The Elderly Patient Flashcards
The ageing ________ are the fastest growing
section of the Australian population. The number of
‘old-old’ _______ is increasing at an even faster
rate.1
(over 65 years)
over 85 years
Life expectancy has risen to _____ years for women
and _____ for men
- 2
79. 7
The over-65s in 2001 made up ______of the Australian
population (13.4% in the US)
12.7%
The over-65s use twice the number of health services
per head of population. They account for____ of all
hospital costs and 75% of all _______ costs
25%
nursing home
Ageing is characterised by the following:
- decrease in______
- reduction in the _______ of organs
- reduced capacity to adapt to______
- increased vulnerability to disease
- increased probability of death
metabolic mass
functional capacity
stress
Degenerative cardiovascular disease emerges with ageing
according to the following approximate guidelines
40 Obesity 50 Diabetes 55\_\_\_\_\_\_\_ 65 Myocardial infarction 70 \_\_\_\_\_\_\_\_\_ 75 Heart failure 80 \_\_\_\_\_\_\_\_\_\_\_\_
Ischaemic heart disease
Cardiac arrhythmias
Cerebrovascular accident
What is the classic triad of aging
confusion, falls, incontinence
The classic triad often represents:
infection
A clinically signifi cant feature in some elderly patients
is the raising of the pain threshold and changes in
homeostatic mechanisms, such as _______
Consequently, these patients may have an abnormal
response to diseases such as appendicitis, pyelonephritis,
internal abscess, pneumonia and septicaemia
temperature control.
One of the best ways to generate a good relationship with the aged is through
home visits
Home visits can be considered in three categories:
1 an_______ visit (especially to a new patient)
2 a patient-initiated but routine request for a ‘check-up
and tablets’
3 the_______—usually 2 to 4 weeks
‘unexpected’
regular call
Forbes points out that at least _________elderly
people feel lonely. It is more likely to affect the_____
widows and widowers, and those affected by disability.
one in three
‘old-old’,
Possible signs of loneliness include:
- 2.
- body language with a ‘defeated’ demeanour
- prolongation of visit including holding on to one’s hand
- verbal outpouring
- drab clothing
- dependence on television
Doctor behaviour that can irritate
and confuse elderly patients:
• having a consulting room with slippery steps, poor
lighting and inadequate handrails
• non-attention to______ by reception staff
• keeping them waiting
• having________in the waiting room and surgery
• being overfamiliar, with addresses such as ‘Pop’ or fi rst
names for elderly females
simple courtesies
low soft chairs
Doctor behaviour that can irritate
and confuse elderly patients:
• shouting at them on the assumption that they are_____
• appearing _____and keen to get the consultation over
quickly
• forgetting their ________ and
concentrating only on their physical problems (i.e. not
treating the whole person)
• forgetting that they have several things wrong with
them and using a different ______ from theirs
deaf
rushed
psychosocial problems
priority list
Doctor behaviour that can irritate
and confuse elderly patients:
being unaware that they may have seen other
practitioners or may be _________
• failing to ask patients to give their understanding of
what is wrong
• omitting to give printed _______
about their problems and medications
taking additional medication
patient education handouts
Doctor behaviour that can irritate
and confuse elderly patients:
omitting to explain __________
• treating them as though they would have little
comprehension of their health and treatment
• failing to respect their privacy, such as__________
• failing to provide appropriate advice on various social
services such as ________ and other support
groups
how the medication will work
not knocking
before entering the examination room
meals on wheels
Assessment of the elderly patient
At all times concentrate on a general
assessment of the patients’ _________ by
evaluating mental status, comprehension, hearing,
vision, mood and speech.
