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Geriatrics Flashcards

1
Q

What are the 4 core features of delirium

A
  1. Inatention (serial 7s, months backwards)
  2. Acute onset and fluctuating
  3. Disorganized thinking
  4. LOC altered (hypervigilant/somnolent)

*Need 1 and 2 and either 3 or 4 for Dx

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2
Q

What are factors that predispose to delirium?

A
  1. Age (RR4)
  2. Functional impairment (
  3. Known cognitive impairment (RR2.8)
  4. Sensory impairment
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3
Q

What are factors that precipitate delirium?

A
  1. Drugs (polypharmacy, sedatives) (RR 4.5)
  2. Physical restraints (RR 4.4)
  3. Infection (RR 3.1)
  4. Bladder catheter (RR 2.4)
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4
Q

What are the 3 delirium phenotypes

A
  1. Hyperactive
  2. Hypoactive
  3. Mixed
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5
Q

What are strategies to prevent delirium when patients have cognitive impairment

A
  1. Orientation protocols
  2. Provision of clocks and calendars
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6
Q

What are strategies to prevent delirium when patients have sensory impairment

A
  1. Provide glasses and hearing aids
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7
Q

What are strategies to prevent delirium when patients have malnutrition

A
  1. Dentures
  2. assistance with feeding
  3. positioning
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8
Q

What are strategies to prevent delirium when patients have fluid and electrolyte imbalances

A
  1. Assess volume status
  2. Normalise glucose and lytes
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9
Q

What are strategies to prevent delirium when patients have sleep deprivation

A
  1. Inpatient unit strategies to reduce noise
  2. Schedule meds and procedures to allow for prorper sleep
  3. Non-pharm measures to prevent sleep deprivation
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10
Q

What are strategies to prevent delirium when patients have Functionnal impairment

A

Mobilize early, get PT, OT involved

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11
Q

What are strategies to prevent delirium when patients have pain

A
  1. Schedule pain control
  2. judicious use of opioids
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12
Q

What are strategies to prevent delirium when patients have iatrogenic complications

A
  1. Remove catheters
  2. Skin care regimens
  3. Bowel regimen
  4. Chest physio
  5. Treat nosocomial infections
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13
Q

What are strategies to prevent delirium when patients are on high-risk meds

A

Minimize benzos, anticholinergics, antihistamines

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14
Q

When should antipsychotics be considered in delirium?

A
  1. Patient is a danger to self or others
  2. Distressing psychosis
  3. Preventing medically necessary care
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15
Q

Give an approach to investigating the cause of delirium

A
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16
Q

What antipsychotics are acceptable in delirium

A
  1. Haldol
  2. Risperidone
  3. Olanzapine
  4. Quetiapine
  5. Lorazepam
  6. Trazodone
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17
Q

What are the cognitive aspects that decline with aging and the ones that are preserved

A
  1. Decline
    1. Performance speed
    2. Short term memory (i.e. recalling a list)
    3. Episodic memory (details about a previous event)
    4. Divided attention/task swiching
    5. Abstract reasoning
    6. “tip of the tongue” phenomenon
  2. Preserved
    1. Semantic memory (What is the capital of Turkey)
    2. Cued recall
    3. Sustained attention
    4. Vocabulary, Syntax, grrammar
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18
Q

What 4 questions should you ask yourself when evaluating cognitive impairement

A
  1. Is it dementia (Or MCI or SCI or something else)
  2. What dementia syndrome is it
  3. How severe is it
  4. Are there reversible causes
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19
Q

List risk factors for dementia

A
  1. Hearing loss
  2. Less education
  3. Smokiing
  4. Depression
  5. Social isolation
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20
Q

Describe the spectrum from SCI to terminal dementia

A
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21
Q

What is SCI

A
  1. No objective impairment on cognitive testing
  2. Preserved function
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22
Q

What is MCI

A
  1. Cognitive decline in 1 or more domains
  2. Objective impairment on cognitive test or screening
  3. Preserved function (normal ADLs IADLs)
    1. Ok to have coping strategies
  4. Not attributed to delirium, depression, psychosis, other medical etiologies
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23
Q

What is dementia

A
  1. Cognitive decline in 1 or more domain
  2. Objective impairment on cognitive screen or testing
  3. Functional impairment
    1. Earliest to go: Driving, finances, meds, meal prep
  4. Not attributed to delirium, depression, psychosis, other medical etiologies
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24
Q

What are the 5 cognitive domains?

