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P-2 Flashcards

1
Q

Potential Delirium Contributing Drugs

A
  • TCAs
  • Anticholinergic (-amine)
  • Benzodiazepines
  • Corticosteroids
  • H2 Receptor Antagonists (-tidine)
  • Narcotics
  • Polypharmacy
  • ETOH
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2
Q

Medical causes of delirium

A
  • Infection (#1): UTI, PNA, Cellulitis, new murmur
  • Medication withdrawal
  • Hypo/hypernatremia, Hyper/hypoglycemia
  • Thyroid dysfunction, Acid-base d/o
  • Surgery
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3
Q

Environmental causes of delirium

A
  • Admission to ICU
  • Bladder catherization
  • Pain (Post Op)
  • Emotional Stress
  • Sleep Deprivation
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4
Q

Altered level of consciousness

A

Not just lethargic/stuporous/coma

  • Can also be Agitated or vigilant
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5
Q

CAM criteria for delirium

A

Acute onset with a fluctuating course and Inattention

and one of the following

  • Disorganized thinking
  • Altered LOC (Hypo or Hyper alert,)
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6
Q

Vegan with delirium

A

Vit B12 deficiency

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7
Q

Treatment for delirium

A

Non-pharmacologic

  • Sleep Protocol; Sleep/wake cycle, Avoid sedatives (promotes delirium)
  • Volume repletion
  • Frequent re-orientation
  • Taper / discontinue Meds (Beers: TCAs, anticholinergics, etc)

Pharmacologic = Last resort

  • Antipsychotics: Haldol (1st line), Olanzapine, Quetiapine, Risperidone
  • Benzodiazepines (last line)
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8
Q

Aphasia

A

Aphasia = loss of ability to use language

Wernicke’s Aphasia:

  • Fluent, word salad
  • unable to understand written or spoken language

Broca’s Aphasia:

  • Non-fluent, expressive aphasia
  • able to read but limited in writing
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9
Q

Apraxia

Agnosia:

Disturbed executive functioning-complex thinking:

A

Apraxia:

  • cannot perform task despite strength to do so (eg can’t tie shoes)
  • difficulty with speech

Agnosia:
- Inability to recognize specific visual stimuli in the absence of visual impairment

Disturbed executive functioning-complex thinking:
- Inability to plan and sequence events

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10
Q

Normal aging vs cognitive impairment

A

Normal Aging:

  • person remembers later and knows they forgot
  • intact learning, stable decline over time
  • no functional impairment.

Mild Cognitive Impairment:
- permanently forgotten and is unaware they forgot it

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11
Q

Dementia is defined by impairment in at least 2 cognitive domains:

A
  • Memory
  • Executive Function
  • Language
  • Visuospatial function
  • Personality Behavior
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12
Q

Dementia’s Key Features of Diagnosis

A

Gradual onset (months/years)

  • Stable Course
  • Cognitive decline is rarely reversible
  • Interferes with ADLs/IADLs
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13
Q

Types of dementia in order of frequency

A
  • Alzheimer’s Disease (MC)
  • Lewy Body Dementia (Parkinsonian sx)
  • Vascular Dementia (strokes, step wise progression)
  • Frontotemporal Dementia (Picks Disease)
  • Other: Parkinson’s Disease (30%), Huntington Disease, Tumor
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14
Q

Alzheimer’s Disease

A

MCC of dementia but is a Dx of exclusion

Classic triad

  • Memory impairment
  • Visuospatial problems; getting lost
  • Language impairment; subtle aphasia
  • Interferes with social/occupational functioning
  • Insidious; NO INSIGHT into their deficits.
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15
Q

Lewy Body Dementia

A

2nd MC cause of Dementia (AD #1)

1 of 4 present = suggestive; 2 of 4 present = probable

  • Fluctuation of cognitive impairment
  • Parkinsonism (bradykinesia, rest tremor, rigidity)
  • Visual hallucinations (know they’re not real, are not disturbed by them)
  • REM Sleep Behavior: Dream enactment; mild-violent punching/kicking

Supported Features:

  • Antipsychotic meds sensitivity
  • falls
  • autonomic dysfunction.
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16
Q

Vascular Dementia

A
  • Sudden onset of cognitive dysfunction
  • Stepwise Decline
  • Clinical/radiological signs of cerebrovascular disease.

