Week 12- Medical Management of The Complex Patient Flashcards
PART 1: THE CAREGIVER
PART 1: THE CAREGIVER
Caregivers:
- The “______________”
- ___% female, ___% spouses, ___% adult children.
- __/__ of caregivers are the sole source of support.
- “invisible workforce”
- 60% female, 20% spouses, 50% adult children
- 1/3
Where do PTs fit in with caregivers? (5)
- Sharing expertise.
- Providing education on safety and efficacy of a task.
- Assisting with home modifications and equipment needs.
- Finding community resources.
- Learning from the caregiver.
- What are some caregiver stressors? (4)
- What are the PT considerations for each?
- ) Physical Health
- Assess home environment and abilities of caregiver. - ) Psychological Health
- Use caregiver burden scales or open conversation about stress levels. - ) Social Well-being
- Use caregiver burden scales or open conversation about stress levels. - ) Economic Well-being
- Access community resources.
How can we assess caregiver outcomes/stressors?
Caregiver Burden Scales
-16 specific to Dementia (more tan 35 available)
What are the dimensions of caregiver burden in Dementia? (3)
- Direct impact of caregiving on caregivers’ lives
- Guilt
- Frustration/embarassment
What is the most widely used measure of caregiver burden that consists of 22 items assessing burdens associated with patient behavioral and functional impairments?
Zarit Burden Interview
What is caregiver burnout?
State of physical, emotional, and mental exhaustion and distress that may include depression, agony, anxiety, etc.
What are the signs of burnout syndrome? (3)
- emotional exhaustion
- depersonalization
- reduction in personal fulfillment
Caregiver Burnout Effects:
- Interferes with _______ of care.
- Risk of mental/physical problems for the caregiver.
- Early patient ____________.
- Increased risk for ________.
- -quality of care
- early patient institutionalization
- abuse
PART 2: MEDICALLY COMPLEX PATIENT
PART 2: MEDICALLY COMPLEX PATIENT
What all should we be looking for when performing a chart review of the medically complex patient? (7)
- Summary of why patient came to ED
- PMH
- Past surgical history
- Medications
- Lab values
- Diagnostics
- Other provider notes
What should we assess for first and why?
Assess cognition first because this will drive the direction of communication and POC.
List of Common Pathological Conditions. (9)
- Coronary Heart Disease (CHD)
- Acute Coronary Syndrome (ACS)
- Heart Failure (HF)
- Pneumonia
- UTI
- Sepsis
- Dizziness
- Dehydration
- Metabolic Syndrome
Coronary Heart Disease:
- Elevated _____ and ____________.
- Systolic HTN, if left untreated, can lead to what?
- Increased arterial stiffness and ventricular wall thickening leads to vascular constriction. These changes lead to reduced EF and increased O2 demand ultimately resulting in _________.
- When CHD progresses to cause ischemia, we get ____________. This is a severe imbalance of O2 demand and supply.
- LDLs and total cholesterol
- LV hypertrophy
- ischemia
- Acute Coronary Syndrome (ACS)
CHD Comorbidities. (4)
- DM
- CA
- Atherosclerosis
- Increased mortality
What is the gold standard diagnostic testing procedures for CHD? (2)
- Graded Exercise Testing
- Cardiac Catheterization
What are some common medications used to treat CHD? (5)
- Diuretics
- Beta-blockers
- Ca+ channel blockers
- ACEi, ARBs
- Statins
Heart Failure:
- Involves a _____ dysfunction in which the metabolic needs are unmet.
- What are the 1st and 2nd leading causes of HF?
- What are the S/Sx? (4)
- pump dysfunction
- 1st = ischemic LV dysfunction d/t CAD, 2nd = HTN
- Fatigue, SOB, decreased activity tolerance, mixed L/R S/Sx
HF Comorbidities. (3)
- Valvular Disease
- CAD
- HCM
How do we test for HF?
- Pitting edema
- JVD
- Adventitious breath sounds
- Dyspnea
- Orthopnea
- Tachypnea
- Desaturation
- BNP values between 100-1000
What are some common medications used to treat HF? (4)
- Diuretics
- ARNIs
- Antihypertensives
- Digoxen
Describe the Pitting Edema Scale.
1+ = 2mm depression with immediate rebound 2+ = 4mm depression with a few seconds to rebound 3+ = 6mm depression with 10-12s to rebound 4+ = 8mm depression with >20s to rebound
Cardiac Considerations:
- Pulse Pressure = _____-_____
- What pulse pressure is normal and what required medical attention?
