Geri, Dementia, PD, Stroke, TIA Flashcards
Cancer screening guidelines for geriatric population
- Prostate cancer
PSA → ages 55-70 based on symptoms, preference and discussion with provider (not recommended for age >70)
Cancer screening guidelines for geriatric population
- Breast cancer
Breast mammogram → every 2 years until age 74
Cancer screening guidelines for geriatric population
- Cervical cancer
Cervical cancer → not indicated after 65 years
Cancer screening guidelines for geriatric population
- Colorectal screening
Colorectal screening → ages 50-75 years
Cancer screening guidelines for geriatric population
- Bone density
Bone density → once at age 65 for women, 70 for men
What are six common geriatric syndromes?
- Polypharmacy
- Cognitive impairment
- Dehydration
- Falls
- Failure to thrive (FTT, frailty)
- Elder abuse
What is the definition of poly pharmacy?
Patients on 5 or more medications
- Consider Beer’s criteria for list of potentially dangerous medications for patients 65+ years
- Complete medication reconciliation
- Deprescribing
Pharmacokinetic considerations in drug therapy for geriatric patients
- Reduction in lean body mass
- Reduced blood flow to the kidneys and liver
- Increased body fat
What two things must the provider consider if a geriatric patient presents with cognitive impairment?
- Alzheimer’s disease: chronic, irreversible illness with gradual onset and steady decline
- Delirium: transient waxing and waning LOC
Lab findings suggestive of dehydration in geriatric population
- BUN/creatinine ratio 25:1 or more
- Sodium >148 mEq/L
How to calculate fluid deficit in dehydrated geriatric patients
Pre-illness weight (kg) - current weight (kg) = fluid deficit (L)
What assessments can be done to determine patients risk for falls?
Timed up and go (TUG) test
- Ability to complete task within 20 seconds or less is good
- Taking longer than 30 seconds indicates high risk of falling
True/false: Immediate ED referral or specialist consultation is indicated for patients with suspected cerebrovascular events
True
What are the three types of stroke?
- Ischemic (most prevalent)
- TIA
- Hemorrhagic
- Intracranial
- Subarachnoid
What is a TIA?
Warning sign of a stroke
- Brain dysfunction in a circumscribed area caused by regional reduction in blood flow (ischemia) resulting in either transient or minor observable clinical symptoms
What is the most common cause of a hemorrhagic stroke?
Uncontrolled HTN (primary cause)
Common clinical presentation of a stroke
- Hemiparesis
- Hemisensory loss
- Visual field defects
- Ataxia - difficulty with balance and coordination
- Dysarthria - difficulty speaking
- Reflex asymmetry
- Babinski’s sign
What is the most common complaint a patient presents with if they have a hemorrhagic stroke?
Headache (“worst headache of my life”)
Components of a physical exam for a patient presenting with possible stroke
- Complete neuro exam to assess deficits
- ABCD score (age, BP, clinical features, duration of symptoms/DM)
- NIH stroke scale
Gold standard diagnostic test for strokes (including additional diagnostic tests)
Gold standard → head CT scan (can miss small infarcts or lesions)
- Can consider contrast or MRI to exclude tumors
Important management considerations for PCP in stroke prevention (secondary management)
- BP control
- Aspirin therapy (lower doses as effective as higher doses, 81 or 325 mg)
- Smoking cessation
- Blood sugar and cholesterol management
How soon should tPA be administered for stroke?
Within 4.5 hours of symptom onset
After stroke stabilization, what important referrals should be made for rehab?
- PT, OT, ST, counseling, palliative care
- Rehab should be scheduled within 48 hours of stabilization
Antiplatelet therapy that can be used for stroke prevention
- Aspirin
- Wafarin (coumadin)
- DOACs (eliquis, xarelto)
- Heparin
What are the antidotes for antiplatelet therapy?
- Warfarin → vitamin K
- Clopidogrel (plavix) and ASA → platelets
- Heparin → protamine
What is dementia?
