Geriatrics Exam 2 Flashcards
1
Q
Ependymal cells
A
CSF cells
2
Q
Astrocytes
A
Bring blood to neurons
3
Q
Oligodendrocytes
A
Myelinate the neurons
4
Q
Microglial cells
A
CNS macrophages - remove waste and heal neurons
5
Q
Nonfunctioning microglia
A
Chronic pain
6
Q
Malfunctioning neurons
A
ALS
Parkinsons
Stroke
Alzheaimer
7
Q
Malfunctioning oligodendrocytes
A
Leukodystrophy
Multiple sclerosis
Neuromyelitis optica
8
Q
Malfunctioning cerebral blood vessels
A
Infection
Hepatic encephalopathy
Migraine
Brain edema
9
Q
Generalized cerebral atrophy
A
Affects a limited area of the brain - cerebral palsy, Picks disease
10
Q
Generalized cerebral atrophy
A
Brain shrinks
11
Q
3 symptoms of cerebral atrophy
A
Dementia, Seizures, Aphasia
12
Q
Leptomeninges
A
Insulation - Pia, Dura
13
Q
Key historical information for a cognitive assessment
A
Duration
Memory
Language
Visuospatial
Executive function
Apraxia
14
Q
Alzheimer disease
A
Amyloid plaques and neurofibrillary/tau tangles
Neurons can’t communicate and brain atrophies
15
Q
Risk factors for alzheimers
A
Age
Female
Ape e4 gene
Hx of head trauma
Lower educational level
Diabetes
Down syndrome
16
Q
Classic triad of alzheimers disease
A
Difficulty learning and recalling information
Visuospatial problems
Language impairment
Usually noticed by friends and family first
17
Q
Moderate alzheimers
A
Recalling demographics
Short attention span
Repetitive statements
Trouble reading/writing
Easily lost
18
Q
Signs of severe alzheimers disease
A
Weight loss
Incontinence
Increased infections
Absent recognition of familiar individuals
Unable to communicate effectively
19
Q
Difference between dementia and delerium
A
Acute - Delerium
Chronic - Dementia
20
Q
Diagnostics for Alzheimers disease
A
Clinical diagnosis
Use imaging to rule out other etiologies
Progressive atrophy of brain tissue
21
Q
First Line Treatment for AD
A
Acetylcholine esterase inhibitors
Donepezil
Rivastigmine - Transdermal
Galantamine
22
Q
SE of acetylcholinesterase inhibitors
A
Nausea, Anorexia, Sleep disturbance, diarrhea
Serious - Bradycardia, AV block, SYncope
23
Q
NMDA receptor antagonists
A
Also for alzheimers mod to severe or non-responsive to acetylcholinesterase inhibitors
Reduces destruction of cholinergic neurons
Memantine (Namenda)
24
Q
SEs of NMDA receptor antagoinists
A
Dizziness, HA, Confusion , Constipation
25
Namzaric
Combines acetylcholinesterase inhibitors and NMDA antagonist (donepezil and Namenda)
26
Non-pharm interventions for alzheimers disease
Physical, Mental and social activity
Music therapy
27
Additional adjunct meds for alzheimers
SSRI for depression
trazodone for sleep wake
28
4 complications of alzheimers
Poor nutritional intake
Urinary incontinence
Skin breakdown
Infections
29
When to d/c alzheimers meds
When patient can no longer express needs
30
Vascular dementia presentation
Less severe memory impairment than AD
Difficulty with timed activities/executive function - one minute test
Behavior and psych similar to AD
Depression MORE severe than AD
Few focal deficits
31
Imaging and treatment for vascular dementia
MRI may show infarcts/white matter lesions
Same tx as AD
32
Risks for vascular dementia
HTN
Smoking
DM
Statins
Antiplatelets
33
Lewy body dementia etiology
Deposits of alpha synuclein at presynaptic terminals
Unknown pathophys
Average age of onset at 75
34
Clinical presentation of lewy body dementia
Spontaneous parkinsonism
Fluctuating cognitive impairment
More severe visuospatial, problems solving and processing difficulties
Visual hallucinations, delusional misidentification
No tremors or response to levadopa
35
Diagnostics for Lewy Body dementia
Greater atrophy of the basal ganglia structures and dorsal midbrain - seen on MRI
