Geriatrics Flashcards
Mini Mental Scoring Tips
Above 24 is great
Below 18 is bad
18-23 is Mild Impairment
6 Pts: House/Car/Dog
3 for remembering them at the start
3 for remembering them after 5 min
5 Pts Each for:
5 TIME: Date/Month/Hour of which day
5 PLACE: where are we?
5 COUNTING BkWards by 7s
or spelling WORLD backwards
3 Pts: Folding
2 Pts: 2 Object Naming
EVERYTHING ELSE IS 1pt !!!
24-30 = No Cognitive Impairment
18-23 = Mild Cognitive Impairment (MCI)
Below 18 = Severe Impairment
Domains to assess in Elders
Physical
Cognitive
Psychological
Social
Quick Mobility Assessment in Elders
TUG Test
Timed
Up and
Go
3 meters between a chair and a cone. Elder is to rise, navigate around the cone and back to seated in less than 12 (she says 10, 12 is too high) seconds.
May use assistive device
Do 1 practice then 2 tests and average
Drug Classes that Cause MOST of the problems for Elders
• Antidepressants
• Antipsychotic drugs
Anticholinergics
• Cardiac medications
• Hypoglycemic agents
* Benzodiazepines
* Statinsquick Elder test for Leg Strength
CHAIR STAND
Arms Crossed over chest
Raise from seated + Return at least 8X in 30 Seconds
Frailty Criteria
Wt Loss - UN-intentional, over 10 lbs in yr
Exhaustion - Self Described
- Low Energy (low interest/ability)
- Tired
- Weak
Sedentary (expends less than 270KCal female/
or 383 Kcal for males) self report
by activity scale.
Slow - 4 meters in more than 6.2 seconds
Strength - Fewer than 8 chair stands in 30 Sec
The SIXTH vital sign?
Gait Speed
Stay above 4 meters in 6.2 seconds!
Assume Frailty if…
Pt leaves home fewer than 3X / week
Prescribe walking program at the mall or local high school and help Pt ensure transportation.
Prescribe an odometer and make them bring it in at every visit or figure out how to have them send their fit bit results to you via email
You can also get BG record programs that can send to you daily or weekly BG reports via the internet - LEARN HOW TO IMPLEMENT these programs!!
How many steps should a person take a week
5000/week
2000/day
How to open a conversation with an Elder about improving fitness:
“Can you tell me how long you think you’ll live?”
“Ok, so you have ____ good years left, How are you going to use them?”
“To be able to use your remaining years as you’d like, we’ll need to increase your strength and fitness to ensure you have at least some reserve strength to call upon in a crisis such as if you get sick or if you’re injured”
Plan:
1) Assess Gait with 4m/6.2 second test
2) Assess Mobility with the TUG test
3) Assess Strength with the Chair Test
4) Assess for Depression/Dementia and
consider treating for depression
with a geriatric friendly SSRI
5) Catalog Pts complaints: energy, strength
loneliness, comorbidities
6) Review Meds and see what you can
Remove
7) Get them UP and Walking or at least
MOVING in some organized program
Assure Transportation
Consider cardiac rehab - ins may
pay for this and they’d get 6 weeks
with a PT and nurse supervising
their program
8) Make END OF LIFE care plan:
IN WRITING, a DNR if that’s what they
want, a LIVING WILL to spell out
the boundaries of care they wish to
receive. Specifically address:
-CPR
-Resuscitation Drugs like
Epi/Amiodarone/Pressors/Atropine
-NGT/ IV feeding IV fluids
- Oxygen Therapy
-Respirator Support
- Surgeries
- Imaging that would only be helpful
if surgery were a treatment option. If
you’re not going to have a surgery to
correct a situation, don’t do the imaging.
These directives would of course be moot if the patient was alert enough to make each one of these health care decisions. They are to guide the healthcare proxy if the pt is not competent or alert enough to make these decisions. By all means, if alert and the pt falls and an Xray needs to be done, Pt can consent to the X-Ray. If Pt is unconscious and states no imaging that would lead to surgery, well then, no, no X-Ray.
Elders of all ages SHOULD be able to:
Walk (how far?)
Carry (how much?)