ability to communicate
Physical examination
The elderly patient expects to
be examined adequately (especially having ___________measured) but requires appropriate dignity
blood pressure
Physical examination
Practice nurse • Prepares for \_\_\_\_\_\_\_ • Helps with questionnaire • Records \_\_\_\_\_\_ • Takes temperature, pulse and respiration • Checks audiometry (if hearing problem) • Checks \_\_\_\_\_\_\_\_\_ (if appropriate) • Prepares cervical smear tray for female patient (if relevant)
examination
weight and height
ocular tension
_______ for assessment of the
non-coping elderly patient
‘Rules of 7’
‘Rules of 7’ in elderly assessment
1 Mental state: _________ Bereavement, incl. pets, Elderly abuse/bullying
2 Eyes: Visual acuity,________
3 Ears: Deafness, e.g. wax Tinnitus
4. Mouth: _____, _________, Malnutrition
- Confusion/dementia Depression
- Cataracts/glaucoma
- Dentition Xerostomia
‘Rules of 7’ in elderly assessment
5 Medication: _________
6 Bladder and bowels: ____________
Polypharmacy Adverse reactions
Incontinence Retention Urinary infection
‘Rules of 7’ in elderly assessment
Locomotion: Gait—\_\_\_\_\_\_\_\_ movement disorder, esp. \_\_\_\_\_\_\_ Arthritis—hips/knees Back/sciatica Feet—\_\_\_\_\_\_\_\_ Circulation Leg ulcers
antalgic;
Parkinson disease
nails; neuropathy
The quick 10-step cognitive impairment test
- 2.
- 4.
1 When were you born?
2 What year is it?
3 What month is it?
4 What is the date today?
The quick 10-step cognitive impairment test
- 7.
8.
9.
10.
5 What is your telephone number? (or if no
telephone) What is your street address?
6 What time is it (to nearest hour)?
7 Who is the Prime Minister of Australia?
8 What year did World War II end?
9 Count backwards from 20 to 1.
10 Repeat the memory test I gave you
The quick 10-step cognitive impairment test
_____ not signifi cant
_____ probably signifi cant
______ signifi cant
Scoring: questions 1 to 8: correct—0, incorrect—2;
questions 9 and 10: correct—0, 1 error—2, >1 error—4
0–8
9–12
13–24
_________
This relatively simple test provides a ready qualitative
screening test to differentiate normal elderly from patients
with cognitive impairment, particularly dementia
The clock-face drawing test
Scoring system for CDT
Scoring system
• _____________—3 points
•______________—2 points
• All correct numbers are included—2 points
• Clock hands are placed in the correct position—2 points
Numbers are in the correct position
A closed circle is drawn
The clinical features of early dementia include:
• poor _______ memory
• impaired acquisition of new information
• mild _____ (cannot remember names)
• ________ (e.g. withdrawn, irritable)
• minimal visuospatial impairment (e.g. tripping easily)
• inability to perform ___________
recent
anomia
personality change
sequential tasks
Even apparently minor problems—such
as the onset of deafness (e.g. wax in ears), visual
deterioration (e.g. cataracts), _______ poor
_______ and diet, urinary tract intercurrent
infection, _______ and ________—can precipitate
abnormal behaviour.
diuretic therapy,
mastication
boredom and anxiety
Mnemonic for dementia
D drugs and alcohol \_\_\_\_\_ E ears, eyes M \_\_\_\_\_, e.g. hyponatraemia, diabetes mellitus, hypothyroidism E \_\_\_\_\_\_\_\_\_\_ N \_\_\_\_\_\_\_\_ T tumours, trauma I infection A \_\_\_\_\_\_\_\_
depression
metabolic
emotional problems (e.g. loneliness)
nutrition: diet (e.g. vitamin B group defi ciency, teeth
problems)
arteriovascular disease → cerebral insuffi ciency
It is important to keep in mind the possibility of abuse
of the elderly, especially where there is ______
a family history
of abuse of members
Over one million elderly people are
estimated to be the victims of physical or psychological
abuse each year in the US.3 We should keep in mind
the occasional possibility of______
Munchausen syndrome
by proxy.
The main differential diagnosis of dementia is
depression, especially major depression, which is termed
________
pseudodementia
The _______ is one way in which
it may be possible to distinguish between depression
and dementia
mode of onset
Those with dementia ________ while
those with depression ___________ and readily give up tasks
have no insight
have no insigh
In response to cognitive testing, the typical response
of the depressed patient is _________, while making
an attempt with a near-miss typifi es the patient with
dementia
‘don’t know’
It is vital to detect depression in the elderly as they
are prone to_____
suicide
The incidence of dementia increases with age, affecting
about 1 person in 10 over _______ and 1 in 5 over ____
65 years
80 years.
dementia or pseudo?
