Chronic Health problem management Flashcards
(113 cards)
1
Q
what is the term that means illness/disease?
A
morbidity
2
Q
what is the term that means death?
A
mortality
3
Q
the co-occurrence of two or more chronic medical or psychiatric conditions, which may or may not directly interact with each other
A
multimorbidity
4
Q
indicates a condition or conditions that coexist in the context of a defined disease or condition
A
comorbidity
5
Q
about how many pt ages 65-69 have 2+ chronic conditions? how much does that increase as they get older?
A
- almost half of those aged 65 – 69 years
- increases 75% among those +85 years
6
Q
challenges faced by providers that are factors of multimorbidity
A
-
lack of evidence for best practice
- inadequate guidelines & EBM - Multimorbidity pts commonly excluded from clinical trials, challenges w/ recruitment and retention - management challenges - Complicated regimens
-
intensified communication
- overlapping tx
- goal setting
- risks vs benefits
- conflicts between clinician-patient priorities - financial compensation - Rarely corresponds to time and effort required to care
7
Q
Approach to the Patient with Multimorbidity American Geriatrics Society (AGS) Guiding Principles
A
- Elicit and incorporate pt preferences into medical decision-making
- Recognize the limitations of evidence in interpreting and applying the medical literature
- Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (life expectancy, functional status, quality of life)
- Consider tx complexity and feasibility when making clinical management decisions
- Choose therapies that optimize benefit, minimize harm, and enhance the quality of life
8
Q
3 steps that can support clinicians in caring for older adults with multimorbidity? what assessments are included?
A
- determine prognosis - Provide appropriate context for elicitation of preferences for tx
-
elicit pt preferences regarding:
- importance of one condition over another
- states of being and how much burden is acceptable in order to achieve a particular outcome (survival, higher functional status, or better quality of life)
- tx in light of associated potential benefits and burdens -
assess tx plan
- Reduce treatment burden and complexity
- BEERS Criteria
- START: SCREENING TOOL to ALERT to RIGHT TREATMENT
- STOPP: SCREENING TOOL OF OLDER PERSONS’ PRESCRIPTIONS
9
Q
what are the goals of the 4 purpose questions?
A
- understand pts view of their quality of life
- undertand pts view of their future
- learn pts value
- learn pts preferences
10
Q
plan considerations for multimorbidity
A
- pt preferences - what matters most to the pt, what outcomes are important
- pt tolerances - bothering outcomes, time it takes until benefits of intervention are achieved
- pt needs - health status, sx contro, flare-ups, conplications
- confirm plan is not overwhelming, unaffordable, unrealistic
11
Q
AGS Action Steps (based on overall health status) for multimorbidity
A
- Action Steps:
- Identify and communicate patients’ health priorities and health trajectory
- Stop, start, or continue care based on health priorities, potential benefit vs harm and burden, and health trajectory
- Align decisions and care among patients, caregivers, and other clinicians with patients’ health priorities and health trajectory - Consider
- life expectancy
- degree of functional impairment
- chronic disease burden
11
Q
few chronic conditions & few to no functional limitations = follow disease-specific guidelines & patient preferences
what life expectancy would we expect?
A
> 10 yrs life expectancy
11
Q
increasing number of severity of chronic conditions and functional impairment = follow the multiple chronic condition actions steps
what is the life expectancy?
A
2-10 yrs life expectancy
12
Q
what are the 8 common chronic conditions in the elderly?
A
- urinary incontinence
- constipation and fecal incontinence
- BPH
- sleep disorders
- sexual dysfunction
- osteoporosis
- DM
- wt loss
12
Q
advanced illness
= guideline-specific care to aggressively treat and manage disease is often NOT best aligned with patient goals and preferences
= focus on aggressive palliative care
= prioritize quality of life over quantity of life
what life expectancy?
A
<1-2 yrs life expectancy
12
Q
AGS’s approach to evaluation and management of the older pt with multi-morbidity (10) (starred)
A
- get primary concern and additional objectives for visit
- complete review of care plan OR focus on specifics of care
- what are the current medical conditions and interventions? is there adherence/comfort with tx plan?
- consider pt preferences
- is relevant evidence available regarding important outcomes
- consider prognosis
- consider interactions with tx and conditions
- pros vs cons of tx plan
- communicate and decide for/against implementation or continuation of intervention/tx
- reassess at selected intervals: benefits, feasibility, adherence, alignment with preferences
13
Q
involuntary loss of urine
what is this term?
