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Geri > P-1 > Flashcards

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
Q

Female over 65 screening

btw Cervical CA: every 3-5 years; until 65

A

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
Q

Screening for old people that’s maybe not necessary with <10 y prognosis

A
  • DM, breast, colon, AAA
27
Q

Prescribing for Older Adults is complicated by multiple factors

A

Physiologic changes/susceptibility
- Lasix @ night = pee @ night = fall @ night = hip fx @ night

Chronic conditions
- multiple medications/drug-drug interactions

Adherence/social support

28
Q

Disease 2/2 Polypharmacy:

20% of people over 65 use 10 or more medications

A

“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
Q

BEER criteria drug classes he pointed out

A

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
Q

Criminal justice considerations

A

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
Q

Mode of travel DVT risk

A

18% increased risk for every 2 hours of travel

26% increased risk for every 2 hours of Air travel

32
Q

What hospital factors can lead to disability and loss of independence?

A
  • Polypharmacy
  • Bedrest
  • Enforced dependence
33
Q

Perioperative Care in Older Surgical Patients

A

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
Q

Assisted Living

A

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
Q

Skilled Nursing Facility (SNF):

A
  • 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
Q

Best place for patients after a stroke

A

Acute Rehabilitation Center:

  • High acuity, post hospital
  • provide minimum of 2 hrs. of intensive rehab daily
37
Q

Nursing:

Some information in case this class makes you not wanna be a PA anymore

A

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
Q

Rehabilitation

A

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
Q

Requirements for Medicare Home Health Services

A

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
Q

Stages of dying

A 
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
Q

Kübler-Ross Model, Stages of Grief

A

Experienced by terminally ill patients and loved-ones

Denial and isolation
Anger
Bargaining
Depression
Acceptance
42
Q

Who is an appropriate Candidate for palliative medical care?

A

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
Q

Hospice

A
  • 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
Q

Whats the difference between Hospice and Palliative care

A

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
Q

S/S of near death

A

Extremity swelling
Coolness in tips of fingers/toes
Molted veins

Geri (11 decks)

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