Geriatrics- Lecture Notes Flashcards
Although people are living longer, they often struggle with multiple chronic diseases and geriatric syndromes that diminish quality of life for both themselves and their families.
Creating care plans specific to older adults enables the primary care provider to improve the quality of life and longevity of older adults and aids families caring for their older loved ones.
The older adult may present vague (nonspecific) symptoms and history; certain serious and treatable conditions may be missed because they are considered by the person or family to be a normal part of aging; or they may be reluctant to report certain issues as they do not want further tests or hospitalization.
Additionally, and commonly, older adults frequently present with altered (atypical) presentation, meaning “no signs and symptoms, unrelated to or even the opposite of what is usually expected”.
- Vague symptoms could be serious and they need more consideration
Health-promotion activities should be incorporated into every patient encounter.
Access to care- hearing deficits, vision, mobility, transportation to and from appointments.
What are the Geriatric Syndrome Markers? SPICES LIST
S – sleep disturbances
P- problems with eating or feeding
I- Incontinence
C- confusion
E- evidence for falls
S – skin breakdown
**any of these complaints they need to be evaluated- what is the cause of these symptoms
Cognition- list of things to cause cognitive changes within the pt.
Not acting right or thinking clearly
DELIRIUM LIST?
D – drugs
E – electrolyte imbalance
L – lack of drugs (withdrawal, uncontrolled pain)
I – infection
R- reduced sensory input (vision or hearing loss)
I – intracranial (cerebral vascular accident or sudural hematoma
U- urinary retention or retention of stool
M – myocardial/pulmonary
Falls?
Falls:
Risk factors for falls include previous falls, increasing age, medications- HTN that can cause hypostatic hypotension, sedative, and cognitive deficits.
Falls among older adults constitute the most common cause of traumatic injury
Fall risk assessment can reduce the risks of falls, decrease the morbidity and mortality associated with falls in older adults, and improve the quality of life for both the patient and loved ones.
What are the 3 questions that are used to identify adults who are at risk for falls?
Three questions are used to identify older adults who are at risk for falls: Red flags to ask the pt. every time you see them
- Have you fallen in the past year?
2. Do you feel unsteady when standing or walking?
3. Do you worry about falling?
Ritual – tool that you can use to screen for falls?
R- Review self-assessment from older adults
I- Identify risk factors (e.g., scatter rugs in the home, lack of grab bars in bathrooms, stairs, and poor home lighting or poor vision).
T- Test gait and balance (recommendation of programs such as yoga, tai chi, Zumba, and other programs for older adults to improve strength, gait, and balance).
U- Undertake multifactorial assessment
A- Apply interventions (e.g., order appropriate fall prevention devices such as canes, walkers, and bathroom grab bars).
L – later follow- up
What is the history to apply to Geriatric syndromes?
Optimizing communication- can they hear you, do they have an assisted device do they need a translator
-Speak directly to your patient unless directed toward their surrogate.- what is the pts perception of what is going on. Do not be negative, may need to interview patient and caregiver separately.
-Assess and manage emotionally charged interactions. Refrain from taking negative energy personally.
- Assess patient and caregiver health literacy and adjust explanations accordingly.
-Gauge the degree of social and financial support- access to water etc.
-Establish patient’s values, preferences, and goals of care.
What physical signs should you look for during a physical exam?
- Orthostatic hypotension: contributes to poor energy, diminished functional status, increased risk of falls, and decline in renal function due to ineffective organ perfusion- significant- dizziness & falls
- Hypothermia/hyperthermia: increased susceptibility in the elderly; less likely to mount a fever in the setting of infection; consider thyroid derangement. Not able to manage temperature.
- Weight loss: Assess access to food; may be presenting feature in mood disorder, thyroid derangement, dementia, malignancy- access to food, depressed, cancer, thyroid problem, dementia forgetting to eat
- Hearing: Check for cerumen impaction- check ears for cerumen impaction most common cause for hearing loss.
