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PCM 2.2 > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Definition and History

A
  • Bismark (Germany 19th century); Old age and Disability Insurance Bill 1889 - Eligibility at 70
  • Older than 65: Social Security Act 1935
  • Medicare: Social Security Act 1965
  • Series of Losses; frail and less well-functioning; multiple concurrent disease processes
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2
Q

Setting

A
  • Home
  • Small Group home
  • Assisted Living
  • Nursing Home (sub-acute and long term)
  • Long term acute care (LTAC)
  • Acute hospital care
  • Hospice
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3
Q

Unique aspects of the geriatric history

A
  • Always review medications
  • Assess activities of daily living
  • Often have concomitant and complex medical problems
  • Depression
  • Cognitive impairment
  • Difficulty with communications
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4
Q

Difficulty with communication

A
  • Hearing, vision, speech (CVA)
  • Inability to afford physician visits
  • Underreporting: intimidated by a busy practice
  • Fear: afraid to find out something is wrong
  • Slower to respond
  • Atypical presentations
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5
Q

PE: Weight

A

Asses Diet and Fluid Status

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6
Q

PE: Pulse and Blood Pressure

A
  • Atherosclerosis and tissue perfusion

- Often have orthostatic changes

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7
Q

PE: HEENT Exam

A
  • Temporal arteritis
  • Decreased lens accommodation
  • Presbycusis
  • Poor dentition/false teeth
  • Decreased olfaction
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8
Q

PE: Chest and Lung Exam

A
  • Kyphotic Changes: decreased lung capacity

- Increased Incidence of Breast cancer

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9
Q

PE: CV Exam

A
  • Thrills and Bruits
  • 1/3 octogenarians have systolic murmur:
    • Aortic stenosis, aortic sclerosis , mitral regurgitation, atrial septal defects, tricuspid regurgitation
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10
Q

PE: Abdominal Exam

A
  • Compression fractures: altered contour
  • Often present atypical/asymptomatic:
    (1) Perforation, ischemia, inflammatory
    (2) Bleeding
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11
Q

PE: GU Exam

A
  • Prostate hypertrophy

- Vaginal and Labial atrophy: (1) squamous cell cancer, (2) Vaginal Bleeding

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12
Q

PE: MSK

A
  • Deformities related to arthritis

- Compression fractions and kyphosis

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13
Q

PE: Neuro Exam

A
  • Olfaction
  • Cognition
  • Gag/speech: aspiration
  • Gait
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14
Q

Focus of Geriatric Care

A
  • Reduce Nursing Home Placement
  • Reduce Hospitalization
  • Quality vs Quantity of Life: ask pt what their goals of care are
  • Socio-economic issues: aging in place, limited income, spend down
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15
Q

Falls - Gait Disturbance

A
  • Multifarious in etiology
  • Evaluation
    1. H&P
    2. Gait and Balance
    3. Neuro exam
    4. CV exam
    5. Lab tests
    6. Physical and Occupational therapy eval
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16
Q

Gait Dist. - H&P

A
  1. full med history w/ medications review (include OTC)

2. LE weakness, gait/balance probs, decreased vision, arthritis, hx of falling, pain

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17
Q

Gait Dist. - Gait and Balance

A

Get up and go test

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18
Q

Gait dist. - Neuro exam

A
  1. mental status
  2. Proprioception
  3. Sensory and Cerebellar Exam
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19
Q

Gait dist. - CV exam

A
  1. dysrhythmia
  2. postural hypotension
  3. murmurs
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20
Q

Gait Dist. - Lab tests

A
  1. CBC
  2. blood chemistries
  3. EKG
  4. HBA1C
  5. Holter monitor
  6. vitamin D (muscle weakness and function impairment in addition to increased incidence of osteoporosis)
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21
Q

Gait Dist. - PT and OT Evaluation

A
  1. Home and hazard assessment/environmental safety

2. Berg Balance Scale

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22
Q

Gait Dist - Treatment

A
  1. PT/OT
  2. Brain Imaging (after falls)
  3. Medication review (reduction)
  4. Pacemaker
  5. Treat underlying conditions - infections, normal pressure hydrocephalus
  6. Murmurs (aortic stenosis)
23
Q

Gait Dist. Consequences

A
  1. Subdural Hematoma - mental decline
  2. Fracture (hip fractures associated with up to 50% mortality at year 1)
  3. Nursing Home Placement
24
Q

