Geriatric Flashcards
decreased cutaneous vasoconstriction/sweat production
impaired response to heat
delayed recovery of dehydration
declining thirst
Impaired response to shock
physiologic drop in CO, LV filling and max HR
Primary aging not induced by diease but may be affected by:
periods of stress, exposure to fluctuating temperatures, dehydration or shock
Optimal aging
Occurs when people don’t have debilitating disease and starts in late 80’s-90’s.
VS: BP
Ao stiffens d/t atherosclerosis, less distensible, SV causes greater rise in BP, esp SBP. Systolic HTN with widened pulse pressure. DBP stops rising in 60th decade.
Other extreme is postural hypotension(orthostatic)- drop in BP upon standing
VS: HR & Rhythm
resting HR unchanged. Pacemake cells decline in SA node, as does mas HR, affecting response to physiologic stress. Elderly more likely to have abn heart rhythms such as atrial/vent ectopy. Asymptomatic rhythm changes usually benign. May cause syncope or temp LOC.
VS: RR and Temp
RR unchanged. Changes in temp regulation lead to suseptibily to hypothermia.
Skin & Nails
skin wrinkles, lax, loses turgor. Vasc of dermis decreases, skin paler and more opaque. Nails lose luster, may yellow and thicken- esp toes.
Actinic purpura
purple patches/macules that fade over time. Come from blood leaked through poorly supported capillaries and spread through dermis.
Hair
scalp loses pigment. Hair grays. Men’s hairline recede- as early as 20’s. Women less sever hair loss. Generalized loss of scalp hair, diameter of each hair smalled. Hair loss on rest of body. As women reach 55, coarse facial hair appears on chin and upper lip, but doesn’t increase further. Mostly applies to light skinned caucasian
Head and Neck: Eyes
Eyes, ears and mouth bear the brunt of old age.
Eyes: fat around eyes atrophy- eyeballs may recede, skin of eyelid may wrinkle- haging loose fold, fewer lacrimal secretion- dry eyes, fat may pusj fascia of eyelids forward- soft bulges, cornea lose luster. Pupils smlaller- harder to see fundus, pupils may be irregular- still repsond to light.
Visual acuity fairly constant. Lens loses elasticity- presbyopia in 5th decade. Increased risk of cateracts, glaucoma, mad degen.Thickened yellow lens impairslight passage- need more light to read.
Color vision diminishes, light adaption slows. Visual fields- by 7-8th decade lose 20-30% peripheral vision.
Head & Neck: Ears
Ears: hearing loss, may start in young adulthood, starts with high pitched sounds. Loss extends to middle and lower ranges. Distorts hearing.
Presbycusis
Normal aging hearing loss
Narrow angle glaucoma
lens grows, pushes iris forward, narrowing angle between iris and cornea- increasing risk
Head & Neck: Mouth
Mouth: dim salivary secretions, decreased sense of taste. Maybe affected by meds or diseases. Decreased olfaction, increased sensitivity to bitter/salt affect taste. Teeth wear down, abraded, lost to caries or other conditions over time.
Dental health reflects bone health. Affects ability to digest some complex nutrients. Blunted taste decreases sense of smell by 50%
Periodontal disease
Chief cause of tooth loss. If no teeth, lower face looks small and sunken, purstring wrinkles. Bony ridges of jaws become reabsorbed, esp lower jaw. Frequency of palpable cervical nodes diminish, but submandibular easier to feel.
Angular Cheilitis
Overclosure of mouth leads to maceration of skin at corners
Thorax & Lungs
Decreased exercise capacity. Chest wall stiffer, harder to move, resp muscles weaker, lose elastic recoil, lung mass declines, residual volume increases. Speed of breathing out with max effort gradually diminishes, cough less effective(dec mucociliary clearance). Skeletal- accentuated dorsal curvature ot thoracic spine= kyphosis- OP vertebral collapse and inc AP diameter of chest. Barrel chest- little effect on function. # Alveoli decrease. Muscle weaker- dec VC, FVC, FEV. Dec resting pO2, Dim chemoreceptor.
Asp, PNA, Hypoxia, DOE
Arcus Senilus
pt over 60yo deposit of calcium and cholesterol salt- appear grey-white ring at edge of cornea
Macular Degeneration
can have no fovea refelx. Drusen(yellow spots) can appear in/around macula- deposits are EC material.
causes poor central vision and blindness
Cerumen Impaction
most common in elderly d/t overgrowth of hair. Most often cause of tinnitus and hearing loss. Cerumen is drier and lore likely to accumulate d/t decrease in sweat glands.
Tinnitus
more prevalent in elderly, can be caused by cerumen, meds, vasc disorders and impair blood flow.
Hearing Loss
Conductive/ Sensorineural( most common in elderly)
Reason d/t decreased blood flow, dec vestibular conduction, loss of acuity.
