Geriatrics 2 Flashcards
What is the best indicator of morbidity?
age
What are the two leading causes of death in older adults?
1) heart disease
2) cancer
When should elderly patients stop getting the flu vaccine?
never, it should be continued annually through the end of life
Which cohort of older adults is expanding the fastest?
those over 85, and in particular, those between 90-95
What is the “oldest continent”? Youngest?
Europe has the highest percentage of geriatrics while Africa has the lowest
What is the life expectancy for a male in the US? How does this change with age?
- life expectancy is 78 years at 65
- at 75, it becomes 84
What is the life expectancy for a female in the US? How does this change with age?
- life expectancy is 86 years at 65
- at 75, it becomes 87
Overall, women live how much longer than men?
about eight years
Why is it clinically important that women live longer than men?
because older women are more likely to be single, poor, living alone and to enter nursing homes
Which race is projected to become the second largest geriatric population behind whites?
Hispanics
What do part A, B, and D medicare cover?
- A: in-hospital expenses
- B: out-patient expenses
- C: drugs
What two financial sources pay for nursing home care?
- out of pocket
- medicaid
What is required to qualify for full medicare benefits?
having paid into the system for 40 quarters (10 years)
What out of pocket costs are associated with part A, B, and D medicare?
- A: 1,200 dollars for 60 days of in hospital care
- B: 20% copay
- D: more complicated and varies by plan
What is important to remember about Part D medicare and less so for the other parts?
patients are penalized by 1% for every quarter they delay picking a part D plan
Who is eligible for medicare?
- those over 65
- those who have been disabled for over 24 months
- those with end-stage renal disease
- those with ALS
Generally speaking, all patient populations recall about what percentage of information provided by their physician?
only 50%, less for geriatric patients
What is the prevalence of low health literacy in geriatric patients?
over 80%
Why is assessing a review of functions so important in the geriatric population?
- predicts outcomes
- allows for monitoring response to treatment
- helps in making diagnoses
- helps determine level of care needed
What do ADL and IADL stand for?
- ADL: activities of daily living
- IADL: instrumental activities of daily living
What are the ADLs?
DEATH
- dressing
- eating
- ambulating
- toileting
- hygiene
What are the IADLs?
SHAFTT
- Shopping
- Housekeeping
- Accounting
- Food Prep
- Telephone
- Transportation
For which diseases, is medication underuse a common problem in geriatrics?
- psych disorders
- asthma/COPD
- heart failure
- hyperlipidemia
- hypertension
- diabetes
- osteoarthritis
- cancer
- pain
What are the ten most common potentially inappropriate drugs used in geriatrics?
inappropriate: - propoxyphene - diphenhydramine - hydroxyzine - oxybutynin - amitriptyline - cyproheptadine excess: - iron supplements > 325 mg daily - ranitidine longer than 12 weeks drug-disease interactions: - COPD and sedatives/hypnotics - constipation and strong anticholinergics
How do we define malnutrition?
- weight loss of more than 10% in sixth months or more than 5% in one month
- or prealbumin < 19 mg/dL
What is the best way to help geriatric patients gain weight?
ensure and protein shakes; there are no safe pills
What is a significant indicator of malnutrition in geriatric patients that is easily recognizable upon observation?
temporal wasting
How many additional calories are needed to help a patient gain one pound per week?
500 calories a day
When should restrictive, therapeutic diets be used in geriatric patients? When should they not?
- they should be avoided unless their clinical value is certain
- this is because these sorts of diets often have reduced taste and geriatric patients may become malnourished
What are some ways to prevent undernutrition in geriatric patients?
- enhance the social aspect
- provide adequate time
- enhance comfort, taste, and appearance of food
- address dental complaints
- cater to patient’s food preferences
What is functional incontinence?
a form of incontinence in which there is no physiologic problem with urination but there is a problem with ambulation that prevents the patient from reaching the bathroom in time
What is overflow incontinence?
incontinence that arises due to an obstruction and increasing amounts of residual volume after voiding
At what age do women and men become equally affected by urinary incontinence?
age 80
What other illnesses does urinary incontinence increase the risk for?
