Week 1 - Health and wellness of the aging adult Flashcards
Age related changes
- reading glasses age 42-50, reduced light to retina, reduced color intensity
- increase vestibular sensitivity
- fertility decline age 35
- increase reaction time
- increase sway with eyes closed
- reduced ankle jerk reflex
- bone density reduction after 50
- increase fat, decrease water
- brain decrease
- reduced sleep pattern/increased wakening
- Hearing - decline starts age 12
- maximum heart rate reduced, (predisposes to sepsis, HF, pneumonia)
- decrease renal perfusion
- increase prostate size by 100%
- sexual dysfunction
Immunizations recommended for older adults
Flu - yearly over 65
Tdap - 1 dose over 65 then every 10 years
Varicella recombinant (shingles) - 2 doses, 2-5 months apart
Pneumovax - 1 dose over age 65
Hep A/B - only for those at high risk, give once
Health promotion for older adults
Reduce risk factors for disease through lifestyle modifications
Alcohol in older adults
- Decrease in body water with age causes increase in blood alcohol levels and increase effects with unchanged intake
- No more than 1 drink per day, no more than 3 drinks on any one given day
- Can worsen chronic conditions (osteoporosis, memory loss, congestive heart failure, HTN, impaired balance, liver disease)
Medications that interact with alcohol
- Antibiotics
- Antidepressants
- Barbiturates
- Benzos
- H2 receptor agonists
- Muscle relaxers
- Non narcotic pain relievers
- NSAIDS
- Opioids
- Warfarin
CAGE questions for alcohol use
- Have you ever felt you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
*Two or more positive answers is considered a positive outcome.
How do you screen for osteoporosis?
Bone mineral density test
- DEXA scan
- Quantitative US of the heel
- Peripheral dexa
Measures calcium and other minerals in bone. Bones containing more minerals are denser, so they tend to be stronger and less likely to break. Bones can become less dense as we age or if we develop certain medical conditions. When too much bone is lost, osteoporosis can develop
FRAX tool
Fracture Risk Assessment Tool
an osteoporosis risk assessment test, uses information about your bone density and other risk factors for breaking a bone to estimate your 10-year fracture risk.
DEXA scan recommendations for women
DXA scan at least once in women at 65 and over and postmenopausal women with increased risk for fracture
DEXA scan recommendations for men
Testing for all men over 70 or aged 50-70 with risk factors
How much calcium to reduce risk of osteoporotic fracture?
1200-1500mg calcium supplement spread through the day (max 500mg at once at meal to optimize absorption)
When to do a cognitive health screening?
With memory complaints or red flags (decrease in ADLs, difficulty finding words, visual spatial difficulties)
What tool can be used for cognitive health screening?
Mini-cog tool–> clock drawing test and three item recall
Breast cancer screening guidelines
- Biennial mammography age 50-74 (after that up to patient and clinician)
Recommended as long as patient has at least 10-year life expectancy
Colon cancer screening recommendations
Polyps turn to cancer in 5-10 years and their incidence increases with age
- Screening ages 50-74
- FIT or fecal occult blood tests – every 1-3 years
- Simoidoscopy or CT colonography – every 5 years
- Colonoscopy – every 10 years
- Selective screening 75-85
Cervical cancer screening
Not needed for those over 65 with adequate screening
- Continue in patients with high risk
o Precancerous lesions
o Immunosuppression
o HIV/HPV
Prostate cancer screening
- Not recommended unless provider wants to
- High risk patients
o Black men
o Positive family history
Patient education for tobacco use
Quitting improves circulation, lowers risk of cancer, stroke, heart attack, improves breathing and BP.
- Increased risk of flu, pneumonia, respiratory illness, weakens bones, leads to vision loss, development of diabetes, ED, delayed wound healing, gum disease, oral cancer
What is the most successful method for quitting smoking?
Pharmacotherapy and counselling
Pharm therapy includes
- Bupropion
- Nicotine replacement (gum, inhaler, lozenge, nasal spray or patch, chantix – varenicline
- Side effects – local skin irritation, nasal irritation, mouth soreness, dyspepsia, insomnia
5 A’s for patients over 50
Assess, advise, agree, assist, arrange
How can you reduce polypharamcy?
- Try nonpharmacologic therapies first
- Verbal and written instructions on how to use medications
How does nutrition change in older age?
- Slower metabolism, decline in physical activity, decreased absorption of nutrients from chronic disease
- Screen for weight loss and malnutrition – contributes to frailty
Diet recommendations for older adults
- Protein 12-20% of calories
- Fiber 14g per 1000 calories consumed (grains, nuts, seeds, fruits, veg)
- Water – predisposed to dehydration. Thirst sensation is blunted.
