Part 24 Flashcards
Glucose Tolerance Test and what is it particularly useful in diagnosing?
- Only performed in patients who have been on unrestricted diet/physical activity for 3 days before testing, involves administration of 50-100g oral glucose administered after 10 hour fast
- Gestational diabetes
HbA1C testing
Measures 70% of glycosylated hemoglobin in blood which remains for the 120 day lifespan of the RBC (avg) (does not reflect acute increase or decrease) and therefore allows for highly accurate measure of blood glucose conc.
__% change in A1C reflects a change of about ___mg/dL in avg blood glucose
1, 30
Microalbumin and microalbumin/creatinine ratio (and what should healthy value be?)
- Microalbumin test is an early indicator of kidney failure (albumin produced in liver and should not be present in blood when kidneys functioning properly) requiring 24 hour urine collection
- Microalbumin creatinine ratio is close to a 24 hour microalbumin test regarding accuracy without requiring 24 hour collection and is thus preferred (<30:1 ratio)
When is an insulin levels ordered? (3)
- evaluate PCOS
- diagnose insulinoma
- Determine cause of hypoglycemia (order alongside c peptide to monitor endogenous insulin levels)
Why order a c peptide level in suspected diabetic patient?
Monitor insulin production by the B cells of the pancreas to determine the cause of hypoglycemia - see if body producing enough of own insulin and are insulin resistant or not
C peptide levels in type 1 vs type 2 diabetics
C peptide level will be zero in type 1 diabetics (not producing insulin), in type 2 if left uncontrolled over time will drop to zero
Actions of thyroid hormone (6)
- Increase body’s metabolic rate and O2 consumption
- calorigenic effect increasing heat production
- increase heart rate and contraction strength
- increase respiratory rate
- stimulate appetite and breakdown of carbs, fats, proteins
- turn on and off various nuclear receptors
What do the C cells (parafollicular cells) of the thyroid produce?
Calcitonin
Synthroid and armour thyroid
Artificial T4 and T3 and T4 respectively (T3 alone not very useful because it has such a short half life requiring frequent dosing intervals)
2 major plasma proteins that are responsible for transport of thyroid hormone
- Thyroid binding globulin
albumin
Only __ T3/4 can penetrate cellular membranes and exert biologic activity
Unbound
Primary hypothyroidism sees a ___ TSH, very low levels of TSH can suggest ___
elevated, hyperthyroidism
Causes of elevated serum T4 (4)
- graves disease
- toxic multinodular goiter
- toxic adenoma
- thyroiditis
Causes of decreased serum T4 (3)
- hypothyroidism
- amiodarone
- post partum transient toxicosis
Hyperthyroidism + antithyroid antibodies suggests…
Hypothyroidism + antithyroid antibodies suggests…
….Graves disease
….hashimoto’s thyroiditis
Radionuclide scanning thyroid imaging
-Use of an isotope of iodine to determine if a nodule is hyperactive or underactive based on how it takes up the iodine (almost all cancers and benign lesions are cold)
Test of choice for thyroid nodule workup
Fine needle biopsy
C peptide
A protein released in equal amounts alongside insulin into the bloodstream allowing it to be a marker of insulin production (endogenous, not present with exogenous) and release in the body
5 P’s of arterial insufficiency
- Pain
- pulseless
- paresthesias
- paralysis
- pallor
- poikilothermia (rare 6th P)
Noninvasive screening for peripheral artery disease (2) and invasive (2)
- Ankle brachial index
- ultrasound
- CTA
- MRA
__% of individuals with one amputation due to peripheral arterial disease will develop ___ on the other side within 2 years
50, gangrene
Early (2) and late sensory symptoms of diabetic foot neuropathy (5)
Early -night cramps -paresthesia Late -loss of touch -deep pain -loss of position sense -anesthesia -loss of deep tendon reflex
Charcot foot definition and mech of action
