Older Adults Flashcards
Malnutrition increases the risk of
Delirium
Depression
Falls
Impaired activity/ function
Mortality
Poor surgical outcome
Longer hospital stay
Readmission
Determinants of food intake in older adults living with nutrition risk (low or poor food intake)
Low income
Live alone
Have low social support
Do not socialize frequently
Don’t drive
Report that they are depressed
Are disabled
Take 5+ meds
Poor oral health
How to detect malnutrition in community
What are the interventions one can do
Nutri-screen
Interventions:
- meal programs / assistance
-cooking and grocery support
-transportation
-financial support
-social programs
-dietitian
Mobilization recommendations for frail older adults
Exercise 3 times per week for 30-45 min at an intensity of moderate- vigorous
Do various modalities including aerobic, resistance, balance and flexibility
10-20 min of training should be dedicated to aerobic training
Mobilization recommendations for pre frail older adult
3 times per week, 45-60 min of moderate to vigorous intensity
30-40 min should be for resistance and balanced training activity
Recommendations for mobilization to non frail older adult
150 min / week of moderate to vigorous activity
Muscle and bone strengthening 2 days per week
What screening tool do you use to detect potential alcohol problems in older adults
SAMI tool
Senior alcohol misuse indicator
A score of >1 suggests that the respondent is a problem drinker or an at risk drinker
Pieces method is a method for what? And what does it stand for
And what do you do with it?
Help screen and assess behaviors in an efficient yet comprehensive way
P-physical
(Get collatersl info on physical causes such as pain, constipation, dehydration, hypoxia, hypotension, hunger, infection, disease, illness, drug related side effects
I-intellectual
-neurological condition that changes the way the pt may perfect or respond to his/ her environment and affects his/her functional ability
E-emotional
C-capabilities (compare ADL to the demands of the environmental)
Low demand= can trigger bordom , anger
High demand = trigger feelings of frustration, anxiety, avoidance, helplessness
E- environment (does jt meet the needs of the pt)
S- social/ cultural
Previous social habits vs now, social interaction, specific cultural aspects
What do you do with it ?
Create a plan that could be the main cause/ causes of his behavior
Follow up
Remember that nature of dementia is progressive and plan should be readjusted if something worked yesterday but not tomorrow
- monitor caregiver burnout
Do you need to report elder abuse in LTC ?
Yes , long term care homes act indicates that it is mandatory to report to the ministry of health and long term care, abuse when you suspect or have evidence that elder abuse is taking place in a long term care home
Do you report elder abuse who don’t live in a long term care home?
The law does not require anyone to report the abuse.
Victims or anyone who suspects elder abuse can report their concerns to the police or to health or social services or get advice from a lawyer
Diagnosis of CKD
If ACR >3, measure again 1-2 times over in the next 3 months (at least 2of 3 results >3 = CKD)
If eGFR <60, measure again in 3 months
You confirm CKD diagnosis after 3 months
When do you refer CKD to nephrology
If eGFR <30 and/or ACR >60
Esp if comorbid conditions and lab values with trends of urine ACR? EGFR , BPs, CVD
What can you do in primary care to manage CKD?
Manage hypertension
Slow CKD down
Reduce risk factors
Minimize further kidney injury
7 As of dementia
Anosognosia (the person doesn’t know they don’t know)
Amnesia (memory loss)
Aphasia (problems with speech)
Agnosia (inability to recognize and attach objects; faces, smells and meaning
Apraxia (loss of ability to plan, initiate and sequence purposeful movement)
Altered perception (changes in perception for example visuospatial challenges in understanding concept of time)
Apathy (loss of drive to initiate activities)
Which opioids should be avoided in older adults
Meperidine
Tramadol
Methadone
Diabetes diagnosis for older adults
FBG >7
A1C >6.5%
Could do random >11.1
OGTT
When should you stop screening for diabetes in older adults
Unlikely to be beneficial after 80
What are A1C targets for functionally independent older people
<7%
Functionally dependent older adult, what is the A1C target
<8%
Frail elderly or with dementia, what is the A1C target
<8.5%
Which test may be used to predict which individuals will have difficulty learning to inject insulin
Clock drawing test
Which anti diabetic agents should be used with caution with older people
SU- avoid , higher risk of hypoglycemia
DPP4- second like to metformin
First line agent for insomnia in elderly
CBT-insomnia
Which pharmacological options could you choose for older adult with insomnia
Which meds do you avoid?
