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Clinical Medicine > geriatrics > Flashcards

geriatrics Flashcards

1
Q

Characteristics that protect you when you are young may not protect you when you are past your reproductive years

A

(antagonistic pleiotropy)

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2
Q

theories of aging

A

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)

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3
Q

reduced ability to maintain homeostasis

A

Homeostenosisis

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4
Q

physiologic changes in CV system of aging

A

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

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5
Q

physiologic changes in respiratory system of aging

A

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

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6
Q

physiologic changes in electrolyte system of aging

A

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

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7
Q

physiologic changes in renal system of aging

A

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

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8
Q

oral heaalth changes in aging

A

o Loss of enamel→ tooth loss
o Decreased saliva→ dry mouth and bad breath
o Decreased taste buds→ decreased taste, less eating → malnutrition

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9
Q

GI changes in aging

A

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

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10
Q

liver changes in aging

A

o Decreased enzymes→ decreased drug metabolism

o Alcohol dependency→ decreased liver function

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11
Q

metabolism changes in aging

A

o Less ability to burn glucose and secrete insulin→ DM
o Decreased Basal metabolic rate
o Decreased ability to sweat and thermoregulate

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12
Q

immune changes in aging

A

o Decreased T cell function→ increased infections

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13
Q

neuro changes in aging

A

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

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14
Q

special senses changes in aging

A

o Decreased high pitched hearing
o Decreased smell and taste
o decreased lens accommodation→ presbyopia and dryness

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15
Q

pain changes in aging

A

o More disease process→ more pain

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16
Q

skeletal system changes in aging

A

o Decreased deposition and increased resorption→ osteoporosis
o Dehydration of intervertebral discs→ decreased stature
o Erosion of cartilage→ joint pain, osteoarthritis

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17
Q

muscle changes in aging

A

o Atrophy→ decreased strength and endurance

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18
Q

sex changes in aging

A

o Don’t assume they aren’t interested!
o Prostate enlargement
o ED
o Vaginal dryness

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19
Q

factors affecting driving in older aduls

A
  • 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
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20
Q

important aspects of social hx in older adults

A

support system, caregiver burden, economic well being, mistreatment, advance directives, spirituality, home safety

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21
Q

3 components of why people fall

A

biomechanical, neuromotor, sensory (sensation, vestibular, visual)

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22
Q

3 components of sensory component of why people fall

A

vision, sensation, vestibular

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23
Q

evolution of falls

A

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

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24
Q

cut off for “falls risk” with timed up and go test

A

>

  1. 5 seconds
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25
Q

4 ds of aging

A

dementia, delirium, depression, dying

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26
Q

older adults that are at risk of abuse

A
  • Female
  • Advanced age
  • Dependent
  • Problem drinker
  • Intergenerational conflict
  • Internalizes blame
  • Excess loyalty
  • Past abuse
  • Stoicism
  • Isolation
  • Impairment
  • Provocative
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27
Q

high risk caregivers

A
  • Problem drinkers, med abuse
  • Mental illness
  • Caregiving inexperience
  • Economically troubled
  • Stressed
  • Socially disengaged
  • Blames others
  • Abused as child
  • Unsympathetic, hypercritical
  • Unrealistic
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28
Q

signs ofabuse

A
  • Frequent unexplained crying
  • Unexplained suspicion or fear
  • Physical findings
  • Pattern bruises
  • Genital, breast or anal bruising
  • Contractures
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29
Q

T or F: you need to prove elder abuse to report it

A

F–adult protection will investigate

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30
Q

or which situations should screening tests for older adults not be followed?

A

low life expectancy or high comorbid conditions: • CHF (Class III, IV), ESRD, Severe COPD (home O2), Severe dementia (MMSE

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31
Q

rec’d breast cancer screening

A

every 2 years 50-74 +/- clinical breast exam (not hard evidence for it in this age group)

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32
Q

how to decide life expectancy of an older adult?