A
  1. Executive function
    1. Any problems paying for something at the store?
    2. Clock drawing
    3. Trails
    4. Abstraction
    5. Letter fluency
  2. Language
    1. Mixing words?
    2. Naming
    3. Phrase/sentence repetition
    4. Animal fluency
  3. Visuospatial
    1. Putting clothes on wrong?
    2. Getting lost?
    3. Intersecting pentagons
    4. Trails, cubes
    5. Clock drawing
    6. Body orientation
  4. Personality
    1. Lost interest in previous activities?
  5. Memory
    1. Remembering appointments?
    2. Losing things?
    3. Immediate recall
    4. Delayed recall
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25
How are each of the cognitive domains tested on the MMSE, MOCA and RUDAS
26
What is the most specific test for executive function?
Clock draw
27
What is the most sensitive test for executive function
MOCA
28
What are the diagnostic criteria for Alzheimer's dementia
1. Dementia AND 2. Insidious onset, gradual progression 3. Initial and most prominent deficits in 1. Memory 2. Non-amnesic 1. Language 2. Visuospatial
29
What are the diagnostic criteria for vascular dementia
1. Cognitive impairment (any domain, most comonly frontal/executive) AND 2. Imaging evidence of cerebrovascular disease 3. +/- temporal relationship
30
What are the two main syndromes of vascular dementia
1. Post-stroke vascular dementia 1. "step wise decline" 2. Subcortical ischemia syndrome 1. More common, insidious onset 2. Imaging: periventricular white matter changes, lacunar infarcts 3. Clinically: Frontal/executive syndrome 4. Supportive findings: Insidious onset, gait disturbance, "slow"
31
What are the diagnostic criteria for dementia with lewy bodies
1. Dementia AND 2. 2 of: 1. Fluctuating cognition 2. Recurrent visual hallucinations 3. Parkinsonism 4. REM sleep behavior disorrder
32
What are supportive but non-diagnostic features of LBD
1. Sensitivity to antipsychotics 2. Postural instability 3. Repeated falls 4. severe autonomic dysfunction 1. Constipation 2. urinary incontinence 3. Orthostasis 4. Syncope 5. Hyposmia 6. Hallucinations or delusions 7. apathy/anxiety/depression
33
What are biomarkers that can suggest a Dx of LBD?
1. Low dopamine uptake in the basal ganglia 2. Abnormal iodine-MING myocardial scintigraphy 3. Polysomnographic confirmation of REM sleep without atonia
34
What is one way to differentiate PD dementia and LBD?
1. "1 Year rule" 1. If dementia precedes parkinsonism or begins within 1 year of onset of the the parkinsonism, then it's LBD
35
What are the diagnostic criteria for FTD
1. Dementia and 3 of: 1. Disinhibition 2. Apathy 3. Loss of empathy 4. Perseveration 1. Unable to switch appropriately between tasks 5. Hyperorality 6. Executive dysfunction
36
What are the diagnostic criteria for Mixed dementia
1. Dementia 2. Any combination of other dementia syndromes 3. Most commonly: alzheimer clinically with imaging findings of vascular dementia
37
What is the suggested workup for dementia
1. History, look for reversible causes 1. Meds 2. EtOH use 3. sleep 2. P/E 1. Cognitive testing 2. MSE 3. Neuro exam wth focus on UMN and parkinsonism 3. Bloodwork 1. CBC, LBC, Calcium, LFTs and liver enzymes 2. Blood glucose 3. TSH 4. Vitamin B12 5. Limited role for biomarkers or genetic testing 4. imaging if indicated
38
What are the indications to get brain imaging in dementia?
1. **B**leeding **r**isk 1. Head trauma 2. anticoagulant use 3. bleeding disorder 2. **A**bnormal presentation 1. Age \>60 2. Rapid, unexplained decline (1-2 months) 3. Shorter duration of dementia (\<2 years) 4. Unusual or atypical cognitive presentation 3. **I**ntracranial lesion 1. Hx of Cancer 2. Unexplained focal neuro signs/symptoms 4. **N**ormal pressure hydrocephalus 1. Gait disturbance 2. Incontinence \*Bottom line if not classic alzheimers, get imaging
39
List the non-pharmacological treatment for dementia and in what stages they are benefitial
40
What are the pharmacological treatment options in dementia and at what stage should each be used?
41
When should cholinesterase inhibitors be considered in dementia
1. Mild dementia
42
What are the side effects of cholinesterase inhibitors
