Gerontology: Common Disorders in Geriatrics Flashcards
Danger Signals! Retinal Detachment
- new onset or sudden ↑ # of floaters/specks on visual field, flashes of light, and sensation that a curtain is covering part of the visual field
- considered a medical emergency that can lead to blindness if not treated
RF:
- extreme nearsightedness
- hx of cataract surgery
- family/personal hx of retinal detachment
Tx:
- laser surgery or cryopexy (freezing)
Danger Signals! Temporal Arteritis
Giant Cell Arteritis
- temporal headache (one-sided) w/ tenderness or induration over temporal artery
- may be accompanied by sudden visual loss in one eye (amaurosis fugax)
- scalp tenderness and jaw claudication on affected side
- associated w/ polymyalgia rheumatica
- screening test: erythrocyte sedimentation rate (ESR) w/ or w/out C-reactive protein (CRP), which is usually ↑
- Temporal artery biopsy is definitive diagnosis
- Considered an ophthalmologic emergency (can cause blindness)
Danger Signals! Acute Angle-Closure Glaucoma
- older adult w/ acute onset of severe eye pain, severe headache,a nd N/V
- eye(s) is/are reddened w/ profuse tearing
- c/o blurred vision + halos around lights
Call 911! Do NOT delay treatment → blindness can occur w/out intervention
- Tonometry is done in ED to quickly measure intraocular pressure, which will be ↑
Danger Signals! Cerebrovascular Accident
AKA Stroke or “brain attack”
- sudden onset of neurologic dysfunction that worsens within hours
Deficits can include:
- blurred vision
- hemianopia (loss of vision in half of the visual field)
- severe headache
- slurred speech
- one-sided upper and/or LE numbness/weakness
- confusion
- S/Sx are dependent on location of infarct
2 types of CVAs:
- ischemic (more common)
- hemorrhagic
In comparison, a TIA is a temporary episode that generally lasts <24 hours
Danger Signals! Actinic Keratosis
Precursor of Squamous Cell Carcinoma
- small rough, scaly, pink-to-reddish lesions that enlarge slowly over year
s- located in sun-exposed areas such as cheeks, nose, back of neck, arms, chest
- more common in light-skinned individuals
- squamous cell precancerous skin lesions
Diagnostic method: Biopsy
- small number of lesions can be treated w/ cryotherapy
- larger # w/ wider distribution are treated w/ 5-fluorouracil cream
Danger Signals! Fractures of the Hip
- acute onset of limping, guarding, and/or inability or difficulty w/ bearing weight on affected side
- new onset of hip/groin pain
- may be referred to anterior thigh or knee
- unequal leg length and external rotation of affected leg
- Hx of osteoporosis or osteopenia
- Major cause of morbidity and mortality in elderly
- up to 20% of elderly w/ hip fractures die from indirect complications (e.g., pneumonia)
Danger Signals! Colorectal Cancer
- unexplained iron-deficiency anemia (23%)
- blood on rectum (37%)
- hematochezia
- melena
- abdominal pain (34%)
- change in bowel habits
- no sx during early stages
- diagnosed d/t screening
- presentation depends on location
- rectal CA can present w/ tenesmus, rectal pain, and diminished-caliber stooks (ribbonlike stools)
- ~20% of cases have distant metastases at time of presentation
→ Refer to gastroenterologist
Danger Signals! Severe Bacterial Infections
- atypical presentation is common
- older adults/elderly w/ bacteremia or sepsis may be afebrile
- ~1/3 to 1/2 of people w/ severe bacterial infections do NOT develop fever and/or chills
- some present w/ slightly lower than normal body temp (<37ºF/98.6ºF)
- WBC can be normal
Atypical presentations also include:
- a sudden decline in mental status (confusion, dementia)
- new onset of urine/bowel incontinence
- falling
- worsening inability to perform activities of daily living (ADLs)
- loss of appetite
- Serious infections include:
- pneumonia
- pyelonephritis
- bacterial endocarditis
- sepsis
Most common infection in older adults >65 years: UTI
Elder Abuse
- screen for abuse, neglect, and financial exploitation
- presence of bruising, skin tears, lacerations, and fractures that are poorly explained
- presence of STD,m vaginal and/or rectal bleeding, bruises on breasts are indicators of possible sexual abuse
- malnutrition, poor hygiene, and pressure injuries
Interview Elder alone with these 3 Questions
- Do you feel safe where you live?
- Who handles your bills and finances?
- Who prepares your meals?
Top 3 leading causes of death (>65 years)
- Heart disease (MI, HF, arrhythmias)
- Cancers (lung and colorectal)
- Chronic lower respiratory diseases (COPD)
Cancer in Older Adults
1. Definition/Etiology
2. CA w/ highest mortality
3. CA w/ second-highest mortality
4. Median age of diagnosis: Breast, Prostate, Lung
- Aging and advancing age are most common RF for CA
- 80% of all CA occur in people >55 years
- CA among older adults may be caused by gene-related DNA damage, familial genetics, ↓ in immunity, ↓ healing rates, environment, and hormonal influences
- Aging and advancing age are most common RF for CA
- Lung and bronchial CA (both genders
- Colorectal CA (both genders
- Breast: 61 years
Prostate: 68 years
Lung: 70 years
Lung Cancer
1. Definition/Etiology
2. Most common Risk Factors
3. Clinical Presentation
4. Treatment Plan
- CA w/ highest mortality (both genders)
- ~1/4 CA deaths are caused by lung CA
- most pts are older adults
- Fewer than 2% are younger than 45 years
- Most common type of lung CA: Non-small cell lung carcinoma (84%)
- CA w/ highest mortality (both genders)
Screening:
- USPSTF recommends annual screening for lung CA in adults (age 55-80) who have at least a 30-pack-year smoking hx and currently smoke (or have quit within the past 15 years)
- screening test is low-dose CT (LDCT)
→ Discontinue annual screening; pt stops smoking for ≥15 years or develops a health problem that substantially limits life expectancy (or ability or willingness for curative lung surgery)
- smoking (80% of cases)
- radon exposure (10%)
- occupational exposures to carcinogens (9-15%)
- outdoor pollution (1-2%)
- smoking (80% of cases)
- older male smoker (or ex-smoker):
- new onset productive cough w/ large amounts of thin mucoid phlegm (bronchorrhea)
- occasional blood-tinged phlegm
- c/o worsening SOB or dyspnea
- persistent, dull achy chest pain; does not go away
