Geriatrics Flashcards
Primary aging
changes in physiologic reserves over time that are independent of and not induced by any disease
More likely in periods of stress (temp, dehydration, shock)
Optimal aging
Occurs in people who escape debilitating disease entirely and maintain healthy lives late into their 80s and 90s.
Usual Aging
Occurs in people who have aged and experienced illness
Factors that influence living to 100
genes- 20%
healthy lifestyle- 20-30%
Blood Pressure
Systolic Raises over time
Aorta and large arteries become atherosclerotic
Diastolic stops rising at the 6th decade
Orthostatic Hypotension in elderly
Heart rate and rhythm
Resting heart rate remains unchanged
Pacemaker cells decline in the SA node
As does maximal heart rate
Response to physiologic stress decreases
Respiratory rate and temp
RR is unchanged
Inc susceptibility to hypothermia
Skin, Hair and Nails
Paler, wrinkly, opaque skin with decreased tugor and vascularization
Actinic Purpura – purple patches that fade over time, comes from poor capillaries with blood diffusion
Actinic Keratoses (face and hands and feet)
Seborrheic Keratoses
Nails yellow and thicken, especially on toes
Hair things, grays and decreases in quantity
Hairloss is genetically determined
55 yo+ women = facial hairs appear on the chin and upper lip
Head and Neck
Decreased salivary secretion and sense of taste with aging
Meds contribute a lot to changes
Decreased olfaction and increased sensitivity to bitterness and saltiness can contribute to decreased taste
Angular Chelitis – overclosure of the mouth may lead to maceration of the skin at the corners
Eyes
Eye fat cushions atrophy
Pupils are smaller and sometimes irregular
Visual acuity diminishes gradually until approx. 70 tears and then more rapidly
Near vision begins to blur
Elasticity loosens
Presbyopia = by 5th decade
Inc risk for cataracts, glaucoma, macular degeneration
Thickening and yellowing of lense = less light to retina = more light needed for reading
Lens grows and pushes iris forward and inc risk for narrow angle glaucoma
Ears
Young adulthood = loss of high pitched sounds
Presbycusis = hearing loss assc with aging
Lungs and Thorax
Capacity for exercise decreases Chest wall becomes stiffer and harder to move Resp muscles may weaken Lungs lose some elastic recoil Lung mass declines Residual volume increases Speed to breathe out diminishes Cough is less effective Kyphosis common Osteoporotic vertebral collapse and increasing the anteroposterior diameter of the chest
CV
Aging affects neck sounds and adds to significance of extra heart sounds like S3 and S4
Torturous aorta can increase jugular venous pressure due to inefficient draining
Systolic bruits heard in the middle or upper portions of the carotid arteries suggest, but do not prove, partial arterial obstruction from atherosclerosis.
After age 40, S3 strongly suggests CHF from volume overload of the left.
4th heart sound= decreased ventricular compliance and impaired ventricular filling. Common in young athletes
Middle-aged and odler adults commonly have a systolic aortic murmur.
Aortic sclerosis - tube
Aortic Stenosis – valve
Mitral regurg happens about 10 years after aortic
Peripheral Vascular
Peripheral arteries tend to lengthen and become torturous
Breast and axilla
Soft granular nodular lumpy
Glandular tissue diminishes and becomes fat
Proportion of fat increases, amount decreases.
Axillary hair diminishes
Male and Female Genitalia, Anus, Rectum, Prostate
Sex interest intact, but frequency diminishes
Erections become more dependent on tactile than erotic cues
Testicles drop lower
Penis decrease sin size
50% older population have erectile dysfunction
BPH in third decade to 7th. Due to androgens
MSK
intervertebral discs become thinner and the vertebral bodies shorten or collapse
Nervous System
Brain volume, number of cortical brain cells decrease, microanatomical and biochemical changes
Older patients are more susceptible to delirium, a temporary state of confusion that may be the first clue to infection or problems with medications
Atrophy of interosseous muscles – first in thumb/first finger
Benign essential tremors = slightly faster and diminish at rest
Reflexes diminish over time, less likely – knee
If assc with other neuro deficits, investigate more
Adjusting the Office Environment
temp regulation brighter light face patient directly quiet room no distrations pocket talker for amplified voice
Shaping the Content and Pace of the Visit
listen to reflections of the past, can be helpful and help them too
assess fatigueuse brief screening tools
Eliciting Symptoms in the Older Adult
Geriatric Conditions – collection of sx/symptoms common in older adults but not specific to dz
Cognitive impairment, delirium, falls, dizziness, depression, urinary incontinence, and functional impairment
Addressing Cultural Dimensions of Aging
Group decision making as opposed to patient autonomy
Common Concerning Symptoms: ADLs
Basic self-care abilities
Do they need help
Bathing Dressing Tolieting, Transferring, Continence, Feeding, Managing Money
Common Concerning Symptoms: Instrumental Activities of Daily Living
Higher function
Do they need help
