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Special Populations > Managing the complex Older Adult > Flashcards

Managing the complex Older Adult Flashcards

1
Q

list common pathologic conditions in older adults

A
  1. CHD
  2. HF
  3. Pneumonia
  4. UTIs
  5. Sepsis
  6. Dizziness
  7. Dehydration
  8. Metabolic Syndrome
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2
Q

describe several pathologic physiologic changes that occur with CHD

A
  1. elevated LDLs and total cholesterol
  2. systolic HTN
  3. increased arterial stiffness and ventricular wall thickening
  4. endothelial dysfunction → vascular constriction
  5. changes lead to reduced EF, increased O2 demand → ischemia
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3
Q

describe how physical inactivity and obesity linked with CHD has a negative impact

A
  1. obesity is linked to DM, CA, atherosclerosis
  2. obesity also linked to increased mortality affecting life expectancy
  3. physical inactivity leads to decreased muscle mass → activity intolerance → functional limitations
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4
Q

describe CAD progression

A

CAD → ischemia → acute coronary syndrome (ACS)

(results in a concomitant increased risk for respiratory failure, syncope, and stroke associated with MIs in older adults)

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5
Q

how is CAD diagnosed?

A
  1. Graded exercise testing and cardiac catheterization → gold standard
  2. cardiac enzymes
    1. troponin → <0.1-0.3
    2. creatine kinase → 0-3
    3. BNP → <100
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6
Q

list common meds for CAD

A
  1. Diuretics
  2. Beta blockers
  3. Ca++ channel blockers
  4. ACEi and ARBs
  5. Statins
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7
Q

what is Heart Failure?

A

a pump dysfunction → metabolic needs become unmet

  • associated with structural defects
  • classified as HFrEF (systolic failure) or HFpEF (diastolic failure)
  • S/S → fatigue, SOB, decreased activity tolerance + mixed R/L S/S
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8
Q

what should be included in a physical exam when a pt has HF?

A
  1. pitting edema assessment
  2. observe for JVD
  3. auscultation for adventitious breath sounds
  4. observe for dyspnea, orthopnea, tachypnea, and desaturation
  5. BNP lab values >100 up to 1000
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9
Q

list common meds for HF

A
  1. Diuretics
  2. ARNIs
  3. antihypertensives
  4. digoxen
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10
Q

incidence and types of pneumonia

A
  1. 6th leading cause of death in community-dwelling older adults
  2. 2nd cause of nosocomial infections (behind UTIs)
  3. types:
    1. community-acquired
    2. hospital-acquired (50% of cases of sepsis, 33% mortality rate)
    3. aspiration pneumonia
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11
Q

what is aspiration pneumonia associated with?

A
  1. malnutrition
  2. tube feeding
  3. poor dental hygiene
  4. dysphagia
  5. decreased saliva production

*increased incidence with PD, CVA, GERD, AD

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12
Q

how is pneumonia diagnosed?

A
  1. Chest xray
    1. positive findings of infiltrates or consolidation
  2. elevated WBC
  3. desaturation of SaO2 even at rest
  4. chest pain, pleuritis
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13
Q

list common meds for pneumonia

A
  1. antibiotics or antivirals
  2. oxygen
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14
Q

list ways to administer oxygen and their general parameters

A
  1. nasal cannula (1-6 LPM) → 24%-44% FiO2
  2. salter high flow nasal cannula (up to 15 LPM) → 54-75% FiO2
  3. high flow nasal cannula (up to 60 LPM) → up to 100% FiO2
  4. partial rebreather mask (6-10 LMP) → 60-80% FiO2
  5. non-rebreather mask (10-14 LPM) → 60-80% FiO2
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15
Q

list some pulmonary considerations

A
  1. average RR 12-20 bpm
    1. inspiratory: expiratory ratio → 1:2
    2. 1:1 = hyperventilation + decreased PaO2
    3. 1:3 = hypoventilation, increased PaCO2
  2. observe expansion of chest wall in all directions
  3. speech → 12-15 syllables per breath at rest
  4. pulse-ox → up to 5-6% error rate, accuracy decreases in dark-pigmented pts
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16
Q

UTI incidence

A
  1. account for ⅓ of infections in nursing home residents
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17
Q

Causes of UTIs

A
  1. Primary cause = urinary stasis
    1. older women → decreased pelvic floor strength, decreased estrogen levels
    2. older men → decreased bladder emptying d/t BPH
  2. indwelling catheter may also cause UTI
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18
Q

major change in older adults with UTI

A

Acute delirium

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19
Q

what is sepsis?

