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CM 4 GERI & NEURO > GERI > Flashcards

GERI Flashcards

1
Q

UTI is an umbrella term encompassing what dzs?

A
  • Asymp Bacteriuria
  • cystitis
  • Prostatitis
  • Pyelonephritis
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2
Q

Most common infectious illness in adults > 65 y/o

A

UTI

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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%)
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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
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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
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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
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7
Q

Define Asymptomatic Bacteriuria

A

isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms of urinary tract

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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

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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

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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

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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
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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

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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)
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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)
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15
Q

Fecal Impaction Management

A
  1. Disimpaction –> In the absence of perforation and if safe to do
  2. Warm water enema –> if above fails
  3. Once Disimpacted –> begin bowel regimen w/ PO polyethylene glycol (MiralaX)
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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
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17
Q

differentiate b/w acute and chronic diarrhea

A

Acute - <14 days

Chronic - >14 days

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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)

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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
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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)

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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:

  1. Hemolytic anemia (<30%)
  2. Thrombocytopenia (<150,000)
  3. ↑ Creatinine than ULN for pt age
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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)

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23
Q

Lactose / Lactulose breath test is used to dx what dz?

what value is +??

A

Chronic diarrhea

lactulose -SIBO (↑20 is positive)

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24
Q

in chronic diarrhea Flex sig/colonoscopy is indicated when?

A

negative cx

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25
Q

Fecal elastase is used to dx?

what does it indicate?

A

chronic diarrhea

Fecal elastase (Pancreatic insufficiency

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26
Q

tx of chronic diarrhea - general measures

A

General Measures

  • Antidiarrheals - Loperamide
  • Cholestyramine
  • Fiber supplementation
  • Supportive care – ↑ PO fluid intake and maintain nutrition
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27
Q

Define Microscopic colitis(Lymphocytic colitis or collagenous colitis)

what age group does it affect

A

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

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28
Q

Dx of Microscopic colitis(Lymphocytic colitis or collagenous colitis)

A

Colonoscopy via biopsy – mucosa usually grossly normal

  • Proximal biopsies are best as the severity of histologic changes decline in the distal colon
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29
Q

tx of Microscopic colitis(Lymphocytic colitis or collagenous colitis)

A

Antidiarrheals – loperamide

Glucocorticoids – Budesonide

Cholestyramine

Bismuth subsalicylate –limited data

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30
Q

Treat underlying issue in chronic diarrhea

Microscopic colitis

celiac disease

pancreatic insufficiency

lactose intolerance

SIBO

A

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

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31
Q

T/F

Tx diarrhea caused by E. coli

A

FALSE

NO - risk of HUS

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32
Q

describe the 4 normal phases of sleep

A

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

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33
Q

what is important to ask elderly when discussing sleep disorders

A
  • 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
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34
Q

differentiate b/w primary & secondary sleeo disorders

List examples of each

A

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
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35
Q

List the 4 types of insomnia:

A
  1. Difficulty falling asleep
  2. Mid sleep awakening
  3. Early morning awakening
  4. Nonrestorative sleep
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36
Q

duration of sx in insomia

Transient / acute -

Short term/subacute –

Chronic

A

Duration of symptoms:

Transient / acute - <1 wk

Short term/subacute – 1wk -3mo

Chronic > 3 mo

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37
Q

Polysomnography is indicated to help dx?

A

is not indicated for regular evaluation of insomnia:)

Dx REM sleep disorders & sleep apnea

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38
Q

nonpharm tx of insomnia

A

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

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39
Q

pharmacologic treatment of insomnia

A

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)
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40
Q

discuss the pros and cons od short vs long acting bzd in insomnia

A

short acting –> rebound insomnia ↑ risk of fall, hallucinations

Long-acting carryover effects –> Habit forming, longer half life

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41
Q

OTC Meds: for insomnia

A

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

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42
Q

most important predictor of sleep apnea

A

obesity

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43
Q

define sleep apnea and pathyphys

A
  • Cessation of airflow that disrupts sleep
  • Collapse of the oropharyngeal structures
  • Breathing stops anywhere from 10 sec to minutes
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44
Q

differentiate b/w the 2 types of sleep apnea & their causes

A

*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
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45
Q

most common sx reported in pts w/ sleep apnes

A

*Daytime sleepiness is most common

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46
Q

sleep apnea bed partner reports

A

Loud snoring

Apnea

Choking Gasping sounds

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47
Q

Morning headache or lethargy/confusion

CVD –> HTN

assoc w/ what dz?

