Geriatrics Flashcards
Increased hormones in elderly
NE
insulin
PTH
vasopressin
Decreased hormones in elderly
Thyroid
Adrenal CSs
Indicators of failure to thrive in elderly
Malnutrition
Physical impairment
Cognitive impairment
Depression
FTT inv in elderly
Limited lab/radiology MMSE, ADL, IADL scales Up and go test Geriatric depression scale Nutritional assessment Medication review Chronic disease evaluation Environmental assessment
ADLs
Ambulating Bathing Continence Dressing Eating Transferring Toileting
IDALs
Shopping Housework Accountin/managing finances Preparing food Transportation Telephone Taking medications
DDx of cognitive impairment in elderly
Delirium
Dementia
Pseudodementia of depression
Prevention of delirium in elderly
Ensure optimal vision and hearing Adequate nutrition and hydration Regular mobilization Avoid unnecessary medication Monitor for drug interactions Avoid bladder catheterization if possible Adequate sleep
Transient causes of incontinence
Delirium Infection Atrophic urethritis/vaginitis Pharmaceuticals Excessive urine output Restricted mobility Stool impaction
Fall assessment
Comprehensive geriatric assessment Labs, as directed by Hx, PEx: CBC Lytes BUN, Cr Glucose Ca TSH B12 U/A Cardiac enzymes ECG CT head
Medications with most impact on falling
Antidepressants
Antipsychotics
Benzodiazepines
In no Hx of fall during the past year
Assessment of gait and balance
If single fall during past year
Gait and balance test
If Hx of recurrent falls
1-focused Hx 2- PEx 3- environmental assessment 4- functional assessment 5- interventions based on findings
Major predictors of outcome
sBP
Pulse pressure
Initiation of pharmacotherapy for age 60 or higher
150/90
If comorbid diabetes: 140/90
1st line of pharmaco in elderly
Diuretics
Add BB if angina or CHF
Add ACEI/ARB if atherosclerosis, DM, CHF, CKD
Mamalnutrition definition
Involuntary wt loss Hypoalbuminemia Hypocholestrolemia Insufficient energy intake Loss of muscle mass Fluid accumulation Loss of subcutaneous fat Decreased hand grip function
Sign that should raise concern about malnutrition
BMI <22 in women
BMI <23.5 in men
Temporal wasting
Triceps skin fold
Sign that should raise concern about malnutrition
BMI <22 in women
BMI <23.5 in men
Temporal wasting
Triceps skin fold
Malnutrition W/U in elderly
CBC, ESR, Lytes, Ca, Mg, PO4, TSH, LFT (INR, Alb, bilirubin), Cr, U/A, B12, folate, transferrin, lipid profile, CXR
Tx of malnutrition
Underlying High calorie intake Supplementation Food/drink thickeners Vitamins/minerals: B12, Ca, VitD Speech/language pathologist Nutritionist
Tx of constipation
Fibre intake
Fluid intake
Discourage chronic laxative use
Constipation definitiin
<3 bowel movements in a week / hard stool
At least 12 wk ( does not need to be consecutive)
Symptoms must have occured in the last 3 mo
Symptom onset more than 6 mo before Dx
1st step in costipation
Is there fecal impaction?
