Test 1 Flashcards
What is the current fastest growing group among the elderly in percentage of growth?
85 years and older
Match correctly demographic group with the correct age: Young old?
65 to 74 years
Which of the following is most commonly reported as the largest single source of income for elderly people?
Social Security
What group of elderly is the poverty rate in the US the highest?
Highest among the old old
What is the leading cause of death in the US for those between the age of 45 and 84 in 2020?
Heart disease
In 2020 COVID was the _______ leading cause of death in the general population?
Third
Which of the following is not part of the “Rule of Fourths”?
Age
Explain the “Rule of Fourths”
The decline in normal function seen as people age
1/4 due to DISEASE
1/4 due to DISUSE
1/4 due to MISUSE
1/4 due to PHYSIOLOGIC
What is true regarding diagnostic testing?
A test is ordered for a specific purpose. The NP should have a plan for the use of each test result value obtained
Why will Janey, 25 years old, experience arthritis differently than 65 year old Mrs. Johnson because:
The body undergoes physiological changes with aging
Knowledge of the bimodality of age onset of certain disease conditions will aid the advanced practice nurse in avoiding misdiagnosis or delay in diagnosis due to lack of recognition
Is loss of low frequency sounds a normal physiologic change in the elderly
NO
The elderly lose the ability to hear high frequency sounds
The nurse practitioner is leading a class of seniors over age 65 years and is teaching about
nutritional needs. One of the men asks why, even though he eats correctly according to the standards presented, he still feels weaker than he did 10 years ago. He also wonders why he gets more infections than he used to. Which of the following are helpful answers? Select all that apply.
- Some people experience a decrease in reserve energy.
- For some people, the immune system weakens.
Jean is a lung cancer patient given 2 to 3 years of survival. Her condition is up and down. Which of the following types of care is indicated for the patient?
Palliative care
Describe palliative care
Palliative care is an interdisciplinary approach to care aimed at improving the quality of life of patients and their families facing a life-threatening illness.
Which of the following is not a future demographic trend among the elderly?
The share of the older population that is non Hispanic white is projected to drop by 5 percentage points
Life expectancy started dropping in 2014 due to what?
Unintentional overdoses
What is the annual limit for poverty in the US
$12,760
What is the typical living arrangements among Americans ages 65 and older?
Living with spouse
Why is it so important to know that older women are more likely to live alone than men? impact?
Lack of social support increased loneliness, and leads to increased risk of health complications r/t poor eating, risk of addiction, lack of exercise), cognitive disorders, depression, and anxiety, falls, elderly abuse, living in poverty
Knowing the increased risks associated with living alone what would you change in your approach as a NP?
-Screen, Screen, Screen (universally for fall, depression, cognitive disorders, elderly abuse, diet, exercise, compliance with trmt)
-Remember most of the elderly won’t report it for fear you might send them to a nursing home, yank their driving license, order expensive test they can’t afford, they might be ashamed, or feel it is part of growing old.
-Be proactive, establish trust and then screen, and act.
Single elder women = less incomes-> be judicious with your orders, make sure they can afford the treatment.
-Be a good primary care provider, only refer if you have to, Copays are much higher with specialists.
What do older adults fear the most?
Loss of independence
10 Common Chronic Conditions for Adults 65+
What are IADLs
What are IADLs?
1. actions are important to being able to live independently/autonomously but are not necessarily required on a daily basis.
2. The Instrumental Activities are not as noticeable as the Activities of Daily Living when it comes to loss of functioning. But functional ability for IADLs is generally lost before ADLs.
3. IADLs can help better determine the level of assistance needed by an elderly or disabled person.
Examples of IADSs
Basic communication skills
Transportation
Meal preparation
Shopping
housework
Managing medications
Managing personal finances
Do white men or black women have longer life expectancy?
Black women
What is the most common cause of death by injury in older adults?
Fall
Definition of ageism
The systematic stereotyping of and discrimination against people because they are old
What are Geriatric Syndromes?
Problems that are typically multifactorial in etiology and that therefore are rare in younger persons and common in the elderly.
7 Examples of Geriatric Syndromes.
Frailty, weakness, dizziness, confusion, gait problems, falls, and incontinence
What is the best approach for an NP regarding Slow Medicine
Slow medicine describes a philosophy and approach that applies the principle of beneficence (first do no harm)
The best ARNP is not the one who makes the most diagnoses, its the one who identifies and addresses the patients most important functional problems
What are some examples of potential icebergs.Or sx. an elderly patient believes in part of a normal aging process
Intellectual impairment
Immobility
Instability
Incontinence
Iatrogenic disorders
What are some physiological changes in the aging process?
Decreased muscle mass
Decreased water
Increased deep fat in elderly
Why is it so important to address the 5 “I” of geriatrics
Older person thinks it is part of aging
Older person is embarrassed to report the issue
Older person is not aware he/she has a problem
Can you provide one example of a rapid screen test for Functional status
Functional Status: Answer yes to one of the following: Because of a health problem, do you need help to: Shop? Do light house work? Walk across a room? Take a bath: Manage household finances? IADLs
Access all other ADLs for self-care (bathing, toileting, dressing, transfer bed to chair, grooming, feeding)
Instrumental: (use telephone, prep meals, manage finances, take meds, doing laundry, housework, shopping manage transportation)
Mobility: (walking inside/outside, climbing stairs, the Katz index tool)
Rapid Screen test for Mobility
“Time up and go” test: unable to complete in <16 seconds
Asses: Comprehensive M/S and neuro assessment. Manage: Treat underlying M/s and neuro assessment
Refer to PT
Rapid assessment for Nutrition?
Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2)
Asses: Mini Nutritional Assessment for older adults
Manage: Oral supplements, meals on wheel, appetite stimulant.
Rapid screen test for Vision?
Unable to read newspaper headline while wearing corrective lenses, unable to read greater than 20/40
Assess: Screen for common eye diseases of older patient: (cataracts, macular degeneration, glaucoma, diabetic retinopathy.
Manage: Refer to eye doctor
Rapid screen test Hearing?
Acknowledge hearing loss when questioned or failed the whispered test at a distant of 2 feet
Assess: Comprehensive HEENT exam
Rinne/weber test
Conductive/obstructive hearing loss
r/v med (Lasix, salicylates cause reversible hearing loss)
Manage: Refer to audiologist
Cognitive function rapid screen tests?
