Geri - Sleep disorders, FTT, Vision and Hearing loss, Skin Lesions Flashcards
what are the 2 types of sleep states?
Nonrapid eye movement (NREM)
REM
what are the 4 stages of sleep?
1 and 2: light sleep
-stage 1 is between wakefulness and sleep
3 and 4: deep sleep (REM sleep)
-Deep restorative sleep occurs here
what’s a “Normal Night”?
Begins with NREM -> REM sleep after 80 minutes -> cycle continued between NREM and REM with REM getting longer
in what state of sleep does deep restorative sleep occur?
REM (stages 3 and 4) - deep sleep
what is insomnia associated with?
daytime fatigue, irritability and problems with concentrating
what are the 4 common types of insomnia?
(1) Difficulty falling asleep
(2) Mid sleep awakening
(3) Early morning awakening
(4) Non-restorative sleep (don’t get into stage 3 or 4 of sleep)
how long do transient/acute insomnia sx’s last?
< 1 week
how long do short/subacute insomnia sx’s last?
1 week - 3 months
how long do chronic insomnia sx’s last?
3 months
sleep disorder NREM presentation?
- Change in sleep structure (stages of sleep)
- Change in sleep pattern (amount and timing) - mid sleep awakening
- Decrease in total sleep time
- Day time fatigue, irritability
- Problems with concentration
sleep disorder dx?
- Sleep questionnaires
- Sleep log
- Interview of bed partner
polysomnography (sleep study) is NOT indicated for regular evaluation of what?
insomnia
how are REM sleep d/o’s dx?
polysomnography (ex: sleep apnea)
sleep disorder NREM non-pharmacologic tx
Sleep hygiene
Behavioral therapy
Bright light therapy
what is sleep hygiene tx?
- Regular wake up times
- Limit daytime napping
- Avoid excess pm fluids, minimize noise, ambient temp
sleep disorder NREM pharmacologic tx?
Benzo’s
Non-Benzo’s (Trazadone)
OTC meds (melatonin, APAP, “night cap”)
why caution with short acting Benzo’s?
rebound insomnia increased risk of fall, hallucinations
why caution with long acting Benzo’s?
can have carryover effects into the day time -> risk of falls
what is sleep apnea caused by?
Collapse of the oropharyngeal structures
how long does breathing stop for in sleep apnea?
10secs-minutes
what is the MOST IMPORTANT predictor for sleep apnea?
Obesity - increased BMI
what are the 2 types of sleep apnea and which one is the M/C?
Obstructive (M/C)
Central
what is Obstructive sleep apnea d/t?
anatomy or obesity
-collapse of oropharyngeal structures (tongue falls back and blocks airway)
what is Central sleep apnea d/t? examples?
brain fails to transmit signals to breathing muscles
Ex:
- Parkinson’s
- Stroke
- CHF
sx’s of sleep apnea?
- Daytime sleepiness (M/C)
- Morning HA (b/c low on O2)
what does the bed partner report in sleep apnea?
- Loud snoring
- Choking
- Gasping sounds
how is sleep apnea dx?
***Polysomnography (measures NREM and REM)
Vitals - hypoxia
Labs - hypoxia, hypercapnia
tx of sleep apnea?
- ***weight loss
- avoid alcohol
- avoid sedatives
- avoid sleeping supine
- ***CPAP
what is periodic limb movement disorder? when does it stop?
recurring episodes of stereotypic rhythmic movements during sleep, generally involving the legs
doesn’t stop -> occurs during sleep
what is restless leg syndrome? when does it start and stop?
uncomfortable irresistible urge to move legs, motor restlessness
occurs just before onset of sleep and stops once asleep
how is PMLD and RLS dx?
PMLD dx with Polysomnography
RLS dx based on pt’s sx’s
tx of PMLD and RLS?
RLS - stretching and massage
Dopaminergic agents
- pramipexole
- ropinirole
Oxy or Clonazepam (but bad adrs in elderly)
what is failure to thrive (FTT)?
