Geriatric exam Flashcards
geriatrics definition
Bismarck in Germany in the 19th century - Old Age and Disability Insurance Bill of 1889 - Eligibility at seventy Older than 65 - Social Security Act of 1935 Medicare - Social Security Act of 1965 Series of losses -- Frail and less well-functioning -- Often with multiple concurrent disease processes
History
Unique aspects of the geriatric history Always review medications Assess activities of daily living Often have concomitant and complex medical problems Depression Cognitive impairment Difficulty with communications - Hearing, vision, speech (CVA) - Inability to afford physician visits - Underreporting – intimidated by a busy practice - Fear – afraid to find out something is wrong - Slower to respond - Atypical presentations
Physical
Weight:
Assess diet and fluid status
Pulse and Blood pressure
Atherosclerosis and tissue perfusion
Often have orthostatic changes
HEENT Exam Temporal arteritis Decreased lens accommodation Presbycusis Poor dentition/false teeth Decreased olfaction
Chest and Lung Exam:
Kyphotic changes
Decreased lung capacity
Increased incidence of breast cancer
Cardiovascular Exam:
Thrills and Bruits
1/3 of octogenarians have a systolic murmur
Aortic stenosis, aortic sclerosis , mitral regurgitation, atrial septal defects, tricuspid regurgitation
Abdominal Exam Compression fractures – altered contour Often present atypical/asymptomatic Perforation, ischemia, inflammatory Bleeding
Genitourinary Exam Prostatic hypertrophy Vaginal and labial atrophy Squamous cell cancer Vaginal bleeding
Musculoskeletal Exam
Deformities related to arthritis
Compression fractions and kyphosis
Neurological Exam Olfaction Cognition Gag/speech – aspiration Gait
The Focus of Geriatric Care
Reduce nursing home placement
Reduce hospitalization
Quality vs. quantity of life
- Ask the patients – what are their goals of care
Socio-economic issues
- Aging in place
- Limited income
- Spend down
Functional Impairments: Falls- gait disturbance
Multifactorial in etiology
Evaluation
H&P
– Full medical history review including medication review (OTCs)
Lower extremity weakness, gait and balance problems, decreased vision, arthritis, history of falling, and pain
Gait and balance
– Get up and go test
Neurological exam (mental status, proprioception, sensory and cerebellar exam)
Cardiac exam (dysrhythmias, postural hypotension, murmurs)
Lab test
– CBC, blood chemistries, EKG, HBA1C, Holter monitor, vitamin D (muscle weakness and function impairment in addition to increased incidence of osteoporosis)
Physical and occupational therapy evaluation
- Home hazard assessment/environmental safety
- Berg balance scale
Functional impairments: urinary incontinence
More common in females (short urethra, child birth), it increases with age, common factor leading to institutionalization/social isolation
Types Stress incontinence Urge incontinence Overflow incontinence Functional incontinence
Evaluation
H&P
Functional alertness/capacity, CHF, abdominal exam (distention), genital exam
CBC, U/A, blood sugar, imaging (Renal U/S), culture
Post void residual – evaluation of emptying
Urinary incontinence treatment:
General
Coping strategies
Pads, hand-held urinals, bed pans, bedside commodes, etc.
