Risk Assessment, Prevention, & Wellness (5%)

Question 1

Advanced care planning

Answer 1

 Advance directives – durable statements of intent based upon the patient’s last written wishes
 Power of Attorney – authorizes another person to make decisions regarding health care when the patient is no longer able
 Living will – states the types of interventions a patient would want in a critical illness and names a surrogate decision maker

Question 2

Primary prevention

Answer 2

• Preventing the health problem
• Most cost-effective form of healthcare
• Ex: immunizations, counseling about safety, injury & disease prevention, smoking cessation

Question 3

Secondary prevention

Answer 3

• Detecting disease early, asymptomatic, or pre-clinical state to minimize its impact
• Ex: screening tests (BPs, mammography, colonoscopy)

Question 4

Common screening recommendations

Answer 4

• PAP smear – starts at age 21, every 3 years after age 21 if normal (can stop at age 65)
• Mammogram – age 40 years, unless presence of risk factors
• Colorectal screening – age 50 unless presence of strong risk factors (can stop around age 75)
• Bone density – all women > 65
• Prostate specific antigen – males, aged 50

Question 5

Protein status labs

Answer 5

• Serum albumin: reflects nutritional status for previous 1-2 months
• Serum transferrin: reflects nutritional status for previous few weeks
• Serum pre-albumin: reflects nutritional status for previous week

Question 6

Nitrogen balance

Answer 6

• An estimate of nitrogen in vs. nitrogen out
• Reflects immediate nutritional status
• Neural balance = burning off all nitrogen going in
• Negative balance = burning off more than going in, a malnourished state
• Positive balance = burning off less than going in, have protein reserve

Question 7

Calculating caloric needs in an acutely ill patient

Answer 7

• Harris-Benedict Equation is more precise but more complicated
• Basic method is an estimate but very close to Harris-Benedict
• All patients: 25-30 kcal/kg/day
• Moderate illness, injury or malnutrition: 30-35 kcal/kg/day
• Critical illness or injury: 35-40 kcal/kg/day

Question 8

To use parenteral nutrition or enteral nutrition?

Answer 8

• First determine if you can use the gut or not and how long you are expecting to need nutritional support
• If you can use the gut and need support for > 6 weeks = enterostomal tube
• If you can use the gut, need support for < 6 weeks, and there is no risk for aspiration = nasogastric tube
• If you can use the gut, need support for < 6 weeks, and there is a risk for aspiration = duodenal tube
• If you can’t use the gut and need support for < 2 weeks = use peripheral vein (VPN)
• If you can’t use the gut and need support for > 2 weeks = use central vein (TPN)
• Remember, the complications of enteral feeding are r/t the solution (DIARRHEA) and complications of parenteral feeding are r/t delivery method (LINE INFECTION, thrombosis, embolism)

Question 9

Minimum exercise requirements

Answer 9

 Aerobic exercise – 150 minutes of moderate-intensity or 75-minutes or high-intensity aerobic exercise (or a combination)
 Muscle strengthening – perform activities that maintain or increase muscle strength at least twice weekly

Question 10

Contraindications to exercise

Answer 10

	Progressive worsening of exercise tolerance or dyspnea at rest over previous 3-5 days 
	Ischemia at low exercise threshold 
	Uncontrolled diabetes 
	Acute systemic illness and/or fever
	Recent embolism (< 4 weeks)
	Valvular heart disease requiring surgery
	MI (< 3 weeks ago)
	New-onset A. fib

Question 11

Organ systems most affected by age-related decline

Answer 11

 Neurological
 Cardiovascular
 Musculoskeletal
 Lower urinary

Question 12

Falls

Answer 12

• Multiple falls are associated with increased risk of death
• Age-related risk factors – female, chronic medical conditions, cognitive impairment, ADL dependence, impaired vision/hearing, polypharmacy, environmental hazards
• Biggest risk factor = previous falls
• Assessment of patient post-fall (history) – what were they doing when they fell, was there an aura, did they have vision loss, did they lose consciousness, what medications they are taking, have they fallen before, etc.
• Assessment of patient post-fall (exam) – vital signs, orthostatics, CV assessment, sensory assessment, gait and balance assessment
• Non-pharm interventions – review medications, prevent/treat osteoporosis, proper footwear, obstacle free/well-lit environment, raise chair heights, add arm rests, PT (if indicated)

Question 13

Maltreatment (e.g., abuse, neglect, etc.)

Answer 13

 Theories of elder abuse – cycle of learned violence, caregiver stress, pathophysiology of abuser (psychological abuse, substance abuse, etc.), and physical/mental impairment of the elder
 Suspicious indicators – description of injury not consistent with physical findings, hx of similar injuries, frequent ER visits
 Emotional indictors – appears afraid, avoids eye contact, “flinches” when you reach out to touch them, withdrawal from social activities
 Physical evidence – bruises, scratches, burns, lacerations in unusual locations, injurious in various stages of healing, misuse of medications, untreated medical needs

Question 14

Overall leading causes of death

Answer 14

 First – heart disease
 Second – malignant neoplasms
 Third – chronic lower respiratory diseases (COPD, pneumonia, flu)

Question 15

Leading causes of death for 15-34 year olds vs. 65+ year olds

Answer 15

 15-34 year olds – 1st = unintentional injury; 2nd = suicide; 3rd = homicide
 65+ year olds – 1st = heart disease; 2nd = malignant neoplasms; 3rd chronic lower respiratory diseases (COPD, pneumonia, flu)

Question 16

US suicide statistics

Answer 16

 Men complete suicides more often than women (17.7 vs. 4.6 per 100,000)
 Among all ages and genders, elderly men have the highest suicide rate (29.0 per 100,000)

Question 17

CAGE Questionnaire

Answer 17

 C – have you ever felt like you out to CUT down on drinking?
 A – have people ANNOYED you by criticizing your drinking?
 G – have you ever felt bad or GUILTY about your drinking?
 E – have you ever had a first drink in the morning to steady your nerves (EYE-opener)?
 If patient answers “yes” to at least 2 questions, there is a high specificity and senstivitiy that the patient has a problem with alcohol