Geriatrics 2.0 Flashcards
Clinical approach to the geriatric assessment/Dx includes ? three domains
What are the three main outcomes of the assessment
Functional
Social
Psychological
Prognosis
Goals
Functional status
? determines what interventions and likely to be beneficial or burdenson to TP
The above answer worsens above ? age and with age related conditions such as ?
Prognosis
> 90y/o
Dementia
Malnutrition
Functional status
When life expectancy is more than ?yrs, same tests and Txs are offered to geriatrics as younger populations
When does this change?
10yrs
<12mon- palliative care
<6mon- hospice
What would be an example of a single Dz process that would have a prognosis better calculated by a Dz-specific instrument
What are 4 examples of advanced directives
Lung Ca metatestases to brain
Medical POA
Out of Hospital DNR
Declaration Mental Health Tx
Directive to Dr and Surrogate
_____ can be viewed as a summary of the overall impact of health conditions on a PT
What are the ADLs
What are the IDLs
Functional status
Continence Feeding Transfer
Toilet Bathe Dress
Driving Money Telephone Shopping Housekeeping Laundry Food prep Taking meds
When does Functional Status need to be assessed
Falls and Gait are the leading cause of injuries and death in older adults and are screened when/how?
How is a PTs gait assessed
Loss of spouse/caregiver
After hospitalization
Severe illness
Annually for incidence/frequency
Time Up and Go- time to get up, walk 3meters and return
Abnormal >15sec
What PTs are at increased risk for falls?
What meds are particularly known for causing them?
Single fall w/ injury
One or more fall past year
Gait/balance issues
Psychotropic drugs
What are the three best efficacious prevention for falls?
In PTs w/ cardioinhibitory carotid sinus hypersensitivity who experience recurrent falls, what is the best suggested Tx
After d/c of predisposing medications, if PT still has PHOTN, then ? medication is recommended?
Medical reduction
Physical therapy
Home safety mods
Dual chamber pacemaker
Fludrocortisone
Intrinsic RFs for falls
Secondary RFs
How much exercise is recommended
Meds Vision PHOTN Atrophy Vit D
Lighting Footwear Tripping hazard Safety measures
150min/wk
Normal vision is ?
Impaired is ?
Legally blind is ?
> 20/40
20/40-200
<20/200 or
Total visual field <20*
Cognitive impairment is an impairment in at least two of what domains?
What test can be done in the office to screen for dementia
Function Language Visuospacial function Memory Personality/Behavior
Mini Cog- three item recall and clock drawing in 2min; both normal, dementia unlikely
What is the next step for PTs that fail a Mini-Cog in office?
What is the in office depression screening tool?
Mini Mental Status Exam, 10min
MOCA- specific, 30min
PHQ 2-
Have you been feeling depressed?
Have you been experiencing anhedonia
DIAPPERS Acronym
Deliriium Infection Atrophic urethritis Pharm Psych Excessive excretion Restricted mobility Stool impaction
When does unintentional weight loss need to be investigated?
What are the six types of elder abuse?
What are the RFs associated w/ abuse
5% <1mon
10% <6mon
Sexual Abandon Finance Emotion Physical Neglect
Institution Caregiver Elder Environment
What are clues abuse may be occurring
How do retinal detachments present?
What type of age related process do PTs complain of
Behavior changes
Lack of clothing/hygiene
Unfilled Rx
Delayed injury presentation
Painless photophobia, floaters and visual field defect
Presbyopia- loss of lens flexibility/curvature, difficulty reading in low light
Nearly half of older adults have vision worse than 20/40 because ?
What step can PTs do to compensate for normal age related loss of vision
Problem w/ glasses
Bright, indirect light
What eye condition is the leading cause of vision impairment in the world
What would be seen on PE?
What is the only Tx
Cataracts- blurred yellow vision w/ increased sensitivity to glare (stain on shirt w/ otherwise appropriate dress)
White haze- mod/worse case
Dec red reflex
Surgery when <20/40
Inhibits daily living
What is the leading cause of irreversible vision in PTs >65
What are the two types
ARMD- impaired central vision
Non-neovascular/Dry, MC:
Gradual blurring of central vision w/ dec reading fine print/facial recognition
PE: Drusen lesions
Tx: Anti-Oxidants, Zinc
Neovascular/Wet:
Metamorphopsia- distorted images
Rapid loss of central vision
Tx w/ refer and anti-VEGF (Bevacizumab)
What are the RFs for AMD
What are two protective factors?
