P-2 Flashcards
Potential Delirium Contributing Drugs
- TCAs
- Anticholinergic (-amine)
- Benzodiazepines
- Corticosteroids
- H2 Receptor Antagonists (-tidine)
- Narcotics
- Polypharmacy
- ETOH
Medical causes of delirium
- Infection (#1): UTI, PNA, Cellulitis, new murmur
- Medication withdrawal
- Hypo/hypernatremia, Hyper/hypoglycemia
- Thyroid dysfunction, Acid-base d/o
- Surgery
Environmental causes of delirium
- Admission to ICU
- Bladder catherization
- Pain (Post Op)
- Emotional Stress
- Sleep Deprivation
Altered level of consciousness
Not just lethargic/stuporous/coma
- Can also be Agitated or vigilant
CAM criteria for delirium
Acute onset with a fluctuating course and Inattention
and one of the following
- Disorganized thinking
- Altered LOC (Hypo or Hyper alert,)
Vegan with delirium
Vit B12 deficiency
Treatment for delirium
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)
Aphasia
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
Apraxia
Agnosia:
Disturbed executive functioning-complex thinking:
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
Normal aging vs cognitive impairment
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
Dementia is defined by impairment in at least 2 cognitive domains:
- Memory
- Executive Function
- Language
- Visuospatial function
- Personality Behavior
Dementia’s Key Features of Diagnosis
Gradual onset (months/years)
- Stable Course
- Cognitive decline is rarely reversible
- Interferes with ADLs/IADLs
Types of dementia in order of frequency
- 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
Alzheimer’s Disease
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.
Lewy Body Dementia
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.
Vascular Dementia
- 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
FrontoTemporal Dementia (Picks Disease)
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
Dementia; Treatment of cognitive impairment
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
Vascular Dementia Treatment
- Reduce Risk factors: HLD, smoking, DM,
- aspirin, clopidogrel
Treatment of Behavioral Problems with dementia
- SSRIs, Olanzapine, Haloperidol
Haloperidol is IM, more of an acute setting Tx
Strokes
Ischemic (MC) or hemorrhagic
Cincinnati stroke scale (1 of 3 = 72% probability)
- Facial droop
- Arm drift
- Speech (slurred or inappropriate words)
Aspirin, plavix
Parkinson Disease Dx
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)
Parkinson Disease Treatment
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
Drugs capable of inducing secondary parkinson
Anti emetics
- Metoclopramide
- Prochlorperazine
- Promethazine
Antipsychotics
- zapine
- apine
- azine
Both are dopamine receptor blocking agents
Depression Diagnosis
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
Essential tremors
- 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
Bone pathology
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)
FRAX indications for bisphosphonates
10-year probability of hip fracture ≥3%
—————-or—————
10-year probability of other major osteoporosis related fracture ≥20%.
Bisphosphonates = the -dronates
Coronary disease
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
HFpEF, HFrEF
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
CHA₂DS₂-VASc
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
Patients with symptomatic PVC’s or non sustained ventricular tachycardia should be on
B blocker = DOC
HTN JNC8
- <60 y/o or CKD, or DM = <140/90
- >60 y/o & no CKD/DM = <150/90
HTN ACC/AHA
Normal: < 120/80 mm Hg
Hypertensive crisis:
- Urgency: >180/120 = prompt changes in meds
- Emergency: >180/120 with signs of organ damage = immediate hospitalization
HTN Treatment
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%
ACE inhibitors
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.
Prevention of Infective Endocarditis
Prophylaxis for dental procedures if high risk:
- Prosthetic heart valve
- Hx of IE
- Cardiac valvulopathy after cardiac transplant
- Congenital Heart Disease
PAD and VTE
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
COPD
- 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
PPI complications
- Psyllium
- Docusate
- **- PEG (least side effects) they can drink a gallon
Rx that can cause hyperkalemia
- spironolactone
- ACE inhibitors
check K levels week after starting ACE
Rx that can cause Hypokalemia
Thiazide and Loop diuretics
Rx that can cause hyponatremia
- SSRI
- Loop diuretics
- antipsychotics
- ACE inhibitors
CKD stages
GFR < 60
- you can treat, make sure they dont have AKI
GFR < 30
- Nephrology referral
What condition is NOT normal in geriatrics, but many people think it is?
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)
What are some of the NORMAL physiologic changes in geriatrics?
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
BPH
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
Hyper/Hypo thyroidism
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
Diabetes
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
Anemia
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.
Infections
Blunted febrile response
- Single >100, persistent >99 or >2° ↑ baseline
Common
- UTI, URTI/LRTI, C. diff, SSTI, Osteomyelitis (DM)
UTIs
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
Influenza
Over 65 = disproportionate # of influenza deaths
Oseltamivir (Tamiflu)
- if Sx started <72hrs ago
- or if severe/comorbidities (COPD)
Pneumonia
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
CURB65
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
What nutrients are less absorbed by geriatrics GI systems, thus low levels are common?
