Geriatrics #2 Flashcards
Criteria to Define Physical Frailty (pathway of intrinsic physiological alterations)
Lost >10 lb unintentionally in the last year or 5 kg.
Exhaustion
Slowness (time to walk 15 feet)
Low activity level <270kcal/week
Weakness (grip strength unsung hand dynamometer)
syndrome present when >= 3 or more
1 or 2 is considered pre-frail. 4-5 = severe frailty
Sarcopenia
Loss of lean body mass and central manifestation of physical frailty
Early manifestation of frailty
Gait speed with grip strength.
Key management approach for frailty and its prevention
Resistance or strength training
Can combine with protein supplement in patients with weight loss or under nutrition
Afferent pupillary defect
Represents significant vision loss
Swinging flashlight test (both pupils should constrict together, if dilates then +)
Retinal detachment s/s
New floater in one eye, flashing light (photopsias), distorted peripheral vision, decreased vision. “Curtain over vision”.
** not associated with ocular pain or hyperemia
Acute narrow-angle closure glaucoma
Adults >50 years old screen every 1-2 years for glaucoma
Dilated fixed pupil and cloudy cornea
Painful, red eye, decreased vision, nausea and vomiting with headache
*sympathomimetic and anticholinergic drugs can bring this on
Open-angle glaucoma
Loss of peripheral vision and then all vision loss.
Asymptomatic
When to refer to opthomology
Decreased vision (20/40 sellens chart), severe pain, photophobia, recent intraocular surgery or glaucoma surgery
Cataracts
Decrease vision, refractive shifts, reduced contrast sensitivity, glare or diploid.
Educative (wet) macular degeneration
Subretinal gray-green membrane
Sudden loss of vision with central vision loss, peripheral vision is maintained
Nonexudative muscular degeneration
Deposits of submacular yellow druses
Slow vision loss not severe usually asymptomatic
goal is to decrease risk of converting to wet form - vitamin supplements C,E, zinc, lutein
Diabetic retinopathy
Decreased/blurred vision, sudden loss of vision, floaters
Annually exams
Strict glucose control. ACE inhibitors help decrease disease progression
Anterior ischemic optic neuropathy
Acute vision loss or field loss - usually in upper or lower hemifield
Thought to be in atherscoleric disease (diabetes, hypertension) or in giant cell arthritis
*prompt systemic corticosteroid treatment is crucial to avoid vision loss.
Associated with phosphodiesterase inhibitors
Conductive hearing loss
Abnormalities of external and middle ear preventing sound reaching the cochlea
(Cerulean impaction, foreign body, bony overgrowth).
(Middle ear effusion, tympanic membrane perforation, otosclerosis)
Sensorineural hearing loss
Abnormalities of the cochlea, cochlear nerve or cochlear nuclei.
(Excessive noise exposure, ototoxic medications, vascular disease)
Presbycusis
“Old age hearing”
Bilateral sensorineural hearing loss - worse with high frequencies
- early detection the better due to brain losing ability to adapt - get hearing aides fast
Sensory presbycusis versus strial presbycusis vs neural presbycusis
- Steeply sloping audiogram losing higher frequencies - have trouble hearing with background noise
- Mild to moderate hearing loss across spectrum of frequencies - good speech discrimination
- Very poor speech discrimination - recommended cochlear implantation over hearing aides
Ways to screen for hearing loss in the primary care setting
Finger rub test, whisper test, simply asking about hearing loss
If concern for hearing loss what should be first and second step
What is the Weber and Rinne test
Observe for obstruction with cerulean, foreign body’s, TM perforations or fluid in middle ear.
SNHL from CHL testing - tuning fork
Weber test - vibrate on knee or elbow and place on forehead bridge of nose - should hear the sound everyone or in both ears. If symmetrical SNHL normal response or not at all. Unilateral SHNL will hear sound in better ear.
Patients with CHL or MHL will localize to the hearing impaired ear
Rinne test - use tuning fork then place on mastoid bone (sound #1) then external auditory meatus (sound 2).
Normal hearing - sound 2 is louder. SNHL - normal sound. CHL and MHL - sound #1 is louder than sound 2.
Who should manage SNHL and CHL.
Referral to audiologist.
SNHL symmetrical can be treated by PCP, everything else HAS to be referred.
Central presbycusis or age related central auditory processing disorder
Changes to auditory perception and speech communication.
(Inability to understand speech in noisy environment or in presence of competing speech)
Which medications cause reversible or irreversible hearing loss
Lasix, oral salicylates, quinines - reversible
Vancomycin and aminoiglycosides -irreversible
Contraindication for irrigating ear
Ear surgery - tubes, tympanic membrane perforation, chronic otitis
Vertigo
Episodic spinning or rotational senstation
BPPV - associated with changes in head position.
or meniers disease - episodic verigo, tinnitus, fluctuation hear loss or sensation of fullness.
Presyncope
Sensation one is going to pass out. Cerebral ischemia 2/2 to orthostatic hypotension.
