geriatrics final Flashcards
in 2000, our Life expectancy is ~__ years
75 years
main causes of death now
Heart disease, cancer, stroke, pneumonia
main causes of death in 1900s
Trauma, infectious disease (TB, pneumonia), HD, stroke and cancer
life expectancy in 1900s
55 years
currently does acute or chronic illness predominate?
chronic
people lose ___% of renal mass by the age of 90
20-30%
30-40% of geriatric patients fall in functioning glomeruli by age __
80
Reduced blood flow is seen in up to___% of people by age 80
50%
there is __% GFR loss with aging
50%
Geriatric Syndromes (5)
1.Sensory loss
o Hearing, vision
- Incontinence
- Balance and gait changes
4. Falls and fractures o Strength and balance o Vestibular function o Medication effects o Bone density
- Polypharmacy and drug interactions
Memory peaks in what age?
30s
Cognitive capacity is more than memory, it includes what three things?
o Visual-spatial perception
o Cognitive processing
o Sensory and motor dependent
Apparent Cognitive changes may reflect what three things?
3 D’S:
o Delirium: may be evidence of reduced cognitive reserves with fluctuations in level of consciousness
o Depression: bimodal distribution
o Dementia: final common pathway of many diseases but is not “normal”
Risk factors which increase vulnerability to infectious disease (14)
- Decreased PF and cough reflex
- Decreased gastric acidity and GI motility
- Atherosclerosis and reduced cap blood flow
- Thin, easily injured skin
- Reduced activity (motor and balance)
- Impaired host defense mechanisms
- Inadequate nutrition
- Lack of immunization
- Neuropsych disease and reduced MS
- Chronic medications
- Chronic diseases
- Previous exposures
- Hospitalizations and LTC facility
- Invasive devices (urinary and venous catheters)
Healthy aging occurs without ____ and _____.
functional impairment and disability
Disability pathway results from the impact of what 4 things?
genetics, disease, lifestyle and behaviors
Risk factors for functional impairment
o Age, gender
o Obesity, exercise
o Chronic illnesses
what are Basic ADLs (6)
o Walking o Dressing o Eating o Bathing o Toilet o Transfer
what are Instrumental ADLs (6)
o Walking distances o Shopping o Cooking (food preparation) o Housekeeping o Using the phone o Managing finances
pt should get Tdap vaccination when/how often?
once at age 65
pt should get Td vaccination when/how often?
every 10 years
pt should get influenza vaccination when/how often?
yearly during flu season
pt should get Pneumococcal vaccination when/how often?
once after age 65
If <65 when received, and 5 years since shot, then give again at or after age 65
pt should get Prevnar 13 vaccination when/how often?
once at 65
At least 3 months after Polyvalent 23
pt should get Zostavax vaccination when/how often?
Once at 65 (or earlier)
Cancers for which we may screen older patients and how to screen for them (5)
- Breast - mammogram
- Cervical – pap test
- Colon - colonoscopy
- Prostate – PSA
- Skin – physical exam
Implementing Preventive Care and screening in older people- 4 questions to consider
- Is the patient at risk for the disease?
- Is it likely to have a proximate benefit?
o Test performance
o Post-test probability - What is the level of risk of the intervention?
o Competing mortality - Is it consonant with patient values and preferences?
what are 3 patient factors when considering CA screening in older patients
o Competing mortality and individual prognosis
o Patient beliefs, level of anxiety, preferences, ie. values
o Life expectancy
4 Physiologic Changes in geriatric patients
- Less body water more body fat
- Less muscle mass
- Decreased hepatic metabolism and renal excretion
- Decreased responsiveness and sensitivity of the baroreceptor reflex
Excretion changes in geriatric patients
- Reduced kidney clearance
o 30-40% fall in functioning glomeruli by 80
o 1% (at age 20) ->30% sclerotic glomeruli - Serum creatinine not accurate predictor of renal function due to decreased muscle mass
o Creatinine secretion reduced ~40%
Generally the elderly are more sensitive to drug effects, especially with what 2 drug classes?
o Anticholinergics
o Benzodiazepines
Homeostasis is more effected by drugs because of what three things?
o Postural BP
o EPS
o Cognition
Risk Factors for Adverse Drug Events (6)
- > 6 chronic disease states
- > 12 doses/day
- > 9 Medications
- Low BMI (<22 kg/m2)
- Creatinine clearance <50 mL/min
- Female
Adverse Drug Events are Linked to preventable problems in the elderly, such as? (6)
o Depression o Constipation o Falls o Immobility o Confusion o Hip fractures
what is Beers Criteria
o Medications that should generally be avoided because they are either ineffective or they pose a high risk
o Medications that should not be used in older persons known to have specific medical conditions
Beers Criteria: Anticholinergic Agents
what are the 3 drug Classes?