Smoking Age White FamHx
Eating green veggies/fish
How does Diabetic Retinopathy present
What exam is needed annually
What two protective steps can prevent Dz progression
Blurred vision w/ scomatoma and field constriction
Dilated, funduscopic exam
Glucose/HTN control
What is the early stage of Diabetic Retinopathy called?
What occurs during this early stage
What happens if this stage continues to develop
Non-proliferative/background retinopathy
Pericyte/endothelium damage leds to inc permeability
Retinal hypoxia increases GF leading to proliferative diabetic retinopathy
Define Glaucoma
When does USPTF recommend screenings
How does this condition present w/ vision changes
2nd MC cause of blindness:
Progressive optic neuropathy where IOP leads to atrophy of optic nerve
No screening
Loss of peripheral vision
Glaucoma affects ? race the most in the US
How is IOP measured
What is used to determine if angle is open or closed?
AfAm around 45y/o
By 80y/o, Hispanic/Latino dominant
Tonometry
Gonioscopy
What is normal IOP ranges
What are 3 types of vision Sxs/Changes that need ASAP referrals
10-21mm
Dec central vision
Ocular pain
Loss of peripheral vision
PT w/ cerumen impaction on L side will have ? PE findings
Sensorinueral hearing loss involves ? structures
Conductive hearing loss involves ?
Webber to L
Rinne BC>AC
Inner ear Cochlea Nerve
Anything preventing sound reaching inner ear (Perf Impaction Effusion)
Hearing loss is independently associated w/ ?
What is the majority of hearing loss categorized as
Inc cognitive decline Disturbed gaits Poor neurocognitive function Dementia Falls
Sensorineural HL, Presbycusis
Mild memory impairment includes subjective problems like ?
How does this differ from normal aging memory loss?
Name recall
Object placement
Normal aging loss remembers info later w/out functional impairment
Prevalence of demetia starts at ? and increases every ?
What type is a common cause of early onset dementai?
Stars at 60, doubles q5yrs
Frontotemporal dementia, <65y/o
Define Mild Cognitive Impairment
How is this type characterized
What is the most severe type of cognitive impairment?
Cognitive function is below normal limit for age/education but not severe enough for dementia
Subjective complaint
Objective impairement
Intact functional status
Dementia
What is required for a Dementia Dx
Two domain deficits severe enough to impact in daily function
What are the 5 types of dementia in order of frequency
What are the 3 parts of an exam for possible dementia
Alzheimer's Dz Lewy Body Vascular Frontotemporal Neurodegenerative
Function: ADL/IADL
Neuro exam
What are the 43steps/tests done for screening for dementia
What genetic testing is done for research on dementia
Mini-Cog
MMSE
MOCA
APOE-e4
What are the 5 parts of a PTs Hx that needs to be focused on for dementia work up
What are subtle hints of early dementia or MCI?
Spatial ability Personality changes Language Ability to learn Trouble w/ complex tasks
Frequent repetition Missed appointments Increased accidents Financial mistakes Dec in hobbies
What is the classic triad of Alzheimer’s Dz
How does this begin to be notices
Memory impairment
Language impairment
Visuospatial problem
Difficulty w/ complex tasks
Disorient: Time Place Person
Language: Anomic Fluent Mute
Agitation becomes common
Lewy Body Dementia
What are some findings that support a Dx
2nd MC form of Dementia Hallucinations Fluctuations Parkinsonism REM sleep d/o
Sensitivity to antipsychotics Autonomic dysfunction
Repeated falls
Syncope
Although not required, what biomarkers support a Dx of DLB
What PE finding presents after or concurent w/ PTs onset of dementia?
Confirmed REM sleep d/o without atonia
Dec dopamine uptake on imaging
Parkinsonism- bradykinesia, resting tremor, rigidity
Do not Tx DLB w/ ? meds
How is Vascular Dementia Dx
Antipsychotics- worsening of EPS Sxs
Neuroleptics- death risk
Radiographic evidence w/ step wise presentation after cortical stroke/focal neuro findings
Frontotemporal Dementia is AKA ? and presents as ?
What are the 3 sub-types
Picks Dz
Onset <60
Behavior Language Semantic dementia
Define Behavior Variant Dementia
What Sxs are highly specific to Behavior Frontotemporal Dementia that distinguish it from Alzheimers
Personality/Behavior changes w/ intact memory
Disinhibition Hyperorality Compulsive/Repetitive behavior Personality/behavior changes Reduced speech
The hyperorality of Behavior FTD is usually seen as ?
