Study Guide Q's: Medically Complex Older Adults Flashcards
what are caregiver stressors? (4 areas)
-
Physical health
- Physical strain
- Injuries from lifting
- Transferring
- Repetitive actions
- Caregivers may neglect their own health
-
Psychological health/QOL
- Emotional distress (depression, anxiety)
- Nearly 50% report emotional difficulty
-
Social well being
- Reduced access to social network
- Decreased conflict resolution
- Reduced time for leisure and social pursuits increases emotional stress
- Potential for family conflicts
-
Economic well being
- Direct cost of caregiving
- Taking on debt
- Financial strain
- Nearly 40% of caregivers report moderate to high degree of financial strain
PT considerations for caregiver stressors
- Physical health: assess home environment and abilities and safety of caregiver
- Psychological health/QOL: use caregiver burden scales or open conversation about stress levels
- Social well-being: use caregiver burden scales or open conversation about stress levels
- Economic well-being: access community resources
- Overall: provide resources to help caregivers cope with stress, identify community resources
- CARE Act (Caregiver Advise, Record, Enable)
- Caregiver intervention programs
- Professional support
- Psychoeducational
- Behavior management/skills training
- Counseling/psychotherapy
- Self-care/relaxation techniques
- Environmental redesign
- Programs can also extend to help bereavement adjustment
caregiver burnout
what does it increase risk for?
- Definition: state of physical, emotional, and mental exhaustion and distress that may include depression, agony, anxiety, etc.
- Burnout syndrome: emotional exhaustion, depersonalization, reduction in personal fulfillment
- Effects
- Interferes with quality of care
- Risk of mental/physical problems for the caregiver
- Early patient institutionalization
- Increased risk for abuse
complete an efficient chart review
- Chart review:
- Summary of why the patient came to the ED
- PMH
- Past surgical history
- Medications
- Lab values
- Diagnostics (xray, MRI, CT, ECG)
- Other provider notes (OT, SLP, MD, OR reports, etc.0
- Note: You may also see complex patients in outpatient settings
coronary heart disease effects (8)
- elevated LDL’s
- Elevated total cholesterol
- Systolic hypertension (if untreated LV hypertrophy)
- Increased arterial stiffness and ventricular wall thickening
- Endothelial dysfunction –> vascular constriction
- Changes –> reduced EF increased O2 demand –> ischemia
- Physical inactivity + excessive caloric intake + decreased muscle mass + decreased metabolic –> obesity
- physical inactivity –> activity intolerance –> functional limitations
coronary heart disease comorbidities (5)
- obesity
- DM
- Cancer (CA)
- Atherosclerosis
- Mortality and decreased life expectancy
coronary heart disease standards of diagnosis
- what is the gold standard diagnosis?*
- what range do you want cardiac enzymes in?*
- troponin, CK, BNP*
- What are the most common meds? (5)*
- gold standard diagnostics
- graded exercise testing
- cardiac cath
- cardiac enzymes
- troponin: <0.1-0.3 ng/mL
- CK 0-3 ng/mL
- BNP <100 ng/mL
- Common meds
- diuertics
- beta blockers
- CCB
- ACEi, ARBs
- Statins
acute coronary syndrome definition
- What leads to ACS?*
- What 3 things does it include?*
CAD -> ischemia -> ACS
Definition: severe imbalance of O2 demand and supply
Includes: unstable angina, NSTEMI, STEMI
Acute coronary syndrome comorbidites (3)
concomitant increased risk for
- respiratory failure
- syncope
- stroke
Heart failure effects
- what is the leading cause? Second leading cause?*
- List 4 general symptoms.*
- pump dysfunction –> metabolic needs unmet
- leading cause: ischemic LV dysfunction due to CAD
- Second leading cause: HTN
S&S:
- fatigue
- SOB
- decreased activity tolerance
- mixed L and R S&S
Heart failure comorbidites (3)
associated with structural defects:
- valvular disease
- CAD
- HCM
Heart failure standards of diagnosis
- what 8 things should you assess for?*
- what are 4 common meds?*
asesses for:
- pitting edema
- JVD
- Adventitious breath sounds
- Dyspnea
- Orthopnea
- Tachypnea
- Desaturation
- BNP values
Common Meds:
- Diuertics
- ARNI’s
- Anti-HTN
- Digoxin
pitting edema scales
0: normal
1: barely perceptible
2: rebounds in <15 seconds
3: rebounds in 15-30 seconds
4: rebounds > 30 seconds
pulse pressure
what is normal and what requires medical attention?
