geriatrics Flashcards
Characteristics that protect you when you are young may not protect you when you are past your reproductive years
(antagonistic pleiotropy)
theories of aging
mutation acculumation (loss of proofreading), mitochondrial dysfunction (extra free radicals from oxidation), telomere shortening, dysregulation of cell cycle (loss of cell cycling and uncontrolled cycling)
reduced ability to maintain homeostasis
Homeostenosisis
physiologic changes in CV system of aging
o Basement membranes thicken around capillaries→ impaired diffusion
o Decreased compliance of aorta=HTN, increased pulse pressure and SVR
o Decreased sensitivity of baroreceptors
o Decreased CO and EF→ decrease coronary flow
o Decreased efficacy of Frank-Starling mechanism
physiologic changes in respiratory system of aging
o Decreased elastin and elastic recoil, early airway closure, can’t get air=obstruction
o Enlargement of alveoli →increased residual volume, decreased vital capacity
o Increased mucus, decreased cilia→ pneumonia
o More V/Q (vent/perfusion) mismatch→ slightly increased Pc02 and lowerd pH
physiologic changes in electrolyte system of aging
o Decreased GFR and can’t concentrate as well=peeing in middle of night
o Decreased thirst drive→ dehydration
o Decreased renal excretion of magnesium and increased laxatives causes hypermagnesemia→ too much membrane stabilization→ dysrhythmias, hypotension, drowsiness, decreased breathing, muscle weakness, constipation, polyuria
physiologic changes in renal system of aging
o Decreased GFR from atrophy of neurons d/t decreased blood flow→ overmedicated
o Decreased tubular reabsorption→ more urine→ nocturia
o Decreased drinking and decreased innervation of bladder→ incontinence
oral heaalth changes in aging
o Loss of enamel→ tooth loss
o Decreased saliva→ dry mouth and bad breath
o Decreased taste buds→ decreased taste, less eating → malnutrition
GI changes in aging
o Decreased replication of cells that secrete digestive enzymes, decreased mucosal cells→ decreased absorption
o Loss of muscle tone→ difficulty swallowing, delayed emptying, constipation, fecal incontinence
liver changes in aging
o Decreased enzymes→ decreased drug metabolism
o Alcohol dependency→ decreased liver function
metabolism changes in aging
o Less ability to burn glucose and secrete insulin→ DM
o Decreased Basal metabolic rate
o Decreased ability to sweat and thermoregulate
immune changes in aging
o Decreased T cell function→ increased infections
neuro changes in aging
o Decreased cerebral blood flow→ brain atrophy
o Decreased # of neurons→ decreased reaction time and decreased muscular coordination
o Decreased neurotransmitters→ tremor
o Altered sleep→ insomnia
special senses changes in aging
o Decreased high pitched hearing
o Decreased smell and taste
o decreased lens accommodation→ presbyopia and dryness
pain changes in aging
o More disease process→ more pain
skeletal system changes in aging
o Decreased deposition and increased resorption→ osteoporosis
o Dehydration of intervertebral discs→ decreased stature
o Erosion of cartilage→ joint pain, osteoarthritis
muscle changes in aging
o Atrophy→ decreased strength and endurance
sex changes in aging
o Don’t assume they aren’t interested!