Memory Impairments may be less severe, with “patchy” deficits.
- Brocas aphasia is prominent

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17
Q

FrontoTemporal Dementia (Picks Disease)

A

Develops younger (50s)

Behavioral Variant (Picks) Highly specific Sx

  • Hyperorality (changes in food preference)
  • early change in personality, behavior, social awareness [disinhibition]
  • compulsive or repetitive behaviors
  • sparing of visuospatial abilities
  • May develop new artistic talents

Language Variant

  • Progressive aphasia
  • Semantic Dementia
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18
Q

Dementia; Treatment of cognitive impairment

A

Cholinestarase Inhibitors

  • Donepezil, rivastigmine, galantamine.
  • Mild/moderate AD. MCI, DLB.
  • Side effects: N/V/D, syncope, bradycardia.

NMDA antagonist

  • Memantine
  • Mod/Severe AD
  • Added to ChEI
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19
Q

Vascular Dementia Treatment

A
  • Reduce Risk factors: HLD, smoking, DM,

- aspirin, clopidogrel

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20
Q

Treatment of Behavioral Problems with dementia

A
  • SSRIs, Olanzapine, Haloperidol

Haloperidol is IM, more of an acute setting Tx

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21
Q

Strokes

A

Ischemic (MC) or hemorrhagic

Cincinnati stroke scale (1 of 3 = 72% probability)

  • Facial droop
  • Arm drift
  • Speech (slurred or inappropriate words)

Aspirin, plavix

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22
Q

Parkinson Disease Dx

A

2nd MC neurodegenerative disorder (AD#1)

  • Dopaminergic cell loss of substantia nigra
  • drug induced with antiemetics & antipsychotics
  • Resting tremor: involuntary “Pill Rolling”
  • Bradykinesia: Slowness of movement
  • Rigidity: stiffness/pain (“lead pipe/cogwheel”)
  • Postural instability
  • strong response to dopaminergic medications (levodopa)
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23
Q

Parkinson Disease Treatment

A

Levodopa:

  • Converted by DOPA-decarboxylase into dopamine.
  • Scheduled: very specific dosing Q 4 - 6 hrs
  • SE: “Wearing off” Dyskinesia/choreiform movements, N/V, dizzy/lightheaded

Carbidopa:
- Prevents peripheral conversion to dopamine

Pramipexole, ropinirole
- Dopamine agonists

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24
Q

Drugs capable of inducing secondary parkinson

A

Anti emetics

  • Metoclopramide
  • Prochlorperazine
  • Promethazine

Antipsychotics

  • zapine
  • apine
  • azine

Both are dopamine receptor blocking agents

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25
Q

Depression Diagnosis

A

Anhedonia and Depressed mood plus ≥ 3 of these (SIGECAPS)

Sleep ↑↓
Interest ↓
Guilt ↑
Energy ↓
Concentration ↓
Appetite ↑↓
Psychomotor ↓
Suicide ↑

Episode is actually a Disorder if there is no other psych issues going on

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26
Q

Essential tremors

A
  • Bilateral, forearms, maybe head
  • improves with alcohol
  • often asw Fhx
  • other neuro Sx absent

1st line Tx

  • OT
  • Propranolol SE: HoTN, bradycardia, bronchoconstriction
  • Primidone (Anticonvulsant) SE: sedation, dizziness, ataxia, confusion

2nd
- gabapentin/topiramate

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27
Q

Bone pathology

A

Osteoarthritis

  • NSAIDs (avoid with CKD, PUD/anticoags, HF)
  • Acetaminophen
  • PT, Orthopedics

Osteopenia:

  • BMD within 1 - 2.5 SD normal (T score -1 to -2.5) on DEXA
  • Ca, Vit. D, ± bisphosphonates (-dronate)

Osteoporosis:

  • T score less than -2.5 on DEXA
  • Ca, Vit. D, bisphosphonates (-dronate)
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28
Q

FRAX indications for bisphosphonates

A

10-year probability of hip fracture ≥3%
—————-or—————
10-year probability of other major osteoporosis related fracture ≥20%.

