Geriatrics Flashcards
2 types of sleep states
- nonrapid eye movement
- rapid eye movement
sleep stages
1 and 2–> light sleep
3 and 4–> deep sleep
Normal night
NREM–> REM after 80 minutes–> cycle continued between NREM and REM w/ REM getting longer
Four common types of insomnia
- difficulty falling asleep
- mid sleep awakening
- early morning awakening
- nonrestorative sleep
Categories of insomnia
Transient/acute- <1 week
Short term/subacute- 1 week to 3 months
Chronic- >3 months
Sleep disorder NREM non-pharmacologic tx
- sleep hygiene
- behavioral therapy
- bright light therapy
Sleep disorder NREM pharmacologic tx
- benzos (caution with short acting–> increased rebound insomnia, falls, hallucinations)
- trazadone
- zolpidem
OTC–> melatonin, APAP
NO BENADRYL
Who gets sleep apnea
obese males over 65
high prevalence in pts with dementia
What type of sleep apnea is most common in the elderly
obstructive
d/t anatomy or obesity
What is the other type of sleep apnea that the elderly doesn’t tend to get as much
Central–> rain fails to transmit signals to your breathing muscles (parkinsons, stroke, CHF)
Presentation of sleep apnea
- daytime sleepiness is most common
- morning HA or lethargy/confusion
- HTN
What would the bed partner of a patient with sleep apnea report
- loud snoring
- apnea
- choking
- gasping sounds
How do you diagnose sleep apnea
polysomongraphy
Treatment of sleep apnea
- weight loss
- avoid alcohol
- avoid sedatives
- avoid sleeping supine
- oral dental devices that reposition the jaw or tongue
- mandibular maxillary advancement
Risk factors for periodic limb movement disorder/restless leg syndrome
- family history
- uremia
- low iron stores
- increased age
Signs and symptoms of PMLD
recurring episodes of stereotypic rhythmic movements during sleep, generally incolving the legs
Signs and symptoms of RLS
uncomfortably irresistible urge to move legs, motor restlessness
-UE not commonly involved’-occurs just before the onset of sleep
Diagnosis of PMLD? RLS?
PMLD: polysomnography
RLS: based on pts symtpoms
Treatment of RLS/PMLD
- depends on the severity of sx*
- RLS–> stretching and massage
- dopaminergic agents (pramipexole, ropinirole)
- oxycodone and clonazepam (caution of bad side effects)
What is failure to thrive
deteriorating state characterized by
- weight loss
- decreased appetite, poor nutrition
- inactivity
- often accompanied by dehydration, depression, impaired immune function and low cholesterol
What is the etiology of failure to thrive
interaction of 3 things
- physical frailty
- disability
- impaired neuropsychiatric function
Risk factors for failure to thrive
- medication side effects
- comorbidities
- psychosocial factors
- weight loss of 5% of body weight over 6 to 12 months
- poor food intake
Cardiovascular health study criteria for frailty
- weight loss (>5% of body weight in one year)
- exhaustion
- weakness
- slow walking speed
- decreased physical activity
*must have 3 of 5
Risk factor measurements for failure to thrive
- mini mutritional assessment
- subjective global assessment
What are important parts of the history you need to obtain if your patient is failure to thrive
- identifying medical and psych disorders
- medications (OTC and RX)
- use of alcohol or illicit drugs
- need to do complete ROS
- assess contributors to poor mobility/disability and difficulty in feeding
What should you consider if your patient has failure to thrive
elder abuse or neglect
PE for failure to thrive
- assess physical and cognitive impairment
- look for signs of disease that cna lead to impairment
- vitals (orthostatic hypotension
- evaluate for dementia with MMSE
- “get up and go test”
Things you should assess for in each section of physical exam if you suspect your patient is failure to thrive
HEENT–> dental caries, poor dentition
Neck–> thyroid mass, LAD
Breast–> masses and LAD
Rectal–> abscess, fecal impaction, occult blood
Vision and Hearing
Neuro–> reflexes, muscle strength, test propioception and sensation
Labs that aid in diagnoses of failure to thrive
- screen for infection (WBC, UA, blood cx)
- check for organ failure (CMP–> lft, cr)
- calcium phosphate
- TSH
- B12 folate
- albumin, prealbumin
- total cholesterol
- vitamin D
Imagine for diagnosis of FTT
only based on clinical suspicion for malignancy, TB, Infection
Goal of FTT treatment
improve quality of life
Consults for a FTT patient
- dietitian
- psychiatrist
- social worker
- physical therapy
- speech therapist
- dentist
Treatment of FTT
- stop non essential medications
- offer ensure
- vitamin supplements if needed
- appetite stimulants (megestrol, dronabinol)
- physical therapy
- anabolic agents
Preferred agent for treatment of depression in FTT
mirtazapine
can also do methylphenidate
Criteria for hospice
- weightloss not due to reversible cause
- chronic or intractable infection
- recurrent aspiration and/or inadequate intake 2/2 pain with swallowing or weakness
- progressive dementia
- progressive pressure ulcers even with extreme care