- if tumor is obstructing a bronchus, it can result in recurrent pneumonia of same lobe
- some may have weight loss
- older male smoker (or ex-smoker):
- CXR (e.g., nodules, lesions w/ irregular borders, pleural effusions)
- next imaging exam: CT scan
- GOLD STANDARD: Positive lung biopsy
- Baseline labs include: CBC, chemistry panel, liver enzymes, bilirubin, creatinine
→ Refer pt to pulmonologist for bronchos and tumor biopsy
- CXR (e.g., nodules, lesions w/ irregular borders, pleural effusions)
Colorectal Cancer
1. Definition/Etiology
2. Risk Factors
3. Clinical Presentation
4. Treatment Plan
- 2nd most common cause of CA in US
- ~20% of cases have distant metastases at time of presentation
- staged using tumor-node-metastasis (TNM) staging system (stages I-IV) - RF:
- advancing age (most common)
- inflammatory bowel disease
- fam hx of colorectal CA, colonic polyps
Lifestyle RF:
- lack of regular physical activity
- high-fat diet, low-fiber diet
- obesity
Screening:
- start at 50 years w/ baseline colonoscopy (repeat Q7-10 years)
- abnormal findings dictate more frequent evaluation
- sigmoidoscopy (Q5 years)
- high-sensitivity fecal occult blood test (FOBT;annually)
- DNA-based screening FOBT (Cologuard) is not available in place of screening colonoscopy, but only for average-risk individuals w/ no prior hix of abnormal colonoscopy findings and/or no fam hx of colon CA
- older adult who presents w/ change in bowel habits (74%)
- w/ or w/out hematochezia or melana (51%)
- abdominal pain (3%)
- may be asymptomatic and present only w/ unexplained iron-deficiency anemia
- pt may report anorexia and unintentional weight loss
- asymptomatic during early stages
- presentation depends on location
- pts w/ rectal Ca can present w/ tenemus, rectal pain, and diminished-caliber stooks (ribbonlike stools)
- older adult who presents w/ change in bowel habits (74%)
- baseline labs: CBC, FOBT, chemistry panel, UA
- check occult blood in stool (e.g., guaiac-based, stool DNA)
- serum carcinoembryonic antigen (CEA) is useful in follow-up
→ Refer to gastroenterologist for colonoscopy and management
- baseline labs: CBC, FOBT, chemistry panel, UA
► If ribbonlike stook (low-caliber stool) in older adults w/ iron-deficinecy anemia → R/O colon CA
** Any patient w/ unexplained iron-deficiency anemia who is older, male, or postmenopausal should be referred for a coloscopy (GI bleed, colon CA)
- If chemistry profile shows marked elevations in serum calcium and/or alkaline phosphatase, it is indicative of cancerous metastasis of bone
Multiple Myeloma
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
- CA of bone marrow, affecting plasma cells of immune system (production of monoclonal immunoglobulins)
- African American have highest incidence (doubled or tripled)
- MM is CA found mostly in older adults
- CA of bone marrow, affecting plasma cells of immune system (production of monoclonal immunoglobulins)
Characterised by elevated (CRAB):
Calcium levels
Renal insufficiency
Anemia
Bone disease
- older-to-elderly adult who c/o bone pain w/ generalized weakness
- bone pain is usually located on central skeleton (chest, back, shoulders, hips, pelvis)
- worsens w/ movement
- rarely occurs at night
- majority have anemia (73%)
- older-to-elderly adult who c/o bone pain w/ generalized weakness
- Baseline labs: CBC, FOBT, chemistry panel, UA
→ Refer to hematologist
- Baseline labs: CBC, FOBT, chemistry panel, UA
Pancreatic Cancer
1. Definition/Etiology
2. Treatment Plan
- most leath CA in terms of prognosis
- 5-year survival rate of 8.2%
- >95% of cases arise from exocrine portion of pancreas
- most pts already have metastases by time of diagnosis
Most common presentation:
- weakness (asthenia 86%)
- weight loss (85%)
- anorexia (83%)
- abdominal pain (79%)
- jaundice (56%)
- Initial labs: AST, ALT, alkaline phosphatase, bilirubin, lipase, and CA 19-9 tumor marker
→ Refer to gastrointestinal (GI) surgeon for Whipple procedure or other interventions
- Initial labs: AST, ALT, alkaline phosphatase, bilirubin, lipase, and CA 19-9 tumor marker
Atypical Presentations in the Elderly
- atypical disease presentation more common in this age group d/t immune system being less robust w/ age
- ↑ risk of bacterial and viral infections d/t changes in skin and mucosal barriers, ↓ cellular and humoral immunity, impaired cell signaling
- vaccines may not be as effective d/t ↓ antibody response
- older adults and elderly more likely to be asymptomatic or present w/ subtle sx
- elderly less likely to have a high fever during an infection → they more likely to have low-grade temp elevations or acute cognitive dysfunction (e.g., confusion, agitation, delirium)
- Cognitive dysfx may also be result of polypharmacy (↑ chances of adverse drug reactions and drug-drug interactions)
Bacterial Pneumonia - Clinical presentation
- fever and chills may be missing or mild (PO temp >100.0º F or rectal >99.5ºF)
- ↑ oxygen requirement → may be only prominent sx
- not cough → if present, cough may be mild and produce little-no sputum (esp if pt is dehydrated)
- may stop eating/drinking water
- start losing weight
- more likely to become confused
- weak w/ loss of appetite
- may become incontinent of bladder and bowel
- tachycardia
- ↑ risk of falls
- WBC may be normal or mildly elevated
- polymicrobial and gram- usually cause of majority of pneumonias in elderly
Urinary Tract Infections - Clinical Presentation
- most common infection in elderly nursing home residents and adults ≥ 65 years
- usually no have fever or can be asymptomatic
- may become acutely confused/agitated
- may become septic w/ mild sx
- new onset of urinary incontinence
Acute Abdomen - Clinical Presentation
elderly pt may have more subtle sx:
- absence of abdominal guarding + other signs of acute abdomen
- abdominal pain may be milder
- WBC may only slightly ↑ or may be normal
- pt may have low-grade fever w/ anorexia and weakness
Acute Myocardial Infarction - Clinical Presentation
- may be asymptomatic
Sx may consist of:
- new-onset fatigue
- back pain
- mild chest pain
Hypothyroidism - Clinical Presentation
subtle and insidious sx:
- sleepiness
- severe constipation
- weight gain
- dry skin
hypothyroidism is very common in pts ≥ 60 years
- problems w/ memory
If severe, may mimic dementia
- slower movements
