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Geriatrics > Chapter 8 > Flashcards

Chapter 8 Flashcards

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1
Q

How is immobility treatment gauged?

A

By improvement in function

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2
Q

Definition of immobility

A

A limitation in independent, purposeful physical movement; it is a measure of function (or lack of), not a dz

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3
Q

Importance of small improvements

A

Can decrease incidence and severity of complications, and improve function, sense of well being, caregiver burden

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4
Q

Musculoskeletal causes of immobility

A 
Arthritides
Osteoporosis
Fxs (esp hip and femur)
Podiatric problems
Other (e.g., Paget's dz)
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5
Q

Neurological causes of immobility

A 
Stroke
Nl pressure hydrocephalus
Parkinson's dz
Dementia
Other (cerebellar dysfunction, neuropathies)
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6
Q

Cardiovascular causes of immobility

A

CHF (severe- low output/perfusion)
Coronary artery dz (frequent angina)
Peripheral vascular dz (frequent claudication)

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7
Q

Pulmonary causes of immobility

A

COPD (severe)

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8
Q

Sensory factors in immobility

A

Impairment of vision, proprioception, touch

Fear (from instability and fear of falling)

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9
Q

Environmental causes of immobility

A 
Forced immobility (in hospitals and nursing homes)
Inadequate aids for mobility
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10
Q

Other causes of immobility

A

Acute and chronic pain
Malnutrition
Severe systemic illness (e.g., widespread malignancy)
Depression
Deconditioning (after prolonged bed rest from acute illness)
Drug side effects (e.g., antipsychotic-induced rigidity
Apathy, fear of falling, lack of motivation

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11
Q

Skins complications of immobility

A

Pressure ulcers

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12
Q

MS complications of immobility

A

Muscular deconditioning and atrophy
contractures
Bone loss (osteoporosis)

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13
Q

Cardiovascular complications of immobility

A

Deconditioning
Orthostatic hypotension
Venous thrombosis, embolism

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14
Q

Pulmonary complications of immobility

A

Decreased ventilation
Atelectasis
Aspiration pneumonia

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15
Q

GI complications of immobility

A

Anorexia
Constipation
Fecal impaction, incontinence

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16
Q

GU complications of immobility

A

Urinary infection
Urinary retention
Bladder calculi
Incontinence

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17
Q

Metabolic complications of immobility

A

Altered body composition (e.g., decreased plasma volume)
Negative nitrogen balance
Impaired glucose tolerance
Altered drug pharmacokinetics

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18
Q

Psychological complications of immobility

A

Sensory deprivation
Isolation
Delirium
Depression

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19
Q

Hx components in assessment of immobile geriatric pts

A

Medical conditions contributing to immobility
Nature and duration of disabilities causing immobility
Pain
Drugs that can affect mobility
Motivation and other psychological factors
Environment

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20
Q

Two things to check in the start for PE

A

Skin

Cardiopulmonary status

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21
Q

MS examination

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A

Muscle tone and strength; symmetry
Joint-ROM; heat; swelling; deformity; erythema; crepitus; mono-poly; large vs small; symmetry
Foot deformities and lesions

22
Q

Neuro exam

Study These Flashcards
A

Focal weakness
Sensory and perceptual eval
Affect, cognition

23
Q

Levels of mobility

Study These Flashcards
A 
Bed mobility
Ability to transfer (bed to chair)
Wheelchair mobility
Standing balance
Gait
Pain with movement
24
Q

General assessment of immobile pts

Study These Flashcards
A

Ascertain pts perceived cause; there is frequently some volitional component, need pt education!
Assess mood and fear (subjective) and affect (objective); fear may be denied, ask caregivers
Assess nutrition, protein, and vit D levels
Pt function with reevaluations