Condition causing weakening of bones of the foot frequently associated with significant nerve damage from something like a diabetic neuropathy
- denervation of small foot muscles due to neuropathy
- weakness of muscle resulting
- disarray of bony structures
- atrophy of leg and foot muscles
- altered weight distribution causes callus, ulcers, pes cavus, and charcot foot
Pes cavus
High arch of foot with fixed plantar flexion that can result from altered weight distribution due to significant nerve damage from something like a diabetic neuropathy
Wagner system of classification of ulcers (4) and then staging (4)
Grade 0: pre or post ulcerative (just beginning or at the end)
1: full thickness ulcer not involving tendon, capsule or bone
2: tendon or capsular involvement without bone palpable
3: probes to bone
Stage A: noninfected
B: infected
C: Ischemic
D: infected and ischemic
Septic foot presentation (5)
- cool clammy skin
- altered mental status
- hypotension
- tachycardia
- tachypnea
- High WBC count
Septic foot treatment (2)
- Broad spectrum antibiotics and cultures to eventually steer treatment direction
- surgery (extensive debridement, wound culture)
Geriatrics
Branch of medicine focuses on health promotion and prevention and treatment of disease and disability later in life also known as gerontology, gerontologist, or a geriatrician
Universal physiologic changes associated with aging (6)
- decreased night vision
- decreased muscle mass
- loss of hair pigment
- decreased lung vital capacity
- decreased height
- decreased reaction time
Functional reserve theory
Idea that most of body’s organ systems have some degree of redundancy so they can continue to function even if some cells are lost to disease or insult, this diminishes as individuals age so acute insult can have more severe consequences
Common, but not inevitable physiologic changes associated with aging (6)
- hearing loss
- macular degeneration
- hypertension and heart dz
- diabetes
- cancer
- dementia
Erickson’s final task of life
Ego integrity vs despair (sense of whole satisfaction with ones life and healthy viewpoint regarding death) that geriatric patients undergo
Cataracts vs glaucoma vs macular degeneration
- Cataracts is the blurring of all vision due to lens opacification, common bilaterally in aging or diabetic, painless slow progressive loss
- glaucoma is loss of peripheral vision either acute (painful, close angle) or chronic (painless, open angle) usually asymptomatic until present with vision loss, laatanoprost is first line treatment (prostaglandin analog) but can also use acetazolamide
- macular degeneration is loss of vision in middle of field either dry (progressive over age with drusen bodies on fundoscopic) or wet (not as common but more aggressive presenting in months with new abnormal vessels appearing on fundoscopic)
3 common hearing problems in geriatrics
presbycusis (hearing loss with age)
conductive (earwax blockage)
tinnitus (medication, acoustic neuroma (remember unilateral sensorineural hearing loss is acoustic neuroma until proven otherwise), hypertension)
Leading cause of death from injury among those >65
complications from falls
Gerontology vs geriatrics
Gerontology involves the social, psychologic, and biomedical study of aging and ALL aspects associated with it (includes social workers, etc) while geriatrics is a medical specialty
Senescence
Aging process at the cellular and organismal levels during the latter part of the life span (last 20%)
Life expectancy
Average lifespan of a specific population (location, gender, age, etc - remember the life expectancy for an individual age 80 is greater than those of age 10 because they have already survived all the car wrecks and such), at birth is 78.7 years overall
Female vs male life expectancy
females 81.2 years while male is 76.2 years
Life span vs health span
Health span is how long an individual retains their health status and capabilities to live a functional life, a goal of geriatrics is to improve this over necessarily just improving life span
Why do we age?