Deteriorating state characterized by:
- weight loss
- decreased appetite, poor nutrition
- inactivity (not moving around a lot)
what is FTT accompanied by?
dehydration, depression, impaired immune function, and low cholesterol
what’s the etiology of FTT?
Interaction of 3 components:
(1) Physical frailty
(2) Disability -> difficulty completing tasks for self-care and independent living (ADLs)
(3) Impaired neuropsychiatric function
what neuropsychiatric d/o’s are M/C in FTT?
Delirium, depression, and/or dementia
what are some RF’s of FTT?
- Med adrs
- Comorbidities
- Psychosocial factors
- Weight loss of 5% of body weight over 6-12 months
- Poor food intake
FTT risk factor measurement for Frailty
Must have 3 or more of these 5 criteria:
(1) Weight loss (>5% of body weight in 1 year)
(2) Exhaustion (by asking questions related to activity)
(3) Weakness (decreased grip strength)
(4) Slow walking speed (>7 seconds to walk 15 feet)
(5) Decreased physical activity (based on kcals)
FTT risk factor measurements
Frailty
Mini nutritional assessment
Subjective global assessment
what’s the subjective global assessment for FTT?
Weight, diet, gi symptoms, functional capacity, physical appearance (decrease in muscle mass or fat)
what vital sign should you look for with FTT?
Look for orthostatic hypotension
-signs of both autonomic dysfunction and/or dehydration (with this, at risk for falls and FTT)
what’s the best PE test for FTT? how’s it done?
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
- Increased risk for fall & FTT if >10 sec
FTT dx is based on what?
history and PE
order appropriate lab tests
- screen for infection
- CMP (LFT, Cr) for organ failure
- Ca, phosphate
- TSH
- B12, folate, vit D
- albumin
- total cholesterol
tx for FTT
treat underlying condition
consult when appropriate (dietitian, psych, PT, etc.)
***REVIEW MEDS FOR POLYPHARMACY
Appetite stimulants, PT, Growth hormones
Psychostimulants for geriatric depression and FTT (methylphenidate)
what are appetite stimulants?
Megestrol - be cautious of edema and DVT
Dronabinol - limit use 2/2 side effects
what med for depression/weight gain in FTT?
Mirtazapine
when do you consider hospice for FTT?
(must be DNR/DNI) -> life expectancy must be < 6 months
what’s the hospice criteria?
- Weight loss not due to reversible cause
- Chronic or intractable infection
- Recurrent aspiration and/or inadequate intake 2/2 pain with swallowing or weakness
- Progressive dementia
- Progressive pressure ulcers even with extreme care (stage III or IV)
what is visual impairment defined as?
best corrected visual acuity worse than 20/40 & better than 20/200 in better seeing eye
what is blindness?
when best visual acuity is <20/200
Common diseases with visual impairment?
- Cataracts
- Age related Macular Degeneration
- Glaucoma
- ***Diabetes
what are cataracts?
Lens opacity which causes glare, blurred vision, alterations of color
risk factors of cataracts?
> 60 y/o
smoking, steroid medication, DIABETES
sx’s of cataracts?
glare-related vision loss
reduction of visual acuity (trouble focusing)
yellow discoloration of lens
***ABSENT RED REFLEX
dx of cataracts?
PAINLESS, progressive decline in vision that doesn’t improve with refraction (glasses, contacts)
cataracts can be confirmed by?
nondilated funds exam showing darkening of red reflex or opacities w/in it
tx of cataracts?
Surgery if 20/50 vision or worse
-Phacoemulsification of the nucleus
REFER TO OPHTHALMOLOGIST
what is macular degeneration?
degeneration of the macular retina leading to central vision loss
what is the 1st sign of macular degeneration?
appearance of yellow-white deposits under the retina in a dilated exam
macular degeneration and associated blindness triples at what age?