Navigate (what obstacles)
Walk 3 blocks, 1/4 mi, 1000 feet
Carry 6.7 lbs
Manage stairs, curbs, getting in + out of the tub
What to do if you discover Pt has Balance problems or Fall Risks?
Write a Prescription for PT with the most Strident therapist you know.
Get them stronger, moving and trained on how to get up after a fall.
What % loss of strength heralds Frailty?
65% is the line so anything above it is in the realm of frailty.
ADLs vs IADLs
ADLs are very basic: Feeding oneself, toileting + bathing.
IADLs allow a person to live independently. Think of the ‘I’ as meaning independence, though it actually stands for instrumental.
Alzheimer’s Disease vs Alzheimer’s Dementia
Alzheimers Disease vs Alzheimers Dementia
The Disease state is brought about by the deposit of beta-amyloid plaques and protein tangles in the brain tissue
This eventually results in cognitive, psychological and social deficits.
Uses/Problems with anticholinergics in elderly
Used to reduce secretions (scopolamine ) and anti spasmodic to slow bowel (Dicyclomine/Bentyl)
scopolamine uses
To counter Clozapine drooling
nausea/motion sickness
Why not use Dipyridamole in Elders?
Causes Orthostatic Hypotension
Short Acting AntiThrombotic (long acting is ok) t
Why not Nitrofurantoin for elders?
If Cr Cl is less than 60, the med doesn’t get concentrated enough in the urine to kill the UTI bug.
It’s renally cleared and if kidneys aren’t functioning, it can build up in the blood to a level that may cause a PULMONARY HYPERSENSISTIVITY rxn that looks a lot like PNEUMONIA or non-cardiogenic pulmonary edema but goes away when the drug is stopped.
To be clear, Nitrofurantoin is great for straight up E.Coli and there’s almost NO RESISTANCE but the kidneys have to work well enough to concentrate the drug in the Urine. Its really an amazing drug that way, does not stay long in the blood at all, goes straight to the bladder.
Its OK in pregnancy UP TO WEEK 38, thereafter it isn’t broken down by the placenta and the fetus has to do it and the fetus doesn’t have the right enzyme to metabolize the drug and could end up getting hemolytic anemia from it. Thats why babies under 1 month should not be given Nitrofurantoin either. They develop the needed enzyme (Glutathione) at about a month.
What CAN we do to Alpha Receptors in the Elderly?
NOTHING
Both Blockers (the rosins) and Agonists (HTN Meds: Clonadine, MethylDopa, Reserpine) cause problems for Elders:
While Alpha Blockers lower BP by BLOCKING A1 Receptors in peripheral vasculature and preventing constriction, they cause ORTHOSTATIC HYPOTENSION for most people. Elders are even more prone to Orthostatic BP falls due to loss of elasticity in their veins and thus get a double whammy
Alpha Agonists lower BP by stimulating ALPHA 2 receptors in the CNS, this then results in RELAXATION of peripheral vasculature. Again, messing around with the diameter of peripheral vasculature in Elders is dicey - their veins just aren’t stretchy or responsive enough anymore and Orthostatic Hypotention will likely result.
Which class of Anti Arrythmics CAN you use in the elderly?
1b: Lidocaine + Phentoin (Dilantin)
ALL class 1 antiarrythmics are Na+ Channel Modifiers.
Class 1a (QUINIDINE, DISOPYRAMIDE) lowers the threshold before the Na+ gates open .
Class 1c: Flecanide + Propophenone, prolongs DePolarization, making it take longer to move a signal along.
Presbycusis
Presbycusis
Presby= Elder (think church) Cusis = think aCOUStic
SARI for Elderly Insomnia
Trazadone
(Serotonin ANtagonist AND Reuptake Inhibitor)
Very nice for Delerium and Insomnia
CAM criteria
Confusion Assessment Method for assessing Delirium
Acute Onset?
Fluctuating mental status?