What would be seen on a MMSE exam
What other Dzs can cause cognitive impairment and dementia
Preferred junk food/carbs
Excessive eating
Normal scores
Parkinson’s
Huntingtons
HIV
Alcoholism
Parkinson’s induced dementia leaves ? intact?
How is cognitive impairment from dementia Tx
How is drug effectiveness proved?
Recognition memory
Cholinesterase inhibitors:
Galantamine Rivastigmine Donepezil
Stable/Improved MMSE/MOCA over 6-12mon
What drug is used for Mod/Sev Alzheimer’s
When is permissive HTN allowed for dementia Tx
Memantine, NMDA antagonist
Added to cholinesterase inhibitors when dementia is mod/sev
Vascular dementia: SBP >150 may improve cognitive function
What drug combo may be beneficial to Vascular Dementia
What meds are used for the behavior problems of dementia
Cholinesterase Inhibitors and Memantine
Antipsychotics- Olanzapine/Risperidone,
best evidence but BBW and only for refractory/serious harm concern
SSRI- Citalopram
Caution: QTc prolongation
Mood stabilizer- Carbamazepin Valproic Acid
What drugs are used off label for Amnestic MCI
What is the most common cause of PTs d/c this class of med?
Use caution when prescribing this class of medication to Pts w/ ?
Cholinesterase inhibitors- GRD
GI- N/V/D
Bradycardia
Cholinesterase inhibitor Donepezil is not recommended to be prescribed in dosages exceeding ?
What is the only reported s/e of Memantine
10mg
HA
Before using medications for dementia induced behavior problems, what needs to be tried?
What Tx types need to be avoided in dementia Tx
Music Pets Walks
Bright light exposures
Gingko NSAIDs Estrogen Vit E
Define GAD
What is one of the most effective Txs
What meds are used
Uncontrollable anxiety and worry interfering w/ daily activities x 6mon
CBT
SSRI
SNRI
When Tx GAD, if an SSRI does not provide benefit, what is the next step?
What anxiolytic med may be used?
Trial of different SSRi prior to starting second line med
Buspirone
Criteria for Major Depression
2wks of Depressed mood and 3-4 of:
SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor SI
When using PHQ-2 screening for depression, what three DDx need to be considered?
What are the s/e or caution of using SSRIs for Tx of depression
Delirium
Cognitive impairment
Chronic medical conditions (weak/fatigue)
Citalopram- QTc prolongation
Fluoxetine- long t1/2 and P-450 suppression
What pharmacotherapy is used for depression
SSRI: F PECS
Fluox/Paroxetine
Esc/Citalopram
Sertraline
SNRI: Des/Venlafaxine
Duloxetine
TCA: Amitriptyline Imipramine Doxepin
Mirtazapine- appetite, insomnia
Buproprion- smoke cessation
What are two s/e of meds used for depression Tx that may last longer than the 1-4wks of other s/e
Weight gain
Sex dysfunction
SSRI- Nausea Sex dysfunction
HTN Fall Bleeding HypoNa SSyndrome
TCA- dry mouth OHOTN urine retention
How often do PTs started on anti-depressant meds need f/u
What is the only med that requires a wash out period?
Abrupt cessation of shorter-acting antidepressants like ? four may result in a discontinuation syndrome with tinnitus, vertigo, or paresthesias
3 x in first 12wks
q3-6mon
Fluoxetine
Citalopram Paroxetine, Sertraline Venlafaxine
When do PTs on anti-depressants need to be referred
Once remission of depression is achieved, how long is Tx maintained
When is this time frame changed?
Failure on two meds
Mania/psychosis
SI
x6mon
High risk for relapse:
>2 depressive episodes or,
depression >2yrs duration
Continue Tx x2yrs/indefinite
What are two types of drug reactions
What 3 drug classes are responsible for 2/3 of all medication related hospitalizations?
Type A, MC- expected but unwanted (BB and Brady)
Type B- idoisyncratic, anaphylaxis
Anti-coag/platelet
Diabetes
What are 3 types of meds that would have decreased absorption in geriatrics
B12 Ca Fe
BEERS Criteria
a
STOPP Criteria
b
START Criteria
c
How often are geriatric falls and depression screened for ?
How often are vision screenings done?
Annually
Initial, q2yrs
When are pneumococcal vaccines recommended and what two are given?
When is herpes zoster vaccine given?
> 65
PPSV-23 and PCV-13
> 50, 2 shots
When are geriatrics screened for diabetes
When are osteoporosis screenings done?
