Module 1 Flashcards
Durable Power of Attorney for Health Care (DPOA-HC)
the surrogate for decision making.
an individual’s wishes for medical care when they lack decision-making capability.
Advanced Directive
wishes regarding resuscitation, hospitalization, treatment goals and limits
living will
ften printed on bright pink forms and wallet cards are given to patients.
POLST (Physician Orders for Life-Sustaining Treatment)/MOLST (Medical)
patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Addresses physical, intellectual, emotional, social, and spiritual needs. Facilitates patient autonomy, access to information, and choice.
palliative care
most prevalent form of dementia that is chronic and irreversible
alzheimers
gradual onset and steady decline in cognition. Short-term memory loss along with one or more of the following:
Disorientation
disturbance in executive function (planning, organizing, and abstract thinking)
Problems with ADLs
At least one common neurologic disorder (aphasia, apraxia, or agnosia)
Alzheimer’s disease
early vs late stage AD ?
Early stages: irritability, withdrawal, and apathy
Late stages: paranoia, hallucinations, delusions, and agitation
Cognitive change in the sick or hospitalized older adult. Transient waxing and waning LOC.
Presentation: acute onset and fluctuations in orientation and attention.
Delirium
State of fluid intake deprivation and/or excess fluid loss. Electrolyte imbalances may accompany (Na is the most significant)
Dehydration
serum lytes (Na <148 mEq/L), BUN/creat (ratio of 25:1 or more suggests dehydration), H/H (elevated)
Dehydration
how to tx Dehydration?
pre-illness weight (kg)- current weight (kg)= Fluid deficit (L) Oral rehydration (up to 1500mL/day) Clysis (sub-Q fluid administration, up to 1500mL/site/day) IV (consider Na level when selecting fluid)
pt education with dehydration
Drink 6-8 eight oz cups of water daily; reduce caffeine and alcohol intake; use sports drinks, tomato juice, or bouillon if Na deficient)
7 kinds of elder abuse
physical, sexual, psychological, financial, neglect, abandonment, and self-neglect.
CM and tx of elder abuse
CM: pressure sores, bruises, change in behavior, poor hygiene or nutritional status.
Tx: report to state adult protective services and/or police.
History to gather in pt w/ hx of falls?
hx of CAD or arrythmias, vision and hearing problems, neurologic dysfunction, lower extremity joint pain/ foot problems, medications
DDROP: diseases, drugs, recovery, onset, prodrome, and precipitants) → post-fall assessment
PE in pts with hx of falls?
Romberg test, nystagmus, CV and neuro exam, mobility, function, and strength, cognition, vision, and hearing
TUG (timed up and go test): <20 secs= low risk of falls; >30 secs=high risk of falls
Diagnostics for frequent fallers
CBC (anemia and infections), electrolytes, BUN/creat, serum glucose, stool occult blood. EKG. MRI if neuro exam positive
addresses the type of care a patient wants as a disease progresses.
5 wishes
unplanned loss of 10% TBW in one year
Frailty aka Failure to Thrive (FTT) →
how to tx FTT?
Tx: adequate protein and caloric intake (options: meals on wheels), 800 IU of Vitamin D, regular exercise
diagnostic labs for frequent fallers
CBC Electrolytes and BUN Glucose stool occult EKG/ MRI if indicated
Dx labs for FTT?
CBC, CMP, BUN/creat, thyroid panel, LFT, Ca, UA, fecal occult blood
a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. For BMI, unintentional weight loss, and acute disease
MUST Screening Tool
acute care setting. 2 questions: loss of appetite and unintended weight loss
MST Screening Tool
six questions related to food in-take, weight loss, mobility, recent psychological stress or acute disease, dementia or depression, and body mass index
MNA-SF
Leading cause of death in Geriatrics
heart disease, cancer, unintentional injury
goal for elderly pts
maintain independence, functional and comfort
5 wishes
- The person i want to make care decisions for me
- The kind of medical tx i want/dont want
- How comfortable i want to be
- How i want people to treat me
- What i want my loved ones to know
Can be delivered at ANY point of an illness
Prediction of life expectancy is inexact
Focus is on the burden of illness (not illness itself)
FAMILY unit is central focus
Palliative Care
Strategies to improve discussion of palliative care
providing patients with educational materials before the clinical visit, personalized messages from PCPs, and questions for the patient and family to consider to aid in the conversation
Managing EOL constipation
Laxative for all pt on opioids; may need multiple classes
Methylnaltrexone (for opioid use constipation)
Managing EOL SOB
May need home O2 to relieve dyspnea
Opioids (small dose) fro breathlessness
Anxiolytics
Fans + cool air, reassurance, relaxation, distraction & massage therapy (alternatives)
Managing EOL Fatigue
Educate about energy conservation
Stagger activities
Treat underlying conditions
Assess ADLs
Consider other causes (depression, medications {BBs}, etc)Managing EOL Nausea
Tx with antiemetics
Consider around the clock tx; may require multiple meds
Constipation is a side effect!!