No concrete consistent reason known, previously thought to be related to evolution but has been discredited, likely multifactorial between genetics, metabolism, and environment, but ultimately due to a disruption in homeostasis (increase in entropy), primary aging is normal physiologic processes and secondary is acquired diseases throughout life, prevention helps save HUGE costs of healthcare - promote the idea of “healthy aging”
Cardiovascular physiologic changes that occur with aging (5)
- decreased myocytes
- increased collagen
- decreased compliance
- increased systolic pressure/LVH
- decreased maximum heart rate
Pulmonary physiologic changes that occur with aging (3)
- reduced chest wall compliance
- reduced respiratory response to hypoxia
- decreased ciliary function
Presbyopia
Reduced accommodation due to decreased compliance of the lens with age, often resulting in elderly individuals having to hold text further away in order to read (farsightedness)
Neurologic physiologic changes that occur with aging
- decrease in cortical gray matter, complexity of connections, neurotransmitter produciton
- demyelination (slowed conduction)
- reduced reflexes/proprioception
Renal physiologic changes that occur with aging (2)
- decline in renal blood flow approx 10% per decade after 50
- often not noticed until much more advanced
Skin/hair physiologic changes that occur with aging (3)
- loss of pigment in hair
- loss of elastin in skin
- thinning of skin
Natural selection theory of aging
Traditional (less scientific) idea that aging and death have been ubiquitous over time, in relative absence of disease, humans still have a maximum lifespan, and this must be because natural selection focuses on selection of favored genetics not how long an organism lives for
Neuroendocrine theory/hypothesis of aging
Modern scientific programmed theorythat there is complex interplay of hormones that regulate vital life functions, but with age hormone levels decline decreasing body’s repair and maintenance systems (ex - IGF-1 role in aging rates)
Thymic stimulating theory/hypothesis of aging
Modern scientific programmed theory that the thymus is the master gland of the immune system (playing a vital role in T cell function) and its size decreases with age resulting in weakening of immune system contributing to aging (birth is 200 g, by age 60 only 3 g)
Telomere (telomerase) theory/hypotehsis of aging
Modern scientific programmed theory (relatively new) that postulates that telomere caps at the ends of chromosomes that do not code but act to maintain chromosomal integrity and as cells divide and chromosomes are copied telomeres are shortened leading to cell damage and death and this leads to aging, telomerase found only in germ or cancer cells could immortalize us
Genetic control theory/hypothesis of aging
Modern scientific programmed theory of planned obsolescence that genetic programming within our DNA contains a biologicla clock set to go off at a predetermined time that when it does signals a cell to age and die, each individual has their own clock and lifestyle can alter it
Hayflick limit theory/hypothesis of aging
Modern scientific programmed theory that derived from experiments demonstrating senescence of cultured human cells and therefore cells are genetically preprogrammed to divide a set number of times (like 40-60) then die, overfed cells divided quicker and died, and that loss of cell leads to aging and death
Autoimmune theory/hypothesis of aging
Modern scientific programmed theory that postulates over time our immune system experiences decline in ability to produce antibodies to fight off disease and ability to differentiate between body’s own cells and dz cells (examples being lupus, scleroderma, cancer, etc) and this leads to damage, aging and ultimately death
The hypothalamus as a control center theory/hypothesis of aging
Modern scientific programmed theory that suggests thru new research the hypothalamus plays fundamental roles in growth, development, repro and metabolism and that age related signaling blocking can slow aging in mice
The wear and tear theory/hypothesis of aging
Modern scientific damage/error theory that suggests the human body is like a machine that wears out due to chronic use and cells are damaged by overuse and abuse or toxins, and that healthy young bodies can repair but with age these systems deteriorate and accumulate
Free radical (oxidative damage) theory/hypothesis of aging
Modern scientific damage/error theory that states free radicals which contain free electrons become destructive in biological systems, attacking and splitting apart other paired electrons, and that free radicals attack cell membranes generating metabolic waste products and also attack collagen, elastin, proteins, DNA’s etc - free radicals are with us from birth produced by metabolic processes similar to rusting of ferrous metals and that antioxidants slow this
Caloric restriction theory/hypothesis of aging
Modern scientific damage/error theory that gradual weight loss to a point of metabolic efficiency results in the maximum health and lifespan (30-40% fewer calories than normal) decrease metabolic activity and therefore free radicals (doing the minimum amount of metabolism to sustain life), high nutrient low calorie diet coupled with moderate supplements and regular exercise (CRON - caloric restriction, optimal nutrition) Has been demonstrated to be accurate in some oraganisms
Waste accumulation theory/hypothesis of aging
Modern scientific damage/error theory that states that during lifespans cells produce more waste products than can properly eliminate, accumulation causes cells to age and die
Mitochondrial theory/hypothesis of aging
Theory built off the free radical (oxidative damage) theory that states that there is free radical/oxidative damage but in this case specifically focusing on that in the mitochondria, and that ATP genesis produces free radicals that can then attack mitochondria and mtDNA which accumulate damage and decrease ATP production over time
Cross linkage theory/hypothesis of aging
Modern scientific damage/error theory that believes cross linking occurs when older biological systems become incapable of removing excess glucose, so excess glucose promotes glycosylation which affects proteins, DNA, connective tissue in body decreasing elasticity, obstructing movement of nutrients and waste,
Error and repair theory/hypothesis of aging
Modern scientific damage/error theory that states DNA typically has highly effective correcting organisms for errors in the copying of DNA essential for life, replication errors increase with age, repair mechanisms are less effective with age, and accumulation of these errors over time damages or destroys cells
Physiology of urination
Requires correct functioning and interaction of CNS, sacral PNS, thoracolumbar SNS, bladder muscle (detrusor), urinary sphincter muscle, and mechanical support of the pelvic fascia and floor - if bladder pressure exceeds urethral then end up urinating (the problem of incontinence).
