Week 10 Geriatrics in Primary Care Flashcards

Question

Older adults face greater risks for fluid imbalance than young and middle adults due to which age-related factor? A. Increased amounts of intracellular fluid and total body water B. Higher proportion of fat to muscle cells C. Faster speed of metabolism D. Increased intestinal motility

Answer 1

B. Higher proportion of fat to muscle cells Older adults ’ bodies have fewer muscle cells and more fat cells than those who are younger. Fat cells contain less fluid than muscle cells; thus the intracellular compartment has less fluid. Both total body water and intracellular fluid volumes are lower than in younger individuals, placing the older adult at higher risk for fluid imbalance.

Answer 2

B. health, social engagement, mental activity, and life satisfaction. The successful aging paradigm suggests that physical health, stimulation of cognitive capabilities, social involvement and engagement, productivity, and life satisfaction are major components of a healthy aging process. Assessment of these components can help the clinician understand an individual ’ s aging process, typical patterns of daily living, and unmet needs.

Answer 3

B. Increases in autoantibodies as a result of altered immune function Due to the change in function of T and B lymphocytes in older adults, the formation of antibodies shifts to form antibodies against a person ’ s own immune system. Normal aging does not in and of itself cause a decrease in thrombocytes or the other cell lines.

Answer 4

C. Decrease in enzymatically active melanocytes Increased sensitivity to sunlight exposure increases in older adults as the number of melanocytes (pigment-carrying cells) decreases. This results in graying hair, reduced capillary blood supply, and fading skin color. Langerhans cells do decrease by 40%, but this is generally assumed to account for the increased hypersensitivity of skin in older adults, not increased photosensitivity.

Answer 5

B. Get Up and Go Test The Get Up and Go Test is a structured observation to evaluate functional mobility. To assess a patient, have the person rise from a chair, walk 10 feet forward, turn, and return to the chair and sit down again. Strength, balance, gait, pace, and coordination in turning are evaluated by the observer.

Answer 6

A. Physical and mental health Evidence suggests that people are sexually active well into their 80s and 90s. The two major factors determining sexual activity are good physical and mental health and previous regular sexual activity. The phrase “ use it or lose it ” seems to be relevant.

Answer 7

D. Emphasize the individual ’ s limitations and likely need for long-term care placement. Aging in place involves modification of the home environment and provision of support to keep aging adults in their homes. Research demonstrates that most older adults wish to remain in their homes and die at home.

Answer 8

A. Change in stature Aging is accompanied by decreased muscle strength, decreased endurance, loss of flexibility and connective tissue elasticity, decreased bone mass, and decreases in stature due to changes in spine architecture.

Answer 9

A. There are types of AD that are inherited and present before age 60. Some types of AD are inherited and present before age 60. There are also other forms of dementia, such as Pick ’ s disease, that have the same outcome as AD but can be found as early as the fifth decade. These diseases have a genetic predisposition and may not be a result of the aging process. It should be remembered, however, that half of all people older than 85 are affected by AD.

Answer 10

A. Cognition The ABCTs are the four main headings of a mental status assessment. The A stands for appearance, the B for behavior, the C for cognition, and the T for thought processes.

Answer 11

C. Sometimes forgets the names of his children Some difficulty with recall is an expected agerelated cognitive change. However, impaired recall of common words or loved one ’ s names may indicate significant decline associated with dementia, including Alzheimer ’ s disease. Further tests of cognitive function and referral to neurology or geriatric specialist are indicated

Answer 12

C. Increasing presbyopia Worsening near vision, or presbyopia, is an expected age-related change. Blurring may indicate the development of cataracts. Chronic itching and tearing, or photophobia, can be related to many disorders.

Answer 13

B. Slower information processing Slowing of processing and accessing information is a cognitive change associated with aging.

Answer 14

C. Rest tremor Onset of motor signs in Parkinson dx is typically asymmetric, with the most common initial finding being an asymmetric resting tremor in an upper extremity. Over time, patients notice symptoms related to progressive bradykinesia, rigidity, and gait difficulty.

Answer 15

C. Agitation and restlessness The older adult with delirium would present with agitated and restless behavior.

Answer 16

D. “What was your mother’s maiden name?” Remote memory is verbalized after hours, days, or years and may be assessed by asking a patient his or her mother’s maiden name. Asking questions about things that happened today, such as how long the patient has been at your office, what time the patient arrived, and what he or she ate for breakfast, tests recent memory.

Answer 17

B. To keep the patient functioning independently as long as possible The main overall goal of therapy for the patient with Parkinson’s disease is to keep the patient functioning independently for as long as possible. There is no drug or surgical approach that will prevent the progression of the disease. Treatment is aimed at controlling symptoms. Depression occurs in more than 50% of patients with Parkinson’s disease, and it is undetermined whether it is a reaction to the illness or a part of the illness itself.

Answer 18

B. Clopidogrel (Plavix) Clopidogrel (Plavix) an antiplatelet drug used to reduce blood clot formation by preventing platelets from “sticking” together and forming blood clots, should be ordered. The safety of Plavix is comparable to that of aspirin (ASA) and it has clear advantages over ticlopidine. Since ASA is not listed as an answer, clopidogrel is the choice. As with ticlopidine, diarrhea and rash are more frequent than with ASA, but GI symptoms and hemorrhages are less frequent. For patients intolerant to ASA because of an allergy or GI side effects, clopidogrel is an appropriate choice. The benefit of ASA in women has not been clearly proved. ASA also has more side effects than ticlopidine. The desired effect is decreased platelet aggregation rather than anticoagulation, which warfarin would accomplish. Nitroglycerin has no effect on platelets.

Answer 19

C. The person with dementia tries to hide problems concerning his or her memory, whereas the person with depression complains about memory To help differentiate between depression and dementia, keep in mind that the person with dementia tries to hide problems concerning memory, whereas the person with depression complains about memory and discusses the fact that there is a problem with memory. Also, with depression there is usually a time-specific onset, and affected clients tend to be apathetic and withdrawn and have a poor self-mage.

Answer 20

A. It is important to take the medication at the dose and times directed without adjustment Carbidopa levodopa (Sinemet) is prescribed with a tightly regimented schedule. Missed, additional, or poorly timed doses have adverse effects over te course of the Parkinson’s patient’s life – including worsening of the disease and its side effects, Sinemet may be taken with or without food.

Answer 21

A. Inability to concentrate, with psychomotor agitation or retardation The prevalence of depression (5%-10%) does not change with age, but depression is often overlooked in the older adult. The diagnosis requires a depressed mood for 2 weeks and at least for of the following 8 signs, which can be remembered using the mnemonic SIG E CAPS (as when prescribing energy caps): S = sleep disturbance; I = lack of interest; G – feelings of guilt; C = decreased concentration; A = decreased appetite; P = psychomotor agitation or retardation, and S = suicidal ideation. Dementia and delirium often coexist with depression. Delirium is a confusional state characterized by inattention, rapid onset, and a fluctuating course that may persist months if untreated. The person with delirium has memory impairment, such as inability to learn new material or to remember past events. With dementia, there is a cognitive deterioration with little or no disturbance of consciousness or perception; attention span and short-term memory are impaired; along with judgement, insight, spatial perception, abstract reasoning, and thought process and content.

Answer 22

C. FAQ The FAQ (Functional Activities Questionnaire) is a measure of functional activities. There are 10 complex, higher-order activities that are appropriate for the initial assessment of Alzheimer’s dx. The MMSE is a test of cognition. The CAGE is a screening tool for alcoholism. The Holmes and Rahe Social readjustment scale measures major life changes for identifying the impact of stress on an individual.

