P-1 Flashcards
5 principles of Geriatric Care
- Decreased Physiologic Reserve
- Functional and cognitive status
- Goals of care and Prognosis
- Societal Context of care
- Impact of multiple conditions/meds and settings of care
What is the clinical impact of a Decreased Physiologic Reserve in elderly patients?
A more rapid decline with illness can result from
the interplay of multiple medical conditions presenting as complex geriatric syndromes:
Complex geriatric syndromes that often go under diagnosed and can occur synchronously
OPS FINDS
- falls
- nutrition
- incontinence
- sensory impairment
- social isolation
- poly pharmacy
- delirium
- oral candidiasis
What geriatric attributes can accurately predict patient function as well as monitor decline?
Measuring Functional and cognitive status
Functional status
- ADL and IADL
- Get up and go test
Cognitive status
- Memory, mental status
What are the ADL’s?
ADL's? Personal care - GT DEBT G - Grooming T - Transferring D - Dressing E - Eating/feeding B - Bathing T - Toilet
What are the IADLs?
Independent living (mental capacity) SCUM S - Shop C - Cook/clean U - Using phone/transport M - Manage meds/money
Four Risk factors for functional decline
- sensory deficits
- polypharm
- comorbid conditions
- hospitalization
Preventing/Treating Functional Decline
Prevention
- Physical activity / Physical therapy
Treatment
- Rehab
- Adressing polypharm (utilize clinical pharmacist)
- PT (ADLs) / OT (IADLs)
- nutritionist
- speech therapy (esp strokes, oropharyngeal dysphagia)
- Treat caregivers (fatigue) and patient
What you should be asking your patient about to guide you on their future care
Goals
- Diagnostic/therapeutic plans should be based on patient goals
Prognosis: more than mortality, what is important to them?
- independence, function, dementia
Some aspects of the Social Context of care include
Financial issues - paying for basic needs
Food insecurity - nutrition, safety, meals on wheels
Caregiving
- Medicare: doesnt cover unskilled care (bathing feeding)
- Medicaid: state dependent limited coverage
- VA: some coverage if 100% disabled
Housing and long term care
Assited living:
- Px with IADL issues; provides laundry etc
Skilled Nurse Facilities:
- wound care, rehab, titration (DM, warfarin)
Long Term Care:
- unskilled personal care, Px with ADL issues
Team Care for geriatric patients can be based on the condition of the patient or where they wish to be treated
Disease Specific - HF, Diabetes, s/p stroke
Program Specific - Hospice, PACE
Site Specific - Home, rehab center, nursing homes
Four key concepts guide the approach to geriatric Dx, A/P
- Teams and clinical sites
- Prognosis
- Patient Goals
- Functional status
Teams and clinical sites
Interdisciplinary vs Multidisciplinary
Interdisciplinary (sync)
- inpatient units
- rehab units
- PACE (program for all inclusive care of the elderly)
- LTC facilities
Multidisciplinary - (asynchronous)
- results in multiple A/P’s
Prognosis
How does life span affect care
> 10 years = most test/treatments are the same as younger patients
<10 years = things start to change, screening/treating vs quality of life
<18 months = consider palliative care services
<6 months = Consider Hospice
USPSTF Grades
A = Recommended, substantial net benefit B = Recommended, moderate net benefit C = Dependent on Px, small net benefit D= Not Recommended, No net benefit I = Inconclusive ammount of evidence
Falls
- leading cause of nonfatal injuries and death in elderly
- ask about annual incidence and frequency
- screen for comorbid gait balance impairments
- get up and go (3 meters) abnormal >15s
They probably wont tell you about it unless you ask
Incontinence
Transient causes of urinary incontinence (DIAPER)
- Delirium
- Infection
- Atrophic urethritis
- Pharm / Psych
- Excessive excretion
- Restricted mobility
- Stool impaction
Cognition and Depression screening
Mini cog - 3 item recall and clock drawing exercise
Mini mental status exam (MMSE) - 10 min
MOCA - 30 min, probably the right one to do
- good for situations where Px and family disagree
- score of 10 = dementia
PHQ2 - 2 questions, 2 wk Hx
- depressed mood and anhedonia, 1 yes = more eval
Unfilled prescriptions are a sign of
elder abuse
Risk for suffering from abuse
- living in same household as caregiver
- socially isolated
- increased dependence
Risk for committing abuse
- family caregiver
- single caregiver, stress
- elder dependence
Immunizations
Influenza annually
Pneumococcal (strep pneumo)
- at 65, PCV 23
Td/TDAP every 10 years
Zostavax/Shingrix (Shingles) = at 60 y/o
Male over 65 screening
DM = With HLD/HTN, BS Every 3 years until 70
Colon CA = FOBT every year, Colonoscopy Q 10y or CT Q 5y until 75
AAA = 1 time US, Men who have ever smoked; until 75
Lung CA = active/quit last 15y & 30+ pack Hx, LDCT every year, until 80
Female over 65 screening
btw Cervical CA: every 3-5 years; until 65
DM = With HLD/HTN, BS Every 3 years until 70
Colon CA = FOBT every year or Colonoscopy every 10y until 75
Breast CA = Mammogram every 2 years until 75
Lung CA = active/quit last 15y & 30+ pack Hx, LDCT every year, until 80
Osteoporosis = DEXA every 3-5 years, 65 until <2y prognosis
Screening for old people that’s maybe not necessary with <10 y prognosis
- DM, breast, colon, AAA
Prescribing for Older Adults is complicated by multiple factors
Physiologic changes/susceptibility
- Lasix @ night = pee @ night = fall @ night = hip fx @ night
Chronic conditions
- multiple medications/drug-drug interactions
Adherence/social support
Disease 2/2 Polypharmacy:
20% of people over 65 use 10 or more medications
“Any symptom in older adult is a medication side effect until proven otherwise”
“Prescribing cascade”
- Adverse effects of one drug treated with another drug.