- Bladder relaxation and filling and closure of bladder neck and sphincter is done by inhibiting parasympathetic tone AND sympathetic stimulation via B adrenergics
- bladder contraction is done via parasympathetic stimulation upon sensory signal being sent that bladder is being stretched and filled, the internal sphincter relaxes
- somatic control of relaxation of pelvic floor via the pudendal nerve including external sphincter
Causes of acute incontinence in elderly (5) which 2 are most common?
- Infection (UTI)***
- delirium
- polypharmacy
- fecal impaction***
- restricted mobility
Urge incontinence and treatment (1)
Sees detrusor muscle contractions (premature parasympathetic stimulation) at low volumes** (overactivity or instability) caused from sensory stimulation, UTI’s, CNS lesions, etc
-anticholinergic drugs (oxybutyin or tolterodine)
Stress incontinence and treatment (4)
Incompetent internal sphincter (normally relaxes with parasympathetic stimulation) causes leakage with increased abdominal pressure (coughing, sneezing, lifting)
-kegels, pessaries, surgery, alpha adrenergic agonists such as pseudoephedrine (have to watch for causing high BP)
Overflow incontinence and treatment (2)
Loss of detrusor muscle contractility via parasympathetic stimulation or sensation due to urethral blockage (in neuropathies, DM, trauma, or bladder outlet obstruction due to BPH or constricture), bladder can’t empty properly so urine just leaks out
-alpha adrenergic antagonists or cholinergic agonists (bethanechol)
Functional incontinence
Situations in which physical, functional, or mental disability makes it impossible to void independently even though the urinary tract may be intact (can’t make it to the toilet)**
Urodynamic testing
Measuring of postvoid residual urine volume (PVR) 50 mL’s normal but over 100mL is a problem or cystometry where the bladder is filled with different capacities and volumes to test for when the sensation and urge is felt by the patient
Basic ADL’s (5)
- bathing
- dressing
- toileting
- grooming
- feeding
Intermediate ADL’s (7)
- shopping for groceries
- technology use
- housework
- meal prep
- laundry
- taking medications
- handling finances
Advanced ADL’s (1)
Vary by individual, include societal, community, family, recreational, and occupational roles
Vulnerable elders scale (VES-13)
Survey that detects vulnerable group (4x chance of death or functional decline) and does not require direct observation as it can be done over phone, includes age, comparative/self rated health, difficulties with ADL’s, physical activities, etc
Get up and go test
Monitoring how fast a geriatric can move 20 feet, with 7-10 being mobile, 11-14 being fairly mobile, 15-19 variable mobile, 20-29 severe restriction, and greater than 30 functionally dependent. >12 seconds HIGH risk for falling**
__ of seniors die with some form of dementia
1 in 3
Mini mental state examination (MMSE) advantages (2) and disadvantage (1)
- can track over time
- highly specific and sensitive
-not quick
Mini cog
Mental assessment involving clock drawing and registration and recall of 3 words, quick as not limited by language or educaiton
MoCA
Longer mental assessment than MMSE that involves visuospacial, naming, memory, attention, language, delayed recall, abstraction, and orientation
FAST scale
Functional assessment staging test for rating dementia that includes mental status as well as ADL’s and motor function to determine hospice eligibility
Polypharmacy
Tendency for older patients to see many providers and need review of medications AND supplements at each visit to ensure there aren’t any interactions or complications, eased by EMR’s generally
Beers criteria