Answer 23

C. When was the last time she was seen normal? Because the patient presents early in the day, is is possible that she awoke with the symptoms, which will mean she is not eligible for emergent rescue with tPA. However, if the daughter reports that Sally was walking and talking during an early breakfast, her “last normal” falls within the guidelines of less than 3 hours since time of onset. Treatment with tPA does not require the patient to be NPO. Prior stroke is an important hx to report, but will not preclude the patent from receiving tPA. A dysphagia screen is routine assessment of stroke patients and is completed in the ED prior to admission of any oral meds.

Answer 24

A. “What does a “rolling stone gathers no moss” means?” Asking the client the meaning of a familiar proverb assesses the abstraction ability. It must be kept in mind that many proverbs are culturally derived, and the client may not have heard them before. Asking the client to subtract numbers tests computational ability. Asking clients what they think is the best tx for their problem elicits information about their mental representation or beliefs about the illness. Asking clients what they would do if a fire broke out in a restaurant assesses their judgment.

Answer 25

C. Early Alzheimer’s dx The total possible score on the MMSE is 30. The median score for persons aged 18- 59 years old is 29. For persons aged 80 and older, the median score is 25. However, with Sophie’s education level there may be cause for concern that she is exhibiting early signs of dementia. A score of 20 to 25 indicates early Alzheimer’s dx, a score of 10 to 19 indicates middle-stage Alzheimer’s dx. Someone with late-stage Alzheimer’s dx may score below 10.

Answer 26

C. Delirium The DSM-5 lists 5 key features that characterize delirium: (1) disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness; (2) the disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day; (3) an additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception); (4) the disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma; (5) there is evidence from the hx, PE, or labs that the disturbance is caused by a medical condition, substance intoxification or withdrawal, or medication side effect

Answer 27

B. Anosmia Anosmia, the loss of smell, is a common nonmotor feature of Parkinson dx. Ageusia, the loss of taste, is also an underappreciated nonmotor feature of Parkinson dx. The olfactory tract is involved early in Parkinson dx as indicated by frequent occurrence of hyposmia or anosmia years or decades before motor symptoms.

Answer 28

C. Bromocriptine Bromocriptine and pergolide mimic dopamine. The other mechanisms of antiparkinsonian treatments are as follows: Anticholinergics restore acetylcholine-dopamine balance; levodopa restores striatal dopamine; and tolcapone and entacapone reduce systemic degradation of oral dopamine.

Answer 29

D. Proprioceptive function When you ask a patient to walk a straight line placing heel to toe, you are assessing the proprioceptive aspect of the nervous system, which control posture, balance, and coordination. Assessing dermatomes and the major peripheral nerves tests sensory function. The cerebellum is one of the neural structures involved in proprioception and can be assessed in many ways, but not by walking.

Answer 30

a. Pneumonia

Answer 31

A. A simple exercise program A simple exercise program, 1 hour twice a week has shown to significantly slower decline in ADLs in patients.

Answer 32

Stroke is the fifth leading cause of death and a leading cause of disability among adults. It is one of the most common reasons for admission to the hospital. Approximately 1 out of every 20 deaths in the United States is caused by stroke. In the past 10 years rate of death from stroke however has fallen by 33%.

Answer 33

``` ● Hypertension ● Obesity ● Atrial fibrillation (AF) / cardiac disease ● Diabetes ● Dyslipidemia ● Excessive alcohol intake ● Physical inactivity ● Smoking ● Diet For completeness the nonmodifiable risk factors are listed below: ● Age ● Gender ● Family history ● Ethnicity ● Previous TIA or stroke ```

Answer 34

● Diet, sodium, exercise, weight, smoking, alcohol intake All patients should receive information and counseling about possible strategies to modify their lifestyle and risk factors.

Answer 35

Blood pressure is the most consistent and powerful predictor of recurrent stroke such that hypertension is causally involved in nearly 70% of all stroke cases. Small reductions in blood pressure have big impacts on incidence of stroke. A reduction in blood pressure of 10/5 mm Hg will reduce the risk of stroke by 35% to 42%. Significant reductions in recurrent stroke were seen with diuretics alone and in combination with angiotensin-converting enzyme (ACE) inhibitors but not with beta-blockers or ACE inhibitors used alone.

Answer 36

recommend a blood pressure goal of less than or equal to 130/80 mm Hg Recommendations from American Heart Association (AHA)/ American Stroke Association (ASA) ● Blood pressure reduction is recommended for both prevention of recurrent stroke and prevention of other vascular events in persons who have had an ischemic stroke or TIA and are beyond the first 24 hours (Class I; Level of Evidence A). ● Because this benefit extends to persons with and without a documented history of hypertension, this recommendation is reasonable for all patients with ischemic stroke or TIA who are considered appropriate for blood pressure reduction (Class IIa; Level of Evidence B). ● An absolute target blood pressure level and reduction are uncertain and should be individualized, but benefit has been associated with an average reduction of approximately 10/5 mm Hg (Class IIa; Level of Evidence B). ● The optimal drug regimen to achieve the recommended level of reduction is uncertain because direct comparisons between regimens are limited. The available data indicate that diuretics or the combination of diuretics and an ACE inhibitor are useful (Class I; Level of Evidence A). ● The choice of specific drugs and targets should be individualized on the basis of pharmacological properties, mechanism of action, and consideration of specific patient characteristics for which specific agents are probably indicated (eg, extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes) (Class IIa; Level of Evidence B).

Answer 37

Recommendations from AHA/ASA ● Statin therapy with intensive lipid-lowering effects is recommended to reduce risk of stroke and cardiovascular events among patients with ischemic stroke or TIA who have evidence of atherosclerosis, an LDL-C level greater than 100 mg/dL, and who are without known CHD (Class I; Level of Evidence B). ● For patients with atherosclerotic ischemic stroke or TIA and without known CHD, it is reasonable to target a reduction of at least 50% in LDL-C or a target LDL-C level of less than 70 mg/dL to obtain maximum benefit (Class IIa; Level of Evidence B). (New recommendation.) ● Patients with ischemic stroke or TIA with elevated cholesterol or comorbid coronary artery disease (CAD) should be otherwise managed according to National Cholesterol Education Program (NCEP III) guidelines, which include lifestyle modification, dietary guidelines, and medication recommendations (Class I; Level of Evidence A).

Answer 38

``` ● Cardiac cause of stroke: AF and PFO ● Extracardiac cause: intracranial and extracranial large vessel atherosclerotic disease (carotid artery / vertebral-basilar disease) Atrial Fibrillation (AF): The optimal intensity of oral anticoagulation for stroke prevention in patients with AF appears to be an international normalizing ratio (INR) of 2.0 to 3.0. ```

Answer 39

● Aspirin ● ACE inhibitor and thiazide diuretic ● Statin ● Consider antidepressant (post-stroke depression can be severe)

Answer 40

common consequence of stroke and reported to occur in almost 40% of patients who have had a stroke. Post-stroke depression is associated with poor functional recovery, poor social outcomes, reduced quality of life and rehab along with increased cognitive impairment. Apathy—motivational disorder is found in 23% to 57% of patients with stroke. Screen patient for depressive symptoms and initiate treatment as necessary—most studies have examined citalopram in post-stroke depression but selective serotonin reuptake inhibitors (SSRIs) in general seem to be effective.