Bisphosphonates = the -dronates

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29
Q

Coronary disease

A

ACS (STEMI, NSTEMI, UA)
- S/S in elderly: dyspnea, neural complaints, dizzy, fatigue

  • Antiplatelet aspirin clopidogrel
  • Statin
  • B blocker
  • ACE/ARB if HFrEF is present
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30
Q

HFpEF, HFrEF

A

HFpEF: >50% EF
- Symptomatic treatment. Loop diuretics

HFrEF: <40%:
- Beta blocker and ACE/ARB are cornerstone

  • Resynchronization: EF <35% (Biventricular pacing)
  • Daily: Na ≤2g, Fluid 1-1.5L, weigh ins
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31
Q

CHA₂DS₂-VASc

A

C - CHF (<40% LVEF)
H - HTN
A - >75yo or equal —– 2 points

D - DM
S - Stroke/TIA or systemic embolism —— 2 points

V - Vascular disease
A - 65-74yo
Sc - Sex category = female

> 2 = anti-thrombotic therapy

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32
Q

Patients with symptomatic PVC’s or non sustained ventricular tachycardia should be on

A

B blocker = DOC

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33
Q

HTN JNC8

A
  • <60 y/o or CKD, or DM = <140/90

- >60 y/o & no CKD/DM = <150/90

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34
Q

HTN ACC/AHA

A

Normal: < 120/80 mm Hg

Hypertensive crisis:

  • Urgency: >180/120 = prompt changes in meds
  • Emergency: >180/120 with signs of organ damage = immediate hospitalization
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35
Q

HTN Treatment

A

HCTZ:
- hypokalemia & urinary freq risk

Furosemide (loop):
- instead of HCTZ with ortho HoTN or if CrCl is <30

B blocker:

  • with CAD, syst. dysfunction;
  • can cause Bradycardia and HoTN risk

ACE:

  • with DM, CHF, LV dysfunction
  • Cough risk, ↑serum BUN & Cr <20%
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36
Q

ACE inhibitors

A

Captopril, Enalapril, Lisinopril

  • Indicated for HTN in patients with diabetes, CHF, LV dysfunction post MI
  • SE: Cough, rash, loss of taste, hyperkalemia, leukopenia and angioedema
  • Renal Trifecta: Diuretics, ACE/ARB, NSAIDs

He seemed to imply they are contraindicated at CrCL of <30, not really true. Lisinopril, however, is a bad choice in this population and all are CI with RAS.

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37
Q

Prevention of Infective Endocarditis

A

Prophylaxis for dental procedures if high risk:

  • Prosthetic heart valve
  • Hx of IE
  • Cardiac valvulopathy after cardiac transplant
  • Congenital Heart Disease
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38
Q

PAD and VTE

A

Edema, Claudication, ABI (<0.9).

Rx:

  • foot care, Podiatry (DM), Daily inspection, PT
  • Anti-platelet, high intensity statin (Atorva 80, or Rosuva 40)
  • Cilostazol (vasodilator) 26 week trial
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39
Q

COPD

A
  • FEV1/FVC <70%
  • Emphysema: Destruction of alveoli.
  • Bronchitis: Cough & sputum, 3 m/year for 2 years

Chronic:

  • SABA (mild symptoms, 2 puffs bid)
  • LABA/Glucocorticosteroids (advair)
  • Anticholinergics
  • Oxygen: <88% Room air

Acute exacerbation:
- Short course prednisone, antibiotic therapy

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40
Q

PPI complications

A
  • Psyllium
  • Docusate
  • **- PEG (least side effects) they can drink a gallon
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41
Q

Rx that can cause hyperkalemia

A
  • spironolactone
  • ACE inhibitors

check K levels week after starting ACE

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42
Q

Rx that can cause Hypokalemia

A

Thiazide and Loop diuretics

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43
Q

Rx that can cause hyponatremia

A
  • SSRI
  • Loop diuretics
  • antipsychotics
  • ACE inhibitors
44
Q

CKD stages

A

GFR < 60
- you can treat, make sure they dont have AKI

GFR < 30
- Nephrology referral

45
Q

What condition is NOT normal in geriatrics, but many people think it is?

