Gerontology: Common Disorders in Geriatrics

Question 1

Danger Signals! Retinal Detachment

Answer 1

• 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)

Question 2

Danger Signals! Temporal Arteritis

Answer 2

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)

Question 3

Danger Signals! Acute Angle-Closure Glaucoma

Answer 3

• 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 ↑

Question 4

Danger Signals! Cerebrovascular Accident

Answer 4

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

Question 5

Danger Signals! Actinic Keratosis

Answer 5

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

Question 6

Danger Signals! Fractures of the Hip

Answer 6

• 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)

Question 7

Danger Signals! Colorectal Cancer

Answer 7

• 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

Question 8

Danger Signals! Severe Bacterial Infections

Answer 8

• 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

Question 9

Elder Abuse

Answer 9

• 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

Question 10

Interview Elder alone with these 3 Questions

Answer 10

1. Do you feel safe where you live?
2. Who handles your bills and finances?
3. Who prepares your meals?

Question 11

Top 3 leading causes of death (>65 years)

Answer 11

1. Heart disease (MI, HF, arrhythmias)
2. Cancers (lung and colorectal)
3. Chronic lower respiratory diseases (COPD)

Question 12

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

Answer 12

1. • 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
2. Lung and bronchial CA (both genders
3. Colorectal CA (both genders
4. Breast: 61 years
   Prostate: 68 years
   Lung: 70 years

Question 13

Lung Cancer
1. Definition/Etiology
2. Most common Risk Factors
3. Clinical Presentation
4. Treatment Plan

Answer 13

1. • 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%)

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)

2. • smoking (80% of cases)
     - radon exposure (10%)
     - occupational exposures to carcinogens (9-15%)
     - outdoor pollution (1-2%)
3. • 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
4. • 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

Question 14

Colorectal Cancer
1. Definition/Etiology
2. Risk Factors
3. Clinical Presentation
4. Treatment Plan

Answer 14

1. 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)
2. 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

3. • 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)
4. • 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

► 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

Question 15

Multiple Myeloma
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

Answer 15

1. • 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

Characterised by elevated (CRAB):
Calcium levels
Renal insufficiency
Anemia
Bone disease

2. • 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%)
3. • Baseline labs: CBC, FOBT, chemistry panel, UA
     → Refer to hematologist

Question 16

Pancreatic Cancer
1. Definition/Etiology
2. Treatment Plan

Answer 16

1. 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%)

2. • 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

Question 17

Atypical Presentations in the Elderly

Answer 17

• 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)

Question 18

Bacterial Pneumonia - Clinical presentation

Answer 18

• 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

Question 19

Urinary Tract Infections - Clinical Presentation

Answer 19

• 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

Question 20

Acute Abdomen - Clinical Presentation

Answer 20

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

Question 21

Acute Myocardial Infarction - Clinical Presentation

Answer 21

• may be asymptomatic

Sx may consist of:
- new-onset fatigue
- back pain
- mild chest pain

Question 22

Hypothyroidism - Clinical Presentation

Answer 22

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

Question 23

Urinary Incontinence - Clinical Presentation

Answer 23

• 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)

Question 24

Urinary Incontinence - Treatment Plan

Answer 24

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

Question 25

Stress Incontinence
1. Definition/Etiology
2. Treatment Plan

Answer 25

1. • 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)
2. • kegel exercises
     - decongestants (pseudoephedrine) if no contraindications

Question 26

Urge Incontinence
1. Definition/Etiology
2. Treatment Plan

Answer 26

1. • 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
2. • Trial of anticholinergics (oxybutynin/Ditropan)
     - tricyclic antidepressants (imipramine)

Question 27

Overflow Incontinence
1. Definition/Etiology
2. Treatment Plan

Answer 27

1. • 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
2. • BPH treatment

Question 28

Functional Incontinence
1. Definition/Etiology
2. Treatment Plan

Answer 28

1. • 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
2. • bedside commod
     - raised toilet seats w/ handles
     - PT for strengthening and gait