A

life-threatening organ dysfunction caused by deregulated host response to infection

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20
Q

T/F: sepsis is the leading cause of hospitalization and most expensive inpatient condition

A

TRUE

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21
Q

describe the pathophysiology of sepsis

A
  1. sepsis differentiated from infection by a dysregulated host response that results in organ dysfunction
  2. loss of adaptive homeostasis in response to infection
  3. high degree of mortality risk with organ dysfunction
  4. urgency for early recognition of sepsis and prompt treatment
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22
Q

list S/S of sepsis

A
  1. lactate > 18 mg/dL
  2. hypotensive
  3. fever >103
  4. HR >90 bpm
  5. RR > 20 bpm
  6. often confirmed infection from culture
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23
Q

describe the clinical progression of sepsis

A

sepsis → severe sepsis → septic shock

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24
Q

what is septic shock?

A

abnormal circulatory and cellular metabolism profound enough to significantly increase mortality

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25
Q

list the criteria for septic shock

A
  1. persisting hypotension that requires vasopressors to maintain MAP at 65 mm HG or greater
  2. blood lactate >2 mmol/L despite volume resuscitation

mortality 4x greater when these criteria are met

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26
Q

describe the pathogenesis of sepsis

A
  1. anti-inflammatory response fails to develop
  2. proinflammatory process become unregulated
  3. results in cascade dysfunction
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27
Q

describe the resultant cascade of dysfunction that occurs with sepsis

A
  1. increased microvascular permeability with transudation into organs
  2. platelet sludging → capillary blockage, ischemia
  3. reperfusion injury
  4. dysregulation of vasodilatory and vasoconstrictive mechanisms
  5. maldistribution of blood flow → shock
  6. immunosuppression from excessive anti-inflammatory response
  7. organ failure → multiple organ dysfunction syndrome (MODS)
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28
Q

list cardiovascular and pulmonary manifestations of sepsis

A
  1. Cardiovascular
    1. hypotension
    2. tachycardia
    3. elevated CO (drops w/septic shock)
    4. systemic vascular resistance drops with septic shock
    5. hypoperfusion exacerbated → lactate accumulation
  2. Pulmonary
    1. tachypnea
    2. hypoxemia (ventilation-perfusion mismatch)
    3. respiratory alkalosis
    4. pulmonary edema and respiratory failure → ARDS
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29
Q

list CNS, Renal, GI manifestations of sepsis

A
  1. CNS
    1. AMS
    2. encephalopathy
    3. polyneuropathy
  2. Renal
    1. oliguria
    2. azotemia
  3. GI
    1. impaired motility
    2. stress ulceration
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30
Q

list hepatic and hematologic manifestations of sepsis

A
  1. hepatic
    1. elevated serum transaminase
    2. hyperbilirubinemia
    3. final stages → hepatic insufficiency
  2. hematologic
    1. leukocytosis
    2. multifactorial anemia
    3. thrombocytopenia and coagulation abnormalities
    4. disseminated intravascular coagulation (DIC) is a late-stage manifestation that carries poor prognosis
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31
Q

Sepsis implications for PT

A
  1. PT can be initiated in ICU/acute care once pt medically stable
  2. pts can safety response to increased vascular and O2 demands of physical exam and treatment
  3. pt status can fluctuate daily, hourly, and by the minute → response-dependent management
  4. required moment to moment interpretation of pt response
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32
Q

list potential sources of dizziness

A
  1. vestibular
  2. visual
  3. proprioceptive
  4. cardiac origin → but syncope is more often the symptom than dizziness
  5. Orthostatic hypotension
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33
Q

PT implications for dizziness

A
  1. ask the right questions
    1. what brought on dizziness?
    2. what were you doing when you got dizzy?
    3. has it happened before?
    4. did you fall?
  2. assess for comorbidities → DM, cardiac, etc.
  3. check meds
  4. assess vitals → check positional BP
  5. sensory assessment
  6. nutritional status
    1. malnourished or dehydrated?
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34
Q

why are older adults more susceptible to dehydration?

