Intro to Geriatrics Flashcards
At what age is someone considered elderly?
> 65 yo
- HOWEVER advances in medicine/prevention have caused dispute in this traditional labeling
Average life expectancy (2014)
78.6 yrs
Life span definition
The number of years a species is expected to survive
Life expectancy definition
The average number of years of life remaining at a specific age
- Based on statistical probability
Chronological age definition
How many years a person has been alive
Biological age definition
The age that most people would be with a body & mind like theirs
- Based on health status
How do we approach signs of “normal aging”
Treat as pathology until proven otherwise
Organ system decline
1% per year from 30 yo
Age-related changes: endocrine
- Impaired glucose homeostasis (increase glucose w/ illness)
- Decrease vit D absorption (osteopenia)
- Decreased thyroxine clearance (decrease T4 dose)
Age-related changes: general
- Decreased volume of TBW (decrease volume of distribution of water soluble drugs)
Age-related changes: respiratory
- Decreased cough reflex (microaspiration)
- Decreased lung elasticity, increase chest wall stiffness, decreased diffusion capacity (decrease resting PO2)
Age-related changes: CV
- Decreased B-receptor responsiveness (decrease CO & HR from stress)
- Decreased baroreceptor sensitivity, decrease SA node automaticity (orthostatic HTN, volume depletion)
Age-related changes: GI
- Decreased hepatic fcn (delayed hepatic clearing drug metabolism)
- Decreased colonic motility, decreased anal/rectal fcn (constipation)
Age-related changes: GU
- Vaginal/urethral atrophy (dyspareunia, bacteruria)
- Prostate enlargement (increase residual urine volume)
Age-related changes: MSK
- Decreased muscle mass (falls)
Age-related changes: nervous system
- Brain atrophy (benign senile forgetfulness)
- Decreased “righting reflex” (body sway, unsteadiness)
- Decreased stage 4 sleep (insomnia, early awakening)
- Impaired thermal regulation (lower resting temp.)
Age-related changes: skin
- Increased elasticity, thinning (wrinkles, sagging)
Age-related changes: eye
- Presbyopia (decreased accommodation)
- Decreased visual acuity (need for increased lighting)
Consequences of normal aging can lead to…
Pathology unless recognized/addressed
Normal aging is a
Diagnosis of exlusion
Most functional loss in older patients is r/t….
Disease and NOT aging itself
Loss of organ function can be thought of as a
Threshold/”tipping point”
Ex) Renal decline -> decrease urination -> stress applied (UTI) -> diminished function/hospitalization
Hallmark of aging is
How well an organ adapts to external stress
Examples of preventative measures to target focal areas of diminished reserve
- Exercise to prevent falls
- Vaccines to prevent pneumonia
Consequences of diminished reserve
- Atypical disease presentation (e.g. PNA: CC = acute confusion)
- Law of diagnostic parsimony (e.g. common cold in young pt. vs elderly)
- Weakened compensatory mechanisms (delayed manifestation of disease (e.g. fever), slow illness recovery
- Increased risk for iatrogenesis (r/t interactions w/ healthcare system)
Law of diagnostic parsimony
Theory of one unifying diagnosis to explain presentation (aka can explain complaints with one single problem)
- Works better in young & middle-aged pt.
Neuropsychiatric changes (e.g. dementia, stroke) are ass. w/
Physical frailty, social isolation
Pt. >65 compose __% of all patients seen; in 40 years it is projected to be __%
33%; 50%
Why is the geriatric population increasing?
- Advances in medicine keep people alive longer
2. Decreased birth rate
Those ages >65 (13% of the population account for __% of healthcare costs
33%
Robust: clinical condition
> 5 yr life expectancy
Frail: clinical condition
<5 yr life expectancy
Moderate dementia: clinical condition
2-10 yr life expectancy
End of life: clinical condition
<2 yr life expectancy
How to determine if a pt. is considered “end of life”
If you’d be surprised if they were living in 1 yr.
