Geriatrics Flashcards
What is frailty?
Age related syndrome of physiological decline characterized by marked vulnerability to adverse health outcomes
5 indicates of frailty
- weight loss 4-5kg
- Exhaustion and fatigue
- Low activity
- Weakness or low grip strength
- Slowness or slowed gait speed
Fragility index score
70 clinical deficit questions. Presence of 25 or more —> .025 (10 present/40 considered).
What is the comprehensive geriatric assessment tool
Multidimensional and multidisplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older adults with frailty
1. Develop a coordinated plan to maximize overall health with aging
Major components of geriatric assessments
- Functional capacity
- Fall risk
- Cognition
- Mood
- Poly pharmacy
- Social support
- Financial concerns
- Goals of care
- Financial planning.
Wat gender and ethnicity to live linger
Women änd white
Definition of aging
progressive decline and deterioration of functional properties at the cellular, tissue, and organ level that lead to a loss of homeostasis, decreased ability to adapt to internal or external stimuli, and increased vulnerability to disease and mortality.
Metric for aging for clinical decision making?
Physiological age, and not chronological age
Genetic Variations linked with Alzheimer’s disease
APOE, the most common Alzheimer disease risk gene.
(Apolipoprotein)
& protocadherin 11 X-linked (PCDH11X)
Cardiovascular changes with aging.
Increased:
left ventricular wall thickness
lipofuscin and fat deposits
ventricular stiffness
Decreased:
maximum heart rate
heart rate variability
responsiveness to receptor-mediated agents
Decreased:
cardiac output and vascular compensation in orthostasis, sepsis, etc
Digestive changes with aging
Increased:
dysphagia
achlorhydria
lipofuscin and fat deposition in pancreas
mucosal cell atrophy
Altered intestinal absorption
Decreased:
iron, B12 and calcium absorption
Age changes with ears
Increased:
conductive deafness (low-frequency sounds)
sensorineural hearing loss (high-frequency sounds)
Decreased:
detection of gravity, changes in speed, and rotation
Age changes with eyes
Decreased:
transparency of the cornea
accommodation and dark adaptation
Difficulty in focusing on near objects
Endocrine changes with age
atrophy of certain glands (eg, pituitary, thyroid, thymus)
parathyroid hormone, atrial natriuretic peptide, norepinephrine, baseline cortisol, erythropoietin
Decreased:
growth hormone, dehydroepiandrosterone, testosterone, estrogen
Changes in target organ response, organ system homeostasis, response to stress, functional capacity
Age changes with immune system
Increased:
autoimmune syndromes
monoclonal gammopathies
reactivation of latent infections
systemic chronic inflammation
Decreased:
vaccine responses
fever response to infection
response to new pathogens
T lymphocytes, natural killer cells, cytokines needed for growth and maturation of B cells
Age changes with muscle
Decreased:
muscle mass
tone and contractility
strength
Biomarker: grip strength
age changes with nervous system
Decreased:
muscle innervation
fine motor contro
Age changes with skin
Decrease elasticity - delayed skin tugor
Age changes in renal system
Decreased:
concentrating ability of kidney
renal clearance of drugs, toxins
ability to resorb glucose
The brain commonly shows volume loss, microvascular changes in white matter, reduced cerebral blood flow, increased permeability of the blood-brain barrier, reduced glucose uptake and utilization, and accumulation of amyloid plaques.
What is most common causes of mobility, functional decline in older adults
Sarcopenia, the geriatric syndrome of reduced skeletal muscle mass and strength, is one of the most important causes of mobility decline, functional decline, and loss of independence in older adults.
Bone mass (or density) is lost with aging, especially in women after menopause, and bones become more brittle.
What is presbycusis
Significant age-associated hearing loss is termed presbycusis
Selection, Optimization, and Compensation model (SOC)?
As individuals age, and realize that their resources, including both cognitive and physical energy, may be limited, they adapt by selecting what is important, optimizing function, and compensating as needed so that desired activities can still be enjoyed.
Example:: enjoy gardening, but have difficulty kneeling or standing outside for long periods of time, can compensate by taking more breaks or working in shorter blocks of time, by reducing the size of the garden, or by moving some gardening indoor
Four guiding ethical principles of American medical practice
respect for autonomy, nonmaleficence, beneficence, and justice.
What is beneficence
Doing good to someone
What is nonmalfience
Doing no harm
How to determine medical capacity
What is your main medical problem right now?
What treatment has been recommended?
If you receive this treatment, what will happen?
If you don’t receive this treatment, what will happen?
Why have you decided to/not to receive this treatment?