A

if many comorbidities “below average” if no comorbidities or few and high functional status “above average”

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33
Q

colorectal cancer screening in older adults

A

50-75 every 10 years with one of the 7 methods. after 75 perform screening on individual basis with RFs

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34
Q

cut off for cervical cancer screening

A

65 with 3 normal paps and not high risk

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35
Q

osteoporosis screen

A

at least once after 65 for women, 70 for men

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36
Q

BG screen in those over 65

A

every 3 years in those with BP > 135/80

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37
Q

AAA ultrasound in those over 65

A

Once for men 65–75 years who ever smoked

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38
Q

cholesterol screen in those over 65

A

Every 5 years, more often in CAD, DM, PAD, prior CVA

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39
Q

what health screens should be done every year in those > 65?

A

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

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40
Q

when to screen for alcohol abuse in > 65 years?

A

initially and then when suspect abuse

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41
Q

T or F: there are no RCTs demonstrating a beneficial effect of multivitamins in the elderly

A

T

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42
Q

is hormone therapy recommended in those >65?

A

no

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43
Q

T or F: most biochemical measures are normal in older adults and aren’t a good measure of nutrition

A

T

44
Q

T or F: serum proteins (albumin) are a good measure of nutritional status in older adults

A

F. albumin affected by many things

45
Q

t or F: chronic medical problems usually have a concurrent nutritional problem

A

T! see percentages of malnourished by disease in geriatric nutrition lecture

46
Q

diseases that have risk of malnutrition

A

RA, COPD, renal failure, heart failures, stroke, dementia, hip fx, cognition issues

47
Q

psychosocial issues that impair good nutrition intake in older adutls

A

depression, substance/etoh abuse, loneliness, isolation, decreased function, moving, poverty, end of life

48
Q

how medications can impair intake in older adults

A

dry mouth, nausea, effect taste perception, decreased appetite

49
Q

causes of significant rapid weight gain in older adults

A

renal or heart failure, ascites, edema

50
Q

goal for obese older adults

A

maintain rather than gain (not lose–will lose lean muscle instead of fat)

51
Q

T or F: in older adults BMI 25-30 is most protective

A

T! esp with chronic dz like HF or COPD

52
Q

components of frailty syndrome (need 3 or more)

A 
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
53
Q

benefits of protein in older adults

A

decreased bone loss and muscle loss, increased bone density

54
Q

4 RFs of failure to thrive

A

impaired physical function
malnutrition
depression
cognitive impairment

55
Q

evaluation of FTT

A 
 Lab / diagnostics
 MMSE, ADL, IADL, “Up & Go Test”
 Geriatric depression scale
 MNA ®
 Rx review
 Chronic disease evaluation
 Assess environment
56
Q

hx and pe examination of FTT

A 
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….)
57
Q

decreased fluid needs in

A 
CHF / COPD
SOB, pulmonary edema
Edema
Fluid overload
Hepatic ascites
Renal failure
Significant HTN
Third spacing fluid
58
Q

increased fluid needs with…

A 
Anabolism
Constipation/Diarrhea
Dehydration
Emesis
Fever
Fistulas / draining wounds
Hemorrhage
Hyperventilation
Heat
Medications
Hypotension
Polyuria
Use of air-fluidized mattress
59
Q

1 cause of dysphagia

A

stroke–always follow up and make sure they are eating OK

60
Q

drugs that increase K excretion (risk of hypokalemia)

A

thiazide and loop diurectics

61
Q

drugs that decrease K excretion

A

ACE, ARB

62
Q

indications for enteral tube feeding

A

swallowing dysfunction, not alert, not expected to eat for 5-7 days,pancreatitis (can insert after the pylorus)

63
Q

CI for enteral tube feedings

A

dysfunctional GI tract, hemodynamic instability, comfort care, refusal

64
Q

causes of medication overuse

A

increasing comorbid conditions, multiple providers and poor communication, treating side effects of other meds, patient saving meds for later use

65
Q

problems of polypharmacy

A

adverse drug reactions, drug-drug interactions, errors in taking meds

66
Q

how do adverse drug reactions present in older adults?

A

usu a non-specific reaction, usu a loss of cognition or function

67
Q

opiods to avoid in older adults

A

meperidine (risk of metabolite), pentazocine (CNS side effects), tramadol (increases seizure risk, don’t use if personal hx of seizures or seizure RFs)

68
Q

T or F: long term use of opioids is safer in older adults than NSAIDSs

A

true! see dr. alexanders handout

69
Q

for which types of pain should opioids be used in older adults?