First signs hearing loss refer to audiologist
Cardiovascular: Neck Vessels
Lengthening/tortuosity of Ao- kinking/buckling of carotid artery. Results in pulsatile mass, mainly in women with HTN, may be mistaken for aneurysm. Torturous Ao- raise L jugular vein pressure, imp drainage within thorax, into RA.
Carotid bruit in middle/upper portion of carotid arteries- suggests part art occlusion( in younger people usually innocent). Warrant investigation-possible stenosis d/t risk for possible ipsilateral stroke
Cardiovascular: S3 S4
Middle/Older aged adults commonly have systolic Ao murmurs. After age 40 S3 suggests dilation of LV from CHF/CMO from volume overload of LV (CAD, VHD)
S4 can be in healthy people, but may suggest dec ventricular compliance/imp vent filling, accompanied by HTN.
Heart sounds are diminished
Cardiovascular: Murmurs
Middle/Older adults commonly have Ao systolic murmur. Detected in 1/4 adults over 60yo. Aging thickens base of aortic cusps with fibrous tissue, calcification follows. Mostly fibrosis/calcification does not impede blood flow(Ao scleoris) but can cause turbulent flow. AS leaflets calcified and immobile, outflow obstruction- has delayed carotid upstroke(aortic sclerois has normal upstroke). Increased M/M with both. Crescendo/decrescendo M at 2RICS- AS/sclerosis. Delay during simultaneous palp of brach/rad art=AS
Sim changes to mitral valve, usually one decade later than Ao, leads to MR- systolic murmur- may become pathologic as volume overload increases in LV. Harsh holosystolic M at apex=MR
Cardiovascular Implications
LVH
Dec CO- dec peripheral perfussion/oxygenation
Dec sens to anything that stim B-adrenergic(SNS, PNS, hormones, drugs, exercise, stress response)
Inc arrhythmias- ICD
syncope- falls/injury
Need for pacer
HF
Heart block
CV musculature
mod-marked hypertrophy(LVH- sustained PMI, CHF- diffuse PMI)
Inc wall thickness LV
Inc myocardial wall thickness in general d/t inc myocytes
Inc fibrous tissue
Inc size LVand LA
walls less pliable, thick, stiff
vessles become dilated and elongated
deposits form matrix- lead to atherosclerotic changes- damage intima- inflammation- injury- occlusion
Leads to PVR, PAD, thrombosis, ischemia
Barorecptors
dec in elderly
regulate HR and MAP
Imp BP response to standing- volume depletion
Higher incidence orthostatic changes with position changes
Peripheral Vascular System
Atherosclerosis- not normal aging but occurs more in elderly
Vesesls dilate and lengthen, torturous, hard
Changes in skin, nails and hair are not specifically d/t arterial insuff- but are often symptoms of.
Screen for Ao anuerysm with back/abd pain- esp men who smoke and have CAD. measure Ao diameter and feel for pulsatile mass
Art occlusion- dim/abs pulses
Temporal Arteritis
Over 50 yo, temporal arteiries become subject to giant cell- loss vision 15%, c/o HA, jaw claudication
Breasts/Axillae
May become granular, nodular or lumpy. Aging- less grandular, more fatty- total amount decreases. Breast flaccid, pendulous. Nipples- ducts may be more palpable as firm stringy strands. Axillary hair diminished
Lumps/mass- check for malignancy
Abdomen
Fat accululates lower abd, hip- more pronouced abd.