Doctrine of double effect
Under this doctrine, if a procedure has both potentially good and bad effects, it can be justified if the action itself is good, if the intent is for the good effect, and if the good effect is not achieved through the bad effect.
The double effect would ethically justify prescribing large doses of opioids if the clinician’s primary intent was for patient comfort and if suppressing respiration was not essential to provide comfort.
substituted judgment standard versus best interest standard,
- Knows patient wishes and fulfills them
- Doesn’t know wish and makes best decision in interest of patient
Medicare Part A
inpatient hospital, subacute skilled-nursing home, home health, and hospice services.
Medicare Part B
covers physicians, nurse practitioners, social workers, psychologists, therapists, laboratory tests, home health services, and durable medical equipment.
Medicare Part D
covers some of the cost of prescription medications.
Medicaid
is a joint federal and state program that provides health insurance to people of all ages who have low incomes and limited savings. Medicaid will pay for long-term custodial care in nursing homes for patients who reach a “spend down” threshold.
Veterans eligible for care from the Veterans Administration health system receive comprehensive care benefits that cover inpatient, outpatient, and pharmacy needs. Receipt of veteran care benefits does not preclude veterans from receiving Medicare or Medicaid benefits if otherwise eligible.
Medicare c
Part A and B services delivered through private managed care plans
Additional services (eg, vision, dental, wellness) may be included
Prescription drug coverage may be included
MA plans (eg, HMOs [most common], PPOs, POS, PFFS, PSO, SNP, MSA)
What is Medicare
is a federal insurance program run by CMS, which pays health professionals and organizations to provide health care for Americans who are ≥65 years old, disabled, or have end-stage renal disease. A
Who is eligible for Medicare A & B
Older Americans (and their spouses) who have had Medicare taxes deducted from their paychecks for at least 10 years are entitled to coverage through Part A without paying premiums. Others may be able to purchase Part A coverage, for up to $458 per month in 2020 depending on how long Medicare taxes were deducted from their paychecks.
Medicare Part B uses other regional insurance companies (“carriers”) to pay physicians, nurse practitioners, social workers, psychologists, rehabilitation therapists, home-care agencies, ambulances, outpatient facilities, laboratory and imaging facilities, and suppliers of durable medical equipment for the Medicare-covered goods and services they provide.
At age 65, older adults become eligible for Part B coverage if they are entitled to Part A coverage and if they are citizens or permanent residents of the US. To obtain this coverage, eligible older adults must enroll in Part B and pay premiums, usually by agreeing to have these amounts deducted from their monthly Social Security checks.
Medigap
Fill some of the holes in the insurance coverage provided by Medicare Parts A and B. Private insurance companies offer Medigap plans
Within 6 months of their initial enrollment in Medicare Part B, beneficiaries are entitled to purchase any Medigap policy on the market at advertised prices. This is referred to as the Medigap open enrollment period and is the only open enrollment available for this coverage. After this period, Medigap insurers can refuse to insure individual beneficiaries or can charge them higher premiums because of their past or present health problems.
Neither Part A nor Part B of the Medicare program covers long-term care, homemaking services, driving safety evaluations, routine dental or foot care, hearing aids, eyeglasses, orthopedic shoes, cosmetic surgery, or care in foreign countries.
Resilience
the ability to adapt to change and adversity and to recover from stressors—is a key concept in healthy aging and can be conceptualized across physical, psychological, and social domains.
Interventions to Build Resilience
Develop personal attributes, eg, vigor, optimism, physical robustness
Improve socialization
Strengthen self-efficacy, self-esteem, and motivation
The processes involved in fostering cognitive decline are
&disease that increase risk of dementia
oxidative stress, inflammation, and glucose and lipid dysregulation
diabetes, midlife hypertension and obesity, depression, physical and cognitive inactivity, and smoki
best studied intervention to prevent or slow functional decline
Physical activity is the best studied intervention to prevent or slow functional decline, and engaging in regular physical activity is the most effective strategy we have to prevent loss of physical function in aging
Major risk factors for sarcopenia
Age & sedentary lifestyle
CVD is the leading cause of morbidity and mortality
AGS Framework for Promoting Healthy Aging by Level of Prevention 5 domains
promoting health, preventing injury, and managing chronic conditions; 2) optimizing cognitive health; 3) optimizing physical health; 4) optimizing mental health; and 5) facilitating social engagement
Primary secondary and tertiary prevention examples
- Primary - Maintain healthful balanced nutrition, Avoid tobacco, Avoid recreational drugs or excess alcohol, Maintain sleep hygiene, Maintain ideal body weight.Practice oral hygiene, Manage stress, Engage in lifelong intellectual pursuits, Participate in enriching social activities
- Secondary - Diabetes treatment, Ischemic heart disease treatment, Early detection of sensory impairment, Caregiver education Fall prevention programs, Osteoporosis screening and management, Dental examinations, Osteoarthritis management
- Tertiary - Rehabilitation services, Use of adaptive equipment, Palliative care, Environmental modification, Elder abuse screening, Accessible family and social supports, Senior safety services
Comprehensive geriatric assessment (CGA)
Multidimensional, multidisciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older adults with frailty
How to screen for vision loss
brief performance-based screen can be accomplished by asking an older adult to read (using corrective lenses, if applicable) a short passage from a newspaper or magazine (SOE=C).