- cellulitis, pressure ulcers, and UTIs from being wet often
- sleep deprivation and falls with fractions as incontinence makes patients get up in the middle of the night
- sexual dysfunction
- depression and social withdrawal
What are some age-related physiologic changes that increase the likelihood of urinary incontinence in geriatric populations?
- detrusor overactivity and decreased contractility
- BPH
- more urine output during the night
- atrophic vaginitis and urethritis
- decreased ability to postpone voiding
- decreased bladder capacity
What is the most common type of urinary incontinence?
stress incontinence
What cause stress incontinence?
sphincter dysfunction due to a weakened pelvic floor
How is stress urinary incontinence treated?
- kegel exercises
- pessary (small foam block)
- surgical correction
How is functional urinary incontinence best treated?
environmental modification
How is urge urinary incontinence treated?
- first with behavior modification including fewer drinks before bedtime, caffeine avoidance, and bladder training
- then with anticholinergics if necessary
What sort of urinary incontinence is treated with an anticholinergic?
urge urinary incontinence
How is overflow urinary incontinence treated?
- correction of the outlet obstruction (BPH with an alpha blocker)
- catheterization
Which urinary incontinence is treated with an alpha-adrenergic inhibitor?
BPH-mediated overflow incontinence
What can happen if you give a patient with overflow incontinence an anticholinergic?
you may cause an acute urinary retention
Why does osteoporosis occur?
because the balance between bone formation and resorption begins to favor resorption
What is osteopenia?
a milder, precursor to osteoporosis
How do we define osteopenia and osteoporosis?
- osteopenia: bone mineral density between 2.5 and 1 standard deviations below standard
- osteoporosis: bone mineral density more than 2.5 standard deviations below standard
How does hip fracture affect quality of life and mortality?
- 50% don’t recover prior function after fracture
- there is 20% excess mortality in the year after hip fractures
What endocrine changes can contribute to osteoporosis?
- estrogen deficiency
- androgen deficiency
- hyperparathyroidism
What is the number one secondary cause for bone loss?
Cushing’s disease
What are risk factors for osteoporosis?
- early menopause
- being White or Asian
- having a sedentary lifestyle
- smoking/alcohol abuse
- low body weight
What is delirium?
an acute, potentially reversible change in mental status, usually caused by an inciting condition
Delirium carries with it what risk for mortality?
increased risk of mortality for up to two years following discharge
What criteria are used to diagnose delirium?
the confusion assessment method (CAM)
What are the diagnostic criteria for delirium?
- acute change in mental status and fluctuating course
- inattention
- and disorganized thinking or altered level of consciousness
What factors are predispose one to an episode of delirium?
- advanced age
- dementia
- functional impairment of ADLs
- medical comorbidity
- male gender
- sensory impairment
How should delirium be approached from a treatment standard?
- identify the underlying disease and address contributing factors
- avoid complications by removing indwelling devices, prevent or treat constipation or urinary retention, and encourage proper sleep hygiene
- review and optimize drug list
- offer orienting stimuli and adequate socialization
- mobilize the patient as soon as possible
- ensure proper nutrition
What are social restraints?
things like a “sitter” or family member in the room with a patient 24/7 rather than physical bindings or pharmaceuticals
What kind of restraints should be used on patients with delirium if needed?
social restraints
How does dementia differ from delirium?
- the course of delirium is more fluctuating and acute than is seen in dementia
- furthermore, a diagnosis of dementia requires both memory and functional impairment
What is the most common form of dementia?
Alzheimer’s disease
What tests are available to screen for dementia?
- MMSE (easiest)
- SLUMS
- MoCA (hardest)
Before diagnosing dementia you must also do what?
rule out other causes of cognitive decline such as medications, infection, depression, etc.
