Geriatrics

Question 0

And 88-year-old male has been hospitalized for the past three days after being found on the floor of his home by a neighbor. He was cachectic and dehydrated at the time of admission, with a serum albumin level of 1.5, normal is 3.5 to 4.7. He has received intravenous fluids and is now euvolemic. He began nasogastric tube feeding two days ago and has now developed nausea vomiting hypotension and delirium. What is going on here, and what are the classic electrolyte problems associated with this condition?

Answer 0

This is refeeding syndrome. It can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding. The shifts result some hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature every feeding syndrome is hypophosphatemia. However the syndrome is complex and may also include abnormal sodium and fluid balance, changes in glucose protein and fat metabolism, thiamine deficiency, hypokalemia, and hypomagnesemia.

Question 1

What are the benefits of placing a percutaneous endoscopic gastrostomy or PEG tube?

Answer 1

Apparently none. PEG tubes are not shown to improve nutritional status, quality-of-life or risk of aspiration pneumonia. There may be some decreased risk of aspiration if the tube is placed below the gastroduodenal junction. Feeding tubes can also cause discomfort and agitation.

Question 2

What is a “timed up-and-go” test? What do its results mean?

Answer 2

Pt is asked to rise from a chair without using his arms, walk three meters, turn and sit back down in chair.

Time more than 14 secs is assoc’d with increases fall risk and >20 secs suggests severe gait impairment

Question 3

Gait abnormality assoc’d with visual impairment

Answer 3

Abducted arms and legs; slow, careful “walking on ice” movements, a wide-based stance and en- bloc turns.

Question 4

Gait abnormality assoc’d with cerebellar degeneration

Answer 4

Wide-based, ataxic, staggering

Question 5

Gait abnormality assoc’d with frontal lobe degeneration

Answer 5

“Magnetic” gait with start and turn hesitation and freezing.

Question 6

Gait abnormality assoc’d with Parkinsonism

Answer 6

Short-stepped shuffling gait, with hips knees and spine flexed. May exhibit festination and en bloc turns.

Question 7

Gait abnormality with motor neuropathy

Answer 7

“Steppage” gait with excessive flexion of hips and knees, short strides, foot slapping and frequent tripping.

Question 8

What is the average life expectancy in the US for men and women?

Answer 8

77 for men and 80 for women

Question 9

What is the life expectancy at age 65 for men and women?

Answer 9

17 years for men and 20 for women

Question 10

What is the life expectancy for men and women at 75?

Answer 10

11 years for men and 13 years for women

Question 11

What is the life expectancy for men and women at 85?

Answer 11

Six years for men and seven years for women

Question 12

What is the life expectancy at 100 for men and women?

Answer 12

Two years for men and three years for women

Question 13

What is the minimal nutrition requirements for an older person in order to maintain weight?

Answer 13

.6 to .8 g of protein per kilogram per day. Fat and cholesterol level should not fall below 10% of the total calories in order to get fat-soluble vitamins. There should be 50 to 100 g per day of carbohydrates in order to prevent ketosis.

Question 14

What is a comprehensive geriatric assessment? What are its components?

Answer 14

It is an overall a valuation of the health and status of an elderly patient. It is a process intended to determine the patient’s medical, psychosocial, and functional capabilities and limitations.

It should include an assessment of cognitive function, affective disorders, sensory impairment, functional status, nutritional status, mobility, social support, physical environment, caregiver burden, health-related quality-of-life, and spirituality.

Question 15

What is the definition of blindness?

Answer 15

Visual acuity of 20/200 or worse

Question 16

What are the risk factors for cataracts?

What percentage of people over age 65 have cataracts? What percentage of people over age 75 have cataracts?

Answer 16

Age, smoking, steroid use, diabetes, UVB exposure and alcohol use

20% of people over age 65 and 50% of people over age 75 have cataracts.

Question 17

What are the risk factors for age-related macular degeneration?

Answer 17

Genetic predisposition, age, smoking, high blood pressure, and fair skin.

Question 18

What are the first and second most common causes of blindness worldwide?

Answer 18

First is age-related macular degeneration, and second is glaucoma.

Question 19

What percentage of people from 65 to 75 have hearing impairment? What percentage of those over 75 have it?

Answer 19

10% from 65 to 75, and 25% of those over 75.

Question 20

What percentage of community dwellers over age 65 fall each year?