Question 29

Mixed Incontinence
1. Definition/Etiology
2. Treatment Plan

Answer 29

1. • symptoms that are a mixture of stress and urge incontinence
2. see above

Question 30

Kegel Exercises - Pt Education

Answer 30

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

Question 31

Behavioral Bladder Training - Instructions & Pt Education

Answer 31

• 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

Question 32

Medications: Anticholinergics

Answer 32

• 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

Question 33

Medications: Beta-3-Adrenergic Agonists

Answer 33

• Mirabegron (Myrebetriq) → 25-50 mg extended-release tablets; second-line therapy

Contraindications:
- hypersensitivity

Question 34

Pelvic Organ Prolapse in Women
1. Definition/Etiology
2. Evaluation

Answer 34

1. • 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

2. • during gyne exam (bimanual exam, speculum exam), instruct pt to bear down or strain so herniation becomes visible and palpable

Question 35

Pelvic Organ Prolapse: Cystocele
1. Definition
2. S/Sx
3. Treatment Plan

Answer 35

Bladder
1. - bulging of anterior vaginal wall
- early stage is usually asymptomatic in all types of pelvic organ prolapse

2. • urinary incontinence
     - voiding difficulties (e.g., needing to reduce prolapse using a finger in vagina for urination/defecation)
3. • Refer for pessary placement
     - surgical repair

Question 36

Pelvic Organ Prolapse: Rectocele
1. Definition
2. S/Sx
3. Treatment Plan

Answer 36

Rectum
1. - bulging on posterior vaginal wall
- herniation ranges from mild to rectal prolapse

2. • feeling of rectal fullness/pressure
     - sensation that rectum does not completely empty
     - rectal prolapse can cause fecal incontinence
3. • kegel exercises
     - avoid straining during BM
     - treat constipation
     - Refer for pessary placement
     - surgical repair

Question 37

Pelvic Organ Prolapse: Uterine Prolapse
1. Definition
2. S/Sx
3. Treatment Plan

Answer 37

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

2. • vaginal discharge or bleeding
     - sensation of vaginal fullness
     - feeling that something is falling into vagina
     - low-back pain
3. • avoid heavy lifting and straining
     - Refer for pessary placement
     - surgical repair by urogynecologist

Question 38

Pelvic Organ Prolapse: Enterocele
1. Definition
2. S/Sx
3. Treatment Plan

Answer 38

Small intestines
1. - small bowel slips into area b/w uterus and posterior wall of vagina
- bulging external vagina

2. • pulling sensation inside pelvis
     - pelvis pressure/pain
     - low-back pain
     - dyspareunia
3. • Refer for surgical repair

Question 39

Chronic Constipation
1. Definition/Etiology/Types
2. Clinical Presentation
3. Treatment Plan/Patient Education
4. Bowel Retraining Program

Answer 39

1. 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

2. • 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)
3. • 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
4. • 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

Question 40

Constipation Treatment Options: Bulk-Forming
1. Examples
2. MOA, indications, SE

Answer 40

1. • Psyllium (Metamucil)
     - Wheat Destrin (Benefiber)
     - Methylcellulose (Citrucel)
     - Polycarbophil (FiberCon)
2. 2 types: Soluble and insoluble fiber (bran and psyllium)
   - absorbs water, adding bulk to stool
   - constipation, IBS, diverticulitis

Question 41

Constipation Treatment Options: Stimulants (irritants)
1. Examples
2. MOA, indications, SE

Answer 41

1. • Bisacodyl (Dulcolax) (PO and suppository)
     - Senna extract (Senokot) (PO)
     - Aloe vera juice
2. • stimulates colon directly, causing contractions
     - drug class: anthraquinone

Question 42

Constipation Treatment Options: Osmotics (hyperosmotic agents)
1. Examples
2. MOA, indications, SE