A
  1. blunted thirst
  2. reduced total body fluid
    1. decreased muscle mass
    2. increased body fat
  3. decreased renal function
  4. physical/mental decline
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35
Q

list risk factors for dehydration

A
  1. advanced age
  2. female gender (increased body fat%)
  3. BMI < 21 and >27
  4. Dementia
  5. Hx of CVA, UI, and infections
  6. use of steroids
  7. polypharmacy
  8. decreased functional independence
36
Q

list and describe the 3 different types of dehydration

A
  1. Hypertonic → water > Na loss
    1. causes → infection, hot temperatures
  2. Isotonic → water = Na loss
    1. causes → vomiting and diarrhea
  3. Hypotonic → water < Na loss
    1. most common cause in older adults
    2. closely monitor Na lab values
37
Q

list S/S of dehydration

A
  1. confusion
  2. lethargy
  3. rapid weight loss
  4. functional decline
38
Q

list the examination techniques and the clinical S/S that would present with dehydration

A
  1. Interview → decreased cog function and mental status
  2. Observation → dry mucosa
  3. Palpation → decreased skin turgor
  4. vitals:
    1. tachycardia
    2. decreased BP
    3. OH
    4. weight loss in short time (<1 kg/day)
  5. JVD → in supine, no appreciable jugular vein
  6. function → decreased muscle strength, balance, and function
39
Q

what is metabolic syndrome?

A

a cluster of conditions that occur together which increase risk for heart disease, stroke, and type 2 diabetes

40
Q

metabolic syndrome is also referred to as _________

A

insulin resistance syndrome (IRS)

41
Q

list the risk factors for metabolic syndrome

A
  1. abdominal obesity
    1. men > 102 cm
    2. women >88 cm
  2. high triglycerides
    1. ≥150 mg/dL
  3. decreased HDLs
    1. men >40 mg/dL
    2. women >50 mg/dL
  4. increased BP = >130/>85
  5. high fasting glucose = >110
42
Q

how do you define fraility?

A
  • multisystem presentation that creates loss of function and physiological homeostasis
  • impaired sensorimotor systems and cognition, polypharmacy, malnutrition that results in decreased ability to cope with stressors
43
Q

how is frailty classified?

A

as one of 3 categories based on the number of clinical attributes

  • not frail = 0
  • prefrail = 1-2
  • frail = 3
44
Q

what is the PT role with fraility?

A

ID frailty and ensure pt/client receives necessary and appropriate services

45
Q

give a measurement for each of the 5 clinical attributes of frailty

A
  1. weight loss → scale or self-report
  2. fatigue → series of questions, 0-6 scale with higher score indicating fatigue
  3. low physical activity → capture sedentary activity pattern with series of questions
  4. slowness → generally <0.8 m/s
    1. 0.65 m/s or less
    2. 0.75 m/s or less
  5. weakness
    1. grip strength → <30 kg (men) and <20kg (women)
    2. STS → <8 in 30 seconds
46
Q

who has fraility?

A
  1. Range → 4-59.1% of community-dwelling adults
    1. frailty phenotype = 15.3%
    2. prefrail older adults = 45.5%
  2. increases with age
  3. higher rates in women, racial/ethnic minorities, lower income
47
Q

highest rate of frailty is ________

A

in nursing homes

as high as 76%

48
Q

describe the phenotype of frailty

A

five clinical attributes

  1. unintentional weight loss >10 lbs
  2. self-reported exhaustion with regular activity
  3. muscle weakness
    1. like in grip strength or STS
  4. slow walking speed → unusual pace over 15 ft
  5. low physical activity
    1. men <383 kcal/week
    2. women <270 kcal/week
49
Q

what is the frailty index?

A

considers number of deficits accumulated over time

  • disability
  • diseases
  • physical and cognitive deficits
  • psychosocial risk factors
  • geriatric syndromes
50
Q

describe social frailty

A
  1. limited social support → increased risk of frailty
  2. loneliness and social isolation associated with slow gait speed and less resilience
51
Q

describe cognitive frailty?

A
  1. steeper cog decline than w/o physical frailty
  2. APOE4 allele not associated with cog frailty
  3. strongly associated with grip strength and gait speed
  4. multiple risk factors:
    1. CV events
    2. nutritional deficits
    3. hormonal imbalance
    4. inflammation
    5. increased Amyloid beta in brain, lifestyle and depression
52
Q

how do you interpret the frailty index for elders?