List of medications deemed to be generally inappropriate for older patients (mainly nursing home) as they are either ineffective or at high risk for adverse events and had higher risk of hospitalization and death
3 categories of drugs/patient type that account for most adverse drug events seen in emergency departments in geriatric populations
- Anticoagulants (heparin, warfarin, xarleto, elequis pradaxa)
- Antiplatelets (clopidegrol AKA plavix)
- Hypoglycemics
Anticholinergic toxicity symptoms (8)
- flushing
- dry skin and membranes
- mydriasis
- altered mental status
- sinus tachycardia
- fever
- urinary retention
- hypertension
Drug classes that can cause anticholinergic toxicity (3)
- 1st gen antihistamines (benadryl and hydroxyzine)
- antispasmotics (scopolamine, dicylomine)
- TCA’s (amitriptyline)
Specific drug used for UTI that should be avoided for geriatric populations due to pulmonary toxicity, hepatotoxicity, etc
Macrobid (nitrofurantoin)
Megestrol (Megace)
Appetite stimulant for cachexia that can be used in geriatric populations BUT increases risk for thrombotic events so often not used
4 types of elder neglect and abuse
- physical
- sexual
- psychological
- financial exploitation
Tobacco use in geriatrics
Cessation significantly reduces risk of CAD, cancers, and COPD, within 5 years of cessation relative risk for all cause mortality falls below current smokers, should be promoted at every visit for current smokers regardless of age
USPSTF aspirin use policy
Discus benefits and harms in patients age 60-69, benefit more likely in those with 10 year cardiovascular risk of >10%, life expectancy of greater than 10 years, PPI reocmmended for all patients >50 y/o on chronic aspirin therapy
Oral cancer screening recommendations USPSTF
No official recommendations, concludes current evidence is insufficient to assess balance of benefits and harms of screening for oral cancer in asymptomatic adults, some studies show that screening is very simple and potentially capable of preventing many cancer deaths worldwide
Length time bias
Refers to how the probability of detecting a cancer is proportional to the growth rate of the cancer meaning that detecting a tumor often means its in the later stages
Familial adenomatous polyposis (FAP) indicates colonoscopy as early as age…
…10
2 absolute risk factors for breast cancer development
- sex
- Age
No specific screening for uterine or ovarian cancers exist. Instead, educate patient on reporting any of these 3 symptoms
- unusual vaginal bleeding or discharge
- bleeding after intercourse
- persistent abdominal discomfort or bloating
Biggest risk factor for testicular cancer and prognosis
Cryptorchidism, high survival rate if caught early
How does alzheimer’s kill?
Typically from a complication as a result, such as aspiration after forgetting muscle memory of swallowing or starvation
Hospice care
Provides support and care for those in the last phases of life limiting illness, recognizes dying as part of normal process of living, affirms life and neither hastens nor postpones death, focuses on quality of life for individuals and their family caregivers
POLST
Physician orders for life sustaining treatment, form completed by MD or PA that lists out what a patient wants regarding CPR, medical intervention, antibiotics, hydration and nutrition, can be changed or revoked at any time
Healthcare agent and healthcare representative
An individual designated in an advanced care directive, if not manually appointed typically goes to spouse then brother then child etc (healthcare representative)
Therapeutic nihilism
Not believing in the value of treatment and believing treatment is useless so doing nothing is acceptable (very toxic mentality in medicine!!!)
