Geriatrics Flashcards
Delirium Diagnosis
1) Inattention +
2) Acute onset, fluctuating course +
3) Disturbance in LOC or cognitive domain (exec function, language, visuospatial, recall) +
4) Disturbance due to medical condition/substance and NOT a pre-existing neurocog disorder
Grading of Dementia
SCI = no objective impairment and preserved function
MCI = objective impairment in 1+ cog domain, but PRESERVED ADLS/IADLS
Mild = normal ADLs, assisted with 1 iADL
Moderate = assisted with 1 ADL or 2+ iADLs
Severe = assisted with 2+ ADL, dependent
End stage = bedbound
*do not screen asymptomatic older adults for cog impairment
What cognitive domains does the MMSE Test?
All except executive function
Good for limited education (English speaking)
Dementia if <=23
What domains does MoCA test?
All
Good for educated (English speaking)
Dementia if <=26
What domains does RUDAS test?
All except attention
Good for non-western cultural upbringing, limited education
Dementia if <=22
What is the most sensitive test for executive function?
MoCA (tests it via the most tests)
What is the most specific test for executive function?
Clock draw
Indications to obtain imaging in work-up of dementia
BRAIN
BR: Bleeding Risk (on anticoagulation, head injury)
A: Atypical dz (early onset <60, rapid decline 1-2mo, shorter duration of dementia <2y, unusual cognitive presentation)
I: Intracranial lesion (Hx cancer, focal neuro deficit)
N: NPH (incontinence, gait disturbance, cognitive impairment)
Indications and S/E for Cholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine)
1) Alzheimer’s Dementia (mild-sev)
2) Mixed Alzheimer’s/Vascular dementia (mild-sev)
3) Lewy Body Dementia/Parkinson’s Dementia
S/E:
- CVS: Bradycardia
- GI intolerance (anorexia),
- GU: incontinence
- Caution in asthma, COPD, seizures
- Avoid in unexplained syncope or conduction defects (except RBBB) bc prolongs QT
Diagnosis & Tx FTD
Dementia + >=3 of: PEALED
- Perseveration (unable to switch btwn tasks)
- Executive dysfunction
- Apathy
- hyperoraLity
- Empathy loss
- Disinhibition
No role for ChEIs
Trazodone or SSRI for behaviors (often paradoxical worsening to antipsychotics)
Androgen deprivation therapy for sexual disinhibition
Treatment BPSD
Non-pharm:
- Identify triggers/ unmet needs
- PIECES: Modify Physical, Intellectual, Emotional, Capabilities, Environmental, and Social factors
- Nonmed Tx as good as meds (eg outdoor therapy, music, massage, touch)
Pharm:
1) Empiric pain control with standing tylenol
2) Risperidone (max 1mg/d) ONLY if:
a) pure Alzheimer’s dementia +
b) no response to no NON-pharm tx +
c) harm to self/others or distressing symptoms
* antipsychotics - 2x stroke risk, 1,6x risk death, NNH 100
New:
- Methylphenidate for apathy (S/E wt loss) in AD
- Pimavanserin (serotonin modulator) for psychosis in any dementia (S/E: H/A, UTI, constipation)
Prevention of cognitive impairment in healthy adults
Hearing aids
Exercise,
Cognitive training +/- social engagement
Mediterranean diet
Tx CV RFs (esp BP and lipids) earlier in life
CPAP (observational studies)
No cognitive enhancers or OTCs (eg vit B/E, folate, gingko, flavonoids, omega3)
Treatment MCI
Exercise (doesn't work in dementia) Cognitive training (inconsistent benefit in dementia) Mediterranean diet (no evidence in dementia) No cognitive enhancers or OTCs
Driving and cognitive impairment
Report for moderate and severe dementia (loss of 1+ ADL or 2+ iADLs)
Treatment depression in elderly
Nonpharm: group based intervention, exercise, CBT
Meds:
SSRIs (1st: sertraline/duloxetine; 2nd: citalopram/ escitalopram if normal QTc) x10-12wk for effect (monitor hypoNa in 1st 2 weeks)
Mirtazepine (sleep, appetite)
Buproprion (activating)
* No paroxetine or fluoxetine bc anticholinergic
Risk Factors for Falls
Modifiable: MOOVE FEE Meds (Benzos, opioids, polypharmacy, antidepressants, antipsychotics) Orthostatic hypotension Osteoporosis screening Vitamin D Deficiency Environmental hazards Footwear/foot care Eyes (cataract repair) Exercise (balance and strength training)
Nonmodifiable: cog decline, movement d/o, MSK, cardiac conditions
Fall Treatment in community dwellers
Exercise program >50hrs (greatest benefit) Med review Home safety - OT/PT referral Cataract repair (females only) VitD supplementation Podiatry/footwear recommendations
*No real benefit in recent studies
Fall Treatment in LONG TERM CARE
Multifactorial intervention: exercise, review of meds and environment hazards, assistive devices, managing incontinence
Hip protectors
Ca/Vit D
Bisphosphonate / Prolia (highest risk reduction)
D/C Physical restraints
Drugs to reconsider in elderly
NSAID Muscle relaxants Narcotics Glyburide Benzos Z-drugs Anticholinergics (TCAs, paroxetine, gravol, benadryl, benztropine, tolteridine, oxybutinin)
Normal Aging: Cognition (after 70)