Significant visual impairment can be confirmed through use of a Snellen chart or Jaeger card; visual acuity worse than 20/40 is the standard criteria for visual impairment.
Referral to opthomology
Testing/screening for hearing loss in older adults
Older adults who acknowledge hearing loss (in the absence of cerumen impaction) should be referred directly for formal audiometric testing. For those who deny hearing loss, further screening with the whisper-voice test is indicated (SOE=B). Inability to perceive a letter/number combination whispered at a distance of 2 feet is considered abnormal and warrants a discussion about referral for formal audiometric testing.
Nutrition concern
Unintentional weight loss of ≥5% in 6 months or a low BMI (<20 kg/m2) suggests poor nutrition and requires further evaluation (SOE=A).
Screening for cognitive defect age/group
a brief cognitive screen should be included in the assessment of all older adults, especially those ≥75 years old (SOE=C).
First type of memory loss in dementia
short-term memory loss is typically the first sign of dementia
Best single screening question for cognitive defect
single screening question is recall of 3 words after 1 minute.
Or
Mini-Cog: recall = 0 or recall <3 and abnormal clock drawing test
Formal testing of cognition are
- Montreal Cognitive Assessment (MoCA) or Saint Louis University Mental Status Examination (SLUMS).
The MoCA, which also assesses concentration, language, and orientation, takes about 10 minutes to complete.
The total possible score is 30 points; a score ≥26 is considered normal.
The SLUMS takes about 7 minutes to complete. The total possible score is 30 points; a score ≥27 is considered normal. Regardless of the instrument used, the results of cognitive testing should be interpreted in the context of the patient’s educational attainment and literacy.
Screening test for depression
Screen with PHQ-2
Answers “Yes” to either of the following (PHQ-2):
In the past month, have you often been bothered by:
feeling down, depressed, or hopeless?
having little interest or pleasure in doing things?
Administer a validated depression scale, eg, 15-item Geriatric Depression Scale or 9-item Patient Health Questionnaire.
Self-care ADL with the highest prevalence of disability, and needing assistance is often the reason for home aide services (SOE=A).
Bathing
How to identify patients with preclinical disability
To identify patients with “preclinical” disability, ie, those who do not yet require personal assistance but who are at risk of becoming disabled, clinicians should ask about perceived difficulty with tasks and whether the individual has changed the way he or she completes a task because of a health-related problem or condition (SOE=A).
Examples of ADLs
Basic ADLs (self-care)
Bathing
Dressing
Transferring from bed to chair
Toileting
Grooming
Feeding oneself
Examples of IADLS
Using the telephone
Preparing meals
Managing household finances
Taking medications
Doing laundry
Doing housework
Shopping
Managing transportation
What typically causes and acute decline in functional status
usually precipitated by illness or injury. Most such new disability episodes lead to hospitalization - Most older adults who become newly disabled recover independent function within 6 months. And higher risk of disability
How often should you screen for falls
Annual screening for falls and fall risk is recommended because older adults may not spontaneously mention falls
How to evaluate mobility
he clinician should first ask the patient to stand from a seated position in a hard-backed chair while keeping his or her arms folded. Inability to complete this task suggests leg (quadriceps) weakness and is highly predictive of future disability (SOE=A). Once the person is standing, he or she should be observed walking back and forth over a short distance, ideally with the usual walking aid. Abnormalities of gait include path deviation; diminished step height or length, or both; trips, slips, or near falls; and difficulty with turning.
The “Timed Up and Go” (TUG) test comprises the actions of rising from the chair, walking 10 feet (3 meters), turning around and returning to the chair, turning again, and then sitting back down in the chair. In individuals who take >12 sec, the risk of falls is increased, and further evaluation is required (SOE=B).
Gait speed is the single strongest predictor of future disability and death (SOE=A).
