Week 10 Geriatrics, Parkinsons, Alz Flashcards
behavioral risk factors to reduce CVA risk?
- balanced diet (fresh fruits, veggies, low fat dairy, fiber, whole grains, proteins, decrease salt)
- exercise
- healthy weight (BMI: 18.5-24.9)
- smoking cessation
- alcohol in moderation (1-2 drinks per day max)
recommended BP goal if had stroke/TIA?
< 130/80
which medications reduce recurrent strokes significantly?
diuretics alone or WITH ace but NOT with BB or ACE alone
AHA/ASA recommendations on statin treatment
- use high intensity statin if:
- have ischemic stroke or TIA who have atherosclerosis
- LDL > 100
- want 50% LDL reduction or < 70
- known CAD
cardiac causes and extra cardiac causes of stroke
- cardiac: atrial fibrillation and patent foramen oval
- extracardiac: intracranial and extracranial large vessel atherosclerotic disease (carotid artery and vertebral basilar disease)
anticoagulant target INR in pts with ischemic stroke / TIA
- target INR: 2.5, range 2-3
- fi can’t take oral, aspirin alone recommended. NO clopidogrel + aspirin = bleeding risk and not recommend for pts with a contraindication to warfarin
post stroke depression
- common in 40% of pts post stroke
- a/s with poor functional recovery, poor social outcomes, reduced QOL
- give SSRI!
most common sx of a TIA (acute stroke)
lasts a few minutes to 1 hr
unilateral paresis and dysarthria (paralyzed speech)
highest risk reduction to prevent stroke in pts that have had a TIA?
- high intensity physical activity at 64%
- BP reduction is 40%
- antiplatelets 37%
- statins 33%
Transient ischemic attack sx’s
- few minutes
- Facial droop
- L sided weakness
- Coming from carotid arteries or vertebral arteries bc of stenosis and emboli to block blood = ischemia
- Embolus will dissolve once blood flow is restored in 24 hrs
- stroke risk of 10% up to 90 days
pts with TIA examination
- close observation x 24 hrs in ER or inpt
- use ABCD2 score for TIA [1-3 pts: output, 4-5: inpt, 6-7 pt: inpt beneficial)
- 1 pt
- Age: 60 yrs old
- BP > 140/_>_90
- Clinical presentation:
- Speech changes
- Duration:
- < 1 hr
- Diabetes
- 2 pts:
- unilateral weakness
- > 1 hour
- 1 pt
intracranial hemorrhage stroke sx’s
- vomiting
- SBP > 220
- severe headache, unilateral facial sag, slurred speech, weakness in an arm and leg, and eye deviation away from the paretic limbs
- no warning or prodromal sx’s
- Majority of cases, pts are up and active
subarachnoid hemorrhage
- c/b aneurysm, AV malformation, bleeding disorder
- Abrupt onset of a severe headache
- *worst headache of my life”* + n/v + signs of meningitis (meningeal irritation) + neurological irritation
- Can have LOC at event
- Risk factors: smoking, HTN, family hx, PCOS, connective tissue disease
- require neurosurgical intervention
stroke diagnostics
-
STAT head non contrast CT *gold standard
- differentiates from ischemic or hemorrhagic stroke
- ECG
- chest radiography
- pulse ox
- ABG
- CBC with platelets, prothrombin time
- PTT
- gluocse
- creatinine
- BUN
- e- values
administer IV thrombolytics within
45 to 60 mins arrival to ED
for ischemic stroke
optimal SBP for acute ischemic stroke is
121 -200 SBP optimal
, if lower with meds, brain already ischemic and lowering BP would worsening hypo perfusion and injury. after acute period of stroke, BP will gradually return to baseline w/o any treatment
if have to use antihypertensive, labetalol and nicardipine used to gradually reduce BP
when is tPA given
indications: 18+, ischemic stroke, onset less than 3 hours (180 mins) to 4.5 hrs
NO: active bleeding, on oral anticoagulant, hx diabetes or previous stroke, > 80 yrs old
ischemic stroke sx’s
MILD headache
visual field defect, ataxia, and dysarthria
resolves w/in few hours
amaurosis fugax (transient, painless loss of vision)
ischemic stroke prevention
aspirin 81 - 325 mg QD
warfarin (Coumadin), Eliquis, Xarelto for pts with risk for cardiac embolism & hypercoaguable states (atrial fibrillation, L ventricular dysfunction with CHF, artificial cardiac valves)
surgical interventions for stroke
mechanical thrombectomy (up to 24 hrs post sx onset)
neurosurgical consultation for SAH, ICH, IICP = carotid endarterectomy for symptomatic carotid stenosis
patient education in stroke
- 1: Focus on risk factor reduction (BP, cholesterol, OSA)
- 2: stroke sx recognition and emergency treatment!
