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”
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
What are the new USPSTF colorectal screening guidelines?
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 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.
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
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
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
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
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.
CAGE Questionaire