A

sleep apnea

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48
Q

dx sleep apnea

imaging & labs

A

Polysomongraphy

Vitals Hypoxia

Labs

  • Hypoxia
  • Hyercapnia (↑CO2)
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49
Q

tx of sleep apnea

A

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%
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50
Q

surgical procedures of sleep apnea

A

Mandibular-maxillary advancement= best

Laser assisted Uvuloplasty –> less effective, 30%

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51
Q

differentiate b/w si/sx of Periodic Limb Movement & Restless Leg

A

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
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52
Q

RF for PLM & RLD

A

+ family hx

uremia

low iron stores

↑ age

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53
Q

Dx of RLD vs PLM

A

PMLD can be dx with Polysomnography

RLS is dx based on patient’s symptoms

  • ↓Ferritin at risk for RLS
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54
Q

Tx of RLD & PLM

A

RLS – may improve with stretching and massage

Dopaminergic agents (Pramipexole, Ropinirole)

Oxycodone .. side effects

Clonazepam – …but again, bad side effects

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55
Q

define FTT

A

Deteriorating state characterized by

  • Weight loss
  • Decreased appetite, poor nutrition
  • Inactivity
  • Often accompanied by dehydration, depression, impaired immune function, and low cholesterol
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56
Q

Etiology of FTT is an Interaction of 3 components

A

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

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57
Q

Screening pts who may be at risk for failure to thrive using what exam?

describe how to perform exam

positive results

A

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
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58
Q

Risk Factor measurement FTT

A

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)

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59
Q

Risk Factor measurement for FTT

define CV health study state and its 5 criteria

A

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)
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60
Q

tx of FTT

A

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)

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61
Q

pharmacologic tx for apeitie stimulants in FTT

A

Megestrol - cautious of edema & DVT

Dronabinol- limit use 2/2 side effects

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62
Q

tx of depression in FTT

A

Medication and CBT

  • Mirtazapine - research has shown better weight gain and increased appetite
  • Psychostimulants for geriatric depression & FTT - methylphenidate start low dose
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63
Q

define visual imapirmnt

A
  • 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
Q

age Hearing Impairment presents

A

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
Q

Most common locations & causes of

inner ear sensorineural HL

conductive HL

A

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
Q

Most common hearing loss is

A

presbycusis - bilateral high frequency sensorineural hearing loss

67
Q

define cataracts

A

Lens opacity which causes glare, blurred vision, alterations of color

68
Q

RF for developing cataracts

A
  • Advanced age, >60
  • Excessive sunlight exposure
  • Smoking
  • Eye trauma
  • Steroid medication
  • Systemic disease: diabetes
69
Q

•Glare-related vision loss

Yellow discoloration of the lens

  • Peripheral dark opacity
  • Alterations in the red reflex

Dx?

A

Cataracts

70
Q

Painless, progressive decline in vision

Decline in vision does not improve with refraction

A

Cataracts

71
Q

Dx of cataracts

A

lens opacity can be confirmed by a non-dilated fundus examination

  • Darkening of the red reflex,
  • Opacities within the red reflex
72
Q

Inability to read, drive, identify faces, or perceive details

Loss of central vision –> peripheral vision is spared

A

Macular Degeneration

73
Q

Leading cause of vision loss age >60

A

Macular Degeneration

74
Q

si/sx of macular degen

A
  • 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
Q

define scotomas

dx?

A

Dark or empty areas in visual field (scotomas)

macular degen

76
Q

differentiate b/w 2 types of macular degen

A

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
Q

Atrophic (nonexudative) “dry”: youn willl see what under dilated fundoscopic eye exam

A

•Yellow globular spots of drusen bodies (proteinaceous material) under macular retina during dilated fundoscopic eye exam

78
Q

tx of macular degen

A

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
Q

Glaucoma is a Group of diseases traditionally defined by a triad of signs including at least 2 of the following: (can be painful)

A

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
Q

types of glaucoma

A

Primary (*** most prevalent in elderly)

  • Primary open-angle -90%
  • Primary closed angle – 10%

Secondary

Congenital

81
Q

differentiate si/sx of open angle vs closed angle galucoa

A

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 pupil
82
Q
  • Blurred vision
  • Halos around lights
  • Impaired dark adaption
  • Vision loss starts in nasal field

dx?

A

Primary Open-Angle (90%) glaucoma

83
Q
  • Blurred vision
  • Headache
  • Nausea/ Vomiting
  • Corneal edema
  • Mid-dilated pupil

Dx?

