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)
What is delirium? What causes it?
Delirium is an acute, fluctuating disturbance of consciousness, associated with a change in cognition or the development of perceptual disturbances. It is the pathophysiologic consequence of an underlying general medical condition such as infection, coronary ischemia, hypoxemia, or metabolic derangement.
What is Pick disease?
- -Pick disease is a pathologic diagnosis and occurs in the minority of clinical cases presenting with signs and symptoms of frontotemporal lobar degeneration.
- -The pathological hallmark of Pick disease are Pick bodies and Pick cells.
- -This is invariably associated with selective atrophy of the frontal and anterior temporal lobes.
- -The largest concentration of Pick bodies is found in the hippocampus and amygdala.
- -Pick bodies are composed of randomly arranged tau filaments.
- -Pick cells are swollen achromatic neurons.
Name 2 differences between Pick and Alzheimer disease.
- depression is common in AD; not in Pick.
2. AD can spare the dentate gyrus; Pick heavily involves this region.
What is mild cognitive impairment (MCI)?
The term “mild cognitive impairment” has been used to describe cognitive impairment in aging that does not meet the criteria for dementia and that is not the result of a known medical condition.
Criteria used to diagnose MCI:
(1) subjective memory concerns
(2) objective impairment in memory on neuropsychological testing
(3) absence of dementia
(4) absence of functional complaints
What is the relationship between MCI and Alzheimer disease?
80% of those diagnosed with MCI will go on to develop AD within 5 to 8 years, and will convert at a rate of approximately 10% to 15% per year compared to general population conversion rates of 1% to 2%
What are the symptoms of dementia?
memory loss, confusion, impaired judgment, personality changes, disorientation, and loss of language skills (not due to delirium or psychiatric disease)
What are the risk factors for VaD?
Hypertension, diabetes mellitus, advanced age, male sex, smoking, and cardiac disease
What are 11 causes of reversible dementia?
- Toxic reactions to medications
- Dietary deficiency
- Vitamin B12 deficiency
- Infections
- Tumors
- Alcoholism
- Inflammatory states
- Hormonal dysfunction
- Environmental toxins
- Drug abuse
- Depression
Name 8 commonly identified risk factors for falls.
- muscle weakness
- history of falls
- gait deficit
- balance deficit
- use of assistive device
- visual deficit
- ADL impairments
- age 80+
Name 6 screening tools/events for falls.
- “Have you fallen recently?”
- observe Timed Up and Go test
- after hospital discharge, new medications
- check orthostatic BPs
- screen for osteoporosis
- labs: CBC, FBG, BUN, creatinine, TSH, B12
What percentage of older men reported partner sexual activity in the past year? What frequency?
39% of men aged 75 to 85 years reported sexual activity with a partner within the previous 12 months, with 54% of these sexually active 75- to 85-year-old men reporting sex at least two to three times a month
What are the protein intake recommendations for elderly?
o Current recommendations for individuals 65+ do not differ from healthy adults (0.6-0.8g/kg/day).
o Some recommend elderly adults should increase protein intake to 1.0-1.25g/kg/day
Name the top 10 causes of death for those 65+.
- Heart Disease
- Malignant Neoplasms
- Chronic Low Respiratory Disease
- Cerebrovascular
- Alzheimer’s Disease
- Diabetes Mellitus
- Influenza and Pneumonia
- Nephritis
- Unintentional Injury
- Septicemia
Name the top 3 causes of disability for those 85+.
- Arthritis/musculoskeletal
- Heart/circulatory
- Dementia
Name the top 3 causes of disability for those 65-84.
- Arthritis/musculoskeletal
- Heart/circulatory
- Diabetes
Name 3 other causes of disability for those 65+ besides arthritis, heart, dementia, diabetes:
Hearing, vision, lung
What are the most bothersome side effects of acetylcholinesterase inhibitors?
tremors bradycardia nausea diarrhea anorexia myalgia
What are the 3 interventions for fall prevention with best evidence?
- Exercise/PT
- Vit. D supplementation
- Multifactorial intervention
(CURRENT)
What are the symptoms of hypothyroidism?
cold intolerance, fatigue, constipation, dry skin, pseudodementia, weight gain, increased blood lipids, bradycardia
What drug is used to treat hypothyroidism?
levothyroxine
What lab tests are performed to assess hypothyroidism?
TSH (increased), free T4 (decreased)
What percentage of people 65+ have missing teeth?
Americans over 65 have an average of 11 missing teeth, and 1/3 are edentulous
What can hyperglycemia cause in older patients?
Hyperglycemia in older patients can cause falls, urinary incontinence, fatigue, confusion
What is the mechanism of osteoarthritis? Is it inflammatory?
degeneration of cartilage and hypertrophy of bone at the articular margins. Inflammation is usually minimal
What are the symptoms of heart failure?
SOB, dyspnea, orthopnea, dependent edema, chronic nonproductive cough
What are the symptoms of heart failure in older adults?
malaise, confusion, irritability, anorexia
How is hypertension diagnosed?
based on the average of a minimum of 9 different BP readings obtained during 3 separate visits
What is the prevalence of sleep difficulty among older adults?
• 50% of community-dwelling elderly complain of sleep difficulty
Pneumonia
- -typical presentation
- -altered presentation in elderly
–typical
Cough, dyspnea, fatigue, fever, anorexia, chills, sweats, headache
–elderly
Extrapulmonary symptoms such as NAUSEA, VOMITING, DIARRHEA, myalgia, and arthralgia are common.
The most sensitive sign of pneumonia in an elderly adult is an INCREASED RESPIRATORY RATE with a respiratory rate of >28 indicating severe pneumonia.
Sepsis
–altered presentation in elderly
–elderly
The most common sign that triggers the clinician to look for infection, FEVER, IS OFTEN ABSENT IN THE ELDERLY PATIENT!
Older patients with bacteremia are less likely than younger patients to have systemic signs such as fever, chills, or diaphoresis
Serious infections may be heralded by nonspecific DECLINES IN FUNCTIONAL OR MENTAL STATUS, or ANOREXIA
MI
–altered presentation in elderly
–elderly
The elderly are much less likely than younger patients to present with “classic” exertional chest heaviness. Instead, older patients more often complain of a vague feeling of dyspnea, abdominal pain, fatigue, confusion, or malaise that may be misinterpreted as consequences of aging or other comorbid illness.
Hypothermia
–altered presentation in elderly
- -elderly
- hypothermic older patients may not complain of feeling cold and may not shiver
- older adults may become hypothermic even without exposure to extremely cold temperatures
Acute abdomen
–altered presentation in elderly
a. Intensity of pain may be less severe in older subjects
b. Altered mental status and hypotension may be the sole indicators of a serious intra-abdominal disease in elders
Each of the 3 incontinence drugs we have discussed is an anticholinergic. What are the side effects of these drugs?
➢ Blurred vision ➢ Confusion ➢ Mydriasis ➢ Constipation ➢ Urinary retention
“Can’t see, can’t pee, can’t shit, can’t spit”
What kind of dementia presents decline in a stepwise fashion?
multi-infarct vascular dementia
What is the frequency of sexual activity for older adults?
The Janus report found that in
patients >65, 69% of men and 74%
of women report some form of
sexual activity at least weekly