-OH = ___mmHg drop in SBP, or ___mmHg drop with increased HR
- HR = increase ___-___ bpm/MET
- BP = increase ___-___mmHg
- DBP-SBP
- Normal = 40mmHg, >60 requires medical attention
-OH = 20mmHg drop in SBP, or 10mmHg drop with inc HR
- 10-20bpm/MET
- 10-12mmHg
Pneumonia:
- ___ leading cause of death in community-dwelling older adults.
- 2nd cause of nosocomial infections (behind _____)
- ___________-ACQUIRED pneumonia accounts for 50% of cases of sepsis and has a 33% mortality rate.
- 6th
- behind UTIs
- HOSPITAL-ACQUIRED pneumonia
What are some ways Pneumonia is diagnosed? (5)
- Chest Xray
- Positive findings of infitrates or consolidation
- Elevated WBC count
- Desaturation of SaO2 even at rest
- Chest pain, pleuritis
What are some common medications used to treat Pneumonia? (2)
- Antibiotics or antivirals
- Oxygen
List (5) ways to administer O2 and their LPM/FiO2 levels.
Nasal Cannula
-LPM = 1-6, FiO2 = 24-44%
Salter High Flow Nasal Cannula
-LPM = Up to 15, FiO2 = 54-75%
High Flow Nasal Cannula
-LPM = Up to 60, FiO2 = Up to 100%
Partial Rebreather Mask
-LPM = 6-10, FiO2 = 60-80%
Non-Rebreather Mask
-LPM = 10-15, FiO2 = 60-80%
- At what FiO2 level is mechanical vent needed?
- Which O2 administration is most common?
- 0.6 (60%)
- nasal cannula
Pulmonary Considerations:
- Average respiratory rate = ___-___ breaths/min.
- 1:1 insp/exp rate suggests _____ventilation, 1:3 suggests ______ventilation.
- Observe expansion of chest wall in all directions.
- Speech = ___-___ syllables/breath.
- Error rate for pulse-ox up to 5-6%, what is the most accurate placement?
- Auscultation: normal vs ________ sounds
- 12-20 breaths/min
- 1:1 suggests hyperventilation, 1:3 suggests hypoventilation
- 12-15 syllables/breath
- earlobe
- adventitious
UTI:
- Accounts for __/__ of infections in nursing home residents.
- What is the primary cause of UTIs?
- What is the BIGGEST change that occurs due to UTIs in OLDER ADULTS?
- 1/3
- urinary stasis (indwelling catheter may also cause)
- ACUTE DELIRIUM
What is the primary cause of urinary stasis leading to UTI in older men vs older women?
- Older women = decreased pelvic floor strength and estrogen levels
- Older men = decreased bladder emptying d/t BPH
- If we see a sudden onset of delirium, what are we thinking?
- Is it easily treatable?
- Infection (often UTI)
- Yes, antibiotics
Sepsis:
- What is it?
- Is the mortality rate low?
- Leading cause of __________ and is the most expensive inpatient condition.
- “Life-threatening organ dysfunction caused by a deregulated host response to infection.”
- No, mortality rate of 51%!
- Leading cause of hospitalization.
Septic Shock:
- What is it?
- Mortality 4x greater when Septic Shock criteria met. What are these criteria? (2)
-Abnormal circulatory and cellular metabolism profound enough to significantly increase mortality.
- ) Persisting hypotension that requires vasopressors to maintain MAP at 65mmHg or greater.
- ) Blood lactate >2mmol/L despite volume resuscitation.
Describe the pathophysiology of sepsis. (6)
- ) Sepsis differentiated from infection by a dysregulated host response that results in organ dysfunction.
- ) Loss of adaptive homeostasis in response to infection.
- ) High degree of mortality risk with organ dysfunction.
- ) Anti-inflammatory response fails to develop.
- ) Proinflammatory process becomes unregulated.
- ) Results in cascade of dysfunction.
Sepsis S/Sx:
- Lactate >___mg/dL
- _____tensive
- Fever >____ degrees
- HR >___bpm
- RR >___breaths/min
- Lactate >18mg/dL
- hypotensive
- Fever >103 degrees
- HR >90bpm
- RR >20 breaths/min
Clinical manifestations of Sepsis can occur in what systems? (6)
- Cardiovascular
- Pulmonary
- CNS
- Renal
- GI
- Hepatic
- Hematologic
Sepsis CV Clinical Manifestations. (5)
- Hypotension
- Tachycardia
- Elevated CO (drops with septic shock)
- Systemic vascular resistance drops with septic shock
- Hypoperfusion exacerbated -> lactate accumulation
Sepsis Pulmonary Clinical Manifestations. (4)
- Tachypnea
- Hypoxemia (vent:perf mismatch)
- Respiratory alkalosis
- Pulmonary edema and respiratory failure -> ARDS
Sepsis CNS Clinical Manifestations. (3)
- Altered mental status
- Encephalopathy
- Polyneuropathy
Sepsis Renal Clinical Manifestations. (2)
- Oliguria
- Azotemia
Sepsis GI Clinical Manifestations. (2)
- Impaired motility
- Stress ulceration
Sepsis Hepatic Clinical Manifestations. (3)
- Elevated serum transaminase
- Hyperbilirubinemia
- Final stages: hepatic insufficiency
Sepsis Hematologic Clinical Manifestations. (4)
- Leukocytosis
- Multifactorial anemia
- Thrombocytopenia and coagulation abnormalities
- Disseminated intravascular coagulation (DIC) is a late-stage manifestation
Sepsis Implications for PT:
- Can we perform PT in ICU/acute care once stable?