3 item recall: Unable to remember all 3 items after 1 minute
Assess: Administer Mini Cog or MMSE
Assessment for co-morbidities (infections, stroke, nutritional deficiencies and manage accordingly)
Depression rapid screen test?
PHQ2: Answer yes to either of the following:
In the past 2 weeks have you often be bothered by:
Feeling down, depressed or hopeless?
Having little interest or pleasure in doing things?
Assess: PHQ-9 or Geriatric depression scale
R/o other illnesses such as hypothyroidism, anemia, Vit d deficiency, recent loss,
Manage: Medication for depression
Refer for counselling.
Name the five I’s of geriatrics
- Intellectual impairment
- Immobility
- Instability
- Incontinence
- Iatrogenic disorders
What is included in a Comprehensive Geriatric Assessment
1.Focuses on elderly individuals with complex problems,
2.Emphasizes functional status and quality of life
3.Takes advantage of an interdisciplinary team of providers
4. Five I’s of geriatrics
Which of the following isnota risk factor for falling in community-living older adults?
Body mass index (BMI) of 25 kg/m2
Previous falls
Gait instability
Vision impairment
Age 85 year of age
A low BMI (less than 20 kg/m2) is a risk factor for falls in older adults. Having a normal weight (BMI 18.5-24.9) or being overweight (BMI 25.0-29.9) may decrease mortality in older adults.
Additional risk factors for falls include age older than 80 years old, female gender, previous falls, balance or gait impairment, decreased upper or lower muscle strength, visual impairment, medications (more than 4 total meds or use of psychoactive med use), depression, dizziness or orthostasis, functional limitations, urinary incontinence, cognitive impairment, arthritis, diabetes, and pain.
What are risk factors for falls?
Age older than 80 years old
Female
Lower body mass index (BMI) less than 20
Previous falls
Balance or gait impairment
Decreased upper or lower muscle strength
Visual impairment
Medications (more than 4 total meds or use of psychoactive med use)
Depression
Dizziness or orthostasis
Functional limitations
Urinary incontinence
Cognitive impairment
Arthritis
Diabetes
Pain
rs. Parsons is 75 years old and is anticipating renewing her driver’s license. The nurse practitioner conducts an eye examination and is concerned to find which of the following? Select all that apply.
1. Visual acuity better than 20/20.
2. Visual acuity worse than 20/40.
3. Abnormality in the six cardinal fields of gaze.
4. Ability to gaze downward.
5. Confrontation test with deficit R>L
Visual acuity worse than 20/40 - Visual acuity of worse than 20/40 suggests weakness in the ability to see.
Abnormality in the six cardinal fields of gaze - Abnormality in cardinal fields of gaze may indicate a neurological condition.
Confrontation test with deficit R>L - Abnormal Confrontation test= deficit in the peripheral visual field, indicative of glaucoma.
What are some ADL’s
- Basic self-care.
- Mobility.
- Continence.
What is most affected by pharmacokinetic change?
Elimination of drugs
What is related to the incidence of gastric acidity declining with age because of decreased intestinal blood flow?
Drug absorption
Drug absorption is affected when gastric acidity declines with age because of decreased intestinal blood flow and fewer absorbing cells in the gastrointestinal (GI) tract. It is also affected with the presence of food and other drugs in the stomach at the same time.
Name an intervention to secure the safe and optimization of pharmaceutical management in older adults?
CHECK FOR ALLERGIES TO MEDS AT EVERY VISIT.
*With each encounter, Update and reconcile the medication list
*Brown paper bag check at least annually
*Update pharmacy info if needed
*Check for the need for refills
*Reviewing medications: check about adherence and cognitive abilities (at least annually)
*Discuss method of medication administration (at least annually) and address if simplification (Extended release meds, combo meds) might help adherence.
*Scrutinize for problem medications:
*Not appropriate for the elderly
*Requiring lab follow up
How often should you do Brown Paper Bag?
At least annually ask patient to bring all his medications ( prescribed, OTC, herbals, supplements) to the office
What should be considered if a elderly patient has a new symptom?
HCP should consider any new symptoms in the elderly as a drug side effect until proven otherwise
What are guidelines for safe prescribing?
Creating an individualized plan
1.Patient life’s expectancy
2.Time till benefit from medication
3.Goal of care
4.Treatment targets
-Symptom-targeted approach
-Disease modifying approach
What should the decision making process be based on?
Beneficence and patient’s autonomy
First do no harm!
How do you optimize prescribing for older adults and medication adherence?
Consider any new sign and/or symptom in the elderly as a drug side effect until proven otherwise
START LOW AND GO SLOW
Try not to start two medications the same time
Search for one medication that might treat two diseases at the same time.
Administration time: Same as the other medication to increase adherence
Use of long acting meds if patient can afford the higher co-pay.
Assess patient and/or care giver knowledge regarding med.
What are some general guidelines for safe prescribing and medication adherence?
-Uses the correct drug
-Prescribes the correct dosage
-Targets the correct condition
-Is appropriate for the patient
Failure in any one of these
can result in adverse drug events (ADEs)
What is Beers Criteria
The Beers Criteria, defined inappropriate prescribing of medication as those drugs whose risks outweigh the benefits, namely as it relates to the geriatric population.
What was the Medication Appropriateness Test developed to address
Some of the weak areas of the Beers Criteria
What was the STOPP/START Criteria developed to determine?
The STOPP/START Criteria were developed to determine when medications should be added and when another might be discontinued for an older patient.
Does the HHS Guide to Geriatric Medications guide in medication prescribing?
NO
After examining Adam, who is 79 years old, the nurse practitioner uses which of the following criteria to adjust Adam’s medications?
Select all that apply
- The Beers Criteria
- Medication Appropriateness Index
- STOPP/START Criteria
What is the STOPP/START Criteria?
STOPP/START criteria
The Screening Tool of Older Person’s Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START)
—Both screening tools are intended to be used together
—Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE
—More thorough than BEERS, as it includes drug-drug interaction, and potential duplications
—Identify inappropriate prescribing, was introduced in 2008 and updated in 2015
STOPP:
Include a list of PIMs (Potentially inappropriate medications)
START:
Include PPOs (potential prescribing omissions)
What does STOPP/START detect?
Detect prescribing of P I M’s (prescribing inappropriate medications)
What does BEERS detect?