Answer 41

Recommendations from AHA/ASA ● For patients with noncardioembolic ischemic stroke or TIA, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I; Level of Evidence A). ● Aspirin (50 mg/d to 325 mg/d) monotherapy (Class I; Level of Evidence A), the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily (Class I; Level of Evidence B), and clopidogrel 75 mg monotherapy (Class IIa; Level of Evidence B) are all acceptable options for initial therapy.

Answer 42

``` Ask about the need for assistive devices and services. A common complication suffered by many patients who have had a stroke is falls. Do not ignore these "little spells" or "trips." These all impede the patient's functional status and can impair rehab and recovery. Providing stroke survivors with assistive devices such as walkers and canes can help them have more freedom and make the caregiver's job easier. Here are some examples of assistive devices that may be helpful: ● Wheelchair ● Bath brush ● Walker ● Shower grab bar ● Reacher/ gripper ● Quad cane ● Shirt buttoner ● Tub bench ● Elevated toilet seat ● Urinal ```

Answer 43

C. Speech impairment There are many mimics of TIA including seizures, migraines, syncope, and metabolic disturbances such as hypoglycemia. Speech impairment is much more likely to be due to TIA compared to other causes. While memory loss, headache, and blurred vision may be associated with TIA and stroke, these symptoms are also associated with many other clinical conditions.

Answer 44

A. Unilateral paresis and dysarthria The most common presenting symptoms in a patient with TIA are unilateral paresis (58%) and dysarthria (21%) and are more likely to be associated with acute cerebral infarct on MRI. Headache, cognitive impairment, and diplopia may also be a part of the clinical presentation of TIA but are less common.

Answer 45

B. High-intesity physical therapy In patients that have had a TIA, high-intensity physical activity has a relative risk reduction of 64% in the prevention of stroke compared to inactivity. Blood pressure reduction conferred a relative risk reduction of 30% to 40%. Antiplatelet medications and statin therapies conferred a relative risk reduction of 18% to 37% and 16% to 33%, respectively.

Answer 46

1) Physical Health 2) Cognition and Mental Health 3) Functional Status 4) Social and Environmental Circumstances 5) Advance Care Planning

Answer 47

● In addition to treating medical problems, the geriatric assessment includes screening patients for risk factors that can affect health and independence. ● Often requires a multidisciplinary team including nutrition, social work, physical therapy, and occupational therapy ● When should it be done? ● Yearly starting at age 75 if healthy ● Yearly when younger than 75 if the patients has multiple comorbidities ● After major illness requiring hospitalization ● May address specific problems during first visit then use rolling assessment over several visits and target one domain per visit ● In general, if the patient has more than 5 year life expectancy, consider age-appropriate screening. ● USPSTF has an electronic tool that gives screening recommendations by age (http://epss.ahrq.gov/ePSS/search.jsp)

Answer 48

``` ● Nutrition ● Vision ● Hearing ● Urinary and bowel incontinence ● Balance problems and history of falls ● Osteoporosis risk ● Polypharmacy ```

Answer 49

``` ● Presbyopia ● Glaucoma ● Diabetic retinopathy ● Cataracts ● Age-related macular degeneration ```

Answer 50

Two-thirds of adults older than 70 have significant hearing loss, one-third of those have severe hearing loss. ● Can lead to social isolation, functional decline, poor quality of life, depressive symptoms, and cognitive deficits Screening ● USPSTF recommends asking patient and caregivers about hearing loss ● Whisper test – Stand 3 feet away and whisper letters and numbers as screening test ● Most common cause of hearing impairment in older adults is presbycusis (multifactorial sensorineural hearing loss) and cerumen impaction (conductive hearing loss).

Answer 51

1. Associated with decubitus ulcers, sepsis, renal failure, urinary tract infections, and increased mortality 2. Psychosocial impairment – restriction of social and sexual activities, increased risk of depression 3. Key deciding factor for nursing home placement 4. Evaluation – fluid intake, medications, cognitive functions, mobility, urologic surgeries 5. Screening questions ● Urge incontinence – Do you have a strong and sudden urge to void that makes you leak before reaching the toilet? ● Stress incontinence – Is your incontinence caused by coughing, sneezing, lifting, walking, or running?

Answer 52

● More than one-third of community-dwelling adults older than 65 fall once per year ● 10% of falls result in major injury ● Leading cause of hospitalization and injury-related death in people older than 75 years old ● Increases risk of nursing home placement ``` Risk factors for falls ● Age older than 80 years old ● Female ● Lower body mass index (BMI) ● 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 ``` Screening ● Get Up and Go Test ● Observing a patient get up from chair without using arms, walk 10 feet, turn around, walk back, sit down (should not take longer than 16 seconds) ￫ anything concerning needs further evaluation ● One fall without major injury and normal Get Up and Go Test ● ￫ No further evaluation needed Decrease fall risk with exercise, physical therapy, home hazard assessment, decreasing psychotropic medications Home assessment and modification can significantly decrease the number of falls (can be done by family or occupational therapy).

Answer 53

● Beers criteria – list of medications to avoid in the elderly ● 20% of community-dwelling adults older than 65 year old take more than 10 meds ● More meds leads to: ● Increased risk of adverse events ● Increased risk of noncompliance (may be noncompliant with one medication but adherent with another), age is not a risk factor for adherence ● Increased drug cost ● Do not focus on number of meds but whether the medications are still indicated ● Tailor to individual circumstances, comorbidities, goals of care, preferences, support system, and ability to adhere to medications

Answer 54

Discontinue medications without clear indication (leftovers from acute conditions or transitions of care) High-risk medications (warfarin, digoxin, hypoglycemic medications) One drug at a time if condition is stable, more aggressive discontinuation if experiencing side effects that may be due to drugs Taper down medications at the rate that you would taper them up (opioids, beta blockers, clonidine, gabapentin, antidepressants) Educate patients on side effects of tapering or discontinuation Communicate with other providers that may be prescribing Oral communication is important but not enough ￫ also provide written instructions, especially if more than one person is involved in medications. Simplifying regimen improves adherence – 80% adherence to one daily dosing versus 50% adherence to 4 times per day dosing

Answer 55

Activities of Daily Living (ADLs) ● Self-care = eating, dressing, bathing, transferring between bed and chair, using toilet, controlling bowel and bladder ● Katz ADL Scale Instrumental Activities of Daily Living (IADLs) ● To live independently = managing medications, preparing meals, housework, managing finances, using the telephone, driving ● Lawton IADL Scale

Answer 56

● Memory (dementia) ● Judgment and executive function (dementia) ● Visual and spatial perception (cataracts, glaucoma, poor night vision) ● Physical (arthritis, neurological conditions, hypoglycemia, adverse drug reactions) ● Assessment of driving-related skills battery has not been validated against driving outcomes

Answer 57

Driving cessation can greatly affect quality of life (decreased social integration, increased depression and anxiety, increased risk of nursing home placement) and many patients are very reluctant to give up driving. Visual and spatial skills are the most relevant predictors of driving impairment. Dementia and cognitive impairment ● Most patients with early dementia or mild cognitive impairment can pass a driver's test. ● Diagnosis of dementia should not be the only reason to revoke a driver's license but experts are unclear about what criteria to revoke in mild dementia. ● By expert consensus, people with moderate dementia should not drive. ● It should be discussed early in the course of dementia that eventually they will have to stop driving.

Answer 58

Driving clinics or driver rehab specialists (occupational therapy) are available but assessments are not standardized. ● Testing takes several hours ● Tests vision, cognition, motor skills ● May be expensive and is usually not covered by insurance Recommend performance-based evaluation through the Department of Motor Vehicles (DMV) if patient has any of the following: ● If caregiver notices new traffic impairments ● Prominent impairments in key cognitive domains (attention, executive function, visual, and spatial perception) ● Mild dementia All state DMVs conduct performance-based road tests. If a person fails, license can be revoked. Mandatory reporting of drivers with dementia in some states but most states have voluntary reporting. Reporting to the DMV is recommended if clinician feels that they are a danger to themselves or others (for example, if the patient has refused to stop driving or if there is a high risk of crash or injury).

Answer 59

● Living will or advance care plan ● Durable power of attorney for health care or medical power of attorney ● Durable power of attorney for finances (DPOAF) ● Last will and testament

Answer 60

Financial capacity = ability to independently manage one's financial affairs in a manner consistent with personal interest ● Loss of financial capacity occurs early in the course of cognitive impairment (one of the first IADLs to decline) ● Can be seen in mild dementia ● Patients with moderate and severe dementia usually cannot manage their finances. ● Can be very psychologically distressing as it is one of the first signs of losing independence ● One of the strongest predictors of caregiver burden ● Makes patients vulnerable for financial abuse

Answer 61

● Education about the need for an advance care plan (ACP) ● Durable power of attorney for finances (DPOAF) ● Discuss at the time of diagnosis of dementia ● Recognizing signs of possible impaired financial capacity ● Assessing financial impairment in cognitively impaired adults ● Recommending interventions to help patients maintain financial independence (automatic deposits or withdrawals) ● Knowing when and to whom to make medical and legal referrals ● Legally obligated to report suspected elder abuse including financial abuse ● May be able to refer to neuropsychology, geropsychology, occupational health, or forensic psychiatry depending on what's available to assess financial capacity. ● If the patient does not have financial capacity, an existing DPOAF can be implemented. If there is no DPOAF then a conservator or guardian is appointed by the state

Answer 62

Dementia Mild cognitive impairment (MCI) Depression Delirium ``` Others to consider: Cerebrovascular dx hydrocephalus hypothyroidism Vit B12 deficiency CNS infection medication effects substance abuse neoplasms ```

Answer 63

depression should be evaluated in all older patients with memory complaints More common in women, patients with chronic medical conditions, persistent insomnia, significant stressful events, functional decline, social isolation ● Use the PHQ-9 to assess ● Scale of 0 to 27 (higher scores indicate depression)

Answer 64