- Are patients able to safely respond to increased vascular and O2 demands on exam/treatment?
- Patient status can fluctuate by the minute, therefore we must provide “________-dependent management”.
- ______ and _______ of O2 must match.
- Yes
- Yes
- response-dependent management
- delivery and consumption
How to Tell Vestibular from Cardiac Dizziness:
Vestibular:
- _______ most common cause in older adults.
- ______ is also common in older adults.
Cardiac:
- ______ is more often the symptom of dizziness.
- _____ and _______ to monitor cardiac function/blood flow.
Vestibular
- Vertigo
- BPPV
Cardiac
- Syncope
- ECG and Holter
How do we rule in/out OH as a cause for dizziness?
Take positional BP
What are some medications that can cause dizziness? (3)
- Antihypertensives
- Diuretics
- Sedatives
What are some things we can do to find the cause of dizziness? (6)
- Ask the right questions!
- Comorbidities (DM, cardiac)
- Medication list
- Vitals (positional BP)
- Sensory assessment
- Nutritional status
Dehydration:
- What are the (3) types of dehydration?
- Why are older adults more susceptible to dehydration? (4)
- What are the S/Sx of dehydration? (4)
- Hypertonic, Isotonic, and Hypotonic Dehydration
- Blunted thirst mechanism, reduced total body fluid, decreased renal function, physical/mental decline
- Confusion, lethargy, rapid weight loss, functional decline
Dehydration Risk Factors:
- ________ age
- _______ gender
- BMI between ___-___
- Dementia
- Hx of CVA, UI, infections
- Use of _______
- ____pharmacy
- Declining functional independence
- advanced age
- female
- BMI 21-27
- Use of steroids
- polypharmacy
______tonic Dehydration:
- Water < Na+ loss
- Closely monitor Na+ lab values
______tonic Dehydration:
- Water > Na+ loss
- Infection, hot temperatures
_____tonic Dehydration:
- Water = Na+ loss
- V/D
- Hypotonic
- Hypertonic
- Isotonic
Which type of dehydration is most common in older adults?
Hypotonic Dehydration
-Water < Na+ loss
Dehydration Clinical S/Sx. (9)
- Decreased cognitive/mental status
- Dry mucosa
- Decrease skin turgor
- Tachycardia
- Decrease BP
- OH
- Weight loss in short time
- JVD
- Decrease muscle strength, balance, function
Metabolic Syndrome:
- What is it?
- Affects about ___% of the US population.
- Also referred to as what?
- “_______ ______”
- Increased incidence of _____ and ___ events.
- A cluster of conditions that increase the risk of heart disease, stroke, and diabetes.
- 30%
- Insulin Resistance Syndrome (IRS)
- “Vicious Cycle”
- T2DM and CV events
What are the criteria for Metabolic Syndrome and how many must they have to be classified?
- ) Abdominal Obesity
- ) High Triglycerides
- ) Decreased HDLs
- ) Increased BP
- ) High fasting glucose
Must have 3+/5
What is Frailty?
Multisystem presentation that creates loss of function and physiological homeostasis.
- What is the key HALLMARK OF FRAILTY?
- What is the role of the PT in treating the frail?
- DECREASED PHYSIOLOGIC RESERVE
- Identify frailty and ensure patient receives necessary and appropriate services.
What are the (5) phenotypes of frailty?
- Unintentional weight loss
- Self-reported exhaustion
- Muscle weakness
- Slow walking speed
- Low physical activity
What are the classifications of frailty based on how many phenotypes they have?
- Not Frail = 0
- Prefrail = 1-2
- Frail = 3+
What are some other tools we can utilize to diagnose frailty besides phenotypes?
- Frailty Index
- Frailty Index for Elders - Questionnaire
- Gait Speed, Grip Strength, Repeated Chair Stands
- Comprehensive Geriatric Assessment (CGA)
- Frailty Index
- TUG (>10s)
- Gait speed (<0.8m/s)
- Frailty Index for Elders (FIFE)
- Phenotype of Frailty
- Life Space
Frailty Assessment Tools:
- Gait Speed 20x more likely
- Grip Strength
- <0.65m/s
- <25kg
- <7x in 30s
What are (3) other aspects of frailty?