o Tricyclic antidepressants
o Antihistamines
o Antispasmodics and muscle relaxants
Beers Criteria: Anticholinergic Agents
what are adverse events with these medications?
o Urinary incontinence
o Constipation
o Confusion, delirium, behavior changes
o Exacerbation of dementia
Beers Criteria: Benzodiazepines
long acting and short acting adverse events
Long-acting
o Prolonged half-life in older adults (days)
o Sedation, cognitive impairment, depression
o Increased risk of falls and fractures (Haldol)
Short-acting
o Increased sensitivity in older adults
o If necessary, use lower doses
what are 2 Non-steroidal anti-inflammatory drugs (NSAIDS) that should be avoided completely?
o Indomethacin has significant CNS side effects
o Ketorolac (Toradol) can cause serious GI and renal effects
Beers Criteria: Pain medications
Long-term use of NSAIDS can cause what adverse effects?
o Potential for GI bleed
o Renal failure
o Heart failure
o High blood pressure
Meperidine (Demerol) has low oral efficacy, active metabolites and __effects
CNS
Beers Criteria: Cardiovascular Agents
Digoxin Should not exceed 0.125 mg/day except when treating ________.
atrial arrhythmias
Beers Criteria: Cardiovascular Agents
Digoxin causes Decreased______ which results increase in toxic effects
decreased renal clearance
Beers Criteria: Cardiovascular Agents
Amiodarone is Associated with ___ interval problems. It has a Lack of efficacy in older adults
QT
according to beers criteria, you should avoid what meds in Parkinson’s disease?
metoclopromide and anti-psychotics (Haldol)
according to beers criteria, you should avoid what meds in Stress incontinence
alpha-blockers
according to beers criteria, you should avoid what meds in Hyponatremia
SSRIs
according to beers criteria, you should avoid what meds in constipation
CCBs
according to beers criteria, you should avoid what meds in cognitive impairment
Anticholinergics, antispasmodics, and muscle relaxants
Three medications caused 1/3 of ED visits in elderly patients, what were they?
o Insulin
o Warfarin
o Digoxin
when taking NSAIDS, Several risk factors place the elderly population at increased risk for GI bleeds, what are they? (5)
o >75 years of age o History of PUD o History of GI bleed o Concomitant use of warfarin o Long term glucocorticoid use
if pt is at increased risk for GI bleed, what treatment should be used instead of NSAIDS?
misoprostol or PPI
For medication safety with geriatric patients, we should prescribe how many medication at a time? and how should we dose it?
- Prescribe one medication at a time
- Start the dose low and titrate up slowly
- Use once daily dosing if possible (Increases patient adherence)
you should Avoid drug-drug interactions that are associated with hospitalizations. For benzodiazepines, you should avoid what meds?
Antidepressant and antipsychotics
you should Avoid drug-drug interactions that are associated with hospitalizations. For ACE inhibitors, you should avoid what meds?
Potassium sparing diuretic or potassium supplement
you should Avoid drug-drug interactions that are associated with hospitalizations. For Warfarin, you should avoid what meds?
New antibiotic, potent CYP inhibitors/inducers
what are the Risk Factors for Adverse Drug Events (6)
- > 6 chronic disease states
- > 12 doses/day
- > 9 Medications
- Low BMI (<22 kg/m2)
- Creatinine clearance <50 mL/min
- Female
People over the age of 65 consume 30% of all prescriptions in the US and___% of all over-the-counter medications, even though they only represent 15% of the US population
40%
Elderly are frequently not included in clinical trials due to _________.
unpredictable drug metabolism and effects
Elderly patients regularly take an average of ___ prescribed medications
4.5
76 year old man with falls and new resting tremor. he has the following medical conditions: o Heart failure o Hypertension o Diabetes o CKD stage 3 o Osteoarthritis o Dementia
and takes the following meds: o Furosimide 20 mg /D o Benazepril 10 mg/D o Metformin 1 gm BID o Glipizide 10 mg /D o Haldol 1.0 mg H
what med should be avoided?