Screening for breast CA
Mammogram every 2 years for robust women until age 74
- Self exam or clinical exam NOT recommended (insufficient data) -> does NOT decrease morbidity & mortality
Screening for colorectal CA
Screen average-risk individuals aged 50-75 years (no test type preference)
USPSTF recommends against screening those >75 and against ever screening those >85
Screening for cervical CA
NOT recommended in women >65 (who have had adequate prior screening & are not high risk)
Do not screen women s/p hysterectomy
Screening for prostate CA
NOT recommended in men >70
Screening in those aged 55-69 is an “individual choice”
Screening for lung CA
Annual screening w/ low-dose CT in those 55-80 who have a 30 pack year hx AND currently smoke or have quit within the last 15 yrs
- D/C once a pt. has not smoked for 15 years OR if acquire a health problem that limits life expectancy
Screening for osteoporosis
Recommended in women <65 who are @ increased risk (determined by clinical assessment tool)
- RF: age, low body mass, excessive ETOH, current smoker, long-term corticosteroid use, h/o fx, h/o falls in past yr
Conflicting evidence for screening in men
Screening for TSH
Consider every 2-5 yrs (insufficient evidence)
Screening for BP
Each visit
Screening for weight
Each visit
Screening for BG
Up to age 70 in overweight/obese pt., q3 years if normal
Screening for cholesterol
Consider for age 65-79 with additional RF
Screening for AAA
Once for men 65-75 with additional RF
Screening for height
Annually
Older adults should be counseled at least once annually about….
- Physical activity
- Alcohol misuse (screening at least once using CAGE)
- Smoking cessation
- Sexual dysfcn & STI (screen only high risk for STI & HIV)
Screening for falls
Annual (recommend exercise interventions to those at risk)
Screening for incontinence
Annually
Screening for cognitive status
If symptomatic
Screening for depression
Annually
Screening for vision
Annually
Screening for hearing
Annually
Screening for nutrition
Obtain wt. @ each visit, height annually -> calculate BMI
Screening for mistreatment
Question w/ clinical suspicion
Screening for safety & preventing injury
- Smoke, CO detectors
- Water heater temperature
- Sun protection
- Test driving skills
- Use of seat belts
- Advanced directive
- Healthcare proxy
Influenza vaccine recommendations
Annually (high dose)
Pneumococcal vaccine recommendations
After 65
Tetanus-diphtheria vaccine recommendations
Every 10 years
Herpes zoster vaccine recommendations
Once after age 60
Aspirin recommendations
Individualized in those >60 w/ an ASCVD score of 10% or greater
- Add a PPI if ASA is used in those >60
Calcium recommendations
Food: should be primary source (~1,200mg target)
Supplementation: 500mg or less at one time, best taken w/ meals and in divided doses
Vitamin D
800 IU daily
Multivitamin
Consider if potentially deficient
Can reduce prevalence of suboptimal vitamin status if formulated @ 100% recommended daily value
Hormone therapy
NOT recommended
What is a problem list?
A problem oriented medical record
What does a problem list include?
All past & current problems (medical & social/psychiatric)
Ideally each entry includes:
- A diagnosis
- A physiologic finding
- A symptom, abnl physical finding, abnl test result
Who should maintain the problem list in the medical record?
PCP (however, others can add to it)
PROBLEM LISTS ARE
DYNAMIC
Why is the problem list important?
“Old” diagnoses might still hold value (e.g. DVT in 1990, presents today w/ CP & SOB)
Who is eligible for an IPPE (initial preventative physical exam)?
Pt. who are within the first 12 months from their effective date of medicare B coverage
- IT IS A ONE TIME BENEFIT
Focus of IPPE
- Modifiable risk factors
- Education
- Counseling
- Referral
- all r/t covered Medicare benefit services
Required elements of IPPE
Review…
- Comprehensive PMH & SH
- RF for depression
- Functional ability & level of safety
- Focused PE (must include BMI, BP, visual acuity)
- +/- EKG (no longer required)
- Brief education, counseling, & referral
- End of life planning upon consent
What does Medicare NOT cover?
Routine PE
Who can perform IPPE?
MD, CNS, NP, PA
When can someone get a Medicare annual wellness visit (AWV)
12 months AFTER effective date of medicare part B coverage period
- CANNOT have received IPPE or AWV in the past 12 months
Who can perform AWV?
MD, CNS, NP, PA, health educator, RD, nutritionist*
*working in a team under the direct supervision of a physician
Components of an AWV
- Health-risk assessment (HRA) - self-reported!
- PMH, SH, hospital stays, meds, allergies
- List of current problems & suppliers involved in care (e.g. pharmacist)
- Ht., wt., BMI, BP
- Assessment of cognitive impairment (by provider or family, friends etc.)
- Review RF for depression, functional ability
- Screening recommendations
- Establish a list of RF for which preventative measures are underway
- Referrals to other HCP
- Voluntary Advanced Care Planning (verbal or written)
When are HRAs implemented?
At initial & subsequent AWV (before or during appt)
AWV must be at least ___ months apart
12
AWV does NOT include
A physical exam
Both IPPE and AWV are
FREE w/ Medicare