36
Areas of atrophy more characteristic of alzheimers
Medial temporal lobe and hippocampus
37
McKeith criteria for Lewy Body diagnosis
Probable
Two core clinical features w/o biomarkers OR One clinical feature w/ biomarkers
Possible
One core clinical feature only or biomarkers only
38
Biomarkers for lewy body dementia
Preservation of medial/temporal lobe structures
Low SPECT/PET dopamine uptake with reduced occipital activity
Prominent posterior slow wave activity on EEG with periodic fluctuations
39
Core clinical features for Lewy Body dementia
Fluctuating cognition
Well-formed, detailed, recurrent visual hallucinations
REM sleep disorder
Brakinesia, rest tremor, rigidity (Parkinsonian signs)
40
Diagnosis of Lewy Body
Only definitive via autopsy
More pronounced cortical atrophy than PD
41
Tx for Lewy body dementia
Cholinesterase inhibitors
Mixed evidence for memantine
Atypical antipsychotics ONLY if severe psychosis
SSRI
Melatonin
Fludrocortisone for orthostatic hypotension
42
Clinical course of Lewy body
10 year survival
Decrease of MMSE 4-5 points per year
43
Frontotemporal dementia presentation
Focal atrophy of frontotemporal cortex
Behavioral variance
Semantic progressive aphasia - decoding
Primary progressive aphasia - Inability to produce words
44
Management of frontotemporal dementia
Safety - driving
Exercise
Speech therapy
Pharm only if behavior modification fails - SSRI or Trazodone
45
Presentationof Normal pressure hydrocephalus (3)
Dementia, incontinence and gait problems
46
Management of normal pressure hydrocephalus
Ventricular shunting abdomen - MC or heart - LC
47
Diagnostics for normal pressure hyrdrocephalus
MRI of brain showing ventriculomegaly out of proportion to sulcal enlargement
48
LP for normal pressure hydrocephalus
Normal opening pressure
Remove 30-50cc of CSF
If gait improves after LP there is a good prognosis for ventricular shunt placement
49
Clinical presentation of delerium
Acute with fluctuating symptoms
Attention deficits
Cognitive impairment
50
3 approaches to the treatment of delerium
Identification and treatment of the underlying cause
Eradication or minimization of contributing factors
Management of delerium symptoms
51
Non-pharm delerium management
Frequent reorientation
Environment optimization
Sensory deficit correction
Restraint avoidance
Self care
Sleep hygeine
52
Pharm indications for delerium
Reserved for those with severely agitated behavior - threatens medically necessary care or poses a safety hazard
Sedate as LITTLE AS POSSIBLE
53
Typical antipsychotic for delerium
Haldol
54
Atypical antipsychotics for delerium
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
55
Benzo for delerium
Lorazepam if the benzo of choice (Ativan)
56
Mini Cog Assessment
3 word recall (3 points)
Clock draw for executive function (2 points)
Less than 3/5 is abnormal
57
1 minute semantic fluency assessment
Name as many items as possible from a category (ie. Fruits) in a minute each unique item= 1 point
58
Cut off scores for one minute semantic fluency assessment
65-74 = 15
75-79 = 14
80-84 = 13
85+ = 11
Further screening for pts below cutoff score
59
Mini mental status examination
Orientation to Place
Oritentation to time
Name three objects
Serial sevens
Recall of three objects
Name two simple objects
Repeat a phrase
Fold paper
Read instructions and follow
Make up a sentence with noun and verb
Copy picture
60
SIngle cutoff for MMSE
Below 24
61
Increased risk for dementia MMSE
Under 21
62
Education level MMSE scores
21 - abnormal for 8th grade
Under 23 abnormal for HS
Under 24 abnormal for college
63
Mild and severe cognitive impairment MMSE
18-23 = Mild
0-17 = Severe
64
SLUMS
Saint Louis University Mental Status Exam