Haldol 1.0 mg H
For patients with no risk factors, fall risk is__%
8%
For patients with 4 or more risk factors, fall risk is __%
78%
Risk factors for Falls (12)
- Age and Female gender
- Past history of a fall
- Lower extremity weakness
- History of stroke
- Balance problems
- Arthritis
- Cognitive impairment
- Psychotropic drug use
- Dizziness
- Orthostatic hypotension
- Vision problems
- Anemia
Immediate Consequences of Falls
- Physical – Fall-related injuries
o 5 – 15% of falls result in fractures or serious soft tissue injuries
o The majority of nonfatal injuries in adults aged 65 and older treated in ED in the US in 2001 were caused by falls
o Account for ~ 10% of ED visits and 6% of urgent hospitalizations
o Loss of function or immobility
o Death - Social – impacts quality of life
- Psychological – Fall-related fear & loss of self-efficacy
what is the most common cause of traumatic brain injuries (TBI)?
falls
Most fractures among older adults are caused by falls. The most common fractures are?
spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.
what medication would you need to reduce to improve postural hypotension?
Anticholinergic, alpha-blockers
if patient has Postural Hypotension, how should they change positions?
change position slowly. Dangle feet before rising from bed
in regards to diet, what should be counseled to patients that have postural hypotension
- Consider liberalizing salt intake - carefully
- Encourage adequate hydration
For Environmental Hazard Modification, what hazards are included?
o Clutter o Electric cords o Slippery throw rugs and loose carpet o Poor lighting o Lack of stair rails o Lack of shower rails / grab bars o Proper shoes
Timed Up & Go Test (assess possibility of falling)
explain process once time starts and average results
- Time starts when the patient initiates movement
- The patient walks 10ft across the room and circles around a marker
- Time stops when the patient returns and is seated in the chair
- Average results are as follows
o Age 60 – 69 7.24 seconds
o Age 70 – 79 8.54 seconds
what should be done with patient prior to timing a Timed Up & Go Test
- Patient can use arms or assistive device – must document if either is used
- Explain the test to the patient
- Demonstrate the test
- Do practice trial
- Perform timed evaluation
- Patient starts from a seated position
what is continuity of care?
Continuity is ‘‘care over time by a single individual or team of healthcare professionals’’ including ‘‘effective and timely communication of healthcare information.’’
what are Pupil Changes with Aging?
- Pupil Decreases in Size
- Slower Light and Dark Adaptation
what are lens Changes with Aging?
- Yellowing of the Lens
- Increased: Scatter and Fluorescence
- Loss of Flexibility / Accommodation
79 year old man in ED with nausea, vomiting and eye pain
you perform an Exam on his left eye and find:
o reduced vision, conjunctival injection, mild corneal edema
o Fixed, mid-dilated pupil
what is the diagnosis?
Closed-angle glaucoma
Closed-angle glaucoma is the Mechanical obstruction of ___.
outflow
in Closed-angle glaucoma, Rapid increase in intra-ocular pressure causes what symptoms?
Eye pain, nausea, halos around lights
what would you see on a physical exam of Closed-angle glaucoma
Exam reduced vision, conjunctival hyperemia, corneal edema
o Fixed, mid-dilated pupil
o Increased intraocular pressure
o Narrow anterior chamber
Closed-angle glaucoma treatment
topical pilocarpine or timolol, IV acetozolomide
what is the Leading Cause of Blindness in the United States
macular degeneration
what is presbyopia?
farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
what is Presbycusis?
is the most common type of Sensorineural Hearing Loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher pitched (higher frequency) sounds.
______ Hearing loss is Due to damage to neurons or hair cells transmitting auditory signals to the brain for interpretation.
Sensorineural
Sensorineural hearing loss due to aging is known as ___.
“presbycusis”
Loud environments, neural tumors, viral insults (acoustic neuritis) can cause what kind of hearing loss?
Sensorineural
_____ Hearing Loss is Due to mechanical damage or obstruction of the middle ear or external auditory canal
Conductive
Examples of middle ear causes of conductive hearing loss
o effusions purulent serous otitis– Eustachian tube dysfunction
o trauma to the boney structures or tympanic membrane (scarring –tympanosclerosis)
o growths such as cholesteotomas or otosclerosis
Examples of external auditory canal causes of conductive hearing loss
o foreign body (cerumen, insect, crayon) o inflammation (otitis externa), or growth (polyp, malignancy)
what test helps differentiate between conductive and sensorineural hearing loss.
Weber Testing
how do you perform the weber test?
Strike the tuning fork and place on the forehead, teeth, or nose.
what are the results of a normal weber test?
No lateralization of sound at all
results of weber test with unilateral conductive loss
Lateralizes to affected ear
results of weber test with unilateral Sensorineural loss
Lateralizes to the normal ear or side you hear better in.
what test helps test for conductive hearing loss?
rinne testing
how do you perform the rinne test?
Strike the tuning fork and place on the mastoid. Have the patient tell you when they stop hearing the sound. Move the fork to beside the ear and check to see if they can hear the sound again.
what are results of a normal rinne test?