Initial if HTN, HyperLipid or Obese
q3yrs
F >65
M >70
When is hyperlipidemia screening done?
When are AAA screenings done?
When is ASA for primary cardiovascular dz prevention recomended?
Initial
q5yrs
65-75 w/ smoking Hx
50-69
How often are breast cancer screenings done?
How often are colorectal screenings?
When are cervical screenings stopped?
q2yrs
Annual FIT
Colonoscopy q10yrs
Stop at 65y/o
When are lung cancer screenings done?
What medications contribute to delerium?
What are the short acting insulins
Annually when 55-80y/o and 30ppy or quit <15yrs
THE BS SOAP
TCA H2 ETOH Benzo Steroids Sedative Opiate Atnicholinergic Polypharm
Inhaling Glu give LISP and tears ASSapart
Inhales Insuline Glulisine Lispro Aspart
What are the Sxs of Urgency UI and the causes
What are the Sxs of Stress UI and the causes
When evaluating stress UI, what is the Dx test?
Involuntary loss then urgency from detrusor over activity or neuro d/o
Involuntary loss after cough/sneeze due to failed sphincter, prior surgery, deliveries
Bladder stress test
Urge UI causes
Common Sxs
Tx
Stroke Alzheimers Parkinson BPH w/ overflow
Urgency, Frequency
Anticholinergics
Stress US causes
Common Sxs
Tx
Urological procedures
Multiple deliveries
Urine lost w/ cough/sneeze
Topical estrogen
Overflow incontinence causes
Common Sxs
Tx
BPH Fecal impaction Pelvic prolapse Fibroids Neuropathy
Poor stream Incomplete emptying
Alpha adrenergic blockers
What can cause an atonic bladder
Common Sxs
Tx
Diabetic neuropathy
Stroke
Complete loss of bladder control
Catheter
Constipation, impaction, cysto/rectocele and prolapses can contribute to incontinence by ?
Dehydration, UTIs and nephrolithiasis contribute by ?
Edema, HyperCa, HyperGlucose contribute by ?
Mass effect impeding bladder neck/urethra
Mucosal/bladder wall irritation
Inc urine volume
How do COPD/Chronic bronchitits contribute to incontinence
How do delirium, dementia and depression contribute?
How does Parkinson contribute?
Cough induced pelvic floor weakening
Impaired cognition, consciousness or motivation
Disrupted neuro control to bladder/sphincter
How is Stress UI assessed?
How is Urge UI assessed?
Supine empty stress test- lay w/ full bladder, coughs
+= leakage
Assesses urethra function/post-void residual
Urodynamics assesses bladder compliance/detrusor activity
What urine analysis findings is not associated w/ urine incontinence and there for is not Tx w/ ?
If PT does bladder diary, how is it done
ASx bacteriuria
W/ ABX
3 days x 24hrs w/ time and volume
How do A-adrenergic agonists contribute to incontinence
How do A-adrenergic antagonists contribute
How do CCBs contribute
Sphincter constriction
Sphincter relaxation
Dec smooth muscle contractility
How is UI Tx
Lifestyle- Weight ETOH Caffeine
Behavior- training, kegel
Pharm- best for urge
Surgery/Device
Function: bladder training Stress: Kegel Topical estrogen Anticholinergic Urge: Estrogen Oxybutynin (antimuscarinic) Mirabegron (B-agonist) Overflow- Doxazosin (a-blocker) Finasteride (5a inhibitor)
Which way does the spine point in scoliosis, kyphosis and lordosis
How does OA present?
What would be seen on images?
S: S or C shaped spine
K: thoracic curves out
L: lumbar curves in
Worse w/ activity, better w/ rest
Joint line tenderness/bone enlargement
Narrowing Osteophytes Sclerosis Cysts
After life style change and warm/cold Tx, what meds can be used?
Acetaminophen/Paracetamol- initial med
NSAIDs if Aceta failure- Naproxen, Ibuprofen
Tramadol
When is acetaminophen related hepatotoxicity seen in OA PTs
How can the risk of NSAID induced GI bleeds be reduced
These protective agents only protect ? part of the GI system
> 3g/day and ETOH/hepatotoxic meds
Cyclo-oxygenase 2 selective agents- Celecoxib Meloxicam
PPIs
Misoprostol
Above Ligament of Treitz
When can Capsaicin cream be used for OA
What is an adjunct therapy
What topicals may be useful in PTs w/ mutiple chronic medical conditions
Knee
Caution w/ hand
Rubefacients: Salicylates
Topical NSAID- Diclofenac
Where are osteoporosis fragility Fxs found
What is the FRAX algorithm
What are the 3 types of Osteoporosis
Hip Vetebrae Wrist
PTs 10yr probability for fragility Fx
1: post-menopause loss of E
2: >75y/o loss of Zinc, dec Ca intake
3: chronic dz/GCSS in M/F
Per USPSTF, only conduct DEXA scans on ?