Answer 20

30 to 40%

Question 21

What demographic has the highest death rate from falls?

Answer 21

White men over age 85

Question 22

What percentage of fractures in people over 75 are upper versus lower extremity?

Answer 22

Lower extremity fractures are two times as common as those of the upper extremity.

Question 23

Define primary versus secondary osteoporosis.

Answer 23

Primary occurs in association with menopause or aging. Secondary is due to conditions other than aging or menopause.s

Question 24

What are the secondary causes of osteoporosis?

Answer 24

Hypogonadism, hyperthyroidism, hyperparathyroidism, Cushing’s; multiple myeloma, lymphoma, leukemia, mastocytosis; malabsorption, small bowel resection,gastrectomy, anorexia nervosa; anticonvulsants, glucocorticoids, methotrexate, cyclosporin A, excess thyroxine; smoking, alcohol; renal failure, renal tubular acidosis; osteogenesis imperfecta, rheumatoid arthritis, Marfan’s, Ehlers Danlos.

Question 25

What is the most common fracture due to osteoporosis?

Answer 25

Vertebral, with the lower thoracic and upper lumbar vertebrae being the most common.

Question 26

Briefly, what is the clinical appearance of a patient with a hip fracture?

Answer 26

The involved limb may appear shorter and be externally rotated.

Question 27

What are the WHO diagnostic criteria for normal bone density, osteopenia, and osteoporosis?

Answer 27

Normal is a bone mineral density within one standard deviation of mean for a young adult or a T score of greater than or equal to -1.

Osteopenia is a bone mineral density value between -1 and -2.5 standard deviations below the mean for a young adult or a T score of -1 to -2.5.

Osteoporosis is a bone mineral density of at least -2.5 standard deviations below the mean for a young adult or a T score of less than or equal to -2.5.

Question 28

What are the prescription medications used to treat osteoporosis?

Answer 28

Bisphosphonates: alendronate or Fosamax, risedronate or Actonel, Ibandronic acid or Boniva.

SERMs or selective estrogen receptor modulators such as the raloxifene.

Estrogen can be used but its risks typically outweigh its benefits.

Calcitonin is used at times in the acute phase of treatment of a fracture. It reduces the number of osteoclasts. It is expensive and long-term probably not as efficacious as other methods.

Teriparatide or Forteo is a synthetic parathyroid hormone. It builds bone but it is very expensive. Injectable only.

Denosumab or Prolia iis it is an RANK ligand inhibitor which blocks osteoclast formation.

Testosterone may be considered in hypogonadal males.

Question 29

What percent of people over 65 have urinary incontinence?

Answer 29

15 to 30% of those in the community. At least 50% of patients in long-term term care are incontinent.

Question 30

Are women or men more affected by urinary incontinence?

Answer 30

Women are more affected by 2/1 until age 80, after which men and women are equally if that affected.

Question 31

What are the risk factors for urinary incontinence?

Answer 31

Advanced age, parity, depression, cerebrovascular disease, heart failure, fecal incontinence, constipation, obesity, COPD, chronic cough, diabetes, impaired mobility, impaired ADLs.

Question 32

What are the causes of detrusor inactivity leading to overflow incontinence?

Answer 32

Neurologic causes: peripheral neuropathy from diabetes, alcoholism or B12 deficiency; damage to the spine afferents by disc disease, tumor, spinal stenosis or neurologic disease.

It may also be intrinsic due to fibrosis from chronic outlet obstruction.

Question 33

What are the causes of outlet obstruction of the bladder?

Answer 33

It is the second most common cause of urinary incontinence and older men. However most obstructed men are not incontinent. It may be caused by benign prostatic hypertrophy, prostate cancer or stricture. In women it is usually from incontinence surgery.

Question 34

What are the medications used to treat urge incontinence?

Answer 34

Oxybutynin or Ditropan, tolterodine or Detrol, trospium or Sanctura, darifenacin or Enablex, solifenacin or Vesicare, and fesoferodine or Toviaz.

Question 37

According to the Beers criteria what NSAID should be avoided in older patients due to its higher rate of adverse CNS effects?

Answer 37

Indomethacin

Question 38

What are the risk factors for death caused by heat wave in an elderly person?

Answer 38

Being confined to bed, not leaving the house daily, being unable to care for oneself. Medical conditions include pre-existing psychiatric illnesses followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease.

