Geriatrics Flashcards
Life Expectancy Estimates
At 65 you have 15 years, 75 you have 10, 85 you have 5, 95 you have 2-3
Vitals to check at each visit
Weight, temp, pulse, BP, respiratory rate Height yearly (for osteoporosis)
Normal skin/nail changes
Wrinkles, loss of turgor, decreased vascularity (pale), thinning, fragility, plaques and purpura
yellow, brittle nails
Hair changes
Hairline recession at temples and vertex
thinning on scalp and body
women have thickened facial hair
When does visual acuity start to diminish?
AKA presbyopia
50, more rapidly after 70
Cataracts start in 60s
What order does hearing diminish?
AKA presbycusis
starts with high pitched, then midland low pitches
Mouth Changes
Darkened teeth, fissures in tongue , tongue sticking to buccal mucosa (xerostomia)
enlarged tongue in pts without teeth
angular cheilitis
What does back and abdominal pain raise concern for?
AAA, esp male smokers
Urinary changes
denervation and contractility of detrusor, loss of bladder capacity, inability to inhibit voiding
What is normal gait velocity?
> 0.8 meters/s or <5 seconds on a 4 meter walkway
What makes up health status of older adults?
Chronic diseases and number
- physiologic changes
- susceptibility to acute illness/injury
Diseases that are major causes of mortality?
Heart disease, cancer (esp lung, colorectal, breast), lung disease, cerebrovascular disease/stroke
-Acutely: pneumonia and influenza
What % of older adults have difficulty with activities of daily living?
40% (1/2 occur chronically/progressively, the other 1/2 catastrophically like hip fracture/stroke)
Precursors to disability
difficulty walking, cognitive impairment, visual impairment
How can we modify consequences of disease?
Health habits (diet, alcohol, smoking), screening, immunizations (flu, pneumonia, zoster), education, access to healthcare, community service support
Primary Prevention
Prevent disease or injury to occur
vaccines, exercise, diets, BP monitoring, safety eval, etc
Secondary Prevention
Intervention for pts with condition to prevent progression to complication (stop smoking with CV disease)
-Screenings!
Tertiary Prevention
Effort to improve care to avoid further complications (rehab to optimize function)
-foot/dental care, geriatric assessment, etc
Principles ofPrevention
Prevalence of the problem and likelihood of effective intervention
What is the main syndromes we want to prevent?
Falls, dizziness, functional decline (these increase risk for disability)
Screening Recommendations
- ACP/AISM: ADL screening, cognitive screening, health status eval
- USPTF: welcome to medicare visit, periodic screening, counseling and immunizations (>65)
Screening for psychosocial problems
PHQ-9, Beck depression Inventory, geriatric depression scale
Recommended Physical Activity
Total of 150 minutes of moderate intensity activity weekly
-helps balance/fall prevention, stamina, CV conditioning, strength/tone/mass, flexibility, osteoporosis prevention
Nutrition Recommendations
- Nutritional requirements stay the same but calorie needs decline
- low body mass index (weight loss of >10lbs in 6 months could be poor nutrition/cancer)
- Mini nutritional assessment
Prevention of osteoporosis
- exercise (weight bearing) and diet for bone health
- walking increases skeletal load-low benefit, strength training is better
Calcium and Vitamin D supplementation
1500 mg calcium citrate daily (500 mg doses), no more than 1000 units vitaminD/day
What is the most preventable problem in an older adult?
Iatrogenesis (problems brought forth by health care workers)
Common iatrogenic problems
- under/over diagnosing
- Bedrest
- over sedation/delirium
- enforced/learned dependency
- transfer trauma
- over treatment/antibx
- polypharmacy
Risks of hospitals
Iatrogenic events, cognition changes, testing (can cause more harm than good), central lines, catheters, changing treatments, unfamiliarity with patient, caregivers not informed on treatment/testing
Complications of bedrest
Pressure ulcers, bone resorption, hypercalcemia, postural hypotension, atelectasis/pneumonia, thrombophlebitis, incontinence, fecal impaction, decreased muscle mass/strength, decreased cardiac output, depression, sensory deprivation
What is the leading iatrogenic event in long term care facilities?
Learned dependence
How to prevent iatrogenic events
- Only prescribe new meds if necessary
- maintain philosophy of care focusing on optimizing function and physical activity
What is the major cause of morbidity/mortality in geriatrics?
Falls! (1/3 living at home fall each year, 1/2 in LTC facilities)
Complications of falls
Injury/fracture, subdural hematoma, hospitalization/iatrogenic, disability
Management of fall risk patients
PT and OT, gait training, muscle strengthening, assistive devices, hip protectors if high risk in LTC facility
Palliative Care
Approach that improves quality of life of patients and their families facing life threatening illness
Four Trajectories of functional decline
- Short period decline before death
- Chronic illness with exacerbations and sudden death
- Progressive deterioration
- Sudden, severe neurological injury
Trajectory 1: short period of decline before death
Cancer, stroke, MI
-they’re healthy then something happens that dramatically drops their health quickly
Trajectory 2: Chronic illness with exacerbations and sudden death
COPD, CHF, end stage liver disease, AIDS
-they have a chronic illness with constant decline, but periods that are worse and get better, but when they get better its not to baseline
Trajectory 3: Progressive deterioration
Neurodegenerative diseases like dementia, Parkinson’s, MS
-constant slow decline
Trajectory 4: Sudden, severe neurologic injury
Sudden severe neuro impairment like stroke, traumatic brain injury, hypoxic ischemic encephalopathy
Get REALLY bad, then a little better and drop off again
Hospice vs Palliative Care
- Hospice: prognosis of <6 months, certified by doc, focus is on comfort not cure, medicare covers it, volunteers provide care, families offered grief counseling for a year after
- Palliative: any time during illness, can try curative treatment, provided by healthcare professionals, medicare covers part of service
Advanced Care Planning
Process for identifying and communicating values and preferences regarding future healthcare
Advance directive
Document that chooses a person to make medical decisions for you
Living will
Expresses your wishes about medical treatment in a terminal condition
POLST
Physician Orders for Life-Sustaining Treatment
-requires valid clinician signature, allows doc to make decisions for you
Medical Surrogate options if patient doesn’t have POA
First is spouse unless they’re legally separated
- then an adult child of patient
- parent
- domestic partner if unmarried
- sibling
- close friend
- if none available, physician can make decisions or court appointed person
Five Wishes Program
Provides online forms for patients to express their wishes if they don’t have someone to be MPOA
Primary goals of care
- Curative: restore health
- Palliative: promote comfort by receiving pain and suffering
- Combination
SPIKES Protocol
Guide to communicate important info with patient and families
- Setting
- Perception-what does pt know?
- Invitation-how much do they want to know?
- Knowledge
- Emotion
- Subsequent