``` ● Acute decline in attention and cognition ● Fluctuating course ● Inattention and disorganized thinking ● Altered level of consciousness ● Hallucinations and psychomotor disturbances ● Altered sleep-wake cycles ● Emotional lability ● May be hypo- or hyperactive delirium ``` Needs urgent evaluation as many causes are life-threatening Dementia is the leading risk factor for delirium, and two-thirds of delirium occurs in patients with dementia.

Answer 65

``` Evidence of decline in one or more cognitive domains ● Learning and memory ● Language ● Executive function ● Complex attention ● Perceptual-motor ● Social cognition ``` The cognitive deficits interfere with independence in daily activities, and at minimum, needs help with complex activities of daily living (such as paying bills) The cognitive deficits are not exclusively due to delirium The cognitive deficits are not explained by another mental disorder (such as schizophrenia or major depressive disorder)

Answer 66

Important to identify (if possible) because can change treatment and will give more prognostic information to the patient and family ``` Alzheimer disease (50%-80% prevalence) ● Rapid forgetfulness, especially of new material ``` Frontotemporal dementia (12%-25%) ● More trouble planning tasks ● More behavioral disturbances and disinhibition Mixed etiology (10%-30%) Vascular dementia (10%-20%) ● More quick onset, more language problems ● Less forgetful than AD especially if cues available Lewy body dementia (5%-10%) ● May have more psychiatric symptoms (eg, psychosis) early in disease

Answer 67

``` Risk factors ● Increased age ● Stroke ● Hypertension ● Apolipoprotein E status ● Family history for AD7 ``` Protective factors ● Higher levels of education ● Physical activity ● Moderate alcohol intake

Answer 68

Reliable information is obtained from the informant as well as cognitive behavioral testing. More likely to come to attention when symptoms involve behavioral problems or dependence on activities of daily living (ADLs). Subjective memory complaints may be less likely to yield diagnosis of dementia than objective memory complaints, although both should be evaluated by validated tests.5 Subjective complaints may be more associated with depression, lower levels of education, older age, male sex, and poorer overall health.5

Answer 69

Mini mental status exam (MMSE) Memory impairment screen Clock drawing test General Practitioner Assessment of Cognition More comprehensive tests: - Modified MMSE - Hopkins Verbal Learning Test or Word List Acquisition Test - Cognitive Assessment Screening Test - Psychogeriatric Assessment Scales - Clinical dementia rating scale

Answer 70

Most widely studied cognitive test Domains: orientation, registration, attention and calculation, recall, language Should be adjusted for patient's age, may be influenced by education level (norms have been published but no score conversions are available) Most helpful for moderate dementia, less for mild dementia Free of charge if used from practitioner's memory, original paper, or source authorized by publisher ● Takes 7 to 10 minutes to administer ● Positive test usually is a score less than 23 to 24 out of 30 ● Sensitivity = 71% to 92% ● Specificity = 56% to 96%

Answer 71

● Tests recall ability ● Patient given nouns in 4 groups (animal, city, vegetable, musical instrument) ● Then given a diversionary task ● Ask to recall nouns: 2 points each if no prompting needed, 1 point for prompted answer ● Allows use for research and license available for commercial use ● Takes 4 minutes to administer ● Cut-off score of 4 yields sensitivity of 80% and specificity of 96%

Answer 72

● Tell patient to "put numbers on the face of a clock" and "make the clock say 10 minutes to 11" ● Can distinguish between normal aging and mild dementia ● Several different ways to score it with differing reliability ● May increase the sensitivity of MMSE to pick up very mild dementia

Answer 73

Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) - FDA approved for mild to moderate AD, NOT severe AD - Side effects: N/V/D, dizziness, weight loss - contraindications: cardiac conduction abnorms, gastric ulcers, hx bleeding N-Methyl-D-aspartate (NMDA) receptor antagonist (memantine) - FDA approved for mod to severe dementia - not beneficial in mild-mod dementia as monotherapy, add to cholinesterase inhibitor as dementia progresses - side effects: HA, sedation, constipation, agitation

