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533 > Week 10 Geriatrics, Parkinsons, Alz > Flashcards

Week 10 Geriatrics, Parkinsons, Alz Flashcards

1
Q

behavioral risk factors to reduce CVA risk?

A
  • 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)
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2
Q

recommended BP goal if had stroke/TIA?

A

< 130/80

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3
Q

which medications reduce recurrent strokes significantly?

A

diuretics alone or WITH ace but NOT with BB or ACE alone

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4
Q

AHA/ASA recommendations on statin treatment

A
  • use high intensity statin if:
    • have ischemic stroke or TIA who have atherosclerosis
    • LDL > 100
      • want 50% LDL reduction or < 70
    • known CAD
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5
Q

cardiac causes and extra cardiac causes of stroke

A
  • cardiac: atrial fibrillation and patent foramen oval
  • extracardiac: intracranial and extracranial large vessel atherosclerotic disease (carotid artery and vertebral basilar disease)
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6
Q

anticoagulant target INR in pts with ischemic stroke / TIA

A
  • 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
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7
Q

post stroke depression

A
  • common in 40% of pts post stroke
  • a/s with poor functional recovery, poor social outcomes, reduced QOL
  • give SSRI!
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8
Q

most common sx of a TIA (acute stroke)

A

lasts a few minutes to 1 hr

unilateral paresis and dysarthria (paralyzed speech)

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9
Q

highest risk reduction to prevent stroke in pts that have had a TIA?

A
  • high intensity physical activity at 64%
  • BP reduction is 40%
  • antiplatelets 37%
  • statins 33%
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10
Q

Transient ischemic attack sx’s

A
  • 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
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11
Q

pts with TIA examination

A
  • 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
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12
Q

intracranial hemorrhage stroke sx’s

A
  • 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
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13
Q

subarachnoid hemorrhage

A
  • 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
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14
Q

stroke diagnostics

A
  • 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
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15
Q

administer IV thrombolytics within

A

45 to 60 mins arrival to ED

for ischemic stroke

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16
Q

optimal SBP for acute ischemic stroke is

A

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

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17
Q

when is tPA given

A

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

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18
Q

ischemic stroke sx’s

A

MILD headache

visual field defect, ataxia, and dysarthria

resolves w/in few hours

amaurosis fugax (transient, painless loss of vision)

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19
Q

ischemic stroke prevention

A

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)

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20
Q

surgical interventions for stroke

A

mechanical thrombectomy (up to 24 hrs post sx onset)

neurosurgical consultation for SAH, ICH, IICP = carotid endarterectomy for symptomatic carotid stenosis

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21
Q

patient education in stroke

A
  • 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
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22
Q

5 domains to assess in an older adult

A
  1. physical health
  2. cognition and mental health
  3. functional status
  4. social and environmental circumstances
  5. advanced care planning
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23
Q

geriatric assessment

A
  • 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
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24
Q

components of pt’s physical assessment

A
  • nutrition
  • hearing
  • vision
  • urinary and bowel incontience
  • balance / hx of falls
  • osteoporosis risk
  • polypharmacy
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25
Q

immunizations for older adults

A
  • 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
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26
Q

cardiovascular screening for older adults

A
  • 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
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27
Q

cancer screening in older adults

A
  • 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)
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28
Q

bone mass screening in older adults

A
  • women: once at 65 yrs
  • men: once at 70 yrs
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29
Q

elderly and driving

A
  • 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
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30
Q

other screenings in older adults

A

insufficient evidence: dementia, hearing, vision, glaucoma

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31
Q

screening for hearing in older adults

A
  • 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)
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32
Q

urinary incontinence in the geriatric population

A
  • 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?
33
Q

leading cause of hospitalization/injury in 75+ adults? screen?