Inappropriate medications to be avoided in older adults
What is the STOPP/START criteria
STOPP/START criteria
The Screening Tool of Older Person’s Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START)
* Both screening tools are intended to be used together
* Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE
* More thorough than BEERS, as it includes drug-drug interaction, and potential duplications
* Identify inappropriate prescribing, was introduced in 2008 and updated in 2015
What is STOPP
Include a list of PIMs (Potentially inappropriate medications)
What is START
Include PPOs (potential prescribing omissions)
START CVS, Respiratory, CNS
START Gastro, Musculoskeletal, Endocrine
What is Prescribing Cascade?
When the side effects from one drug causes a new illness that has to be treated with another drug and then that process continues
What are some strategies to prevent prescribing cascade and polypharmacy
- Accurate medication reconciliation at each visit
- Always consider s/s as a potential drug adverse event and ID patient at high risk
- Define overall care goals in the context of life expectancy
- Awareness of the drug cost and other barriers to improve compliance
- Awareness of pharmacokinetics changes with aging
- Estimate the benefits vs harm in relation to each new medication
- Use of behavioral modifications and nonpharmaceutical approach to treat new conditions
- Keep up to date with guidelines
Prescribing Cascade
Mrs. Williams, an asymptomatic 80 years old, states my sister in law got COPD, and she is younger than me, so she asks you to order spirometry for herself. You explain that this test is likely not covered by Medicare because:
Medicare only covers tests that are approved according to the stringent guidelines of the U.S. Preventive Services Task Force (USPSTF).
* Grade A and B are covered by Medicare and on rare occasion with good documentation Grade C.
Screening tests NOT recommended by USPSTF
UPSTF recommends against screening on asymptomatic patient (grade D)
With this test
Asymptomatic bacteriuria - Urinalysis
Coronary artery disease - ECG, Treadmill test, or electron beam CT
Carotid artery stenosis - Duplex U/S
COPD - spirometry
Pancreatic cancer - U/s, abdominal palpation, or serologic markers
The focus of advanced nurse practitioners is to provide primary preventive service . This is defined as activities that focus on:
- Preventing the occurrence of a disease or condition.
What do primary preventitive strategies focus on?
Primary preventive strategies focus on immunization, well-checks, and other health maintenance activities. It is viewed as the most effective form of health care
Secondary preventive strategies focus on?
Secondary preventive strategies focus on screening, and detection of diseases before symptoms appear
Tertiary preventive strategies focus on?
Tertiary preventive strategies focus on rehabilitation management of existing conditions .
What do NP focus on?
Nurse practitioners focus on the wellness–illness continuum.
The focus of advanced nurse practitioners is to provide primary preventive service . This is defined as activities that focus on:
- Preventing the occurrence of a disease or condition.
Jack, 64 year-old reports a positive family history of colon cancer. He states “ half of my family died from colon cancer”. You decide to start him on a low dose aspirin to prevent colorectal cancer? What type of prevention is this intervention?
1- Primary
Pauline, 78-year-old was recently diagnosed with Rheumatoid arthritis. Her NP suggests her to join the local support group. A support group that allow members to share strategies for living well with RA is considered?
Tertiary prevention
What is Tertiary prevention
Tertiary preventionaims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include:
cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.)
support groups that allow members to share strategies for living well
vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.
Recommendations based on age and expeted risk/benefits include calculation of life expectancy
≥ 5 years of remaining life expectancy: Robust
Less than 5 years of remaining life expectancy and/or moderate dementia (2- 10 years of remaining : Frail
End of Life: <2 years of remaining life expectancy
Hospice < 6 months of remaining life expectancy to be eligible
What is the USPSTF stance on breast exams?
BTW the Task force recommend against self breast examination for all women.
USPSTF recommend biennial screening mammography for women aged 50 to 74. So IF Simone was robust with life expectancy above 5 years, she should get screened
Remember, it is not recommended, if after conversation with the patient she wants it, well you should order it . Respect for autonomy is key, but let’s say she was due for a colonoscopy, GI doctor might not want to put her under due to her frailty. And screen with FIT instead.
USPTSF Recommends: Strongly recommends screening for colorectal cancer starting at 50 till 75 years. With substantial benefits. What grade is this?
Grade A
USPTSF recommends against routine colorectal cancer screening in adults 75-85 year old, but clinicans may consider screening an individual patient based on professional judgement
Grade C
USPTSF recommends against routine papsmears in women screening who have had a total hysterectomy for benign disease
Grade D
USPTSF recommends biennial screening mammography for women 50-74 years. With a moderate benefits
Grade B
USPSTF Grade definitions
Mister Rolez, 72 yo, asymptomatic Latino male asking to be screened for prostate
cancer. His brother was diagnosed with stage IV prostate cancer, with bone metastasis to the bone. Which of the following answer provided is accurate?
The USPSTF recommend against PSA based screening for prostate cancer in asymptomatic males over the age 70.
Let say’s Mister Rolez, younger brother, Raoul, 64 yo Latino asymptomatic patient asked you the same question. What would be your answer for the brother?
“Let discuss your concerns first, then I let you know about the procedures risk and benefits, and we can decide to go ahead or not with the test”
Mrs. Charlston, 60 year-old Caucasian female admits: ‘I smoked on average 20 cigarettes for 40 years. I finally managed to quit 10 years ago”
What is her ppk/year history.
40 pack/year
How would you report it in your SOAP note.
40 pack/year. Quit 2011
Mrs. Charlston, 60 year-old Caucasian female admits: ‘I smoked on average 15 cigarettes for 45 years. I finally managed to quit 10 years ago”
Should he be screen for lung cancer?
1- No, she smoke less than 20 cigarettes and quit more than 5 years ago
2- Yes, she should be screened for the next 5 years with low dose CT
3- yes, all smokers regardless of ppk/year should be screen till they are 70 year old
4- NO, she is not a smoker anymore. She quits, her risks are back to normal.
Please update your lecture notes, USPSTF just updated their guidelines in 2021, just one change. Instead of 30 ppk/year limit, the upper limit is 20 ppk/year the rest is the same
Question: You see a 62 year-old women with a recent total hysterectomy with cervical removal. an no PMH of GU cancer. You recommend her next pap smear to be.
Neither now or in the future
Task force recommendations: 21 to 65 yo every 3 years. So if she had a total hysterectomy due to GU cancer, you will continue with the recommendation as if she still had a cervix. And stop as recommended
Adequate screening = Three consecutive negative cytology results or 2 consecutive negative HPV results within 10 years before cessation of screening, with the most recent test within 5 years
According to the updated 2021 USPSTF Guidelines for colorectal cancer. Screening could start for all patients at?