What do the DEXA results correlate to ?
Female >65
Normal: > -1.0
Penia: -1 - -2.5
Porosis:
How is Osteopenia Tx
When is pharmaceutical Tx for osteoporosis indicated?
DXA is MC used to assess what two locations?
Ca/Vit D w/ exercise
Porosis
Penia w/ FRAX hip Fx ?3% or other Fx risk 20% or higher
Lumbar Femur
How is Osteoporosis Tx
Bisphosphonates: RAIZ-onate
HRT
Romozumab
Calcitonin
Denosumab
Teri/Abaloparatide
SERM: Raloxifene
What is pathognemonic for Delirium
What other key features will be seen?
Acute change in baseline mental status over hrs/days
Fluctuating Rambling Altered LoC Inattention Disorganized
What may be the only sign of an underlying illness in frail/dementia PTs
What is the MC post-op complication in older adults?
Nearly all terminally ill PTs experience ? prior to death
Delirium
Delirium
Delirium
What are the 3 types of delirium
The presence of ? form is indicative of poor prognosis
Hyperactive
Hyperalert
Hypoactive- often unrecognized but MC in older hospitalized PTs
Hypoactive
Due to increased issues, what herbs in combo w/ psychoactive drugs risk delirium development
What is the most effective strategy for preventing delirium
What is the foremost precipitating factor causing delirium
St. John’s wort, kava, and valerian root
Non-pharm interventions
Medications
Since delirium may be the indicator of an occult infection, what needs to be investigated?
Define the CAM Assessment
Joint infection Abdominal issue PNA UTI New cardiac murmur
Acute and fluctuating and,
Inattention and,
Disorganized or Altered LoC
What meds can be used in the Tx of delirium
What are the 4 presenting features of Parkinsons
Neuroleptic, typical: Haldol Neuroleptic, atypical: Olanzapine Quetiapine Risperidone Benzo
Resting tremor- pill rolling
Bradykinesia- shuffle gait
Rigidity- cog wheel
Instability- late feature
Parkinson’s is the 2nd MC ? and is due to ?
If this presents in PTs older than 75, what is the cause
Neurodegenerative d/o Dopaminergic cell loss of substantia nigra
Mean onset 60-65, later onset indicated idiopathic or secondary
Since Parkinsons is a clinical Dx, what must be present for Dx
How does this requirement present on PE
Bradykinesia and one cardinal manifestation
Slow movement
Micrographia
Masked facies
Festinating gai
? is the MC presenting Sx of Parkinson
How is postural instability tested for?
What is at the center of the PE for these PTs
Resting tremor 3-6 Hz
Pull test- more than 2 corrective steps is abnormal
Extrapyrimidal exam
When would genetic testing for the Parkinson’s PARK gene be warranted?
What is the MC cause of Parkinsonism
What is the strongest alert for PTs to have Secondary PD
Strong FamHx
Onset <40y/o
Idiopathic PDz
Lack of response to increased Levodopa dosage
What causes Vascular Parkinsonism
How doe these PTs present differently
Chronic ischemic damage
Multiple brain infarcts
Akinetic rigid syndrome, more severe in legs and gait is more prominently affected
What are the MC causes of drug induced parkinsonisms?
Define Atypical Parkinsonism
Anti-emetic
Anti-psychotic
Dopamine depletors- Reserpine, Tetrabenzine
Parkinson Plus- Disabling features like autonomic failure, early falls/dementia that are not seen in PD
How are Essential Tremors different from PD tremors
What are the two major causes of morbidity/mortality in PD PTs
More symmetric
Higher frequency
Extension/Flexion, not pronate/supinate
Dysphagia
Gait dysfunction
How is the ‘wearing off’ phenomenon of PD meds Tx
What meds are used for dementia/psychosis in PD
What meds can be used for psychosis
Shorten dose interval
Add COMT/MAOI
ChEIs- GRD
Quetiapine Clozapine Pimavanserin*
What meds are the first and second line agents for depression in PD?
These two need to be avoided when PTs are taking ?
What medication/systemic issue management may be d/c as PD progresses?
1st: SSRI
2nd: SNRI
MAOIs- Selegiline
HTN
What 3 meds are used for last line OHOTN in PD PTs?