Utilized to screen for mild cognitive dementia
More sensitive than other assessments but longer
Used if poor MMSE score
65
Questions on the SLUMS assessment
Q1-3 = Attention, immediate recall, Orientation
Q4 and 7 = Delayed recall
Q5 = Calculation
Q6 = Memory using semantic fluency
Q8 = Digit span
Q9 = Visual spatial
Q10 = Executive function
Q11 = Exec. func. with extrapolation
66
HS+ scoring for SLUMS
27-30 = Normal
21-26 = Mild neurocognitive disorder (MNCD)
1-20 = Dementia
67
Less than HS scoring for SLUMS
25-30 = Normal
20-24 = MNCD
1-19 = Dementia
68
Montreal Cognitive assessment
For mild cognitive impairment
More detailed, time intensive, and sensitive
Versions for different languages and audiovisual impairment
Measures the same things as SLUMS
69
Percent of falls with injury
50%
70
Most commonly missed fall injury
C-spine activity
71
4 strongest risk factors for falls
Previous falls
Decreased muscle strength
Gait/Balance impairment
Specific medication use
72
4 common fractures from falls
Hip, wrist, humerus (head), ribs
73
Hip fracture patients who will die within the first year
1/3
Usually from a fall sideways
74
Hx taking for Falls
WHY did you fall - usually accidental and precipitated by an environmental hazard (can be prevented)
Expected/Unexpected
What they were doing (micturation syncope)
Lightheaded, aura, etc.
LOC
75
Medications that may cause falls
Psycotropic drugs
Benzos
BP drugs
ANticholinergic
76
Functional reach test
Stand perpendicular to the wall - reach out and see how far you can go without taking heels off the ground
Under 6 inches is concerning for fall risk
77
Tests for balance
Heel to toe and romberg
78
Differentials to consider for falls
Anemia
B12 deficiency
UTI Thyroid
Electrolyte disorders
Pneumonia
Always check neuro
79
Goal for immobility
Optimize mobility in the patient and promote small movements
80
Stage I pressure ulcer
Inflamed and red on the outside, may be boggy
81
Stage II pressure ulcer
Extension of inflammatory response through the dermis and intosubcutaneous fat junction
May look like an abrasion or ulcer with distinct edges
82
Stage III Ulcer
Full thickness skin ucer extending through SQ fat but not through underlying fascia
Infection and nectrosis - crater like
83
Stage IV ulcer
Extension of ulcer through deep fascia to the bone, osteomyelitis and septic arthritis
84
Treatment for Stage I and II ulcers
Clean wounds with warm normal saline
Avoid pressure and moisture
Cover open wounds with dressing
Abx if needed for II
85
Treatment for Stage III ulcer
Debride
Cleanse and dress
Culture
86
Treatment for stage IV ulcer
Tussue biopsy for culture
IV ABX - Bactrim, Vanc maybe
Cleanse and dress
Surgical consult
87
Visual impairment
Over 20/40
88
Legal blindness
20/200
89
Age related visualchanges
Cataracts
Glaucoma
Macular degeneration
Diabetic retinopathy
90
Common hearing loss in the elderly
High frequency loss
Check for cerumen impaction
Can lead to false diagnosis of dementia
91
Hearing loss and medicare
Required for annual medicare wellness visit
Hearing aids not paid for
92
Incontinence for which diapers should not be used
Bowel incontinence to avoid UTIs
93
Length of coverage for rehab facilities with medicare
14 days post hospital discharge
94
HELP
Hospital Elder Life Program
Goal to prevent delerium in older hospitalized adults
Implementation of mobility, cognitive, sleep, and medication protocols
33% reduction in delerium
95
6 Aspects of HELP
Quiet environment
Nonpharmalogical sleep
Improve cognition
Hydration and Nutrition
Early Mobility
Hearing/Vision adaptations
96
ACE model
Acute Care for Elders
Goal to prevent functional decline and improve quality of care for older adults during hospitalization
