GERIATRICS Flashcards
GERIATRICS
Older adults are defined as those 65 years and above.
Young Old: 65-74 years of age
Old: 75-84 years of age
Oldest-old: 85+ years of age
As patients age there are increased complications.
There is a decreased ability to maintain homeostasis as people age. Most often cardiac, musculoskeletal, renal, and neurological body systems are vulnerable to illness as people age.
FUNCTIONAL ASSESSMENT
People often lose function in a variety of areas as they age. Assessment of function is key to determining a patient’s needs. When interviewing the patient review cognitive status, physical and mental health, and social and economic resources. Daily function is often related to changes in health, and this may result in changes in living status and ability to perform ADLs.
Assess Advanced ADLs: complex measures of functional status or losing ability in these activities (working, volunteering, social activities, recreational activities, connection with peers and community).
Assess Instrumental ADLs: activities that contribute to independence (shopping, housekeeping, accounting, food preparation, transportation/telephone use/skills).
Assess basic ADLs: Dressing, eating (independent), ambulating, transferring/toileting, hygiene
Frailty is a word used to describe elderly adults who show decreased functional reserve. People defined as frail are at increased risk for functional decline and death. There are multiple assessment tools for frailty and functional assessment. Frail patients often have a slow gait, weak hand grip strength, low energy expenditure, weight loss, and possibly cognitive decline.
Treatment of frailty is supportive in nature.
ENVIRONMENTAL ASSESSMENT
This assessment focuses on personal competence and physical limitations.
The NP will focus on home condition such as: proper lighting, temperature, colors, floor coverings, furniture, bathroom hazards, medications, chemicals, and toxins.
FALLS
As Americans we laugh and joke about falls when we see an America’s Funniest Home Videos clip on television or online. But ask yourself, are falls really funny? Specifically is it funny when Great-aunt Lisa is skateboarding with the grandchildren and hits a stick or rock on the pavement resulting in a fall. It may be funny, unless Great-aunt Lisa is on Coumadin or Xarelto and hits her head….She might have a subdural hematoma or a subarachnoid hemorrhage.
Complications from falls are the leading cause of death in people over the age of 65.
33% of geriatric people fall annually. The frequency of falls increases as people age. Hip fractures are the most common injury leading to functional impartment, nursing home placement, and death.
Every older adult should be asked about falls…assess, assess, assess.
ASSESSMENT
Vital sign assessment
Strength evaluation
Cardiac exam (arrhythmia, murmur)
ROM evaluation
Cognition exam: Mini-mental examination
Proprioception exam
Examine legs ad feet, footwear
Assistive device use
Gait assessment: “Up and Go test”- ask patient to stand from sitting without use of hands, walk 10 feet, turn around, walk back, and sit down.
<10 seconds: normal,
>30 seconds needs assistance with mobility tasks,
>10-30seconds vary widely in regards to gait, balance, and function.
New medications or change in dosage of medicine
Alcohol or recreational drug use
First fall or has the patient experienced multiple falls
Loss of consciousness
Environment assessment
Risk factors: poor lighting, throw rugs, clutter
Causes of Falls
Impaired vision or hearing
Age related changes resulting in altered balance and increase in postural sway
Rarely due to a single cause
Hypotension
Change in reaction time
Altered balance or gait
Medication (sedative/hypnotics, antidepressants, benzodiazepines most often associated with falls)
Use of multiple medication
Environmental hazards
Improper use of assistive devices for ambulation
Complications of Falls
High mortality- 20% of patient die after sustaining a fall resulting in a fracture
Fear of falling
Brain hemorrhage (i.e. subdural hematoma)
Dehydration
Electrolyte imbalance
Pressure ulcer
Hypothermia
Rhabdomyolysis
Prevention and Interventions
Risk assessment annually
Family education on preventing falls
Refer to physical therapy for gait training
Weight training, exercise program
Teach proper use of cane or walker
Treat contributory medical conditions (i.e. cataracts, hypotension)
Mobile phone or phone at floor level, lightweight radio call system
Minimize medications and dosage
Remove home hazards (declutter)
Install hand rails and grab bars
Prevent and treat osteoporosis (i.e. vitamin D, Boniva)
Proper footwear
NUTRITIONAL CONCERNS
It is important to review nutrition with the geriatric patient. Weight loss is frequently found in the elderly population. Recently there has been some findings of obese geriatric patients as well. It is important to review laboratory and radiologic studies for patient losing weight.