o Prostate enlargement
o ED
o Vaginal dryness
factors affecting driving in older aduls
- Poor visual acuity and contrast sensitivity
- Dementia
- Impaired neck and trunk rotation
- Limitations of shoulders, hips, ankles
- Foot abnormalities
- Poor motor coordination and speed of movement
- Medications and alcohol that affect alertness
important aspects of social hx in older adults
support system, caregiver burden, economic well being, mistreatment, advance directives, spirituality, home safety
3 components of why people fall
biomechanical, neuromotor, sensory (sensation, vestibular, visual)
3 components of sensory component of why people fall
vision, sensation, vestibular
evolution of falls
history: circumstances, meds, fear of falling, comorbidities
PE: orthostatic BPs, eval of sensory systems–vision, sensation, vest., neuro assessment, cognitive assessment, timed up and go test
cut off for “falls risk” with timed up and go test
>
- 5 seconds
4 ds of aging
dementia, delirium, depression, dying
older adults that are at risk of abuse
- Female
- Advanced age
- Dependent
- Problem drinker
- Intergenerational conflict
- Internalizes blame
- Excess loyalty
- Past abuse
- Stoicism
- Isolation
- Impairment
- Provocative
high risk caregivers
- Problem drinkers, med abuse
- Mental illness
- Caregiving inexperience
- Economically troubled
- Stressed
- Socially disengaged
- Blames others
- Abused as child
- Unsympathetic, hypercritical
- Unrealistic
signs ofabuse
- Frequent unexplained crying
- Unexplained suspicion or fear
- Physical findings
- Pattern bruises
- Genital, breast or anal bruising
- Contractures
T or F: you need to prove elder abuse to report it
F–adult protection will investigate
or which situations should screening tests for older adults not be followed?
low life expectancy or high comorbid conditions: • CHF (Class III, IV), ESRD, Severe COPD (home O2), Severe dementia (MMSE
rec’d breast cancer screening
every 2 years 50-74 +/- clinical breast exam (not hard evidence for it in this age group)
how to decide life expectancy of an older adult?
if many comorbidities “below average” if no comorbidities or few and high functional status “above average”
colorectal cancer screening in older adults
50-75 every 10 years with one of the 7 methods. after 75 perform screening on individual basis with RFs
cut off for cervical cancer screening
65 with 3 normal paps and not high risk
osteoporosis screen
at least once after 65 for women, 70 for men
BG screen in those over 65
every 3 years in those with BP > 135/80
AAA ultrasound in those over 65
Once for men 65–75 years who ever smoked
cholesterol screen in those over 65
Every 5 years, more often in CAD, DM, PAD, prior CVA
what health screens should be done every year in those > 65?
height, weight, BP, TSH in women, physical activity, smoking cessation, sexual activity, falls, incontinence, cognition, depression, vision and hearing, BMI, safety and preventing injury (including health care directives), influenza
when to screen for alcohol abuse in > 65 years?
initially and then when suspect abuse
T or F: there are no RCTs demonstrating a beneficial effect of multivitamins in the elderly
T
is hormone therapy recommended in those >65?
no
T or F: most biochemical measures are normal in older adults and aren’t a good measure of nutrition
T
T or F: serum proteins (albumin) are a good measure of nutritional status in older adults
F. albumin affected by many things
t or F: chronic medical problems usually have a concurrent nutritional problem
T! see percentages of malnourished by disease in geriatric nutrition lecture
diseases that have risk of malnutrition
RA, COPD, renal failure, heart failures, stroke, dementia, hip fx, cognition issues
psychosocial issues that impair good nutrition intake in older adutls
depression, substance/etoh abuse, loneliness, isolation, decreased function, moving, poverty, end of life
how medications can impair intake in older adults
dry mouth, nausea, effect taste perception, decreased appetite
causes of significant rapid weight gain in older adults
renal or heart failure, ascites, edema
goal for obese older adults
maintain rather than gain (not lose–will lose lean muscle instead of fat)
T or F: in older adults BMI 25-30 is most protective
T! esp with chronic dz like HF or COPD
components of frailty syndrome (need 3 or more)
Weight loss >4.5 kg in past year Exhaustion – often or most of the time Very low to no physical activity Low walking speed (6-7 sec) Low hand grip strength
benefits of protein in older adults
decreased bone loss and muscle loss, increased bone density
4 RFs of failure to thrive
impaired physical function
malnutrition
depression
cognitive impairment
evaluation of FTT
Lab / diagnostics MMSE, ADL, IADL, “Up & Go Test” Geriatric depression scale MNA ® Rx review Chronic disease evaluation Assess environment
hx and pe examination of FTT
Hx & Clin Dx •Medical / surgical history •Current Dx …including Rx Clin. Signs & Phys Exam •Inflammation present? fever, hypothermia, tachycardia, etc. •Edema, wt gain/loss, nutrient deficiency symptoms Anthropo-metrics •Height, weight, BMI, waist circumferences, skin-folds…. body composition Lab •Serum albumin, prealbumin •CRP, WBC, BG •Neg N+ balance, ↑REE Diet •Diet history; 24-hour recall Function Outcomes •Strength and physical performance (gait, grip, stand/sit….)