> 70 y/o
what’s the leading cause of vision loss in >60 y/o?
macular degeneration
risk factors of macular degeneration?
smoking, family hx, HTN
what are the 2 types of macular degeneration?
Atrophic (nonexudative) “dry” (M/C)
-***Yellow drusen bodies
Neovascular (exudative) “wet”: 90% of legal blindness
-Growth of abnormal blood vessels; sometimes can see bleeding
in what macular degeneration are yellow drusen bodies seen?
atrophic (nonexudative) “dry” macular degeneration
sx’s of macular degeneration?
***Loss of central vision (peripheral vision is spared)
bilateral
dark or empty areas in visual field (scotomas)
distortion of straight lines (b/c only have peripheral vision)
dx of macular degeneration?
Refer to opthomologist
Fundoscopic exam
what are the yellow drusen spots seen in atrophic “dry” macular degeneration?
protein material
tx of macular degeneration?
No effective treatment
Neovascular AMD may benefit from focal photocoagulation or photodynamic therapy
Laser surgery is the main treatment for neovascular AMD
Central vision loss of b/l eyes -> consider referral for low-vision rehabilitation
what’s the main treatment for neovascular AMD?
laser surgery
what’s the definition of Glaucoma?
Triad of signs including at least 2 of the following:
(1) Elevated intraocular pressure
(2) Optic disc cupping
(3) Visual field loss
what’s the most common type of glaucoma in elderly?
Primary open-angle
what is 3x as risky for glaucoma occurrence/
family hx
can vision loss in glaucoma be reversed?
NO!!! vision loss in glaucoma can’t be reversed
how can you prevent glaucoma?
screenings q2-4 years until age 64 then every 1-2 years >65
when does vision loss occur in glaucoma?
after a significant amount of nerve damage is done
Primary open-angle glaucoma sx’s?
- Blurred vision
- Halos around lights
- Impaired dark adaption
- Vision loss starts in nasal field
Primary closed-angle glaucoma sx’s?
- Blurred vision
- HA, N/C
- Corneal edema
- Mid-dilated pupil
dx of glaucoma?
Tonometry – measures the IOP
Optic Disc assessment and gonioscopy (measures anatomic configuration of the anterior chamber angle open vs. closed)
Visual Field Exam
what is normal eye pressure on tonometry? pressure in POAG? COAG?
-Normal eye 10-21 mm Hg
POAG – may have normal pressure
Closed angle has higher pressure
what is seen on Optic DISC assessment and gonioscopy for glaucoma?
Enlarged optic disc cup with pallor
Nasal displacement of the retinal vessels on the disc
tx of Glaucoma?
-Lower the IOP
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
what’s the goal of glaucoma tx?
to stabilize visual field loss and optic nerve damage
when does hearing loss start to decline?
Hearing starts to decline by 9dB/decade once you hit age 55
what’s the most common type of hearing loss?
presbycusis - bilateral high frequency sensorineural hearing loss
-innear ear sensorial hearing loss
what is conductive hearing loss due to?
external or middle ear problem
M/C is infection, tumor, WAX!!!
most common cause of sensorineural hearing loss?
inner ear
Presbycusis
other causes of sensorineural hearing loss?
noise, infection, Meniere’s, trauma
Gentamycin (ototoxic) -> affects CN 8
causes of conduction hearing loss?
outer/middle ear
- ***WAX
- external otitis/otitis media
etiology of Presbycusis
Pure-tone threshold sensitivity diminishes
both cochlear hair cells and the spiral ganglion cells in the vestibulocochlear nerve can be affected
what are the 3 main affected areas of Presbycusis hearing loss?
sensory, metabolic, neural
what is affected in the sensory area in Presbycusis?
loss of hair cells and a high-frequency hearing deficit
what is affected in the metabolic area in Presbycusis?
loss of stria vascularis and a low-frequency hearing deficit
what is affected in the neural area in Presbycusis?
loss of ganglion cells and a variable pattern of hearing loss
what’s the HALLMARK presentation of Presbycusis?
progressive, symmetric loss of high-frequency hearing
bilateral and bilateral tinnitus
what is presbyasmasis?
loss of vestibular end-organ function
causes dizziness in Presbycusis
dx of Presbycusis?
based on hx - progressive, bilateral
***Audiologist evaluation
whispered test
***Weber test will be normal
when does the ALS hearing association recommendation audiometric testing and for who?
recommends anyone older then 50yrs old should complete audiometric testing every 3 years
what test will be normal in Presbycusis?
