting** --\> rebound insomnia ↑ risk of fall, hallucinations
**Long-acting** carryover effects --\> Habit forming, longer half life
41
OTC Meds: for insomnia
**Melatonin** – as we age see a ↓ in melatonin
**Benadryl** NOT recommended --\> anticholinergic & sedating
**Acetaminophen** may be helpful alternative “night cap” – may help fall asleep but will disrupt sleep later in the night
42
most important predictor of sleep apnea
obesity
43
define sleep apnea and pathyphys
* Cessation of airflow that disrupts sleep
* Collapse of the oropharyngeal structures
* Breathing stops anywhere from 10 sec to minutes
44
differentiate b/w the 2 types of sleep apnea & their causes
\*_Obstructive_ : 84% due to anatomy or obesity
* From weak muscles or muscle loss in throat/ oropharyngeal
_Central_: Brain fails to transmit signals to your breathing muscles to trigger breathing.
* Parkinson’s Stroke CHF
45
most common sx reported in pts w/ sleep apnes
\*Daytime sleepiness is most common
46
sleep apnea bed partner reports
Loud snoring
Apnea
Choking Gasping sounds
47
Morning headache or lethargy/confusion
CVD --\> HTN
assoc w/ what dz?
sleep apnea
48
dx sleep apnea
imaging & labs
_Polysomongraphy_
Vitals Hypoxia
Labs
* Hypoxia
* Hyercapnia (↑CO2)
49
tx of sleep apnea
_Weight loss_
_Avoid ETOH_, especially at night & sedatives
_Avoid sleeping supine_
_Oral-dental devices_ reposition jaw / tongue
_CPAP_ – Continuous Positive Airway Pressure, prevent airway collapse
_Surgical procedure_s --\> mixed results
* Mandibular-maxillary advancement= best
* Laser assisted Uvuloplasty- less effective, 30%
50
surgical procedures of sleep apnea
Mandibular-maxillary advancement= best
Laser assisted Uvuloplasty --\> less effective, 30%
51
differentiate b/w si/sx of Periodic Limb Movement & Restless Leg
**PLM** - recurring episodes of stereotypic rhythmic movements during sleep
* (legs & UE)
**RLS** - irresistible urge to move legs, motor restlessness occurring just before sleep
* Legs ONLY
52
RF for PLM & RLD
+ family hx
uremia
low iron stores
↑ age
53
Dx of RLD vs PLM
**PMLD** can be dx with Polysomnography
**RLS** is dx based on patient’s symptoms
* ↓Ferritin at risk for RLS
54
Tx of RLD & PLM
**RLS** – may improve with stretching and massage
_Dopaminergic agents_ (Pramipexole, Ropinirole)
_Oxycodone_ .. side effects
_Clonazepam_ – …but again, bad side effects
55
define FTT
Deteriorating state characterized by
* Weight loss
* Decreased appetite, poor nutrition
* Inactivity
* Often accompanied by dehydration, depression, impaired immune function, and low cholesterol
56
Etiology of FTT is an Interaction of 3 components
**1.Physical frailty:** weight loss, malnutrition, & inactivity
**2.Disability** - Difficulty completing tasks for self care and independent living (ADLs)
**3.Impaired neuropsychiatric function** - Delirium, depression, and/or dementia are the most common
57
Screening pts who may be at risk for failure to thrive using what exam?