A
incontinence (UI)
14
Q
UI is Classified as a ____ _____, not a disease
A
geriatric syndrome
15
Q
epidemiology of UI
A
- ~15%–30% of healthy older adults experience some urinary leakage
- MC women > men
- Often goes unreported because of embarrassment
16
Q
physiology of normal urination
A
- Afferent pathways (via somatic/autonomic nerves) carry info on bladder volume to spinal cord as bladder fills
- sympathetic tone closes bladder neck, relaxes dome of bladder, and inhibits parasympathetic tone
- Somatic innervation maintains tone in pelvic floor musculature
- When urination occurs, sympathetic and somatic tones diminish
- Parasympathetic cholinergically mediated impulses cause bladder to contract
- All of these processes are under influence of higher centers in the brainstem, cerebral cortex, and cerebellum
17
Q
causes of UI
A
- Aging alone does not cause UI
- medical conditions
- meds
- lower urinary tract dz - age-related changes
- bladder capacity
- residual urine
- involuntary bladder contraction - decline in bladder outlet and urethral resistance pressure in women
- diminished estrogen influence and laxity of pelvic floor structures
- childbirth, surgeries, deconditioned muscles
18
Q
4 types of UI
A
- overflow
- stress
- urge
- functional
19
Q
UI leakage may be (3)
A
- transient
- episodic
- persistent
leakage based on risk factors
20
Q
risk factors for UI
A
- Increasing age
- Female gender
- Multiparity
- Cognitive impairment
- Genitourinary surgery
- Obesity
- Impaired mobility
- Prostate enlargement
- Bladder prolapse
- Urethral strictures
- Bladder stones
- Estrogen-deficient tissue atrophy
21
overflow incontinence potential causes
Benign prostatic hyperplasia (BPH)
prostate cancer
urethral stricture
GU organ prolapse
anticholinergic
neuropathy
spinal cord injury
detrusor underactivity - impaired urothelial sensory function, fibrosis, low estrogen, peripheral neuropathy (DM, Vit B12 def, ETOH), spinal cord detrusor efferent nerve damage (MS, spinal stenosis)
bladder outlet obstruction - fibroids, organ prolapse
tumors
urethral stricture
uterine incarceration from a retroverted uterus
22
loss of urine in the setting of excessive bladder volume as a result of impaired bladdre wall contraction or urinary sphincter relaxation
overflow incontinence
23
s/s of overflow incontinence
Dribbling, weak urinary stream, intermittent or continuous leakage, hesitancy, frequency, nocturia, high post-void urinary volume
24
Loss of urine when abrupt increase in intra-abdominal pressure exceeds urethral sphincter closing pressure
stress incontinence
25
s/s stress incontinence?
causes?
- Often small volumes, associated with activities such as cough, laugh, sneeze, standing, or bending
- Potential causes: Genitourinary (GU) atrophy or prolapse, urethral sphincter trauma, pelvic floor weakness
26
Loss of urine caused by uninhibited detrusor muscle activity at inappropriately low urinary volumes
Urge Incontinence (aka Overactive Bladder)
27
s/s of urge incontinence? causes?
- Small- or large-volume leakage, abrupt onset, urgency, frequency
- Potential causes: Bladder irritants, stones, infection or FB, detrusor noncompliance (scarring, fibrosis, and aging)
28
Loss of urine in the setting of a normal structural and functional urinary system
what is this term?
**functional incontinence**
permanent or temporary
29
s/s of functional incontinence?
causes?
- Impaired awareness/concern, altered cognition
- Potential causes: Dementia, delirium, depression, immobility, impaired manual dexterity, excessive urine output
30
H&P for UI
H - duration, frequency, severity
PE - CV, abd, GU, peripheral motor and sensory, genitalia, pelvic
31
labs for UI
1. check metabolic, infectious, malignant
- BMP - lects, glucose, creatinine, Ca
- UA - RBC, WBC, proteins, culture
- extensive evaluation if needed
32
imaging for UI
1. US bladder scan
- bedside or hospital
- ambulatory or nursing home setting
- <50mL in bladder after voiding
- >200mL - significant bladder dysfunction
2. imaging of kidney and urinary tract - nephrolithiasis, cysts, tumors and obstruction
3. **renal US and CT** - first line
- evaluates structure and function
33
what are the reversible conditions of UI
Delirium
Restricted mobility, retention
Infection, inflammation, impaction
Polyuria, pharm
34
management for general UI
use voiding diary - at least 48 H
review meds
35
what is considered an acute UI case?