Must have both for Delirium plus either/or
Disorganized Thinking
and/or
Altered Level of Consciousness
Alert
Drowsy
Stupor
Coma
If they have 1+2 and either 3 or 4, you have Delirium
WHAT is Depakote
It is an ANTI-CONVULSANT but…
Also a Mood Stabilizer, try instead of an antipsychotic in elderly BiPolars/Schitzos
Also helps with headaches and it’s primary use is Anti-Seizure
BPH drugs that cause orthostatic hypotension
Alpha 1 Blockers
Prazosis (Minipress)
Tamulosin (Flowmax)
Cataract risk drug class
Steroids
SSRIs safer for Elders?
Certaline (Zoloft)
Escitalopram (Lexapro)
Dementia wherein Social Graces and Judgment go first
Fronto-Temporal Lobe Dementia or PICKS Dz
shrinks the frontal and temporal lobes visibly on MRI
Caused by protein malfunction, mainly genetic predisposition
Common Infections in the Elderly
Pneumonia
UTI
Shingles
C Dif
Influenza
VRE: Vanco Resistant Enterococcus
Intestines, UTI + Wounds (does live on
skin) Use Dapto & Linezolid
MRSAHow to kill VRE
Daptomycin
Dapto causes Rhabo so watch BUN/Cr
1st Line for MRSA
Vanco
1st line for c Dif
Flagyl or
Vancomycin PO - only PO use of vanco
Influenza Rx
Tamiflu if under 72 hrs (3 days)
Shingles
Acyclovir
Tinnitis, vertigo & fullness in the ear on one side
Meniere’s Dz
Low Salt + Diuretics
Rust Colored Sputum Pneumo:
Strep Pneumo: Macrolide or Doxy
BPPV?
Benign Paroxismal Positional Vertigo
Dix-Halpike TEST is the Dx - Nystagmus on fall back from sitting with legs out
Eply Maneuver is the treatment
Chlamydia Pneumo
Azithromycin or Doxy
Hospital Acquired Pneumo
Vanco + Levofloxacin + Imipenem
Hospital acquired is high risk for multi drug resistance. Risk increases with length of stat, over 5 days fear the worst and hit your pt with all three.
Low Risk: Levofloxacin alone or
Macrolide + 3rd Gen (Azithro + Rocephin)
UTI drugs for elderly
Bactrim DS
Cipro
Nitrofurantoin (GFR over 60)
Cephalexin (Keflex 1st generation Cephalo)
Causes of Low Back Pain in Elders
Arthritis Osteoporosis/Compression Fracture AAA Kidney Infection/UTI Muscle Strain Reticulopathy and/or herniated disc Spinal Stenosis - shopping cart folks Sciatica Cancer mets to the spine
Abd pain in Elders
Mesenteric Colitis/Ischemic Colitis -
High Serum Lactate in late/severe ischemia
AAA
Diverticulitis
Constipation
Ischemic Colitis - CT w/contr, Colonoscopy is Dx
Mesenteric Ischemia - need Angiogram, its a
vessel blockage cau
Mesenteric vs Colonic Ischemia vs Ischemic Colitis?
Mesenteric Ischemia is reduced blood flow to the small intestine and colonic ischemia is obviously reduction in bf to the colon
When the colon has reduced supply, it hurts (colitis) This is visible on a colonoscopy and there may bloody diarrhea - but really you want to do an angiogram to spot the blockage.
Acute onset is usually caused either by a clot (usually a cholesterol clot and pt will have known CAD already) or it can be caused by vasoconstriction of the mesenteric arteries by vasopressors during shock treatment
Chronic onset is usually d/t Atherosclerosis and presents as pain, often @ splenic flexure or left side, 15-30 min after a meal lasting 6 hours, throughout the attempt at digestion. There is
Mesenteric is decreased blood flow to the sm bowel
Acute: clot Abdominal Pain out of proportion to the exam, narcotics don’t help
Chronic: Atherosclerosis
Colonic is decreased blood flow to the colon
Pain and discomfort often at the splenic flexure with bloody Diarrhea (red)
Unilateral Tinnitis, Unilateral Facial paralysis and gradual unilateral hearing loss
Acoustic Neuroma: Tumor on Cr 8
Get MRI
Glycemic Agents most likely to cause Hypoglycemia
Sulfonureas: Glipizide, Glimeperide
Insulin
Braden Scale
Predicts Pressure Point Risk:
1) Does Pt FEEL pressure?