- Vitamins – A, C, E
- 5 a day
Aspirin use in older adults
- Benefits vs risk – benefits outweigh risk when CVD risk is high and bleeding risk low
- Start when 10 year CVD risk is >15%
- Continue when 20 year CVD risk is > 10%
- Stop for 10 year CVD risk >5%, high risk for bleeding or patient preference to avoid bleeding
- Promote lifestyle interventions – exercise, less alcohol, heart healthy diet, smoking cessation, adequate sleep
Physical activity for older adults
- 150 min moderate intensity, 75 minutes vigorous activity weekly
- Tai chi to reduce fall risk
- Start with PT for those with balance or gait impairment
- Helps control chronic illness and promotes brain health
Cultural competency
a set of congruent behaviors, attitudes and policies that come together in a system, organization or among professionals that enables effective work in cross-cultural situations.
Cultural humility
Personal lifelong commitment to self-evaluation and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities
When choosing a medication what should you consider?
- Pharmacokinetics
- pharmacodynamics
- cognitive ability
- financial constraints
- functional deficits
- varying treatment endpoints
- availability of evidence-based medicine
How to prevent polypharmacy?
Start low go slow
- Anticholinergic effects include sedation, confusion, retention, constipation
Screening tools
a. Beers criteria
b. START and STOPP (screening tool of older persons potentially inappropriate prescriptions AND screening tools to alert doctors to the right treatment)
BEERS Criteria
Drugs have limited effectiveness in the older population or serious risk of adverse events, safer alternatives available
1. Purpose
2. Related to older adults
3. Risks: adverse drug reactions (ADR)
Pharmacokinetic changes with age
Decline in organ function - enhanced susceptibility to adverse effects
Decreased physiologic reserve (absorption, distribution, metabolism and elimination)
Decreased first pass metabolism (increased drug serum concentration)
- Oral nitrates, beta-blockers, CCBs, estrogens
Decreased rate of absorption (decreased clinical effect)
- Furosemide
Decreased lean mass and total body water (decreased volume of distribution)
- Digoxin, lithium
Increased fat content (increase volume of distribution)
- Diazepam, chlordiazepoxide, flurazepam, alprazolam
Decreased PO intake (decrease serum protein concentration with decreased bintin)
Decreased renal elimination (increase drug half life)
- Aminoglycosides
- Vancomycin
- Digoxin
- Salicylates
-
Changes in medication absorption:
- Decreased acidity in the stomach, gastric motility, first pass metabolism
- Decrease absorption for drugs requiring acidic environment
- Changes in topical absorption due to skin changes, atrophy, reduced blood flow
Changes in medication distribution:
Lipophilic medications have a larger volume of distribution, longer elimination phase and prolonged therapeutic/toxic effect
* Phenytoin, valproic acid, diazepam, olanzapine, amiodarone, lidocaine
Changes in medication metabolism
Body’s process of altering the medication
- Decrease in liver size and blood perfusion
Changes in medication elimination
Conversion to inactive metabolites in the liver, excretion in bile, or kidney elimination
- Decrease in glomerular filtration rate
- absorption, distribution, metabolism and elimination)
- Decline in organ function ‚ enhanced susceptibility to adverse effects
- Starting dose for more renally excreted drugs should be based on estimate CrCl rate, monitor patients for overdosing/underdosing
Pharmacodynamic changes
Response of the body to the drug
- Greater response to CNS depressants of benzos and opioids and anticoagulant effects of warfarin and heparin
How and when to start/stop a medication
Take into account:
- Patient life expectancy
- Time until benefit from med
- Goals of care
- Treatment targets
Guidelines for safe prescribing
- Problems often have more than one cause
- New complaints or increasing dysfunction most likely from medication adverse events
Prescribing cascade – new complaint assumed to be from disease rather than a drug, leads to addition of new drugs, increasing the risk of adverse events
Pain results in NSAIDS script, raised BP then HTN meds, then needs thiazide diuretics, then gout treatment, metoclopramide –> Parkinsons treatment
Always include medication adverse effects in the differential diagnosis
Medication adherence
the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider
Medication compliance
Patient adapting to new medication
Medication persistence
Duration a patient will continue to take the treatment
Telehealth Law
o Can prescribe controlled substances via telehealth
o Can prescribe buprenorphine to new and existing patients with opioid use disorder via telephone
o Must be in same state
Telehealth Security and Privacy
o Need to assure privacy and confidentiality
o Meet HIPPA guidelines