45 YEAR OLD
What are the new USPSTF colorectal screening guidelines?
Stool Based Test in screening for colorectal cancer
Screening Tests for Colorectal Cancer
Stool Based Tests: Bowel prep and anesthesia not required
Please note Stool based tests are not a replacement for direct visualization tests: Colonoscopy, Sigmoidoscopy.
High level of false positive which lead to unnecessary colonoscopy.
High sensitivity gFOBT: Every year (not the old hemoccult II)
FIT: Every year.
SDNA-FIT (Cologuard): Every 1 or 3 years
Direct Visualization Test aka colonoscopy
Direct visualization test:
colonoscopy every 10 years
Sigmoidoscopy every 5 years or Sigmoidoscopy every 10 years plus FIT every year
CT colonography every 5 years
Colon capsule: USPSTF no recommendation.: More research needed.
USPTSTF and American College of Gastroenterology recommend colonoscopy and FIT as the primary screening modalities for CRC screening.
Please note: For patients unwilling or unable to undergo colonoscopy (Make sure you chart accurately) you may consider Stool screening tests, CT Colonoscopy or Colon capsule. Please chart got chart. (ACG, 2021)
USPSTF Screening Guidelines for ETOH misuse is what grade in all adults 18+
Grade B
Providing behavioral counseling to reduce ETOH misuse in adults 18+ is what grade according to USPSTF?
GRADE B
How often should you ask a >65yo about their alcohol use?
Atleast annually
What is the ETOH guideline for an adult over 65
Adults over age 65 who are healthy and do not take medications should not have more than:
3 drinks on a given day
7 drinks in a week total (So about one drink daily)
Older adults are at risk for serious alcohol problems who drink more then recommended amount (NIH, 2018)
What is the AGS definition of high risk drinking?
American Geriatrics Society (AGS) has defined high-risk drinking as more than 3 drinks on heavier drinking occasions or more than 7 drinks per week for adults 65 and older
Alcohol content chart
Geriatric Lab Values & Interpretations of Hematology
A1C Goal in Geriatrics
GFR and Chronic Kidney Disease
Explaining GFR to a patient
Thyroid Fuction Tests
What are the risk factors to be diagnosed with metabolic syndrome
Metabolic syndrome
* Atleast three of the risk factors to be diagnosed with metabolic syndrome:
* A large waistline, which means a waist measurement of
* 35 inches or more for women
* 40 inches or more for men
* A high triglyceride level, which is 150 mg/dL or higher
* A low HDL cholesterol level, which is
* Less than 50 mg/dL for women
* Less than 40 mg/dL for men
* High blood pressure, which is a reading of 130/85 mmHg or higher.
* A high fasting blood sugar, which is 100 mg/dL or higher
What is considered underweight for an elderly patient?
BMI <20
What are some normal physiologic changes in the elderly
First, there is a reduced physiological reserve of most body systems, particularly the cardiac, respiratory, and renal systems. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there are the changes in the sympathetic response, which contribute to orthostasis and falls, as well as lack of hypoglycemic response. Fourth, there is impaired immunological function: infection risk is greater and autoimmune diseases are more prevalent.
Manifestations of disability
Ex of Disease-related disability
Exercise intolerance in a CHF patient
Manifestations of disability Disuse-related disability
Shortness of breath on exertion in a sedentary older person
Manifestations of disability
Misuse-related disability
Arthritis knee in a former football player
Manifestations of disability
Disability related to physiologic changes
Difficulties reading fine print
Tasks of the healthcare provider r/t Manifestation of Disability
- If problem is a disease -> medical treatment
- If problem is disuse -> Behavioral management
- If problem is misuse -> Prevent deterioration and preserve function
- If problem is physiologic aging -> assist with adaptation, and compensation for the disability
What is Reduced Physiological Reserve
Physiologic reserve – Definition
The remaining capacityof an organ or body part tofulfilits physiological activity; (especially) in thecontextof stress, disease,ageing, orimpairment.
Significant impairment from disease, disuse, misuse or physiologic aging result impaired functional reserve
What does depletion of physiologic reserve lead to
What does depletion of physiologic reserve lead to
Reduced homeostatic mechanisms
Leads to….
- Difficult to maintain a balanced physiologic environment.
- Delayed return to homeostatic state
- Impairment worsened during time of stress.
Reduced physiological reserve leads to
- Decreases ability to adapt to stress.
- More susceptible to disease
Presbycuccis
Presbycuccis: Loss of high frequency sounds starting at 55 yo.
CV changes in the elderly
- Cardiac functions no change at rest with normal CO and HR
- Cardiac reserve declines compromising ability to respond to stress -> decreased activity tolerance
- Baroreceptors (which stabilize blood pressure with activity) are less sensitive as one ages, which can lead to orthostatic hypotension.
Heart valve sclerosis - Increased vascular vessels thickness and stiffness -> diminished vessel compliance and greater systemic vascular resistance->elevated systolic with constant diastolic
Pulmonary system changes in the elderly
- Muscle strength and endurance deteriorate -> Less effective inspiration and expiration
- Decreased elasticity of lungs tissues and loss of elastic recoil, increased chest wall rigidity -> decreased vital capacity.
- Skeletal changes -> barrel chest -> increased residual volume
- Decreased number of alveoli-> decrease in oxygenation to the vital organs
- Decreased cilia, macrophages, cough reflex -> risk of infections, bronchospasms and obstruction
What is increased physiologic diversity
As people age they become more diverse. This explains why individualized care rather than protocol-based care is especially important in the geriatric population.
Name the conquences of agesim
Low self esteem, isolation, reduced opportunities and depression
Effect of ageism in the delivery of care
- Withhelding care
- Lack of knowledge regarding the rule of fourths
- Physiologic changes equal 25% not the majority of the decline in function.
- Overmedications instead of non pharmaceutical approaches
- Time management: it takes longer to care for an elderly patients with multiple comorbidities, and diseases, but everyone get their 15 minutes or less. -> misdiagnoses
Explain the concept of functionally oriented approach rather than specific diagnostic approach
- The HCP should ID functional deficits adversely affecting patient prognosis and quality of life
- Can we do something about it -> Medical intervention
- ID what can not be improved with medical treatment -> Rehab, social support and yes empathy.
- The best ARNP is not the one who makes the most diagnoses, it’s the one who identifies and addresses the patient’s most important functional problems.