A gait speed of 0.8 meters/sec allows for independent ambulation in the community; a speed of 0.6 meters/sec allows for community activity without use of a wheelchair. These norms indicate that older adults who can walk 50 feet in an office hallway in ≤20 sec should be able to walk independently in normal activities.
4 stage balance test
Balance can be tested progressively by asking the older adult to stand first with his or her feet side by side, then in semi-tandem position, and finally in tandem position. Difficulty with balance in these positions predicts an increased risk of falling (SOE=A
Driving risk for older adults.
the number of crashes per mile driven and the likelihood of serious injury or death are higher than for any age group other than those 16–24 years old (SOE=A).
Risk factors for automobile accidents in older adults
poor visual acuity (worse than 20/40) and contrast sensitivity; dementia, particularly deficits in visual-spatial skills and visual attention; impaired neck and trunk rotation; and poor motor coordination and speed of movement
Risk of driving cessation in older adults
recommendations to stop driving should not be proffered lightly because driving cessation can lead to a decreased activity level and increased depressive symptoms
Polypharmacy, which is very common in older adults, can be the cause of many adverse reactions and result in hospitalizations and increased morbidity
Table 3—NURSE Mnemonic for Expressing Empathy
Technique
Example phrases
Name the emotion
“This news looks like it made you sad.”
“You look surprised by this news.”
Understand
Attempt to understand where the emotions are coming from
“If I understand what you are saying, you are worried what this news means for your family.”
“What upsets you most about this?”
Respect
Respect patient/caregiver experience and emotional response
“I am so impressed with the strength you have shown dealing with this illness.
Support
Express support and create a partnership
“We will be here for you and your mother no matter what the future has in store.”
Explore
Explore the emotion further
“Could you say more about what you mean when you said…”
“Tell me more.”
Five distinct domains have been identified as relevant to the care of older adults with multimorbidity:
considering patient preferences, interpreting the evidence, formulating a prognosis, determining clinical feasibility, and optimizing therapies and care pl
CARDIOVASCULAR DISEASE IS LEADING CAUSE OF DEATH IN WOMEN. Increased risk in lesbian women why
Increased rate of smoking - twice as likely to report being heavy smokers & higher BMI’s.
3 times higher risk of CVD in women with BMI > 29 kg/m2.
When should you complete osteoporosis screening in transgender adults.
After age 65 to any transgender older adult, while those who have completed gonadectomy without hormone replacement may need screening sooner
Greatest group at risk for HIV infection
Gay, bisexual, and other MSM remain the group at greatest risk of acquiring HIV infection, with MSM >50 years old accounting for over half of all new HIV infections.
Older adults who are of racial or ethnic minorities appear to be at greater risk of death from HIV infection/AIDS (SOE=A).
According to CDC guidelines, sexually active MSM who engage in high-risk sexual behavior should be routinely assessed for gonorrhea, chlamydia, syphilis, herpes simplex virus, and human papillomavirus.
Importance of Gait speed and survival
Gait speed, which reflects walking activity, was shown in an analysis of 9 cohort studies to predict survival as well as a number of other clinical factors, including age and chronic disease (SOE=A).
Regular physical activity in adults improves ?
Regular physical activity reduces risk of what?
cardiorespiratory and muscular fitness
It reduces the risk of many diseases, including coronary heart disease, stroke, hypertension, some lipid disorders, type 2 diabetes, colon cancer, breast cancer, osteoporosis, and depression, risk of unhealthy weight gain and assists in weight loss
Recommended activity for older adults
Moderate intensity aerobic physical activity for 150 minutes a week. (5-6 point scale out of 10). Should be able to talk but not sing or feel breathe less.
vigorous-intensity activity for at least 75 minutes each week (7-8)
Engaging in a combination of moderate- and vigorous-intensity activity is also acceptable. Every 2 minutes of moderate-intensity activity counts the same as 1 minute of vigorous-intensity activity
well as muscle-strengthening activities involving major muscle groups twice per week
Balance therapy (tia chia)
How to avoid activity - related injuries.
Appropriate pre-participation screening and gradual progression of strength training exercises are the most important recommendations for avoiding activity-related injuries. The risk of injury is directly related to the size of the gap between a person’s usual level of activity and his or her new level of activity.
What type of activity is recommended in patients with obesity osteoarthritis or balance problems
aerobic and resistance exercise using water or other low-impact options.
What is lag time & how to use for preventive measures
If the lag time to benefit from a preventive health intervention (ie, the amount of time between undergoing an intervention until benefit) is greater than the individual’s remaining expected life span, then the preventive health measure is not indicated.