sudden onset
acute illness
subsides after illness/med is resolved
36
management for conservative therapy for UI
*curable or controllable in many, esp those who have adequate mobility and mental functioning*
1. _behavioral modifications_
- Toileting after meals, prior to bedtime, or before vigorous physical exercise if these events are regularly associated with incontinence
- Scheduled voiding (every 2 hrs) & prompted voiding
- Frequent inquiry about the need to pass urine & assistance to the toilet when the response is “yes.” (used by caregivers of cognitively impaired adults with functional or urge incontinence)
2. _Pelvic muscle training_ (*Kegels*)
3. _Lifestyle modification_ (*wt loss, fluid restriction, reduce caffeine, stop smoking*)
4. _Depends or pads_
5. _Wicking devices_ for skin protection
37
management for overflow UI
1. Refer to specialist if from previous vaginal or urethral surgery
2. Refer to specialist for chronic urinary retention
3. Cystocele - pessary or surgery tx
4. Detrusor underactivity tx limited, address reversible causes
5. Sacral nerve stimulation for idiopathic or neurogenic underactivity
38
management for stress UI
1. Stress = **6-12 wks conservative therapy trial**
- behavioral, lifestyle, kegals, topical vaginal estrogen therapy if peri- or post-menopausal
2. 2nd line = external support devices (_pessaries_)
3. Third line = _surgery_ (midurethral sling procedures aka bladder tack-up), urethral bulking _injections_
4. _Alternatives_ (limited data) = intravesical balloon, electrical stimulation of pelvic floor, electroacupuncture, pulsed magnetic stimulation
5. _men_ - penile clamps, transurethral bulking agents, perineal slings, artificial urinary sphincter
39
management for urge UI
1. **conservative tx** (exercise, lifestyle, behavior)
2. **meds**
- works 1-2 wks
- stop and restart PRN
3. acupuncture-like nerve stimulation
- tibial nerve stimulation
- botox - 3-12 months, surgically implanted nerve stimulation
4. _mixed stress and urgent_
- tx predominant one (F)
- combo therapy (M)
- tx most recent first
40
meds for urge UI management
1. antimuscarinics - oxybutynin, tolerodine
2. Beta-2 adrenergic agonist
3. anticholinergic
- antihistamines
- antispasmodics
- antipsychotics
- antiparkinsons
- TCAs
41
MOA of anticholinergics for UI
effects on bladder wall & sphincter – stops signals to brain that triggers bladder contractions by blocking the action of the chemical messenger acetylcholine
42
SE of mirabegron
HTN
43
what are the 2 preferred antimuscarinics for UI? what are they better for?
1. tropsium
2. darifenacin
better for cognitive
44
SE of anticholinergic
Dry mouth & tachyarrhythmias
Constipation & drowsiness
Urinary retention & decreased
cognitive function
Blurred vision (near)
45
management for functional incontinence
- Alternative receptacles (male urinal, bedside commode)
- Planned trips to the bathroom
- Reminders to void
- Adjunctive measures (protective pads and undergarments)
- External catheters for men (aka condom catheter)
46
when to refer for UI
- Sudden onset w/ associated abd/pelvic pain
- Gross/microscopic hematuria in the absence of UTI
- Culture-documented recurrent UTI
- New neurologic sx
- Suspected urinary fistula or urethral diverticulum
- Chronic catheterization
- Difficulty passing a urinary catheter
- Pelvic organ prolapse beyond the hymen
- hx of pelvic reconstructive surgery or pelvic radiation
- Urinary retention
- Persistent elevated postvoid residual
47
what is constipation and fecal incontinence
- Hard or lumpy stool
- Straining
- Sensation of incomplete evacuation
- Sensation of anorectal obstruction or blockage
- Manual maneuvers to facilitate ≥25% of defecations (eg, digital evacuation, support of the pelvic floor)
- **<3 defecations/wk**
48
One of the most frequent GI disorders
encountered among older adults in clinical practice
constipation and fecal incontinence
- ~40% of people >65 y/o
- Less common than UI
- 30-50% of pts with UI have fecal incontinence
49
causes of constipation and fecal incontinence
1. _Disruption of stooling process_
- Constipation
- Problems with laxative use
- Neurological disorders
- Colorectal disorders
2. _Chronic constipation_
- The hard stool of the impaction irritates the rectum
- Results in production of mucus and fluid
- Fluid leaks around the mass of impacted stool and precipitates incontinence
50
s/s of constipation and fecal incontinence
1. bloating, fullness, incomplete evacuation
2. "alarm symptoms"
- hematochezia
- Fhx of colon cancer/inflammatory bowel disease
- anemia
- positive fecal occult blood test
- wt loss >10 pounds
- constipation that is refractory to tx
- new onset constipation without evidence of potential primary cause
3. rectal exam