Air conduction > Bone conduction – Patient hears the fork when placed BESIDE the ear
what are results of an abnormal rinne test?
Bone conduction > Air Conduction – Patient does not hear the fork placed BESIDE ear. Signifies a conductive hearing loss on the affected side.
describe deliriums onset, duration, attention, and consciousness
onset: abrupt
duration: hours to days
attention: impaired
consciousness: reduced, fluctuating
describe dementia onset, duration, attention, and consciousness
onset: slow, insidious
duration: months to years
attention: normal, except in severe cases
consciousness: clear
describe depression onset, duration, attention, and consciousness
onset: recent, may be associated with loss
duration: stable, may be worse in morning
attention: usually normal
consciousness: clear
On Folstein MMSE, what score = impairment
<24 c/w impairment
can MMSE distinguish dementia from delirium?
no
in the mini cog test what results = demented?
when recall = 0
or if recall is 1 or 2 and the clock is abnormal
characteristics of major depression
o Acute, nonprogressive o Depression o Affective before cognitive o Attention impaired o Orientation intact o Vocal memory complaint o Gives up on testing o Language intact o Patient complains o Better at night o Criticizes self o Self-referred
characteristics of dementia
o Insidious & progressive o Depression mild if present o Cognitive before affective o Recent memory impaired o Orientation impaired o Minimizes memory problem o Patient makes effort o Possibly aphasic o Family complains o Sundowning o Criticizes others o Referred by others
PHQ-2 is a Screen for ____
Depression
Treatment of Dementia- can use what 2 meds?
- Cholinesterase inhibitors
- Memantine
in dementia, _______ shows improvement in surrogate end points for mod-severe disease
Memantine
in treating dementia, does Cholinesterase inhibitors
or Memantine have better improvement in surrogate endpoints and is better tolerated by patients?
Memantine
The “Real” Treatment of Dementia consists of Managing behavioral sx, such as?
o Aggression
o Wandering
o Physical and chemical restraints
o Co-morbid depression
when treating dementia you should Recognize and manage _____ stress
caregiver
______ is the cardinal feature for diagnosis of delirium
INATTENTION
what are the three subtypes of delirium ?
o Hyperactive – agitated, hyperalert
o Hypoactive – calm and confused, lethargic
o Mixed – features of both
what are some Modifiable risk factors in regards to Delirium ?
(8)
- Medications
- Polypharmacy (>3 new inpt meds)
- Physical restraints and catheters
- Sleep deprivation
- Immobility
- Uncontrolled pain
- Medical illness (organ failure, electrolytes, etc)
what should be included in the evaluation of delirium?
7
- Vital signs, pulse ox, volume status
- Focused exam including determining baseline cognition, urine output, last BM
- Blood glucose
- Review medications
- Consider medication withdrawal as a cause
- Testing – CBC, BMP, UA, CXR, EKG
- Additional testing if clinically indicated
what Is the most important thing to do in regards to managing delirium?
identifying underlying cause
how do you manage delirium?
- Try to identify underlying cause
- Prevent complications and provide supportive care
o Avoid bed rest, catheters, mobilize patient
o Sleep at night, awake during day
o Monitor nutrition status and output
o Consider aspiration precautions
o Enlist the help of family
name 3 Psychological Expressions of Anxiety
- Insomnia
- Irritability
- Poor coping skills
Goals of Palliative Care
- Improve the quality of life of patients living with debilitating, chronic or terminal illness
- Prevention and relief of suffering by early identification, assessment, and treatment of distressing symptoms
- Accomplished by combined efforts of an interdisciplinary team
Palliative Care Definition
- Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of patients and families)
- Appropriate at any stage of illness and simultaneously with all other medical treatments
Palliative Care vs. Hospice
- Hospice, as defined by the Medicare hospice benefit, is a health care delivery system under which support and services are provided to a patient with a terminal illness where the focus is on comfort rather than curing an illness.
- Thus, hospice can be considered a program that delivers palliative care to patients at the end of life, while palliative care can be appropriately offered to patients at any time along the trajectory of any type of serious illness, even concurrent with restorative, life-prolonging therapies.
- Hospice is a model of palliative care that is offered to patients at the end of life when curative or life-prolonging therapy is no longer indicated.
- While all care that is delivered by hospices can be considered palliative care, not all palliative care is delivered in hospices.
The majority of nonfatal injuries in adults aged 65 and older treated in ED in the US in 2001 were caused by what?
falls
WHEN evaluating delirium, what lab tests should be done?
CBC, BMP, UA, CXR, EKG
when is palliative care appropriate?
Appropriate at any stage of illness and simultaneously with all other medical treatments