2) Is area exposed to MOISTURE?
3) Is Pt IMMOBILE?
4) Does Pt EAT enough?
5) Friction & Shear - can Pt move himself over
the sheets of must he be dragged?
Staff should use a draw sheet to move
such a patient to prevent friction + shear
4 levels of skin break down
1) Hyperemia - redness occurring after an 30 minutes of pressure, disappears an hour after pressure is removed. BLANCHABLE
2) Ischemia - O2 starvation caused by 2-6 hours of continuous pressure. Hurts - may take 36 hrs to disappear LESS BLANCHABLE
3) Necrosis - Cell death occurring after 6 hrs of continuous pressure. Skin turns blue/grey and indurated (hard). NON-BLANCHABLE
4) Ulceration - occurs days up to 2 weeks after Necrosis, may become infected
Staging of DeCubitus/Pressure Ulcers
Stage 1) Red, blanchable, Skin intact
Stage 2) Skin not intact, blister/ulcer through epidermis/superficial dermis. Blanchable because blood supply in deep dermis is not yet compromised
Stage 3) Blood Supply, nerves and glands are eaten through all the way to the muscle. Non-Blanchable and usually not painful because the nerves are dead. Slough is classic stage 3 though if it obscures the bottom of the sore, it makes the wound unstagable
Stage 4) Through the Muscle to the Bone. Slough + Eschar may be present
UnStagable - you cannot see the “bottom” of the ulcer - slough or eschar in the way
Slough vs Eschar
Slough is classic stage III, white (uninfected) to yellow/green/brown (varying stages of infection) stringing goo which could possibly be taken for connective tissue/tendon but isn’t.
Eschar is black. If you see anything black, its eschar. Early eschar is HARD but once bacteria set it, it gets boggy + soft. Late eschar is soft and known as UNSTABLE ESCHAR.
Why not give Haloperidol (Haldol) IV?
It is a cardiac risk in the elderly (and the NP said in everyone)
Give it IM in Dementia Emergencies
Its an antipsychotic and an anti-emetic
incontinence associated with BPH
Over Flow
In Females, Overflow is usually caused by a neural problem like MS or Diabetic Neuropathy.
It could also be caused in females or males by a urethral stricture that makes emptying a problem such that the bladder swells beyond its capacity with overflow leaking out.
Bladder retention could be the issue in either sex, look for an anticholinergic medication that could cause urinary retention.
Of course, the overfull bladder can reflux urine up into the kidney if it can’t dribble it out the urethra.
Urge Incontinence caused by
Over Active Bladder, UTI or even uterine prolapse in females
Rx is an Anticholinergic to relax the detrusor muscle
Functional Incontinence
The water works are fine but GETTING to the bathroom is difficult.
Regular toileting with assistance or a commode should help.
Perhaps PT to increase strength and pain control? Loose those statins if they’re on board to stop any rhabdo/weakness they may be causing.
Stress incontinence
MOST COMMON incontinence in females
pelvic floor and sphincter muscles weaken as well as uterine prolapse.
Obesity inherently weakens the pelvic floor and is a huge risk for stress incontinence.
If prolapse, Hysterectomy may help, Kegals, even some stem cell inoculation of the sphincter muscle is being done in europe, not here though. Have to travel. New mycotes form and their strong + young!
Oxybutynin, used for what?
Tolteradine
Incontinence control
Anticholinergics, both blocks muscarinic receptors and prevent contraction of smooth muscle.
Oxybutynin blocks all 3 Muscarinic receptors and is 1/5 as strong as Atropine.
Tolteradine only blocks M2 + M3
Causes the whole host of Anticholinergic (Mad as a Hatter, dry as a bone, hot as a hare, blind as a bat, red as a beet) rxns
ALWAYS clear closed angle glaucoma before using, NEVER with MYASTHENIA GRAVIS
Will worsten overflow incontinence as it will cause further stasis of the detrusor.
INCONTINENCE RISKS
Female Fat SMOKING Childbirth Post Menopausal Estrogen Defecit BPH or Prostatitis Diabetes Nerve Disorders: MS, Spinal Trauma
Meds that cause incontinence
All the Antis:
Anticholinergics Antihistamines Antidepressants Antipsychotics Benzos
Alpha Agonists: Pseudophedrine can cause the sphincter to constrict causing overflow
Alpha Blockers: Zosins may over relax the prostate….