- palpating hard stool
- assessing for masses, fissures, sphincter tone
- hemorrhoids
- push effort during defection
- posterior vaginal masses in women
51
labs for constipation and fecal incontinence
1. CBC
2. TSH
3. fecal occult blood testing
4. abd plain films - detects significat stool retention in colon and suggest dx of megacolon
52
management for constipation and fecal incontinence
1. Lifestyle modifications
- Diet (Increase fiber and fluids)
- Exercise
2. Fiber supplements
3. Stool softeners/emollients
5. Stimulants
6. Osmotic cleansing agents / enemas
7. Proper management of constipation; Correct laxative use
9. If neurological, pelvic floor exercises
10. If all else fails, incontinence undergarments
53
Common condition in older men that can lead to diminished quality of life
(hint: genitourinary condition)
BPH
54
epidemiology of BPH
Approaches 50% by the sixth decade of life
Close to 90% in men aged 80 years and older
Older men who are symptomatic from BPH underreport their sx to their clinicians
55
pathophys of BPH
1. Have smooth muscle and epithelial cell proliferation in the prostatic transition zone
2. Associated with Dihydrotestosterone (DHT)
3. Circulating testosterone is converted to DHT by 5-alpha-reductase, which binds to androgen receptors in prostate
4. # of epithelial cells increase within transition zone of prostate gland
5. This hyperplasia causes enlarged prostate gland
6. Leads to bladder outlet obstruction and increased smooth muscle tone and resistance
56
h&p for BPH
1. sensation of not emptying bladder completely
2. urine storage problems
3. voiding problems
4. mild sx
- Behavioral modifications - Limit fluid intake before bed or travel, Avoid constipation, Limit mild diuretics (caffeine, alcohol), wt control, Limit bladder irritants (seasoned/irritative foods), Increase activity, regular strenuous exercise
- Double voiding
- Timed voiding regimens
- Kegel exercises
57
meds for BPH
1. alpha-adrenergic receptor blockers (-**osin**) - relaxes smooth muscle in bladder neck
- doxazosin
- tamsulosin
- terazosin
- silodosin
- alfuzosin
2. 5-alpha reductases inhibitors (-**steride**) - use if ED
- finasteride
- dutasteride
58
SE of alpha-adrenergic receptor blockers
dizziness & rhinitis, hypotension (Flomax & Rapaflo with fewer SEs)
Start low, titrate up, take h.s., monitor BP, avoid cataract surgery, ED
59
persistant sx of BPH management
_surgery_
1. _Prostatic urethral lift_ - mechanically opens the prostatic urethra and relieves obstruction
2. _water vapor thermal therapy_ - uses convective water vapor energy to ablate prostatic tissue, no thermal effects occur outside prostate or targeted tx zone
3. _TURP_ - uses eletrocautery to resect prostatic tissue from level of bladder neck
60
complications with BPH
1. Outlet obstruction from enlarged prostate may lead to urinary retention
associated with development of:
- urinary retention
- recurrent UTIs
- acute kidney failure
- chronic kidney disease
61
referrals for BPH
- Complications of renal insufficiency
- Refractory urinary retention
- Recurrent UTIs
- Recurrent bladder stones or gross hematuria
- Rising post-void residual urine volume - Bilateral hydronephrosis with renal functional impairment
- Persistent or bothersome symptoms after basic management does
not work
- Present with severe symptoms
62
causes of sleep disorders
medications
1. rsp - pseudoephedrine, beta agonists, theophylline, phenylpropanolamine
2. antidepressants - bupropion, fluxetine, paroxetine, sertraline, venlafaxine
3. CV - furosemide, BB
4. other - corticosteroids, cimetidine, phenytoin, caffeine, nicotine, alcohol
63
criteria for insomnia
1. must have sleep compliant
2. sleep complaint must occur despite adequate opportunity and circumstances for sleep
3. There must be daytime impairment related to the nighttime sleeping difficulty
- fatigue or malaise
- mood disturbance or irritability
- daytime sleepiness
64
insomnia assessments
1. sleep questionnaires
2. sleep logs
3. sx checklists
4. psych screening
5. interviews of bed partners
65
management for sleep disorders
1. improve sleep hygiene
2. meds - benzos, sedating antidepressants , melatonin
3. non-prescription meds - tylenol
- bedtime dose of analgesic agents alone may be safe and helpful if pain disrupts sleep
66
what special pt population have more sleep disruption, more arousal, lower sleep efficiency
dementia
- Sundowning, a worsening of confusion or agitated behaviors at night, is present in up to 20% of pts with dementia
- Antipsychotic and sedative hypnotic agents not effective
- Sensory interventions (aromatherapy, thermal bath and calming music
with hand massage) may be beneficial
67
what factors affect sleep quality in LT care facility pts?