1. GI intolerance (anorexia) 2. Urinary retention 3. WIld or vivid dreams 4. Bradycardia
43
List CI to cholinesterase inhibitors
1. Conduction defects (except RBBB) 2. Bradycardia 3. unexplained syncope Use with caution in asthma, COPD, Seizures
44
What are the indications for NMDA RA (memantine) in AD?
1. Moderate-severre dementia (MMSE \<13)
45
How should vascular dementia be treated?
1. Optimize vascular risk factors 2. Cholinesterase inhibitors 3. ASA only indicated in the presence of micro infarcts, not with only white matter changes
46
How is lBD and PDD treated
Cholinesterase inhibitors
47
What is the treatment for FTD
1. No orle for cholinesterase inhibitors 2. No medication has been shown to reduce the cognitive decline in FTD 3. Trazodone or SSRIs for behaviours (cautiously as they can have paradoxical worsening) 4. ADT for sexual disinhibition
48
List the behavioral and psychological symptoms of dementia
1. Psychosis: Delusions, hallucinations, suspiciousness 2. Aggression: Verbal, physical, defensive, resistance to care 3. Agitation: restlessness, anxiety, vocalisation, repetitive action, pacing, wandering, hoarding 4. Depression: Sadness, guilt, hopelessness, irritability, suicidality 5. Mania: irritability, euphoria, pressured speech, sexual disinhibition, 6. Apathy: motivation, withdrawn
49
What are the non-pharmacological management options for BPSD
1. Identify and modify triggers or "unmet needs" 1. PIECES approach: Identify contributing **p**hysical, **i**ntellectual, **e**motional, **c**apabilities, **e**nvironmental, and **s**ocial factors 2. Non-pharm more efficacious than meds 1. Outdoor therapy 2. Music and massage 3. Massage and touch 3.
50
What are the pharmacological treatment options in BPSD
1. Empiric pain control: Tylenol 2. Risperidone if all 3 conditions met 1. Pure AD 2. Non-pharm Rx non-effective 3. Risk to self or others OR distressing psychotic symptoms * \*Re-evaluate and taper q3 months
51
What black box warning applies to antipsychotics
1. Increased stroke risk x2 2. Increased death risk x1.6 3. NNH=100
52
What are the differences between depression in adults and elderly persons?
1. In elderly: 1. Chief complaint may be somatic or cognitive 2. More complexity 3. "pseudodementia" is the cognitive symptom of dementia in depression 4. Less suicide attempt, better success rate
53
What are 2 screening questionnaires for the identification of depression in the elderly
1. Patient health questionnaire 9 (PHQ-9) 2. Geriatric depression scale (GDS)
54
What non-pharmacological treatments can be offered in depression in the elderly?
1. Group based interventions 2. Physical activity 3. CBT, Problem-solving therapy 4. ECT has excellent evidence in refractory depression
55
What are the pharmacological treatment options for depression in the elderly
1. SSRI 1. 1st line: Sertraline, duloxetine 2. 2nd line: Citalopram, escitalopram (Watch QT) 3. \*Longer trial of effect (10-12 weeks) 4. \*Avoid paroxetine and fluoxetine (anticholinergic) 5. \*Monitor for hyponatremia in 1st 2 weeks 6. \*Increase dose if partial response or add another antidepressant (lithium, aripiprazole)
56
What screening should be done to identify and prevent falls
1. Screen annually for falls in persons above 65 1. Have you fallen in the past year 2. Do you feel unsteady when standing, walking 3. DO you worry about falling?
57
List modifiable risk factors for falls
58
Give a categorization of "types of fall"
59
What should be assessed on physical exam when investigating a fall
1. Vitals: Orthostatic 2. CVS: AS, Arrythmia, carotid bruit 3. Neuro: Motor, sensory, cerebellar, parrkinsonism 4. MSK exam: Foot exam, knee and hip, osteoporosis 5. Gait assessment: Timed up and go (OR 2.4) 6. Cognitive testing: MMSE (cognitive impairment LR 13) 7. Vision and hearing screen
60
List fall management strategies for _LTC_
1. Multifactorial intervention 1. Exercise 2. Med review 3. Assess environmental hazards 4. Assistive devices 5. manage incontinence 2. Hip protectors 3. Dietary calcium and vitamin D supplementation 4. Consider bisphosphonate/denosumab
61
What DM med should be avoided in the elderly