Question 64

What are the normal cardiovascular changes that are associated with aging?

Answer 64

Decreased cardiac output, decreased maximum heart rate, and decreased stroke volume as well as increased systolic and diastolic blood pressure.

Question 65

What are the normal respiratory changes associated with aging?

Answer 65

Increased residual lung volume and decreased vital capacity

Question 66

Who should be screened for osteoporosis?

Answer 66

All women greater than equal to 65 years old and all men greater than equal to 70. For men and women ages 50 to 69, the presence of risk factors associated with low bone density would merit testing. These include low bodyweight, previous fracture, family history of osteoporosis with fracture, history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions.

Question 67

What are potential risk factors for Alzheimer’s disease?

Answer 67

Age and family history are the two greatest risk factors. The presence of apolipoprotein E or APOE gene on chromosome 19 increase increases the risk for Alzheimer’s. Other possible risk factors include previous head injury, female gender, and less education.

Question 68

What is tachyphemia?

Answer 68

Running all the words together as you speak. This is one of the signs of Parkinson’s.

Question 69

What is hypomimia?

Answer 69

Sad or masked facies. One of the possible signs of Parkinson’s.

Question 70

What conditions may mimic Parkinson’s disease?

Answer 70

Multiple system atrophy or MSA, progressives supra nuclear palsy or PSP, senile chorea, drug induced movement disorders, and essential tremor.

Question 71

What is multiple system atrophy?

Answer 71

It is a spectrum of diseases that includes olivopontocerebellar atrophy, Shy-Drager syndrome, and Striatonigral degeneration.

Symptoms include all of those of Parkinson’s with the additional symptoms of autonomic dysfunction, cerebellar signs, and sometimes myoclonus.

Question 72

What is progressive supranuclear palsy?

Answer 72

It is a degenerative disease, usually with onset in the late 50s. It accounts for 4% of cases of parkinsonism. There is a rapid progression within 3 to 5 years with marked incapacity and death within 10 years. there is a limitation of voluntary gaze.

Question 73

What is senile chorea?

Answer 73

It is a condition that occurs in people 60 and older. It involves involuntary complex movements of the face,mouth and tongue. It is not associated with Huntington’s or mental disturbance.

Question 74

What are the features of essential tremor?

Answer 74

It is the most common form of tremor. It is an action tremor. The arms head and voice are most commonly involved. Prevalence increases with age. there are familial forms linked to chromosomes 2p and 3q.

Question 75

Describe Medicare parts A through D

Answer 75

Part A is free and covers inpatient costs, nursing facilities, home healthcare, and hospice care. Part B requires a premium payment and covers outpatient care, x-rays, and lab work. Part C, or Medicare advantage, covers enrollment in HMOs or PPOs if they are approved. Part D is the Medicare prescription drug benefit.

Question 76

What are the drugs of choice in elderly people for depression?

Answer 76

Sertraline and citalopram. This is because they are less likely to interact with other drugs than alternative selective serotonin reuptake inhibitors such as fluoxetine and paroxitine.

Question 77

If an older adult does not respond well within two months to a combination of counseling, increased social interaction and a drug such as citalopram or sertraline, what would be the next drug that should be added?

Answer 77

Bupropion

Question 78

What is the quickest way to screen for cognitive deficits in older adults?

Answer 78

Ask for three word recall at one minute in combination with asking the day of week, month and year. Three or more wrong answers is 90% specific for dementia.

Question 79

In regards to extraordinary care and end-of-life, what are the five wishes?

Answer 79

One. Who do you want to make healthcare decisions for you when you can’t?
Two. What kind of medical treatment do you want or want to specifically decline?
Three. How comfortable do you want to be?
Four. How do you want people to treat you?
Five. What do you want your loved ones to know?

Question 80

What percentage of individuals older than 65 years are cared for in long term care facilities?

Answer 80

5%

Question 81

How long should it take an 84-year-old women to walk a 6 m course if she is not at increased risk for hospitalization?

Answer 81

Six seconds or less.

Question 82

Is past cigarette use a risk factor for osteoporosis?

Answer 82

No, only current use.

Question 83

What questionnaire is recommended for screening older adults for alcoholism?

Answer 83

The short Michigan alcoholism screening test – geriatric version or the SMAST – G.