- appears apathetic
Urinary Incontinence - Clinical Presentation
- should NOT be considered “normal” aspect of aging
- evaluate ALL cases
- may be short term and temporary (e.g., UTI, high intake of tea/coffee) or chronic
- 2-3x more common in women
RF:
- obesity
- increasing parity
- vaginal delivery
- menopause
- age
- smoking
- diabetes
Some foods/drinks worsen urinary incontinent d/t diuretic effect:
- tea
- caffeine
- alcohol
- carbonated drinks
- citrus fruits
- spicy foods
- some meds (diuretics, sedatives) may have similar effect
- different types (see slides)
Urinary Incontinence - Treatment Plan
First-line:
- lifestyle modifications for all types
- If obese, advise weight loss (most helpful for stress incontinence)
- smoking cessation if smoker
Dietary → avoid certain beverages (alcohol, coffee team carbonated drinks) and excessive fluid intake (>64 oz)
- ↓ fluid intake before bedtime
Constipation → treat to ↓ risk of urinary retention and subsequent urge or overflow incontinence
Kegel Exercises (pelvic floor exercises) → all types of urinary incontinence, esp stress incontinence
- been found to be helpful w/ fecal incontinence
- use absorbent pads and underwear made for urinary incontinence
- For mod-advanced pelvic organ prolapse (cystocele, rectocele, enterocele, uterine prolapse, vaginal eversion) → refer to urologist of gynecologist specializing in urinary incontinence and pelvic organ prolapse repair
Stress Incontinence
1. Definition/Etiology
2. Treatment Plan
- increased intra-abdominal pressure (laughing, sneezing, bending, lifting) causes involuntary leakage of small-to-medium volume of urine
- highest incidence in middle-aged women (peak at 45-49 years)
- increased intra-abdominal pressure (laughing, sneezing, bending, lifting) causes involuntary leakage of small-to-medium volume of urine
- kegel exercises
- decongestants (pseudoephedrine) if no contraindications
- kegel exercises
Urge Incontinence
1. Definition/Etiology
2. Treatment Plan
- sudden and strong urge to void immediately before involuntary leakage of urine
- involuntary loss of urine can range from mod-large volumes
- condition aka “overactive bladder”
- high incidence in older men and women
- sudden and strong urge to void immediately before involuntary leakage of urine
- Trial of anticholinergics (oxybutynin/Ditropan)
- tricyclic antidepressants (imipramine)
- Trial of anticholinergics (oxybutynin/Ditropan)
Overflow Incontinence
1. Definition/Etiology
2. Treatment Plan
- frequent dribbling of small amounts of urine from overly full bladder d/t blockage of flow (e.g., BPH or underactive detrusor muscle [e.g., spinal cord injury, MS])
- highest incidence in older men
- frequent dribbling of small amounts of urine from overly full bladder d/t blockage of flow (e.g., BPH or underactive detrusor muscle [e.g., spinal cord injury, MS])
- BPH treatment
Functional Incontinence
1. Definition/Etiology
2. Treatment Plan
- problems w/ mobility (walking to the toilet) or inability to pull down pants in a timely manner
- approx 25% of women aged 57-85 years
- problems w/ mobility (walking to the toilet) or inability to pull down pants in a timely manner
- bedside commod
- raised toilet seats w/ handles
- PT for strengthening and gait
- bedside commod
Mixed Incontinence
1. Definition/Etiology
2. Treatment Plan
- symptoms that are a mixture of stress and urge incontinence
- see above
Kegel Exercises - Pt Education
Tell patient to:
- identify muscles used to stop urinating (stop urinating midstream to confirm this); do NOT tighten muscles of abdomen, buttocks, thighs, and legs at the same time
- squeeze and hold these muscles and slowly count to 5
- relax and release these same muscles to a slow count of 5
- repeat this 10 x; aim for at least 3 sets of 10 repetitions 3x/daily for 15-20 weeks
Behavioral Bladder Training - Instructions & Pt Education
- bladder training to delay urination after feeling urge to urinate
- at first, have pt try holding off urinating for 10 mins each time
- goal: lengthen time between trips to bathroom to Q2-4 hrs
- double voiding helps to empty bladder more completely to avoid overflow
- double voiding means urinating and then waiting a few minutes and voiding again
Medications: Anticholinergics
- Oxybutynin (Ditropan) → 2.5-5 mg PO TID (immediate release)
- Other formulations include extended release, transdermal patch (twice a week), and transdermal gel
- Tolterodine (Detrol, Detrol LA) → 1-2 mg immediate-release tablet
- 2-4 mg extended-release capsule
Contraindications:
- urinary retention
- gastric retention
- severe ↓ motility of GI tract
- uncontrolled narrow-angle glaucoma
Medications: Beta-3-Adrenergic Agonists
- Mirabegron (Myrebetriq) → 25-50 mg extended-release tablets; second-line therapy
Contraindications:
- hypersensitivity
Pelvic Organ Prolapse in Women
1. Definition/Etiology
2. Evaluation
- herniation of the bladder (cystocele), rectum (rectocele), uterus (uterine prolapse), small bowel (enterocele), or vagina (vaginal vault prolapse)
- caused by weakening of pelvic muscles and supporting ligaments
- during early stage, pelvic organ prolapse is usually asymptomatic
- advise pt to avoid heavy or excessive straining, which can worsen condition
- avoid chronic constipation d/t straining worsening pelvic organ prolapse
- during gyne exam (bimanual exam, speculum exam), instruct pt to bear down or strain so herniation becomes visible and palpable
Pelvic Organ Prolapse: Cystocele
1. Definition
2. S/Sx
3. Treatment Plan
Bladder
1. - bulging of anterior vaginal wall
- early stage is usually asymptomatic in all types of pelvic organ prolapse
- urinary incontinence
- voiding difficulties (e.g., needing to reduce prolapse using a finger in vagina for urination/defecation)
- urinary incontinence
- Refer for pessary placement
- surgical repair
- Refer for pessary placement
Pelvic Organ Prolapse: Rectocele
1. Definition
2. S/Sx
3. Treatment Plan
Rectum
1. - bulging on posterior vaginal wall
- herniation ranges from mild to rectal prolapse
- feeling of rectal fullness/pressure
- sensation that rectum does not completely empty
- rectal prolapse can cause fecal incontinence
- feeling of rectal fullness/pressure
- kegel exercises
- avoid straining during BM
- treat constipation