Worse in evening or night
Orientation is reasonable
dementia
pseudo
In _____ the earliest
manifestations are personality change and alteration
of behaviour, including social dysfunction
frontal dementias
______ is characterised by any two of visual
hallucinations, spontaneous motor Parkinsonism and
fl uctuations in the mental state
Dementia
with Lewy bodies
In patients with dementia, _____ judgment, verbal fl uency and the ability to ________ also become impaired.
Abstract thinking,
perform complex tasks
The many guises of dementia can be considered in
terms of four major symptom groups:
- _______: due to loss of cognitive abilities
- ______: based on personality change,
- __________based on disturbed mood
and personal distress - ________—causing distress and
disturbance to others
Defi cit presentations—
Unsociable presentations—
Dysphoric presentations—
Disruptive presentations
In patients with dementia, Driving is a problem, especially as many are reluctant to give up their licence. Those with ______ are more likely to cause road accident
mild dementia
If uncertainties arise in drivign or a patient is recalcitrant,
refer to the _________
local Road Traffi c Authority
Demented patients are vulnerable to superimposed delirium, which is often due to: 1. 2. 3. 4.
- urinary tract infection
- other febrile illness
- prescribed medication
- drug withdrawal
The best
option for PD and AD appears to be the administration of:
- levodopa to maximum dose
* quetiapine at night
The cholinesterase
inhibitors _________, ____, ________
appear to delay progression of dementia to a modest
extent only.
donepezil, galantamine, and rivastigmine
Available drugs for Alzheimer disease
Cholinesterase inhibitors
- donepezil (Aricept) ______
- galantamine (Reminyl) prolonged release ______
- rivastigmine (Exelon)
rivastigmine (Exelon) 4.6 mg transdermal daily for
4 weeks, then______
5 mg (o) nocte for 4 weeks, increase to 10 mg nocte as tolerated
8 mg (o) daily for 4 weeks, increase to 16 mg daily
1.5 mg (o) bd for 2 weeks,
increase gradually up to 6 mg bd
9.2 mg daily
Aspartate (NMDA) antagonist
• memantine (Ebixa) _______
5 mg (o) mane for 1 week → 5 mg bd week two → 10 mg bd from week 4
True about RCTs on donepezil and riva
- only ______ improvement overall
- greatest improvement with _____ doses
modest
higher
True about RCTs on donepezil and riva:
- higher doses less well tolerated
- long-term effi cacy ______
- clinical effectiveness in ______ has not been
demonstrated
unknown
severe disease
In AD Tx,
the evidence shows
that ________ must be treated with rivastigmine
6–12 mg/day for 6 months for one patient to display
clinically meaningful improvement
13 patients
Tx of Psychotic Sx of AD
1.
2.
3.
olanzapine 2.5–10 mg (o) daily or risperidone 0.5–2 mg (o) daily or haloperidol 0.5 mg (o) nocte up to 2 mg bd
To control symptoms of anxiety and agitation use:
______
oxazepam 15 mg (o) one to four times daily
benzodiazepines should be used only for short
periods________ as they tend to exacerbate
cognitive impairment in dementia
(maximum 2 weeks)
In AD, Defi ciencies of ______, ________, ______should be treated.
folate,
vitamin B12 and vitamin D
This ‘popular’ term is also referred to as ‘age-related
memory loss’ or ‘mild cognitive impairment’ of ageing
Benign senescent forgetfulness
Features of Benign senescent forgetfulness
- 3.
- short-term forgetfulness
- inability to fi nd the right word
- embarrassment about shortcomings
Features of Benign senescent forgetfulness
4.
5.
6
- feeling dithery
- inability to fi nd items stored away
- forgetting to pay accounts
The risk factors for late life
suicide are:
- male
- single
- recent bereavement
- social isolation
- recent relocation
- poor pain control
- feeling helpless/hopeless
- anhedonia
- indicating a wish to die
- recent alcohol abuse
________ is that condition where the symptoms
and signs of paranoid psychosis appear for the fi rst
time in the elderly
Paraphrenia
In patients with Paraphrenia, it is usually an elderly
female, presents with ______, such as
a feeling of being watched or persecuted and even
_______
paranoid delusions
hallucinations.
Tx of paraphrenia
Treatment
is with an anti-psychotic agent e.g. risperidone or
olanzapine.