A

Primary Closed-Angle (10%) glaucoma

84
Q

dx glaucoma

A

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
Q

tx glaucoma

goal

meds

surgical

A

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
Q

surgical tx for glaucoma

A

Laser trabeculoplasty

87
Q

meds for tx galucoma

A

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
Q

causes of Sensorineural hearing loss

A
  • *Presbycusis *Main Cause
  • Noise Infection
  • Meniere’s
  • Trauma
  • Tumors
  • Endocrine & systemic
  • Iatrogenicà ototoxicity of medications
  • Neurogenic
89
Q

causes of conductive HL

A
  • External otitis
  • Trauma
  • Cerumen
  • Tympanic Membrane Perforation
  • Cholesteoma
  • Otosclerosis
  • Paget’s disease
  • Otitis Media
  • Tumors
90
Q

Sensorineural hearing loss: hear better in_____ ear

VS

Conductive – hear better in_____ ear

A

Sensorineural hearing loss: hear better in unaffected ear

VS

Conductive – hear better in affected ear

91
Q

Inner Ear Causes of HL _____

Outer/Middle Ear Causes ____

A

Inner Ear Causes of HL– sensorinueral (Presbycusis_

Outer/Middle Ear Causes – conductive

92
Q

define Presbycusis

A

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
Q

Presbycusis The three main affected areas:

A

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
Q

Most common type of sensorineural hearing loss

A

Presbycusis

95
Q

Hallmark si/sx of Presbycusis

A

Hallmark : progressive, symmetric loss of high-frequency hearing

96
Q

si/sx of Presbycusis

A

Hallmark : progressive, symmetric loss of high-frequency hearing

Bilateral Tinnitus: in both ears

Dizziness: from loss of vestibular end-organ function, called “presbyastasis”

97
Q

In Presbycusis Whispered test & Weber test will be

(normal or abnormal)??

A

In Presbycusis Whispered test & Weber test will be normal

98
Q

tx of Presbycusis

A

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
Q

Describe Fall factors

extrsinsic

instrinsic

situation

A

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
Q

Fall Prevention Strategies:

A

Correction of Vision deficits

Treatment of CV abnormalities –> such as sick sinus syndrome patient may need a pacemaker

↓ psychotropic meds –> 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
Q

meds that can lead to falls

A
  • Psychotropic medications
  • Neuroleptics
  • Benzodiazepines
  • Antidepressants
  • Cardiovascular medications
  • Analgesics
  • Antihistamines
102
Q

in a fall pt NCCT Head or MRI are indicatd when?

A
  • rapid progression of gait imbalance
  • incontinence
  • slow gait
  • recurrent falls.
103
Q

define pressure ulcer

location

highest risk

most commonly found where?

A

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
Q

what tool is used for Risk assessment for pressure ulcers

A

Braden Scale

105
Q

List and define each pressure ulcer stage

A

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
Q

Extrinsic and intrinsic factors form ulcers

A

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
Q

ulcer prevention strategies

A

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
Q

tx of pressure ulcers

A

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
Q

some dressings which can be used for autolytic debridement of ulcers –

A

collagenase

papain/urea

papain/urea-chlorophyll.

110
Q

Elderly limitation to healing ???

A

LOW vascular flow

111
Q

define delirium & RF

A

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
Q

drug causes of deliruim

A
  • Analgesics, Antibiotics, Antivirals,
  • Anticholinergics

Hypnotics and sedatives

113
Q

causes of delirium

A
  • 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
Q

si/sx of delirium

A

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
Q

dx of delirium

A

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
Q

list diagnostic fts of CAM

dx what dz?

A

delirium

CAM (need 1&2 + 3 or 4)

  1. Acute onset & fluctuating course
  2. Inattention
  3. Disorganized thinking
  4. Altered LOC
117
Q

tx of delirium when dangerous behavior

A
  • Antipsychotics (ex. Haldol, olanzapine)
  • Cholinesterase inhibitors
  • Antidepressants
  • BZD for withdrawal
  • Restraints – last resort
118
Q

define dementia

A

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
Q

LP is apprioriate dx tool on dementai when??

A

LP in age <55 or rapidly developing dementia

120
Q

Tx of dementia

Mild-severe AD, DLB, VaD, PDD

Moderate to severe AD -

Severe AD -

DLB

FTD

A

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
Q

define depression

A

5+ symptoms for 2wk period

change from previous functioning

At least one :

  1. depressed mood
  2. loss of interest or pleasure
122
Q

si/sx of depression

A

“SIG-E-CAPS”

  • Sleep disturbances
  • DEC interest/pleasure
  • Guilty feelings
  • Dec energy
  • DEC concentration
  • Appetite change s
  • DEC psychomotor function
  • Suicidal ideations
123
Q

tx of depression

A

Conservative measures (ex. exercise, bright light therapy)

Psychotherapy (CBT)

Antidepressants

ECT

124
Q

what depressed pt should we monitor due to their inc risk of what severe complication?