Answer 74

``` o Anti-inflammatory o Estrogen o Statins o Antioxidant vitamins o Ginkgo biloba o Acetyl-L-carnitine o Lecithin ```

Answer 75

A cholinesterase-inhibitor ● May show symptomatic improvement or slowing of progression for 6 to 12 months, with possible benefits at 2 to 3 years ● Studies have not shown a significant difference between donepezil and placebo in terms of caregiver well-being, time of caregiving, or costs of care

Answer 76

● No FDA-approved treatment ● Cholinesterase inhibitors have not been shown to slow progression to AD, although the expert consensus guidelines say that it may be considered for patients with MCI.

Answer 77

More focus on aggressive treatment of hypertension and diabetes ● Consider aspirin and lipid-lowering agent5 ● Consider cholinesterase-inhibitor in mixed vascular and Alzheimer disease

Answer 78

Cognitive training o Targeted practice and training in specific domains of cognition, usually memory and executive functioning o Has not shown significant difference in mild dementia compared to control Cognitive rehab programs o More geared toward improving functionality in everyday life o May improve cognitive function in patients with MCI o Has not shown significant difference in mild dementia compared to control Reminiscence therapy o Allows patient to revisit memories and experiences o Significant improvement in cognitive and depressive symptoms

Answer 79

There are no psychotropic agents that are FDA approved for treatment in dementia, although there are several medications that are commonly used Agitation with delirium or psychosis o Atypical antipsychotics (risperidone, olanzapine, quetiapine) are commonly used o May increase risk of metabolic syndrome and stroke o Black box warning for atypical antipsychotics issued by FDA in 2005 for elderly patients with dementia-related psychosis as they found an increased rate of death compared to placebo. o If these medications are used, they should be targeted at a specific symptom with plans to taper and remove medication within 6 months. ``` Agitation and aggression o Anticonvulsants (divalproex, carbamazepine) ``` Depression or anxiety o Selective serotonin reuptake inhibitors (SSRIs) (such as sertraline and citalopram) or buspirone o Avoid tricyclic antidepressants (TCAs) as they may worsen agitation and increase risk of falls. o Benzodiazepines may be used for short-term treatment of anxiety5 although this may worsen confusion, increase risk of falls, and cause paradoxical agitation o No consensus on choice of medication Insomnia - consider trazodone All of these symptoms can occur at any time throughout the course of dementia, although they are more common as dementia advances. Nonpharmacologic interventions to calm and reorient patients include music, videotapes of family members, maintaining a familiar environment, and caregiver training.

Answer 80

Persons with AD may live 3 to 20 years (average 8 years) Early planning allows patient and family to make financial, legal, and medical decisions while patient still has capacity to make decisions for themselves. The financial and health care surrogates would only be asked to make decisions if the patient were to lack the capacity to make decisions for themselves. Medical o Designation of health care power of attorney o Discussions of quality of life, boundaries to medical interventions, and advance care planning o Creating a living will Financial o Designation of financial power of attorney o Adding financial power of attorney (POA) to financial accounts o Creating a (financial) will

Answer 81

Living arrangements: Eventually patients will be unable to live alone. Patient and family should consider whether they have the time and financial resources to care for a patient at home, or whether to consider nursing home placement. ``` Safety: o Monitor medications early on o Limit or stop driving (many states do evaluations for free through the Department of Motor Vehicles) o Monitor use of cooking and appliances o Remove firearms from the home o Home safety assessments ``` Caregiver self-care is very important as the emotional and financial stresses of caring for a family member with dementia can be significant

Answer 82

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), delirium is characterized by 4 key features: ● Disturbance in attention (decreased ability to direct, focus, and sustain attention) and orientation to the environment ● Development of the disturbance over a short period of time (usually hours to days) which fluctuates over the course of the day ● A change in cognition or the development of perceptual disturbance that is not explained by a preexisting condition (eg, dementia) ● The disturbance is not caused by a severely reduced level of arousal, such as coma Given the sudden onset of her condition in the setting of no prior history, this situation would be best classified as an acute delirium.

Answer 83

Recognition of the diagnosis is the most important aspect to appropriate management. Some estimates state that up to 70% of delirium goes unrecognized in the inpatient and outpatient settings. Because the patient will most likely be unable to provide an adequate history, details should be elicited from family or witnesses nearby. Key points of history that should be investigated are signs or symptoms of recent infection, history of organ failure, a medication list, history of substance use, and psychiatric history including recent evidence of depression.

Answer 84

The differential diagnosis for delirium should include a wide range of processes such as electrolyte or metabolic imbalances, infections, intoxications, withdrawals, psychiatric illness or onset of dementia, or vital sign instability such as hypoxia or hypotension. For more severe episodes of delirium, seizure or stroke should also be included on the list of possible causes. One of the greatest risk factors for the development of delirium is age, as the elderly are most susceptible to risk factors such as change in surroundings, depression, medication changes, or acute stressors such as surgery or hospitalization due to illness. For all patients, up to 30% of delirium cases may be due to medications or alterations in their metabolism. For this case, inquiring about her past medical history reveals a clue. Review of Mrs. Hayes's history would reveal that she had been taking alprazolam 3 times a day for her anxiety for quite some time, but she has been unable to tolerate her medications over the past several days. This sudden withdrawal of a benzodiazepine is the most likely source of her symptoms.

Answer 85

Most practitioners consider any episode of delirium to be a medical emergency that requires rapid evaluation and intervention. Because a full history and physical are not possible over the phone, it is important that this patient is brought to the emergency department for a full evaluation right away.

Answer 86

In this case, a full history is vital in establishing need for a further workup. Most likely, Mrs. Hayes does not have acute delirium in this case, based on the slow onset of the concerning symptoms and her ability to focus on questions posed to her. There is no history of difficulty with more basic activities of daily living (ADLs), and this is more likely an early presentation of dementia rather than an acute delirium. Differentiating between delirium and dementia can be difficult, especially in later stages of dementia, and is made more difficult in that dementia is a significant risk factor for the development of delirium. Assessment tools such as the Confusion Assessment Method (CAM) for delirium and the Mini Mental Status Exam (MMSE) for dementia may help confirm each diagnosis. A history of sudden onset or fluctuation during the day is a key indicator that there is delirium with or without underlying dementia. It is reasonable to screen for additional psychiatric features in this situation. Other psychiatric conditions, such as depression, often manifest as an acute delirium or dementia-like picture in older patients. In younger patients other psychiatric illnesses, like schizophrenia or manic syndromes, may be initially presented as delirium.

Answer 87

As mentioned earlier, the elderly are at the greatest risk of developing delirium due to an often reduced capacity to handle physical and psychological stressors. Elderly patients often respond to a multitude of conditions by developing delirium, often evidenced by withdrawal, confusion, or agitation. The most common of these conditions include infections (such as urinary tract infections, pneumonia, or skin infection), pain, sleep deprivation (leading to what is commonly called "sundowning"), depression, volume depletion, or medication effects. Delirium is also a common feature seen in patients with advanced malignancy or who are recently postoperative from complex procedures.

Answer 88

Primary interventions that are effective during treatment and for prevention of delirium should focus on environmental factors, such as reorientation, appropriate sleep hygiene, visual or hearing aids if these are impaired, maximizing mobilization, and avoiding physical restraints unless the patient poses a significant risk to themselves or others. One component of the environment that may be vital to a delirious patient (and that usually escapes the attention of providers) is interpersonal need of social interaction, which can continue to exist despite a loss of communication or comprehension. In many situations, the mere presence of a family member or even medical staff can be enough to alleviate the stress of isolation often seen in delirious and demented patients. Of course in many cases, pharmacotherapy is an important component in the effective treatment of acute delirium. This becomes more important especially for patients with hyperactive or aggressive delirium. Pharmacotherapy focuses on altering common neurotransmitters involved in delirium such as acetylcholine, dopamine, serotonin, and gamma-aminobutyric acid (GABA).