25
Lab assessment
ESR- helpful in following pts with PMR; nonspecific (infection, malignancy) Rheumatoid factor- false positives (rate increases with age); false negatives (esp early in process) Uric acid- blood levels may support suspicion, but: crystals in synovial required for diagnosis of gout, CPPD ANA: sensitive for autoimmune dz; positive only 20-30% for RA Anti-CCP: specific and sensitive for RA
26
Maxims of immobility managment
Goal driven (prevention of complication, optimize function and mobility) Target diseases and disabilities (by diagnosis) Multispecialty involvement (PT, OT) Frequent reassessment Environmental manipulation
27
Algorithm for joint pain
Is it joint or periarticular (tendonitis, bursitis) or polymyalgia? Is it monoarticular (OA) or polyarticular? Is it inflamed or not? Is it acute onset, 1st M-T? Think gout If more muscle than joint, think PMR
28
Monoarticular joint pain
``` Inflammatory- consider: -Gout -CPDD (pseudogout) -Septic arthritis Noninflammatory- consider: -Osteoarthritis ```
29
Polyarticular joint pain
Inflammatory- consider: -Rheumatoid arthritis Noninflammatory- consider hx: -Osteoarthritis
30
What is the most common joint disease?
`Osteoarthritis | The major cause of knee and hip pain in the elderly
31
Characteristics of OA
Cartilage destruction Osteophyte formation Loss of joint space (in wt-bearing joints) Insidious, brief morning stiffness, crepitus Usually 1 or few joints, not polyarthritis
32
Dx of OA
X-ray Wt-bearing film shows narrowed joint space; U/s, MRI more accurate, comprehensive, but more expensive
33
Tx of OA
Nonpharm- wt loss, PT, exercise, ice, heat Pharm- APAP, NSAIDs, intra-articular steroids, glucosamine +/- chondroitin controversial, visco-supplementation (intra-articular injections of hyaluronan or hyaluronic acid polymers) Surgical: joint replacement, arthroscopy Vit D, glucosamine, chondroitin of doubtful benefit
34
What is helpful in diagnosing other arthritides?
``` Synovial fluid analysis Joint X-ray ESR H/h (anemia in RA and PR) Anti-CCP RF ```
35
Onset of RA
Usually age 20-40, but may have new onset of RA in elderly (20% of all cases)
36
What RA affects
``` PIP (ulnar deviation) MCP Wrist Elbow Shoulder TMJ C-spine Hip Knee Ankle MTP ```
37
Characteristics of OA
``` Inflammatory Polyarticular With symmetry Joint synovitis Prolonged morning stiffness ```
38
Lab findings in OA
RF usually, but not always, elevated, esp early
39
Diagnostic criteria for RA
``` Must have 5 of 7, 1st 4 continuous for >6 wks Morning stiffness (1 hr or more) Arthritis of 3 or more joints with swelling or fluid Swelling of 1 or more wrist, PIP, MCP joints Symmetrical joint swelling Positive serum RF Rheumatoid nodules (sub-Q, hands, fingers, knuckles, elbows) X-ray: erosions, decalcification in affected joints ```
40
Labs in RA
``` H/h frequently normochromic, normocytic anemia, thrombocytosis ESR, CRP elevated: not specific RF sensitivity only 70-80% Anti-CCP sensitive; specificity >90% ANA not sensitive; shows autoimmune SLE ```
41
Radiography of RA
Plain films of hands, wrists, feet initially Lack of bony remodeling, symmetric joint space narrowing Cortical bone erosions: indistinct margins, dot-dash pattern of cortical loss Periarticular osteopenia
42
RA tx goals
Control pain Maximize functional status Modify disease Advanced age doesn't necessarily preclude use of DMARDS
43
RA management
Think both symptomatic management and dz-modifying Don't wait to start DMARDs (N-B first) 1st 2-3 mos DMARDs from different classes additive Refer to rheumatologist if ongoing active disease > 3 mos maximal therapy Use steroids only for brief flare sx; but low dose c-s effective, and better than NSAIDs Think med-induced gastritis; PPIs, surveillance, caution in Hep C, or liver dz Screen for latent TB if using TNF inhibitors
44
When is PMR most common?
Older women
45
What is PMR associated with?
Temporal arteritis, esp when ESR >75 mm/h Untreated, can lead to blindness Biopsy the temporal artery; treat aggressively
46
Prognosis of PMR
Tends to be self-limited 1-2 yrs
47
Lab findings of PMR
Increased ESR | Anti-CCP usually neg
48
Dx of PMR
Clinical; immediate response to corticosteroids confirms
49
Findings of PMR
``` Prolonged morning stiffness Wt loss Fever Muscle pain Symmetry Hip Shoulders ```
50
Tx of PMR
Prednisone 10-20 mg/day | Most will need Rx for >2 yrs then taper off; may relapse
51
Inflammatory vs Noninflammatory
All newly inflamed joints with significant effusion should be tapped, cultured (with Gram stain) to r/o infection, a cause of osteomyelitis, joint destruction OA usually not associated with inflammatory response, RA and PMR always are
52
First line treatments for OA, RA, PMR
OA: NSAIDs or other anti-inflammatories RA: DMARDs PMR: steroids

Geriatrics (2 decks)

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