- HTN is most important independent and modifiable risk factor
- Atrial fib → 5x risk of stroke, need anticoagulant
5 domains to assess in an older adult
- physical health
- cognition and mental health
- functional status
- social and environmental circumstances
- advanced care planning
geriatric assessment
- screens for risk factors that can affect health and independence
- starts age 75 if healthy (start < 75 if have multiple comorbidities)
- after major illness requiring hospitalizations
components of pt’s physical assessment
- nutrition
- hearing
- vision
- urinary and bowel incontience
- balance / hx of falls
- osteoporosis risk
- polypharmacy
immunizations for older adults
- PCV 13 (Prevnar 13) & PPSV 23 (Pneumovax 23)
- after 65 yrs - 1 dose
- flu annually
-
Shringrex/zoster
- everyone after 50 yrs old - 2 doses, 2-6 months part
- tetanus (Tdap) once
- Td every 10 years
cardiovascular screening for older adults
- abdominal aorta ultrasound: once in males who have ever smoked after 65 yrs
- hypertension at EVERY visit (no age restriction)
- height / weight every visit
- glucose in overweight/obese until age 70
- fasting lipid panel every 5 years unless levels are high or other CV risk factors present
cancer screening in older adults
- colorectal cancer: start age 50 - 75 (76-85 individualized)
- cervical cancer screening: STOP after age 65
- breast mammogram: every 2 years until 74 yrs old
- NO prostate specific antigen screening (individualized)
bone mass screening in older adults
- women: once at 65 yrs
- men: once at 70 yrs
elderly and driving
- Assess memory, judgment and executive function (dementia), arthritis, neuropathy, hypoglycemia, adverse drug reactions
- moderate dementia should NOT drive
- visual and spatial perception (cataract, glaucoma, poor night vision) - predictors of impaired driving
- vision, hearing, balance, gait, range of motion, and strength of hips and knees
- recommend to DMV if:
- new traffic impairments
- impairments in attention, executive function, visual, spatial perception
- mild dementia
other screenings in older adults
insufficient evidence: dementia, hearing, vision, glaucoma
screening for hearing in older adults
- USPSTF recommends asking patient and caregivers about hearing loss
- Whisper test
- most common: presbycusis (gradual loss/sensorineural hearing loss) and cerumen impaction (conductive hearing loss)
urinary incontinence in the geriatric population
- Key deciding factor for placement in nursing home
- Evaluation – fluid intake, medications, cognitive functions, mobility, urologic surgeries
- Screen:
- Urge: Do you have a strong and sudden urge to void that makes you leak before reaching the toilet?
- Stress; Is your incontinence caused by coughing, sneezing, lifting, walking, or running?
leading cause of hospitalization/injury in 75+ adults? screen?
- Falls!
- 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
- if have 1 fall w/o major injury and normal get up and go test → no further eval needed
- home assessment by family or OT
geriatric syndromes
- polypharmacy
- cognitive impairment
- dehydration
- falls
- failure to thrive
- elder abuse
polypharmacy
use or misuse of multiple drugs (5+ meds) but rx and non rx + interactions
most prevalent consequence: adverse drug reaction → change in mental status, sedation, falls
polypharmacy management
- Beers criteria, IPET (improved prescribing in elderly tool), START (tool to alert doctors to right treatment), STOPP
- is med still indicated?
- Once a day dosing best
- Carry up to date med list and review every visit
- order drugs with computerized drug data
- pharmacodynamics and adverse effects more heavy in older adults
how to discontinue meds in polypharmacy
- 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, BB, clonidine, gabapentin, antidepressants)
- Educate patients on side effects of tapering or discontinuation
- Communicate with other providers that may be prescribing
barriers to med adherence in older adults
- forgetting to take → organize with pill counters, put someone in charge
- pt doesn’t think it helps → educate or stop med
- difficulty taking or too expensive → substitute med
depression screening
- Depression 2 Q screen:
- During the past month, have you been bothered by feelings of sadness, depression, or hopelessness?