decreased fluid needs in
CHF / COPD SOB, pulmonary edema Edema Fluid overload Hepatic ascites Renal failure Significant HTN Third spacing fluid
increased fluid needs with…
Anabolism Constipation/Diarrhea Dehydration Emesis Fever Fistulas / draining wounds Hemorrhage Hyperventilation Heat Medications Hypotension Polyuria Use of air-fluidized mattress
1 cause of dysphagia
stroke–always follow up and make sure they are eating OK
drugs that increase K excretion (risk of hypokalemia)
thiazide and loop diurectics
drugs that decrease K excretion
ACE, ARB
indications for enteral tube feeding
swallowing dysfunction, not alert, not expected to eat for 5-7 days,pancreatitis (can insert after the pylorus)
CI for enteral tube feedings
dysfunctional GI tract, hemodynamic instability, comfort care, refusal
causes of medication overuse
increasing comorbid conditions, multiple providers and poor communication, treating side effects of other meds, patient saving meds for later use
problems of polypharmacy
adverse drug reactions, drug-drug interactions, errors in taking meds
how do adverse drug reactions present in older adults?
usu a non-specific reaction, usu a loss of cognition or function
opiods to avoid in older adults
meperidine (risk of metabolite), pentazocine (CNS side effects), tramadol (increases seizure risk, don’t use if personal hx of seizures or seizure RFs)
T or F: long term use of opioids is safer in older adults than NSAIDSs
true! see dr. alexanders handout
for which types of pain should opioids be used in older adults?
funcitonal impairment b/c of pain, decreaseD QOL b/c of pain, moderate to severe pain
good analgesic adjutants for neuropathic pain in older adults
antidepressants (TCAs, SNRIs) or anticonvulsants (GABA)
adjuvant meds for pain control of localized neuropathic pain
topical lidocaine
adjuvant pain control for inflammation/bone pain in older adults
corticosteroids
which drug is good at the end of the life to decrease discomfort from SOB?
morphine
criteria for hospice admission for alzheimers
Specific diagnosis: Alzheimer’s, Lewy Body
•PPS of 30% and FAST of 7c or worse
•Documented history of significant decline in the prior 6-12 months and Medicare wants to see a 10% weight loss
•Lost the ability to ambulate and to make sensicalconversation
Need assist with 6/6 ADLs (eating, bathing, dressing, toileting, transferring and continence) and be incontinent of bowel and bladder
•History of pressure ulcers, skin breakdown and repeated infectionssupports admission
•Having multiple co-morbid chronic conditions also helps to justify admission
hospice eligibility for CHF and COPD
CHF should be NYHA class IV.Dyspnea at rest and O2 dependence.Medicare wants a history of multiple hospitalizations and exacerbations
hopsice eligibility for renal failure dx
For renal failure the GFR should be <15 or <10 with hyperkalemia and symptoms of renal failure: fatigue, nausea.