What is iatrogenic disease?
Illness cause by US. (medical providers)
How do you prevent iatrogenic disease?
Most iatrogenic disorders can be avoided by using simple precautions, ie, increased knowledge of contraindications, restriction of self-medication, and lowering the number of concomitant drugs.
Slow medicne, start low and go slow
Physiological reserve definition
The remainingcapacityof an organ or body part tofulfilits physiological activity; (especially) in thecontextof stress, disease,ageing, orimpairment.
Pallative Care
Palliative care is a service offered by many hospice agencies to provide symptom management and comfort care to patients who may not have a terminal diagnosis, cannot be certified as having a life expectancy of less than 6 months, or do not want to sign a DNR or forgo other life-sustaining or curative treatments (such as a patient with cancer who wants to continue to receive chemotherapy but is having pain, nausea, or shortness of breath that is poorly controlled).
How does pallative care promote quality of care
Palliative care plays an important role in enhancing patient’s quality of life by improving their ability to achieve personalized goals, such as symptom control and social support, while setting realistic expectations through impeccable communication
What are common symptoms at the end of life
End-of-life symptoms commonly include pain, delirium, dyspnea, nausea and vomiting, constipation, noisy secretions, cough, and fever
What is the SPIKES protocol
SPIKES is an acronym for presenting distressing information in an organized manner to patients and families. The SPIKES protocol provides a step-wise framework for difficult discussions such as when cancer recurs or when palliative or hospice care is indicated.
What are the key points when considering preventative health measures in older adults?
Examples of Primary, Secondary and Tertiary Prevention
It is important to consider the effect of preventive health measures not only on quantity of life but also on quality of life, satisfaction with life, and in maintaining independence
Preventive health recommendations for older adults need to be individualized based on patient health, function, risk of disease, and preferences
What are the 50+ Screening Recommendations
Breast cancer screening
Cervical cancer screening
Colorectal cancer screening
People who have smoked or do smoke should discuss lung cancer screening
Prostate cancer screening
Osteoporosis
Abdominal aneurysm
Breast cancer screening recommendations
Breast Cancer
Breast Exam:
* Self breast exam : Not recommended (grade D)
* Clinical breast exam (CBE): Insufficient evidence (grade I)
* ACS ( American Cancer Society) recommend that all women should be familiar with their normal breast tissue and report any changes to their HCP.
* USPSTF B: Women with a person or fam hx of breast, ovarian, tubal, or peritoneal ca or an ancestry assoc with BRCA1/2 gene mutation
* USPSTF D: No routine testing for BRCA1/2
USPSTF Breast Cancer Screening Rec.
Screening frailed patient:
Choosing Wisely® = not to recommend breast cancer screening to older women without considering their life expectancy, because women with < 10 years of remaining life expectancy are exposed to immediate harms of screening with little chance of benefit
Screening frailed patient:
Choosing Wisely® = not to recommend breast cancer screening to older women without considering their life expectancy, because women with < 10 years of remaining life expectancy are exposed to immediate harms of screening with little chance of benefit
USPTSF Cervical Cancer Screening
US
USPTSF A
Women aged 21 to 65 years
* 21 - 29yo Screen for cervical ca every 3 years
* 30 - 65yo Screen for cervical ca every 3 years with cytology alone every 5 years for for hrHPV alone or q 5 years with cotesting
**USPTSF D **
* for women <21yo
* hx or hysterectomy with rem of cervix and no hx of cervical ca or precancerous lesions
* women > 65yo with adequate prior screening and no risk of cervical ca
USPSTF Screening for Colorectal cancer
Screen all adults 45-75
76-86 discuss
Screening includes: High sensitivity guaiac fecal occult blood test or fecal immunochemical test every year
Stool DNA- Fit 1-3 years
C/T every 5 years
Flex sig every 5 years
Flex sig every 10 years + annual FIT
Colonoscopy every 10 years
USPSTF Screening for Prostate Cancer
Screening for prostate ca begins with PSA.
Elevated PSA can be caused by BPH, prostatis (inflammation) or ejaculation.
USPSTF does not recommend DRE for screening only in men with elevated PSA as secondary test
What are American Cancer Society recommendations for prostate cancer screenings?
- Age 50 for men who are at average riskof prostate cancer and are expected to live at least 10 more years.
- Age 45 for men at high riskof developing prostate cancer. This includes African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an early age (younger than age 65).
- Age 40 for men at even higher risk(those with more than one first-degree relative who had prostate cancer at an early age).
What are the recommened frequency of testing for PSA
- Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years.
- Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.
- men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing
Normal PSA findings
0-2.5: Normal PSA for a man 40-50 yrs.
2.5-3.5: Normal PSA for a man 50-60 yrs.
3.5-4.5: Normal PSA for a man 60-70 yrs.
4.5-5.5: Normal PSA for a man 70-80 yrs.
What can falsely raise a PSA
- BPH
- Older age
- Prostatitis
- Ejaculations (When you order PSA strongly suggest no ejaculation a day or two before test)
- Riding a bicycle ( no riding a day prior to test)
- Urologic procedures (including DRE)
- Medications: Testosterone replacement.
USPSTF Lung cancer screening
- Screen every year with a low dose CT
- Stop screening once a person has not smoked for 15 years or has a health problem that limits life expetancy or the ability to have lung surgery
- Stop screening at 80yo regardless of history
Who gets screened for lung cancer
Adults 50 to 80 who have 20 pack year smoking hx and currently smoke or quit within last 15 years
USPTSF: Osteoporosis screening
Evidence lacking regarding optimal interval if Screening result is unremarkable
The National Osteoporosis Foundation recommends assessing BMDevery 2 years
And more often if Osteoporosis is present.
USPTSF: Osteoporosis screening
Evidence lacking regarding optimal interval if Screening result is unremarkable
The National Osteoporosis Foundation recommends assessing BMDevery 2 years
And more often if Osteoporosis is present.
What is included in healthy lifestyle counseling?
