Geriatrics Flashcards
leading causes of death >65 y/o
coronary heart disease 31% cancer 20% CVA COPD pneumonia/flu
leading cause of disability >65 y/o
arthritis HTN hearing impairments heart impairments catcalls and chronic sinusitis orthopedic impairments diabetes and visual impairments
aging changes: cell, tissue, organ
cellular changes:
- increase in size
- decrease in cell capacity to divide and reproduce
- arrest of DNA synthesis and division
tissue changes:
- accumulation of pigmented materials, lipofuscins
- accumulation of lipids and fat
- CT changes: decreased elastin, degradation of collagen
Organ changes:
- decrease in functional capacity
- decrease in homeostatic efficiency
primary regulators of aging:
hypothalamus, pituitary gland, adrenal gland
muscular changes of aging
**may be due more to decreased activity levels (hypokinesis) and disuse than from aging process
loss of muscle strength
- peaks at age 30-50
- accelerating loss (20-40% by 65 in non-exercising adult)
loss of power (force/unit time)
-significant losses in speed of contraction, changes in nerve conduction and synaptic transmission
loss of skeletal muscle mass (atrophy)
- both size and # of muscle fibers decrease
- by age 70 loss of 33% muscle mass
changes in muscle fiber composition
- selective loss of fast twitch fibers
- increase proportion of slow twitch
changes in muscular endurance
- decreased muscle tissue oxidative capacity
- decreased peripheral blood flow, oxygen delivery to muscles
- altered chemical composition; decreased ATPase, glycoproteins and contractile protein
- collagen changes: denser, irregular, loss of water content and elasticity- affects bone, tendons, cartilage
skeletal changes of aging
cartilage changes:
- decreased water content, becomes stiffer, fragments and erodes
- by age 60 >60% have degenerative joint changes, cartilage abnormalities
loss of bone mass and density::
- peak bone mass at age 40
- between 45-70, bone mass decreased (in women by 25%, 15% in men)
- loss of calcium and bone strength, especially trabecular bone
- decreased bone marrow RBC production
intervertebral discs:
-flatten, less resilient due to loss of water content (30% loss by age 65) and loss of collagen elasticity; trunk length, overall heigh decreases
senile postural changes: -FHP - kyphosis of thoracic spine flattening of lumbar spine with prolonged sitting, tendency to develop hip and knee flexion contractures
Neurological changes with age
atrophy of nerve cells in cerebral cortex
- overall loss of cerebral mass/brain weight of 6-11% between 20-90
- accelerated loss after age 70
changes in brain morphology
- gyral atrophy
- ventricular dilation
- generalized cell loss in cerebral cortex
- presence of lipofuscins, senile or neuritic plaques, and neurofibrillary tangles: significant accumulations associated with pathology (alzheimer’s)
- more selective cell loss in BG (substantia nigra and putamen), cerebellum, hippocampus, locus coeruleus
decreased cerebral blood flow and energy metabolism
changes in synaptic transmission
- decreased synthesis and metabolism of major neurotransmitters (ACh, dopamine)
- slowing of many neural processes, especially in polysynaptic pathways
changes in SC/peripheral nerves
- neuronal loss and atrophy: 30-50% loss of AHC, 30% loss of posterior roots by age 90
- loss of motoneurons results in increase in size of remaining motor units
- slowed nerve conduction velocity: sensory> motor
- loss of sympathetic fibers: may account for diminished, autonomic stability, increased incidence of postural hypotension in older adults
age related tremors (essential tremor)
- isolated symptoms- hands, head, voice
- exaggerated by movement and emotion
sensory changes with age
Vision:
Hearing:
Vestibular/balance control
somatosensory
taste and smell
-gradual decrease in taste sensitivity
-decreased smell sensitivity
(smokers, chronic allergies, respiratory infections, dentures, CVA -hypoglassal involvement)
vision changes with age
decline in visual acuity, accommodation, color discrimination, cornea reflex
Additional vision loss with pathology:
- cataracts
- glaucoma
- senile macular degeneration
- diabetic retinopathy
- CVA- hemianopsia
meds: impaired or fuzzy vision may result with antihistamines, tranquilizers, antidepressants, steroids
hearing changes with age
Outer ear:
-build up of cerumen (earwax) results in conductive hearing loss- common in older men
Middle ear:
-min degenerative changes of bony joints
Inner ear:
-significant changes in sound sensitivity, understanding of speech, and maintenance of equilibrium may result with degeneration and atrophy of cochlea and vestibular structures, loss of neurons
Types of hearing loss
- conducting hearing loss
- sensorineural hearing loss
- presbycusis hearing loss
Hearing loss with pathology:
- Otosclerosis: immobility of staples results in profound conductive hearing loss