Sulfonylureas
62
In what order should antihyperglycemics be added in elderly patients if there is no reason to use another order
1. Metformin, then DPP-4, then SGLT2 then long acting insulin
63
What is the A1C target for frail patients or patients with dementia
8.5%
64
Should antihypertensives or antihyperrglycemics be intensified in hospital for elderly patients
generally no
65
What are the BEERS criteria for potentially inappropriate medications in elderly patients
66
List ADLs and IADLS
67
What is the rockwood clinical frailty scale
68
What are the various types of elder abuse?
1. Physical 2. Verbal 3. Emotional 4. Sexual 5. Financial 6. Neglect
69
What is the most common fracture resulting from elder abuse, what is less likely to be accidental
Most common: humerus Unlikely to be accidental: zygomatic
70
What vaccinations are recommended in older adults
1. Annual influenza \>65 2. TD every 10 years 3. Pneumococcal: prevnar and pneumovax at 65 4. Zosterr 5. COVID
71
What are normal neurological changes associated with aging
1. Cognition 1. Changes occur after age 70, should not affect function 2. Executive function 1. Reduced processing and performance speed 1. Reduced reaction time, finger tapping, timed tests 2. Attention span: difficulty with multitasking 3. Semantic memory/fund of knowledge, procedural memory preserved 4. registration preserved 2. Cranial nerves 1. Vision: Reduced accommodation, reduced contrast sensitivity, dark adaptation, depth perception 2. Hearing: presbycusis: bilateral symmetric sensorineural hearing loss, decreased high frequency hearing, cerumen impactiono 3. Diminished olfaction 3. Peripheral nervous system 1. Decreased or absent ankle reflexes 2. Decreased vibration sense to ankle, decreased proprioception 4. Autonomic nervous system 1. Decreased baroreceptor response, increased vascular tone, decreased elasticity 2. Decreased innervation of detrusor muscle 5. Gait 1. 10-20% reduction in gait velocity and stride length, increased stance width, increased time in double support phase
72
What are normal cardioovascular changes associated with aging
1. Isolated systolic HTN with widened pulse pressures 2. Thickend valves, stiffened LV, Less tolerance too increased workload. EF normal 3. 50% LA enlargement, No RV or RA changes 4. Max HR decreases by 5-6 beats per decade
73
What are normal resiratory changes associated with aging
1. PFTs 1. Increased RV, ERV, FRC due to gas trapping 2. Decreased VC, FVC, FEV, Compliance, FEV1/FVC 2. increased dead space 3. Increased VQ mismatch 4. Changes in surfactants + decreased ciliary function and elasticity 5. Decline in diffusion capacity (5% per decade)
74
What are normal renal changes associated with aging
1. 30% decline in renal mass 2. CrCL decreases by 7.5 to 10 ML/min/decade 3. 30% of glomeruli sclerosed by age 75 4. Ability to maximally dilute decreased 5. Hydroxylation of vitamin D decreased 6. EPO production preserved
75
What are normal GI changes associated with aging
1. Reflux from reduced tone at LES 2. Preserved nutrient absorption in small intestine 3. Colonic changes in motility with decreased myenteric neurons, diverticula formation, greater water absorption, subsequently harder stool 4. Liver: decrerased mass and blood flow 1. Phase 1 reactions: reduced oxidation 2. Phase 2 reactions: Preserved glucuronidation
76
What are normal MSK changes associated with aging
Decreased bone and muscle mass, worst iin arms and legs
77
What are normal immune changes associated with aging
1. Immunosenescence: decreased efficiency 2. More severe infections 3. Slower recovery
78
What are normal endocrine changes associated with aging
1. Post menopausal women: reduced estrogen = vaginal atrophy 2. Reduced GH and testosterone = reduced DHEA secretion 3. Increased cortisol = reduced bone density, fractures, memory loss 4. Vasopressin responds less to osmolality: Less renal response and less thirst
79
What are normal sleep changes associated with aging
1. Longer to initiate 2. Reduced stage 3 and 4 3. No REM changes
80
How does aging affect pharmacokinetics