A
  • Score of 0 yes answers = no frailty
  • Score of 1-3 yes answers = frailty risk
  • score of 4 or greater yes answers = frailty risk
53
Q

what 3 tools/assessments have good predictive capacity for frailty?

A
  1. gait speed <0.65 m/s = >20x more likely to be frail
  2. grip strength <25 kg = 6x more likely to be frail
  3. chair stands <7x in 30 seconds = 14x more likely to be frail
54
Q

list 3 other aspects/types of frailty

A
  1. cognitive frailty
  2. psychological frailty
  3. social frailty
55
Q

describe psychological frailty

A
  1. depression common (20-53%)
  2. low resilience + depressive symptoms can predict frailty
  3. high resilience and well-being reduced likelihood of frailty
56
Q

describe the continuum of degrees of frailty

A

fit (not frail) → mild frailty (prefrail) → moderate frailty → severe frailty (end stage)

57
Q

describe the degree of frailty:

Fit (not frail)

A

physically active, no restrictions. Few chronic conditions, if any

functional characteristics:

  1. gait speed >1.0-1.2 m/s
  2. 30s CRT 15 reps or more
  3. independent floor transfer
58
Q

how are mobility disability and frailty different?

A

it takes longer to recovery with frailty

59
Q

describe the degree of frailty:

Mild frailty (prefrail)

A

adaptations to mobility, life space mobility restrictions start. Impaired recovery from illness/injury

functional characteristics:

  1. gait speed 0.8-1.2 m/s
  2. 30s CRT 8-15 reps
  3. Modified floor transfer
60
Q

describe the etiology of frailty

A

multifactorial → genetic, environment, metabolic, lifestyle stressors

overall = impaired homeostatic mechanics

61
Q

describe the degree of frailty:

Moderate frailty

A

loss of independence evident, needs assistance. Life span restrictions

functional characteristics:

  1. gait speed 0.5-0.8 m/s
  2. 30x CRT <8 reps
  3. assistance for floor transfers
62
Q

describe the degree of frailty:

Severe Frailty

A

dependent ADLs/mobility, inactive, dying. Life expectancy 6-12 months

functional characteristics:

  1. gait speed <0.5 m/s
  2. 30s CRT unable
  3. floor transfer unable
63
Q

what are the implications for frailty?

A
  1. recognize the degree of frailty for optimal pt management
  2. earlier detection = delay transition to lower state of frailty
    1. increases chance of “aging in place”
  3. increased frailty = longer and potentially incomplete recovery
  4. understanding the relationship between frailty, disability, and comorbidity → all distinctly different yet intertwined!
64
Q

describe the pathophysiology of frailty

A
  1. pro-inflammatory state
  2. blunted immune response
  3. autonomic dysfunction
  4. kidney dysfunction
  5. anemia
  6. malnutrition
  7. endocrine dysfunction
65
Q

list Frailty Assessment Tools

A
  1. Comprehensive Geriatric Assessment (CGA) → most comprehensive method
  2. Frailty Index → score of >0.5, 100% dead in 20 months
  3. TUG >10 seconds
  4. Gait speed <0.8 m/s
  5. Frailty Index for Elders (FIFE) → self report
  6. Phenotype of Frailty → may use STS instead of handgrip strength
  7. Life space → <60 points indicates 4.4x higher risk of SNF placement during subsequent 6 years
66
Q

what is key component for treating frailty?

A

EXERCISE!

  1. reduces biological age
  2. addresses sarcopenia
  3. 12-week program can show sig gains
  4. high intensity is key
    1. 40-80% of 1RM
    2. 8 reps for 1 set, working up to 3 sets
  5. LE > UE exercises
  6. don’t forget power and agility!
67
Q

what can be used to safely calculate 1 rep maxes?

A

Holten Diagram

68
Q

every pt returning home should practice __________

A

floor transfers

it reduces risk of serious adverse health outcomes (e.g rhabdomyolysis)

69
Q

list interventions (other than exercise) for frailty

A
  1. Nutrition
    1. Mini Nutritional Assessment → screen for weight loss
    2. focus on underlying cause
    3. EEA supplementation
    4. Vitamin D supplementation
  2. Hormone treatment
    1. SARMS and testosterone may treat sarcopenia
    2. results still inconclusive
  3. Pharmaceuticals
    1. Med review essential
    2. deprescribing → statins, glucocorticoids, anticholinergics, benzos
    3. vitamin D 800-1000 IUs/day

1.