- systolic – diastolic BP
- Normally 40mmHg
- >60mmhg requires medical attention
Orthostatic hypotension
20mmhg in SBP, or 10mmHg drop with increased HR
response to exertion (HR, BP)
- Normally HR increases 10-20 BPM per MET level
- Normally BP increases 10-12mmHg
recovery from exerrtion HR response
what does reflexive HR after exercise indicate?
- Within the first minute, there should be a significant decrease in BP and HR
- Reflexive HR increase suggests venous pooling or orthostasis
diagnosis of pneumonia (5)
- Chest x-ray
- Positive findings or infiltrates or consolidation
- Elevated WBC count
- Desaturation of SaO2 even at rest
- Chest pain, pleuritis
common meds for pnuemonia (3)
- Antibiotics
- Antivirals
- Oxygen
regular nasal cannula LPM and FiO2
LPM: 1-6
FiO2: 24-44%
High flow nasal cannula LPM and FiO2
LPM: up to 60
FiO2: Up to 100%
Partial rebreather mask LPM and FiO2
LPM: 6-10
FiO2: 60-80%
Non rebreather mask LPM and FiO2
LPM: 10-15
FiO2: 60-80%
Salter high flow nasal cannula
LPM: Up to 15
FiO2: 54-75%
pulmonary PT considerations
- what is the average respiratory rate (breaths/min)
- What is the inspiratory/expiratory ratio
- what ratio suggests hyperventilation/decreased PaO2 and what 2 conditions might cause this?
- What ratio suggests hypoventilation/increased PaO2 and what condition might cuase this?
- How many syllables per breath at rest?
- What is the error rate for a pulse ox? What is the best place to use it?
- Observations for the PT
- Respiratory rate
- Average is 12-20/min
- Inspiratory: expiratory ratio
- Normally 1:2
- 1:1 suggests hyperventilation and decreased PaO2 (anxiety, uncontrolled DM)
- 1:3 suggests hypoventilation, increased PaCO2 (hypoxia)
- Observe expansion of chest walls in all directions
- Speech
- Should have 12-15 syllables per breath at rest
- Pulse ox
- Up to 5-6% error rate
- Accuracy decreases in dark pigmented patients
- Earlobe is the most accurate placement
- Auscultation
- Normal vs. adventitious sounds
- Respiratory rate
UTI PT considerations
- what percent of nursing home infections does this account for?*
- What is the primary cause in older women? Older men?*
- How does a UTI present symptom wise in older adults?*
- Accounts for 1/3 of infections in nursing home residents
- Causes
- Primary cause: urinary stasis
- Older women
- Decreased pelvic floor strength
- Decreased estrogen levels
- Older men
- Decreased bladder emptying due to BPH
- Older women
- Indwelling catheter
- Primary cause: urinary stasis
How does this often present in an older adult?
- S&S not always the same as in younger patients
- Big change in older adults is acute delirium
Sepsis definition
what is it is the leading cause of?
- Definition: life threatening organ dysfunction caused by a deregulated host response to infection
- Leading cause of hospitalization and most expensive inpatient condition
Pathophys of sepsis
- Differentiated from infection by a dysregulated host response that results in organ dysfunction
- Loss of adaptive homeostasis in response to infection
- High degree or mortality risk with organ dysfunction
- Urgency for early recognition of sepsis and prompt restraint
- Anti-inflammatory response fails to develop
- Proinflammatory process becomes unregulated
- Results in a cascade of dysfunction
- Increased microvascular permeability with transduction into the organs
- Platelet sludging –> capillary blockage, ischemia
- Reperfusion injury
- Dysregulation of vasodilatory and vasoconstrictive mechanisms
- Maldistribution of blood flow –> shock
- Immunosuppression from excessive anti-inflammatory response
Organ failure –> multiple organ dysfunction syndrome
S&S of Sepsis
- lactate level?