Aging may blunt acute abd- pain may be less severe, fever less, signs of peritoneal inflam reduced/absent
check for bruits and Ao diameter/pulsatile mass
GI
dec motility
dec vasc flow
dec gastric acidity
gastric emptying slowsfeels full longer
dec appetite
inc diverticulosis
inc polyps
inc NSAIDS- affects lining- inc PUD,GERD,esophagitis
GI: Stomach
inc gastric pH
dec blood flow
dec absorption calcium vit d
GI Implications
constipation
dec absorption Vitamins, esp B12
dec calcium absorption- OP
Rectal mass found with colon CA
GI: Liver
dec blood flow
dec metabolism toxins
dec size
protein synthesis dec
dec hepatic drug elim
Cytochrome P450 less efficient/effective 50%
dec excr of drugs met in liver
POLYPHARM concerns
GI: Gallbladder
inc cholelithiasis
bile acid syntheisis dec
Ask id cholecystectomy- important
GU: Incontinence
Stress- weak sphincter- cough,sneeze,laugh
Urge- sudden urge, muscles contact inappr
Overflow- Men, nocturnal- unable to full empty- leakage, no urge
Functional- mental physical interference
Inc residual volume
Inc not normal aging but causes can be d/t atrophyof muscles or dec sensation
Male Genitalia
Sex interests remains intact, freq of sex declines. Dec testosterone level- erection dependant on tactile stim, less cues. Penis size decr, testicles drop lower in scrotum. Protracted illness may lead to dec teste size. Pubic hair dec,gray. ED affect 50%- usually d/t hypogastric cavernous art insuff or ven leakage through subtunical venules
Female Genitalia
Ovarian Fxn dim 5th decade. Estrogen falls, hot flashes- up to 5 years- sweating, palpitations, chills, anxiety. Sleep/mood swing problems. Vag dryness, urge incont, dyspareuria. Pubic hair gray, sparse. Labia, clitorus smalled, vagina narrows, shortens, mucosa pale,thin,dry loss of lube. Within 10 yrs of menopause, ovaries nonplapable. Sexuality unchanged
Atrophic vaginitis
Freq UTI
Vulvovaginitis
urge/stress incont
Check for masses, Paget’s disease, erythema
BPH
begins 3rd decade- hyperplastic prostate
overflow incont, esp nocturnal
dec blood flow to penis- ED
GU implications
freq UTI
nocturia
incont
skin breakdown
embarrassment
social isolation
Renal
function dec
Cr Cl dec 10ml/decade
dec Na exc/conserv
dec concentrating capacity
dec blood flow
dec GFR
Consider kidney function when ordering renally excreted drugs
Muscuoskeletal
Subtle loss in Ht d/t intervertbral discs thin, bodies shorten or collapse from OP. Kyphosis, inc AP diameter esp women. Muscles decrease in bulk, power, ligaments lose tensile strength. ROM dim, partly d/t OA.
Immobility- leads to rapid muscle loss
Age 40yo- can see OA changes on xray
DJD- changes in OA
Joint inflam- RA, gout
Sarcopenia
decrease muscle mass 1% per year after age 25yo
Osteopenia
loss of skeletal bone mass
MS Implications
OP- fractures
falls/injuries
dec flexibility, balance, stamina, endurance, strength
enc reg exercise routine
PT/OT after hopsitalization
MS: Joints
art cart loses thickness
d/t dehydration of cart, also wear and tear.
Inc in arthritis, need OR
Nonarticular cart grows with aging- ears, nose
Endocrine: Thyroid
atrophies
nodules inc
hypo/hyper subtle- harder to Dx
most freq cause of afib in elderly
Endocrine: Pancreas
Inc Insulin resist
Imp glucose homeostasis
Post prandial gluc tol inc by 10mg/dl per decade
Inc gluc in resp to illness
Neurologic
Intelligence dec after 40yo
slowing process takes longer
mild forgetfullness not pathological
Loss of nerve cells dec- hippocampus- short term
Brain atrophy
Dec cortical brain cells
Motor
less speed, dec skeletal muscle
May dev benigh tremor- often a/w Parkinson. Benigh tremors are faster and disappear at rest, no muscular rigidity.
Lose vibratory sense in feet/ankles
Position sense may dim
Abd and ankle reflex dim/absent
If assymetrical- search for another reason
Immune Response
dec humoral antibody resp
dec T cell fxn
inhibitory effect on immune system
dec immune system
By the time the elderly are showing symptoms, they could be septic
Dec immune- inc suseptibilty for infections/malignancy
Hematolgy
H&H dec slightly
MCV inc
Anemia most common in elderly
ESR inc significantly
Clotting inc(fibrinogen, coag factor V, VII, IX)
polypharmacy
Tips for Interviewing Elderly
Face patient, eye level
talk low pitch, quiet room
50% HOH
allow extra time
Allow reminiscense
Go slow, don’t rush
bright light
use aidess
ADL’s
capacity to perform
Also ask about Instrumental ADL’s- higher level of functioning
Medications
thorough medication history
Polypharmacy dangerous
common, fatal
seeing more than one practitioner
D/T: dec liver met, dec GFR, often takes several doses to build up, some meds inh/enh other drugs, hypnotics=danger, alpha blockers=hypotension, anticholinergic meds more evident
Nutrition
take history
those with chronic disease at risk
esp GI, poor dentition, depression, other psyche, drugs.
In under wieght elderly albumin is independant risk factor for maortality
Pain
80% visits for pain
Usually MS
Older less likely to report
ask with every visit
acute vs chronic
Functional Assessment Tools
Tinetti Balance and gait eval
Get up and go test
timed walking test
GARS
Smoking/ETOH
Smoking bad any age
ETOH abuse rises with age
Dec detection/treatment with elderly
Lots of drugs interact with alcohol
Chronis drinkers: cirrhosis, GIB, GERD, gout, HTN, DM, insomnia, gait DO, depression
Advanced Directives/ Palliative Care
End of Life wishes
Screening
Vision/hearing
Exercise
Immunizations
Household safety
Cancer
Depression
Dementia/ Mild Cognitive Impairment
Elder Mistreatment
Immunizations
Flu annually
Pneumococcal good for life after 65, Q5yrs prior
Zoster- over age 60yo
Tetanus every 10 years
Depression Screening
affects 10% elderly
nder diagnosed
Men over 85 at higher risk of suicide
Dementia
Slow, insidious onset. Hard to detect initially. MCI- mild cognitive impairment
Amnesic MCI- affects memory
Non amnesic MCI- not memory but language or visuospatial.