describe how to perform exam
positive results
**Evaluate for dementia with MMSE**
“Get up and go test”
* Rise from chair not using arms, walk 10 feet, turn and return to the chair and sit
* Complete in 7-10 sec
* ↑ risk for fall & FTT if \>10 sec
58
Risk Factor measurement FTT
**Frailty** – represents decreased physiologic reserve that can affect multiple body systems causing poor health outcomes
* Results in impaired physical function, weight loss and malnutrition
**CV health study state must have 3 or more of these 5 criteria**
* Weight loss (\>5% of body weight in 1 year)
* Exhaustion (by asking questions related to activity)
* Weakness (decreased grip strength)
* Slow walking speed (\>7 seconds to walk 15 feet)
* Decreased physical activity (based on kcals)
**Mini nutritional assessment**
**Subjective global assessment:** Weight, diet, GI symptoms, functional capacity, physical appearance (decrease in muscle mass or fat)
59
Risk Factor measurement for FTT
define CV health study state and its 5 criteria
**CV health study state must have 3 or more of these 5 criteria**
* Weight loss (\>5% of body weight in 1 year)
* Exhaustion (by asking questions related to activity)
* Weakness (decreased grip strength)
* Slow walking speed (\>7 seconds to walk 15 feet)
* Decreased physical activity (based on kcals)
60
tx of FTT
**Appetite stimulants**
* _Megestrol_ - cautious of edema & DVT
* _Dronabinol_ - limit use 2/2 side effects
**Physical therapy**
**Anabolic agents** - _Growth hormones_ showing promise for improvement in functional status, physical and cognitive function
**Dementia** --\> Increase support and provide social interaction
**Depression**
* Medication and _CBT_
* _Mirtazapine_ --\> research has shown better weight gain and increased appetite
**Psychostimulants** for geriatric depression & FTT (_methylphenidate_ start low dose)
61
pharmacologic tx for apeitie stimulants in FTT
Megestrol - cautious of edema & DVT
Dronabinol- limit use 2/2 side effects
62
tx of depression in FTT
Medication and _CBT_
* _Mirtazapine_ - research has shown better weight gain and increased appetite
* Psychostimulants for geriatric depression & FTT - _methylphenidate_ start low dose
63
define visual imapirmnt
* Defined as best corrected visual acuity worse than 20/40 & better than 20/200 in better seeing eye
* Visual Impairment increases rapidly with age, especially \>75
64
age Hearing Impairment presents
Hearing starts to decline by 9dB/decade _once you hit age 55_
* 33% of \>65yrs old have hearing loss
Doubles each decade beginning at age 60 --\>
* %16 of persons aged 60
* 32% at 70yr old
65
Most common locations & causes of
inner ear sensorineural HL
conductive HL
Presbycusis is the most common cause – _inner ear sensorial hearing loss_
_Conductive Hearing Loss_ is usually due to external or middle ear problem.
* Most common infection, tumor, WAX.
66
Most common hearing loss is
presbycusis - bilateral high frequency sensorineural hearing loss
67
define cataracts
Lens opacity which causes glare, blurred vision, alterations of color
68
RF for developing cataracts
* Advanced age, \>60
* Excessive sunlight exposure
* Smoking
* Eye trauma
* Steroid medication
* Systemic disease: diabetes
69
•Glare-related vision loss
Yellow discoloration of the lens
* Peripheral dark opacity
* Alterations in the red reflex
Dx?
Cataracts
70
Painless, progressive decline in vision
Decline in vision does not improve with refraction
Cataracts
71
Dx of cataracts
_lens opacity_ can be confirmed by a _non-dilated fundus examination_
* Darkening of the red reflex,
* Opacities within the red reflex
72
Inability to read, drive, identify faces, or perceive details
Loss of central vision --\> peripheral vision is spared
Macular Degeneration
73
Leading cause of vision loss age \>60
Macular Degeneration
74
si/sx of macular degen
* Inability to read, drive, identify faces, or perceive details
* Loss of central vision -\> peripheral vision is spared
* bilateral
* Impaired color vision
* Dark or empty areas in visual field (_scotomas_)
* Distortion of straight lines
75
# define scotomas
dx?
Dark or empty areas in visual field (scotomas)
macular degen
76
differentiate b/w 2 types of macular degen
**trophic (nonexudative) “dry”:**
* Yellow globular spots of _drusen bodies_ (proteinaceous material) under macular retina during dilated fundoscopic eye exam
**Neovascular (exudative) “wet”:**
* 90% of legal blindness
* Growth of abnormal blood vessels
* Sometimes can see bleeding
* _Fluorescence angiography_ --\> neovascular network can show bleeding or exudation & help w/ tx
77
Atrophic (nonexudative) “dry”: youn willl see what under dilated fundoscopic eye exam
•Yellow globular spots of drusen bodies (proteinaceous material) under macular retina during dilated fundoscopic eye exam
78
tx of macular degen
**Neovascular "wet" AMD** --\>
* Laser surgery - main tx
* focal photocoagulation or photodynamic therapy
_Central vision loss of b/l eyes_ --\>
* consider referral for *low-vision rehabilitation*
79
Glaucoma is a Group of diseases traditionally defined by a triad of signs including at least 2 of the following: (can be painful)
Group of diseases traditionally defined by a triad of signs including at least 2 of the following: (can be painful)
* ↑ IOP
* Optic disc cupping
* Visual field loss
80
types of glaucoma
_Primary_ (\*\*\* most prevalent in elderly)
* Primary open-angle -90%
* Primary closed angle – 10%
_Secondary_
_Congenital_
81
differentiate si/sx of open angle vs closed angle galucoa
**Primary Open-Angle (90%)**
* Blurred vision
* *Halos around lights*
* *Impaired dark adaption*
* *Vision loss starts in nasal field*
**Primary Closed-Angle (10%)**
* Blurred vision
* Headache
* *Nausea/ Vomiting*
* *Corneal edema*
* *Mid-dilated pupi*l
82
* Blurred vision
* Halos around lights
* Impaired dark adaption
* Vision loss starts in nasal field
dx?