- Cognitive Frailty
- Psychological Frailty
- Social Frailty
What are the 4 degrees of frailty and their measures on the following:
- Gait Speed
- 30s CRT
- Floor transfers
Fit (not frail)
- Gait = >1.0-1.2m/s
- 30s CRT = 15 reps or more
- Independent floor transfers
Mild Frailty
- Gait = 0.8-1.2m/s
- 30s CRT = 8-15 reps or more
- Modified floor transfers
Moderate Frailty
- Gait = 0.5-0.8m/s
- 30s CRT = <8 reps
- Assisted floor transfers
Severe Frailty
- Gait = <0.5m/s
- 30s CRT = Unable
- Unalbe to floor transfer
Describe how frailty affects response to stress. (Healthy vs Frailty)
- In a healthy individual, you are at the top of independence. When you have a minor illness, your independence level only slightly drops.
- When you are a FRAIL individual, you are at the lower end of independence. When you have a minor illness, you drop further into dependence.
What is the difference between mobility disability and frailty?
Mobility disability may have a larger metabolic reserve vs frail persons.
Pathophysiology of Frailty. (7)
- Pro-inflammatory state
- Blunted immune response
- Autonomic dysfunction
- Kidney dysfunction
- Anemia
- Malnutrition
- Endocrine dysfunction
Etiology of Frailty. (3)
- Multifactorial (genetic, environmental, metabolic, lifestyle stressors)
- Acute and chronic diseases (results in multisystem impairments across multiple physiologic systems)
- Impaired homeostatic mechanisms
- Progressive __________ exercise is a key component for treating frailty.
- ___ week programs can show significant gain.
- _____-intensity effort is key.
- resistance
- 12 week program
- high-intensity
Frailty Exercise Parameters:
- ___-___% 1RM
- 8 reps for 1 set, working up to __ sets.
- Are LE or UE exercises a priority?
- 40-80% 1RM
- 3 sets
- LE
Why is floor transfer training important? What can increased time on the floor lead to?
If stuck on floor, can cause rhabdomyolysis from compressed areas.
What are some other interventions used to treat frailty? (3)
- Nutrition
- Hormone treatment
- Pharmaceuticals
Frailty Primary Prevention (Triple Aim):
- Regular engagement in ____-____ physical activity.
- _________ stimulating activities.
- Healthy diet/supplementation as needed.
- Ideal sleep.
- Maintaining proper body ________.
- __________ control (blood sugar, blood pressure, blood lipids).
- mod-vig physical activity
- cognitively stimulating
- body weight
- metabolic control
Frailty Secondary Prevention (Triple Aim):
- Use assessment too to identify key underlying deficits.
- Implement a _________ approach. (med management, falls prevention, nutritional support, social/psych support, exercise program)
-multimodal
Osteoporosis: -What is it? How is it different from osteopenia? -12.6% of adults over \_\_\_. -What are the (2) types of osteoporosis?
- Metabolic bone disorder resulting in decreased bone mass and density.
- Osteopenia is a lesser form of osteoporosis
- over 50
- Primary (postmenopausal, idiopathic), Secondary (following disease condition)
Osteoporosis Risk Factors:
- ____-_______ (_______ deficiency)
- Other hormonal factors
- ______ lifestyle
- Vitamin ___ deficiency
- Smoking
- Asian/caucasian
- Excessive caffeine consumption
- post-menopausal (estrogen deficiency)
- sedentary lifestyle
- Vitamin D deficiency
What are T scores and how do they define osteoporosis?
-WHO diagnostic classification in postmenopausal women, men over 50. Cannot be applied to healthy and young population.
What is the difference between T-scores and Z-scores?
- T-scores are better at determining if you have osteoporosis.
- Z-scores are better at assessing your 10-year risk for developing osteoporosis.
- Osteoporosis T-score = _____
- Osteopenia T-score = _____
- Osteoporosis T-score = -2.5 or less
- Osteopenia T-score = -1 to -2.5
Pharmacological Treatments for Osteoporosis. (7)
- Vitamin D + calcium
- Fluoride supplements
- Bisphosphonates
- Calcitonin
- Injected human parathyroid hormone
- Raloxifene
- Other: surgery to reduce kyphosis/realign vertebrae
What are some exercises to build bone/strength in Osteoporosis? (2)
Standing / WBing exercises
Strengthening, flexibility, and balance activities
***Dosage depends on bone loss and level of fitness
What are some exercises to avoid in Osteoporosis? (3)
- Trunk flexion and excessive rotation
- High impact exercises
- Joint mobilizations/manual percussion