-Gait, balance, and proximal muscle strength: assessed via Timed Get up and Go Test, functional reach test, and Tinetti balance assessment tool
Geriatric Syndromes: What are some differential dx?
- Coronary artery disease: Elderly patients with coronary heart disease often present with atypical symptoms, including exertional dyspnea. Silent myocardial ischemia is also common.
2. Constipation: In older adults, constipation due to slow transit is very common and may be associated with fecal impaction and overflow fecal incontinence.
3. Delirium: Nearly 30% of older patients experience delirium at some time during hospitalization.
4. Urinary tract infection (UTI): UTI is the most common infectious illness in adults aged ≥65 years, but diagnosis of UTI is fraught with difficulty because of the high prevalence of asymptomatic bacteriuria and pyuria, neither of which should be treated unless symptomatic. Asymptomatic bacteriuria is a marker for debility, but treatment does not improve outcomes and may cause harm.
5. Depression: It is more common in elderly females. If left untreated, it is often the precursor of overt dementia.
6. Insomnia: Late-life insomnia is often persistent and may prompt self-medication with over-the-counter sleep aids or alcohol.
7. Hearing difficulties: Some studies showed increased incidence of dementia in patient with hearing difficulties.
8. Visual Impairment: Macular degeneration, glaucoma, and cataracts are the most commonly encountered causes, and a yearly eye exam is important
Sudden change in behaviors- constipation and UTI- number 1 cause for incontinence. If their bowels are full of stool this can press on bladder. Impacted- overflow fecal incontinence.
Diagnostic Procedures/Other: Geriatric Syndromes?
- Avoid unnecessary patient/caregiver burden if results will not significantly enhance the plan of care.
- Consider risks/harms, cost, time, travel, pain/discomfort, anxiety, and recovery time for all testing under consideration.
- Take into consideration renal function for imaging (with contrast) studies involving contrast.
- Many lab results require comparison with age-specific reference values (e.g., thyroid-stimulating hormone, A1c, prostate-specific antigen, D-dimer).
What are some General Treatment Measures- for Geriatric Syndromes?
. Optimize nonpharmacologic options first.
2. Align with patients’ goals of care.- to make sure careplan aligns.
Ex. Lesion on skin does not want chemo because of age. Etc.
3. Feasibility for patient and caregivers: Assess cost, availability, travel burden, and adherence to treatment plan.
4. Compliance
Medications - @ risk for adverse drug reactions-
- At greater risk of ADR (adeverse drug reactions) from medications due to?
age-related changes in the?
- Absorption
- Distribution
- Metabolism
- elimination of medications.
. Polypharmacy is defined as?
The practice of administering many different medications concurrently for a single disease or to treat coexisting conditions, a practice that increases the risk of adverse drug reactions.
**Giving different meds at the same time to treat different conditions- leads to adverse drug reactions.
How many drugs is considered polypharmacy?
- 5 or More = polypharmacy
What adverse events has polypharmacy been linked to?
- Falls
- Confusion
- Extrapyramidal symptoms
- Syncope
We want to start low & go slow
Pill burden
Check allergies
Consider renal & hepatic function
What can we do?
- Start low and go slow.
- Be cognizant of pill burden, drug–drug interactions, and risks of polypharmacy.
- Adjust dose for renal and hepatic function, volume of distribution, and decreased protein binding (more free/active drug available).
- Medication Reconciliation at each visit. Can get med rec list from their pharmacy.
- Ask patients to bring all their medications in the original containers to each office visit.
- The AGS Beers Criteria is a valuable resource- KNOW!! and should be used as a prescribing guide in all settings except for palliative care and hospice care.
Do not use Beers criteria for palliative care or hospice care!
Deprescribing
- Educate on how to correctly take medications. Have patient return demonstration of repeat instructions back.
- Utilize pill organizers- alarm & lock for patients with dementia helps pts not to double up on meds- keep alarming until box is locked. This helps the pt. to not double up on medications.
- Print updated list at each visit.
- Evaluate meds that they are on- is this med necessary?
is this med causing nasty side effects? – deprescribing.
Is their any meds that we can cut back on?