Colchecine can cause urge incontinence
Diuretics may lead to large volumes being introduced into the bladder on short notice, increasing functional and or urge incontinence
Avoid meds that end in:
Ine One Ide BiTal Pam Poxide Zosin
-ine likely anticholinergic
-one antispasmodics/ amiodarone-esq anti
arrhythmic and HORMONES
-ide antiarrythmics + Sulfonureas
-bital phenobarb sedatives, OD risk esp
in liver dz/compromise
-Pams or -Poxides = Benzos reduced
elimination increases fall/delirium risk
- All NSAIDS and Aspirin cause gastric ulcers
take with omeprazole if they must
be given
Choral Hydrate
Bad for Elderly
Its an Insomnia med./ hypnotic
Replace with Trazadone (an SARI) for sleepless delirium
Emergent Eye 911
Acute Closed Angle Glaucoma
Presentation:
Elderly w/presbyopia but no dx of glaucoma.
Boring, periorbiatal pain w/vision deficits
HA on same side as eye pain
N/V may occur
Anticholinergics can cause it as can dim lighting (emerging from movie theater..)
Cause prolonged QT
TriCyclics - brugada like formations on keg
Erythromycin
TUG test for
Mobility in under 10 seconds
Timed Up + Go
Around the cone and back in under 10!
Most common Elder fractures
Hips Wrists + Spine
drugs above which an elder is thought to risk polypharmacy
4
START + STOPP Criteria
Beyond Beers criteria for elder drug problems incorporates replacements
SSRI risk in Elders
Hyponatremia
DON’T use Prozac or Paxil
Do try Certaline (Zoloft) or Lexapro instead
Accurately assesses Delirium in 95% of cases
CAM Assessment
Confusion Assessment method
Acute Onset change in mental status
Change fluctuates throughout interview
_______________________both required____
Disorganized Thinking
Hallucinations
Sleep Wake reversal
_______ 2 required________________
Alternative to antipsychotic for elders
Depakote is (believe it or not) safer
Deficits in cognition without deficits in ADLs
Mild Cognitive Impairment
Hospice vs Palliative Care
Hospice: Terminal Dx required, no aggressive life saving methods, pain management
Palliative: No particular Dx required, aggressive life saving possible
Mild pain in elders
Tylenol (day) or Tramadol (night w/depends)
Don’t exceed 300mg of Tramadol daily in Pts over 75
Celecoxib + Miloxicam are cox2 selective NSAIDS which could be used
If using benzos to sleep, do use depends to
prevent falls
New things you get to SCREEN for on the Welcome to Medicare Exam since 2012
1X Carotid doppler between 65-66
1X AAA Abd Doppler between 65-66
Falls on the Butt cause
Spinal Compression Fracture
Look to see that spine gets wider as you go down, pay attention to suspicious looking vertebrae
Med that Causes Tinnitis
Aspirin
Use this to cleanse pressure ulcers
Dakin Soln (Sodium Hypochlorite - bleach)
Weak bleach debrides and disinfects gently, then apply wet to dry dressings moistened with NS.
If you hear bruits…
GET A CAROTID DOPPLER
Dementia Risks
Age Poor Lifestyle Low Education Mental Retardation Syphyllis Head Trauma aPO e4 mutation Presenillin 1 mutation for early onset ALZ
Never give Haldol/Haloperidol ….
IV to Elders
Also use a reduced dosage in elders 0.5-1mg only
Look like dementia
Depression Hearing loss Syphyllis Hypothyroid Thymine/B9 and B12 Deficiency TBI
Common Hospital Rx that precipitates Dementia
Anesthesia
Significance of Presenilin 1 Mutations
Present in 70% of early onset Alzheimers
Rispridol risk
Causes stroke in elders, use Quetiapine instead for antipsychotic/Schitzo/Disordered thought in elders
Never use Memantine with
Lasix
Its an NMDA Blocker used in Alzheimers and Parkinsons
aka Namenda
monitor renal function if using memantine in elders
1 Cause of delirium in Alz Pts
UTI
See delirium, check UA/UC
Metamucil for elders?