- HR?
- RR?
- 3 other things?
- Lactate >18mg/dL
- Hypotension
- Fever >103 degrees
- HR >90 BPM
- RR >20 breaths/min
- Often confirmed infection from culture
clinical manifestations of sepsis
- CV (5)
- Pulmonary (4)
- CNS (3)
- Renal (2)
- GI (2)
- Hepatic (3)
- Hematologic (4)
-
Cardiovascular
- Hypotension
- Tachycardia
- Elevated CO (drops with septic shock)
- Systemic vascular resistance drops with septic shock
- Hypoperfusion exacerbated -> lactate accumulation
-
Pulmonary
- Tachypnea
- Hypoxemia (VQ mismatch)
- Respiratory alkalosis
- Pulmonary edema and respiratory failure -> ARDS
-
CNS
- Altered mental status
- Encephalopathy
- Polyneuropathy
-
Renal
- Oliguria (abnormal low urine production)
- Azotemia (elevation in BUN & serum creatinine)
-
GI
- Impaired motility
- Stress ulceration
-
Hepatic
- Elevated serum transaminase
- Hyperbilirubinemia
- Final stages: hepatic insufficiency
-
Hematologic
- Leukocytosis
- Multifactorial edema
- Thrombocytopenia and coagulation abnormalities
- Disseminated intravascular coagulation (DIC) is a late stage manifestation that carries poor prognosis
progression of sepsis to septic shock
sepsis –> severe sepsis –> septic shock
septic shock criteria definition and mortality
- what type of hypotension?*
- What blood lactate volume?*
- Definition: abnormal circulatory and cellular metabolism profound enough to significantly increase mortality
- Criteria
- Persisting hypotension that requires vasopressors to maintain MAP at 65mmHg or greater
- Blood lactate >2mmol/L despite volume resuscitation
- Mortality is 4x greater than when these criteria are met
implications for PT regarding sepsis
- Sufficient evidence shows PT can be initiated in ICU/acute care once patient is medically stable (patients can safely respond to increased vascular and oxygen demands of physical exam and treatment)
- Patient status can fluctuate daily, hourly, and by the minute
- Response dependent management
- Required moment to moment interpretation of patient response
- Delivery of oxygen must match oxygen consumption
Dizziness sources
- Vestibular
- Vertigo is the most common cause in older adults
- BPPV
- Cardiac origin
- Syncope is more often the symptom than dizziness
- ECG and Holter to monitor cardiac dysfunction
- Echocardiogram to monitor blood flow
- Orthostatic hypotension
- Take positional BP to rule in or out OH
- Medications
- Antihypertensives
- Diuretics
- Sedatives
how to determine source of dizziness
- How to determine
- Ask the right questions
- What brought on the dizziness?
- What were you doing when you got dizzy?
- Has it happened before?
- Did you fall?
- Comorbidities
- DM
- Cardiac
- Medications
- Anything that causes dizziness
- Vitals
- Check positional BP
- Sensory assessment
- Vision
- Somatosensory
- Vestibular
- Nutritional status
- Malnutrition
- Dehydration
- Ask the right questions
causes of dehydration in the older adult (4)
- Blunted thirst mechanism
- Reduced total body fluid (decreased muscle mass, including body fat)
- Decreased renal function
- Physical/mental decline
risk factors for dehydration in older adults (8)
- Advanced age
- Female gender (including % body fat)
- BMI <21 and >27
- Dementia
- History of CVA, UI, infections
- Use of steroids
- Polypharmacy
- Decreased functional independence
S&S dehydration (4)
- Confusion
- Lethargy
- Rapid weight loss
- Functional decline
Examination vs. Clinical Signs and Symptoms for Dehydration
What are the three types of dehydration?
