geriatric/inpatient Flashcards
1
Q
IP frame of mind - examination
IP/home management
A
- chart review
- pateitn interview: PLOF, current ADLs, support system, living environment
- systems review: cognitive/communication, psycho-emotional, CV/P, integumentary, MSK, NM, movement system benchmark task
- physical exam items: including outcome measures
2
Q
chart review “keys”
IP/home management
A
- PMH, admission information
- PLOF
- living situation and support
- medications
- imaging
- operative report
- precautions (WB status)
- lab values
3
Q
lab values
IP/home management
A
- hemoglobin (Hgb): iron rich protein in RBCs carrying O2 to tissues
- male: 13.5-17.5 g/dl
- female: 12-15.5 g/dl
- hematocrit (Hct): measure of how much space RBCs take up in blood
- male: 38.5-50%
- female: 34.9-44.5%
- prothrombin time (PTT): measure for clotting factors that assesses for clotting deficiencies (too low is blood clot, too high is bleeding risk)
- normal 11-13.5
- international normalized ratio (INR): ratio of PTT in reference to normal range
- normal 2-3 with anticoagulants
- blood glucose levels: fasting 70-110 mg/dL
warfarin/coumadin: PT/INR
heparin: PTT
4
Q
risk factors for DVT
IP/home management
A
5
Q
diagnosing DVT
IP/home management
A
6
Q
PE risk factors
IP/home management
A
7
Q
diagnosing PE
IP/home management
A
8
Q
screening for fall risk
IP/home management
A
- qualitative assessment
- tests/meaures: TUG, 5xSTS, 4m/10m gait speed, functional reach test (FRT)
- additional: 6MWT, 2MWT, Berg, functional gait assessment, dynamic gait index, performance oriented mobility assessment (POMA), short physical performance battery (SPPB)
9
Q
exam essentials - benchmark tasks
IP/home management
A
- bed mobility
- transfers: floor, chair, commode, car
- gait
- stair navigation
10
Q
key considerations after IP exam
IP/home management
A
- prognosis and discharge planning
- screening/referrals
- communication with other providers
- post-discharge recommendations: impacts re-hospitalization rates
11
Q
PT role in early recovery
IP/home management
A
- prevention: complications - pneumonia, DVT, HAD, contractures, debuti, post-surgical precautions
- compensation: promote safe, functional independence with ADs, braces, education and movement training
- remediate: pain, mobility issues, wound healing
- referral to other disciplines: mental health, ADL needs, speech/swallowing
- discharge planning: destiation (home, SNF, IP rehab), level of support equipment/devices needed, safety, recommendation on further rehab (home, OP)
- communication is critical: documenation, verbal handoffs
12
Q
re-admission risks
IP/home management
A
- chances of re-admission 3x more likely is discharge plan by PT not followed
- current level of function
- functional trajectory (stable, improving, declining)
- barriers to care (level of support, availability of services)
- 37% increased risk of readmission with unmet ADL needs
13
Q
home health
IP/home management
A
- qualification for home health
- physician must certify that patient is home bound (patient needs assistance or requires great physical effort to leave)
- patient must be under a doctor’s care
- typically only leave home for appointments (or religious services)
- patient requires skilled therapy (important for documentation)
- considerations
- personal/patient safety: learn who is currently in home, each visit - record falls, ER visits, med changes, vital signs
- bring barrier for bag
- patient in decline/distress: call PCP and provide details, call 911 if decline continues
14
Q
examples of skilled home health services include
IP/home management
A
- wound care for pressure sores or a surgical wound
- patient and caregiver education
- specialized therapy services, including PT, OT, and SLP
- intravenous or nutrition therapy
- injections
- monitoring serious illness and unstable health status
15
Q
most common diagnoses in home health
IP/home management
A
- total joint replacements
- fractures
- CVA
- progressive neurological conditions
- fall risk
- dementia
- chronic pain
- incontinence
- wounds
- COPD
- heart failure
16
Q
skills used by PT in home health
IP/home management
A
- gait training
- transfer training
- home exercise programdevelopment
- home exit management
- fall prevention
- progressive resistaive exercises
- pain management
- incontinence training
- wound care
- neuropathy treatment
17
Q
safety in home health
IP/home management
A
- situational safety: observe your environment, pets/other obstacles, use all situational awareness aspects
- patient safety and emergency response: PCP, 911, dispatch health
- personal safety
18
Q
home health documentation
IP/home management
A
- OASIS: for start of care, 335 pages
- home bound status
19
Q
summary of home health
IP/home management
A
- home health serves a variety of patients who have complex health needs and who are home bound
- team of care providers
- need for outcome measures to show skilled need and progression
- OASIS is standard for initial examination documentation and serves to open the case