Urinary Incontinence (UI)

A
  • more common in females (dt short urethra and child birth)
  • increases with age
  • common factor leading to institutionalization/social isolation
25
Q

UI Types

A
  1. Stress incontinence
  2. Urge incontinence
  3. Overflow incontinence
  4. Functional incontinence
26
Q

UI Evaluation

A
  1. H&P
  2. Functional alertness/capacity, CHF, abdominal exam (distention), genital exam
  3. CBC, U/A, blood sugar, imaging (Renal U/S), culture
  4. Post void residual - evaluation of emptying
27
Q

UI Treatment

A

= Coping Strategies

  1. pads, hand-held urinals, bedside commodes etc
  2. social isolation
  3. foley (indwelling catheters) = poor management choice/last resort dt (a) limits mobility and is a safety risk, (b) significant cause of infections
28
Q

UI - DIAPERS

A 
Drugs 
Infection 
Atrophic Vaginitis 
Psychiatric 
Endocrine 
Restricted Mobility 
Stool Impaction
29
Q

Urge Incontinence Treatment

A
  1. Bladder Training/toileting schedule
  2. Medication: Anticholinergic medication for detrusor muscle instability, Reduce/eliminate caffeine, Treat underlying infections
30
Q

Stress Incontinence Treatment

A
  1. Kegel exercises
  2. Medications:(A) Estrogens – some data reveal that oral estrogens make the condition worse, (B) Alpha adrenergic agonists
  3. Surgery urethropexy or pubovaginal slings
  4. Pessary: uterine prolapse
31
Q

Overflow Incontinence Treatment

A

= Important for preservation of renal function

  1. post void residual volume is elevated
  2. fecal impaction
  3. prostate enlargement (tx = finastride or alpha adrenergic antagonist)
  4. Treatment w/ augmented voiding maneuvers (a) suprapubic pressure (b) valsalva maneuver (c) intermittent catheterization
32
Q

Constipation Def

A
  • Patient specific, decreased frequency of bowel movements for the particular individual, but usually fewer than three evacuations a week
  • Includes impaction that requires manual disimpaction, incomplete elimination, painful elimination, dry/hard stool
33
Q

Constipation Etiologies

A
  1. Medication - opiates, anticholinergics, antidopaminergic, calcium channel blockers
  2. Mechanical obstruction – tumor, prolapse, adhesions
  3. Neurological – CVA, MS
  4. Systemic – hypothyroid, diabetes, inflammatory, electrolyte disorders
  5. Dehydration and inactivity
34
Q

Constipation H&P

A
  1. Medications, fluid intake, disease history
  2. Abdominal distention and pain
  3. Rectal exam – tone, impacted stool, hemorrhoids, strictures, or fissures
  4. Neurological exam – rectal tone (spinal cord impairment)
35
Q

Constipation Lab tests

A
  1. Electrolytes, BUN, creatinine, TSH, calcium
  2. Colonoscopy – carcinoma?
  3. Abdominal X-ray
  4. CT of the abdomen
36
Q

Constipation Treatment

A
  1. Bulk laxatives- The exception is for treatment opiate-induced constipation, need to use peristaltic stimulants
  2. Osmotic agents
  3. Enemas
  4. Stool Softeners
  5. Hydration
  6. Maintaining physical activity
37
Q

Pressure Ulcers def and risk factors

A

Def: ischemic soft tissue injury usually over a boney prominence

Risk factors: immobility, poor nutritional status, incontinence, vascular insufficiency, altered level of consciousness

38
Q

Braden Scale

A

Risk assessment tool for pressure ulcers

39
Q

Pressure ulcer staging

A
  • repeated inspection is fundamental to prevention and the ongoing treatment

Stage 1 - intact skin with non-blanchable redness

Stage 2 - partial thickness loss, open ulcer or blister with a pink wound bed

Stage 3 - full thickness tissue loss, subcutaneous tissue present, tunneling and slough

Stage 4 - full thickness with exposed underlying structures, bone, muscle, tendon

Unstageable - covered by slough and/or eschar and underlying structures cannot be visualized