- Paget’s disease
- Hypothyroidism
Vestibular/balance changes with aging
- degenerative changes in otoconia of utricle and saccule
- loss of vestibular hair-cell receptors
- decreased # of vestibular neurons
- VOR gain decreases
begins at age 30, accelerated decline 55-60
- diminished acuity, delayed reaction times, longer response times
- reduced function of VOR; affects retinal image stability with head movements, produces blurred vision
- altered sensory organization: older adults more dependent on somatosensory inputs for balance
- less able to resolve sensory conflicts when presented with inappropriate visual or proprioceptive inputs due to vestibular losses
- postural response patterns for balance are disorganized: characterized by diminished ankle torque, increased hip torque, increased postural sway
Additional loss of vestibular sensitivity with pathology:
- Meniere’s disease
- BPPV
- meds
- CVA
- cerebellar dysfunction
- migraine
- cardiac disease
Somatosensory changes with age
decreased sensitivity of touch associated with decline of peripheral receptors, atrophy of afferent fibers; LEs more affected than UE
proprioceptive losses, increased thresholds in vibratory sensibility (beginning around age 50); greater in LEs than UE
loss of joint receptor sensitivity; losses in LE, cervical joints may contribute to LOB
cutaneous pain thresholds increased: greater changes in upper body areas (UEs, face) than in LEs
Additional loss of sensation with pathology:
- diabetes, peripheral neuropathy
- CVA, central sensory losses
- peripheral vascular disease, peripheral ischemia
cataracts
opacity, clouding of lens d/t changes in lens proteins; results in gradual loss of vision- central first than peripheral
- increased problems with glare
- general darkening of vision
- loss of acuity
- distortion
glaucoma
increased intraocular pressure, with degeneration of optic disc
- atrophy of optic nerve
- results in early loss of peripheral vision (tunnel vision)
- progresses to total blindness
senile macular degeneration
loss of central vision associated with age related degeneration of the macula, compromised by decreased blood supply or abnormal growth of blood vessels under the retina
- initially patients retain peripheral vision
- may progress to total blindness
diabetic retinopathy
damage to retinal capillaries
- growth of abnormal blood vessels and hemorrhage leads to retinal scarring and finally retinal detachment
- central vision impairment
- complete blindness is rare
homonymous hemianopsia
loss of half of the visual field in each eye
- nasal half of one eye and temporal half of other eye
- -produces an inability to receive info from R or L side
- corresponds to side of sensorimotor deficit
impaired or fuzzy vision may result with which common meds?
antihistamines
tranquilizers
antidepressants
steroids
conductive hearing loss
mechanical hearing loss from damage to external auditory canal, tympanic membrane, or middle ear ossicles
results in hearing loss (all frequencies), tinnitus, may be present
sensorineural hearing loss
central or neural hearing loss from multiple factors
- noise damage
- trauma
- disease
- drugs
- arteriosclerosis
presbycusis hearing loss
sensorineural hearing loss associated with middle and older ages
characterized by bilateral hearing loss, especially at high frequencies first, then all
-poor auditory discrimination and comprehension, especially with background noise; tinnitus
presbyopia
visual loss in middle and older ages characterized by inability to focus properly and blurred images due to loss of accommodation, elasticity of lens
Meniere’s disease
episodic attacks of characterized by tinnitus, dizziness, and a sensation of fullness or pressure in the ears
also experience sensorineural hearing loss
Benign paroxysmal positional vertigo
BPPV
brief episodes of vertigo (
common meds with vestibular side effects
antihypertensives -postural hypotension
anticonvulsants
tranquilizers
sleeping pills
aspirin
NSAIDS
cognition changes with age
changes typically >mid 60s
significant declines 80s
*most significant in years preceding death
decreased perceptual speed
impaired numerical abilities
memory: short term first, task specific
cardiovascular changes with age
- may more more d/t inactivity and disease than aging
degeneration of heart muscle with accumulation of lipofuscins (characteristic brown heart); mild cardiac hypertrophy, L ventricular wall
decreased coronary BF
cardiac valves thicken and stiffen
changes in conduction system: loss of pacemaker cells in SA node
changes in blood vessels: arteries thicken, less distensible; slowed exchange through capillary walls; increased peripheral resistance
resting BP rise: SBP>DBP
decline in neurohumoeral control: decreased responsiveness of end organs to beta adrenergic stimulation of baroreceptors
decreased blood volume, hemopoietic activity of bone