Answer 42

1. • sorbitol
     - lactulose (Cephulac)
     - Polyethylene glycol or PEG 3350 (MiraLAX)
     - Glycerin suppositories
2. • draws fluids by osmosis to ↑ fluid retention in colon
     - suppositories are for rectal use only

Question 43

Constipation Treatment Options: Saline Laxatives
1. Examples
2. MOA, indications, SE

Answer 43

1. • magnesium citrate
     - magnesium hydroxide (MoM)
     - Magnesium sulfate (Epson salt)
2. • saline attracts water into intestinal lumen (small and large intestines)
     - not examined in older adults; use w/ caution d/t hypermagnesemia risk

SE:
- fluid and electrolyte imbalances

Question 44

Constipation Treatment Options: Guanylate cyclase-C receptor agonist
1. Examples
2. MOA, indications, SE

Answer 44

1. • Linaclotide (Linzess)
     - Plecanatide (Trulance)
2. • stimulates intestinal fluid secretion and transit; for IBS, chronic idiopathic constipation

Contraindications:
- mechanical GI obstruction (known or suspected)

Question 45

Constipation Treatment Options: Chloride channel activators
1. Examples
2. MOA, indications, SE

Answer 45

1. Lubiprostone (Amitiza)
2. • idiopathic chronic constipation, IBS

Contraindications:
- Hx of mechanical obstruction

Question 46

Constipation Treatment Options: 5-HT(4) receptor agonists, opioid antagonists, lubricants
1. Examples
2. MOA, indications, SE

Answer 46

1. • Prucalopride (Motegrity)
     - Methylnaltrexone (Relistor)
     - Naloxegol (Movantik)
     - Mineral oil
2. • idiopathic chronic constipation; opioid-induced constipation
     - opioid-induced constipation
     - d/c maintenance laxatives prior to starting therapy

Contraindications:
- GI obstruction
- pts at risk for obstruction

Lubricants are not absorbed

Question 47

Constipation Treatment Options: Stool softeners
1. Examples
2. MOA, indications, SE

Answer 47

1. • docusate sodium (Colace)
2. • softens stools (does not stimulate colon)
     - stool becomes soft and slippery

Question 48

Dementia and Cognitive Impairment
1. Most common cause of neurodegenerative dementia?
2. Most common cause of non-neurodegenerative dementia?
3. Considerations

Answer 48

1. most common cause of neurodegenerative dementia → Alzheimer’s (60-80%)
2. most common cause of non-neurodegenerative dementia is vascular dementia (CVA)
3. • 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!

Question 49

Assessment of Functional Status (ADLs): Basic vs instrumental vs advanced

Answer 49

• 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

Question 50

Katz Index of Independence in ADLs
1. Definition
2. Criteria/Measures

Answer 50

1. measure used to assess older adult’s independence
2. 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)

Question 51

Lawton Instrumental ADL Scale
1. Definition
2. Criteria/Measures

Answer 51

1. • assesses an older adult’s independence
     - most useful for identifying how a person is functioning at present time
     - to identify improvement/deterioration over time

• 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

Question 52

Fried Physical Frailty Phenotype
1. Definition
2. Criteria/Measures

Answer 52

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”

Question 53

Cognitive Performance Scales: MMSE
1. Definition
2. Elements/Criteria/Measures

Answer 53

1. • brief screening exam to assess for cognitive impairment
     - high sensitivity and specificity

Score
- 0-10 (severe)
- 10-20 (moderate)
- 20-25 (mild)
- 25-30 (questionable significance; mild deficits)

2. 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

Question 54

Cognitive Performance Scales: Mini-Cog test
1. Definition
2. Elements/Criteria/Measures

Answer 54

1. • 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)
2. 3 steps:
3. 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)
4. 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”
5. 3-word recall
   - ask pt to recall 3 words you stated in step 1

Question 55

Cognitive Performance Scales: Addenbrooke’s Cognitive Examination III (ACE-III)
1. Definition
2. Elements/Criteria/Measures