Primary Open-Angle (90%) glaucoma
83
* Blurred vision
* Headache
* Nausea/ Vomiting
* Corneal edema
* Mid-dilated pupil
Dx?
Primary Closed-Angle (10%) glaucoma
84
dx glaucoma
**Tonometry** – measure the IOP
* Normal eye 10-21 mm Hg
* POAG – may have normal pressure
**Optic Disc assessment and gonioscopy** (measures anatomic configuration of the anterior chamber angle open vs closed)
* Enlarged optic disk cup with pallor
* Nasal displacement of the retinal vessels on the disk
**Visual Field Examination**
85
tx glaucoma
goal
meds
surgical
Lower the IOP -\> Goal is to stabilize visual field loss and optic nerve damage (**_Diamox_**)
**Medical Therapy:**
_Medications_ – lower IOP through reduction on aqueous production or resistance to outflow
* Beta-adrenergic antagonists
* Alpha-aderenergic agonists
* Muscarinic agonists
* Carbonic anhydrase inhibitors
_Surgical Tx_ – when refractory to medications.
* Laser trabeculoplasty
86
surgical tx for glaucoma
Laser trabeculoplasty
87
meds for tx galucoma
Lower the IOP --\> Goal is to stabilize visual field loss and optic nerve damage (**Diamox**)
**Medical Therapy:**
_Medications_ – lower IOP through reduction on aqueous production or resistance to outflow
* Beta-adrenergic antagonists
* Alpha-aderenergic agonists
* Muscarinic agonists
* Carbonic anhydrase inhibitors
88
causes of Sensorineural hearing loss
* \*Presbycusis \*Main Cause
* Noise Infection
* Meniere’s
* Trauma
* Tumors
* Endocrine & systemic
* Iatrogenicà ototoxicity of medications
* Neurogenic
89
causes of conductive HL
* External otitis
* Trauma
* Cerumen
* Tympanic Membrane Perforation
* Cholesteoma
* Otosclerosis
* Paget’s disease
* Otitis Media
* Tumors
90
Sensorineural hearing loss: hear better in\_\_\_\_\_ ear
VS
Conductive – hear better in\_\_\_\_\_ ear
**Sensorineural** hearing loss: hear better in _unaffected_ ear
VS
**Conductive** – hear better in _affected_ ear
91
Inner Ear Causes of HL \_\_\_\_\_
Outer/Middle Ear Causes \_\_\_\_
Inner Ear Causes of HL-- sensorinueral (Presbycusis\_
Outer/Middle Ear Causes -- conductive
92
# define Presbycusis
Pure-tone threshold sensitivity to hear diff tones diminishes
•Both the cochlear hair cells and the spiral ganglion cells in the vestibulocochlear nerve can be affected
93
Presbycusis The three main affected areas:
**Sensory** : loss of hair cells & high-frequency hearing deficit
**Metabolic**: loss of stria vascularis & Low-frequency hearing deficit
**Neural**: loss of ganglion cells and a variable pattern of hearing loss
94
Most common type of sensorineural hearing loss
Presbycusis
95
Hallmark si/sx of Presbycusis
Hallmark : progressive, symmetric loss of high-frequency hearing
96
si/sx of Presbycusis
Hallmark : progressive, symmetric loss of high-frequency hearing
Bilateral Tinnitus: in both ears
Dizziness: from loss of vestibular end-organ function, called “presbyastasis”
97
In Presbycusis Whispered test & Weber test will be
(normal or abnormal)??