Decreased short term functions (short term and episodic long term memory, processing speed, rxn time, attention, multitask switching, abstract reasoning)
Preserved long term functions (LTM, language, cued recall, sustained attention, registration, functioning)
Normal Aging: Neuro
Gait: Decreased velocity/stride length, increased stand width/time in double support
CNs: Decreased visual accommodation/ contrast sensitivity / dark adaptation / depth perception, high frequency hearing loss, diminished sense of smell
Peripheral nerves: Decreased ankle reflexes, vibration sense, proprioception
Autonomic nerves: Decreased baroreceptor response, decreased detrusor innervation, increased vascular tone causing increased sBP>DBP
Sleep: Longer to initiate, dec stage 3/4, preserved REM
Normal Aging: CVS
Systolic HTN >DBP --> increased pulse pressure Decreased HR (subclinical brady) HFpEF Valve sclerosis/stenosis LA enlargement
Normal Aging: Resp
Increased RV/ERV/FRC, dead space, VQ Mismatch
Decreased: VC, FVC, FEV1, DLCO, compliance
Preserved: FEV1:FVC
Normal Aging: Renal
Decreased GFR -30% dec renal mass lose 7.5 -10mL/ min/ decade
Decreased VitD hydroxylation / production
Preserved EPO production
Normal Aging: GI
Increased constipation (dec motility, more water absorbed)
Increased GERD bc loss of LES tone
Preserved nutrient absorption in SB
Decreased oxidation/phase 1 liver metabolism
Normal Aging: MSK
Decreased muscle and bone mass (sarcopenia) legs>arm
No focal or diffuse weakness
Normal Aging: Endo
Decreased estrogen –> vulvovaginal atrophy
Decreased testosterone
Increased mean cortisol concentration –> decreased bone density, fractures, and memory loss
Increased vasopressin response to volume (less thirst)
Confusion Assessment method (CAM)
1) Inattention (serial 7s, months backwards)
2) Acute onset and fluctuating (from observation)
3) Disorganized thinking (can stone float on water)
4) LOC altered (hypervigilant, somnolent)
Dx: 1 AND 2 + 3 OR 4
Dementia risk factors
Hearing loss Less education Smoking Depression Social isolation
Vascular dementia dx
Cognitive impairment (any domain, often frontal/executive):
- Stepwise (post stroke) or insidious (subcortical ischemia, lacunar infarcts, white matter changes) with gait disturbance and “slow”
AND
Imaging evidence +/- temporal relationship
BPSD (behavioural & psychological sx of dementia) Sx
Psychosis: delusion, hallucination, suspicious
Aggressive: verbal, physical, resist care
Agitation: restless, anxious, vocalization, repetitive action, hoarding, pacing, wandering
Depression: suicidality, sadness, guilt, hopeless
Mania: euphorea, sexual disinhibition, irritable
Apathy: amotivation, withdrawn
Screening q’s for falls
Fall in past year?
Unsteady when walking?
Fear of falling?
If yes to any, look for risk factors:
- Med review
- Timed up and go
- Cognitive testing
- Px exam: neuro, MSK, CVS, vision/hearing, orthostatic BP
If NO to all 3, not at risk: educate on falls, check for vit D deficiency, offer referral for activity
Beers criteria inappropriate meds
Anticholinergics, BZD, sliding scale, glyburide, NSAIDs, muscle relaxants
DDI: opioid/benzo, opioid/gabapentinoid, warfarin/macrolide
Renally cleared: cipro, septra, enox, spironolactone, gabapentin
Drug disease interaction: AchEi in syncope, metoclopramide in PD, AED in falls
Elder abuse fracture
MC: humeral - but can be accidental
Zygomatic less likely accidental
Vaccinations for elderly
Tdap - once per lifetime
Td (tetanus, diphtheria) q10y
Influenza - annually >65
Pneumococcal: Prevnar + Pneumovax (8wks later) 65 y
Zoster: Shingrix (non-live) vs Zostavax (live)
COVID 3 doses if >70
Nutritional deficiency findings
H&N: Fragile hair (Zn, Cu), Poor night vision (vit A), Anosmia (Zn), Caries (fluoride, Angular Chelitis (Fe, B2), Goiter (Iodine)
CV: CHF (B1)
Derm: Follicular hemorrhage (C), Sun exposed dermatitis (B3), bleeding (K), poor wound healing (Zn, Fe)
Nails: koilonychyia (Fe)
MSK: OP/osteomalacia (D)
Neuro: paresthesia (B12), cog impairment (B3, 9, 12)
Weight loss Tx
NonPharm: minimize restrictions, ensure oral health, high energy supplements, eat with others/assistance, exercise, nutritional support
Pharm: multivitamin, Ca 1200mg daily, Vit D 1000U daily, +/- Fe/B12
No evidence for dronabinol or megestrol acetate
Urinary Incontinence Types
Stress - involuntary w/ exertion, stress, cough, sneeze
Urge (MC women)- strong need to void and involuntary
Mixed - combined stress+urge
Overflow - obstruction, neurologic
Functional - cognitive, functional mobility difficulty
Incontinence Mx
First line: limit fluid intake, limit caffeine/EtOH, weight loss, treat constipation, timed voiding, kegel exercises, pessary, bladder training
Meds if refractory:
Stress - no pharm, only surgical
Urge - antcholinergics (oxybutynin and tolterodine - relax detrusor, increase bladder capacity) not v effective and ++ side effects. Other options: mirabegron (beta Ag) or botox into detrusor