Morphine (roxanol) in end of life care
-indicated for pain, dyspnea, tachypnea, can be administered sublingually in some cases but contraindicated in renal failure, metabolites are neurotoxic so if build up can cause myoclonus or delerium
Oxycodone (oxyfast) in end of life care
Indicated for pain, dyspnea, and tachypnea, can be administered sublingually and is more okay to use with renal failure (GFR <30)
Lorazepam (ativan) in end of life care
Indicated for anxiety, agitation, restlessness, seizure activity, myoclonus, has synergistic effect with opioids, may be effective for palliative sedation
Haloperidol (haldol) in end of life care
Indicated for acute agitation, psychosis, and delirium, administered PO and IM but unpopular with nursing homes because can increase stroke risk
Hyoscyamine (levsin) in end of life care
Powerful anticholinergic used mainly for GI symptoms such as spasms and colic and respiratory secretions (death rattle)
Flibanserin (addyi) function (geriatric sexual activity)
Unknown mech of action to treat premenopausal women with hypoactive sexual desire disorder, black box warning with interactions with alcohol
The aging male sexual characteristics (4)
- reduced penile sensitivity
- reduced volume of ejaculation and force
- refractory period longer
- FERTILITY RETAINED**
Acute mental status change does not indicate dementia, but rather CNS changes and functional decline can be the first indicator of these 4 things
- UTI
- pneumonia
- hydration status
- constipation
Periodic examination of nursing home patients by a provider***
At least once every 30 days for the first 90 days after admission, then once every 60 days thereafter, acute as needed
Assisted living units
Where residents remain independent while receiving assistance as needed with personal care, medications and medically based treatment can happen here***, transportation, housekeeping, meals, and other daily needs, a step down from nursing home (long term care facility) but a step up from an elderly residential community
Eroxen gel use and MOA
OTC cream for ED that changes temp on skin stimulating nerve endins and increasing blood flow
Most common thyroid disease in the elderly
Subclinical hypothyroid disease (elevated TSH with normal serum T4)
Drugs that can cause hypothyroidism (5)
- amiodarone
- lithium
- phenytoin
- carbamezapine
- gleevac
Thyroid replacement therapy in elderly
For overt hypothyroidism, 25 mcg initially of levothyroxine starting at a low dose (already at increased risk for cardiac complication) and increase in increments of 25 mcg
Hyperthyroidism treatment options (3)
- medications (methimazole or propylthiouracil)
- radioactive iodine
- surgery as back up
Thyroid storm
Acute hyperthyroidism, occurs after operation, trauma, infection or radiaoactive idoine therapy that causes fever, confusion, agitation and potentially coma or death, life threatening but low death rate compared to myxedema (not as common as myxedema either)
Medication causes of diabetes (4)
- high dose or long term steroid use
- thiazide diuretics
- statins
- furosemide
Most common 3 presenting symptoms in young with diabetes
Polyuria, polydipsia, polyphagia
Hyperglycemic hyperosmolar nonketoic syndrome in geriatrics
More often seen in elderly (kids see diabetic ketoacidosis more often, has no ketones present and patient is NOT acidotic), associated with severe dehydration and severe electrolyte disturbances often due to underlying kidney problems, decreased sensation of thirst or access to water
Sulfonyurea mechanism of action vs biguanides (metformin)
Sulfonyureas lower blood sugar by stimulating release of insulin, biguanides (metformin) decreases glucose release from the liver
Sick sinus syndrome definition, presentation
Generally occurs in geriatric populations due to most often replacement of sinus node by fibrous tissue, often present as bradycardia, hypotension, orthostasis, ekg changes (may indicate for a holter monitor
Sick sinus syndrome treatment options (2)
- treat drug induced causes
- pacemaker insertion**
Tachybrady syndrome
Sick sinus syndrome co-ocurring with afib, aflutter, or PSVT therefore indicating that treatment will require both pacemaker insertion and rate controlling medications
Paroxysmal, persistant, vs permanent atrial fib
Paroxysmal self terminates or terminates with treatment in 7 days, persistant is greater than 7, permanent is when physician and patient have decided not to pursue and rhythm controls strategy
Atrial fib management options (5)
- B blocker
- nondihydropyridine calcium channel blocker