Answer 55

1. • useful in detection of mild cognitive impairment, Alzheimer’s, and frontotemporal dementia
2. Screening test composing of tests of:
   - attention
   - orientation
   - memory
   - language
   - visual perceptual
   - visuospatial skills

Question 56

Cognitive Performance Scales: Revised Index of Social Engagement (RISE)
1. Definition
2. Elements/Criteria/Measures

Answer 56

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

Question 57

Cognitive Performance Scales: Geriatric Depression Scale (Short Form: GDSS-SF)
1. Definition
2. Elements/Criteria/Measures

Answer 57

1. -15-question screening tool for depression in older adults
   - takes 5-7 minus
   - can help provider quickly determine if further assessment is necessary

Question 58

Cognitive Performance Scales: Patient Health Questionnaire-9 (PHQ-0)
1. Definition
2. Elements/Criteria/Measures

Answer 58

1. 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

Question 59

Delirium
1. Definition
2. Etiology
3. Clinical Presentation
4. Treatment Plan

Answer 59

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

2. • 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
3. pt may be:
   - acute and dramatic onset
   - excitable
   - irritable
   - combative
   - with short attention span, memory loss, and disorientation
4. • remove offending agent
     - treat illness, infection, or metabolic derangements
     *delirium resolves)

Question 60

“Sundowning” Phenomenon
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

Answer 60

1. • occurs in both delirium a nd dementia
     - starting at dusk/sundown
2. • severe agitation
     - confusion
     - combative
     * Sx resolves in the AM
     - seen more w/ dementia; recurs commonly
3. • 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)

Question 61

Dementia
1. Definition/Etiology
2. Differential Diagnoses
3. Mild Cognitive Impairment

Answer 61

1. • 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
2. • 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
3. • 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

Question 62

Executive function

Answer 62

• self-regulation skills, attention, planning, multitasking, self-control, motivation, and decision-making skills
• higher level cognitive skills are regulated in frontal lobes of brain

Question 63

Alzheimer’s Disease
1. Definition/Etiology
2. Clinical presentation (Mild vs moderate vs severe)

Answer 63

1. 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%
2. 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

Question 64

Aphasia

Answer 64

difficulty expression and understanding language

Question 65

Apraxia

Answer 65

difficulty w/ ross motor movements such as walking

Question 66

Agnosia

Answer 66

inability to recognize familiar people/objects

Question 67

Types of Dementia: Alzheimer’s
1. Brain Pathology
2. Presentation

Answer 67

1 cause of dementia

1. • deposits of beta amyloid protein and neurofibrillary tangles on frontal and temporal lobes
2. 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

Question 68

Types of Dementia: Vascular dementia
1. Brain Pathology
2. Presentation

Answer 68

2 cause of dementia

1. multi-infarct/ishemic damage d/t atherosclerotic plaques, bleeding, and/or blood clots
2. • S/sx of stroke w/ cognitive sx
     - memory loss
     - impaired executive function
     - impaired judgment
     - apathy
     * Location of infarct determines sx

Question 69

Types of Dementia: Dementia w/ Lewy bodies
1. Brain Pathology
2. Presentation

Answer 69

1. alpha-synuclein protein (Lewy bodies)
2. • sleep disturbance/insomnia
     - visual hallucinations
     - executive function is impaired
     - parkinsonism (muscle rigidity, tremors)
     - fluctuations in alertness and cognition
     - sensitive to adverse effects of neuroleptics

Question 70

Types of Dementia: Parkinson’s disease
1. Brain Pathology
2. Presentation

Answer 70

1. loss of dopamine receptors in basal ganglia of substantia nigra
   * 40% of parkinson’s pts develop dementia
2. • rigidity
     - bradykinesia
     - difficulty initiating voluntary movements
     - pill-rolling tremor
     - masked facies
     - depression
     - + features of DLB (sleep disturbance, visual hallucinations)

Question 71

Types of Dementia: Frontotemporal dementia
1. Brain Pathology
2. Presentation

Answer 71

Pick’s disease
1. orbital and frontal areas of brain (orbitofrontal)