Hypertonic dehydration
Isotonic dehydration
Hypotonic dehydration
hypertonic dehydration
water > Na+ loss
caused infection or hot temp
isotonic dehydration
water = Na+ loss
caused by vomitting or diarrhea
hypotonic dehydration
water < Na+ loss
caused by diuertics (most common cause in the older adult)
what is metabolic syndrome?
what are the risk factors for it? (5)
- Insulin resistance syndrome
- Definition: Vicious cycle of obesity, decreased insulin sensitivity, higher levels of blood glucose, release of more insulin, elevated free fatty acids, reduced glucose oxidation, increased production of LDLs (elevates triglycerides and decreases HDLs)
- 3 or more CV risk factors
- Abdominal obesity
- High triglycerides
- Decreased HDLs
- Increased BP
- High fasting glucose
How is metabolic syndrome diagnosed?
PT implications for metabolic syndrome
- Affects 30% of the US population
- Increased incidence of T2DM and CV events
What are the 5 phenotypes of fraility?
- Weight loss
- Fatigue
- Low physical activity
- Slow gait speed
- Weakness
Weight loss fraility phenotype
lost greater than 10 lbs uninentionally
measured via scale or self report
fatigue fraility phenotype
exhaustion with regular activity
measured by series of questions, 0-6 scale with higher score indicating fatigue
Low physical activity fraility phenotype
sedentary behavior
< 383 kcal/week for men, <270 kcal week for women
measured by sedentary activity pattern captured via series of questions
Slow gait speed fraility phenotype
usual pace over 15 feet
generally: less than 0.8 m/s
0. 65 m/s or less (W<159 cm or M<159 cm or M>173 cm)
weakness fraility phenotype
grip strength less than 30 kg for men and less than 20 kg for women
sit to stand: less than 8 in 30 seconds
fraility index tool
what does a score of >0.5 mean?
- Considers the number of deficits accumulated over time
- Disability
- Diseases
- Physical and cognitive deficits
- Psychosocial risk factors
- Geriatric syndromes (falls, delirium, UTI, etc.)
- 70 items
- Score of >0.5: 100% dead in 20 months
fraility index for elders tool
- Self report
- Scores
- 0 yes answers = no frailty
- 1-3 yes answers = frailty risk
- ≥4 yes answers = frailty risk
- 3 criteria: gait speed, grip strength, and repeated chair stands
- All predictive for frailty and 6 month mortality
- Gait speed greatest indicator for multidimensional frailty
- Scores
- Gait speed
- Grip strength <25kg = 6x more likely to be frail
- Chair stands <7x in 30 seconds = 14x more likely to be frail
TUG score for fraility
more than 10 seconds
gait speed for fraility
less than 0.8 m/s
Life Space measure for fraility
<60 points indicates 4.4 higher risk of SNF placement during subsequent 6 years
Fit (not frail) description
physically active
no restrictions
few chronic conditions, if any
fit (not frail) functional characteristics
Gait speed > 1.0-1.2 m/s
30s CRT with 15 reps or more
independent floor transfer
mild fraility/pre frail description
adaptions to mobility
life space mobility restricitons start
impaired recovery from illness/injury
functional charactersistics of pre-frail
gait speed 0.8-1.2 m/s
30s CRT, 8-15 reps
Modified floor transfer
moderate fraility functional description
loss of independence evident, needs assistance, life space restrictions
moderate fraility functional characteristics
gait speed 0.5-0.8 m/s
30s CRT <8 reps
assistance for floor transfer
severe fraility (end stage) description
dependent ADL’s/mobility
inactive/dying
life expectancy 6-12 months
severe fraility functional characteristics
gait speed <0.5 m/s
30s CRT unable
floor transfer unable
be able to apply this diagram to a clinical scenario
pathophys of fraility characteristics (7)
- Pro-inflammatory state
- Blunted immune response
- Autonomic dysfunction
- Kidney dysfunction
- Anemia
- Malnutrition
- Endocrine dysfunction
etiology of fraility
- Multifactorial
- Genetic
- Environmental
- Metabolic
- Lifestyle stressors
- Acute and chronic diseases
- Result in multisystem impairments across multiple physiologic systems
- Impaired homeostatic mechanisms
how does fraility look across the ICF model?
