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Gen Med: Geriatrics > Geriatric Emergency Medicine > Flashcards

Geriatric Emergency Medicine Flashcards

1
Q

How are current elderly different than past generation of elderly?

A
  1. Differences between future >65 population and past:
    A. Better educated
    B. Less poverty: however, many seniors have not saved enough money for the length of their retirement
    C. Fewer children
    D. More ethnic/racial diversity
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2
Q

What are the contributing factors for resource utilization by geriatrics?

A
  1. Shrinking Primary Care
  2. Gerontologist Deficit
  3. Lack of financial Incentives
  4. Complexity of Care
  5. ED most Appropriate??
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3
Q

What complications can arise after an ED visit by an elderly pt?

A
  1. Increased risk for medical complications
  2. functional decline
  3. Poorer quality of life
  4. Within 3 months, 27% of seniors discharged from ED
    A. ED Revisit
    B. Hospitalization
    C. Death
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4
Q

What are the GEM Care goals?

A
  1. Inpatient Care only as necessary
  2. Outpatient Care for most
  3. Reduce Admission rate
  4. Improve Quality of Care
    A. Geriatric EM principles
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5
Q

What is included in Home care?

A
  1. INdependent healthy living
  2. Chronic disease management
  3. Community clinic
  4. Dr’s office
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6
Q

What is included in residential care?

A
  1. Assisted living

2. Skilled nursing facility

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7
Q

What is included in acute care?

A
  1. Specialty care
  2. Community hospital
  3. ICU
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8
Q

What are the proposed trajectories of dying?

A
  1. Sudden death
  2. Terminal illness
  3. Organ failure
    A. CKD, hepatic dz, etc.
  4. Fraility
    A. Dementia
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9
Q

What factors may contribute to the hazards of hospitalization?

A
  1. Insomnia
  2. incontinence
  3. isolation
  4. restraints
  5. polypharmacy
  6. sensory depreivation
  7. unfamiliar environment
  8. malnutrition
  9. immobility
  10. infection
  11. depression
  12. delerium
  13. deconditioning
  14. ulcers
  15. falls
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10
Q

What are the basic tenets of GEM care/senior ED?

A
  1. Physical Plant
  2. Staff Education
  3. Hospital Care Integration
    A. Social Work
    B. Case Management
    C. Pharmacist
  4. Patient Comfort Extras
    A. Cheaters, warm blankets, hearing aides
  5. Palliative Care Introduction
  6. Outpatient Care Integration
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11
Q

What is included in outpt care integration?

A
  1. PCP
  2. Visiting Nurse’s
  3. Home Health Aides
  4. Transportation
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12
Q

What population does a senior ED target?

A
  1. Active functioning seniors!!!
    A. Most to lose if they decompensate
    B. Still have quality of life and low health care costs
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13
Q

Define dementia

A

a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning

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14
Q

What is dementia characterized by?

A
  1. Memory loss
  2. Decreased judgment
  3. Cognitive decline
  4. Motor decline
  5. Behavior changes
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15
Q

What is the course of dementia?

A
  1. Unable to determine onset
  2. Slow and progressive
  3. Long duration
  4. Normal vigilance (early and mid)
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16
Q

What are the types of dementia?

A
  1. Alzheimer’s
  2. Fronto-temporal
  3. Vascular
  4. Primary progressive Aphasia
  5. Lewy Body
  6. Parkinson’s
  7. Mild Cognitive Impairment
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17
Q

How is dementia screened for?

A
  1. Six Item Screener
  2. Mini-Cog
  3. OMC
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18
Q

What is the 6 item screener?

A
  1. Say and ask patient to repeat:
    A. Apple, table penny
  2. Ask year, month, day
    A. Ask to repeat the 3 items

≤ 4: positive cognitive impairment

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19
Q

What is the mini cog test?

A
  1. Give three words
  2. Diagram a clock and a specific time
  3. Recall the three words
    A. 1 point for each word recalled
  4. 2 points for a correct clock
  5. Score 3-5 neg for dementia
20
Q

Who is screened for dementia?

A
  1. Minor injuries; family concerned
  2. Falls, no delirium
  3. Seniors still at home
  4. All?
21
Q

What are the goals of communication with the elderly w/ dementia?

A
  1. Effective communication
  2. Decrease anxiety
  3. Enhance self respect
22
Q

What is the KISS concept of communication?

A
  1. Simple structure
  2. Avoid multiple clauses
  3. Avoid patronizing style (respect)
  4. Repetition (changing phraseology)
  5. Speak with pauses
23
Q

What are some pearls for communication with pts w/ dementia?

A
  1. Do not re-orient
    A. Increases agitation
  2. Live in their world
  3. Talk about the past
24
Q

What comorbidities are common with advanced dementia?

A
  1. Pneumonia, febrile episodes, eating disorders are common in advanced dementia
  2. High 6 month mortality rates
25
Q

What is important to know about palliative care?