Assess Radiology/Lab Findings:
CBC
TSH
Creatinine
Calcium
Albumin
Prealbumin
Transferrin
Testoterone (in men)
Urinalysis
Chest X-ray
These studies may help find cause of the weight loss: metabolic or neoplastic in nature.
As the NP you should assess the patient’s social environment, cognition, mood, and dental health.
Obese patients particularly those with a BMI> 30kg/m2 have risks of multiple comorbidities including hypertension, diabetes mellitus, osteoarthritis, and heart disease. In addition there are increased risks of urinary incontinence, cancer, and reduced functional capacity.
Ask your patient does he or she take a multivitamin to assist in meeting daily allowance for nutrition.
Protein- geriatric patients require a minimum of 0.8g/kg/day. An albumin level less than 3.5 indicates protein deficiency and malnutrition. In addition low protein consumption leads to poor wound healing.
Calcium- requirements should be individualized to the patient. The absorption of calcium decreases with age. Be mindful of lactose intolerance of patients. It is important to be aware of diagnosis such as cancer, hyperparathyroidism, nephrolithiasis, and osteoporosis.
BMI: <18.5= underweight, 18.5-24.9= normal weight, 25-29.9=overweight, >30=Obese
Review medications list. Medications that may increase appetite include: antidepressants, tranquilizers, narcoleptics, steroids, and hormones. These medications may benefit patients who are underweight but those who are overweight or obese may need some adjunct therapies to either maintain weight or help lose weight.
Always perform a nutritional risk assessment. The history is key! Ask your patient about involuntary weight loss/gain, change in appetite, or change in clothing size.
Indications of nutritional risk include: 5 pound weight loss in 1month, 5% of body weight loss in 1 month, 7.5% loss of body weight in 3 months, 10% loss of body weight in 6 month. (unintentional weight loss).
TREATMENT
Weight loss
Oral nutritional supplements of 200-100 calories/day
Add Megace as appetite stimulant
Hand feeding of those unable to feed themselves
Tube feeding if unable to have hand feeding
Liquid artificial nutrition (tube feeding) is not recommended for those with end-stage dementia
Weight gain/obesity
Modest reduction in calories 500-700 calories/day
Add regular physical activity
Bariatric surgery (reserved for select group of geriatric patients)
ELDER ABUSE AND NEGLECT
The mistreatment of elder patients is defined as “actions that cause harm or creat a serious risk of harm to an older adult by a caregiver or other person who stands in a trust relationship to the older adult, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.”
Females are at a higher risk of mistreatment than males. >90% of the time the elder knows the abuser.
Abuse frequently is not reported because of embarrassment, intimidation, and isolation.
TYPES OF ABUSE
Physical- violence that results in pain or injury
Pushing
Slapping
Hitting
Improper physical restraints
Emotional- resulting in mental anguish
Intimidation
Threatening
Shunning
Isolation
Yelling
Insulting
Sexual-forced or non-consensual sexual activity
Rape
Molestation
Sexual harassment
Forced viewing of pornography
Financial exploitation
Withdrawing money from accounts
Signing over assets
Removing valuable possessions
Caregiver neglect
Isolating the elder
Unhealthy diet
Over sedation
Poor hygienic living conditions
Non-attention to physical state
Self-neglect
Poor hygiene
Unsanitary home environment
Untreated medical conditions
RISK FACTORS FOR ELDER ABUSE
Lack of close family
Increasing age
Physical or mental impairment
Clue to possible abuse include behavior changes around caregiver, delays between occurrences of injuries and when treatment was sought, inconsistences between injury and explanation, hygiene, lack of clothing, not filling prescriptions
Observe and talk with every elder person alone for part of the visit (See Table 4-6)
If self-neglect is suspected assess for decision-making capacity, if able to make decisions provide resources and support. If patient does not have full decision-making ability the patient may require intervention such as guardianship, in-home help, or placement in a supervised setting. The aid to capacity evaluation tool is a valid and reliable source for determining decision-making capacity. Please review this website.