A

Incontinence

Functional = Get up and Go test → to PT
Stress = Cough, laugh, sneeze; → urology
Overflow (BPH) = Tamsulosin(a blocker) or finasteride

Urge (overactive bladder) = abrupt onset, urgency

  • antimuscarinincs eg oxybutynin
  • Estrogen (only transvaginal)
46
Q

What are some of the NORMAL physiologic changes in geriatrics?

A 
Slow wound healing
Decreased immune response
Decreased muscle mass/bone density
Decreased exercise capacity/lung volume
B12, Folate, and Iron deficiency
Dehydration due to decreased thirst
47
Q

BPH

A

Lower urinary tract symptoms (LUTS):
- frequency, nocturia, hesitancy, weakness, postvoid dribbling, incomplete bladder emptying

alpha blockers
- doxazosin/terazosin/tamsulosin/alfuzosin

5alpha reductase
- finasteride (typically 2nd line)

TURP, TUIP

48
Q

Hyper/Hypo thyroidism

A

Normal TSH = 0.5 - 4.0

HYPOthyroidism (Typical S/S, ± AMS/depression, CHF, HLD, HTN)

  • Primary (↑TSH, ↓T4); Secondary (↓TSH, ↓T4)
  • Subclinical = TSH <10 without Sx
  • Treatable = TSH >10, or TSH 5-10 with Sx
  • 12.5mcg (cardiac)- 25mcg; f/u Q 4-6wks, goal = Euthyroid w/o SE

HYPERthyroidism

  • Subclinical = Low TST, normal T4
  • S/S nonspecific: ± afib, bone loss, functional decline
  • Decrease their synthroid or iodine 131 ablate them
49
Q

Diabetes

A

Dx = A1c ≥6.5, Fasting ≥126, 75-g 2-hour ≥200

Complications

  • Acute: DKA/HHS
  • Chronic: Macrovascular (MI, CVA, PVD); Microvascular (Retinopathy, Neuropathy, nephropathy)
  • ↑ risk: MCI, depression, incontinence, falls, functional decline

Tx

  • <7 (old & healthy); <8-9 (if dying soon)
  • Metformin (biguanide) SE = nausea/diarrhea
50
Q

Anemia

A

Defined as Hgb <13g/DL men; <12g/DLm women
- Common in elderly (10%), but not normal

Sx: Fatigue, dyspnea, palpitations, lethargy, confusion, orthostasis, syncope

Tx: Manage underlying conditions.

51
Q

Infections

A

Blunted febrile response
- Single >100, persistent >99 or >2° ↑ baseline

Common
- UTI, URTI/LRTI, C. diff, SSTI, Osteomyelitis (DM)

52
Q

UTIs

A

Asymptomatic Bacteriuria = Tx not recommended

UTI:

  • 1st Line: TMP/SMX, Nitrofurantoin
  • 2nd Line (allergy/resistance): Fluoroquinolones
  • 3 days; Female; 10-14 days male or female with severe Sx
53
Q

Influenza

A

Over 65 = disproportionate # of influenza deaths

Oseltamivir (Tamiflu)

  • if Sx started <72hrs ago
  • or if severe/comorbidities (COPD)
54
Q

Pneumonia

A

CAP
- Azithro or doxycycline (Azithro = QT prolongation)

If Comorbidities present
- Resp. quinolone (gemi, levo, moxifloxacin)
or
- Beta-lactam plus macrolide

  • beta-lactam = cefotaxime, triaxone, ampicillin
  • macrolide = Azithro or alt doxy
55
Q

CURB65

A

All worth 1 point

  • Confusion
  • Urea >7 mmol/L
  • Respiratory rate >30 breaths/min
  • BP: SBP <90, DBP <60
  • ≥65 years

Total (30-day mortality) ie should you admit

  • 1 (3.2%) Outpatient
  • 2 (13%) Outpatient or Inpatient
  • 3 (17%) Inpatient +/- ICU
56
Q

What nutrients are less absorbed by geriatrics GI systems, thus low levels are common?