Drop in systolic artieral blood pressure of at least 20 mmHG or 10 mmHG in diastolic
Cardiac, dehydration, vasovagal Parkinsonism
Disequilibrium
Imbalance or unsteadiness with walking
Mixed dizziness
Most common type of dizziness with >2 types of dizziness.
How to evaluate for dizziness
Checking orthostatic vital signs - if +, review medications
Evaluate for nystagmus - if present peripehral or central lesion of vestibula
Medications use in dizziness
Therapy for dizziness
Antihistamines (meclizine) - not for chronic or disequilibrium, has anticholinergic properties
Can make dizziness worse if used long term.
Vestibular rehabilitation
Risk with ophthalmic corticosteroids
Ocular hypertension that can lead to glaucoma 2-3 weeks.
Syncope - (sudden loss of consciousness) medication induced
A-blockers, B-blockers, CCB, ACE inhibitors, tricyclic antidepressants
What is a positive postural hypotension
A decrease in systolic BP >20 mmHg.
Techniques to use to increase BP to avoid LOC
Leg crossing, arm tensing, hand grip, buttock clenching
Recommended protein intake
0.8 g/kg/day but 1-1.2 show to protect lean mass, grip strength and reduce risk of functional decline
Recommend intake of vitamin D in >70 years old
1,000 units
What diet is recommended in older adults
Mediterranean diet
Albumin and Prealbumin
Albumin is indication of longer term nutrition
Prealbumin shorter nutrition
Both not accurate in acute settings of inflammation
Risk for morbidity and mortality is albumin
Tool to assess nutrition
Mini-nutritional assessment
What is clinically significant weight loss
10 lbs or >5 % of body weight over 6-12 months
Drugs for appetite stimulant
Little proof to support and often cause many side effects
Do not improve long-term survival
Types of urinary incontinence
Urgency - leakage with urgency
Stress - leakage with effort or exertion - cough running
Mixed - combined stress and urgency
overflow - increased PVR from bladder outlet obstruction
Treatment for urinary incontinence
Bladder training - pelvic floor muscle exercises
Antimuscarinic agents (anticholinergics) - oxybutin - biggest long term risk is cognitive impairment. Dry mouth with Consitpation
Highest cure rate for Urinary incontinence
Surgery
Botox injection can be given but cannot give with urinary retention history
Stage 1; 2;3;4;unstageable and deep tissue
Nonblaanchle erythema
Partial skin loss with explored dermis - blisters
Full thickness - fat agranulation tissue may have slough.
Full thickness - fascia, muscle, tendon, ligament ion exposure
Cannot see what the extent is - unstageable
Persistent non blancable deep red/maroon or purple
When should you not use negative pressure therapy
Over necrotic or infection wounds ; if no improvement in 2 weeks, discontinue
When should you swab a wound
If redness erythema fever, increased drainage - purulent drainage with high suspicion for infection
Types of dressings:
Hydrocolliod
Semipermeable
Hydrogel
Foam
Alginate
Collegian
Silver containing
Honey
1 &2 - Clean wounds with no necrosis (retains moisture)
Dry wounds with some necrosis
Control of extudate to protect the wound
Control of exudate
Partial or full thickness with minimal necrosis
Contract bacteria balance
Debriding agent on non-infected wounds
Fall within the past year is the most predictive risk for future falls
Most modifiable risk factors for falls
Medication use/poly pharmacy
Recommendation for patients with a fall or worried about falling
Older adult with >2 falls or a fall with injury
Gait, strength and balance testing.
Multifactorial fall risk assessment.
Most common used test for strength and balance
Timed get up and go test
Osteoporosis definition
Bone mineral density of T <= -2.5 or minimal trauma fx in patients with osteopenia (t score of <-1.0-2.5)
*lumbar spine, femoral neck, hip or 1/3 radius
Severe osteoporosis is a T score of <2.5 in the presented of >= 1 fragility fracture
Calculate FRAX score in patients with osteoporosis
Risk fractures for osteoporosis
Age
Female
Low body weight
Physical inactivity
Glucosteriods
Asain ro white
Smoker , alcohol use
Low dietary calcium and vitamin d
What hormone does calcium and vitamin D deficiency increase
Parathyroid hormone which increases rate of bone reabsorption
When to screen for osteoporosis risk fractures
All post menopausal women and men >=50 years old
When should you screen for osteoporosis with BMD testing
All women >=65 years old
Or women and men <65 years old with risk fractures or history of fracture.
Screen all men >70 years old.
- uses central bone mineral density testing
FRAX screen
Estimates 10 year probability of fracture at the hip or major osteoporotic fracture.
Prevention of osteoporosis
Excerise 5 times per week for 30 minutes - weight bearing exercises
Calcium intake of 1200 (up to 2500 in heart patients is safe) , VItamin d of 600. 800 over >70.
Keep vitamin D level >30.
Treatment of osteoporosis
All post-menopausal women, or men >50 who have osteoporosis per DEXA or fragility fracture
Osteopenia with fragility fax of >3% OR MAJOR osteoporic fracture >20%
>1 year life expectancy
Start within 14 days of treatment
Biphosphonates - decrease bone reabsorption and bone remodeling.