SIGNS OF ABUSE
Injuries-burns, bite marks, hematomas, lacerations, lesions form improper restraint use, black or swollen eyes, abrasions, fractures, bilateral extremity bruising
Malnutrition
Personal hygiene
Improper dress
Dehydration
Pressure ulcers
Pain
ROM problemens
Genital/rectal: bleeding, discharge, infection, irritation, injury, scarring, STDs
Anxiety
Depression
Most states have a mandatory statue for reporting abuse and neglect. The states offer full protection from civil or criminal liability for people who report abuse.
PAIN
Pain is a major cause of immobility in elderly patients. Immobility can cause excruciating pain from contractures or through exacerbation of painful conditions such as RA. Pain is often under diagnosed and undertreated in the geriatric population. Pain assessment is now the 5th vital sign. The NP should always ask about pain and use a tool (FACES, numeric scale, verbal descriptor scale) to assess pain.
Pain is NOT a normal part of aging. Chronic pain is secondary to some pathological process. Barriers to reporting pain include: lack of knowledge about effects of uncontrolled pain, inability to express pain, fear, family suggesting not to take medication, misbelief that pain is part of aging, thinking that pain will not be evaluated, concerns of additions, and fear of side effects.
PHARMACOLOGICAL TREATMENT
Tylenol
Nonopiods
Topical treatment: capsaicin, ketamine gel, lidocaine patch
Steroid injection
NSAIDs and COX-2 inhibitors should be avoided and used rarely with caution
SSRIs
TCAs
Anticonvulsant (like gabapentin and pregabalin for neuropathic pain)
Oral corticosteroids
Avoid muscle relaxants and benzodiazepines
Opiods when nonpharmacological and Tylenol are not affective and pain is impacting function and quality of life
NONPHARMACOLOGICAL TREATMENT
Rest
Physical and occupational therapy
Yoga
TENS
Acupuncture
Cold/hot therapy
Guided imagery
Distraction
Massage
Music
Relaxation
Strengthening exercises (exercise is key to reduce immobility)
DEMENTIA
An acquired, persistent, and progressive impairment in intellectual function with compromise of memory and at least 1 other cognitive domain (i.e. aphasia), apraxia, agnosia, impaired executive function.
Diagnosis requires significant decline in function and interferes with ability to work or have a social life
NP should ask rate of progression of deficits and their nature, presence of neurologic symptoms, family history of dementia, medications.
Neurologic exam focuses on mental status assessment. Short-term memory loss, word-finding difficulty, visuospatial dysfunction, executive dysfunction, apathy, apraxia
Assess B12, free T4, and TSH, CBC, Chem 13, and lipid profile. MRI brain is preferred but CT Brain scan is appropriate if cannot have MRI.
Aerobic exercise, frequent mental stimulation, maintain as active role as possible. Acetylcholinesterase inhibitors, memantine
DELERIUM
An acute, fluctuating disturbance of consciousness, associated with a change in cognition or development of perceptual disturbances. Usually develops secondary to medical condition such as an infection, hypoxemia, or coronary ischemia.
Confusion assessment scale (CAM)
CBC, Chem 13 (assess BUN and electrolytes), UA, EKG, ABG, Chest Xray, CT scan, LP
Supportive care. Reassure and reorient the patient. Treat underlying cause. Eliminate unnecessary medications and avoid foley catheters and restraints.
Antipsychotics sich as Haldol or Seroquel are the drugs of choice. If prescribed assess EKG for changes in QT interval. Avoid benzodiazepines except if in benzodiazepine withdrawl.
POWERPOINT
When assessing the older adult there are four domains that are different in this age group. Along with
the normal adult assessment the Nurse Practitioner also must assess the physical health domain,
functional health domain, psychological health domain and the social-environmental and quality of Life
measures domain. All four of these domains are assessed on the yearly Medicare annual visit. These
four domains interact in complex ways to influence the health and functional status of the geriatric
population.
Slide 3
The physical health domain starts with the physical examination of the patient. The next step in this
domain is a medical history. Obtaining a medical history may be hard to obtain. Some older adults tell
you about what has happened to them but can only describe the event. The rest they expect you to fill
in the blanks.
The next step is the nutritional assessment, and the final portion is the Medication
review.