- Refer for pessary placement
- surgical repair
- kegel exercises
Pelvic Organ Prolapse: Uterine Prolapse
1. Definition
2. S/Sx
3. Treatment Plan
Uterus
1. - cervix descents midline (apical) into vagina
- cervix feels firm w/ pale-pink color and os visible
- w/ 3º full prolapse, a tubular saclike protrusion is seen outside the vagina
- vaginal discharge or bleeding
- sensation of vaginal fullness
- feeling that something is falling into vagina
- low-back pain
- vaginal discharge or bleeding
- avoid heavy lifting and straining
- Refer for pessary placement
- surgical repair by urogynecologist
- avoid heavy lifting and straining
Pelvic Organ Prolapse: Enterocele
1. Definition
2. S/Sx
3. Treatment Plan
Small intestines
1. - small bowel slips into area b/w uterus and posterior wall of vagina
- bulging external vagina
- pulling sensation inside pelvis
- pelvis pressure/pain
- low-back pain
- dyspareunia
- pulling sensation inside pelvis
- Refer for surgical repair
Chronic Constipation
1. Definition/Etiology/Types
2. Clinical Presentation
3. Treatment Plan/Patient Education
4. Bowel Retraining Program
- 2 types: idiopathic & functional
- constipation is most common GI complaint
- self-treatment is common w/ OTC fiber and laxatives
- has many 2º causes (e.g., prescriptions, OTC drugs, neurologic ds [Parkinson’s, dementia[, IBS, diabetes, hypothyroidism, etc)
Lifestyle RF:
- immobility
- low-fiber diet
- dehydration
- milk intake
- ignoring urge to have BM
- hx of long-term constipation (years)
- describes stool as dry and hard; “ball-like” pieces
- large-volume stools, difficult to pass
- straining often to pass stool
- accompanied by feelings of fullness and bloating
- takes laxatives daily (laxative abuse)
- noted hemorrhoid, bleeding (reports bright-red blood on toilet paper and blood streaks on stool surface)
- hx of long-term constipation (years)
- education and behavior modification (bowel training)
- teach “toilet” hygiene (e.g., going to bathroom at the same time each day; advise not to ignore urge to defecate)
- dietary changes such as eating dried prunes and/or drinking prune juice
- increase intake of fruit and vegetables
- ingest bulk-forming fibers (25-35 g/day) daily; do not take w/ med (will absorb drugs); take w/ full glass of water (can cause intestinal obstruction)
- ↑ physical activity, esp walking
- ↑ fluid intake 8-10 glasses/day (if no contraindication)
- consider laxative treatment; avoid daily use of laxatives (except for fiber supplements) and chronic tx w/ laxatives
- education and behavior modification (bowel training)
- choose time of day pt prefers for BM (usually in AM about 20-40 mins after eating breakfast)
- spend about 10-15 mins on toilet each day at same time
- avoid straining
- choose time of day pt prefers for BM (usually in AM about 20-40 mins after eating breakfast)
Constipation Treatment Options: Bulk-Forming
1. Examples
2. MOA, indications, SE
- Psyllium (Metamucil)
- Wheat Destrin (Benefiber)
- Methylcellulose (Citrucel)
- Polycarbophil (FiberCon)
- Psyllium (Metamucil)
- 2 types: Soluble and insoluble fiber (bran and psyllium)
- absorbs water, adding bulk to stool
- constipation, IBS, diverticulitis
Constipation Treatment Options: Stimulants (irritants)
1. Examples
2. MOA, indications, SE
- Bisacodyl (Dulcolax) (PO and suppository)
- Senna extract (Senokot) (PO)
- Aloe vera juice
- Bisacodyl (Dulcolax) (PO and suppository)
- stimulates colon directly, causing contractions
- drug class: anthraquinone
- stimulates colon directly, causing contractions
Constipation Treatment Options: Osmotics (hyperosmotic agents)
1. Examples
2. MOA, indications, SE
- sorbitol
- lactulose (Cephulac)
- Polyethylene glycol or PEG 3350 (MiraLAX)
- Glycerin suppositories
- sorbitol
- draws fluids by osmosis to ↑ fluid retention in colon
- suppositories are for rectal use only
- draws fluids by osmosis to ↑ fluid retention in colon
Constipation Treatment Options: Saline Laxatives
1. Examples
2. MOA, indications, SE
- magnesium citrate
- magnesium hydroxide (MoM)
- Magnesium sulfate (Epson salt)
- magnesium citrate
- saline attracts water into intestinal lumen (small and large intestines)
- not examined in older adults; use w/ caution d/t hypermagnesemia risk
- saline attracts water into intestinal lumen (small and large intestines)
SE:
- fluid and electrolyte imbalances
Constipation Treatment Options: Guanylate cyclase-C receptor agonist
1. Examples
2. MOA, indications, SE
- Linaclotide (Linzess)
- Plecanatide (Trulance)
- Linaclotide (Linzess)
- stimulates intestinal fluid secretion and transit; for IBS, chronic idiopathic constipation
Contraindications:
- mechanical GI obstruction (known or suspected)
Constipation Treatment Options: Chloride channel activators
1. Examples
2. MOA, indications, SE
- Lubiprostone (Amitiza)
- idiopathic chronic constipation, IBS
Contraindications:
- Hx of mechanical obstruction
Constipation Treatment Options: 5-HT(4) receptor agonists, opioid antagonists, lubricants
1. Examples
2. MOA, indications, SE
- Prucalopride (Motegrity)
- Methylnaltrexone (Relistor)
- Naloxegol (Movantik)
- Mineral oil
- Prucalopride (Motegrity)
- idiopathic chronic constipation; opioid-induced constipation
- opioid-induced constipation
- d/c maintenance laxatives prior to starting therapy
- idiopathic chronic constipation; opioid-induced constipation
Contraindications:
- GI obstruction
- pts at risk for obstruction
Lubricants are not absorbed
Constipation Treatment Options: Stool softeners
1. Examples
2. MOA, indications, SE
- docusate sodium (Colace)
- softens stools (does not stimulate colon)
- stool becomes soft and slippery
- softens stools (does not stimulate colon)
Dementia and Cognitive Impairment
1. Most common cause of neurodegenerative dementia?
2. Most common cause of non-neurodegenerative dementia?
3. Considerations
- most common cause of neurodegenerative dementia → Alzheimer’s (60-80%)
- most common cause of non-neurodegenerative dementia is vascular dementia (CVA)
- one of most helpful methods of diagnosing dementia is eliciting a thorough hx of changes in pt’s memory, behavior, fx, and personality from family members and close contacts
RULE OUT of secondary causes is done by ordering:
- syphilis tests (only if high clinical suspicion based sexual hx or travel)