What is deprescribing?
This can be difficult good idea & rapport of the pt. Good knowledge of the pt.
Ex.xanax 25 yrs- do not want to stop it- why is it bad. Need to edu on chronic benzopenzopines- may need to refer to psych to help assist. This is your drug this is on your list . . .
Deprescriping?
- Deprescribing medications is difficult and daunting.
2. The goal of deprescribing is to reduce/manage polypharmacy and improve patient outcomes, which may include reducing falls, pill burden, delirium, nausea, constipation, or other symptoms. Consult Dr. about concerns of the medications.
3. Improves medication appropriateness in older people with life-limiting illness and limited life expectancy.
4. Being familiar with deprescribing and having conversations with patients, family/caregivers, and other providers (cardiologists, oncologists, neurologists) about deprescribing are essential components of caring for individuals with life-limiting illness, as many patients at the end of life have significant pill burden.
Geriatric Clinical Pearls?
Don’t recommend percutaneous feeding tubes in patients with dementia; instead, offer oral-assisted feeding. Feeding tubes do not prolong life and may worsen suffering and thirst in this population. Tube feeding decreases quality of life, pain suffering & aspiration
Geriatric Clinical Pearls?
- Avoid antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia
Geriatric Clinical Pearls?
- Nonpharmacologic interventions are more efficacious than pharmacologic interventions for reducing aggression and agitation in adults with dementia. Antipsychotic medications increase risk of death. They may have a role in a carefully considered overall palliative plan that focuses on nonpharmacologic means of soothing agitation. And in individuals who are being cared for at home, lack of antipsychotics may add caregiver burden and hence hasten placement.
Geriatric Clinical Pearls?
In diabetes care, meticulously avoid hypoglycemia, which is of far greater potential harm to the patient than is hyperglycemia. Metformin is generally safe.
The major goal, especially in care of the older or more debilitated population, is maintenance of glucose levels below those that cause symptomatic polyuria and polydipsia.
This is not a specific A1c target.
We want to focus on levels of sugar where they are not asymptomatic
Geriatric Clinical Pearls?
More risky for hypoglycemic vs. hyperglycemic.
- Don’t use benzodiazepines or other sedative hypnotics in older adults for insomnia, agitation, or delirium.
- Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Delirium in patients seen in the ED and hospital is not likely caused by bacteriuria or lower UTI but usually by other causes.
Geriatric Clinical Pearls?
- Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal (GI) effects.
- Don’t recommend screening for breast, colorectal, prostate, or lung cancer without considering life expectancy and the risks of testing, overdiagnosis, and overtreatment.
Geriatric Clinical Pearls?
- Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations. Work with the pt. to eat more foods- more appealing foods.
- Don’t prescribe any medication without conducting a drug regimen review. Deprescribe when possible. Try to not cause any new problems & interactions for the pt.
- Don’t use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
Do not give antibiotics for asymptomatic bacteriauria-
Informed Consent & Ethics:
Informed consent has two elements: These are?
- Informed: Information given to the patient about procedure or treatment
- Consent: The patient’s autonomous agreement
To be informed, the patient must receive, in terms that they can understand, all the information that would affect a reasonable person’s decision to consent to or to refuse the procedure or treatment.
The information should include all of the following:?
- Description of proposed procedure or treatment
- Name and qualifications of person performing the procedure
- Explanation of the potential for death or serious harm or for the discomforting side effects during or after the treatment
- Alternative treatments available
- The effects of not having treatment
What are the ethical principles?
Autonomy
Beneficence
Nonmaleficence
Veracity
Confidentiality
Fidelity
Justice
ETHICAL: ?
- Examine the data.
- Think about which person(s) should be making the decision.
- Humanize the options by constructing a decision tree.
- Incorporate the ethical principles, legal statutes, standards of care, and so on.
- Choose an option.
- Act.
- Look back and evaluate.
Capacity & Competence:
Capacity
- Involves a clinical evaluation by an authorized health care provider
Focuses on perceived ability of patient to participate with understanding in the process of informed consent - Do you believe the pt. understands consent.