Answer 89

C. Presbycusis

Answer 90

A. Body mass index (BMI) of 25 kg/m2

Answer 91

A. Sertraline

Answer 92

A. Financial abuse is a form of elder abuse.

Answer 93

C. Tests of visuospatial skills are the most relevant predictors of driving impairment.

Answer 94

D. Moderate alcohol intake

Answer 95

B. Mild cognitive impairment

Answer 96

A. Alzheimer disease

Answer 97

A. Feeding difficulties

Answer 98

C. Can hold head up independently but cannot sit up independently, two hospitalizations for aspiration pneumonia Hospice is a medical service that cares for patients with end-stage illness when the primary focus is on symptom management at the end of life. In the United States, Medicare sets hospice requirements; most other insurance plans have adopted these requirements. Patients qualify for the Medicare hospice benefit if two clinicians (usually the referring clinician and the hospice medical director) agree that the patient likely has less than 6 months to live if the illness were to take its natural course. While it is difficult to predict a patient's medical trajectory with certainty, current hospice eligibility guidelines identify patients with dementia as having less than a 6-month prognosis if they have a Functional Assessment Staging tool (FAST) stage 7c (unable to ambulate independently) and at least one of the following medical conditions: aspiration pneumonia, pyelonephritis or upper urinary tract infection, septicemia, pressure ulcer (multiple, stage 3 or 4), recurrent fever after treatment with antibiotics, and eating problems (such as decreased intake, weight loss, or albumin level less than 2.5 g/dL).

Answer 99

C. 4 -5 years The median survival time after diagnosis of dementia is 4.5 years when all patients with dementia are considered but changes based on age of diagnosis. For people diagnosed in their 60s, the median survival time after diagnosis is approximately 11 years. For people diagnosed in their 90s, the median survival time is approximately 4 years.

Answer 100

C. Memantine Memantine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has been shown to slow cognitive deterioration with moderate to severe AD, but has not been shown to benefit patients with mild AD. Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine have been shown to decrease cognitive decline in patients with mild to moderate AD.

Answer 101

Medicare does not pay for a classic "annual physical." ● They pay for a one-time screening physical exam for the purpose of health promotion and disease prevention. ● This is called the IPPE, or Initial Preventive Physical Examination ● It is a screening visit, and not meant to be an evaluation for all her medical problems. ● This is a one-time Medicare benefit that patients can receive. ● After the initial 12 months of eligibility have passed, or after they has received the one-time IPPE, they can receive an Annual Wellness Visit (AWV) (which does NOT include an annual physical) yearly The one-time IPPE must include all of the following elements: 1) History a. Medical history ▪ Medicines, supplements ▪ Alcohol, tobacco, drug use ▪ Diet and exercise b. Risk Factors for depression – use a screening tool (eg, Beck depression inventory, Patient Health Questionnaire 2 [PHQ-2]) c.Functional status and safety assessment ▪ Use any standardized screening tool to assess (at a minimum): ▪ Hearing ▪ Activities of daily living (ADLs) ▪ Fall risK ▪ Home safety 2) Examination a. Measurements: height, weight, BMI, blood pressure b. Vision c. Other screening exam based on history and risk 3) End-of-life planning (verbal or written information to be given) a. Advance directive planning 4) Counselling Based on the information obtained above, offer education, counselling, referral as appropriate a.Provide patient with a written plan (a checklist) for the following screening ▪ EKG as appropriate ▪ Medicare-covered screening tests (essentially, US Preventive Services Task Force A and B recommendations)

Answer 102

● CPT code is G0402 (for the IPPE) ● ICD-10 code is Z00.0 series (Encounter for general adult medical examination) In truth, CMS does not require a diagnosis code for this covered service and they state "you may use any diagnosis code you choose" as it will be covered by Medicare from the CPT alone. (If you do a screening electrocardiogram (ECG), the CPT codes change slightly to G0403-405 depending on whether an electrocardiogram, the interpretation, or both are provided.)

Answer 103

You have provided an additional E/M service in addition to her screening physical. You can add a CPT code 99213 for a mid-level E/M visit, with a 25 modifier since you are adding an additional service, with an ICD-10 of M19.90 for generalized osteoarthritis.

Answer 104

You need to add a GE modifier if you see the patient on your own or a GC modifier if you see the patient with your attending physician.

Answer 105

Medicare does not pay for an annual physical. After the one-time IPPE, they do not pay for even a screening physical. For all subsequent years, the Annual Wellness Visit (AWV) is intended to identify problems, to prevent problems, and to make sure the patient receives the appropriate screening, education, guidance, and referral. It is not a "classic annual physical." It is important to provide the patient with the information about what these visits cover so that they have the appropriate expectations for these visits. For the Annual Wellness Visit (AWV), these are the required elements: 1) History o Health Risk Assessment (HRA) ▪ This assesses: Demographic data, self-assessed health status, psychosocial risk, behavioral risk, ADLs (self-care--bathing/dressing; life skills--shopping, meals, banking) o Standard Patient History ▪ Standard – past medical, family, and social history ▪ Depression Screening (use a tool, eg, Beck depression inventory, PHQ-2) ▪ Assessment functional ability (direct observation or a screening tool) ▪ Activities of daily living (ADLs) ▪ Fall risk ▪ Hearing assessment ▪ Home safety 2) Assessment o Measurements: height, weight, BMI, blood pressure ▪ Other measurements based on identified risk (waist circumference) o List other current providers o Cognitive impairment ▪ By direct observation, care provider reports, or by screening tool 3) Counselling o Establish a written screening schedule for the next 5 to 10 years (including): ▪ USPSTF A and B screening recommendations by age ▪ Advisory Committee on Immunization Practices (ACIP) vaccines recommendations ▪ Patient's prior screening history ▪ This is the PPPS (Personalized Prevention Plan of Service) o Establish a list of risk factors and conditions of patient ▪ Medical diagnoses ▪ Mental health conditions ▪ List of treatment options, with risks and benefits o Personalized health advice--counselling or referral to programs for: ▪ Risk reduction, wellness ▪ Fall prevention ▪ Nutrition ▪ Physical activity ▪ Tobacco cessation ▪ Weight loss

Answer 106

● CPT code: G0438 for the initial AWV, and all subsequent AWVs are G0439 ● ICD-10: Z00.0 series (Encounter for general adult medical examination) Note: You may choose to do a problem-based visit for Medicare patients since most older patients have medical problems and work in preventive services to these visits. However, these Medicare wellness visits provide a strategy and structure to make sure you preserve time for these complex patients to get the screening and counselling done, ensure it is comprehensive, and also get paid for it.

Answer 107

Ischemic: - thrombosis - blockage of blood flow d/t arteriosclerosis - embolic - blood clot formed elsewhere travels to cerebral circulation Hemorrhagic/intracerebral hemorrhage: - primary: majority of ICH r/t chronic HTN - secondary: ICH d/t cerebrovascular abnorm (tumor, impaired coag) - subarachnoid hemorrhage: typically d/t aneurysm rupture, AVM, or bleeding d/o

Answer 108

modifiable: HTN, DM, smoking, HLD, obesity, poor diet/nutrition, physical inactivity, afib, ETOH HTN is most important independent RF unmodifiable: older age, men, AA, fam hx

Answer 109

sudden numbness/weakness of face, arm, leg, esp one side sudden confusion or trouble speaking or understanding speech sudden trouble seeing in one or both eyes sudden trouble walking, dizziness, loss of balance or coordination sudden severe HA with no known cause

Answer 110

transient neuro symptoms that resolve lasts few mins to hours resembles early stroke - numbness, weakness, flaccidity, visual changes, ataxia, dysarthria precedes 10% of strokes typically requires 24 hr observation ER lifestyle mod to prevent ischemic stroke use ABCD score to determine course of tx

Answer 111

ischemic event evolves over course of a few hours if carotid involved: ipsilateral eye affected = amaurosis fugax: transient painless loss of vision hemispheric ischemia: numbness/weakness of contralateral face/limbs language diff cognitive/behavior changes

Answer 112