- vit B12 deficiency
- TSH
** Refer all pts w/ suspected Alzheimer’s ds and PD to neurologist for diagnostic evaluation and management!
Assessment of Functional Status (ADLs): Basic vs instrumental vs advanced
- self-care activities that are necessary for “independent” living depending on person’s environment (e.g., home, retirement community, nursing home)
Basic ADLs:
- eating (self-feeding)
- personal hygiene (brushing teeth, bathing)
- ambulation (walking, wheelchairs)
- bowel and bladder management
Instrumental ADLs (IADLs):
- shopping
- preparing meals
- housework
- using electronics (stoves, telephones, TV)
- managing finances
- driving a care
Advanced ADLs (AADLs):
- fulfilling multiple roles (spouse, parent, caretaker) while also participating in recreational/occupational tasks
Katz Index of Independence in ADLs
1. Definition
2. Criteria/Measures
- measure used to assess older adult’s independence
- contains 6 items
- each scored “1” (independence; ability to perform tasks w/ no supervision, direction, or personal assistance)
- “0” (dependence; needs supervision, direction, personal assistance, or total care)
Highest score: 6 (independent)
- lowest: 0 (very dependent)
Independence is defined as:
* Bathing
- able to bathe self completely or needs help in bathing only one body part (e.g., back, genitals)
* Dressing
- can get clothes from clothes/drawer and put on clothes w/out help (except tying shoelaces)
* Toileting
- able to get on/off toilet, including pants/underwear
- cleans genital area w/out help
* Transferring
- able to move in/out bed or chair unassisted
- mechanical transfer aids acceptable
* Continence
- has complete control (urination and defecation)
* Feeding
- can get food from plate into mouth
- able to feed self (ok if another person prepares food)
Lawton Instrumental ADL Scale
1. Definition
2. Criteria/Measures
- assesses an older adult’s independence
- most useful for identifying how a person is functioning at present time
- to identify improvement/deterioration over time
- assesses an older adult’s independence
- contains 8 categories, considered more complex than activities measured in Katz Index
- individuals are scared at their highest level of functioning in each category
- Score range: 0 (low function, dependent) - 8 (high function, independent)
Categories:
- ability to use the phone
- shopping
- food preparation
- housekeeping
- laundry
- mode of transportation
- responsibility for own medications
- ability to hand finances
Fried Physical Frailty Phenotype
1. Definition
2. Criteria/Measures
1/2. Five criteria used to measure frailty
- weight loss (>10 lb)
- weakness (grip strength; measure w/ digital hand dynamometer)
- exhaustion (self-report)
- walking speed (15 feet)
- physical activity (kcal/week)
- an individual who meets 1-2 of the criteria has “intermediate” frailty
- an individual who meets ≥3 criteria is considered “frail”
Cognitive Performance Scales: MMSE
1. Definition
2. Elements/Criteria/Measures
- brief screening exam to assess for cognitive impairment
- high sensitivity and specificity
- brief screening exam to assess for cognitive impairment
Score
- 0-10 (severe)
- 10-20 (moderate)
- 20-25 (mild)
- 25-30 (questionable significance; mild deficits)
- Elements:
► Orientation to time and place
- ask about year/season/date/day/month
- where are we now? Name state (county, town/city, hospital, floor)
► Short-term memory
- name 3 unrelated objects and instruct pt to recite all 3 words
►Attention and calculation
- serial 7s (ask pt to count backward from 100 by 7)
- Alternative: instruct pt to spell world backward
►Recall
- say to pt, “Earlier I told you the names of 3 things, can you tell me what they were?”
► Language
- show pt 2 simple objects (e.g., pencil, coin); instruct pt to name them
- instruct pt to repeat phrase “no ifs, ands, or buts”
- give pt one blank piece of paper; instruct pt to “take paper in your right hand, fold it in half, and put it on the floor”
- write on paper “Close your eyes” ; instruct pt to read and do what it says
►Complex commands
- writing a sentence: instruct pt to make up and write a sentence about anything
- copying a design: use questionnaire w/ a picture of 2 pentagons that intersect
Exam tip: a question will ask you to identify the MMSE “activity” that is being performed
- when a person is asked to interpret a proverb (given by the NP); this is a test of abstract thinking
* MMSE is most popular screening test for dementia and most commonly used test for Alzheimer’s ds
Cognitive Performance Scales: Mini-Cog test
1. Definition
2. Elements/Criteria/Measures
- a 3-min tool to sreen for cognitive impairment in older adults in primary care setting
- high sensitivity and specificity
- score: 0-2 (dementia); 3-5 (no dementia)
- a 3-min tool to sreen for cognitive impairment in older adults in primary care setting
- 3 steps:
- 3-word recognition (1 pt for each word)
- instruct pt to repeat 3 words
- there are 6 versions of words that can be used
Ex: banana, sunrise, chair (version 1) OR leader, season, table (version 2) - clock drawing (score as normal or abnormal)
- instruct pt to draw a clock by putting numbers first
- indicate a specific time by saying “set hands to 10 past 11” or “set hands at 20 minutes after 8” - 3-word recall
- ask pt to recall 3 words you stated in step 1
Cognitive Performance Scales: Addenbrooke’s Cognitive Examination III (ACE-III)
1. Definition
2. Elements/Criteria/Measures
- useful in detection of mild cognitive impairment, Alzheimer’s, and frontotemporal dementia
- Screening test composing of tests of:
- attention
- orientation
- memory
- language
- visual perceptual
- visuospatial skills
Cognitive Performance Scales: Revised Index of Social Engagement (RISE)
1. Definition
2. Elements/Criteria/Measures
1/2. - used for pts in long-term care facilities
- measures social engagement and east in interactions w/ others
Ex:
- engaging in planned activities
- accepting invitations
- pursuing involvement in facility life
- initiating interactions
- reacting positively to interactions
Cognitive Performance Scales: Geriatric Depression Scale (Short Form: GDSS-SF)
1. Definition
2. Elements/Criteria/Measures
- -15-question screening tool for depression in older adults
- takes 5-7 minus
- can help provider quickly determine if further assessment is necessary
Cognitive Performance Scales: Patient Health Questionnaire-9 (PHQ-0)
1. Definition
2. Elements/Criteria/Measures
- 9-item depression scale
- assist in diagnosis of depression
- monitors treatment response
