Geriatrics Flashcards
Describe long-term care -
Skilled Nursing Facility
Skilled nursing facilities (SNF) are subsets of nursing facilities that receive payment for skilled nursing services under Medicare Part A. SNF services include rehabilitation therapies and/or skilled nursing care, such as intravenous therapy, wound care treatment for deep pressure ulcers, or close-monitoring posthospitalization in medically complex residents.
Describe continuing care
Continuing care retirement communities (CCRCs):
Geographically localized and self-contained spectrum of living arrangements from independent housing to nursing home care
List the predictors for nursing home admission and identify the goals of nursing home care.
Predictors for nursing home admission:
- Functional determinants, such as decline in strength and balance, and impairment in ADLs, especially in toileting, dressing, and eating.
- For those older than 75 years of age, a decline in cognition is a consistent risk factor.
- Most nursing facility residents lack sufficient personal and financial support to remain in their homes. Adequate caregiver support, both informal and formal, explains why many functionally dependent older adults are able to remain in community settings.
- Falls
- Incontinence
Goals of nursing home care:
- To cure when appropriate
- To restore and maintain function
- To offer comfort
Describe issues of caregiver fatigue.
Problems associated with caregiving:
- Caregivers face physical, emotional, and financial demands, and often neglect their own physical and emotional health
- Signs of caregiver burnout include multiple somatic complaints, increased stress and anxiety, circular thinking, social isolation, depression, and weight loss.
Possible interventions to reduce care burden:
- Having patients attend adult day care centers to provide respite for caregivers
- Recruit other family members to participate in and assist with care
- Referral to Area Agencies on Aging Caregiver support programs
- A referral of the caregiver to individual psychiatric treatment may be advisable and helpful
Distinguish between the various services covered by Medicaid, Medicare and other types of health care for the elderly.
Medicare benefit payments Part A (Hospital) 35% Part B (Physician Services) 29% Part C (Medicare Advantage) 23% Part D (Prescription Drug) 12% Home health care ordered by physician for rehab (not chronic care management, household help, IADL support) Skilled Nursing Home care- after qualified hospitalization, need for short-term skilled care or rehabilitation (not chronic care management) Hospice Care
NOT covered by Medicare Most LTC services Deductibles Eyeglasses Hearing aids Dental services
Medicaid: State & Federal funds State administered Means tested (based on whether patient has means or not) All ages Largest payer of LTC, mostly nursing home, services Payments to those with low incomes. Many “spend down” assets to qualify. In Oregon, and some other states, Medicaid pays for home & community-based services as well as nursing home services.
Compare and contrast advance directives with POLST.
Advance directives:
For anyone 18 and older
Provides instructions for FUTURE treatment
Does not guide Emergency Medical personnel
Guides inpatient treatment decisions
Appoints a Health Care Representative
POLST: For anyone seriously ill (any age) Provides instructions for CURRENT treatment Guides Emergency Medical personnel Guides inpatient treatment decisions
What are the 2 categories of conservatorship? Describe them.
There are two broad categories of conservatorship that are commonly used, those of finance and of person. Conservatorship of finance is a fairly self-evident term. Conservatorship of person grants a more global responsibility for assuring that the individual is kept safe and that decisions are made either as substituted judgment or on the basis of the individual’s best interests. These decisions may involve, for example, medical care, where a person will live, what help the person will receive to maintain himself or herself. The person may retain the ability to make a will (testamentary competence), even when he or she has been adjudicated as incompetent of person and finance.
What is the most rapidly growing segment of the population?
Persons over the age of 85.
Those over 65 will account for 20% of the population by 2030.
Define the differences between Young Old, Middle Old, and Old Old.
Young old: 65-74
Middle old: 75-84
Old old: 85+
Describe the common causes of falls among the elderly.
Muscle weakness history of falls gait deficit balance deficit use assistive device arthritis impaired ADL depression cognitive impairment age > 80 visual deficit environmental hazards use of psychotropic meds
Define crystallized intelligence.
information and skills gained from experience
Define fluid intelligence.
flexible reasoning and problem solving approaches
Discuss the expected changes in common lab values that occur as a result of aging (6)
- Arterial oxygen pressure: DECREASE
- 2-hr post-prandial glucose: INCREASE
- serum lipids: INCREASE
- serum testosterone (men): DECREASE
- serum estradiol (women): DECREASE
- serum creatinine: no change (muscle mass decreases while clearance also decreases) but clinically significant
Describe the effect of polypharmacy on the geriatric population. (risks/adverse effects)
- Adverse drug reactions account for up to 10% of hospital admissions among the elderly
- Adverse drug reactions are the 4th-6th leading cause of death among hospitalized patients
- Major cause of confusional state; medications cause 1/4 cases of inpatient delirium
- Increased risk of constipation
- Substantially increased risk of drug interactions
- Major cause of accidents (falls) and illness in the elderly
- Cognitive impairment increases as the number of medication increases
What immunizations and chemoprophylaxis are recommended for elderly patients?
pneumococcal pneumonia vaccine
influenza vaccine
aspirin for primary prevention of myocardial infarction
CDC guidelines also recommend zoster vaccine and tetanus vaccines
Name 5 dementia drugs
donepezil tacrine rivastigmine galantamine memantine
Name 3 incontinence drugs
tolterodine tartrate
oxybutynin
trospium chloride
What are the elements of a POLST form?
In Oregon:
- CPR
- Medical interventions - comfort, limited, or full
- Artificially administered nutrition
- Documentation of discussion
- Signature of provider
What are the ADLs?
bathing, dressing, toileting, continence, grooming, feeding, and transferring
What are the IADLs?
SHAFT • Shopping • Housework – laundry, housekeeping, telephoning, taking meds • Accounting • Food preparation • Transportation
Name 7 factors that put geriatric patients at risk for iatrogenic disease.
- polypharmacy
- multiple chronic conditions
- multiple providers
- hospitalization, medical/surgical procedures
- atypical presentations of illness
- impaired cognitive/functional capacity
- reduced reserves/altered compensatory mechanisms
What specific nutritional guidelines are different for older adults?
- calorie requirements decline due to decrease muscle mass and decreased physical activity.
- lower calorie requirements increase risk of malnutrition -> change to protein/nutrient-rich foods
- current recommendations don’t call for increase in protein/kg of body weight, although some sources do recommend an increase
- 55-70% calories from carbs
- Adults 65+ have a reduced ability to regulate fluid intake and are therefore more likely to become dehydrated when health status or environment changes
- Supplementing the diet with any of the commercially available concentrated fiber sources may be necessary, especially in the frail elderly.
What are the most important vitamins/minerals to monitor in the elderly?
B12, Vitamin D and Calcium
Name the four most common vision changes in the elderly.
Presbyopia
Cataracts
Macular degeneration
Glaucoma (chronic)