In Presbycusis Whispered test & Weber test will be **normal**
98
tx of Presbycusis
**Hearing Aid** (can also help with tinnitus)
**Cochlear implant**: only if failed hearing aids
**Assisted listening devices**
* _Telecoil_ which is connected to hearing aids
* Lights instead of bells
**Auditory rehab** active listening training, speech reading, and communication enhancement
99
Describe Fall factors
extrsinsic
instrinsic
situation
**Extrinsic Factors:** Rugs, clutter, poor lighting, footwear “floppy slippers” (around me)
**Intrinsic Factors:** abnormalities in an organ system – sensory control, central processing and effector output. “Balance” “Sensory” (me)
**Situation Factors:** risk-taking behaviors such as failing to use a walker, not wearing glasses.(what I did)
100
Fall Prevention Strategies:
**Correction of Vision deficits**
**Treatment of CV abnormalities** --\> such as sick sinus syndrome patient may need a pacemaker
**↓ psychotropic med**s --\> Encourage ↓ use of sleep aids, avoid sedating medications
**Vitamin D replacement**--\> Vit D supplementation has shown to improve functional status,
* goal is to achieve 25-OH Vit D level \> 32 ng/ml
**Implementation of Exercise Program**
**Prescribe Assisted devices**
**Home Safety Assessment** - often is covered in Medicare programs (shower chairs)
**Use of Medical Alarms and Lifelines**
**Behavior Modification**
101
meds that can lead to falls
* Psychotropic medications
* Neuroleptics
* Benzodiazepines
* Antidepressants
* Cardiovascular medications
* Analgesics
* Antihistamines
102
in a fall pt NCCT Head or MRI are indicatd when?
* rapid progression of gait imbalance
* incontinence
* slow gait
* recurrent falls.
103
# define pressure ulcer
location
highest risk
most commonly found where?
Localized injury that results from unrelieved pressure to the skin and underlying tissue
* _occur over bony prominences_ (sacrum, ischial tuberosity, greater trochanter, heels and lateral malleoli)
_Highest risk_ are those with comorbid conditions, immobility and reduced tissue perfusion.
_Most common_ in nursing home residence and hospitalized patients
104
what tool is used for Risk assessment for pressure ulcers
Braden Scale
105
List and define each pressure ulcer stage
**Stage 1:** intact skin
* nonblanchable reddness
**Stage 2:** Partial thickness
* shallow open ulcer w/ red/pink wound bed. no slough
**stage 3:** Full thickness
* fat may be visable but bone, tendon or muscle is not
* slough may be present that does not obscure depth of tissue loss
**Stage 4:** Full thickness w/ exposed tendon/muscle
* slough or eschar present
* tunneling
**Unstageable Pressure Injury:** Obscured full-thickness skin and tissue loss
* extent of tissue damage cannot be confirmed bc it is obscured by slough or eschar
**Deep Tissue Pressure Injury**: Persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
106
Extrinsic and intrinsic factors form ulcers
**Extrinsic** is the constant pressure from immobility and shear forces related to skin sliding and moisture on the skin.
**Intrinsic** include decreased sensory perception and malnutrition
107
ulcer prevention strategies
Improve mobility and ↓ friction & pressure
Frequent turning and positioning – q2H
Air mattresses / Foam Mattresses
Air suspension devices
Nutritional interventions
* optimum protein intake 1.0-1.2/kg/day
* Vitamins C and Zinc supplementation
108
tx of pressure ulcers
**Maintain a Moist wound healing environment** – will heal 40% faster than air-exposed wounds
**Topical Dressings** - Hydrogels, Hydrocolloid, Alginates
**Growth factors**
**Debridement** – necrotic debris increases risk of bacterial infections and delays healing.
109
some dressings which can be used for autolytic debridement of ulcers –
collagenase
papain/urea
papain/urea-chlorophyll.
110
Elderly limitation to healing ???
LOW vascular flow
111
define delirium & RF
A change in the level of consciousness / Cognitive dysfunction
Risk factors:
* Advanced age
* Underlying brain disease (ex. dementia, stroke, Parkinson’s)
* Post-op patients
112
drug causes of deliruim
* Analgesics, Antibiotics, Antivirals,
* Anticholinergics
Hypnotics and sedatives
113
causes of delirium
* D rugs, dehydration, discomfort (pain), detox
* E lectrolytes, endocrine, EtOH, environment
* L ungs (hypoxia), liver, lack sleep, long ED stay
* I nfection, infarction (cardiac, cerebral)
* R estricted movement/mobility, restraints, renal failure
* I ntracranial, injury, intoxication
* U rinary retention/constipation, unfamiliar environment
* M etabolic, metastatic, malnutrition
114
si/sx of delirium
**Develops over a short period of time (hours-days)**
_•Fluctuating LOC_
_•Cognitive dysfunction – losing sense of self_
_•Disorientation_
* Altered speech/ dysphasia
* Visual hallucination
* Sleep cycle disturbances
* Tremor
115
dx of delirium
**MMSE**
* Name
* Where we are
* Test memory – repeat 3 numbers/objects
* Count back from 7
**CAM** (need 1&2 + 3 or 4)
1. Acute onset & fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered LOC
116
list diagnostic fts of CAM
dx what dz?