1. Absorption: relatively unaffected 2. Distribution: Less muscle and water, more fat 1. Water soluble drugs: increased serum concentration 2. Lipid soluble drugs: Increased half life 3. Metabolism 1. Reduced hepatic metabolism 4. Eliminatiion 1. Reduced GFR
81
How can peri-operative delirium be managed?
1. Risperidone after _cardiac_ surgery 2. Dex medetomidine intra op
82
How is ICU-related delirium managed
Eye mask and earplugs Dexmedetomidine
83
What are signs of zinc deficiency
1. Fragile hair 2. Impaired wound healing 3. Anosmia
84
What are signs of coppe deficiency
1. Fragile hair
85
What are signs of vitamin A deficiency
1. Poor night vision
86
What are signs of fluoride deficiency
1. caries
87
What are signs of Iron deficiency
1. Angular cheilitis 2. Impaired wound healing 3. Koilonichia
88
What are signs of vitamin B2 deficiency
angular cheilitis
89
What are signs of iodine deficiency
goiter
90
What are signs of vitamin C deficiency
1. Follicular hemorrhage
91
What are signs of vitamin B1 deficiency
CHF
92
What are signs of vitamin B3 deficiency
1. Sun exposed dermatitis 2. cognitive impairment
93
What are signs of vitamin K deficiency
1. bleeding
94
What are signs of vitamin D deficiency
Osteoporosis/osteomalacia
95
What are signs of vitamin B12 deficiency
1. Paresthesia 2. Cognitive impairment
96
What are signs of vitamin B9 deficiency
Cognitive impairment
97
List the most common causes of unintentional weight loss in elderly patients
1. **Malignant disease** 2. **Psychiatric disorders** 3. GI disease 4. Endocrine disorders (esp hyper T4) 5. CV disease 6. Nutritional disorders or alcoholism 7. Resp disease 8. Neurologic disorder 9. Chronic infection 10. renal disease 11. CTD 12. Drug-induced 13. Unknown 14. Inability to get food: 1. Finances 2. Functionnal hability 3. Cognition/depressioon 4. Other psych issues 5. Dentition 6. dysphagia
98
List non-pharmacological options for the management of unintentional weight loss
1. **Minimize dietary restrictions** 2. Optimize energy by 1. Maximize intake with high-energy foods at best meal of the day 2. Smaller meals more often 3. **Offer favorite foods and snacks** 4. Provide finger food 3. Optimize dietary texture 4. Ensure adequate oral health 5. High energy oral supplements 1. or add fats or oils to usual foods 6. Time supplements between meals 7. **Eat in the company of others or with assistance** 8. Trial of flavor enhancers 9. Regular exercise 10. **Use community nutritional supports**
99
What are the pharmacological management options for unintentional weight loss
1. Daily multivit supplement 2. Calcium intake 1200mg from all sources 3. Vitamin D 1000UI daily 4. Supplement Iron, B12 if indicated
100
List the 5 types of urinary incontinence
1. Stress 1. involuntary leakage on stress/exertion/cough/sneezing 2. Urge 1. Sudden, strong need to void with involuntary leakage 3. Mixed 1. Combination of stress and urge 4. Overflow 1. Bladder overdistention 5. Functional 1. Cognitive, functional, mobility
101
What is the most common type of incontinence in older women?
1. Mixed or urge
102
What is the first line treatment for incontinence?
1. **lifestyle modifications** 1. Limit fluid intake, caffeine, ETOH 2. Weight loss 3. Timed voiding 4. Treat constipation 2. Kegel exercises or pessary 3. Bladder training if cognitively intact 4. Prompted voiding if cognitive impairment
103
What are the second line options to treat urinary incontinence
1. Stress 1. No pharmacology 2. Surgery 2. Urge 1. Anticholinergics (oxybutynin, tolterodine) 1. Effectiveness low, ++ side effects 2. Beta agonists like mirabegron 3. Botox of the detrusor
104
What are possible underlying causes for constipation?
1. Meds! 1. Anticholinergics 2. opiates 3. iron 4. calcium 5. CCB 6. NSAIDS 2. Immobility 3. Neuro: 1. PD 2. DM 3. Stroke 4. Spinal cord injury 4. Volume depletion 5. Metabolic: 1. HypoT4 2. HyperCa 3. HypoK 6. Mechanical obstruction 7. Dementia/depression 8. Low dietary fibre
105
List red flags in constipation
1. FMHx of colon Ca 2. Hematochezia 3. Anemia 4. Weight loss 5. +FOBT 6. Persistent constipation non-responsive to treatment 7. Acute onset
106

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