Falls in the elderly are a major problem as _____of people
over the age of 65 experience at least one fall per year,
with 1 in 4 of these having ______
30%
signifi cant injury
The ________ test: a brief test of
postural competence
‘get up and go’
Steps for get up and go:
1 Get up from chair without ____
2 Observe normal gait and ______
3 Carry out the _________ (slight push with eyes
closed).
4 Observe _______ (heel toe, straight line).
use of arms
360° turn.
Romberg test
tandem walking
Ageing is associated with increased rates of adverse
drug reactions.1 The rate of adverse drug reactions for a
single medication rises from about ______ at age 20 years to about ______at age 70 years.
6%
20%
For fewer than six medications taken concurrently, the
rate of adverse drug reactions is about______.
6%
For more than
six medications taken concurrently, the rate of adverse
drug reactions jumps to _____
20%.
Approximately ______of
elderly patients admitted to hospital are suffering adverse
drug reactions.
15%
Most adverse drug reactions are ______ rather than type B (idiosyncratic).
type A (dose related)
The fi ve mechanisms of adverse drug reactions in
the elderly are
- Drug–drug interaction
- Drug–disease interaction
- Age-related changes leading to increases in drug plasma concentration
- Age-related changes leading to increased drug sensitivity.
- Patient error
The fi ve mechanisms of adverse drug reactions in
the elderly
__________ For example, beta-blockers given
concomitantly with digoxin increases the risk of heart
block and bradycardia
Drug–drug interaction.
______ For example, in the presence
of kidney impairment, tetracyclines carry an increased
risk of kidney deterioration
Drug–disease interaction.
______. Decreased kidney excretion can extend
the half-life of medication, leading to accumulation and
toxicity
Age-related changes leading to increases in drug plasma
concentration
____________
For example, there is some suggestion that the
pharmacological response to warfarin, narcotics and
benzodiazepines is increased in the elderly
Age-related changes leading to increased drug sensitivity.
______Multiple medications can lead to this. The incidence and prevalence of dementia also
increases with age. Other problems include failing
eyesight and reduced manual dexterity.
Patient error.
In a study on adverse drug reaction in elderly patients the drugs most frequently causing admission to hospital were: 1. 2. 3. 4. 5
- digoxin
- diuretics
- antihypertensives (including beta-blockers)
- psychotropics and hypnotics
- analgesics and NSAIDs
The same study showed that drugs regularly
prescribed without revision were:
- barbiturates
- benzodiazepines
- antidepressants
- antihypertensives
- beta-blockers
- digoxin
- diuretics
The elderly may need much lower doses of
______ and ________than younger patients to
produce the same effect, thus rendering them more
susceptible to adverse effects and toxicity
anxiolytics and hypnotics
The elderly
are especially liable to accumulate the _____
longer-acting
benzodiazepines
In particular, any drug or combination of drugs with
anticholinergic properties (e.g. tricyclic antidepressants,
anti-Parkinsonian agents, antihistamines, phenothiazines
and some cold remedies) can precipitate a ____
central
anticholinergic syndrome.
Both ___ and ______
have been shown to produce a greater fall in blood
pressure in elderly compared with younger subjects,
presumably related also to a reduced homeostatic
response
ACE inhibitors and calcium-channel blockers
SE in the elderly
Confusion, falls,
psychomotor impairment
BZD
SE in the elderly
Confusion, falls, asthma,
insomnia
β-blockers
SE in the elderly
Confusion
Cimetidine
SE in the elderly
Nausea, confusion
Digoxin
SE in the elderly
Incontinence, falls,
hyponatraemia,
hypokalaemia
Diuretics
SE in the elderly
Confusion, falls,
dystonia, hallucinations,
agitation, postural
hypotension
Levodopa
Confusion, extrapyramidal
symptoms
Metoclop
Confusion, postural
hypotension, falls,
constipation
Phenothiazines
SE in the elderly
Confusion, falls, ataxia,
Parkinsonism, urinary
problems
Phenytoin
SE in the elderly
Postural hypotension,
incontinence
Prazosin
SE in the elderly
Nausea, agitation,
insomnia
SSRI antidepressants
SE in the elderly
Confusion, falls,
postural hypotension,
constipation, urinary
problems, eye problems
Tricyclic antidepressants
SE in the elderly
Constipation
Verapamil
The starting dose of a drug in the aged should be
at the_____of recommended ranges. Dosage
increments should be gradual and reviewed regularly.
lower end