Screening recommendations for older adults - when to do for >10 year life expectancy or 5-10; mod dementia or end of life
Mammography -Every 2 years if <75 years old; consider stopping if ≥75 years old
Pap smear - Stop at @ 65
PSA antigen - Consider discussing pros/cons if remaining life expectancy >10 years; stop at age 70
Colon cancer - Fecal occult blood test or fecal immunochemical test & Colonscopy (every 10 years)- Yearly up to age 75, stop at age 86, shared decision-making ages 76–85 - if 5-10year life expectancy
Lung CA screening - Consider annually in those at riskd, stop at age 80 or adult has not smoked for >15 years; 5-10 YR expectancy - Consider in those at riskd, stop at age 80 or adult has not smoked for >15 years`
DEXA screening for osteoporosis - At least once after age 65 in women, or age 60 if high risk; consider if 5-10 year life expetancy if not already done
None of above recommended in mod dementia or end of life or 5-10 year life expectancy except lung CA screening
Diabetes screening
Thyrotropin
Ultrasonography for abdominal aortic aneurysm
Cholesterol
HIV, HEP B/C
40–70 years old who are overweight or obese every 3 years with fasting plasma glucose, hemoglobin A1c (HbA1c), or oral glucose tolerance test and implementing lifestyle changes (healthy diet, physical activities) in those with abnormal blood glucose (SOE=B). - stop after age 70
Consider in all age/patient population
Once for men 65−75 years old who ever smoked; consider in men who never smoked
Screen to allow for risk assessment and shared decision-making
High risk individuals
Immunization recommendations
1. Influenza
2. Pneumococcal
3. Tetanus
4. Herpes zoster series
Annually - in everyone
Once after age 65
Booster every 10 years - not recommended in end of life
Once after age 50
Aspirin prevention recommendations
Not recommended in adults ≥70 years old. Consider in those 50–59 years old with >10% risk of cardiovascular disease; shared decision-making for men 60–69 years old
No recommended in 5-10 life expectancy, mod dementia or end of life
Vitamin d and calcium supplementation
Consider vitamin D at 1,000 IU with calcium at 500–1,200 mg/d in adults ≥65 years old
women 50–74 years old participating in the mammography screening trials found that on average it takes approximately 10 years before one death from breast cancer is prevented for 1,000 women screened
Should you teach self breast examinations
The USPSTF found insufficient evidence to recommend for or against clinical breast examinations (CBEs) and recommends against teaching breast self examination (BSE), because BSE may lead to unnecessary biopsies and is not associated with a survival benefit
Thyroid disease - sub clinical hypothyroidism
Subclinical hypothyroidism - asymptomatic condition which serum TSH is upper threshold but normal T4. However, TSH levels rise with age, fluctuate, and are sensitive to acute illness and certain medications.
Based on expert opinion, a TSH level >10 mIU/L (on two separate occasions 6–12 months apart) is generally considered the threshold for initiating treatment.
Hypertension recommendation in older adults
Other society guidelines continue to recommend a target BP of 150/90 mmHg in adults ≥ 60 years old.
When to use statin therapy
high-intensity statin therapy is generally recommended for adults with LDL-C ≥190 mg/dL. In addition, the ACC/AHA 2019 guidelines recommend a high-intensity statin for adults with >20% risk 10-year risk. These guidelines consider adults with ≥7.5%–20% risk as being at intermediate risk and recommend consideration of moderate-intensity statins after a risk discussion
TB testing in elederly
For all new residents and employees of long-term care facilities, the CDC recommends screening with the two-step Mantoux test unless these individuals have documentation of a previous positive reaction. The CDC also recommends a chest radiograph of all persons with a reaction >10 mm to identify current or past disease.
Core domains of comprehensive geriatric assessment
functional status, mobility, gait speed, cognition, mood and emotional status, nutritional status, comorbidities and polypharmacy, geriatric syndromes (fall risk, delirium, incontinence, dentition, vision/hearing impairment), social and financial status, goals of care, and advanced care planning.
How often should you screen for falls.
Annually
The USPSTF recommends exercise interventions for community-dwelling adults ≥65 years old who are at increased risk of falls, with high risk defined by history of falls and/or problems in physical functioning and limited mobility (SOE=A). The USPSTF recommends individualized decision-making in offering these other interventions and recommends against vitamin D supplementation for fall prevention in older adults without osteoporosis or vitamin D deficiency.
When do you recommend Aspirin use for CVD prevention
Therefore, the ACC/AHA now state that aspirin should not be used in the routine primary prevention of CVD.
USPSTF recommends aspirin in adults 50–59 years old with ≥10% 10-year CVD risk, and individualized decisions in adults 60–69 years old with ≥10% 10-year CVD risk