Umbrella term for group of brain disorders that affect the frontal, temporal, and parietal lobes
- Progressive loss of memory and behavioral changes that interfere with independence of ADLs
Common presenting symptoms of dementia
- Memory loss (e.g. forgetting a name, misplacing keys)
- Personality changes
- Language disturbances
- Problems with independent ADLs
Clinical presentation of Lewy body dementia
- Visual hallucinations
- Motor impairments
- Postural instability
- Sleep disturbances
Alzheimer’s disease clinical presentation
- Early stage
- Short term memory loss
- Anxiety
- Depression
- Word finding and naming problems
Middle stage symptoms of Alzheimer’s disease
- Worsening memory, language, judgement, disorientation to time and place
- Neuropsychiatric symptoms (paranoia, hallucination, delusional thinking)
- Urinary incontinence
- Perseveration
- Loss of impulse control
Late stage symptoms of Alzheimer’s disease
- Motor rigidity
- Prominent neurologic deficits (apraxia, agnosia)
- Severe cognitive and language impairment
Physical exam components when assessing a patient with dementia
- Careful and detailed history from family or caregivers
- Complete physical exam with detailed neuro exam
- Get up and go test
- Review all medications (especially anticholinergics)
Diagnostic testing for dementia
- Labs: CBC, TSH, vitamin B12, folate, metabolic screen
- Serum drug levels
- Digoxin, carbamazepine (tegretol), theophylline, divalproex sodium (depakote)
- Imaging to identify mass lesions, vascular lesions, infections → does not confirm diagnosis
- CT scan, MRI, PET scan
Dementia management
- Non pharmacologic
- Address safety concerns (driving, cooking, etc.)
- Obtain health care proxy, durable power of attorney
- Referral to neurology, support groups
Dementia management
- Pharmacologic
- Supplementation with 200 IU of vitamin E
- Cholinesterase inhibitor
- Donepezil (aricept), rivastigmine (exelon), galantamine (razadyne)
- NMDA receptor antagonist
- Memantine (namenda)
- SSRIs for depression
- Avoid antipsychotics
What is delirium?
Acute change in mental status
- Often first and only indicator in older adults of underlying physical illness (e.g. infection, MI, drug toxicity)
- Leading complication of hospitalization for older adults
- Treat precipitating causes and symptoms
What is Parkinson’s disease?
Slowly progressive neurodegenerative disease
- Loss of dopamine, too much acetylcholine
Parkinson’s disease clinical presentation
- Asymmetric or unilateral tremor (resting, disappears with action, “pill rolling”)
- Rigidity (“cog wheeling” during movement)
- Bradykinesia with freezing
- Flexed posture with loss of postural reflexes
- Shuffling gait with decreased arm swing
- Masked facies
- Hypophonia
Possible causes of Parkinson’s disease
- Genetics
- Environmental factors (pesticides)
- Abnormalities in protein processing
- Oxidative stress
- Mitochondrial dysfunction
- Inflammation and immune regulation
Physical exam and diagnostic studies for Parkinson’s disease
- Assess postural reflexes, motor-sensory testing
- Diagnostic tests
- No labs or imaging indicated
- Diagnosis based on distinctive history and physical exam findings with two of the three cardinal features:
- Tremor
- Bradykinesia
- Rigidity
- (+) symptom response to levodopa
Non pharmacologic management of Parkinson’s disease
Symptomatic treatment
- Neurorehabilitation strategies
- Physical activity (dance, treadmill, boxing, tai chi)
- Cognitive exercises (crossword puzzles, sudoku)
Pharmacologic management of Parkinson’s disease
- Levodopa-carbidopa (sinemet)
- Selegiline (eldepryl)
- Dopamine agonists
- Anticholinergics
- Catechol O-methyltransferase inhibitors
- Amantadine
Can complications occur with longterm use of levodopa?
Yes - complications occur after 5+ years of use
- Motor fluctuations (wearing-off phenomenon)
- Involuntary movements (dyskinesia)
- Abnormal postures of extremities and trunk (dystonia)
What antidepressants should be prescribed for patients with Parkinson’s disease?
- Pramipexole
- Venlafaxine
- Sertraline