increased blood coagulability
decreased SV d/t decreased myocardial contractility
max HR declines with age
CO decreases 1% per year after age 20 d/t decreased HR and SV
orthostatic hypotension: common in elderly d/t reduced baroreceptor sensitivity and vascular elasticity
possible ECG changes: longer PR and QT intervals, wider QRS, increased arrhythmias
pulmonary changes with age
chest wall stiffness- declining strength of respiratory muscles results in increased work of breathing
loss of lung elastic recoil, decreased lung compliance
changes in lung parenchyma: alveoli enlarge, become thinner; fewer capillaries for delivery of blood
changes in pulmonary blood vessels: thicken, less distensible
decline in total lung capacity: RV increases, VC decreases
forced expiratory volume (airflow) decreases
altered pulmonary gas exchange: oxygen tension falls with age
blunted ventilatory responses of chemoreceptors in response to respiratory acidosis: decreased homeostatic responses
-blunted defense/immune responses: decreased ciliary action to clear secretions, decreased secretory immunoglobilins, alveolar phagocytic function
*clinical signs of hypoxia are blunted; changes in mentation and affect may provide important cues
cough mechanism is impaired
gag reflex is decreased, increased risk of aspiration
prolonged recovery from respiratory illness
integumentary changes in age
changes in skin composition:
- dermis thins with loss of elastin
- decreased vascularity; vascular fragility results in easy brushing (senile purpura)
- decreased sebaceous activity and decline in hydration
- appearance: skin appears dry, wrinkled, yellowed and inelastic; age spots appear
- general thinning and graying of hair due to vascular insufficiency and decreased melanin production
Loss of effectiveness as protective barrier:
- skin grows and heals more slowly, less able to resist injury and infection
- inflammatory response is reduced
- decreased sensitivity to touch, perception of pain and temp; increased risk for injury
- decreased sweat production with loss of sweat glands results in decreased temp regulation and homeostasis
GI changes in age
decreased salivation, taste and smell
-inadequate chewing (tooth loss, poorly fitting dentures), poor swallowing reflex may lead to poor diet, nutritional deficiencies
esophagus: reduced motility and control of lower esophageal spincter; acid reflux and heartburn, hiatal hernia common
stomach:
- reduced motility, delayed gastric emptying
- decreased digestive enzymes and hydrochloric acid
- decreased digestion and absorption
- indigestion common
decreased intestinal motility
-constipation common
Renal system changes with age
kidneys
- loss of mass and total weight with nephron atrophy, decreased renal BF, decreased filtration
- blood urea rises
- decreased excretory and reabsorptive capacities
bladder:
- muscle weakness
- decreased capacity, causing urinary frequency
- difficulty with emptying, causing increased retention
- urinary incontinence common
- increased likelihood of UTI
osteoporosis
disease process resulting in reduction of bone mass
- failure of bone formation (osteoblast) to keep pace with bone reabsorption and destruction (osteoclast)
- high risk of fractures
- trabecular bone more than cortical; common areas: vertebrae, femoral neck, distal radius/wrist, humerus
osteoporosis= BMD >2.5SD below young, normal mean
osteopenia= BMD between 1-2.5 SD below the mean
Etiology:
- hormonal deficiency associated with menopause and hypogonadism (estrogen and androgen)
- age related deficiencies
- nutritional deficiency: calcium, excessive alcohol & caffeine
- decreased physical activity/mechanical loading
- diseases that affect bone loss: hyperthyroidism, diabetes, hyperparathyroidism, rheumatic disease (lupus), celiac disease, gastric bypass, pancreatic disease, multiple myeloma, sickle cell, end stage renal disease, Paget’s disease, cancer, and chemotherapeutic drugs
- meds that affect bone loss: corticosteroids, thyroid hormone, anticonvulsants, catabolic drugs, some estrogen antagonists, chemotherapy
- additional risk factors: family history, caucasian/asian, early menopause, thin/small build, smoking
common pathological conditions associated with the elderly
MS:
- osteoporosis
- fractures
- degenerative arthritis (osteoarthritis)
Neurological:
- stroke
- degenerative diseases: PD
Cognitive disorders:
- delirium
- dementia
- depression
Cardiopulmonary disorders:
- HTN
- CAD
- PVD
- chronic bronchitis
- COPD
- asthma
- pneumonia
- lung cancer
Integumentary:
-pressure ulcers
Metabolic pathologies:
-Diabetes
Fractures
*high risk associated with low BMD, age, comorbid diseases, dementia, psychotropic meds
Hip fracture:
~50% won’t resume pre-morbid level of function
95% are femoral neck fractures or intertrochanteric
vertebral compression fractures:
- T8-L3
- typically from routine activity: bending, lifting, standing