Slide 4
Increased blood pressure puts the patients at increased risk for cardiovascular morbidity. Postural
changes can be worsened and become symptomatic with antihypertensive vasodilator, and tricyclic
antidepressant therapy. A baseline rate is important for future complaints of dyspnea. This can be an
indication of pneumonia or heart failure. We need to look at weight changes. An increase may indicate
edema or ascites. Gradual weight loss is normal but more than %5 in one year could indicate and
underlying disease.
Slide 5
Poor personal hygiene and grooming can be signs of poor overall function, caregiver’s neglect,
depression, and often indicates the need for intervention. Slow thought processes and speech usually
represents an aging change, Parkinson’s disease, or depression. Ulcerations of the lower extremities can
indicate lower extremity vascular disease. Pressure ulcers can be easily over-looked on immobile
patients. Diminished turgor is often results from atrophy of subcutaneous tissue rather than volume
depletion. When dehydration is suspected, skin turgor over the chest and abdomen is the most reliable
sites to check.
Slide 6
With the ears you may expect to find diminished hearing. In the eyes they may have diminished vision
even with corrective lenses. These patients may also have cataracts. It is important that they receive
yearly eye exams looking for glaucoma. The patients may have missing teeth. If they have dentures, they
should be removed to check for evidence of poor fit and other pathology in the oral cavity. Area under
the tongue is a common site for early malignancies. Actinic keratoses and basal cell carcinomas are
common but most of the lesions found on the skin are benign. Crackles can be heard in the absence of
pulmonary disease and heart failure. It can often indicate atelectasis. Prominent aortic pulsation can
often be abdominal aneurysms and should be evaluated by ultrasound. Testicular atrophy is normal.
Atrophic vaginal tissue may cause symptoms such as dysuria. Pelvic prolapse, cystocele and rectocele
are common. Periarticular pain can result from a variety of causes and is not always the result of
degenerative joint disease. Each area of pain should be carefully evaluated and treated. ROM often
cause pain resulting from inflammation, scarring from old injuries and neurological disease. If
limitations impair function rehabilitation or physical therapy may be necessary. Edema can result from
venous insufficiency or heart failure. Treatment is necessary if impairing ambulation, contributing to
nocturia, predisposing to skin breakdown or causing discomfort. Unilateral edema should prompt search
for DVT. When assessing the cardiovascular we look at irregular rhythms. An important one with older
adults is Atrial Fib. Systolic murmurs are common and most often benign. Carotid bruits need further
evaluation. Vascular bruits often present in patients with symptomatic peripheral vascular disease.
Slide 7
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Slide 8
You need to get height and weight to determine the BMI. A BMI greater than 30 means your patient is
overweight. A BMI 22-30 within normal weight. A BMI under 22 is underweight.
Slide 9
Weight gain could suggest edema, heart failure, hypothyroidism, or diabetes. Weight loss could suggest
an underlying disease. If you have a patient that has extensive weight loss look for lung cancer especially
if the patient is a former or current smoker. You also need to make sure the patient can cook for
themselves and can afford to feed themselves.
Slide 10
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Slide 12
You need to ask your patient if they can bath themselves and cook their own meals. You need to ask
your patient who gives them assistance and provides them support. Find out if the patient needs an
assistive device for ambulation. Ask if they have fallen in the last year. If they do use an assistive device,
ask them if they use it at home. If they do not encourage the patient to use it all the time especially at
home. Many patients only use these devices when they are out. Many do not use them at home, and
this makes them a risk for falling. Need to ask the patient if they can get their own clothes out and dress
themselves. Need to ask the patient if they have are incontinent of bowel or urine.
Slide 13
You need to ask your patient if they drive. If not, how do they get to MD appointments. Who takes them
grocery shopping? Need to ask them if they can do their own shopping. Make sure they can keep their
house clean, wash clothes etc. If they can’t do these things find out who helps them.
Slide 14
Mild cognitive impairment can sometimes be reversed. Detection is important and can promote re-
evaluation of treatment regimens possibly eliminating potentially inappropriate medications.
Depression is very important in the elderly. The PHQ2 and PHQ9 are tools to detect depression. We
must identify those who are at risk for suicide. Older males are especially susceptible to suicide.
Slide 15
Social status revolves around social isolation and resources available. For the elderly living in the
community, they can be at risk for social isolation if they have a poor social network. Resources that are
factored into their socio-environmental health include living situation, housing, transportation, income,
assets, and financial burden from health concerns