Social isolation
Foley (indwelling) catheters are a poor choice for management – a last resort
Limits mobility and is a safety risk
Significant cause of infection
DIAPERS
Drugs, Infection, Atrophic vaginitis, Psychiatric (dementia, delirium, depression) , Endocrine (diabetes, hypercalcemia), Restricted mobility (neurologic or musculoskeletal), Stool impaction
Urge incontinence Bladder training/toileting schedule Medication Anticholinergic medication - detrusor muscle instability Reduce/eliminate caffeine Treat underlying infections
Stress incontinence
Kegel exercises
Medications
Estrogens – some data reveal that oral estrogens make the condition worse
Alpha adrenergic agonists
Surgery urethropexy or pubovaginal slings
Pessary – uterine prolapse
Overflow incontinence treatment – important for the preservation of renal function
Post void residual urine volume is elevated
Fecal Impaction
Prostatic enlargement – the prostate is always growing in men under the influence of testosterone
Treatment Medication
Finasteride
Alpha adrenergic antagonists
Treatment with augmented voiding maneuvers
Suprapubic pressure
Valsalva maneuver
Intermittent catheterization
Constipation
Definition: Patient specific, decreased frequency of bowel movements for the particular individual, but usually fewer than three evacuations a week
Includes impaction that requires manual disimpaction, incomplete elimination, painful elimination, dry/hard stool
Etiologies
Medication - opiates, anticholinergics, antidopaminergic, calcium channel blockers
Mechanical obstruction – tumor, prolapse, adhesions
Neurological – CVA, MS
Systemic – hypothyroid, diabetes, inflammatory, electrolyte disorders
Dehydration and inactivity
Constipation
Evaluation
H&P
Medications, fluid intake, disease history
Abdominal distention and pain
Rectal exam – tone, impacted stool, hemorrhoids, strictures, or fissures
Neurological exam – rectal tone (spinal cord impairment)
Lab test Electrolytes, BUN, creatinine, TSH, calcium Colonoscopy – carcinoma? Abdominal X-ray CT of the abdomen
Constipation
Treatment
Bulk laxatives The exception is for treatment opiate-induced constipation, need to use peristaltic stimulants Osmotic agents Enemas Stool Softeners Hydration Maintaining physical activity
Pressure ulcers
(ischemic soft tissue injury usually over a boney prominence)
Risk factors: immobility, poor nutritional status, incontinence, vascular insufficiency, altered level of consciousness
Braden scale – risk assessment tool
Staging – repeating inspection is fundamental to prevention and ongoing treatment
Stage 1 - intact skin with non-blanchable redness
Stage 2 - partial thickness loss, open ulcer or blister with a pink wound bed
Stage 3 - full thickness tissue loss, subcutaneous tissue present, tunneling and slough
Stage 4 - full thickness with exposed underlying structures, bone, muscle, tendon
Unstageable - covered by slough and/or eschar and underlying structures cannot be visualized
Treatment
Prevention – pressure relieving devices/mattresses, turning and barrier creams while avoiding shearing forces, reduce moisture – diapers
catheters can be used in as a last resort; can they lead to UTIs
Moist dressings (allow for a healing environment), antibiotics for infection, surgical debridement, enzymatic debridement, consider osteomyelitis – non-healing wounds
Cognitive impairment
Benign senescent forgetfulness
mild recall/memorizing inability
Dementia
loss of memory, language, visuospatial orientation, executive functions
Depression
Inadequate finances, loss of spouse/significant other/children, functional decline
Widely under recognized due to its non-specific presentation
Pseudo-dementia
Sensory impairment – Increased safety risks
Olfaction loss:
Spoiled food in refrigerator
Vision loss:
Presbyopia, cataracts, open-angle glaucoma, macular degeneration, diabetic retinopathy
Hearing loss leads to isolation, frustration of others
Presbycusis – high frequencies followed by speech frequencies
Decrease in thirst perception
Dementia
Presents as a slow, progressive disease
- Impaired memory and new learning
- Behavior and personality changes
- Hallucinations
Chronic and progressive loss of memory and cognitive function resulting in social and safety decline
– Wandering and high injury risk
Identify the underlying etiology if possible – potentially reversible
– i.e. B-12 deficiencies, normal pressure hydrocephalus, neurosyphilis, hypothyroidism, seizure disorder
Types of dementia
- Multi-infarct (vascular) dementia
- Lewy Body dementia
- Alcoholic dementia
- Parkinson’s disease related dementia
- Alzheimer’s dementia (SDAT)
- Pseudo-dementia (depression)
- Pick’s disease