Are ADLs or IADLs first to be lost during early dementia?
IADLs
What is most often the first ADL lost in the course of dementia?
hygiene
Which ADL is the most likely to initially warrant a home health aide?
bathing
What MMSE score indicates moderate dementia?
10-19
In what order are basic functions lost during dementia?
- IADLs before ADLs
- hygiene before other ADLs
- generally speaking: first learned as a child are the last to be lost
How is dementia treated pharmacologically?
- primarily with cholinesterase inhibitors (donepezil, rivastigmine, galantine) in the mild to moderate stages
- NMDA receptor antagonist (memantine) for moderate to severe
How does depression differ from delirium and dementia?
depression manifests with more somatic complaints than memory and function complaints
What treatment options are available for geriatric patients with depression?
- psychotherapy (CBT, interpersonal or problem-solving)
- SSRIs are preferred drug
- ECT is available for major depression, those with a suicide risk or mania
Under what circumstances is ECT indicated for depression in the elderly? What are the contraindications?
- indicated for major depression, cases with a risk of suicide or instances of mania
- contraindicated in those with increased ICP, pheochromocytoma, intracerebal hemorrhage, recent MI, etc.
What is the response rate for geriatric patients with depression receiving mono therapy?
- 40% improve within 6 weeks and another 15-25 after an additional 6 weeks
- overall, a relatively strong resposne
What is the most common prescribing error when it comes to depression?
failure to increase the dose to the recommended level within the first two weeks of treatment
When you’re treating a geriatric patient with depression and mono therapy fails, what other options should you consider?
- consider switching to a different drug class
- add psychotherapy
- consult a geriatric psychiatrist
Why do geriatric patients have a higher risk of pressure ulcer?
- local blood supply to skin decreases
- epithelial layers flatten and thin with age
- there is decreased amounts of subq fat
- collagen fibers lose their elasticity
- tolerance to hypoxia decreases
What are the four stages of pressure ulcers?
1) persistent erythema of intact skin, won’t blanch
2) partial-thickness skin loss involving epidermis, dermis, or both
3) full-thickness skin loss involving damage or necrosis of subq tissue
4) full-thickness skin loss with extensive destruction to muscle, bone, or supporting structures
What is a deep tissue injury?
- an area of tissue that painful, firm, mushy, boggy, or warmer/cooler than adjacent tissue
- little or no ulceration and no way to detect how deep it’s going
- the wound is typically dark
What is an unstageable pressure ulcer?
- one for which the depth of injury cannot be assessed due to the presence of a hard eschar or significant slough
- stable (dry, adherent, intact, and without erythema) eschars should not be removed
What are the four major complications of pressure ulcers?
- sepsis
localized infection, cellulitis, osteomyelitis - pain
- depression
What is the mortality rate of those who develop a pressure ulcer?
60% in older persons within one year of hospital discharge
What are the intrinsic risk factors for developing a pressure ulcer?
- age
- nutritional status
- arteriolar blood pressure
What are extrinsic risk factors for developing a pressure ulcer?
- pressure, friction, or shear
- moisture (urinary or fecal incontinence)
What steps related to skin care should be taken to avoid pressure ulcers?
- daily systematic skin inspection and cleansing
- reducing factors that promote dryness (increase humidity, apply moisturizer, reduce exposure to cold)
- avoid massaging over bony prominences
- reduce moisture from incontinence, perspiration, etc.
- minimize friction and shear using proper repositioning, turning, etc.
What mechanical loading steps should be taken to avoid pressure ulcers?
- reposition at least every two hours
- keep head of the bed at lowest elevation possible
- use lifting devices to decrease friction and shear
- remind patients in chairs to shift weight every 15 minutes
- do not use doughnut seat cushions
Under what circumstances should doughnut seat cushions be used to prevent pressure ulcers?
they shouldn’t; they’re contraindicated because they may cause such ulcers
Where are most pressure ulcers found?
on the heels