40
Q

Pressure Ulcers Treatment

A
  1. Prevention – pressure relieving devices/mattresses, turning and barrier creams while avoiding shearing forces, reduce moisture – diapers (catheters can be used in as a last resort; can they lead to UTIs)
  2. Moist dressings (allow for a healing environment), antibiotics for infection, surgical debridement, enzymatic debridement, consider osteomyelitis – non-healing wounds
41
Q

Cognitive Impairment

A
  1. Benign senescent forgetfulness - mild recall/memorizing inability
  2. Dementia - loss of memory, language, visuospatial orientation, executive functions
42
Q

Depression

A
  • Inadequate finances, loss of spouse/significant other/children, functional decline
  • Widely under recognized due to its non-specific presentation
  • Pseudo-dementia
43
Q

Sensory Impairments

A
  • increased safety risks
    1. Olfaction loss - Spoiled food in refrigerator
    2. Vision loss- Presbyopia, cataracts, open-angle glaucoma, macular degeneration, diabetic retinopathy
    3. Hearing loss leads to isolation, frustration of others
    • Presbycusis – high frequencies followed by speech frequencies
      1. Decrease in thirst perception
44
Q

Dementia Presentation

A
  • presents as a slow, progressive disease
    1. impaired memory loss and new learning
    2. behavior and personality changes
    3. hallucinations
  • Chronic and progressive loss of memory and cognitive function resulting in social and safety decline
    1. Wandering/high injury risk
45
Q

Dementia Etiology

A

Identify the underlying etiology if possible – potentially reversible
i.e. B-12 deficiencies, normal pressure hydrocephalus, neurosyphilis, hypothyroidism, seizure disorder

46
Q

Types of Dementia

A
  1. Multi-infarct (vascular) dementia
  2. Lewy Body dementia
  3. Alcoholic dementia
  4. Parkinson’s disease related dementia
  5. Alzheimer’s dementia (SDAT)
  6. Pseudo-dementia (depression)
  7. Pick’s disease
47
Q

Dementia H&P

A
  • Med/substance hx
  • living/safety arrangements
  • Basic Activities of daily living (ADLs)
  • Instrumental Activities of Daily living (IADLs) = executive functions
  • weigh loss, missed apts, DRIVING, repeatedly wearing same clothes, inappropriate phone calls
  • MMSE, GDS
48
Q

Dementia Management

A
  • Lab test/ Evaluation – Rule out reversible causes
  • Cholinesterase inhibitors and/or NMDA receptor antagonists
  • Antidepressants (SSRIs, SNRIs)
  • Structured day
  • Simple, calm and direct communication
  • Reorientation
  • Realistic goals (caregiver denial)
  • Attention to safety
  • Agitated or aggressive
  • *Restraints = Contributes to physical deconditioning, pressure sores, depression, disorientation
49
Q

Polypharmacy

A

= greater than five medications

  • consider drug interactions, med errors, altered phamacodynamics and pharmacokinetics
  • **Geriatricians are often best known for the number of medications they discontinue, rather than how many they prescribe
50
Q

Polypharmacy considerations

A
  • Beers List: Safe geriatric drug list
  • loss of lean body mass (altered vol of distribution)
  • decreased cytochrome P450 activity w/ age
  • decreased renal/tubular function w/age
  • Multiple DRs and pharms
  • Brown bag rounds - comprehension of meds = poor
  • prophylactic meds in hospitalized pts
51
Q

Polypharmacy - Management Strategies

A
  • risk to benefit ratio
  • start one new med at a time
  • START LOW AND GO SLOW
  • Review OTC and herbals/supplements for interactions
  • duplicate meds
  • provide detailed, plain English instructions w/ reasons for taking
  • pill box reminders
  • review prescribers and their roles
52
Q

Care Settings: Hand - offs

A
  • readmission to hospital

- Reimbursement

53
Q

Nursing Homes

A
  • OBRA 1987 = highly regulated
  • Team approach to care
  • Two focuses of care= Short stay rehab and long term care
  • Variable expertise
  • Limitations of type of care
  • Pharmacy/diagnostic limitations
54
Q

Advanced Directives

A
  1. Goals of individual care?
    - Five wishes
    - Durable Med Power of Attorney
  2. Capacity - do they understand the consequences of their decisions?
  3. DNR
    - poor outcomes of resuscitation rates
    - not the same as do not treat
    - MOST = Med Orders for Scope of Treatment; POLST = Physician’s Orders for Life Sustaining Treatment

PCM 2.2 (4 decks)

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