delirium
## Footnote
**CAM** (need 1&2 + 3 or 4)
1. Acute onset & fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered LOC
117
tx of delirium when dangerous behavior
* Antipsychotics (ex. Haldol, olanzapine)
* Cholinesterase inhibitors
* Antidepressants
* BZD for withdrawal
* Restraints – last resort
118
define dementia
Progressive and significant decline from previous level
Short term memory impairment AND
* Language
* Attention
* Orientation
* Visual/spatial skills-motor
* Executive functioning
Interferes with social or occupational functioning
119
LP is apprioriate dx tool on dementai when??
LP in age \<55 or rapidly developing dementia
120
Tx of dementia
## Footnote
**Mild-severe** A**D, DLB, VaD, PDD**
**Moderate to severe AD** -
**Severe AD** -
**DLB**
**FTD**
**Mild-severe** **AD, DLB, VaD, PDD**
* _Cholinesterase Inhibitor_s - Donepezil, Rivastigmine, Galantamine
**Moderate to severe AD** -
* Memantine (NMDA Receptor Antagonist)
**Severe AD** -
* Cholinesterase Inhibitor/Memantine Combo
Avoid antipsychotics in **DLB**
SSRIs for **FTD**
121
define depression
5+ symptoms for 2wk period
change from previous functioning
At least one :
1. depressed mood
2. loss of interest or pleasure
122
si/sx of depression
**"SIG-E-CAPS”**
* Sleep disturbances
* DEC interest/pleasure
* Guilty feelings
* Dec energy
* DEC concentration
* Appetite change s
* DEC psychomotor function
* Suicidal ideations
123
tx of depression
Conservative measures (ex. exercise, bright light therapy)
Psychotherapy (CBT)
Antidepressants
ECT
124
what depressed pt should we monitor due to their inc risk of what severe complication?
White male very likely to commit suicide \*\*\* --\> MONITOR THESE PTS!!
125
MoCA test is used to help dx?
dementia
126
define AD & si/sx
**Insidious loss of episodic memory**
**•Memory impairment (earliest Sx)**
* Visuospatial & language deficits
* Apathy
* Social isolation
* Irritability
127
RF for AD
* Age \>70 (dx mid 60s)
* Trisomy 21
* FHx ( ApoE4 gene)
128
Dx AD
what do we see on MRI
Amyloid beta plaques & neurofibrillary tangles
**Brain MRI** (hippocampal & temporal lobe volume loss
129
Tx of AD
mild-mod
mod-severe
severe
**Mild-mod:** Cholinesterase inhibitors
* donepezil
* rivastigmine
* galantamine
**Mod-severe:** Memantine
**Severe** :Combo therapy
130
AD differs from lewy body dementia
**AD**- memory loss early sx
**Lewy bosy** - memory loss late sx
* hallmark is visual hallucinations
131
si/sx of lewy body dementia
**Visual hallucinations (hallmark) \*\*\*\***
**REM behavior disorder** – lose muscle paralysis (talking / walking in sleep)
**Memory loss (late Sx)**
DEC exec function
Attention deficits
Visuospatial impairments
132
dx of lewy body dementia
MRI & histology
Abnormal protein (α-synuclein) deposits in the neurons
MRI (global volume loss)
Histology Lewy Body
133
AVOID ANTIPSYCHOTICS!!!! in what dz bc they can cause death cause death
Lewy bodies dementia
134
2 types of Frontal temporal dementia
* Behavioral (most common)
* Primary progressive aphasia
135
si/sx of frontal temporal dementia
•Personality disorder
**•Loss of exec function (early sign)**
_•Hyperorality_
_•Frontal release signs_ (resurfacing of primitive reflexes)
•Memory and visuospatial functioning relatively preserved
_•Aphasia (early in disease)_
136
dx of frontal temporal dementia
MRI & histology
Hyperphosphorylated tau inclusion bodies (pick bodies)
MRI (frontotemporal volume loss
137
Tx of FTD
SSRIs
138
Stroke / MI --\> THEN sx begin
* Abrupt onset, focal Sx
* Focal deficits on exam
Dx??