- amiodarone (typically in younger population)
- cardioversion
- anticoagulation depending on CHADS2-VASc score >=2 (warfarin, xarleto, pradaxa, eliquis)
Aortic sclerosis vs aortic stenosis
Sclerosis is calcifying of valve and affects up to 1/3 all elderly patients, aortic stenosis is narrowing of valve and occurs at lower rates but progressively increases with age
Mechanical vs bioprosthetic heart valve choice in geriatric patients
Mechanical last much longer while bioprosthetic decay after 10-20, but mechanical require long term anticoagulation (monitor INR) while bioprosthetic don’t - in geriatrics choose bioprosthetic because life expectancy of geriatrics is shorter than functional life of bioprosthesis often
2 drug classes that are cornerstone of systolic failure therapy
B blockers
ACE inhibitors
Sleep complaints in geriatric patients*****
Should be indication to perform comprehensive H&P to identify the cause, should always be pursued as a symptom of a health problem not a diagnosis in and of itself
1 treatment choice for older adults with sleep problems
Cognitive behavioral therapy
Insomnia base definition
Taking a long time to fall asleep (30-45 min) or waking up many times at night or waking up early and not being able to go back to sleep
Advanced sleep phase syndrome and treatment options (2)**
- Entire circadian rhythm being off, go to bed much earlier in evening and wake up much earlier, many try to force themselves to stay awake, typically most common in young children and elderly
- bight light therapy and exercise
Diagnostic gold standard study of sleep apnea
-polysomnogram**
Restless leg syndrome treatment options (3) and what is the big ADR with these choices? (1)
- gabapentin
- mirapex (prampiexole)
- requip (ropinerole)
-dizziness and sedation and may fall asleep without warning!!!!
Periodic limb movement disorder
Brief muscle twitches, jerking movements or upward flexing of feet in clustered episodes lasting minutes to hours, most of time cause is unknown, may occur along RLS and only treated when co-occurring, thought to be potentially due to kidney disease, DM, anemia, etc
REM behavior disorder
Occurs when patient acts out dreams, other parasomnias may mimic so need eval at sleep center with polysomnogram, possible link to parkinsons
REM behavior disorder treatment options (3)
- clonazepam
- antidepressants
- melatonin
Questions in a patient that has depression (4)
- have they attempted before?
- do they have a plan?
- how likely it is they will act on thoughts?
- anything that would prevent?
Mild cognitive impairment (MCI)
Cognitive decline greater than expected for an individuals age and educational level but not interfering with activities of daily living, may represent transition between normal aging and earliest stages of dementia
Pathophysiology of dementia (4)
Unknown but few contributing factors
- degeneration of neurons (hippocampus for memory particularly short term, cerebral cortex for functioning and speech)
- Reduced cholinergic transmission (low acetycholine in the hippocampus, very low in advanced stage)
- Neuritic plaques and beta amyloids (form outside of neurons and all hallmark found upon autopsy)
- neurofibrillary tangles and tau (hallmark feature of Alzheimer disease where tangles form inside neurons result from disruption of orderly arrangement of microtubules)
- homocysteine (formed from dietary methionine, increased risk of alzheimar’s disease occurs in those with elevated plasma levels - believed to promote atherosclerosis or direct injury to nerve cells, risk reduced by eating foods or taking vitamin supplements
Amyloid hypothesis
Amyloid protein deposition in the brain is associated with alzheimers dissease pathology and a decline in cognitive function, toxic to hippocampus and when injected directly into brain produce condition identical to alzheimer’s disease but only in old age not young so aging must make brain more susceptible
4 cholinesterase inhibitors approved by FDA for treatment of mild to moderate alzheimer’s disease, effectiveness
- tacrine (cognex)
- donezepil (aricept)
- rivastigmine (exelon)
- galantamine (reminyl)
Treatment can produce clinically significant improvement but modest effects at best so guidelines do not recommend drugs for all patients, use of anticholinergics can blunt their effect
Tacrine (cognex) mech of action
centrally acting noncompetitive reversible cholinesterase inhibitor, can also block reuptake of dopamine, seratonin and norepi
Tacrine (cognex) ADR’s