Weber test (pt hears sound equally in both ears)
Presbycusis tx?
- hearing aid
- cochlear implant (if hearing aid fails)
- assisted listening devices
- auditory rehab
syncope is associated with…
followed by…
associated with loss of postural tone
followed by complete and quick recovery
sharp rise in syncope at what age?
70 y/o
men often have more what type of syncope?
cardiac syncope
pathophysiology of syncope?
Result of decreased baroreceptor reflex sensitivity
-elderly persons may not be able to maintain cerebral blood flow by increasing HR and vascular tone in the setting of hypotension
Elderly more sensitive to the effects of vasodilators and hypotensive drugs
More sensitive to volume loss, GI bleeding, standing up from sitting
what are the 3 types syncope?
Reflex (M/C)
Cardiac (Brady/tachy arrhythmia - supraventricular and ventricular)
Unknown
what are the 4 types of Reflex syncope?
Vasovagal (M/C)
Orthostatic hypotension
Carotid sinus hypersensitivity
Situational
what’s vasovagal syncope?
Development of inappropriate cardiac slowing and arteriolar dilation from a decrease in sympathetic tone
Originates in the heart
vasovagal syncope d/t?
Emotional or orthostatic stress:
- venipuncture/painful stimuli
- fear
- prolonged standing
- heat exposure
- exertion
what is the prodrome that vasovagal syncope is associated with? secondary to?
- Nausea
- Pallor and sweating
This is secondary to an increase in vagal tone
even if think syncope is vasovagal, what do you need to r/o? do what tests?
that it is NOT cardiac syncope
-do ECHO, put on heart monitor, test electrolytes, make sure not a stroke BEFORE SAY PT WAS VASOVAGAL
what is orthostatic hypotension?
Postural decrease in systolic BP of at least 20 mmHg
causes of orthostatic hypotension?
Decreased intravascular volume: infection, diuretics
Drugs: TCA, HTN
-Beta and alpha blockers, hydralazine, ACEs
Vasodilators: CCB and nitrates (more common in elderly)
Primary autonomic insufficiency: Parkinson’s
Secondary autonomic insufficiency
-DM, ETOH (impairs vasoconstriction)
what is carotid sinus hypersensitivity syncope?
BP and HR are controlled within the carotid sinus of aortic arch
Increase in BP or pressure applied to the carotid sinus activates vagal efferents -> slows the HR and decreases BP
what is situational syncope caused by?
Cough, sneeze, BM, postmicturation, post exercise, post prandial
sign and sx’s of syncope?
- Abrupt onset
- Prompt recovery of dull consciousness
- transient loss of consciousness
-Maybe Prodrome of: sweating, lightheaded, dizzy, nausea
get what test done on everyone that presents with syncope?
EKG -> could have WPW
upright tilt table test diagnostic if? useful to distinguish b/w?
syncope is d/t bradycardia and hypotension
Helpful to distinguish between reflex and orthostatic hypotension
tx of syncope?
Treat finding or underlying condition
what are pressure ulcers?
Pressure on susceptible tissues causing skin breakdown
Visible evidence of the pathological changes in blood supply to the dermal tissues
primary source of pressure ulcers is in what setting?
acute hospital
pressure ulcer tx?
Maintain a moist wound healing environment (heal faster than air-exposed wounds)
Topical dressings
-Hydrogels, Hydrocolloid, Alginates
Growth factors
Surgical Debridement