Check for constipation with nausea
Managing EOL Anorexia/ cachexia
Small amounts of food Try varieties of food Tx underlying causes (nausea, constipation) Counsel family (often more concerned about this than patient → mutual goal setting)
Managing EOL Delirium
Assess for reversible causes
- Drugs, Eyes and Ears (sensory deprivation), Low-flow states (not enough O2 or blood to brain), Infections, Retention, Intracranial, Metabolic disorders
Avoid excessive stimulation
Frequent re-orientation
Family education and respite care → exhausting and hard on the family
Meds (haldol, risperidone {EXTREME caution}, olanzapine)
Managing EOL Depression
Common in elderly
Psychotherapy, cognitive therapy, pharm options (BEERS list elderly, no TCAs; zoloft common and well tol in elderly)
Managing EOL Anxiety
Counseling, find approach for pt and family
benzos/SSRIs
Managing EOL communication (Palliative)
SPIKES
S- setting P- perception I- invitation K-knowledge E-empathy S-Summary
Provides care for people/families with TERMINAL illness
Prognosis of 6 mos
Typically given at home
Belief is everyone has right to die pain free and in dignity
Provide support for family while pt is alive and after they pass
Hospice
AD primary symptom:
short term memory loss + 1 or more of the following (disorientation, disturbance, in executive functioning, problems with ADLs + 1 or more (aphasia, apraxia, agnosia)
most significant electrolyte imbalance in elderly
Na
CM of dehydration in elderly
Nonspecific (confusion, lethargy, rapid weight loss, functional decline)
PE for dehydration in eldelry
Med hx: include assessment of fluid intake, functional status, weight and cognition; constipation can indicate dehydration CV exam (orthostatics); body temp may be elevated, mucous membranes not dry until severe dehydration Skin turgor poor assessment in elderly
Diagnostics for dehydration in elderly
Lytes (Na >148), BUN/creat ratio (>25:1), osmolality, hct (elevated), hgb, glucose
Resp and GU infections are common → UA and CXR if needed
Management for dehydration in elderly
Determined by severity; oral replacement preferred if a viable option
Clysis (subq admin of fluids) less costly option than IV
IV FASTEST
**after dehydration is reversed, can take weeks to months to regain functional or cognitive losses
Labs/ dx for malnutrition
TSH, glucose, lytes, vit D
Unintended Weight loss of >_____ % during 6-12 months needs further investigation
> 5%
Diagnostics/Screening for unintentional wt loss
Mini Nutritional Assessment (MNA) for undernutrition and frailty
CBC, LFTs, CMP, thyroid function tests, lytes, fecal occult blood; hgb a1c if DM is suspected
Imaging: CXR, endoscopy, gastric emptying scan, colonoscopy, EKG/echo IF INDICATED
pharm management for unintentional wt loss
Dronabinol
Artificial feedings
(fda approved cannabinoid) can help with n/v from chemo as well; megestrol typically for pt with HIV, COPD, CF, cancer → large SE profile (thromboembolic events, HTN, adrenal insufficiency)
Dronabinol
Non-Pharm management for unintentional wt loss
Smaller meals, high protein foods
Exercise
Address underlying causes including psychosocial
Dental care, structured meal time, social meal time, assess beverage consistency
Screening tools for unintentional weight loss
Mini Nutritional assessment short form
Malnutrition screening tool- (MNA)
Malnutrition universal screening tool
asks about BMI unintentionally weight loss and acute disease
Malnutrition universal screening tool
1 questions- unintentional weight loss and one about appetite
Malnutrition screening tool- (MNA)
a screening tool to help identify elderly patients who are malnourished or at risk of malnutrition. (65 +) 6 questions about food intake,
Mini Nutritional Assessment – Short Form (MNA®-SF)
in place to prevent long term care facilities from penalizing whistleblowers, increased funding for adult protective services, grants for LTC staff training, and civil and monetary consequences for failing to report abuse
Elder Justice Act (EJA)
most common cause of elder falls
MOST are mechanical (trip over something)
Post fall assessment
(DDROPP)
Diseases (underlying or new)
Drugs (prescribed, not prescribed, alcohol?)
Recovery (could they recover themselves or need help)
Onset (sudden or prodrome?)
Prodrome
Precipitants (acute → trip, run into something, uneven ground, new place)
diagnostics for frequent faller
CBC, lytes, BUN, glucose, stool occult blood, EKG, MRI
Multidimensional geriatric syndrome
Increased vulnerability to stressors r/t reduced capacity of multiple physiological sx
Increased risk of adverse health-related outcomes (falls, disability, hospitalization, death)
Frailty (FTT)
how to dx frailty (FTT)
MUST meet 3 of 5 s/s
- Poor muscle strength
- Poor gait speed
- Unintentional weight loss
- Exhaustion
- sedentary behavior
PE for frailty (FTT)
Focus on organ failure, malignancy, infection
Check dentition, denture fit, gag reflex, swallowing ability
Hearing, vision, cognitive function, mood, mobility, functional status
FS: ability to perform ADLs, interact and contribute to family/community
Labs for frailty (FTT)
CBC, lytes, TSH, glucose, kidney function, LFTs, Ca, UA, fecal occult
Possible CXR
Goals of Tx for Frailty (FTT)
Prevent injury, hospitalizations, remediate symptoms, optimize QOL
AD8- Dementia screen
USPSTF- insufficient data tro recommend for screening for dementia, ONLY done after concern for cognitive impairment
STEADI
(stopping elderly accidents, deaths and injuries)
use or misuse of multiple drugs (>5 per person or any not medically indicated), including non-prescrition
Polypharmacy
Should avoid ___ drugs with dementia. H2 blockers ok but avoid in pts at high risk for delirium
PPIs
Avoid Bactrim = ______ in those with decreased Cr clearance d/t hyperkalemia risk
ACE/ ARB
Avoid _______ + Cipro, Bactrim, macrolides (except Zithromax) d/t bleeding risk - check IMR closely
Warfarin
Avoid SSRIs, SNRIs, and ____ in those w/ h/o falls. start low and go slow
TCAs
carefully monitor for _____ with tramadol, diuretics, SSRIs, SNRIs
hyponatremia
who should take caution in ASA for primary prevention
those > 70