A

B12, Calcium, Iron

57
Q

SSTI

A

Staph/Strep are Most common.

Staph = Clindamycin; Doxycyline
- MRSA (purulent SSTI) = vanc, dapto, clinda, linezolid or Doxy PO

Strep/MSSA = 1st generation cephalosporin
- cephaloridine, cephapirin, cefazolin, cephalexin, cephradine, and cefadroxil

58
Q

GI

A

C diff

59
Q

No seriously what do i need to know about C diff

A

It is a SSTI Gastrointestinal

60
Q

C diff Treatment

A
  • rehydration

- metronidazole or oral vancomycin

61
Q

Diverticulitis

A

Uncomplicated diverticulitis

  • pain, fever, ↑ WBC but stable with no palpable mass or peritoneal signs
  • xray: no pneumoperitoneum, perforation, sepsis = outpatient Tx
  • clear liquids (2-3d) + PO Abx (x 2wk)
  • Metro + Septra or quinolone or 3rd gen cephalosporin

Diverticulitis is complicated if an abscess, stricture, or fistula develops

  • tachycardia, HoTN, ± lethargy, confusion, mass in LLQ, peritonitis, draining fistula
  • hospitalization, NPO, IV fluids & ABx, Blood Cx, abd. CT
  • no improvement in 48-72 = repeat CT, consult surgery/interventional radiology
62
Q

Stool transit time is __________ in geriatric patient?

A

Increased

63
Q

What is the best test to identify adequate renal function? How is it calculated?

A

GFR

Calculated from creatinine clearance

64
Q

What depression screening tool is recommended?

A

PHQ-2. If positive, a PHQ-9

65
Q

What amount of weight loss requires further evaluation?

A

> 5% of bodyweight in 1 month or 10% in 6 months

66
Q

What two mechanisms are usually the cause of drug-drug reactions?

A

Cytochrome P450 interactions (usually inhibitory)

Use of 2 or more drugs with mutually reinforcing physiologic effects (ie digoxin and a B-blocker - both can cause 3rd degree heart block)

67
Q

What causes a decreased GFR?

A

Decreased renal tubular function

68
Q

What is a strategy to reduce the number of medications a geriatric patient must take?

A

Try to find one medication that will treat multiple conditions

69
Q

What may be the first indication of new or worsening health problems in a geriatric patient?

A

New difficulties with ADLs and IADLs

70
Q

What are the most common chronic conditions of the elderly?

A
  • Arthritis = ASAP and NSAID
  • Hypertension = HCTZ, B blocker, ACE/ARB
  • CAD = ASA, Clopidogrel, atorvastatin 80, B blocker
  • Hearing/Vision impairment
71
Q

In general, what skin changes occur with aging?

A

Skin becomes thinner, dry, rough, and brittle. Wounds heal more slowly
There are fewer sweat glands - less sweating.

72
Q

What are lentigo?

A

Liver spots

73
Q

What happens to the nails?

A

They become dry and flattened.

May observe onychomycosis (fungal nail infections)

74
Q

What do basilar crackles indicated in the geriatric patient?

A

Maybe nothing. Can be a normal finding

75
Q

What happens to the normal PaO2 as we age?

A

PaO2 decreases by 10 for every 10 year age increase.

76
Q

Why are the elderly at higher risk for pulmonary illnesses?

A

Decreased mucociliar transport.
Loss of effective cough reflex
Diminished cellular immunity

77
Q

What changes in liver function tests are to be expected with advanced age?

A

None. LFT’s should not change

78
Q

Why do the elderly experience increased sodium loss?

A

Decreased function of the RAAS

79
Q

A serum creatinine over what indicates renal disease in a geriatric patient?

A

> 1.5 mg/dL

80
Q

What lab values tend to increase in the elderly?

A

ESR,
Autoantibodies,
Alkaline Phosphatase

81
Q

What lab values tend to decrease in the elderly?

A

PaO2
Albumin
B-12

82
Q

What is the best way to avoid adverse drug reactions?