Considering clinical condition and personal habits, counsel older adults about:
* Physical activity— at least annually
* Nutrition – obtain weight at each visit and height annually to calculate BMI
* Alcohol misuse—initially, then if symptomatic
* Smoking cessation—every visit
* Sexual dysfunction and sexually transmitted infections—routinely
Clinical recommendations for exercise in the elderly to promote and maintain health
- Moderate-intensity aerobic activity; minimum: 30 min 5 days/wk, or
- Vigorous-intensity aerobic activity; minimum: 20 min on 3 days each week
Exercise rec in the elderly to promote and maintain health and physical independence
8–10 exercises ≥2 nonconsecutive days/wk using the major muscle groups
Exercise rec in the elderly to maintain flexibility
Flexibility exercises on ≥2 days/wk for at least 10 min each day
Exercise recommendations in the elderly to reduce the risk of injury from falls
Exercises that maintain or improve balance (recommended for community-dwelling older adults with substantial risk of falls)
What immunizations are recommended by medicare and USPSTF?
Flu double strength
Pneumoccal (1 dose PCV15 followed by PPSV23 1 year later OR 1 dose PCV20)
Hepatitis B
Herpes Zoster 2 doses
Tdap the Td or Tdap booster every 10 years
What are the USPSTF screening rec for alcoholism
- Screen all adults 18 years or older for ETOH misuse (Grade B)
- Provide behavioral counseling to reduce ETOH misuse (grade B)
- Ask all older adults ≥ 65 years old at minimum annually about their alcohol use
Adults over age 65 who are healthy and do not take medications should not have more than:
- 3 drinks on a given day
- 7 drinks in a week total (So about one drink daily)
- Older adults are at risk for serious alcohol problems who drink more then recommended amount (NIH, 2018)
What is the screening test for alcohol misuse?
*AUDIT, AUDIT-C, or single-question screening (e.g., “In the past year, have you had four or more drinks in 24 hours?”)
What is on the Alcohol Use Disorders Identification Test (AUDIT-C)?
- How often do you have a drink containing alcohol?
- How many drinks containing alcohol do you have on a typical day when you are drinking?
- How often do you have 6 or more drinks on one occasion?
CAGE Questionaire
USPSTF Smoking Cessation screening recommendations
- USPSTF: Ask all adults about tobacco use and provide behavioral interventions and approved pharmacotherapy for cessation. (grade A)
- report it in ppk/year
Use the Five A’s to intervention when addressing smoking cessation
Five major steps to intervention are the “5 A’s”: Ask, Advise, Assess, Assist, and Arrange.
* Ask about tobacco use at every visit,
* Advise to quit,
* Assess willingness to quit
* Assist : behavioral modification and pharmacotherapy
* Arrange: designate a quit date, and provide close medical follow-up in person or over the phone routinely for next 3 months.
How to caculate pack years
It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on.
If you suspect there is an issue with safety and preventing injury the screening recommendation is :
Check smoke detectors and carbon monoxide detectors, check water heater temperature, use sun protection, assess driving skills, wear seat belts, complete advance directives and determine health care proxy
If you suspect there is mistreatment of older adults you should
Question with clinical suspension
Common chemoprophylaxsis (multivitamins) for the elderly
Frailty
an inability to maintain or regain homeostasis effectively causing a cumulative decline across multiple systems of functioning
Homeostenosis
Therefore, an increased vulnerability to disease
What are some strategies for Patient-Provider communication
- Consider the physical space
- Determine a suitable environment
- Pay attention to privacy, comfort, and quiet
- Ensure all equipment is available and in working order
- Introduce yourself
- Address the patient by last name
- Face the patient directly
- Sit at eye level
- Speak slowly
- And yes do start with open-ended questions: Take into account potential low health literacy.
What are some communication strategies to accommodate patients in needs
- Inquire about hearing deficits; raise voice volume accordingly
- If necessary, write questions in large print
- Allow ample time for patient to answer
What are the 5 I’s of a complete geriatric assessment
Five I’s of geriatrics
1. Intellectual impairment
2. Immobility
3. Instability
4. Incontinence
5. Iatrogenic disorders
What does a comprehensive geriatric assessment include
- Focuses on elderly individuals with complex problems,
- Emphasizes functional status and quality of life
- Takes advantage of an interdisciplinary team of providers. and the five I’s
6 Principles of a Geriatric Assessment
Goal: Promote wellness, independence
Focus: Function, performance (gait, balance, transfers)
Scope: Physical, cognitive, psychologic, social domains
Approach: Multidisciplinary
Efficiency: Ability to perform rapid screens to identify target areas
Success: Maintaining or improving quality of life
Describe key points when discussing geriatric assessments
Geriatric assessment is a multifaceted approach to the care of older adults, wit the goal of promoting wellness and independent function
What are the elements of a rapid screen?
Incorporate into routine office visit:
* 1- Rapid screening of targeted areas followed by comprehensive assessment in area of concerns
* Rapid screening of targeted areas
* Completed by trained office staff (MA, LPN)
* Completed by patient/surrogates at home or office
* 2- Rolling Assessment
* Target one area for screening with each office visit.
Rapid Screen Test
Functional Status
Answer yes to one of the foll0wing to assess IADLs:
Because of a health problem, do you need help to:
Shop?
Do light housework?
Walk across a room?
Take a bath or shower?
Manage household finances?
Assessment and Management
Assess all other ADLs for:
self care (bathing, toileting, Dressing, transfer bed to chair, grooming, feeding)
Instrumental (use telephone, prep meals, manage finances, take meds, doing laundry, housework, shopping, manage transportation)
Mobility: (walking inside/outside, climbing stairs,
The Katz index tool.
Rapid Screen Test
Mobility
“Time up and go” test: unable to complete in <16 seconds
Assessment and Management
Comprehensive M/S and neuro assessment. Treat underlying M/s and neuro assessment
Refer to PT
Rapid Screen Test
Nutrition
Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2)
Assessment and Management
* Mini Nutritional Assessment for older adults
* Oral supplements, meals on wheel, appetite stimulant.
Rapid Screen Test
Vision
Unable to read newspaper headline while wearing corrective lenses, unable to read greater than 20/40
Assessment and Management
* Screen for common eye diseases of older patient: (cataracts, macular degeneration, glaucoma, diabetic retinopathy.
* Refer to eye doctor
Rapid Screen Test
Hearing
Acknowledge hearing loss when questioned or failed the whispered test at a distant of 2 feet
Assessment and Management
* Comprehensive HEENT exam
* Rinne/weber test
* Conductive/obstructive hearing loss
* r/v med (lasix, salicylates cause reversible hearing loss)
* Refer to audiologist
Rapid Screen Test
Cognitive function
Answer yes to either of the following:
In the past 2 weeks have you often be bothered by:
Feeling down, depressed or hopeless?
Having little interest or pleasure in doing things?