- one of the most validated tools in mental health
- can be used for all patient populations
Delirium
1. Definition
2. Etiology
3. Clinical Presentation
4. Treatment Plan
AKA Acute Confusional State
1. - reversible, temporary process
- duration is usually brief (hours to days)
- 2º to medical condition, drug, intoxication, adverse reaction to medicine
- prescription meds (opioids, sedatives, hypnotics, antipsychotics, polypharmacy)
- substance abuse (alcohol, heroin, hallucinogens); plants (jimsonweed, salvia)
- drug-drug interactions, adverse reactions, psychiatric illness
- abrupt drug withdrawal (alcohol, benzodiazepines, drugs)
- preexisting med conditions, ICU pts w/ sensory overload
- infections, sepsis (UTI and PNA most common infections)
- electrolyte imbalance, HF, renal failure
- prescription meds (opioids, sedatives, hypnotics, antipsychotics, polypharmacy)
- pt may be:
- acute and dramatic onset
- excitable
- irritable
- combative
- with short attention span, memory loss, and disorientation - remove offending agent
- treat illness, infection, or metabolic derangements
*delirium resolves)
- remove offending agent
“Sundowning” Phenomenon
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
- occurs in both delirium a nd dementia
- starting at dusk/sundown
- occurs in both delirium a nd dementia
- severe agitation
- confusion
- combative
* Sx resolves in the AM
- seen more w/ dementia; recurs commonly
- severe agitation
- avoid quiet and dark rooms
- have well-lit room w/ a radio, TV, or clock
- familiar surroundings are important; do not move furniture or change decor
- avoid drugs affecting cognition (antihistamines, sedatives, hypnotics, narcotics)
- maintain routines
- observe and minimize triggers
- use distractions (e.g., watch TV, take a walk, play music, reminisce)
- avoid quiet and dark rooms
Dementia
1. Definition/Etiology
2. Differential Diagnoses
3. Mild Cognitive Impairment
- irreversible brain disorder, involving loss of learned cognitive and physical/motor skills
- presentation and s/sx are dependent on etiology and location of brain damage
- gradual and insidious onset except if caused by stroke or acute brain damage
- affects executive skills adversely
- irreversible brain disorder, involving loss of learned cognitive and physical/motor skills
- IMPORTANT to obtain thorough health/medical/drug hx
- pt should be accompanied by family during interview; family members/friends will report pt’s s/sx → refer to neurologist for further assessment
- R/O correctable causes (vit B12 deficiency, hypothyroidism, major depression, infection, adverse/drug interactions, heavy metal poisoning, neurosyphilis, etc)
- Parkinson’s dementia and dementia w/ Lewy bodies (DLB) may resemble each other
- Remember that normal pressure hydrocephalus can cause dementia-like sx that mimic Alzheimer’s ds
- preferred imaging test for dementia s/sx → MRI of brain
- IMPORTANT to obtain thorough health/medical/drug hx
- early phase of some brain disorders such as Alzheimer’s ds, CVA dementia, Parkin’s ds, frontotemporal dementia
- ACE-III has showed high diagnostic accuracy in individuals w/ mild cognitive impairment
- early phase of some brain disorders such as Alzheimer’s ds, CVA dementia, Parkin’s ds, frontotemporal dementia
Executive function
- self-regulation skills, attention, planning, multitasking, self-control, motivation, and decision-making skills
- higher level cognitive skills are regulated in frontal lobes of brain
Alzheimer’s Disease
1. Definition/Etiology
2. Clinical presentation (Mild vs moderate vs severe)
- rare before 60 years
- prevalence doubles Q5 years after 65 years
- accumulation of neurofibrillary plaques/tangles → permanent brain damage
- ↓ in acetylcholine production
- avg life expectancy of ≥65 when diagnosed is 4-8 years
- seizures occur in 10-20% - 3 A’s: Aphasia, Apraxia, Agnosia
Mild (2-4 years) → usually still functioning independently, but fam/friends may notice early s/sx
- problems coming up w/ right word when talking
- forgetting something that was just read/seed
- repeats same questions
- forgets important dates
- losing/misplacing important objectds
- getting lost on familiar routes
- problems managing personal finances and money
- poor judgment
- becomes withdrawn, anxious, and/or depressed
- easily upset
- personality changes
Moderate (2-10 years) → usually longest stage; requiring greater levels of care
- wanders and gets lost
- has problems w/ speech and following instructions
- stops paying bills
- may start conversation and forget to complete sentences
- loses ability to read/write
- has problems recognizing familiar people (agnosia) and unable to recall current/past information about themselves
- demonstrates personality and behavior changes (delusions/compulsions)
Severe (1-3 years) → disease sx are severe; pt requires total care
- unable to feed self
- incontinent of bowel/bladder
- unable to control movements, so they stop walking and use wheelchair or are bedridden
- incoherent or mute and have difficulty communicating pain
- apathetic
Aphasia
difficulty expression and understanding language
Apraxia
difficulty w/ ross motor movements such as walking
Agnosia
inability to recognize familiar people/objects
Types of Dementia: Alzheimer’s
1. Brain Pathology
2. Presentation
1 cause of dementia
- deposits of beta amyloid protein and neurofibrillary tangles on frontal and temporal lobes
- Early signs:
- short-term memory loss (e.g., difficulty remembering names and recent events)
- wandering
- apathy
- apraxia
- aphasia
- agnosia
→ progression to impaired judgment
- executive skills
- confusion
- behavior changes
Terminal stage characterized by:
- difficulty speaking
- swallowing
- walking
Types of Dementia: Vascular dementia
1. Brain Pathology
2. Presentation
2 cause of dementia
- multi-infarct/ishemic damage d/t atherosclerotic plaques, bleeding, and/or blood clots
- S/sx of stroke w/ cognitive sx
- memory loss
- impaired executive function
- impaired judgment
- apathy
* Location of infarct determines sx
- S/sx of stroke w/ cognitive sx
Types of Dementia: Dementia w/ Lewy bodies
1. Brain Pathology
2. Presentation
- alpha-synuclein protein (Lewy bodies)
- sleep disturbance/insomnia
- visual hallucinations
- executive function is impaired
- parkinsonism (muscle rigidity, tremors)
- fluctuations in alertness and cognition
- sensitive to adverse effects of neuroleptics
- sleep disturbance/insomnia
Types of Dementia: Parkinson’s disease
1. Brain Pathology
2. Presentation
- loss of dopamine receptors in basal ganglia of substantia nigra