What complication is nearly universal in PD Pts
Fludrocortisone
Midodrine
Droxidopa
Constipation- Polyethylene glycol and Senokot daily
What drug is proven to work as monotherapy to decrease the motor Sxs of PD
What are the 5 classes of drugs used in Tx and their benefits
Non-ergot agonist/Dompaine agonist- Pramipexole, less motor fluctuations
Dopamine agonist- less motor fluctuation
Anti-cholinergis- relieve tremors/dystonia
MAO-BIs- Sele/Rasagiline; mild anti-depressant
COMT-Is- E/T-capone; improve mobility
What is the TxDOC for PD PTs >70y/o
This drugs is preferred because ? meds are not tolerated in this age group
What are the TxDOC for PTs <70y/o
Levodopa
Dopamine agonists- Pramipexole Rpinirole
Amantadine
Anticholingergics
Dopamine agonists- Pramipexole Ropinirole
What is the benefit of Levodopa
This medication has less benefit on ? Sxs
What PT education goes w/ this Rx
Decreases tremor
Speech/gait
30min prior to meal on empty stomach
Sinemet CR at bedtime
What type of diet change can help benefit PD PTs on medications
What is the only medication proven to reduce dyskinesia and frozen gaits?
Dec protein diet
Amantadine
What is the MC movement d/o and its AKA
How do these present
What are the strongest RFs
Essential tremors;
Familial tremor
Bilateral tremor in hand/arm, head, voice and trunk
Age FamHx
Essential tremors are variants of ? Dx
PTs will present w/ relief by doing ?
How are these Tx
Cervical dystonia
Alcohol
1st: OT Propranolol (non-sel BB) and Primidone or 2nd- Gaba/Topiramate Zonisamide alternate to Top Surgical: unilateral thalamotomy
When do the risks for stroke begin and how rapidly does this increase?
What are the two types of strokes and their prevalence
Starts at 55y/o
Doubles q10yrs
Ischemic
Hemorrhagic intracerebral, subarachnoid)
What are the 3 parts to the Cincinnati stroke scale
What are the two phases of Dx
What is the preferred imaging for work up
Face droop Arm drift Speech
Acute triage
Etiology investigation after Dx
CT w/out contrast
What are the 5 sub-types of ischemic strokes
Intracerebral hemorrhages usually have ? underlying etiology
Atherosclerosis- stenosis Determined- dissection Undetermined- cryptogenic Embolism- AFib Small vessel- Lacunar
HTN
Amyloid angiopathy
Anti-coag related hemorrhage
What form of imaging is 90% sensitive for detecting intracerebral infarction
What form of imaging is the the gold standard for Dx of aneurysms/vascular malformations
DW-MRI
CTA
Digital subtraction angiography
What are the 3 inclusion criteria for use of tPA reperfusion therapy
C/i for use
Ischemic stroke Dz w/ neuro deficit
Sxs <3hrs/4.5hrs if <80
18y/o or older
SHIP BLASTS Stroke <3mon Head injury <3mon Intracranial hemorrhage PT >15sec BP >185/110 LP <7d Anticoag/artery puncture <7d Surgery <14d Thrombocytopenia <100K
Ischemic stroke PTs don’t need HTn intervention unless BP is over ?
? is not a barrier/RF for reperfusion therapy
220/120
Age
? is the least treatable form of stroke
What is the BP goal for these PTs
What RF/barrier is present here that was not present in tPA consideration
Intracerebral hemorrhage
<140
> 80 inc mortality
Neuro/Heme stable PTs should start BP reduction regimes ? long after strokes
What long term Tx is recommended to lower future issues
What mes are the mainstay of secondary prevention
24hrs
Statins
Antiplatelet:
ASA mono therapy- 1st
ASA + Dipyridamole and Clopidogrel mono therapy
PTs w/ minor ischemic stroke or high-risk transient ischemic attack, early, short-term combination of ? meds reduces subsequent stroke risk
ASA and Clopidogrel
When are Warfarin anticoagulants initiated after strokes
What class is as effective w/ lower risks?
? Tx is more effective in PTs w/ carotid artery stenosis than medical therapy
ASA bridge w/in 2wks
DOACs-
Dabi/Riva/Apixaban
Carotid Endarterectomy <2wks to prevent recurrent stroke
How do TIAs present
What are the 3 main mechanisms
PTs w/ TIAs are at risk for having a stroke w/in ?