Strategy
- Group Medicine by patient disease or syndromes treated
BEER criteria drug classes he pointed out
First gen antihistamines = highly anticholinergic, risk of confusion/delirium
TCA = highly anticholinergic = ortho HOTN
Benzos = Increased sensitivity, delirium, falls, Fxs
Male androgens = Cardiac problems, BPH
Muscle relaxants = poorly tolerated anticholinergic affects
Criminal justice considerations
Consider a recent Hx with the law as potential:
- cognitive impairment
- substance abuse
- psychiatric disease.
Screen those recently released for
- a history of victimization
- depression/suicidality
- infectious diseases. Ex. hepatitis B and C and HIV
Mode of travel DVT risk
18% increased risk for every 2 hours of travel
26% increased risk for every 2 hours of Air travel
What hospital factors can lead to disability and loss of independence?
- Polypharmacy
- Bedrest
- Enforced dependence
Perioperative Care in Older Surgical Patients
Pre-Op
- Cardiovascular Screening: ACC/AHA
- Pulmonary Screening: CXR with cardiopulmonary disease/no films<6mths
Post-Op
- Opiod/NSAID AE: HoTN, resp. depression, sedation, constipation, PUD/CKD
- Delirium 2/2 Pain, infection, hypoxia, hypoglycemia, electrolyte imbalance
Assisted Living
Help with laundry, housekeeping, meal preparation.
- Rx administration
- dementia special care units
- Home medical care (house calls)
- home health agency care (social work/rehab/skilled nursing/hospice)
- private case management.
NEITHER Medicare nor Medicaid cover it:
- Personal Resources or optional long-term care insurance programs.
Skilled Nursing Facility (SNF):
- IV medications
- Daily wound care
- Rehabilitation 5-days of week.
Medicare Part A
- requires 3 day hospital stay, within 30 days of d/c
- covers first 20 days, with patient copay the remaining 100 days.
- three months before it can be used again
Best place for patients after a stroke
Acute Rehabilitation Center:
- High acuity, post hospital
- provide minimum of 2 hrs. of intensive rehab daily
Nursing:
Some information in case this class makes you not wanna be a PA anymore
Registered Nurse (RN):
- Nursing Assessments (delirium, mini cog)
- pass medications, manage IV access
- provide skilled treatments
Licensed Vocational Nurse (LVN):
- 2 year training.
- pass medications, provide some treatments.
- No formal clinical assessment training
Certified Nurse Assistants (CAN):
- 40hr certification program. Provide ADLs (PA equivalent)
Rehabilitation
Physical Therapists (PT):
- Gait/balance training
- strengthening after a debilitating episode
- PT assistants: No formal training. Establish workout routines
Occupational Therapists (OT):
- Therapy for ADLs and IADLs
- Focus on small motor skills of hands.
Speech/Language Pathologists:
- Focus on deficits of speech and swallowing
Requirements for Medicare Home Health Services
Homebound (ie condition makes it hard to leave home)
Skilled Need:
- Wound/catheter care, PT, med education (DM/warfarin)
Face to Face Encounter:
- with provider within 90d before or 30 days after start of care
Part time/intermittent service:
- <7d/wk or <8 h/day over a period of 3 wks or less
- for a condition requiring services at least once every 60 days
Stages of dying
Stage 1 (life focus) = Life expectancy 20+ years - Thoughts forward-reaching, growth-oriented
Stage 2 (end of life inevitability) = Life expectancy < 5 years - Frequent awareness of mortality
Stage 3 (the process of dying) = Life expectancy < 6 months - Renewed focus on life after death
Stage 4 - the act of dying = Life expectancy < 1 month
Kübler-Ross Model, Stages of Grief
Experienced by terminally ill patients and loved-ones
Denial and isolation Anger Bargaining Depression Acceptance
Who is an appropriate Candidate for palliative medical care?
Palliative care
- interdisciplinary care for serious life threatening illnesses
- anyone living with a serious illness: HF, COPD, Cancer, dementia
- helpful at any stage of illness
- best provided from the point of diagnosis.
- goal is to enhance patients quality of life
Hospice
- comfort care, attempts to cure illness are stopped
- terminal illness, 6 months or less to live
Offered in two types of settings
- Home
- Facility (nursing home, hospital, hospice center)
- Provider- pain management
- Nursing- meds, triage, bowel/bladder management, wound care, hygiene
- Counseling- spiritual, personal
- Planning- financial, family care
Whats the difference between Hospice and Palliative care
Palliative
- Dz was diagnosed that is probably going to kill you
- But you still have 18 months to live so lets improve your quality of life
Hospice
- Tx for your dz has failed and your gonna die in the next 6 months
- So lets stop hurting you by trying to cure you and make you feel better instead
S/S of near death
Extremity swelling
Coolness in tips of fingers/toes
Molted veins