signs of active dying
cheyne-stokes respirations, signs of organs shutting down (no urine, jaundice, edema), cool extremities ,mottling of extremities from small capillary clots, low BP, fever, decreased consciousness, fatigue, restlessness, anorexia
advance directives are only for the end of life
F: they can be for at any other time in the persons life that they can’t make a decision
health care agent or health care power of attorney
can make decisions about health care for the patient
living will aka health care instructions
set of instructions about a patients wishes of medical care esp that care intended to sustain life
DNR order
instructions not to do life sustaining measurs
good resource for end of life resources
honoring choices minnesota
5 D’s to review your health care directives
decade, death, divorce, diagnosis, decline
intrinsic risk factors of falls for older adults in hospitals
Gait, balance issues Peripheral neuropathy Vestibular dysfunction Muscle weakness Vision impairment Impaired ADLs Advancing age Dementia
extrinsic risk factors of falls in older adults
Environment Hazards
Poor footwear
Restraints/Tethers
Medications for sleep she recommends trazodone or melatonin
modifiable risk factors of delirium
Sensory impairment Immobilization Medications Acute neurologic disease Concurrent illness Metabolic derangements Surgery Pain Emotional distress Disruption of sleep pattern
non modifiable risk factors of delirium
Dementia or cognitive impairment Age >65yo Hx of delirium, stroke, neurologic disease Multiple comorbidities Male sex Chronic renal or liver disease
medications to avoid in delirium
opioids, anticholinergics: scopolamine, diphenhydramine, atropine, muscle relaxants (baclofen and cyclobenzaprine), benzos, barbituates, corticosteroids (ramp you up, can’t sleep), dopamine agonists (bromocriptine, levodopa, pramipexole), H2 blockers
delirium dx
inattentive, and acute and fluctuating + either altered consciousness or disorganized thinking
work up of delirium
Review medications !!
Perform focused history and physical exam
Basic labs / studies:
CBC, glucose, lytes, Cr, BUN, Ca, UA, pulse ox, ekg
Offending drug? Remove it
Trauma or focal neuro finding? Head imaging
Infection? Treat it
No obvious etiology? Consider B12/folate, TSH, toxin screen, eeg, etc
supportive tx of delirium
Maintain hydration Mobilize patient, avoid restraints Reduce noise, limit staff changes Orienting stimuli (glasses, hearing aides) Maintain day/night cycle, sleep protocol Manage pain Reassurance Bedside sitter Feed them
T or F: fever may not be present in older patients with an active infection
T
indications for catheter use
acute urinary retention, to help a perineal sore heal, need for accurate Ins and outs in critically ill pt, periop use, requiring prolonged immobilization, end of life for comfort
6 ways to prevent pressure ulcers
Pressures ulcer assessment on admission Reassess all patients for risk daily Inspect skin of at-risk patients daily Manage moisture Optimize nutrition/hydration Minimize pressure
Intrinsic RFs for ulcers
immobility, poor nutrition, incontinenc,e circulatory compromise,neurologic deficits (dementia, spinal cord injury)
scales to assess risk for pressure ulcers
norton scale, braden scale
ways to relieve prevent pressure ulcers in immobile older adults
reposition every 2 hours, remind people in wheelchairs to move every 15 minutes, use lifting devices not transfers when possible, , keep head of bed at lowest elevation, use foam or dynamic surfaces, keep good nutrition, change briefs at least every 2 hours, check skin daily, cleanse daily
when an ulcer is healing–do you decrease its stage?
no, a stage 4 is always a stage 4, just document state of healing
signs of wound healing
granulation tissue
scale to assess ulcer healing
PUSH (pressure ulcer scale of healing)
main RFs for osteoporosis
incrreasing age, prior fx, low BMI, female, smoking, etoh
DEXA scan rec’ds
> 65 and <65 with FRAX >9.3%
when can you skip DEXA scan?
can make dx clinically by fragility fx: a fx in Spine, hip, wrist, humerus, rib, and pelvis
◦Occur from a fall from a standing height or less, without major trauma such as a motor vehicle accident
ways dz can present non specifically in older adults
Weakness/ Fatigue Weight loss/ Failure to Thrive Falls Immobility Incontinence Cognition Change Mood Change Social Crisis
when do we treat bacteria in urine?
when they are symptomatic, many of them have bacteria in their urine all theme