``` back of brain vertigo N/V nystagmus diplopia dysconjugate gaze ```

Answer 113

``` Age >/= 60 = 1 pt BP >/= 140/90 = 1 pt Clinical presentation: - unilateral weakness w/ or w/o speech changes = 2 pts - speech changes, no unilateral weakness = 1 pt Duration: - >/= 60 min = 2 pt - = 59 min = 1 pt Diabetes = 1 pt ``` 1-3 points = 1% 48hr stroke risk - neuro consult, possible outpt tx and eval 4-5 points = 4.1% 48 hr stroke risk - hospitalization justified 6-7 points = 8.1% of 48 hr stroke risk - hospitalization beneficial

Answer 114

typically no prodrome sudden onset of hypertensive crisis - 180/120 almost always occurs while awake w/activity sudden onset HA, unilateral facial droop, slurred speech, eye deviation 5- 30 min progression paralysis, aphasia

Answer 115

``` vomiting SBP > 220 severe HA coma decreased LOC s/s progression over mins- hrs ```

Answer 116

``` abrupt onset "worst HA of life" thunderclap HA N/V dizziness LOC meningeal irritation atypical HA for weeks leading up to event seizures ```

Answer 117

NIH stroke scale on ALL pts w/ possible stroke MUST fo dx studies to determine ischemic vs hemorrhagic: - CT (most common & time sensitive) 1st test to complete - ischemic areas will not be visible immediately after s/s onset - very sensitive for hemorrhage - MRI more sensitive in acute phase of ischemic stroke if possible seizure: ECG, CT, ABG/SPO2, EEG CBC, PT, PTT, serum glucose, Cr - Do NOT do before CT, dont delay Carotid US TEE: obtain clear images of heart and blood clots (afib?) TTE: finds source of clots in heart that may have traveled to brain to cause stroke cerebral angiogram holter monitor

Answer 118

obtain CT & administer thrombolytics (if indicated) within 45- 60 mins of ED arrival

Answer 119

rehab needs: >/=14 severe = long term care 6- 13 adequate: acute inpt rehab = 5 mild: 80% DC home

Answer 120

immediate transport to stroke facility

Answer 121

primary and secondary interventions: BP control, anti-thrombotic therapy, smoking cessation, diet/nutrition, physical activity, OSA mgmt, BG control, HLD mgmt educate on stroke s/s & instruct to immediately call 911

Answer 122

Can be evalated/ tx outpatient evaluate probable cause: afib, carotid stenosis - get carotid US & ECG RF management

Answer 123

neuro consult tPA & revacularization (thrombectomy) tPA given within 4.5 hrs of s/s onset

Answer 124

``` BP mgmt reversal of anticoag if on one - Warfarin = Vit K - ASA or Plavix = give platelets - heparin or lovenox - protamine sulfate ```

Answer 125

> 18 y.o. clinical dx of ischemic stroke s/s onset < 180 min before tPA admin

Answer 126

PO anticoag DM & previous stroke hx > 80 y.o. NIHSS > 25

Answer 127

prevention beneficial regardless of age, gender, BP, or DM dx ASA: standard preventative care Warfarin/other DOACs: pt @ risk for embolism/hypercoaguable state - Afib, LV dysfunction + CHF, artificial heart valves thienopyridines (Plavix or Ticlid): allergic to ASA

Answer 128

progressive loss of memory & behavioral changes, personality changes, language disturbances which interfere with independence in ADLs Alzheimer's dx vascular dementia Lewy body dementia

Answer 129

mild cognitive impairment HTN, DM, HLD, peripheral vascular occlusion fam hx, old age, Down syndrome

Answer 130

``` visual hallucinations motor impairments postural instability sleep disturbances can have psychosis ``` more psychiatric symptoms

Answer 131

quicker onset more language problems less forgetful than AD

Answer 132

rapid forgetfulness, esp of new material

Answer 133

memory loss, personality changes, language disturbances, diff w/ ADLs

Answer 134

no single standardized test dx of exclusion - detailed hx from fam or caregivers - complete physical and neuro exam - brief mental status or cognitive screening tests can be completed to ID pts most likely to benefit from more comprehensive assessment

Answer 135

CBC, CMP. TSH, B12, folate, serum drug levels baseline brain imaging w/ non-contrast CT or MRI

Answer 136

depends on stage of dementia - tx all correctable factors that may impair cognition to improve ADLs & delay disability - activities that promote & enhance cognition & social engagement - durable POA - address safety concerns - driving, kitchen

Answer 137

``` no single dx study CBC, BMP, thyroid, B12, folate, serum drug levels possible imaging brain biopsy postmortem = definitive dx initial cognitive testing (clock) ``` REFER to neuro to confirm

Answer 138

meds delay progression, not curative 1st line = cholinesterase inhibitors - refer to neuro for med mgmt - Donepezil - mild- mod AD NMDA (memantine) - mod- severe AD w/ cholinesterase inhibitor SSRIs - Citalopram for neuropsych s/s like agitation CBT - mold to mod AD

Answer 139

``` memory loss, poor judgement withdrawn, depressed perceptual disturbances personality changes time & spatial disorientation ```

Answer 140

``` recent & remote memory worsens increased aphasia (slowed speech & understanding) apraxia, hyperorality disorientation to place & time restlessness or pacing perseveration, irritability loss of impulse control ```

Answer 141

``` incontinent bowel/bladder loss of motor skills, rigidity decreased appetite, dysphagia agnosia, apraxia severely impaired communication possible inability to recognize family members or self in mirror loss of most or all self-care abilities severely impaired cognition, depressed immune system ```

Answer 142

neuro consult helpful w/ unclear clinical pic unusual presentation or depression present - consult endstage dementia - hospice referral speech therapy for swallowing or dysphagia in late stages driving, kitchen and home safety evals by OT

Answer 143

bed bound status | late stage of dementia

Answer 144

acute change in MS often only indicator in older adults of underlying physical illness: infection, MI, drug toxicity/withdrawal

Answer 145

hallmark --> clouding of consciousness w/ inability to focus, sustain, or shift attention change in cognition, including impairment in short-term memory, disorientation, & perceptual disturbances symptoms develop rapidly and fluctuate in severity

Answer 146

delirium superimposed on dementia pt w/ underlying dementia @ greater risk for delirium w/ acute illness

Answer 147

ID & tx of precipitating causes | management of symptoms such as agitation, restlessness, and hallucinations

Answer 148

depression in older adults can lead to memory loss, attention deficits & problems with initiation cognitive symptoms often persist as residual symptoms in patients for whom depression has remitted cognitive problems that coincide with onset of MDD ep in context of previously normal cognition - more likely d/t depression significant depression related cognitive impairment can result in dementia follow up with older adults w/ depression related cognition impairment even after depression remits

Answer 149

Not recommended by USPSTF is a part of the Medicare Annual Wellness: MMSE, Mini-Cog

Answer 150

pneumococcal influenza herpes zoster tetanus or TD

Answer 151

``` dementia hearing vision glaucoma falls ```

Answer 152

role of PCP to review with pt allows for autonomy regarding manner & location of death, relieves family burden and conflict

Answer 153

describes patients wishes about resuscitation, hospitalization, tx goals & limits, health care proxy

Answer 154

use or misuse of 5 or more drugs not clinically indicated & interact w/ each other drug distribution & clearance affected by normal aging can lead to MS change, sedation, falls Mgmt review all meds @ each visit, compare w/ BEERS list, encourage updated med list start low & go slow w/ prescribing