A

funcitonal impairment b/c of pain, decreaseD QOL b/c of pain, moderate to severe pain

70
Q

good analgesic adjutants for neuropathic pain in older adults

A

antidepressants (TCAs, SNRIs) or anticonvulsants (GABA)

71
Q

adjuvant meds for pain control of localized neuropathic pain

A

topical lidocaine

72
Q

adjuvant pain control for inflammation/bone pain in older adults

A

corticosteroids

73
Q

which drug is good at the end of the life to decrease discomfort from SOB?

A

morphine

74
Q

criteria for hospice admission for alzheimers

A

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

75
Q

hospice eligibility for CHF and COPD

A

CHF should be NYHA class IV.Dyspnea at rest and O2 dependence.Medicare wants a history of multiple hospitalizations and exacerbations

76
Q

hopsice eligibility for renal failure dx

A

For renal failure the GFR should be <15 or <10 with hyperkalemia and symptoms of renal failure: fatigue, nausea.

77
Q

signs of active dying

A

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

78
Q

advance directives are only for the end of life

A

F: they can be for at any other time in the persons life that they can’t make a decision

79
Q

health care agent or health care power of attorney

A

can make decisions about health care for the patient

80
Q

living will aka health care instructions

A

set of instructions about a patients wishes of medical care esp that care intended to sustain life

81
Q

DNR order

A

instructions not to do life sustaining measurs

82
Q

good resource for end of life resources

A

honoring choices minnesota

83
Q

5 D’s to review your health care directives

A

decade, death, divorce, diagnosis, decline

84
Q

intrinsic risk factors of falls for older adults in hospitals

A 
Gait, balance issues
Peripheral neuropathy
Vestibular dysfunction
Muscle weakness
Vision impairment
Impaired ADLs
Advancing age
Dementia
85
Q

extrinsic risk factors of falls in older adults

A

Environment Hazards
Poor footwear
Restraints/Tethers
Medications for sleep she recommends trazodone or melatonin

86
Q

modifiable risk factors of delirium

A 
Sensory impairment
Immobilization
Medications
Acute neurologic disease
Concurrent illness
Metabolic derangements
Surgery
Pain
Emotional distress
Disruption of sleep pattern
87
Q

non modifiable risk factors of delirium

A 
Dementia or cognitive impairment
Age >65yo
Hx of delirium, stroke, neurologic disease
Multiple comorbidities
Male sex
Chronic renal or liver disease
88
Q

medications to avoid in delirium

A

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

89
Q

delirium dx

A

inattentive, and acute and fluctuating + either altered consciousness or disorganized thinking

90
Q

work up of delirium

A

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

91
Q

supportive tx of delirium

A 
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
92
Q

T or F: fever may not be present in older patients with an active infection

A

T

93
Q

indications for catheter use

A

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

94
Q

6 ways to prevent pressure ulcers

A 
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
95
Q

Intrinsic RFs for ulcers

A

immobility, poor nutrition, incontinenc,e circulatory compromise,neurologic deficits (dementia, spinal cord injury)

96
Q

scales to assess risk for pressure ulcers

A

norton scale, braden scale

97
Q

ways to relieve prevent pressure ulcers in immobile older adults

A

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

98
Q

when an ulcer is healing–do you decrease its stage?

A

no, a stage 4 is always a stage 4, just document state of healing

99
Q

signs of wound healing

A

granulation tissue

100
Q

scale to assess ulcer healing

A

PUSH (pressure ulcer scale of healing)

101
Q

main RFs for osteoporosis

A

incrreasing age, prior fx, low BMI, female, smoking, etoh

102
Q

DEXA scan rec’ds

A

> 65 and <65 with FRAX >9.3%

103
Q

when can you skip DEXA scan?

A

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

104
Q

ways dz can present non specifically in older adults

A 
Weakness/ Fatigue
Weight loss/ Failure to Thrive
Falls
Immobility
Incontinence
Cognition Change
Mood Change
Social Crisis
105
Q

when do we treat bacteria in urine?

A

when they are symptomatic, many of them have bacteria in their urine all theme

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