A

Use the lowest number of drugs at the lowest effective dose possible

83
Q

If a patient has low serum albumin levels, what effect will be seen on drugs that bind to protein?

A

Lower available albumin means less drug will be bound and more will be free, in effect, making the drug more potent. (Remember, bound drug is inactive. Only free drug is active)

84
Q

At what life expectancy should palliative care be services be considered?

A

< 18 months

85
Q

At what life expectancy should hospice be considered?

A

> 6 months

86
Q

If ADL impairments are significant……..?

A

Nursing home placement is usually required.

87
Q

Standard screening may not capture subtle functional impairments in high functioning elders.

What should you focus on? What are you looking for?

A

Identify and inquire about a target activity that they enjoy.

Suspect early functional impairment or the onset of depression and/or dementia if the patient begins to drop the activity.

88
Q

What is a more sensitive method for detecting arthritis, weakness, and neuro impairments compared to a standard neuro exam?

A

Specific gait assessment

89
Q

The snellen eye chart tests far vision. What tool is used to test near vision?

A

Jaeger card

90
Q

How long does a mini mental state exam take?

A

At least 10 min

91
Q

What are the parts of a mini-cog exam?

A

3 item recall

Clock drawing exercise

92
Q

When should a geriatric patient get the pneumococcal vaccine?

A

Age 65

93
Q

When should a patient get the Herpes Zoster vaccine?

What is the #1 complication of shingles that the vaccine helps prevent?

A

Age 60

Post herpetic neuralgia

94
Q

Scabies

A

S arcoptes scabiei
- nodular scabies, crusted/Norwegian scabies, bullous scabies

  • digital web spaces, volar wrists, penis, areolas
  • 2nd lesions: papules, nodules, eczematous dermatitis, hyperkeratotic crusted plaques, vesicles/bullae
  • Pruritus is intractable and debilitating.

DDx:
- atopic dermatitis, contact dermatitis, drug eruption, and urticarial bullous pemphigoid

95
Q

Topical steroids

A

Class 1: Clobetasol propionate

Class 2: Fluocinonide

Class 3: Triamcinolone acetonide 0.5%

Class 4: Triamcinolone acetonide 0.1%

Class 5: Hydrocortisone valerate 0.2%

Class 6: Triamcinolone acetonide 0.025%, Desonide

Class 7: Hydrocortisone

96
Q

Stuck on papules/plaques

MC on Trunk > Extremities/head/neck

A

Seborrheic Keratosis:

97
Q

Precursor to squamous cell cancer (SCC):

  • Face, lips, ears, forearms, dorsal aspect of hands
  • “Sandpaper” texture
  • Etiology: excess sun exposure
A

Actinic Keratosis

Small = Cryotherapy
Large (field) = imiquimod (Aldara) or fluorouracil (Effudex)

98
Q

Pearly pink papule

Telangiectasia

A

Basal Cell Carcinoma (BCC)

99
Q

papules, plaques, or nodules

Secondary changes include rough adherent scale, central erosion, or ulceration with crust

A

SCC

100
Q

ABCDE

A

Malignant Melanoma

  • Incidence & mortality continue to rise in elderly
  • Treatment options are limited
  • increased patient education and prevention
101
Q

Sleep disorders

A

R/o ID anemia first

Restless leg syndrome

  • iron supplement (ID anemia)
  • Lifestyle changes
  • Dopamine agonist (pramipexole, ropinorole)
102
Q

WHO’s view on the minimum teeth required to be considered functional

A

20

103
Q

MC fungal infection in humans

A

oral candidiasis

104
Q

Complications of LTC (low teeth count)

A
  • Malnutrition

- Aspiration PNA (anaerobes = clindamycin)

105
Q

Delirium, Dementia, Depression

A

Delirium

  • acute onset, diurnal fluctuations; duration = hours/days/weeks
  • disoriented, impaired, inattentive, distorted, delusional

Dementia

  • chronic/gradual onset, progressive; duration = months/years
  • aware, paranoid, aphasia, agnosia, superficial affect

Depression

  • abrupt onset; duration = 6 weeks to years
  • minimally impaired, paranoid, insomnia, depressed affect

Geri (11 decks)

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