Assessment and Management
* PHQ-9 or Geriatric depression scale
* R/o other illnesses such as hypothyroidism, anemia, Vit d deficiency, recent loss,
* Medication for depression
* Refer for counselling.
What is included in the assessment of nutritional status?
- Visual inspection
- Rapid screen test:
- Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2) If positive
- Mini-nutritional assessment for older adults (MMA)
- Comprehensive Physical assessment
- Laboratory tests
-Serum albumin to help determine protein and immune status.
-Serum cholesterol and homocysteine to determine risk level for CVD. Levels below 160 may indicate gastrointestinal problems.)
-Blood glucose in diabetics and periodically in non-diabetic elders since glucose intolerance increases with aging.
-Hemoglobin/hematocrit to evaluate for anemia, a prevalent condition in the elderly.
-Vitamin B12 (especially in vegans, with indications of achlorhydria and gastrointestinal problems).
The focus of geriatric assessment is on
function
Successful assessment promotes
wellness and independence
Strategies that enhance ________________
with older patients should be used
communication
A comprehensive assessment includes __________, __________, ____________, and ___________ ascpects of health.
A comprehensive assessment includes physical, cognitive, psychological, and social aspects of health
What is Specific Functional Assessment
Two methods: Self report see previous slides and performance:
Timed Get Up and Go test:
Qualitative; timed; assesses gait, balance, and transfers
Sensory capacity
—Read from a newspaper
—Whisper test
Gait speed
—Strongest predictor of future disability and death
Balance:
—Sharpened Romberg test: Test balance: feet together/semi tandem
What does a Psychological Health assessment include?
Cognitive Assessment
Psychologic Assessment
Spiritual Wellbeing
Cognitive Function
- Perception, memory, and thinking
- The processes by which a person:
- Perceives information
- Recognizes information
- Registers information
- Stores information
- Uses information
Why screen for cognitive loss?
Most people with dementia do not complain of memory loss
Cognitively impaired older persons are at risk for accidents, delirium, medical nonadherence, and disability
Prevalence of cognitive decline
Doubles every 5 yr after age 65
Nearly 50% of those aged 90
When should you avoid cognitive screening tests?
- Report screening results with the appropriate context in which these were obtained
- Avoid assessment periods:
- Immediately on awakening from sleep (wait at least 30 minutes)
- Immediately before and after meals
- Immediately before and after medical procedures
Two step approach in cognitive fx testing
- Always obtain a baseline
- Benchmark subsequent results with baseline
Name two global instruments to screen for cognitive impairment
Folstein’s Mini Mental State Examination (MMSE)
The Montreal Cognitive Assessment (MOCA)
Folstein’s MIni Mental State Examination (MMSE)
Assesses orientation, attention, memory, concentration, language and constructional ability
The Monteal Cognitive Assessment (MOCA)
Assesses: attention and concentration, executive functions, memory, language, vosuoconstructional skills, conceptual thinking, calculations and orientation
How do you assess psychological status
- Ask, “Do you often feel sad or depressed?”
- If patient responds affirmatively do further evaluation, eg, Geriatric Depression Scale or PHQ-9
- Other short instrument : Geriatric Depression Scale (short or long form)
- Watch for signs of anxiety, bereavement: if suspect: administer GAD-7
Polypharmacy
- Prescribing many drugs with long term use
- Prescribing five or more drugs with long term use (90 days or above)
- Prescribing potentially inappropriate medications (P I M’s)
- Underprescribing, overprescribing, and misprescribing, duplication
4 parts of Pharmacokinetics
Absorption
Distribution
Metabolism
Elimination
Age related changes to absorbtion in the elderly
Absorption is the least pharmacokinetic factor impacted by aging
* Reduced stomach acidity
* Decreased absorption of calcium carbonate and antifungal po
* Decreased gastric motility
* Reduced drug absorption in the small intestine
* Decreased First pass metabolism
EFFECTS OF AGING ONVOLUME OF DISTRIBUTION (VD)
Age-associated changes in body composition can alter drug distribution
body water lower VD for hydrophilic drugs
lean body mass lower VD for drugs that bind to muscle
fat stores higher VD for lipophilic drugs
plasma protein (albumin) higher percentage of drug that is unbound (active)
Definition of Volume of Distribution
Definition: A medication’s distribution describes the extent to which a drug passes into different body compartments
Aging and metabolism
Two phases:
* Phase 1 Metabolism:
* Cytochrome P450: reduction and oxidation of the drug
* Age related decline in phase one due to reduction of hepatic perfusion and liver size and mass (varied greatly among people, due to genetic confounder)
* Decrease first pass metabolism
* Lead to increased half-life
* Phase 2 metabolism: Hepatic conjugation of the drug to make substance inactive and facilitate excretion
* Phase 2 is usually not affected by normal aging changes
Steady state
overall intake of adrugis fairly in dynamic equilibrium with its elimination. Reach usually after 5 half-lives
KIDNEY FUNCTION IS CRITICAL FOR DRUG ELIMINATION
Elimination: via
* Most drugs are excreted the kidneys
* Rate of elimination is influenced by
* Glomerular filtration
* Tubular secretion
* Reasorption
Kidney and elimination of drugs in the elderly
- With aging:
- kidney size
- renal blood flow
- number of functioning nephrons
- renal tubular secretion
- Aging, common geriatric disorders, polypharmacy can impair kidney functions
- Reduced elimination potential drug accumulation and toxicity
- GFR and tubular function declines with aging
Pharmacodynamics
Effects of the drugs on the body and mechanisms of their action
Pharmacodynamics and aging
Pharmacodynamics in aging: limited data
* Might be related to change in receptor affinity or number.
* Older adults have higher sensitivity to benzodiazepines and other central nervous depressors such as opiods, and anticoagulant effect of heparin and Coumadin
* Decreased sensitivity to some drugs: Beta blocker
* Overall prescriber should assume greater sensitivity to drugs.
Risk factors for ADEs
- 6 or more concurrent chronic conditions
- 12 or more doses of drugs/day
- 9 or more medications
- Prior adverse drug event
- low BMI (less than 22)
- Age 85 or older
- Estimated CrCl < 50 mL/min
- History of prior ADE
How to prevent a prescribing cascade
The key to preventing prescribing cascades lies
in the avoidance and early detection of adverse
drug reactions and an increased awareness and
recognition of the potential for adverse reactions.