Using the telephone, shopping, preparing food, housekeeping, laundry, transportation, taking medicine
Common Concerning Symptoms: Medications
80% on at least 1 med 30% 8+ 50% adverse drug rxn inc exercise might be best for insomnia meds most common for fall poly pharm? Keep amount of drugs small
Nutrtion
Underweight = serum albumin for all cause
Chronic dz and poor dentition, oral or GI disorders, depression = undernutrition
Acute and persistent Pain
Pain is subjective
Persistent pain
More than 3 months
•Assc with physiologic or functional impairment
•Can fluctuate in character and intensity over time
•Common cause: arthritis, cnacer, claudication, leg cramps, neuropathy, radiculopathy
Acute
• Distinct onset
• Obviousl pathology
• Duration short
• Common: post sx, trauma headache
Always ask for pain each visit, even mild impairment
Ask caregiver
Assising pain includes comprehensive evaluation of its effects on quality of life, social interactions, and functional level
Engage patient
Smoking and Alcohol
QUIT smoking Detection of alcoholism is low, we need to detect Can exacerbate – cirrhosis, GI bleeding, reflux dz, gout, HTN, DM, nsomnia, Gait disorders, and depression How to detect Memory loos, cognitivie impairment Depression, axiety Neglect of hygiene, appearance Poor appetite, nutritional deficits Sleep disruption HTN refract to therapy Blood sugar control probs Sz refract to therapy Impaired balance and gait, falling Recurrent gastritis and esophagitis Difficulty managing warfarin dosin Use CAGE (2+ = alch)
Advanced Directives and Palliative Care
Providing information Invoking the patients preferences Identifyinf proxy decision makers Conveying empathy and support Encourage EOL care, DNRs, Written health proxy or power of attorney.
When to screen
Base off their circumstances rather than age
Life expectancy, time interval until benefit from screening accrues, and patient preference should be taken into account
If life expectancy is short, give immediate treatment to benefit pt in remaining time
If suffering, avoid more screening, but test for things that can aid prognosis
Vision and hearing
Assess acuity objectively
Ask about hearing loss then do whisper test
Exercise
Regular aerobic exercise to improve strength
Mild 30 mins 5 days per week
Vigor 20 mins 3 days per week
Immunizations
Flu: 50+ yo yearly
Pneumococcal: 65+ yo every 5 years
Zoster: 60+ yo
Household safety
Handrails on both sides of any stairway
Wll lit stairways, paths, walkways
Rugs secured by non-slip backing or adhesive tape
Grab bards and non-slip mat or safety strips in the bath or shower
Smoke alarms and plan of escaping fire
Cancer screening
Breast- Biennially til 75, every 2-3 years if life expectancy is 4 years or more
Cervical- Pap smears every 5 years or 3 years
Colon- Eevry 10 years beginning at 50
Lung cancer and ovarian cancer not recommended
Skin and oral cancer in high risk is okay
Depression
65 yo men = suicide
10 % = depressed
10% of men
20% of women
Dementia and mild cognitive impairment
Slow onset
Mild cognitive impairment (MCI)
Cognitive loss with dementia (mild)
Doesn’t interfere with social or vocational function
Amnestic MCI – memory is affected
Non-amnestic MCI – language or visuospatial function affected
AACI – age assc cognitive impairment
Elder mistreatment
Signs of abuse
Malnutrition
Lymph nodes over time
Palpable cervical nodes gradually dimishes with age and falls below 50% between 50 and 60 years
Submandibular glands are easier to feel
What is the 6th vital sign?
Implement skills directed to function assessment
What do you if your patient is a poor historian?
Ask the patient if it is ok to talk to their family about it
What are geriatric syndromes?
characterized by the interaction and probable synergism among multiple risk factors (falls, dizziness, depression, urinary incontinence, and functional impairment)
What do you ask about in end of life care?
DNR? Identify proxy decision makers Provide info Explore patients preferences Convey empathy and support
What two items do you add to the general assessment for VS?
Pain and functional Assessment
What is functional status?
ability to preform tasks and fulfill social roles associated with daily living across a wide range of complexity
What are types of geriatric screening tools?
physical features
cognitive functions
psychosocial functions
urinary incontinence
How do you screen for dementia?
mini cog
What do you have to make sure to look for in the mouth during a physical exam?
CANCER, under tongue and on the floor
What is the first step for cardio PE on the elderly?
JVP
Where does fat accumulate?
lower abdomen
When looking at an elderly females genitalia, what do you need to look for?
Bluish swelling-possible varicosities
Caruncles-prolapse of fleshy erythmatous mucosal tissue at the urethral meatus
clitorial enlargement
What can you not palpate during a rectal exam?
the anterior median lobes
What is diapers?
Acronym for incontinence
Delirium Infection Atrophic vaginitis/urethritis Pharmaceuticals Excess urine out put Restricted mobility Stool retention
What is ddrriipp?
A look for incontinence
Drug Side Effects Delirium Restricted Mobility Retaining stool Inflammation Infection Psychogenic Polyuria