treatment parameters for a pre-fail adult vs. frail adult picture
exercise parameters for a frail adult
- Progressive resistance exercise is a key component for treating frailty
- Reduces biological age
- Addresses sarcopenia
- 12 week programs can show significant gains
- High intensity effort is key
- 40-80% 1RM
- 8 reps for 1 set , working up to 3 sets
- LE exercises are a priority over UEs
- Also include core
- Don’t forget power and agility
functional training for the frail adult
- Floor transfers
- Learning to get up from the floor requires practice
- Every patient returning home should learn this skill
- Reduces risk of serious adverse health outcomes
what other interventions might be used to treat fraility? (3)
nutrition
hormone therapy
pharm
nutrition to treat fraility
- Mini Nutritional Assessment
- Screen for weight loss
- Screen for underlying cause
- EEA supplementation
- Vitamin D supplement
hormone treatment for fraility
- SARMS and testosterone may treat sarcopenia
- Results still inconclusive
pharm to treat fraility
- Medication review essential
- Deprescribing
- Statins
- Glucocorticoids
- Anticholinergics
- Benzodiazepines
- Vitamin D: 800-1000 IUs/day
primary prevention of fraility in the context of the triple Aim
- Regular engagement in moderate to vigorous physical activity
- Cognitively stimulating activities
- Healthy diet and supplementation as needed
- Ideal sleep
- Maintaining proper body weight
- Metabolic control (blood sugar, blood pressure, blood lipids)
secondary prevention of fraility with the Triple Aim view in mind
- Use assessment tool to identify key underlying deficits
- Implement a multimodal approach
- Medication management
- Falls prevention
- Nutritional support
- Social/psychological support
- Exercise program
prevalance, cause, risk factors for osteoporosis
- Prevalence
- 12.6% of older adults over 50
- 10 million affected in the US
- Causes
- Primary: postmenopausal or idiopathic
- Secondary: following disease condition
- Risk factors
- Post menopausal (estrogen deficiency)
- Other hormonal factors
- Hyperparathyroidism
- Cushing syndrome
- Sedentary lifestyle
- Vitamin D deficiency
- Cigarette smoking
- Asian or Caucasian
- Excessive caffeine consumption
what is the difference between osteoporosis and osteopenia?
- Osteopenia: low bone density that compromises the bone’s ability to absorb loads (lower than normal, but not as low as osteoporosis)
what are T scores?
- T scores
- WHO diagnostic classification in postmenopausal women or men over 50
- Cannot be applied to young population
- From Google: Your T-score compares your bone mass to that of a healthy young adult. The “T” in T-score represents the number of standard deviations, or units of measurement, your score is above or below the average bone density for a young, healthy adult of your same sex.
pharm treatments for osteoporosis
- Vitamin D + calcium
- Ca+ at least 1000mg
- Postmenopausal 1500mg
- Vitamin D 800-1000 IU
- Ca+ at least 1000mg
- Fluoride supplements
- Promotes bone deposition
- Bisphosphonates
- E.g. alendronate (Fosamax)
- Calcitonin
- Secreted by a thyroid gland to lower blood calcium
- Injected human parathyroid hormone
- Decreases bone resorption
- Raloxifene (Evista)
- Selective estrogen modulators
- Other: surgery to reduce kyphosis, realign vertebrae
Develop PT treatment plan that can safely build bone density or prevent bone fractures in individuals with osteoporosis vs. osteopenia.
- Regular weight bearing activities
- Appropriately dosed strength training
- Exercises to build bone strength
- Standing / WBing exercises
- Strengthening, flexibility, and balance activities
- *Dosage depends on degree of bone loss and level of fitness
- Exercises to avoid
- Trunk flexion and excessive rotation
- High impact exercises
- Joint mobilizations/manual percussion
- Patient education
- Customized exercise program to promote strength while minimizing the risk of injury
- Nutrition: calcium and vitamin D
- Fall reduction
- Appropriate use of AD
- Home assessment
- Medication review