2. • 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)

Question 72

Types of Dementia: Mixed dementia
1. Brain Pathology
2. Presentation

Answer 72

1. mixture of ≥2 types (e.g., Alzheimer’s and vascular dementia)
2. • If Alzheimer’s and vascular, sx of both conditions are present

Question 73

Types of Dementia: Wernicke-Korsakoff syndrome
1. Brain Pathology
2. Presentation

Answer 73

Wernicke’s encephalopathy
1. Chronic thiamine (vit B1) deficiency d/t chronic alcohol abuse → brain damage
* caused by vit B1 (thiamine) deficiency

2. • confusion
     - disorientation
     - indifference
     - horizontal movement nystagmus (both eyes

• 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

Question 74

Types of Dementia: Normal Pressure Hydrocephalus
1. Brain Pathology
2. Presentation

Answer 74

1. ↑ amount of cerebrospinal fluid (but normal intracranial pressure)
2. • 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

Question 75

Dementia
3. Treatment Plan
4. Medications (Mild-advanced)

Answer 75

1. 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
2. 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

Question 76

Dementia
5. Adjunct Treatment
6. Rehabilitation
7. Driving and Early-Stage or Mild Dementia
8. Complications

Answer 76

5. • 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
6. • Cognitive rehabilitation → may help during early stages of dementia
     - Occupational therapy → may improve ADL performances
7. • evaluate for safety and monitor regularly
     - ask family/friends about pt’s driving ability, traffic accidents, getting lost, difficulty making decisions, and so forth
8. • death is usually d/t an overwhelming infection (PNA, sepsis)
     - Hip fractures are also common cause of death (from complications)

Question 77

Parkinson’s Disease (PD)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

Answer 77

1. • 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
2. 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)

3. • 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

Question 78

Parkinson’s Disease: Medications - Carbidopoa-levodopa

Answer 78

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)

Question 79

Parkinsonism-hyperpyrexia syndrome

Answer 79

occurs w/ sudden withdrawal or dose reductions of levodopa/dopamine agonists (e.g., bromocriptine, ropinirole)

S/Sx
- fever
- autonomic dysfx
- muscular rigidity
- AMS

Question 80

Parkinson’s Disease: Medications - Dopamine agonists

Answer 80

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)

Question 81

Parkinson’s Disease: Medications - Monoamine oxidase-B (MAO-B) inhibitors

Answer 81

• 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)

Question 82

Parkinson’s Disease: Medications - Treatment for tardive dyskinesia (extrapyramidal sx)

Answer 82

• Give anticholinergics: Benztropine (Cogentin)
• Give amantadine (Symmetrel/Osmolex ER): Antiviral (treats type A influenza) and dopamine agonist

Question 83

Parkinson’s Disease: Treatment
1. Nonpharmacologic
2. Devise assistance/surgery

Answer 83

1. • exercise
     - PT, SLP
     - mindfulness
     - meditation
2. • consider continuous infusions or deep brain stimulation

Question 84

Parkinson’s Disease
5. Complications

Answer 84

• 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

Question 85

Essential Tremor
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

Answer 85

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

3. • 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

-Primidone (Mysoline) 25-750 mg/daily HS
► Refer to neurologist for evaluation and tx

Question 86

Neurocognitive Findings (definitions): Abulia

Answer 86

• loss of motivation or desire to do tasks
• loss of willpower
• indifference to social norms (e.g., urinates in public)

Question 87

Neurocognitive Findings (definitions): Akathisia

Answer 87

• intense need to move d/t severe feelings of restless ness

Question 88

Neurocognitive Findings (definitions): Akinesia

Answer 88

• reduced voluntary muscle movements (e.g. PD)

Question 89

Neurocognitive Findings (definitions): Amnesia + antegrade amnesia + retrograde amnesia

Answer 89

• 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)