Alendronate, risedronates
Has poor absorption so must wait 30 minutes before drinking/eating.
Side effects of biphosphonates
GI upset
Osteonecrosis of jaw
Aysptical fractures - get xray if develop groin/hip pain
When do you discontinue biphosphantes
Drug holiday in 5 years at low risk fo fax, >-2,5 or no change on DEXA
Discontinue in elderly if no longer ambulatory or have a <2 year life expectancy
Denosemab —> no drug holiday as bone remodeling reverses after 6 months.
Greastest risk factors for Alzheimer’s disease
Age and family history
What causes dementia
Set of proteins within the brain affect neuronal function causing cell death.
What things can slow cognitive decline
Physical activity and cognitive training
Subjective complaints from patient or family member should be followed with cognitive assessment
What are the screening test for dementia
Mini-cog assessment, SLUMS (st Louis university mental statue), and Montreal cognitive assessment.
When should you order brain imaging on patients concerning for dementia
Not routinely used.
<65 years old, sudden onset or rapid progression, focal deficits, history of fall or recent trauma.
Typical features of Alzheimer’s disease
Slow gradual onset with memory loss.
Stage 3- recognized by family
Stage 4 - medical interviewer can identify.
Stage 6- need help dressing /tolieting etc.
Vascular dementia
Sudden or gradual, areas of ischemia/hemorrhagic, symptoms will depend on location of vascular changes.
Levy body
Gradual onset, typically with visual hallucinations and REM sleep disorders.
Parkinson like symptoms develop later.
Parkinson’s Disease
Gradual develops late stage Parkinson’s
Frontotemporal demtnia
<60 years old. Have emotional changes, disinhibition, language issues before memory issues.
Primary goal of treatment with dementia
Enchance quality of life, symptom improvement not curavtive.
Medications for dementia
Cholinesterase inhibitors
- donepezil, rivastigmine, galantamine.
- slow the breakdown of achetycholine
- used for mild to severe dementia.
- side effects mostly GI symptoms - headaches, dizziness, orthostasis.
- no role in frontotemporal dementia
- stop if no improvement/rapid decline
Namenda
Used in moderate to severe AD
CAn be used with Cholinsternase inhibitors.
Behavioral symptoms with dementia how to treat
Nonpharmalogical FIRSTLINE!! - reduce stimulation, redirection.
Can use antipsychotics - but all carry black box warning with increased risk of mortality (seroquel better tolerated).
Delirium
**underlying process.
Acute onset - tends to fluctuate - can last weeks to months - if >6 months likely dementia or mild neuro cognitive disorder
Screening for delirium
CAM test
Medications that can cause delirium
Anticholinergics (oxybutin, benztropine)
H2 blockers (Pepcid)
Bendodiapzines
Opioids
Antipsychotic medication
Antihistamines (benadryl)
Treating delirium
Try to treat underlying cause
Nonpharmalogical ways first - orientation to clocks, make sure hearing aides/glasses etc on.
Use antiphycotics ONLY if unable to manage behaviors and causing harm to Staff and self.
Do not use benzodiazepines in delirium associated with hepatic encephalopathy
Depression
Loss of pleasures and interest in previously enjoyable activities (anhedonia) for at least 2 weeks
Depressed mood most of the day nearly every day
- effects females more than males.
5-16% of the older adults live with depression
Screening test for depression
PHQ9 or PHQ-2 —> >10 good sensitivity depression - start treatment. >15 warrants to and physicality consult or admission
Geriatric depression scale —> can be used in dementia. 5-8 mild, 9-11 mod. & 12-15 severe.
Must rule out other causes of depression like
Hypothyroidism, anemia, vitamin deficiency and metabolic disorders
Prolonged grief disorder/complex bereavement disorder
Symptoms presisted most days for the last 12 moths
- preoccupation with deceased or circumstances of the death, intesense sore or emotional pain, perisisnent hearing or longing
Treatment of depression
Takes 4 weeks to see if peopel will respond by 12 weeks.
Zoloft and lexapro usually well tolerated
Paxil - highly anticholinergic
*ECT is effective and preferred treatment of choice in severe depression with suicidal thoughts or not responding to treatment
What lab do you need to check prior to initiang SSRIS
NA level - risk of SIADH
Serotonin Syndrome
Worsening behaviors, diaphoretic, GI upset, fever, hyper reflex is, shivering, rhabdo, seizures
BIpolar 1 disorder
Persistently abnormal elevated mood - latesting at least a week
- grandiosity, flight of ideas, activity, sleep decreased, talkativeness
Treatment for bipolar
Mood stabilizers /anticonvulsants
1. Lithium, depakote, tegretol -
2. Antipyschotics
Bipolar II
Hypomanic episode and past depressive episodes
Hyponmaic episodes last only 4 days - no 1 week like bipolar II mania
Antidepressants, steroids can cause this in older adults