Uses comprehensive geriatric assessment and interprofessional team-based care
97
8 Aspects of the ACE model
Mobility
Good Nutrition
Continence
Orientation
Healthy Sleep
Inclusion of patient in care plan
Frequent review of care plan
Skin integrity
98
Indications for Urinary Catheterization
Urinary retention
Urinary incontinence resistant to ALL OTHER treatments
I/O monitoring
End of life
Bladder pharm
Surgery
Immobilization
99
2 inappropriate indications for catheter
Incontinence that has NOT failed other managements
Urine specimen in a patient who can void spontaneously
100
Absolute CI to a foley catheter
Urethral injury
101
Relative CIs for foley catheter
Urethral stricture
Recent urinary tract surgery
Presence of artificial sphincter
Consult Urology
102
Risks of indwelling catheters
Infection
Limits mobility
Stones
Bladder cancer
103
Alternatives to catheter placement
Bladder training (Kagel exercise, diary)
Scheduled toileting
Adjunct stimulation techniques (tap water, thigh stroke, suprapubic tapping)
Adjunct to facilitate complete emptying of the bladder (prostate, bend forward)
104
Pharm alternatives for urinary catheterization
Antimuscarinics (Oxybutynin, Tolterodine, Darifenacin)
Beta-3 Agonist (Mirabegron)
Alpha adrenergic blockers for BPH (Tamsulosin(Flomax))
105
Surgical alternatives to folwy catheter placement
Sling or bladder neck suspension in women
Anatomic repair or prostatic resection
106
SE of antimuscarinics
Anticholinergic
107
SE of Tamsulosin
Orthostasis and dizziness
108
Eligibility for short stay rehabilitation
Skilled needs following hospitalization - Medicare part A
109
Eligibility for Long-term institutional care
24/7 assistance needed for safety or due to functional impairment
110
Conditions commonly treated in rehab
Pulm rehab - COPD
Cardiac rehab - Post MI/CHF
PAD Rehab - Exercise and walking
Stroke rehab
Arthritis rehab - Fall prevention etc.
111
Indications for transfer from SNF to ER
Uncontrollable pain
Acute exacerbation
Infection and IV abx need
Falls, AMS, Behavior change
Family request
112
Reasons NOT to transport to hospital
End of life - staff don't want patient to die there
Vague symptoms
Family request
113
Medicare Part A coverage
Inpatient hospital care
SNF care
Hospice care
Home health care
114
Medicare Part B coverage
Medically necessary services
Preventive services
Mental health
Equipment & Supplies
Limited outpatient drugs
115
Part D coverage
DRUGS
Each plan has its own formulary
116
Medicare Part C
Advantage plans - Offered by approved companies
Limit on what you have to pay of pocketper year
Mustt have A and B to enroll
117
4 Principles of medical ethics
Autonomy
Nonmalifesensce
Benefisence
Justice
118
Capacity
Determined by a clinician - make sure patient has decision making capacity
Clock draw/consult psychiatry
119
Competence
Ability to act reasonably
Determined by court
120
5 Elements of a patient's decision making capacity
Patient must make a decision
Patient must explain reason behind decision
Decision cannot result from delusions or hallicinations
Decision must be consistent with patient values and preferences over time
121
4 parts of informed decisionmaking
Nature of proposed intervention
Potential risks and benefits
Alternatives
Risks of not going through with it
Avoid medical jargon and understand what patient knows, wants to know, and understands
122
MPOA hierarchy
Spouse
Adult children
Siblings
Parents
Health Care Team
123
1st line palliative care pain management
Acetominophen for mild pain
Give lowest possible dose that is effective for all meds
124
Drug for "death rattle"
Scopalamine patch
125
When not to screen for breast cancer
Life expectancy under 5 years - personal values