Competence?
- A legal determination of abilities, performed by a court judge
Involves medical information but not limited to medical issues
Decision-making capacity: Evaluate in four areas:
- ability to understand information about treatment
- ability to appreciate how that information applies to their situation
- ability to reason with that information
- ability to make a choice and express it: https://www.aafp.org/pubs/afp/issues/2001/0715/p299.html
Use a structured approach to assessing decision-making capacity, including an assessment of language barriers, identification and remediation of reversible causes of incapacity and a comprehensive interview to assess the ability to consent. Include appropriate formal assessment tools.
Capacity is dynamic
Reassess at new (or changing) significant health care decision/informed consent points. May need to reassess pt. with any health changes like acute delirium.
The order of succession for decision-making is: spouse, adult child, parent, adult sibling, adult with close relationship. This is what happens if the pt. does not have advanced health directives etc. —- Look at a youtube video for this to understand this concept.
End of Life Care
Older adults should be asked about their end-of-life (EOL) preparations at annual office visits, when entering the hospital, or when undergoing an outpatient procedure, even if they are healthy.
Advanced Directives should be included in the patient’s medical record, and the individual and/or the health-care agent should be given copies. Carry these when they are traveling & also keep a copy on their refrigerator.
The provider should instruct the individual to carry the form when traveling and to adhere a copy to their refrigerator door at home as emergency services are trained to look there for advance directives
Serious conflicts can occur when a health-care agent’s decisions do not coincide with other family members’ wishes, creating increased suffering and difficulty at their loved one’s end of life and during the grieving process.
Durable Power of Attorney- the POA has complete control over the pts whole life
Health Care Proxy- only over medical decision
Living Will- pts specify who can take over their properties & make decisions.
POA= complete control
Healthcare Proxy= medical only
End of Life Care: Forms
DNR/Allow a Natural Death (AND)- allow natural death
Instructs health-care providers not to initiate CPR if the patient’s breathing stops or their heart stops beating.
Individuals should understand that sometimes CPR is only partly successful at resuscitating; if the individual survives, they may suffer damage to the brain or other organs or become permanently dependent on mechanical ventilation. Rib fractures on the frail patients.
Individuals who expect to die soon may prefer a natural death over aggressive interventions.
Using the language allow a natural death (AND) may be more appropriate when talking with patients about the progression to death.
POLST (Physician Orders for Life Sustaining Treatment)- You can break what you want down
- The first section on the POLST form addresses cardiopulmonary resuscitation (CPR).
- do you want CPR are you a full code - The second section of the POLST form discusses medical interventions with options including
Full Treatment
Limited Interventions
or Comfort Measures Only.- similar to allow natural death
- The third decision-making section on the POLST form is the nutrition and fluid section
**tube feeding section you can put a limit down- example you can put tube feeding down for the pt. wanting it for a month.
End of Life Care: MY 5 Wishes- start for pts and families not ready to make decisions. Do not feel comfortable with the provider in the office. This is a booklet that gives an approach to what the patients want. Tools to encourage family communication, and the patient can take control of their choices. The patient not being sure of what they want to do . . . this is a good booklet to give to the pt and their family.
- My Five Wishes is an advance directive created by the nonprofit organization Aging with Dignity for people in the United States.
- It provides a complete approach to discussing and documenting (1) advance care planning and individual preferences related to comfort, spirituality, etc.; (2) a durable power of attorney; and (3) specific life support options.
- The document is a guide that connects families, communicates with health-care providers, and shares the individual’s sense of desired care.
- A very special aspect of My Five Wishes is the sections in which individuals can write messages to their loved ones.
End of Life Care: Palliative Care Vs. Hospice Care- Know watch youtube video.
The Center to Advance Palliative Care defines palliative care as a specialty that focuses on 1. management of disease
2. comfort and communication
3. and quality of life for patients with active, progressive disease.
Care is focused on the patient’s needs rather than on their prognosis. What can we do to make them comfortable
What are the 3 key domains of palliative care?