- Have you often been bothered by a lack of interest or pleasure in doing things?
- if+ → do 2nd assessment or refer to psychiatry
- Geriatric Depression Scale
- Hamilton Depression Scale
- if+ → do 2nd assessment or refer to psychiatry
FNP role in financial capacity
- Education need for advance care plan (ACP)
- Durable power of attorney for finances (DPOAF)
- is none, existing DPOAF or conservator/guardian is appointed by state
- Discuss at time of diagnosis of dementia
- Durable power of attorney for finances (DPOAF)
- Recognizing and assessing signs of impaired financial capacity
- Recommend interventions for financial independence (automatic deposits or withdrawals)
- Knowing when and to whom to make medical and legal referrals
- Report suspected elder abuse including financial abuse
Cognitive impairment
- Alzemiers and dementia
- short term memory loss
- disorientation
- disturbance in executive functioning (planning, organizing, abstract thinking)
- ADL problems
- aphasia (impaired language), apraxia (impaired motor; can’t tie shoelace) , agnosia (can’t understand info from senses ie can’t understand smell)
- delirium - acute onset, fluctuations in orientation and attention esp if hospitalized
dehydration in older adults
- sodium imbalance
- most common cause: fever, poor intake, drug, NGI fluid loss
- check: orthostatic hypo, pulse, temp
- labs: e-, BUN/Cr, osmolality, H&H (concentrated)
Dementia DSM 5
- Evidence of decline 1 or more:
- Learning and memory
- Language
- Executive function
- Complex attention
- Perceptual-motor
- Social cognition
- cognitive deficits interfere with independence in daily activities, and needs help with complex activities of daily living (paying bills)
- not due to delirium
- not another mental disorder (schizophrenia or major depressive disorder)
Falls
- assess sensory, central/peripheral nervous system
- most important risk factors: vision and hearing
- contributing factors:
- lower extremity weakness
- ortho hypo
- CNS condition
- unsafe environment (throw rugs)
- balance exercises
- tai chi
post fall assessment
DDROPP
- Diseases
- Drugs
- Recovery (how long take to improve)
- Onset
- Prodrome
- What sx did they have prior to fall
- precipitating factors
- Were they sick before this happening? fever/flu like sx’s?
fall labs
- CBC
- electrolytes
- BUN/Cr
- cult stool (GI bleed - anemia)
- ECG
Frailty (FTT) and tx
- unplanned 10% + loss body weight in < 1 year
- progressive loss of energy, strength, and stamina leading to decreased function and general physical and cognitive deterioration resulting in a physiologic vulnerability
- look at irreversible causes (depression)
-
increase protein and caloric intake → boost plus (protein)
- daily multivitamin
- 800 IU of vitamin D
- weight training
- get family involved
sus for elder abuse
- Bruises in the breast, or genitalia
- sudden withdrawal from me that i know or change in behavior = psychological abuse
- Change in financial situation or checks signed by other = financial exploitation
- Bed sores, poor hygiene, nutritional deficiencies, hoarding or inappropriate clothing for season = neglect
dementia screening
- Dementia screening:
- 3-word recall and clock face.
- If abnormal, administer MMSE (Mini Mental Status Exam) or MOCA (Montreal Cognitive Assessment)
- Offer neuropsychiatric evaluation or perform further primary care evaluation of cognitive impairment such as comorbid medical problems, medication adverse effects, or mood disorder.
dementia diagnostics
- no single test
- CBC, CMP, TSH, B12, folate
- UA drug test (r/o cancer, infection)
- baseline brain imaging with CT
delirium hallmarks
- Clouding of consciousness, inability to focus, sustain, or shift attention, and a change in cognition
- Impairment, perception disturbances
- Prominent deficit of environment
- Sx develop rapidly and vary in severity
pt has TIA, send to ED or outpatient?
- ABCD score for acute cerebral vascular syndrome:
- Age, BP, clinical presentation, diabetes
- 1-3 pts: outpatient
- 4-7: hospitalization
- 1 pt for:
- > 60 yrs
- BP > 140/> 90
- speech changes (no unilateral weakness)
- < 59 mins duration
- diabetes
- 2 pts for:
- unilateral weakness
- > 1 hour duration
how is dementia diagnosed?