A
  • 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
34
Q

geriatric syndromes

A
  • polypharmacy
  • cognitive impairment
  • dehydration
  • falls
  • failure to thrive
  • elder abuse
35
Q

polypharmacy

A

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

36
Q

polypharmacy management

A
  • 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
37
Q

how to discontinue meds in polypharmacy

A
  • 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
38
Q

barriers to med adherence in older adults

A
  • 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
39
Q

depression screening

A
  • Depression 2 Q screen:
    1. During the past month, have you been bothered by feelings of sadness, depression, or hopelessness?
    2. 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
40
Q

FNP role in financial capacity

A
  • 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
  • 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
41
Q

Cognitive impairment

A
  • 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
42
Q

dehydration in older adults

A
  • 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)
43
Q

Dementia DSM 5

A
  • 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)
44
Q

Falls

A
  • 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
45
Q

post fall assessment

A

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?
46
Q

fall labs

A
  • CBC
  • electrolytes
  • BUN/Cr
  • cult stool (GI bleed - anemia)
  • ECG
47
Q

Frailty (FTT) and tx

A
  • 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
48
Q

sus for elder abuse

A
  • 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
49
Q

dementia screening

A
  • 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.
50
Q

dementia diagnostics

A
  • no single test
  • CBC, CMP, TSH, B12, folate
  • UA drug test (r/o cancer, infection)
  • baseline brain imaging with CT
51
Q

delirium hallmarks

A
  • 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
52
Q

pt has TIA, send to ED or outpatient?

A
  • 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
53
Q

how is dementia diagnosed?

A
  • 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
54
Q

dementia meds

A
  • 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
55
Q

what nonpharmacologic interventions have been studied in patients with mild dementia?

A
  • 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
56
Q

behavioral disturbances of progressive dementia and tx

A
  • 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
57
Q

DSM 5 for delirium

A

Acute onset!

  1. Decreased ability to direct, focus, and sustain attention and orientation to the environment
  2. alt to lucid periods
  3. Short = Hrs - days; fluctuating
  4. Cognition changes or perceptual disturbance that is not explained by a preexisting condition (eg, dementia)
  5. not caused by a severely reduced level of arousal, such as coma
58
Q

key points of hx in delirium

A
  • sx’s of recent infection
  • history of organ failure
  • medication list
  • history of substance use
  • psychiatric history including recent evidence of depression
59
Q

greatest risk factor for delirium

A
  • age
  • elderly most susceptible bc reduced capacity to handle change in surroundings, depression, med changes, acute stressors [surgery/hospitalization])
60
Q

delirium mangement

A

medical emergency! send to ER

61
Q

what assessment tools confirm delirium and dementia?

A

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

62
Q

interventions for prevention and tx of delirium

A
  • 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
63
Q

demential hospice requirements

A

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)
64
Q

FTT labs

A
  • CBC
  • electrolytaes
  • kidney and thyroid studies
  • fasting blood glucose
  • liver function tests
  • Ca
  • UA
  • stool for occult blood x3
  • chest xray
65
Q

FTT focus on

A

sx’s, organ failure, infections, cancer

66
Q

most powerful risk factor for recurrent stroke ?

A
  • 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
67
Q

mild cognitive impairment

A

transition b/t normal aging (forgetfulness) and dementia

close monitoring bc it’s a risk factor for dementia

68
Q

3 types of dementia

A
  • 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
69
Q

Alzheimers stages & sx’s

A
  • 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
70
Q

Parkinson’s cardinal features

A
  • 3 cardinal manifestaions: T.R.A.[P.]
  1. Tremor - asymmetric/unilateral resting tremor
  2. Rigidity: lead pipe rigidity
  • cogwheeling rigidity
  • resistance to passive movement in all directions

3. Akinesia: absent of movement, bradykinesia

  • Postural instability, pill rolling
71
Q

Parkinsons diagnosis

A

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

72
Q

Parkinson physical examinations

A
  • 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
73
Q

Parkinson’s non motor disorders

A
  • 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
74
Q

parkinson hallucination med tx

A
  • if delirium, treat underlying cause
  • if not delirium, then give pimavanserin, 2nd line quetiapine/Seroquel
75
Q

parkinson med treatment

A
  • 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
76
Q

parkinsons non pharm tx

A

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
76
Q

parkinsons non pharm tx

A

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
77
Q

delirium hallmarks

A

Clouding of consciousness, inability to focus, sustain, or shift attention, and a change in cognition

  • Sx develop rapidly and vary in severity
78
Q

pseudomentia

A
  • 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

533 (19 decks)

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