Transient neuro dysfunction from neuro/retinal ischemia but nor infarction
Flow, low Embolic Lacunar
Half w/in 2days
90days
Define Takotsubo Cardiomyopathy presentation
What will be seen on imaging
What medication is used for the Tx of dilated cardiomyopathy
Mimics STEMI w/out arterial occlusion in women
Octopus pot- apical ballooning of ventricles
Bisoprolol
What meds are used for long term coronary dz management
What medications are used for HFrEF <40%
What meds are used for HFrEF <35%
Statin
Anti-platelet
BBs
ACE/ARB- HFrEF
BB Sacubitril-Valsartan
ACE/ARB Spirinolactone/Eperenon
Resynch/pace
What meds are used for HFpEF >50%
How much salt and liquid intake do these PTs need to limit to?
HTN Na restriction Loops
2g and 1-1.5L/day
What are the 4 EKG changes seen in HyperK
What 3 meds are used for HyperK redistribution
What two methods are used for elimination
Peaked T
Dropped P
Wide QRS
Sine waves
Insulin Albuterol NaBicarb
Furosemide Dialysis
What is the only Tx for bradycardia
What is the MC presenting complaint
Pacemakers
Fatigue
Bradyarrhythmias include ? rhythms
Tachyarrhythmias include ? rhythms
Sinus brady
Sinus pause
TachyBrady- PSVT to Brady; worse prognosis
VT/VF Afib/flutter NSVT
PVC
Drug of choice for endocarditis prevention
What is and is not given for TIA
Amoxocillin
Give ASA
No tPA
Indications to increase insulin
Dec in ADL/IADLs indicates ?
If accurate functional info is essential for planning ?, what is the most invaluable form of info
DM and A1c >8
Worsening Dz process
Combo of multiple conditions
Adaptive caregiver
Caregiver help
Direct observation by OT/PT
PT present w/ TIA, vision loss and arm weakness, first med given is ?
When is MOCA used
When is CAM used
ASA
MOCA- dementia
CAM- delirium
Define HASBLED acronym
Score estimates risk of bleeding on anticoags as assess AFib d/os: HTN Abnormal renal/liver 1-2pts Stroke Bleeding Labile INR Elderly >65y/o Drug/Alcohol 1-2pts 0-1: low 2: moderate 3-6: high
How fast is BP lowered during HTN Emergencies
What is the Tx goal for these PTs
MAP dec 10-20% first hr
Gradual over next 23hrs
Final reduction by 25% from baseline
What vasodilators are used for HTN Emergencies
What adrenergic inhibitors are used?
Na nitropursside Nicardipine Fenoldopam Nitro Enalaprilat Hydralazine
Labetalol
Esmolol
Phentolamine
ANCA/AHA HTN categories
JNC8 Categories
Norm 120/80 or less
Elevated 120-129/<80
Stage 1: 130-139/80-89
Stage 2: >140/>90
<60/DM/CKD: <140/90
Over 60: <150/90
INVEST Research findings
HTN Tx in PTs >80y/o with CAD compared to PTs <80 years, J-curve relationship between lower DBP and increased all-cause mortality, nonfatal MI/strokes
What are 4 common conditions in older PTs that complicate HTN Dx and management
White Coat HTN- higher in office than out w/ NO anti-HTN meds; confirmed w/ monitoring
OrthoHOTN: risk for first fall
Post-Prandial HOTN
Pseudohypertension: high peripheral pressure compared to arterial pressure from atherosclerosis
HTN Tx for non-AfAm PTs
HTN Tx for AfAm TPs
HTN Tx fo TPs w/ CKD should include ? meds
ACE/ARB CCB Tzd
Tzd CCB (Verapamil, Diltiazem)
ACEI/ARB
When/how are HTN medication adjustments made
Triad for Aortic Stenosis
How are they Tx
Up-titrate or add after 1mon if BP goal not reached
Syncope Angina Dyspnea
Fluids, Consult
What is the MC cause of aortic stenosis
If found ? finding indicated an early case of Dz
What is the MC for the most severe cases of aortic stensosis
Calcified aortic valve dz
Aortic valve sclerosis
Bicuspid AV
? is the MC indication for major cardiac surgery after coronary bypass
How is this Tx
Aortic stenosis
AVReplacement
Transcatheter AVReplacement after CT
How is aortic regurg Tx if PT is not a surgical candidate
What is the initial and preferred imaging when evaluating for suspected aortic regurg?
Chronic dilator therapy
TTE w/ referral
When is endocarditis prophylaxis indicated prior to dental?