-increase in serum alanine aminotransferase in almost 50% of patients, requiring LFTs as it can cause focal necrosis and hepatitis while being used
Donezepil (aricept) function
Acetycholinesterase inhibitor used for treatment of severe alzheimar’s disease, high degree of selectivity in CNS with little peripheral activity, has long half life and can be dosed once daily and has no major interactions with minimal ADR’s (no hepatotoxicity, only really weight loss and nausea) unlike tacrine making it a preferred agent
Rivastigmine (exelon) function
Acetycholinesterase inhibitor used for treatment of severe alzheimer’s disease similar to donezepil in that it has no major ADR’s but is unique in that it can be applied as a patch opposed to oral
Memantine (namenda) drug class, mech of action, function, ADR (1)
- NMDA receptor antagonist
- modulates action of glutamate (excitatory CNS neurotransmitter) by blocking NMDA receptor and therefore blocks calcium influx when extracellular glutamate is low but allows influx when extracellular glutamate is high (improves memory by allowing signaling when it is necessary and not small constant releases of glutamate causing continued entry of calcium which negatively impacts memory)
- approved for treatment of moderate to severe alzheimer’s disease, causes modeset effects that can slow decline in function and may cause symptoms to improve
- well tolerated, can cause confusion and hallucinations
Antipsychotics use in dementia patients (2) and ADR (1)
Used to treat agitation, although not FDA approved, atypical 2nd gen (risperdone and olanzapipne) generally prescribed because of decreased risk of extrapyramidal effects
-increased risk of death for unknown reasons in elderly
How does age alter oral absorption?
It generally doesn’t in absence of malabsorption syndromes
Volume of distribution and its impact in the elderly drug distribution
Theoretical space in a given patient that a drug occupies, significantly affected by relative proportions of lean body mass vs fat, as we age see fat increase relative to lean mass, as a result lipid soluble drugs will have a greater Vd than water soluble drugs which have smaller, medications that are water soluble tend to see higher conc per dose resulting in more intense effects, while fat soluble tend to sequester into fat prolonging half life and decreasing intensity of effects
Metabolism of drugs in the liver and its impact on the elderly
Hepatic blood flow decreases steadily by age, can decrease significantly first pass effect and can see increased activity per unit dose in older patient
Protein binding of drugs and its impact on the elderly
Not clinically significant changes in healthy elderly but those with severe chronic disease or malnutrition - hypoalbuminemia becomes relevant when considering drugs that are highly bound to protein, because fewer binding proteins increases plasma conc. and increases intensity of effects to potentially toxic levels
Excretion of drugs and its impact on the elderly
Renal drug excretion undergoes progressive decline from adulthood onward, coexistence of renal pathology can further compromise function, renal functioning should be assessed in nephrotoxic drugs (creatinine clearance huge for this)
Chronic pain definition
Unpleasant sensory and emotional experience associated with actual or potential tissue damage who have pain for 3-6 months or more than expected
Pharmacodynamic vs pharmacokinetic
What the drug does the body vs what the body does to the drug
Nociceptive pain vs neuropathic pain
Nociceptive is either visceral (internal) or somatic (muscles and skin) due to stimulation of pain receptors resulting typically from injury or arthritis and is treated with both opioid and nonopioid agents, vs neuropathic is disturbance of either peripheral or central nervous system resulting in dysethesias and is treated with adjuvant agents such as anticonvulsants or antidepressants
Analgesia ladder
- acetaminophen
- NSAIDs
- Codeine, hydrocodeine in combo with acetaminophen
- morphine, hydromorphine, fentanyl
Pallliative care
Combination of physical, spiritual, and psychological approaches providing relief from symptoms and stress of illness with goal being to improve quality of life for patient or family, occurs ALONGSIDE treatment (unlike hospice when we stop treatment and just alleviate pain to impending death), will not hasten death!!!
Broca’s aphasia
Classically localized to regions affecting the frontal lobe, characterized by nonfluency and sparse output, comprehension is relatively spared but getting words out is challenging