- child complaint: immediate, severe local spinal pain, increased with trunk flexion
Stress fractures:
- in elderly common in pelvis, proximal tibia, distal fibula, metatarsal shafts foot
- observe for local tenderness and swelling
UE fractures: humeral head, Colle’s fracture
Degenerative arthritis
osteoarthritis
noninflammatory, progressive disorder of joints
- typically hips, knees, fingers and spine
- pain swelling and stiffness (>AM) or with overuse
- muscle spasm
- loss of ROM and mobility; crepitus
- bony deformity
- muscle weakness secondary to disuse
delirium
fluctuating attention state causing temporary confusion and loss of mental function
-acute disorder, potentially reversible
Etiology:
- drug toxicity and/or systemic illness, oxygen deprivation to the brain
- environmental changes and sensory deprivation
S&S:
- acute onset, often at night; fluctuating course with lucid intervals; worse at night
- duration: hours to weeks
- may be hypo or hyper alert, distractible; fluctuates over course of day
- impaired orientation
- illusions/hallucinations
- memory deficits: immediate and recent
- disorganized thinking, incoherent speech
- sleep/wake cycles always disrupted
dementia
loss of intellectual functions and memory, causing dysfunction in daily living
Criteria:
- deterioration of intellectual functions
- disturbance in higher cortical functions: language (aphasia), motor skills (apraxia), perception (agnosia)
- memory impairment: recent and remote
- personality changes: alteration or accentuation of premorbid traits
- alertness is usually normal
- sleep often fragmented
- mini-mental
Alzheimer’s disease
10-20% of >65 y/o population
generalized atrophy of brian with decreased synthesis of neurotransmitter, diffuse ventricular dilation
Types:
- senile dementia, alzheimer’s type (SDAT): onset >60 y/o
- presenile dementia (PDAT): onset 40-60 y/o
S&S:
- dementia: insidious onset, with generally progressive deteriorating course
- periods of agitation and restlessness, wandering
- sundowning syndrome: confusion and agitation increases in late afternoon
multi infarct dementias
20-25% of dementias
etiology: small and large vascular infarcts in both gray and white matter of brain, producing loss of brain function
S&S:
- sudden onset rather than insidious; step wise progression
- spotty and patchy distribution of deficits; areas of preserved ability along with impairments
- gait and balance abnormalities, weakness, hyperreflexia
- emotional lability common
- associated with history of stroke, cardiovascular disease, HTN
depressive symptoms
nutritional problems
sleep disturbances
psychomotor changes: inactivity with resultant functional
impairments, weakness or agitation
fatigue or energy loss
feelings of worthlessness, low self esteem, guilt
inability to concentrate, slowed thinking, impaired memory, indecisiveness
withdrawal from family and friends, self neglect
recurrent thoughts of death, suicidal ideation
decline in cognitive function
CAD
40% of ppl 65-74 y/o and 50% >75
Angina: not always a consistent indicator of ischemia in elderly
-SOB and ST segment depression may be more reliable
Acute MI:
- clinical presentation may vary from younger adults
- may present with sudden dyspnea, acute confusion, syncope
- double mortality rate
conduction system diseases: pacemaker dysfunction results in low CO
pneumonia
initial symptoms may vary
-instead of high fever and productive cough, may see altered mental status, tachypnea, dehyrdration
diabetes
aging associated with deteriorating glucose tolerance
-type 2 affects as 10-20% over age of 60
associated with obesity and sedentary lifestyle
adverse drug reactions for elderly
confusion/dementia
sedation/immobility
weakness
postural hypotension
depression
drug induced movement disorders
- dyskinesias
- akathisia
- esstential tremor
- parkinsonism
incontinence
meds that can cause confusion/dementia in elderly
tranquilizers barbiturates digitalis antihypertensives anticholinergics analgesics antiparkinsonians diuretics beta blockers
meds that cause sedation/immobility in the elderly
psychotropics
narcotic analgesics
meds that cause weakness in elderly
antihypertensives vasodilators digitalis diuretics oral hypoglycemics
meds that cause postural hypotension in the elderly
antihypertensives diuretics antidepressants tranquilizers nitrates narcotic analgesics
meds that cause depression in elderly
antihypertensives antiinflammatories antimycobacterials antiparkinsonians diuretics vasodilators
drugs that induce movement disorders in elderly
Dyskinesias:
- long term use of neuroleptic and anticholinergics
- levodopa
Akathisia: motor restlessness
- antipsychotics
Essential tremor:
- antidepressants
- adrenergic drugs
Parkinsonism:
- antipsychotics
- sympatholytics
drugs that cause incontinence in elderly
barbiturates
benzothiazides
antipsychotics
anticholinergics