What types of procedures are of highest of risk to PTs
When is prophylaxis not warranted before a procedure
Prosthetic heart valve
IE Hx
Congenital heart Dz
Valvulopathy after transplant
Manipulation of gingiva, periapical region or oral mucosa
GU/GU
What ABX is used for infective endocarditis prophylaxis
How does peripheral arterial dz and VTE present
How are these PTs managed
Amoxicillin
Pain w/ rest, MC in calf
Relief w/ movement
Hygiene/daily inspect
Refer to podiatry
Tobacco cessation
High intensity statins
What medication is sued for peripheral artery Dz
What are the 6 Ps of acute arterial occlusion
What is the MC form of peripheral artery dz in older adults
Cilostazol- PD-3 inhibitor
Paresthesia Pallor Pulselessness Poikilothermia Paralysis PooP
Atherosclerosis
? is the 3rd MC cause of CV death in US
What are 3 common RFs
Usually Duplex US is used, but what form of imaging is used to evaluate the pelvic vasculature
VTE
Ortho surg Immobile Malignancy
CTV and MRV
How are VTEs Tx initially
What meds are used for long term management
How long are Txs maintained
Heparin/LMWH
Fondaparinux
Vit K antagonists
DOACs
LMWH
Discrete cause- 3mon
Unknown cause- 6-12mon
When there is no etiological finding that is age/gender appropriate for a Dx of VTE, what is the next step
What is the only anticoagulant that has approved dose reduction for older PTs w/ renal impairment
Malignancy screening
Enoxaparin
Rivaroxoban is c/i in PTs w/ CrCl below ?
Direct thrombin inhibitor med
What are the reversal methods for anticoagulants
<15mL/min
Dabigatran
VKA: Vit K, FFP, Prothrombin
Dabi: Idarucizumab
Riva/Apix: andexanet
Vascular incompetency causes ?
Venous obstruction causes ?
How are these cases Tx
Reflux
Outflow
Elevation/compression
Diuretics
What types of skin changes can occur due to chronic venous insufficiency
Where are insufficiency induced ulcers found
Hemosiderin stain
Lipodermatosclerosis
Atrophie blanchie
Medial malleolus
How are venous Dzs classified
C0: no visible sign of dz C1: telangiectasis/reticular veins C2: varicose C3: edema C4: skin changes C5: healed ulcer C6: active ulcer
How are acute COPD exacerbation’s managed
What meds are used
O2 Albuterol Ipratropium Prenisone
Beta agonist- Albuterol Anticholinergic- Ipratropium PO GCCS- Prednisone NPPV ABX- mod/sev exacerbation
Define COPD
Define Emphysema
Define Chronic Bronchitis
Inflammatory respiratory dz w/ limited airflow, incompletely reversible w/ dilators, and FEV1/FVC <70%
Destruction of alveoli
Cough and sputum x 3mon for 2yrs
COPD is the ? leading cause of death
What meds are used for Tx
When do PTs need to be placed on home air?
4th
Chronic:
GCSS Anticholinergics LABA SABA
<88% on RA
<55mmHg
ABCD classification for COPD
What are the grades
Exacerbation, L side:
>2 hospital admission
1< admissions
Under, horizontal:
MRC 0-1, Cat <10
MRC 2 or more, Cat 10 or more
1: SoB w/ walking up hill
2: can’t keep up w/ others
3: stops when walking 100ft
4: too breathless to leave home
SABAs for COPD
LABAs for COPD
SAMAs/Anticholinergic
LAMAs/Anticholinergic
Albuterol
Levalbuterol
Formoterol
Salmeterol
Ipratropium
Oxitropium
Tiotropium
Umeclidinium
What medication is reserved as 3rd line agent for COPD
What ABX are used for exacerbations
Methylxanthines: Theophylline
Mild: Macrolide Cephalosporin Doxy or TMP/SMX
Mod/Sev: Augmentin, FQN
COPD Tx by group
A: SABA or SAMA B: LABA or LAMA C: LAMA D: LAMA or LAMA and LABA or, LABA and ICS
COPD group GOLD 2B is not responding to LAMA and LABA, what meds are added
What lab work should be checked
ICS
Eosinophil
What type of airflow obstruction results are seen in asthma PTs
What are the two types
FEV1/FVC 0.7 or less
Long- atopy/allergy
Late- obesity/tobacco
S/Sxs of interstitial lung dz
What would be seen on PE
Dry cough
Wheeze
Dyspnea
Chronic exercise intolerance
Velcro rales
Adenopathy
R heart failure