A
  1. Have the discussion!
  2. Inform HCP
    A. So the ED doesn’t have do CT’s reflexively
  3. Control costs
  4. Avoid burdensome interventions
26
Q

Define delerium

A
  1. Acute decline in attention and cognition
  2. Common, life threatening
  3. Potentially preventable, reversible
  4. Result of an underlying condition
    A. Often Iatrogenic
27
Q

Differentiate between delirium and dementia

A
  1. Delirium: ACUTE Confusional State

2. Dementia: CHRONIC Confusional State

28
Q

How does delirium affect the healthcare system?

A
  1. Complicates 20% of the 12.5 million admitted seniors
  2. Increases hospital costs by $2500 per patient
  3. Substantial outpatient costs
    A. Institutionalization
    B. Homecare
29
Q

What is the mortality rate for delirium?

A
  1. Phenomenally prevalent
  2. Hospital Mortality Rate: 22-76%
  3. One year mortality rate: 35-40%
  4. Under diagnosed: clinical
30
Q

What is the etiology of delirium?

A
  1. Etiology is multifactorial

A. Combination of a susceptible host and degree of insult

31
Q

What are the clinical characteristics of delirium?

A
  1. Hyper and hypo active forms
  2. 50% with underlying dementia
  3. Abrupt onset of confusion
  4. Fluctuating course (lucid intervals)
  5. Inattention
  6. Disorganized thinking
  7. Altered LOC
  8. Altered sleep
  9. Hypoactive variant (often missed)
32
Q

How is delirium dxed?

A 
1. Extremely difficult
A. Dementia vs. delirium or both
2. Clinical
3. Specificity: 98%;  Sensitivity: 16-35%
4. Bedside Tools
5. Not just Altered MS, rule out UTI or pneumonia
6. Look for the myriad of causes. 
7. Big DDX
8. Use the tool: CAM
33
Q

What is the confusion assessment method?

A
  1. Acute Onset : Yes or No or Uncertain
  2. Inattention: “ “
  3. Disorganized Thinking:” “
  4. Altered LOC ““
  5. Diagnosis: Must have 1&2, plus either 3 or 4
34
Q

How is delirium treated?

A
  1. Underlying cause
  2. Non pharmacologic
    A. Calm environment
    B. Re-orientation (opposite of dementia)
    C. Family support
    D. Natural spectrum UV light
35
Q

What are the general rules for treating delirium in the elderly?

A

Start low, Go slow

36
Q

What are the dosing guidelines and SE for Haloperidol for delirium?

A
  1. 0.5 – 1.0 IM!!!
  2. Extrapyramidal
  3. QTc effects
  4. Effectiveness demonstrated
37
Q

What can be the SE of benzo’s for delirium?

A
  1. Paradoxical excitation
  2. Over sedation
  3. Respiratory depression
    DON’T USE THEM IN ELDERLY
38
Q

What is included in the OMC (orientation, memory, concentration) exam?

A
  1. Year?
  2. Month?
  3. Repeat this phrase after me:
    A. John Brown, 42 Market Street, Chicago
  4. Time?
  5. Count backwards from 20 to 1
    6 .Say the months in reverse order
  6. Repeat the memory phrase
  7. SCORE
39
Q

What is the anticholinergic burden?

A
  1. Memory Impairment
  2. Cognitive decline
  3. Dry mouth
  4. Hallucinations
  5. Confusion
  6. Urinary retention
  7. Falls
40
Q

What can polypharmacy and anticholinergic burden lead to?

A
  1. ↑ risk for cognitive decline
  2. ↑ risk of dementia
  3. Improvement with discontinuation
  4. Higher anticholinergic use associated with increased risk of dementia
41
Q

What is the anticholinergic scale?

A
  1. Drugs assigned 1, 2 or 3 points
  2. Totaled
  3. Score of 3 or greater defines increased risk
42
Q

How can polypharmacy be managed?

A
  1. Simplify prescribing
  2. Discontinue Unnecessary drugs
  3. Consider ADE for any new symptom
  4. Non Pharmacologic
  5. Reduce dosages
  6. Adhere to guidelines
    A. BEERS
    B. STOPP
43
Q

Define elder abuse

A

“actions or the omission of actions that result in harm or threatened harm to the health or welfare of the elderly”

44
Q

What are the types of elder abuse?

A
  1. Physical
  2. Sexual
  3. Emotional
  4. Financial
  5. Neglect
  6. Abandonment
  7. Self-Neglect
45
Q

What are the rf for elder abuse?

A
  1. Dependency
  2. Social Isolation
  3. Psych of abuser
    A. Desire for drugs, money, possessions
46
Q

Why is elder abuse less seen?

A
  1. Fail to consider in elderly
  2. Unrecognized
  3. Not often reported by senior; co-dependency relationship with perpetrator
  4. No mandatory reporting in NYS
  5. AP can only act with senior’s permission!!
47
Q

What questions should be considered when suspecting elder abuse?

A
  1. Afraid of anyone
  2. Touches without permission
  3. Left alone for long periods
  4. Threatened or yelled at
  5. Denied meds or equip needed
  6. Taking money without permission
    (for caregivers) Having difficulties?

Gen Med: Geriatrics (5 decks)

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