- Mini Mental Status Exam :orientation, registration, attention and calculation, recall, language
- good for moderate dementia (not mild)
- memory impairment screen
- tests Recall Ability: say nouns in 4 groups (animal, city, vegetable, musical instrument), then give task, recall nouns. 2 pts if no hints, 1 pt for hints
- clock drawing test
- put #’s on face of clock and make the clock say 10 minutes to 11
- general practitioner assessment of cognition
- modified mini mental state exam
- severity of dementia
- Hopkins Verbal Learning Test or Word List Acquisition Test4
- More helpful for mild cognitive impairment or highly educated patient
- Cognitive Assessment Screening Test
- Psychogeriatric Assessment Scales
- Screens for depression and stroke
- Clinical Dementia Rating Scale
- Assesses functional and cognitive performance
dementia meds
- Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
- mild to moderate AD
- Side effects include nausea, vomiting, diarrhea, dizziness, and weight loss.
- Gastrointestinal (GI) side effects may be worse with rivastigmine, less with galantamine, least with donepezil.
- Donepezil - muscle cramps and sleep disturbance.
- Contraindicated in patients with cardiac conduction abnormalities or gastric ulcer disease with a history of bleeding.
- N-Methyl-D-aspartate (NMDA) receptor antagonist (memantine)
- moderate to severe dementia
- May be added to cholinesterase inhibitor as dementia progresses.1,5
- Side effects include headache, sedation, constipation, and agitation.2
what nonpharmacologic interventions have been studied in patients with mild dementia?
- Cognitive training and rehab programs
- improving functionality in everyday life
- may help with cognitive function in patients with MCI but NOT mild dementia
- Reminiscence therapy
- revisit memories and experiences
- Significant improvement in cognitive and depressive symptoms
behavioral disturbances of progressive dementia and tx
- Agitation with delirium or psychosis
- Atypical antipsychotics (risperidone, olanzapine, quetiapine) are commonly used
- May increase risk of metabolic syndrome and stroke
- Black box warning for atypical antipsychotics → increased rate of death
- to targeted at a specific symptom with plans to taper and remove medication within 6 months.
- Agitation and aggression
- Anticonvulsants (divalproex, carbamazepine)
- Depression or anxiety
- SSRIs = sertraline and citalopram or buspirone
- NO TCAs = worsen agitation and increase risk of falls.
- Benzodiazepines short-term treatment of anxiety but worsen confusion, increase risk of falls, and cause paradoxical agitation.
- Insomnia → trazodone
DSM 5 for delirium
Acute onset!
- Decreased ability to direct, focus, and sustain attention and orientation to the environment
- alt to lucid periods
- Short = Hrs - days; fluctuating
- Cognition changes or perceptual disturbance that is not explained by a preexisting condition (eg, dementia)
- not caused by a severely reduced level of arousal, such as coma
key points of hx in delirium
- sx’s of recent infection
- history of organ failure
- medication list
- history of substance use
- psychiatric history including recent evidence of depression
greatest risk factor for delirium
- age
- elderly most susceptible bc reduced capacity to handle change in surroundings, depression, med changes, acute stressors [surgery/hospitalization])
delirium mangement
medical emergency! send to ER
what assessment tools confirm delirium and dementia?
Confusion Assessment Method (CAM) for delirium
Mini mental status exam (MMSE) for dementia
*hx of sudden onset or fluctuation during the day = delirium
also screen for depression, schizophrenia
interventions for prevention and tx of delirium
- primary interventions: environmental factors (reorientation, sleep hygiene, visual or hearing aids if impaired, maximizing mobilization, avoiding physical restraints)
- interpersonal need of social interaction important in delirious pts! have family member or staff present so there’s no isolation
- if hyperactive/aggressive delirium: meds that are involved in acetylcholine, dopamine, serotonin, and GABA
demential hospice requirements
if 2 clinicians (referring clinician and hospice medical director) agree pt has < 6 months to live if illness were to take natural course
need to be Stage 7C on Functional Assessment Staging Tool (FAST) - unable to move independently and at least 1 of:
- aspiration pneumonia
- pyelonephritis
- upper UTI
- septicemia
- pressure ulcer (stage 3 or 4)
- recurrent fever after tx with antibiotics
- eating problems (decrease intake, weight loss or albumin < 2.5)
FTT labs
- CBC
- electrolytaes
- kidney and thyroid studies
- fasting blood glucose
- liver function tests
- Ca
- UA
- stool for occult blood x3
- chest xray
FTT focus on
sx’s, organ failure, infections, cancer
most powerful risk factor for recurrent stroke ?