* 40% of parkinson’s pts develop dementia - rigidity
- bradykinesia
- difficulty initiating voluntary movements
- pill-rolling tremor
- masked facies
- depression
- + features of DLB (sleep disturbance, visual hallucinations)
- rigidity
Types of Dementia: Frontotemporal dementia
1. Brain Pathology
2. Presentation
Pick’s disease
1. orbital and frontal areas of brain (orbitofrontal)
- personality change
- social withdrawal
- loss of spontaneity
- loss of motivation/desire to do task (abulia)
- impulsive
- disinhibition
- exhibits utilization behavior (e.g., uses and reuses same object as in using a spoon to eat, comb hair, waving it)
- personality change
Types of Dementia: Mixed dementia
1. Brain Pathology
2. Presentation
- mixture of ≥2 types (e.g., Alzheimer’s and vascular dementia)
- If Alzheimer’s and vascular, sx of both conditions are present
Types of Dementia: Wernicke-Korsakoff syndrome
1. Brain Pathology
2. Presentation
Wernicke’s encephalopathy
1. Chronic thiamine (vit B1) deficiency d/t chronic alcohol abuse → brain damage
* caused by vit B1 (thiamine) deficiency
- confusion
- disorientation
- indifference
- horizontal movement nystagmus (both eyes
- confusion
- If caught early, tx w/ high-dose thiamine may reverse some sx; msot have permanent brain damage
- thiamine IV in high doses can help, but if late diagnosis, permanent brain damage
Types of Dementia: Normal Pressure Hydrocephalus
1. Brain Pathology
2. Presentation
- ↑ amount of cerebrospinal fluid (but normal intracranial pressure)
- difficult walking (body bent forward, legs wide apart, slow)
- impaired thinking
- executive function impaired
- ↓ concenrtraion
- apathy
- changes in personality
* brain shunt surgery to ↓ intercranial pressure may help
- difficult walking (body bent forward, legs wide apart, slow)
Dementia
3. Treatment Plan
4. Medications (Mild-advanced)
- Most pts w/ Alzheimer’s ds are taken care of at home by family or caregiver during early stages
- as ds progresses, many pts are placed in skilled nursing facilities or assisted-living dementia units
- in later stages, families may concern hospice care - Mild-moderate (MMSE 10-26)
- begin trial of cholinesterase inhibitor (↑ longevity of acetylcholine)
Ex: - donepezil (Aricept)
-rivastigmine (Exelon)
- galantamine
- n-methyl-D-aspartate (NMDA) receptor agonist memantine (Namenda) PO daily - BID
Moderate-to-advanced dementia (MMSE <17)
- add memantine (10 mg BID) to cholinesterase inhibitor
- or use memantine alone
Severe dementia (MMSE <10)
- continue memantine or discontinue drug
→ Improvement within 3-6 months; stop if no longer effective
Dementia
5. Adjunct Treatment
6. Rehabilitation
7. Driving and Early-Stage or Mild Dementia
8. Complications
- Physical activity/exercise have shown to slow functional decline in pts
- Axona (caprylidene) → prescription triglyceride-rich medical food (consumed as a shake), addressing diminished cerebral glucose metabolism by assisting body in metabolizing ketone bodies as alternative fuel source for brain → should be medically supervised
- Vit E 2,000 IU daily recommended for ild-mod Alzheimer’s ds → NOT recommended for other forms of dementia
- Physical activity/exercise have shown to slow functional decline in pts
- Cognitive rehabilitation → may help during early stages of dementia
- Occupational therapy → may improve ADL performances
- Cognitive rehabilitation → may help during early stages of dementia
- evaluate for safety and monitor regularly
- ask family/friends about pt’s driving ability, traffic accidents, getting lost, difficulty making decisions, and so forth
- evaluate for safety and monitor regularly
- death is usually d/t an overwhelming infection (PNA, sepsis)
- Hip fractures are also common cause of death (from complications)
- death is usually d/t an overwhelming infection (PNA, sepsis)
Parkinson’s Disease (PD)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
- progressive neurodegenerative ds w/ marked ↓ in dopamine production
- more common after 50 years
- men more likely to have PD than women (1.5:1)
- PD dementia is common, up to 40%
- depression is common, up to 2/3 of all pts
- progressive neurodegenerative ds w/ marked ↓ in dopamine production
- Classic 3 sx:
- tremor (worse at rest)
- muscular rigidity
- bradykinesia
Elderly pt c/o:
- gradual onset of motor sx
- pill-rolling tremors of hands
- cogwheel rigidity w/ difficulty initiating voluntary movement
- walks w/ slow shuffling gait
- has poor balance, often falls (postural instability)
- generalized muscular rigidity w/ masked facies
+ mood ds: anxiety and depression
- excessive daytime sleepiness
- difficulty w/ executive function (making plans, decisions, tasks)
- may have s/sx of dementia
- worsening seborrheic dermatitis (white scales, erythema)
- Mild sx → do not markedly interfere w/ function, not necessary to prescribe carbidopa-levodopa immediately after diagnosis
- consider tx for significant bradykinesia or gait disturbance, mod-severe hand tremors (dominant hand), depending on pt preference & degree that tremors interfere w/ ADLs, work, and social fx
- ask pt about fatigue (71%), more common than tremors (68%)
- may nap more frequently
- Mild sx → do not markedly interfere w/ function, not necessary to prescribe carbidopa-levodopa immediately after diagnosis
Parkinson’s Disease: Medications - Carbidopoa-levodopa
First-line: Carbidopa-levodopa (Sinemet) TID
- dopamine precursor
- start at low doses; Sinemet 25/100 mg (half tablet) PO BID-TID w/ meal/snack to avoid nausea
- titrate up slowly to control sx
- sudden withdrawal or dose reductions of levodopa/dopamine agonists (e.g., bromocriptine, ropinirole) may be associated (rarely) w/ akinetic crisis or parkinsonism-hyperpyrexia syndrome
Adverse SE:
- motor fluctuations (wearing-off phenomenon)
- dyskinesia
- dystonia
- dizziness
- somnolence
- nausea
- headache
- eventually will develop tardive dyskinesia (tx w/ benztropine, amantadine, etc)
Parkinsonism-hyperpyrexia syndrome
occurs w/ sudden withdrawal or dose reductions of levodopa/dopamine agonists (e.g., bromocriptine, ropinirole)
S/Sx
- fever
- autonomic dysfx
- muscular rigidity
- AMS
Parkinson’s Disease: Medications - Dopamine agonists
Ergot types
- bromocriptine (Parlodel)
- has limited use in PD
- replaced by newer dopamine agonists that are nonergot types → pramipexole (Mirapex)
- Do not abruptly discontinue dopamine agonists
- dopamine withdrawal syndrome (8-19%) causes panic attacks, anxiety, craving drug
Adverse effectds:
- can cause impulse control ds (compulsive gambling, sex, or shopping)
Parkinson’s Disease: Medications - Monoamine oxidase-B (MAO-B) inhibitors
- Selegiline (Eldepryl)
- rasagiline (Azilect)
- Does not have dietary restrictions like MAOIs
Adverse SE:
- insomnia
- jitteriness
- hallucinations
- do NOT combine w/ MAOIs or serotonin antagonists (SSRIs, triptans)
Parkinson’s Disease: Medications - Treatment for tardive dyskinesia (extrapyramidal sx)
- Give anticholinergics: Benztropine (Cogentin)
- Give amantadine (Symmetrel/Osmolex ER): Antiviral (treats type A influenza) and dopamine agonist
Parkinson’s Disease: Treatment
1. Nonpharmacologic
2. Devise assistance/surgery
- exercise
- PT, SLP
- mindfulness
- meditation
- exercise
- consider continuous infusions or deep brain stimulation
Parkinson’s Disease
5. Complications
- Acute akinesia: loss of voluntary movement; sudden exacerbation of PD
- Dementia (40%)
- frequent falls → fractures of fact, hips, etc
- drug-related adverse effects such as tardive dyskinesia, dystonia, motor fluctuations
Essential Tremor
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
1/2. - most common type of action/postural tremor
- usually seen in arms/hands
- may progress to include head
- exact etiology: unknown
- can occur in children + adults
- not curable but sx can be controlled by meds
- sx can worsen w/ anxiety
- may improve w/ small amounts of alcohol
- meds can be taken PRN (anxiety) or daily
- Propranolol 60-320 mg/daily
- long-acting propranolol (Inderal AL) is also effective, but provides same response as “regular propranolol”
→ CONTRAINDICATION (beta-blockers)
- Asthma, COPD
- 2º/3º heart block
- bradycardia
- Propranolol 60-320 mg/daily
-Primidone (Mysoline) 25-750 mg/daily HS
► Refer to neurologist for evaluation and tx
Neurocognitive Findings (definitions): Abulia
- loss of motivation or desire to do tasks
- loss of willpower
- indifference to social norms (e.g., urinates in public)
Neurocognitive Findings (definitions): Akathisia
- intense need to move d/t severe feelings of restless ness
Neurocognitive Findings (definitions): Akinesia
- reduced voluntary muscle movements (e.g. PD)
Neurocognitive Findings (definitions): Amnesia + antegrade amnesia + retrograde amnesia
- memory loss
Antegrade amnesia → memory loss of recent events (occurs during disease)
retrograde amnesia → memory loss of events in the past (before onset of disease)
Neurocognitive Findings (definitions): Anomia
Problems recalling words/names
Neurocognitive Findings (definitions): Aphasia
- difficulty using (speech)
- understanding language
- can include difficult w/ speaking, comprehension, and written language
Neurocognitive Findings (definitions): Apraxia
- difficulty w/ or inability to remember learned motor skill
Neurocognitive Findings (definitions): Astereognosis
- inability to recognize familiar objects place in the palm (place a coin on palm w/ eyes closed and ask pt to identify object)
Neurocognitive Findings (definitions): Ataxia
- difficulty coordinating voluntary movement
Neurocognitive Findings (definitions): Confabulation
- “lying” or fabrication of events d/t inability to remember event
Neurocognitive Findings (definitions): Dyskinesia
- abnormal involuntary jerky movements
Neurocognitive Findings (definitions): Dystonia
- abnormal movements and muscle tone (continuous muscle spasms)
What is the #1 most common cause of dementia in the US? What is #2?
1 Alzheimer’s
#2 Vascular (CVA)
Exam Tip* recognize classic presentation of PD and Alzheimer’s + “sundowning phenomenon”
What is first-line treatment for PD:
levodopa (Sinemet) immediate release
What is selegiline (Eldepryl)?
MAO-B drug w/out food interactions
- affects serotonin system
* any drug altering serotonin will ↑ risk of serotonin syndrome
What are drugs that alter serotonin? Why is this important?
- SSRIs
- SNRIs
- TCAs
- MAOIs
- triptans
- ↑ risk of serotonin syndrome
What is essential tremor? What is first-line treatment?
an “action” or postural tremor (not a resting tremor)
First-line: beta-blockers (propranolol)
What is one of the most common cause of acute mental status changes in the elderly?
UTIs
- order a UA in all elderly pts w/ acute mental status changes or delirium
Why do some clinicals postpone start levodopa in early-onset PD? What drug(s) can exacerbate or worsen PD’s sx?
- younger than 60 years
- because of higher incidence of levodopa-related dyskinesia
- Cholinergic drugs can exacerbate/worsen PD sx
Other common geriatric conditions
- acute diverticulitis
- anemia
- bacterial pneumonia
- COPD
- heart failure
- DM2
- Glaucoma
- Heart disease/murmurs
- HLD
- HTN
- macular degeneration
- Menopause/atrophic vaginitis
- temporal arteritis
Pharmacologic Issues in Older Adults - Why is this a problem?
Drug clearance is affected be:
- renal impairment
- less efficient liver cytochrome P450 system
- malabsorption
- relatively higher fat:muscle tissue ratio (extends half-life, fat-soluble drugs)
- ↑ sensitivity to benzos, hypnotics, TCAs, and antipsychotics
American Geriatrics Society (AGS) provides Beers Criteria list of potentially inappropriate meds
- Deprescribing measures should be used when appropriate for elderly pts
Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Constipation
- anticholinergics
- CCBs
- opioids
Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Dizziness
- anticholinergics
- antihypertensives
- sulfonylureas (long-term use)
Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Delirium & Dementia
- anticholinergics
- benzodiazepines
- corticosteroids
- H2 antagonists
- sedative hypnotics
Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Falls
- anticonvulsants
- antidepressants (SSRTs and TCAs)
- antihypertensives (specifically alpha-blockers → orthostatic hypotension)
- antipsychotics
- benzodiazepines
- opioids
Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Urinary incontinence
- anticholinesterase inhibitors
- antidepressants
- antihistamines
- antihypertensives (specifically CCBs, diuretics, alpha-1 blockers)
- antipsychotics
- opioids
- sedative-hypnotics
Beers Criteria: Potentially Inappropriate Meds for Older Adults
- Alpha-blockers → high risk of orthostatic hypotension
- Terazosin (Hytrin)
- clonidine (Catapres)
- Antihistamines
- Diphenhydramine (Benadryl)
- Newer generation has lower incidence (Claritin)
- Antidepressants (tricyclic)
- amitriptyline (Elavil)
- imipramine (Tofranil)
- doxepin (Silenor)
- Atypical antipsychotics → BBW: higher risk mortality in elderly from nursing homes
- quetiapine (Seroquel)
- olanzapine (Zyprexa)
