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P-1 Flashcards

1
Q

5 principles of Geriatric Care

A
  • 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
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2
Q

What is the clinical impact of a Decreased Physiologic Reserve in elderly patients?

A

A more rapid decline with illness can result from

the interplay of multiple medical conditions presenting as complex geriatric syndromes:

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3
Q

Complex geriatric syndromes that often go under diagnosed and can occur synchronously

A

OPS FINDS

  • falls
  • nutrition
  • incontinence
  • sensory impairment
  • social isolation
  • poly pharmacy
  • delirium
  • oral candidiasis
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4
Q

What geriatric attributes can accurately predict patient function as well as monitor decline?

A

Measuring Functional and cognitive status

Functional status

  • ADL and IADL
  • Get up and go test

Cognitive status
- Memory, mental status

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5
Q

What are the ADL’s?

A 
ADL's?
Personal care - GT DEBT
G - Grooming
T - Transferring
D - Dressing
E - Eating/feeding
B - Bathing
T - Toilet
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6
Q

What are the IADLs?

A 
Independent living (mental capacity)
SCUM
S - Shop
C - Cook/clean
U - Using phone/transport
M - Manage meds/money
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7
Q

Four Risk factors for functional decline

A
  • sensory deficits
  • polypharm
  • comorbid conditions
  • hospitalization
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8
Q

Preventing/Treating Functional Decline

A

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
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9
Q

What you should be asking your patient about to guide you on their future care

A

Goals
- Diagnostic/therapeutic plans should be based on patient goals

Prognosis: more than mortality, what is important to them?
- independence, function, dementia

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10
Q

Some aspects of the Social Context of care include

A

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
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11
Q

Housing and long term care

A

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

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12
Q

Team Care for geriatric patients can be based on the condition of the patient or where they wish to be treated

A

Disease Specific - HF, Diabetes, s/p stroke

Program Specific - Hospice, PACE

Site Specific - Home, rehab center, nursing homes

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13
Q

Four key concepts guide the approach to geriatric Dx, A/P

A
  • Teams and clinical sites
  • Prognosis
  • Patient Goals
  • Functional status
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14
Q

Teams and clinical sites

Interdisciplinary vs Multidisciplinary

A

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

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15
Q

Prognosis

How does life span affect care

A

> 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

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16
Q

USPSTF Grades

A 
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
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17
Q

Falls

A
  • 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
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18
Q

They probably wont tell you about it unless you ask

A

Incontinence

Transient causes of urinary incontinence (DIAPER)

  • Delirium
  • Infection
  • Atrophic urethritis
  • Pharm / Psych
  • Excessive excretion
  • Restricted mobility
  • Stool impaction
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19
Q

Cognition and Depression screening

A

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

20
Q

Unfilled prescriptions are a sign of

A

elder abuse

21
Q

Risk for suffering from abuse

A
  • living in same household as caregiver
  • socially isolated
  • increased dependence
22
Q

Risk for committing abuse

A
  • family caregiver
  • single caregiver, stress
  • elder dependence
23
Q

Immunizations

A

Influenza annually

Pneumococcal (strep pneumo)
- at 65, PCV 23

Td/TDAP every 10 years

Zostavax/Shingrix (Shingles) = at 60 y/o

24
Q

Male over 65 screening

A

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

25
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
26
Screening for old people that's maybe not necessary with <10 y prognosis
- DM, breast, colon, AAA
27
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
28
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
29
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
30
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
31
Mode of travel DVT risk
18% increased risk for every 2 hours of travel 26% increased risk for every 2 hours of Air travel
32
What hospital factors can lead to disability and loss of independence?
- Polypharmacy - Bedrest - Enforced dependence
33
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
34
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.
35
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
36
Best place for patients after a stroke
Acute Rehabilitation Center: - High acuity, post hospital - provide minimum of 2 hrs. of intensive rehab daily
37
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)
38
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
39
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
40
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
41
Kübler-Ross Model, Stages of Grief
Experienced by terminally ill patients and loved-ones ``` Denial and isolation Anger Bargaining Depression Acceptance ```
42
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
43
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
44
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
45
S/S of near death
Extremity swelling Coolness in tips of fingers/toes Molted veins

Geri (11 decks)

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