B12, Calcium, Iron
SSTI
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
GI
C diff
No seriously what do i need to know about C diff
It is a SSTI Gastrointestinal
C diff Treatment
- rehydration
- metronidazole or oral vancomycin
Diverticulitis
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
Stool transit time is __________ in geriatric patient?
Increased
What is the best test to identify adequate renal function? How is it calculated?
GFR
Calculated from creatinine clearance
What depression screening tool is recommended?
PHQ-2. If positive, a PHQ-9
What amount of weight loss requires further evaluation?
> 5% of bodyweight in 1 month or 10% in 6 months
What two mechanisms are usually the cause of drug-drug reactions?
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)
What causes a decreased GFR?
Decreased renal tubular function
What is a strategy to reduce the number of medications a geriatric patient must take?
Try to find one medication that will treat multiple conditions
What may be the first indication of new or worsening health problems in a geriatric patient?
New difficulties with ADLs and IADLs
What are the most common chronic conditions of the elderly?
- Arthritis = ASAP and NSAID
- Hypertension = HCTZ, B blocker, ACE/ARB
- CAD = ASA, Clopidogrel, atorvastatin 80, B blocker
- Hearing/Vision impairment
In general, what skin changes occur with aging?
Skin becomes thinner, dry, rough, and brittle. Wounds heal more slowly
There are fewer sweat glands - less sweating.
What are lentigo?
Liver spots
What happens to the nails?
They become dry and flattened.
May observe onychomycosis (fungal nail infections)
What do basilar crackles indicated in the geriatric patient?
Maybe nothing. Can be a normal finding
What happens to the normal PaO2 as we age?
PaO2 decreases by 10 for every 10 year age increase.
Why are the elderly at higher risk for pulmonary illnesses?
Decreased mucociliar transport.
Loss of effective cough reflex
Diminished cellular immunity
What changes in liver function tests are to be expected with advanced age?
None. LFT’s should not change
Why do the elderly experience increased sodium loss?
Decreased function of the RAAS
A serum creatinine over what indicates renal disease in a geriatric patient?
> 1.5 mg/dL
What lab values tend to increase in the elderly?
ESR,
Autoantibodies,
Alkaline Phosphatase
What lab values tend to decrease in the elderly?
PaO2
Albumin
B-12
What is the best way to avoid adverse drug reactions?
Use the lowest number of drugs at the lowest effective dose possible
If a patient has low serum albumin levels, what effect will be seen on drugs that bind to protein?
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)
At what life expectancy should palliative care be services be considered?
< 18 months
At what life expectancy should hospice be considered?
> 6 months
If ADL impairments are significant……..?
Nursing home placement is usually required.
Standard screening may not capture subtle functional impairments in high functioning elders.
What should you focus on? What are you looking for?
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.
What is a more sensitive method for detecting arthritis, weakness, and neuro impairments compared to a standard neuro exam?
Specific gait assessment
The snellen eye chart tests far vision. What tool is used to test near vision?
Jaeger card
How long does a mini mental state exam take?
At least 10 min
What are the parts of a mini-cog exam?
3 item recall
Clock drawing exercise
When should a geriatric patient get the pneumococcal vaccine?
Age 65
When should a patient get the Herpes Zoster vaccine?
What is the #1 complication of shingles that the vaccine helps prevent?
Age 60
Post herpetic neuralgia
Scabies
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
Topical steroids
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
Stuck on papules/plaques
MC on Trunk > Extremities/head/neck
Seborrheic Keratosis:
Precursor to squamous cell cancer (SCC):
- Face, lips, ears, forearms, dorsal aspect of hands
- “Sandpaper” texture
- Etiology: excess sun exposure
Actinic Keratosis
Small = Cryotherapy
Large (field) = imiquimod (Aldara) or fluorouracil (Effudex)
Pearly pink papule
Telangiectasia
Basal Cell Carcinoma (BCC)
papules, plaques, or nodules
Secondary changes include rough adherent scale, central erosion, or ulceration with crust
SCC
ABCDE
Malignant Melanoma
- Incidence & mortality continue to rise in elderly
- Treatment options are limited
- increased patient education and prevention
Sleep disorders
R/o ID anemia first
Restless leg syndrome
- iron supplement (ID anemia)
- Lifestyle changes
- Dopamine agonist (pramipexole, ropinorole)
WHO’s view on the minimum teeth required to be considered functional
20
MC fungal infection in humans
oral candidiasis
Complications of LTC (low teeth count)
- Malnutrition
- Aspiration PNA (anaerobes = clindamycin)
Delirium, Dementia, Depression
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