How to prevent a prescribing cascade
The key to preventing prescribing cascades lies
in the avoidance and early detection of adverse
drug reactions and an increased awareness and
recognition of the potential for adverse reactions.
What are the general guidelines for safe prescribing
Review current drug therapy
- Review current drug therapy
- Discontinue unnecessary therapy
- Consider adverse drug events for any new symptoms
- Consider nonpharmacologic approach
- Start low and go slow
- Understand effect of drugs in the elderly
- Reduce the dose
- Simplify the dosing schedule
- The fewer drug the better
—Avoid inappropriate polypharmacy
—One drug many use: Use of one drug to address more than one disease. (ARB: HTN and Gout; Remeron: Depression, insomnia, and unintentional weight loss; CCB: HTN and neuroprotective)
General guideline for safe prescribing
Creating an individualized plan
1. Patient life’s expectancy
2. Time till benefit from medication
3. Goal of care
4. Treatment targets
1. Symptom-targeted approach
2. Disease modifying approach
Decision-making process based on beneficence and patient’s autonomy.
Optimizing prescribing for older adults and medication adherence
- consider any new sign and/or symptom in the elderly as a drug side effect until proven otherwise
- Principle of slow medicine (see week 1 PPTs) based on beneficence
** START LOW AND GO SLOW** - Try not to start two medications the same time
- Search for one medication that might treat two diseases at the same time.
- Administration time: Same as the other medication to increase adherence
- Use of long acting meds if patient can afford the higher co-pay.
- Assess patient and/or care giver knowledge regarding med.
General guidelines for safe prescribing and medication adherence
- Uses the correct drug
- Prescribes the correct dosage
- Targets the correct condition
- Is appropriate for the patient
Failure in any one of these
can result in adverse drug events (ADEs)
Screening tools
STOPP/START criteria
The Screening Tool of Older Person’s Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START)
Both screening tools are intended to be used together
Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE
More thorough than BEERS, as it includes drug-drug interaction, and potential duplications
Identify inappropriate prescribing, was introduced in 2008 and updated in 2015
STOPP:
Include a list of PIMs (Potentially inappropriate medications)
START:
Include PPOs (potential prescribing omissions)
What is BEERS criteria
What is the AGS Beers Criteria®? The AGS Beers Criteria® includes lists of certain medications worth discussing with health professionals because they may not be the safest or most appropriate options for older adults. Though not an exhaustive catalogue of inappropriate treatments, the five lists included in the AGS Beers Criteria® describe particular medications with evidence suggesting they should be:
Avoided by most older people (outside of hospice and palliative care settings);
Avoided by older people with specific health conditions;
Avoided in combination with other treatments because of the risk for harmful “drug-drug” interactions;
Used with caution because of the potential for harmful side effects; or
Dosed differently or avoided among people with reduced kidney function, which impacts how the body processes medicine.
What are the 5 categories in the BEERS criteria
1. PIMs to be avoided for all older adults
2. PIMs to be avoided in certain diseases/syndromes
3. PIMs to be used with caution
4. PIMs to be avoided/adjusted in patients with renal disease
5. Drug–drug interactions to be avoided
Advantages of BEERS criteria
Informed by extensive evidence review
Robust grading methodology
Concise
Increases awareness of poly pharmacy
Aids in the decision making when choosing drugs
Disadvantes of BEERS criteria
- No RCT evidence of clinical benefit when used as an intervention.
- Under-prescribing not addressed.
- Alternative safer drugs not suggested.
What does STOPP stand for?
Screening Tool of Olders People’s Potentially Inappropriate Prescriptions
**Prescriptions that are potentially inappropriate in persons aged ≥ 65 years **
What is START criteria
START: Screening Tool to Alert doctors to Right
(i.e. appropriate, indicated) Treatments.
Treatments that should be considered for people ≥ 65
years of age, where no contraindication exists
STOPP/START is broken down into psysiological systems where BEERS is not
Screening test for insomnia?
Epworth
Risk factors of insomnia
50% of elderly adults of age 65 regularly complain of poor sleep.
Patients with medical and psychiatric comorbidities have higher frequencies of insomnia placing our geriatric population at an increased risk.
Rates of insomnia in patients with chronic pain and psychiatric disorders range from 50%-75%. Women, regardless of ethnicity, are more likely to suffer from insomnia.
Causes of Insomnia are Multifaceted:
Predisposing Factors: Aging, female gender, comorbid conditions, vulnerability to insomnia such as anxiety, depression, hyperarousal, and dementia
Precipitating Factors: Triggers for insomnia such as a loss of a spouse, retirement, moving to a new home
Perpetuating Factors: Maladaptive habits or beliefs that a person has acquired to deal with insomnia such as spending long periods in bed or taking naps
Insomnia in older adults is often comorbid with medical and psychiatric illnesses and their symptoms (i.e. restless leg syndrome, sleep apnea, GERD, musculoskeletal illness, drugs) (Buysse et al., 2019)
Diagnostic screenings for insomnia
Diagnostic Tests/Screenings:
* Labs to rule out organic disease: CBC with diff, CMP, TSH, A1C, & Vit D (Last labs drawn April 2021)
* PHQ-9 Score: 16 (moderate to severe depression); Other screening tools: GDS, BDI, HAM-D, QIDS-SR
Non Pharmacological Approach to Insomnia
Non-Pharmacological Approach:
* Cognitive Behavioral Therapy for Insomnia (CBT-1, Stimulus Control, Sleep Restrictive Therapy, Sleep Hygiene
Pharmacological Approach to the management of Insomnia
Pharmacological Approach:
Trazodone 25 mg q HS
Verbal consent for treatment obtained. Taper off Xanax when insomnia, depression, and anxiety controlled. Initiate daily sleep diary and instruct patient to bring to next appointment. Sleep hygiene, identify and eliminate factors contributing to daytime sleepiness.
Education follow up for Insomnia
Patient Education:
Set a regular bedtime/wake time every day. Sleep only as much as you need to feel rested, then get out of bed.
Avoid caffeine after lunch, and large meals & alcohol near bedtime. Do not smoke (particularly in evening).
Get regular exercise during the day, but avoid rigorous exercise within two hours of bedtime.
Keep room quiet and dark. Use fan, white noise machine, blackout shades and/or eye mask. Avoid electronics
Follow up for Insomnia
Follow-Up:
Return to office in 2 weeks to follow-up on symptoms, CBT-I, adjust medications if necessary, & reinforce education