NO!
Give colace or prune juice + increase fluids!
Delirium Protocol
LET THEM SLEEP!
-No Vitals at night
-No TV after 8
-No Nonemergent Labs at night
-Promote Day/Night orientation with window
shades up during day
--Assist with meals + offer snacks
-Get up out of bed for all meals
-Bladder scan if no urine in 6 hrs, strait
cath if retention is identified
-Notify MD if no BM 3 days
-Offer fluid dq2hs unless NPOElders should be able to walk/carry/navigate:
3 blocks (1000 feet)
carry 6.7lbs
navigate stairs curbs in + out of tub
This %age loss = Frailty
65% of strength lost
Unintentional Wt loss of 10+ lbs in last year
Exhaustion
Sedentary/Sitting
less than 8 chair stands in 30 seconds
Opiates Nifedapine Antihistamines 1st gen Anticholinergics Antipsychotics Tricyclics
All Cause constipation
The Sixth Vital Sign
GAIT 4 meters in less than 6.2 seconds
Contraindication to Dementia Dx
Delirium
Delirium Dx
Rapid onset w/fluctuating course
Primary deficit is attention, not memory
Dementia can coexist
May be Hypo or Hyper Active
Digoxin dose
Don’t exceed 0.125 mg/day
Risk: Brady with the sloped RS wave
Dialysis is…
DANGEROUS!!!
The 1st 6-12 months is very likely to kill you
infection risk AV fistula risk Lethargy Pain Itching Dizziness GI Disturbance Torsades Peritonitis (for Peritoneal dialysis)
PVD - Peripheral Vascular Dz encompasses
Arterial Dz: 1) Atherosclerosis 2) Smoking Damage to arterial wall elasticity Lower legs are 3) Reynauds
SXS: Dusky Cool Extremities & Claudication. Dangling should make it better, elevation makes it worse. More likely to be unilateral than venous dz.
Venous Dz:
1) Chronic Venous Insufficiency: Valve Damage leads to swelling, edema, bronzing in feet, calves
2) DVT
3) PE
4) Thrombophlebitis
5) Varicose Veins
SXS: Bronzing, Itching + Edema, dull achy, cordy varicosities
Hyponatremia:
Normal Range Na+?
Signs + Sxs
Common Causes in Elderly?
Normal Na+ is 135-145 mEq/L
Signs + Sxs of hyponatremia range from nausea + malaise all the way to altered level of consciousness, seizure + coma d/t brain edema and even brain herniation and death!
Antipsychotics and Diuretics are often the culprit as well as OVERHYDRATION and low salt diet. Thiazides are more prone to causing low Na+ than are LOOPS. Ultraendurance runners, especially females are candidates for hypo Na+ as are post surgical pts (d/t irrigation and or over hydration)
ORGAN FAILURE: CHF, Liver, Renal as well as Pneumonia are common causes of Hyponatremia
Get Orthostatic Bps, a CBC/CMP to establish volume status and do a full exam with special eye out for CHF, Renal and Liver issues.
Consider Volume Overload (if on IV or a renal patient) Consider Cerebral Salt Wasting CSW caused by increased ICP d/t cerebral hemorrhage of swelling and consider the Kidneys a very likely source for the problem.
Don’t forget to consider SIADH (syndrome of inappropriate ADH secretion) if there is no CHF, no renal dz or impairment, no liver impairment and no thyroid impairment and urine osmolarity is over 100, more like 400-500.
Alpha 2 Agonists
Central HTN control
Clonadine
Reserpine
Methyl Dopa
May cause orthostatic hypotension as well as bradycardia
Amiodarone
Pulmonary Fibrosis
Antipsychotics
Stroke risk
Pilocarpine
Cholinergic (OK to use)
for
Open Angle Glaucoma
Peripheral vision loss, increased cup to disc ratio. Pilocarpine causes constriction of the pupil opening up the schwaans canal
Early/Late Alzheimers
Donepezil
Rivastigmine - aCHesterase inhibitor
Can also use in parkinsons
late: Memantine (not with lasix, renal risk)