Vascular dementia
139
Stepwise progression of vascular dementia
* Frontal-executive
* L Parietal- aphasia
* R Parietal- visuospatial
140
vascular dementia:
Memory impairment is an (early/late) onset
vascular dementia Memory impairment (late onset)
141
dx of vascular dementia
MRI
Focal deficits
MRI (cortical/subcortical punctate lesions, volume loss, white matter lesions
142
match si/sx w/ type of dementia (VD, AD, LBD, FTD)
## Footnote
Memory loss early sx
Memory loss late sx
Visual hallucinations
Loss of exec function (early sign)
Memory impairment (late onset)
Memory loss early sx - AD
Memory loss late sx - LBD
Visual hallucinations - LBD
Loss of exec function (early sign) - FTD
Memory impairment (late onset) - VD
143
compare / contrast dementia, delirium, depression
onset
course
duration
conciousness
attention
psychomotor changes
reversibility
144
define osteoporisis and causes
Low bone mass, thinning of trabecular bone
Decreased bone strength and increased risk of fractures
145
RF for osteoporosis
* **Age \>65**
* **Estrogen deficiency** (ex. post-menopause, oophorectomy)
* Low BMI
* FHx
* Meds (ex. GCs, warfarin, PPIs, lithium)
* Lifestyle (ex. smoking, inactivity)
* Hx of trauma
* Immune disorders
146
Presence of fragility fracture indicated ??
osteoporosis
147
dx osteoporosis
**DEXA scan** (T-score
Fracture assessment tool (**FRAX**)
* 10 year probability of an osteoporotic fractures ≥20% OR a hip fracture ≥3%
148
Interpret T score values for osteoporisis
T Score \> -1.0 = Normal
T Score - 1.0 ≥ to \> -2.5 = Osteopenia
T Score ≤ - 2.5 = Osteoporosis (up to -4)
T Score ≤ - 2.5 with fracture = Severe Osteoporosis
149
interpret Z-score
• Score \> -2.0 within expected range for age
Z Score ≤ -2.0 should warrant further investigation for other causes low bone mass (drugs, other disorders in endocrine, GI, renal)
150
define T score vs Z score
**T score** - Average BMD of a 30-year-old of the same gender
## Footnote
**Z Score:** Average BMD of person _of the same age_ and gender
150
FRAX Underestimate risk in those with
* Recent or multiple fractures
* Burst steroids \< 3 months (i.e COPD)
* Diabetes
* Validated for femoral neck DXA only
151
tx of osteoprosis
first line
second line
severe
SERMs
**FIRST LINE:** Bisphosphonates
* Fosamax, Boniva, Reclast
* NO CKD or GFR \<30
**RANK ligand inhibitor** - Denosumab
* Sudden discontinuation of denosumab triggers drop in BMD and increased fx risk.
* Must replace with alternative pharmacotherapy
**Severe Osteoporosis** : Anabolic agents
* teriparatide
* Romosozumab
**SERMs** (raloxifene)
* Inhibits bone resorption, decrease risk of vertebral fx, reduce of breast ca
152
vit D deficency prevention
## Footnote
Adults with no regular sun exposure year round
Older patients (≥ 65yo)
Post menopausal
**Adults with no regular sun exposure year round**
* Vitamin D3 600-800 IU (15-20ug) daily
**Older patients (≥ 65yo)**:Vitamin D3 800-1000 IU daily
**Post menopausal:**
* Vitamin D3 800 IU
* and 1200mg calcium
153
dx of vit D deficency
interpret measurements
Normal
Insufficiency
Deficiency
25-hydroxyvitamin D (25 [OH] vitamin D)
(storage form in liver – long ½ life 15 days)
* Normal 20-40 ng/mL
* Insufficiency 12-20 ng/mL
* Deficiency \< 12 ng/mL
154
tx of vit D deficency
* 10-15 min of sunlight x2-3/week
* Vitamin D2/D3 supplementation
155
causes of vit D deficency
* DEC dietary intake/absorption
* Inadequate sunlight exposure
* Older age
* Comorbidities affecting hydroxylation (renal or liver disease)
156
active vs storage form of vit D
**25-hydroxyvitamin D (25 [OH] vitamin D)**
* storage form in liver
* long ½ life 15 days
**1,25-dihydroxycholecalciferol= 1,25-hydroxy Vitamin D Calcitriol**
* Active form, Made in Kidney
* Increases Ca (and phosphorus) uptake from intestines