- Symptom management
- psychosocial-spiritual support
- facilitation of medical decision making are three key domains of palliative care
The goals of palliative care are to?
(1) alleviate symptoms in a compassionate way
(2) neither hasten nor postpone death
(3) provide a support system for patients and their families by integrating the psychological and spiritual aspects of patient care throughout the trajectory of illness
It is associated with?
- Reduced hospital costs, especially if implemented within 3 days of admission of a hospitalized adult with life-limiting illness
- Can effectively improve patient and family satisfaction.
Individuals receiving palliative care services can continue curative treatments, therapies, and trials.
Hospice – cannot do curative treatments, therapies & trials
palliative care – Can DO curative treatments, therapies & trials
hospice= no curative treatment
HAPC- certification in palliative care through their programs.
End of Life Care: Hospice Care
The Medicare hospice benefit requires that patients forgo aggressive and curative treatments for their terminal diagnosis, and typically does not cover therapies (physical/occupational).
Medicare hospice eligibility criteria are that – There are hospice services for all age groups too! This is just focused on older adults. Does not cover PT/OT
(1) the patient is eligible for Medicare Part A (Hospital Insurance)
(2) the patient’s primary care provider and the hospice medical director certify that the patient is terminally ill and has 6 months or less to live if the illness runs its normal course,
(3) the patient provides informed consent to receive hospice care
(4) the patient receives care from a Medicare-approved hospice program (U.S. Centers for Medicare & Medicaid Service, 2021).
Medicare hospice eligibility criteria are that – There are hospice services for all age groups too! This is just focused on older adults. Does not cover PT/OT
(1) the patient is eligible for Medicare Part A (Hospital Insurance)
(2) the patient’s primary care provider and the hospice medical director certify that the patient is terminally ill and has 6 months or less to live if the illness runs its normal course,
(3) the patient provides informed consent to receive hospice care
(4) the patient receives care from a Medicare-approved hospice program (U.S. Centers for Medicare & Medicaid Service, 2021).
Medicare hospice benefits offer four levels of hospice care:
- Routine home hospice care is provided to terminally ill hospice patients with stable symptoms.
- General inpatient hospice care is utilized for individuals whose symptoms cannot be managed in their current location or during the last few days of their life.
- Respite care provides family caregivers a scheduled break from the demands of in-home caregiving.
- Crisis care provides short-term, in-home, around-the-clock hospice care for patients with uncontrolled symptoms or active dying process.
Hospice care provides durable medical equipment as well as covering the cost of all medications related to the hospice diagnosis.- bedside commodes hospital beds etc for equipment.
End of Life Care:
Prognostication? KNOW
!! Estimating prognosis can be challenging- can consult the patients specialist!!
- Many patients, even after discussions with their doctors, harbor unrealistic ideas about their prognosis and the likely benefits of medical treatments.
- They may have been told that there is a small chance that a treatment will “work” but have no understanding of what this possibility might mean in regard to longevity and quality of life.
- Many providers do not want to “take away hope,” so they avoid talking about how much longer the patient may live.
- Providers may avoid prognostication and rely on the specialist to prognosticate.
- Estimating prognosis is challenging even in illnesses with a defined trajectory, such as malignancy; however, online resources may help health-care providers to determine prognostic estimates, particularly for complex patients.
End of Life Care:
- What is your understanding of where things stand now with your illness?
- As you think about your illness, what is the best and the worst that you think might happen?
- What about this illness has been most difficult for you?
- What are your (hopes, expectations, worries, etc.) for the future?
- As you think about the future, what is most important to you? What matters most to you?
- Do you have a strong religious or spiritual belief? If so, to whom do you talk about spiritual matters?
- Would you like this person to be involved in your decision making at this time?
- With the time left, what would you like to accomplish?
- What thoughts have you had about why you got this illness at this time?
- What might be left undone if you were to die today?
- What is your understanding about what happens after you die?
- Given that your time is limited, what legacy do you want to leave your family?
- What do you want your children (or grandchildren or friends) to remember about you?
Geriatric Depression Screening Tool