AACI- age associated cognitive impairment- mild cognitive changes in late life
Alzeheimer’s Dementia
amnesic memory impairment, deter language, and visuospatial defects. Initial loss of high ADL. Mood change or apathy apparent. Psychosis/agitation late.
Test with MMSE
Elder Abuse
abuse, neglect, exploitation, abandonement
Functional Status
6th VS
10 min Geritric Screener
D- delirium,
I-Infection
A-Atrophic urethritis/vaginitis
P-Pharmaceuticals
E-Excess UOP- hyperglycemia, CHF
R-Restricted mobility
S-Stool Impaction
ask about ADL, IADL, Sex fxn, gait assessment
Falls Assessment
Assess with routine exams
Gait velocity
Widening of base, slowing and lengthening of stride, diff turning- correlated with risk for falls
GARS
Gait abn rating scale
sum of 16 facets, total score reflects fall risk
HPI
Disorientation/Confusion
onset, duration, associated problems, meds
Isolated systolic HTN
SBP >140 after age 50, CHD triples in men, inc risk of CVA
Widened PP >60- inc risk for CV, renal and stroke
assess for LVH
Orthostatic Hypotension
10-20% elderly, 30% NH residents
causes: meds, autonomic DO, DM, prolonged BR, blood loss, CV DO
Tachypnea
>25 BPM, lower resp infection or CHF, COPD
Hypothermia
common in elderly
Wt/Ht/BMI
calculate for nutrition assessment
Undernourished seen with ETOH, depression, gog impair, malignancy, chronic organ failure, meds, social isolation, poverty
MMSE
Use for suspected cognitive impairment.
Tests for orientation, registration, attention, calculation recall, language
pseudoscars
white depigmented patches
Seborrheic keratoses
raised yellow lesions, greasy, velvety/warty
comedones
blackheads- on cheeks or around eyes
Herpes Zoster
inc risk with age, reactivation of latent varicella zoster virus
Senile Ptosis
eye atrophy from loss of fat, levator palpebrae
Arcus Senilus
white ring around limbus
Cataracts
leading cause of blindness in the world.
RF- smoking, UV b, high ETOH intake, DM, meds, trauma
Wide angle glaucoma
inc cup to disk size, caused by irreversible optic neuropathy and leading to loss of peripheral vision and central vision and blindness. 3-4X more prevalent in AA.
Drusen bodies
check fundi for colloid bodies causing alter in pigment
Oral Malodor
poor oral hygiene or periodontal disease
Gingivitis may arise from peridontal disease.
clitoral enlargement
Androgen-producing tumors or use of androgen creams
Estrogen stim cervical mucus with ferning
HRT, endometrial hyperplasia, estrogen producing tumors
Restricted mobilty of uterus
inflam, malignancy, surgical adhesion.
Leiomyomas
enlarged uterine fibroids.
Malignant leiomyosarcoma
Palp ovaries with Ovarian CA
Parkinson’s
slow tremors, pill rolling, rigidity, bradykinesia, micrographia, shuffling gait, diff turning in bed, opening jars, rising from chair.
Aggravated by stress, inhibited during sleep or movement.
Persistent blinking and diff walking heel to toe also common
3D’s of altered mental status
Dementia
Depression
Delirium
Dementia
Clinical syndrome of failing memory and impairment of other intellectual functioning- can have features of delirium
progressive and disabling
NOT inherent aspect of aging
Depression
Common psyche DO, mild to psychotic, variety symptoms
Delirium
acute confusional state accompaned by DO of perception
Alt MS, attention span, sleep patterns, affect
Behaviors vary from intense agitation to sluggishness
Hallucinations and delusions often experienced
may superimpose on dementia- may occur with acute illness like infection, stroke, med side effect
Symptoms that may indicate Dementia
learning/retaining new info
handling complex tasks
reasoning ability
spatial ability and orientation
language
behavior
Normal Lapse vs Dementia
Normal Dementia
forget a name not recogn a family member
leave kettle on forget to serve meal just made
finding right word subs inapprop word
forget date/day getting lost in own neighborhood
UA to balance CHBK not recogn #
lose keys/glasses putting iron in freezer
getting blues in sad sit rapid mood swings(unexpl)
grad changes with aging sudden personality changes
other Cognitive areas to evaluate
insight/judgement
thought content
mood/affect
Social Assessment
caregiver
economic state
elder mistreat
sexual health
suicide