70
Q

primary prevention of frailty includes what?

A
  1. regular engagement in moderate to vigorous physical activity
  2. cognitively stimulating activities
  3. healthy diet and supplementation as needed
  4. ideal sleep
  5. maintaining proper body weight
  6. metabolic control
    1. blood sugar, BP, blood lipids, etc.
71
Q

what is included in secondary prevention of Frailty?

A
  1. use of assessment tool to ID key underlying deficits
  2. implement a multimodal approach
    1. medication management
    2. falls prevention
    3. nutritional support
    4. social/psych support
    5. exercise program
72
Q

what is osteoporosis?

A

a metabolic bone disorder resulting in decreased bone mass and density

73
Q

what bones are impacted more by osteoporosis?

A

higher proportion of cancellous bone affected → vertebrae, femoral neck

74
Q

what is the prevalence of osteoporosis?

A

12.6% of adults over 50

10 million affected in US

75
Q

what are the 2 types of osteoporosis?

A
  • Primary
    • postmenopausal or idiopathic
  • Secondary
    • following a disease condition (ie Cushing syndrome)
76
Q

list risk factors for osteoporosis

A
  1. post-menopausal (estrogen deficiency)
  2. other hormonal factors
    1. hyperparathyroidism
    2. Cushing syndrome
  3. sedentary lifestyle
  4. Vitamin D deficiency
  5. Cigarette smoking
  6. Asian, Caucasian
  7. Excessive caffeine consumption
77
Q

what is the difference between osteopenia and osteoporosis?

A

osteopenia → low BMD that compromises the bone’s ability to absorb loads (lower than normal but not as low as osteoporosis)

78
Q

how is osteopenia determiend?

A

DEXA scores: T-scores and Z-scores

  1. T-scores
    1. WHO diagnoses classification in postmenopausal women, men over 50
    2. cannot be applied to healthy and young populations
  2. Z-scores
    1. reporting BMD in healthy pre-menopausal women, men under 50, children
79
Q

WHO defined osteoporosis as a T-score of what?

A

< -2.5

Osteopenia T-score = -1 - -2.5

80
Q

describe/interpret ranges of T-scores

A
  1. normal BMD 0-1
  2. osteopenia range (below average) -1 to -2.5
  3. Osteoporosis range (sig below average) is -2.5 to -4
81
Q

describe treatment methods for osteoporosis

A
  1. Vitamin D + Calcium
  2. Fluoride supplements → promotes bone deposition
  3. Bisphosphonates
  4. Calcitonin → secreted by thyroid gland to lower blood Ca+
  5. injected human parathyroid hormone → decreases bone resorption
  6. regular WBing activities → appropriately dosed strength training
  7. Raloxifene → selective estrogen modulators
  8. surgery to reduce kyphosis, realign vertebrae
82
Q

What to do and not to do, exercising with osteoporosis

A
  1. What builds bone/strength?
    1. standing WBing exercises
    2. strengthening, flexibility, balance activities
    3. dosage dependent on degree of bone loss and level of fitness
  2. What should be avoided?
    1. trunk flexion and excessive rotation
    2. high impact exercise
    3. joint mobs/manual percussion
83
Q

Pt edu pertaining to osteoporosis

A
  1. customized exercise program to promote strength while minimizing risk of injury
  2. nutrition → Ca+ and Vit D
  3. Fall reduction
    1. appropriate use of AD
    2. home assessment
    3. med review
84
Q

describe primary disease prevention

A

instilling healthy behaviors to prevent disease

  1. start young! educate your younger pts
  2. good nutrition, avoid smoking regular physical activity
  3. check BP
85
Q

describe secondary disease prevention

A

managing the disease

  1. control disease progression, stay active, limit functional loss, control BP
  2. manage meds, maintain status
86
Q

describe tertiary disease prevention

A

prevent further deterioration of disease state

  1. manage medical condition to prevent decompensation
  2. maintain level of mobility, prevent further decline
  3. energy conservation

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