- blood pressure with HTN involved in 70% of all stroke cases
- 5% weight reduction can improve overall health with 10% being goal (reducing BP of 10/5 mmHg reduce stroke up to 42%)
- diabetes, smoking, HLD, obesity, nutrition, diet, physical inactivity
mild cognitive impairment
transition b/t normal aging (forgetfulness) and dementia
close monitoring bc it’s a risk factor for dementia
3 types of dementia
- Alzheimers (most common) - amyloid plaques and neurofibrillary tangles and atrophy of the cerebral cortex (amount of atrophy does NOT correlate to degree of cognitive impairment)
- Vascular dementia - if pt has HTN, HLD, DB or occlusive dz (higher risk) for infarct in tiny arteries in the brain
- Lewy body dementia - Lewy body causes brain death and loss of dopamine and acetylcholine
Alzheimers stages & sx’s
- prognosis: 9 years
- early:
- short term memory loss
- anxiety / depression
- personality changes
- middle/second stage:
- worsening of memory, language, judgment
- disorientation of place and time
- paranoia, hallucinations, delusional thinking
- urinary incontinence
- late stage:
- motor rigidity
- apraxia
- agnosia
- severe cognitive and language impairment
- date
Parkinson’s cardinal features
- 3 cardinal manifestaions: T.R.A.[P.]
- Tremor - asymmetric/unilateral resting tremor
- Rigidity: lead pipe rigidity
- cogwheeling rigidity
- resistance to passive movement in all directions
3. Akinesia: absent of movement, bradykinesia
- Postural instability, pill rolling
Parkinsons diagnosis
if try dopamine therapy/Levodopa and have good response, confirms diagnosis
neuroimaging shows Lewy bodies (gold standard) BUT done after they’re dead
no DaTScan if hx/exam suggests PD
Parkinson physical examinations
- postural reflexes = sudden, firm pull on shoulders from behind
- cog wheeling rigidity = grasp pt’s elbow at antecubital region, slowly flex/extend elbow or pronate/supinate forearm
- festination = walks faster with short steps
- freezing phenomenon (motor block) can’t do active movements, feet glued to ground
- kinesia paradoxa = move normally for short burst of motor activity when physically cued
Parkinson’s non motor disorders
- depression, anxiety
- dementia
- psychosis / halluncations
- forced closure of eyelides
- orthostatic hypotension
- hypophonia speech/soft, excessive salivation but can’t swallow
- aspiration pneumonia = death
- thicken up liquids
- increased sweating
- constipation
- micrographia handwriting
- urinary incontinence
- dopamine dysregulation syndrome
- manic sx’s - don’t stop meds abruptly
- RBD (REM sleep behavior disturbances)
- nightmares = give Clonazepam (Klonopin) every night
- daytime sleepiness/fatigue
parkinson hallucination med tx
- if delirium, treat underlying cause
- if not delirium, then give pimavanserin, 2nd line quetiapine/Seroquel
parkinson med treatment
- carbidopa - levodopa (Sinemet) gold standard
- 100-150mg/d
- >60 yrs old
- selegiline (Eldepryl) [MAOI-B]: - use WITH Sinemet to allow easier entry and prolonged effects (not monotherapy)
- mirapex [Dopamine agonist]
- for < 60 yrs early PD mono therapy
- > 60, adjunct with Sinemet
- orthohypo
- amantadine (antiviral)
- WITH sinemet for advanced PD akinesia and rigidity
parkinsons non pharm tx
adjunct:
- OT, PT, speech therapy
- treadmill training, boxing, tai chi
- cognitive exercises: crossword puzzles/sudoku
- deep brain stimulation - surgery for advanced PD
- improves motor fluctuations
- depression = refer psychiatrist
- hospitalize if pneumonia, DVT, PE
parkinsons non pharm tx
adjunct:
- OT, PT, speech therapy
- treadmill training, boxing, tai chi
- cognitive exercises: crossword puzzles/sudoku
- deep brain stimulation - surgery for advanced PD
- improves motor fluctuations
- depression = refer psychiatrist
- hospitalize if pneumonia, DVT, PE
delirium hallmarks
Clouding of consciousness, inability to focus, sustain, or shift attention, and a change in cognition
- Sx develop rapidly and vary in severity
pseudomentia
- Due to depression which leads to memory loss, attention deficits, and problems with initiation
- Depression can lead to memory loss, attention deficit, problems with initiation