- as a new graduate, look for an agency which provides mentoring
20
Q
older adult are what percent of average PT caseload
IP/home management
A
46%
21
Q
how many baby boomers in US
IP/home management
A
- 80 million (1/4 of US population), born 1946-1964
- number of adults > 64 expected to double over the next 25 years
22
Q
unique characteristics of geriatrics of population
IP/home management
A
- heterogeneity: some working, some disabled
- activity vs inactivity/immobilization
- organ systems associated with symptoms are less likely to be the source of the problem
- confusion does not mean brain lesion
- falling does not mean neuropathy
23
Q
common characteristics in geriatric population
IP/home management
A
- decreased cognition
- decreased CV reserve and lung function
- frailty
- malnutrition or dehydration
- increased fall risk
- increased risk of incontinence
- incidence of polypharmacy
- potential for more equipment needs
- potential for more family involvement in care
24
Q
deteriorating cognition in geriatrics - 3 Ds
IP/home management
A
- delirium: sudden severe confusion due to rapid changes in brain function that occur with physical or mental illness
- dementia: not a disease, but a group of symptoms resulting in confusion and memory loss, that is slower in onset and progressive
- depression: “common cold among older adults,” 28%
due to infection, ETOH, UTI
25
assessing cognition in geriatrics
| IP/home management
* mini mental status exam (MMSE)
* montreal cognitive assessment (MoCA)
* both sensitive and specific
26
cardiac reserve and lung function considerations in geriatrics
| IP/home management
* vasculature (especially arteries) are stiffer
* higher risk for dysrhythmias
* less muscle mass, so activity is greater percentage of "strength reserve"
* all will get a touch of emphysema and COPD as we age
* more susceptible to pneumonias and influenza
* be proactive - assess, treat, refer
27
frailty in geriatrics
| IP/home management
* decreased cognition, dehydration, malnutrition, polypharmacy, decreased sensorimotor input and integration
* 3 or more: decreased grip strength, slow walking speed, unintentional weight loss, self-reported fatigue, low physical activity
28
malnutrition and dehydration in geriatrics
| IP/home management
* malnutrition: depression, dementia, medication side effects, fatigue, pathology
* dehydration: due to dementia, decreased response to thirst, medications, overutilizaiton of caffeine, low salt diets
* both can contribute to delayed healing, confusion, and susceptibility to infection, and are exacerbated by surgery and illness
29
increased BMI in geriatrics
| IP/home management
* 30% in 65-74, 20% over age 74
* related to: decreased strength, decreased gait velocity, decreased self-reported physical function, other health issues (DM, heart disease), increased risk of cancer
* exam measures: BMI, skin fold thickness, waist circumference, waist-to-hip ratio
* paradox: BMI > 25 is decreased risk of osteoporosis, lower BMI had increased mortality risk
30
risk of falls in the older adult
| IP/home management
* fall risk: 33% of people over 65 fall each year, but < 1/2 talk to HC providers about it
* risk of women falling is 49% higher than in men
31
impacts of falls
| IP/home management
* leading cause of fatal and nonfatal injuries in older adults
* 1 in 5 who fracture hip when falling die within 1 year
* in 2013, direct costs of $34 billion related to falls and 2.5 million nonfatal falls where treated in EDs
* > 75 YOs whoe fall are 4-5x more likely than those 65-74 to be admitted to LTC for a year or longer
* fear of falling and related limitations in activity causes increased risk of falls by reducing mobility and fitness
32
patient perception and fall risk
| IP/home management
* decreased confidence in maintaining balance and fear of falling commonly result in avoidance behavior and activity restriction
* results in declines in physical function
* possible assessment tools: activities-specific balance confidence scale (ABC), falls efficacy scale (FES)
33
what is the 2nd most common reason for LTC
| IP/home management
incontinence
34
polypharmacy in geriatrics
| IP/home management
* concurrent use of 2-5 prescribed medications (the norm, not the exception)
* potential effects on patient: adverse drug events, drug-drug interactions, poor adherence to medication regimen, changes in pharmacokinetics and pharmacodynamics, presence of liver disease may increase med potency, poor nutrition can increase medication potency
* potential effects of PT interventions on pharmokinetics: exercise increases absorption from injected meds, physical agents like cryotherapy and thermal agents affect circulation locally, electrotherapy and massage can have effect on local circulation
35
pharmacokinetics - changes in older adults
| IP/home management
* absorption: decreases in gastric emptying and nutriction - increased number of meds
* distribution: reduced lean body mass with increased body fat changes
* metabolism: rates change due to decreases in hepatic enzyme production and blood flow