Answer 155

prevalent in older adults sodium electrolyte imbalance most significant (confusion, weight loss, FTT) causes: environmental, increased metabolic demands, pharmacologic factors, normal aging changes presents: confusion, lethargy, rapid weight loss, functional decline - constipation (lack of water intake) - orthostatic BP, rise in pulse, dry MM, poor skin turgor - BUN/Cr ration 25:1 - sodium > 148 (acute mental status changes) - elevated hematocrit

Answer 156

pre-illness weight - current weight = fluid deficit rehydrate oral (preferred) clysis (non emergent subcutaneous upper arm/unable to take PO) IV hydration - fastest - 1/2 of calculated fluid loss in 1st 24 hrs, min 1500mL

Answer 157

6- 8 ox water/juice a day take full glass with meds caffeine, alcohol (beer) diuretics & should be avoided

Answer 158

complete fall assessment DDROPP - diseases, drugs, recovery, onset, prodrome, precipitants Romberg test w/ sternal nudge & check for nystagmus, CV and neuro exam, postural VS, mobility, strength, cognition, vision & hearing CBC, lytes, BUN, Cr, glucose, OB, ECG

Answer 159

progressive loss of energy, strength, & stamina leading to decreased function/physical/cognitive deterioration red flag: unplanned weight loss of 10% or more of body weight in last year weakness, inability to care for self, dizziness, weight, memory loss & depression

Answer 160

``` CBC lytes kidney & thyroid function fasting blood glucose LFTs calcium UA stool of OB x3 ```

Answer 161

physical, sexual, psychological, financial exploitation, neglect, abandonment, & self-neglect 1 in 6 adults > 60 y.o. have experienced abuse for > 1 yr higher risk in those w/ disability/dementia

Answer 162

home setting: report to state adult protective services | Long term setting: report to long term care ombudman/police if immediate risk

Answer 163

fam hx (1st degree relative) pesticide exposure concussion hx urban/industrial areas w/ high copper, Mg, & lead levels hydrocarbon solvent exposure (trichloroethylene) milk consumption excess body weight anemia older age - 70 y.o. illict substances: mescaline, ecstacy, acid, those that cause dopamine surges causes greater risk of PD w/ hx of hallucinogenic abuse

Answer 164

smoking cigarettes stimulates nicotinic receptors lowers incidence of PD

Answer 165

cardinal features: resting asymmetric/unilateral tremor bradykinesia (w/ freezing) rigidity postural changes/instability r/t dopamine depletion

Answer 166

``` TRAP: Tremor Rigidity (classic increased resistance to passive movement of a joint in 90% pts) Akinesia (slow movement like a sloth) Postural instability (falling) ``` resting hand tremor "pill rolling" increases w/ walking (can be earliest sign) masked facies (decreased blink rate/facial expression) hypophonia (soft speech) Aprosody of speech (monotone), dysarthria, palilalia (repetition of words/phrases)

Answer 167

excessive salvation, diff swallowing & speaking forgetfulness, constipation, urinary retention hyposmia (reduce/altered sense of smell

Answer 168

depression, psychosis | daytime sleepiness, fatigue

Answer 169

gold standard: post-mortem neuropathic exam rest tremor w/ unilateral onset & excellent response to dopaminergic therapy is important criteria

Answer 170

Carbidopa/Levodopa (Sinemet) most effective drug for tremor, rigidity symptoms Dopamine agonist (Requip, Mirapex) MAO B (selegiline or rasagiline) Anti viral drug (Amantadine [Symmetrel]) anticholinergics

Answer 171

deep brain stimulation - almost a cure, not quite a cure but controls people - can pull back med doses in pts - contraindication = space occupying lesion in brain, dementia (need to be cleared from psychiatry)

Answer 172

speech therapy, dance therapy cognitive exercises exercise & PT

Answer 173

``` falls early in dx poor levodopa response symmetric motor signs lack of tremor early dysautonomia ```

Answer 174

DRIVING, FRAGILITY, DEHYDRATION, FALLS, POLYPHARMACY, HEARING LOSS, ABUSE

Answer 175

55-69 YO, Q 2-3 YEARS

Answer 176

HOARDING, ANXIOUS, BRUISING IN VARIOUS STAGES, INAPPROPRIATE CLOTHING. FINANCIAL, PHYSICAL, EMOTIONAL, NEGLECT.

Answer 177

LOW SODIUM, HIGH H&H, ELECTROLYTE IMBALANCE, CREATININE/BUN ELEVATED, DRY TONGUE, DRY MUCOUS MEMBRANES, CONFUSED, LOW SKIN TURGOR. FLUID DEFICIT = PRE -ILLNESS WT - CURRENT WEIGHT. GIVE 1/2 NEEDED IN 24 HOURS, MIN 1.5L

Answer 178

45-75 YEAR OLD, Q 10 YEARS IF THEY HAVE IBD Q8 YEARS after dx THEN EVERY 3-5 YEARS. IF PATIENT HAS A 1ST DEGREE RELATIVE SCREEN 10 YEARS BEFORE THEIR FAMILY MEMBER'S DIAGNOSIS THEN REPEAT EVERY 5 YEARS.

Answer 179

CAROTID ULTRASOUND

Answer 180

LEWY BODY DEMENTIA

Answer 181

UNILATERAL WEAKNESS, NUMBNESS OF FACE, ARM, OR LEG, SLURRED SPEECH, BLURRY VISION, TROUBLE WALKING, DIZZINESS, LOSS OF BALANCE OR COORDINATION, SUDDEN SEVERE HEADACHE WITH NO KNOWN CAUSE

Answer 182

ACUTE INPATIENT REHAB

Answer 183

DELIRIUM DUE TO INFECTION, POSSIBLY UTI

Answer 184

RESTING, UNILATERAL TREMOR`

Answer 185

POST MORTEM NEUROPATHIC EXAM, CLINICALLY DIAGNOSED, RESTING UNILATERAL TREMOR, EXCELLENT RESPONSE TO DOPAMINERGIC THERAPY.

Answer 186

AMANTADINE

Answer 187

LEVADOPA (SINEMET) GOLD STANDARD, MOA-B (SELEGILINE), DOPAMINE AGONISTS (REQUIP), AMANTADINE. LEVADOPA ONLY WORKS FOR APPROXIMATELY 15 YEARS, START ON A DIFFERENT MEDICATION IN YOUNGER PATIENTS.

Answer 188

TREMOR, RIGIDITY, AKINESIA, POSTURAL INSTABILITY, MASKED FACIES, HYPOPHONIA, EXCESSIVE SALIVATION, DIFFICULTY SWALLOWING, CONSTIPATION, URINARY RETENTION, HYPOSMIA, DEPRESSION, DAYTIME SLEEPINESS, COGWHEELING RIGIDITY, PARKINSON SHUFFLE

Answer 189

each office visit, no age restriction

Answer 190

BG in overweight/obese until age 70

Answer 191

fasting lipid panel every 5 years unless levels are high or CV RF

Answer 192

each visit

Answer 193

abdominal aorta US in males who have ever smoked after 65 y.o.

Answer 194

none after age 65

Answer 195

every 2 years until 74

Answer 196

PSA in M 55- 70 based on symptoms/preference | NOT recc > 70 y.o.

Answer 197

once at age 65 (F) | once age 70 (M)

Answer 198

45- 75 y.o. recc 76-85 y.o selectively screen