Lower dose doxepin <6mg (TCA)
Or
Melatonin
Avoid:
-benzos
-z drugs
-antihistamines (d/t anticholinergic effect)
Osteoporosis risk factors
What happens if your T score is > -2.5
Or
Your 10 yr fracture risk is <15%
Low risk
Do not recommend pharmacotherapy
R/a 5 years
What if your 10year fracture risk is 15-19.9%
Or
Tscore is <-2.5 and age is <70
Suggest pharm therapy
What if 10 year fracture risk is >20%
Or
Tscore is <-2.5
Recommend pharm
What are Nonpharm options for osteoporosis
Balance and muscle strengthening exercises twice weekly
Suggest eating foods rich in calcium and protein (1200mg of PO intake)
Suggest vitamin D 400units (19-50y without osteoporosis)
Health Canada recommends 600units if osteoporosis
What age should you do BMD with no risk factors
70
Age 55 with previous fracture , when should you do BMD
Obtain BMD and calculate frax
What do you worry about with biphosphonate therapy
Atypical femoral fracture
Signs and symptoms of atypical femoral fracture
Thigh or groin pain, unilateral or bilateral
Management of AFF
stop biphosphonate stat
Refer to ortho surgeon stat
Plain xray stat
Should have a drug holiday after 5 years of biphosphonate therapy
Or 3 years with annual IV
Reasonable approach:
-measure BMD after 2-3 years of drug holiday and recalculate FRAX
- if lost BMD and is in high risk , resume for another 3-5 years
When is drug holidays not recommended and when is it recommended
If you’ve had a previous fracture of spine or hip = not recommended
Recommended if:
Deemed high risk at the onset of therapy (>20% fracture risk)
-no prior history of vertebral fracture or hip fracture
-no fragility fracture
-femoral neck BMD Tscore is >- 2.5
Gout flare first line options
NSAIDs (initiate 24 hours of acute gout attack)
Indomethacin is superior 25-50mg TID
Colchicine (not recommended >36h after symptoms)
1.2 mg initially then 0.6mg 1h later for total 1.8mg
Oral corticosteroids
Prednisone 25-50mg po daily x 5 days then stop
You want to avoid starting or stopping allopurinol during attacks as it may destabilize the microtophi and prolong the attack.
What should you monitor for with couchicine and NSAIDs
If at renal risk = SCr
Colchicine = CBC, CK, renal function q6months
Non pharm approaches to hyperuricemia
Diet low purine
Weight loss
smoking cessation
Decrease alcohol (esp. beer)
Drink 2L of water per day
Exercise
Acute attack : rest, elevate limb, ice, avoid contact
Non pharm approaches to hyperuricemia
Diet low purine
Weight loss
smoking cessation
Decrease alcohol (esp. beer)
Drink 2L of water per day
Exercise
Acute attack : rest, elevate limb, ice, avoid contact
When do you initiate maintenance / prophylaxis dose for gout
Recurrent attacks >2/ year
Uric acid levels >800
Chemotherapy
Advanced tophi on radiographic image
CKD > stage 2
What is first line for maintenance / prophylaxis gout treatment
Allopurinol 100-300mg daily
Wait 2 weeks post flare to start
Target uric acid <360
What do you monitor with allopurinol
Renal function and uric acid levels Q 3 months for 1st year then Q6motnhs
Can reverse tophi after months to years of use
Which meds causes hyperuricemia and gout
Which condition causes gout
3 Ds risk factor of gout
Drugs ( ACEI/ARB, ASA, Chemo, cyclosporine, diuretics (HCTZ, loop), ethambutol, lead, levodopa)
Diseases (HTN, CKD, obesity, hyperglycaemia, hyperlipidemia, surgery/ trauma)
Diet (purine rich foods (alcohol, fish, red meat)