* elimination: decline in capacity of renal function (kidney issues - stays in system longer)
36
beers criteria for potentially inappropriate medications (PIMs)
| IP/home management
* screening tool of older persons' potentially inappropriate medication (STOPP)
* list include: CV, endocrine, CNS, GI meds, pain meds, anticholinergics, antithrombotics, antidepressants
* rationale varies: orthostatic hypotension, sedation, delirium, hemorrhage, thrombosis, glycemic instability, falls, CVA
37
cancer risk with age
| IP/home management
* median age of CA diagnosis is 66, 50% CA above 66
* chronic inflammation (infections, abnormal immune reactions, conditions such as obesity)
* DNA damage leads to CA
* example: ulcerative colitis have increased risk of colon CA
* unplanned weight loss, night sweats, night pain, unchangeable pain
38
adaptive equipment and family care
| IP/home management
* more focus on compensation initially: ADLS assist (consult OT), mobility assistance
* unmet ADL needs associated with 37% increase in risk for hospital readmission
* family and community involvement and support critical to maintaining independent living: in home support, local support for transportation/shopping, consult with social worker/care coordinator
39
muscular system - changes in older/elderly patient
| IP/home management
* sarcopenia
* degeneration of neuromuscular junction
* decrease in total number of motor units
* type II > type I muscle fibers decrease in size and number
40
skeletal system - changes in older/elderly patient
| IP/home management
* significant loss of bone mass by age 80
* female more than male
* decreased ability to regenerate bone - extended healing times
* bone mass max at 25-30 years
41
neurological system - changes in the older/elderly patient
| IP/home management
* cerebral cortex atrophy and decrease in cerebral blood flow
* decrease in neurotransmitter level
* 10-15% decrease in nerve conduction velocity
* visual, auditory, vestibular, and proprioceptive function impairments increase
42
connective tissues - changes in the older/elderly patient
| IP/home management
* nutrition and vascular flow decrease
* physiological changes
* result: structural failure at 1/3 of load needed for failure in younger ligaments in people over 60 years old
43
articular cartilage - changes in the older/elderly patient
| IP/home management
* decrease in chondrocyte density and activity
* decrease in water content in ECM
* chondroitan sulfate content drops, keratin sulfate increases
* increased collagen cross-linkages
* result: decrease in tensile strength and fatigue resistance, increased rigidity and breakdown
44
intervertebral disc - changes in the older/elderly patient
| IP/home management
* water content decreases
* decline in vascularity
* accumulation of degraded materials
* result: decrease in ability to distribute stress and maintain alignment
45
population effects - geriatrics
| IP/home management
* 30-60% strength loss between age 30-80
* 20% decrease in reaction time
* 35-40% increase in falls after age 60
* falls are leading cause of fatal injuries in US for those > 70 YO
* 850,000 fractures in people > 65: $14 billion in healthcare
46
common orthopedic conditions - geriatrics
| IP/home management
* osteoporosis
* osteoarthritis/DJD
* DDD
* spinal stenosis
* spinal decompression/fusion
* joint arthroplasty
* degenerative RTC tears
* fractures: spine, wrist, proximal humerus, hip, pelvis
47
osteoporosis
| IP/home management
* decreased mineral content and weakening of bones (porous bone)
* osteoclast activity outpaces osteoblastic activity
* peak bone mass at 23-30 YO
* plays part in 2 million fx's per year
* diagnosis: T-score on bone mineral density (DXA scan)
* osteopenia: -1.0 to -2.4
* osteoporosis: -2.5 or less (25% loss of bone mass)
* 10.3% prevalence in US
* 80% of those with disease are female
48
osteoporosis risk factors
| IP/home management
* older age
* family history
* small skeletal history and lean muscle mass
* history of fractures
* sedentary lifestyles
* smoking and alcohol abuse
* poor nutrition
* steroid medications
* RA
* GI absorption diseases, decreased sex
49
thoracic spine fractures
| IP/home management
* posture
* wall-occiput distance: heels and back against wall, eyes face forward, line through occiput/ear/eye
* measure wall to occiputal protuberance (in cm)
50
lumbar spine fracture
| IP/home management
* rib-pelvis distance (L spine vertebra fx)
* stand in erect posture with UEs parallel to floor
* PT hands rest horizontally in axillary line
51
how can PT help prevent complications to osteoporosis
| IP/home management
* education: diet, posture, ETOH/smoking
* exercise: 4% decrease in fracture rate, no significant effect on number of fractures
* avoid repetitive trunk flexion
* fall prevention programs
52
compression fracture treatment
| IP/home management
* vertebroplasty: fluroscopic cement injection
* kyphoplasty: balloon inserted to create a cavity, then inject cement after removal (less likelihood of cement leakeage)