A

White male very likely to commit suicide *** –> MONITOR THESE PTS!!

125
Q

MoCA test is used to help dx?

A

dementia

126
Q

define AD & si/sx

A

Insidious loss of episodic memory

•Memory impairment (earliest Sx)

  • Visuospatial & language deficits
  • Apathy
  • Social isolation
  • Irritability
127
Q

RF for AD

A
  • Age >70 (dx mid 60s)
  • Trisomy 21
  • FHx ( ApoE4 gene)
128
Q

Dx AD

what do we see on MRI

A

Amyloid beta plaques & neurofibrillary tangles

Brain MRI (hippocampal & temporal lobe volume loss

129
Q

Tx of AD

mild-mod

mod-severe

severe

A

Mild-mod: Cholinesterase inhibitors

  • donepezil
  • rivastigmine
  • galantamine

Mod-severe: Memantine

Severe :Combo therapy

130
Q

AD differs from lewy body dementia

A

AD- memory loss early sx

Lewy bosy - memory loss late sx

  • hallmark is visual hallucinations
131
Q

si/sx of lewy body dementia

A

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
Q

dx of lewy body dementia

MRI & histology

A

Abnormal protein (α-synuclein) deposits in the neurons

MRI (global volume loss)

Histology Lewy Body

133
Q

AVOID ANTIPSYCHOTICS!!!! in what dz bc they can cause death cause death

A

Lewy bodies dementia

134
Q

2 types of Frontal temporal dementia

A
  • Behavioral (most common)
  • Primary progressive aphasia
135
Q

si/sx of frontal temporal dementia

A

•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
Q

dx of frontal temporal dementia

MRI & histology

A

Hyperphosphorylated tau inclusion bodies (pick bodies)

MRI (frontotemporal volume loss

137
Q

Tx of FTD

A

SSRIs

138
Q

Stroke / MI –> THEN sx begin

  • Abrupt onset, focal Sx
  • Focal deficits on exam

Dx??

A

Vascular dementia

139
Q

Stepwise progression of vascular dementia

A
  • Frontal-executive
  • L Parietal- aphasia
  • R Parietal- visuospatial
140
Q

vascular dementia:

Memory impairment is an (early/late) onset

A

vascular dementia Memory impairment (late onset)

141
Q

dx of vascular dementia

MRI

A

Focal deficits

MRI (cortical/subcortical punctate lesions, volume loss, white matter lesions

142
Q

match si/sx w/ type of dementia (VD, AD, LBD, FTD)

Memory loss early sx

Memory loss late sx

Visual hallucinations

Loss of exec function (early sign)

Memory impairment (late onset)

A

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
Q

compare / contrast dementia, delirium, depression

onset

course

duration

conciousness

attention

psychomotor changes

reversibility

A
144
Q

define osteoporisis and causes

A

Low bone mass, thinning of trabecular bone

Decreased bone strength and increased risk of fractures

145
Q

RF for osteoporosis

A
  • 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
Q

Presence of fragility fracture indicated ??

A

osteoporosis

147
Q

dx osteoporosis

A

DEXA scan (T-score

Fracture assessment tool (FRAX)

  • 10 year probability of an osteoporotic fractures ≥20% OR a hip fracture ≥3%
148
Q

Interpret T score values for osteoporisis

A

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
Q

interpret Z-score

A

• 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
Q

define T score vs Z score

A

T score - Average BMD of a 30-year-old of the same gender

Z Score: Average BMD of person of the same age and gender

150
Q

FRAX Underestimate risk in those with

A
  • Recent or multiple fractures
  • Burst steroids < 3 months (i.e COPD)
  • Diabetes
  • Validated for femoral neck DXA only
151
Q

tx of osteoprosis

first line

second line

severe

SERMs

A

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
Q

vit D deficency prevention

Adults with no regular sun exposure year round

Older patients (≥ 65yo)

Post menopausal

A

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
Q

dx of vit D deficency

interpret measurements

Normal

Insufficiency

Deficiency

A

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
Q

tx of vit D deficency

A
  • 10-15 min of sunlight x2-3/week
  • Vitamin D2/D3 supplementation
155
Q

causes of vit D deficency

A
  • DEC dietary intake/absorption
  • Inadequate sunlight exposure
  • Older age
  • Comorbidities affecting hydroxylation (renal or liver disease)
156
Q

active vs storage form of vit D

A

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

CM 4 GERI & NEURO (4 decks)

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