If fecal impaction present
Manual disimpaction
Enemas
Suppositories
Bowel regimen to prevent recure
If no fecal impaction
Remove costipating medications Fluid Activity/exercise Fiber intake (20-30 g/d) Timed toilet training
If no response to 1st line
Milk of Magnesia Lactulose Peh/Lyte Senna compounds Bisacodyl
No respose, High dose PEG
No responwe, lubiprotone, biofeedback, alvimopan, methylnaltrexone
Supplements causing constipation
Iron
Ca
Stool incontinence inv
If cause not apparent Is it true incontinence/frequency/urgency? Stool studies Endorectal U/S Colonoscopy Sigmoidoscopy Anoscopy Anorectal manometry/functional testing
Mx of fecale incontinence due to physiological changes with age:
Loperamide, Diet/bulking agents for loose stool, Increase fluid intake Biofeedback Retraining of pelvic floor muscles Surgery
neurogenic fecal incontinence Mx
Medication Abdominal massage Digital stimulation Biofeedback Behavioural training Prevent autonomic dysreflexia
Mx of fecal incontinence due to cognitive problem
Regular defecation program
Psychiatric consult
Meds causing pressure ulcer
Antihypertensives
Prevention of pressure ulcer
Frequent repositioning
Pressure reducing devices
Nutrition
Managing incontinence
Stages of pressure ulcer
1, persistent erythema
2, partial thickness (epiderm, derm)
3, full thickness (hypoderm)
4,full thickness (damage to muscle, bone, supporting structures)
Tx of pressure ulcer
Optimize nutritional status
Minimize pressure on wound
Analgesia
Debridement if necrosis ( mechanical, enzymatic, autolytic)
Sharp debridement urgently if risk of sepsis/cellulitis
Dressing (to absorb exudate, barrier against friction)
Maintain moist wound environment
Tx infection (topical genta, silver, mupirocin)
Bx chronic wounds
Refer to wound care
If diabetic: cast walker, orthopedic shoes, orthotics for offloading
Red flags for elder abuse
Delay in seeking medical attention
Disparity in histories
Implausible or vague explanations
Frequent emergency room visits for exacerbations of chronic disease
Presentation of functionally impaired pt without designated caregiver
Lab findings inconsistent with Hx
Bruising
Broken bones
Injuries
Suspicious changes in accounts: POA, wills
Deserted in public place
Mx of elderly abuse
Interview pt alone
Assess safety
Determine capacity to make decisions about living arrangements
Establish need for hospitalization or alternate accommodation
Involve multidisciplinary team
Educate and assisst caregiver
Immunizations for people 65 and older
Td q 10 y
Pneumococcal vaccine
-if no previous vaccination, PCV13, then PPSV23 the followimg year
-if previously received PCV, no 2nd dose.
Influenza, every autumn
Zoster: one time dose
Elder abuse signs
Poor eye contact Withdrawn nature Malnourishment Hygiene issues Cuts Bruises Inappropriate clothing Medication compliance issues
Functional approach to driving
Unimpaired vision
Adequate cognition
Ability to maintain consciousness
Physical mobility
Driving with
Hx of impaired driving with alcohol,
High probability of future impaired driving
Should not drive
Driving with Alcohol dependence/abuse
Advise not to drive
Alcohol withdrawal seizure
Must complete rehabilitation program
Must remain abstinent and seizure-free for 6 mo
Driving with HTN
If sustained BP>170/110, evaluated carefully
Driving with hypotension
If sustained BP<90/60, if syncopal, discontinue driving until treated
Asymptomatic CAD
No restriction
Stable angina
No restriction
STEMI
No driving for 1 mo following discharge
NSTEMI with significant LV damage
No driving for 1 mo following discharge
CABG
No driving for 1 mo following discharge
NSTEMI with minor LV damage
No driving for 48h if PCI, 7d if no PCI
Unstable angina
No driving for 48h if PCI, 7d if no PCI
TIA
should not allow driving until complete assessment
Stroke
Should not drive for at least 1 mo
Mild-mod COPD
No restrictions
COPD requiring O2 supplementation
Road test with supplemental O2
Mod-sev dementia
Contraindication
Inability to perform 2 or more IADL or any ADL
Mild dementia
Assess
Specialized driving testing centre
If deemed fit to drive, re-evaluate q 6-12 mo
If poor performance on MMSE, clock drawing, Trail B, investigate more
DM controlled with diet/OHA
No restrictions
DM on insulin
Drive if no severe hypoglycemic episode in the last 6 mo
Hearing problem
If Acute labyrinthitis Positional vertigo with horizontal head movements Recurrent vertigo Advise not to drive until resolved
Musculoskeletal disorders
Report etiology, prognosis, extent of disability
Post operative, conscious sedation
No driving for 24 h
Post operative, general anesthesia
No driving for >24 h
First sigle unprovoked seizure
No driving for 3 mo until complete neurological assessment
Epilepsy
Can drive if seizure-free on meds
Sleep disorder
If believed to be at risk, but refuses investigation with a sleep study or appropriate treatment, should not drive
Visual acuity for driving
Contraindicated if <20/50 (both eyes examined simultaneously)
Visual field for driving
Contraindication: <120° along horizontal meridian, 15° above and bellow fixation with both eyes examined simultaneously
Depression Tx as an end-of life symptoms
Psychostimulants:
Methylphenidate
Ketamin
Hiccups in end-of-life setting
Dry sugar Breading in paper bag Chlorpromazine Haloperidol Metoclopramide Baclofen Marijuana
Increased sensitivity to these drugs:
Warfarin Digoxin Sedatives Antipsychotics Narcotics
Decreased sensitivity to
BB
Benzodiazepine of choice in the elderly
LOT
Lorazepam
Oxazepam
Temazepam