Question 90

Neurocognitive Findings (definitions): Anomia

Answer 90

Problems recalling words/names

Question 91

Neurocognitive Findings (definitions): Aphasia

Answer 91

• difficulty using (speech)
• understanding language
• can include difficult w/ speaking, comprehension, and written language

Question 92

Neurocognitive Findings (definitions): Apraxia

Answer 92

• difficulty w/ or inability to remember learned motor skill

Question 93

Neurocognitive Findings (definitions): Astereognosis

Answer 93

• inability to recognize familiar objects place in the palm (place a coin on palm w/ eyes closed and ask pt to identify object)

Question 94

Neurocognitive Findings (definitions): Ataxia

Answer 94

• difficulty coordinating voluntary movement

Question 95

Neurocognitive Findings (definitions): Confabulation

Answer 95

• “lying” or fabrication of events d/t inability to remember event

Question 96

Neurocognitive Findings (definitions): Dyskinesia

Answer 96

• abnormal involuntary jerky movements

Question 97

Neurocognitive Findings (definitions): Dystonia

Answer 97

• abnormal movements and muscle tone (continuous muscle spasms)

Question 98

What is the #1 most common cause of dementia in the US? What is #2?

Answer 98

1 Alzheimer’s

#2 Vascular (CVA)

Exam Tip* recognize classic presentation of PD and Alzheimer’s + “sundowning phenomenon”

Question 99

What is first-line treatment for PD:

Answer 99

levodopa (Sinemet) immediate release

Question 100

What is selegiline (Eldepryl)?

Answer 100

MAO-B drug w/out food interactions
- affects serotonin system
* any drug altering serotonin will ↑ risk of serotonin syndrome

Question 101

What are drugs that alter serotonin? Why is this important?

Answer 101

• SSRIs
• SNRIs
• TCAs
• MAOIs
• triptans
• ↑ risk of serotonin syndrome

Question 102

What is essential tremor? What is first-line treatment?

Answer 102

an “action” or postural tremor (not a resting tremor)

First-line: beta-blockers (propranolol)

Question 103

What is one of the most common cause of acute mental status changes in the elderly?

Answer 103

UTIs
- order a UA in all elderly pts w/ acute mental status changes or delirium

Question 104

Why do some clinicals postpone start levodopa in early-onset PD? What drug(s) can exacerbate or worsen PD’s sx?

Answer 104

• younger than 60 years
• because of higher incidence of levodopa-related dyskinesia
• Cholinergic drugs can exacerbate/worsen PD sx

Question 105

Other common geriatric conditions

Answer 105

• acute diverticulitis
• anemia
• bacterial pneumonia
• COPD
• heart failure
• DM2
• Glaucoma
• Heart disease/murmurs
• HLD
• HTN
• macular degeneration
• Menopause/atrophic vaginitis
• temporal arteritis

Question 106

Pharmacologic Issues in Older Adults - Why is this a problem?

Answer 106

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

Question 107

Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Constipation

Answer 107

• anticholinergics
• CCBs
• opioids

Question 108

Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Dizziness

Answer 108

• anticholinergics
• antihypertensives
• sulfonylureas (long-term use)

Question 109

Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Delirium & Dementia

Answer 109

• anticholinergics
• benzodiazepines
• corticosteroids
• H2 antagonists
• sedative hypnotics

Question 110

Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Falls

Answer 110

• anticonvulsants
• antidepressants (SSRTs and TCAs)
• antihypertensives (specifically alpha-blockers → orthostatic hypotension)
• antipsychotics
• benzodiazepines
• opioids

Question 111

Geriatric Syndromes associated w/ Polypharmacy (meds causing syndromes): Urinary incontinence

Answer 111

• anticholinesterase inhibitors
• antidepressants
• antihistamines
• antihypertensives (specifically CCBs, diuretics, alpha-1 blockers)
• antipsychotics
• opioids
• sedative-hypnotics

Question 112

Beers Criteria: Potentially Inappropriate Meds for Older Adults

Answer 112

• 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)