1. Multiple physical illnesses
2. Debility
3. Minimal sunlight exposure
4. Increased prevalence of primary sleep disorders
5. Medications
6. Inactivity
7. Daytime sleeping
8. frequent nighttime arousals - Nighttime noise and light, Disruptive nighttime nursing care activities
68
how to improve sleep disorders in LT care facility pt
1. Increase in daytime activity levels to enhance wakefulness
2. Socialization and exercise programs
3. Bright light therapy may decrease daytime sleeping
4. Reduction of nighttime noise
5. Consistent sleep hygiene practices
6. Application of multicomponent nonpharmacological interventions to
improve sleep/wake patterns
69
sexual dysfunction is MC in who?
among older men AND women
70
MC type of sexual dysfunction in men? what is its cause?
**ED**
* MCC of ED is **vascular disease**
* Alterations in the pituitary hypothalamic–gonadal axis may result in hypogonadism and decreased libido
* Changes in penile innervation makes erection more difficult
71
cause of sexual dysfunction in women
often multifactorial
1. Lack of estrogen causes vaginal dryness
2. Lack of testosterone decreases libido
72
diagnosing sexual dysfunction
A complete sexual history
A review of medications
A targeted physical exam
For men, check testosterone levels
73
management of male sexual dysfunction
*Decreased libido with hypogonadism*
1. Testosterone replacement therapy (may improve libido)
- _CI to testosterone tx_:
--- Hx of prostate or breast cancer
--- Polycythemia
--- Severe lower urinary tract sx
--- ED
3. _Meds_ - Viagra or Cialis (make sure that it is safe for pt to engage in intercourse before)
4. Vacuum constrictive devices
5. Alprostadil penile injection
74
management for female sexual dysfunction
Hypoestrogenism after menopause
1. Silicone or water-based lubricants
2. Low-dose topical vaginal estrogens
3. Pelvic floor exercises
75
Skeletal disorder characterized by low bone mass and deterioration of bone tissue. This leads to compromised bone strength, resulting in bone fragility and susceptibility to fractures
osteoporosis
76
epidemiology osteoporosis
1. MC in women > men
- Incidence among men is increasing
3. Prevalence increases with age
4. Primary Osteoporosis - Occurs in _both men and women_
5. Secondary Osteoporosis - Secondary hyperPTH (caused by vit D def) accounts for ~20% of secondary causes
77
cause of osteoporosis
1. _Primary Osteoporosis_ - Bone loss associated with normal aging process
2. _Secondary Osteoporosis_ - Bone loss caused by a variety of diseases, conditions, or drugs
78
risk factors of osteoporosis
1. Women >65 years of age
2. Men > 70 years of age
3. White vs. Asian race
- compared with white women, Asian women consume less calcium - lactose intolerance
4. Low body weight (<127 lbs or BMI <20)
5. Family history of osteoporosis
6. Personal history of fragility fracture
7. Long-term use of glucocorticoids
8. Alcohol > 2 – 3 drinks per day
9. Estrogen deficiency
10. Testosterone deficiency
11. Low calcium intake
12. Vitamin D deficiency
13. Sedentary lifestyle
14. Tobacco use
79
how to diagnose osteoporosis
1. Bone mass is assessed with bone density measurements
2. **DEXA - Gold standard** to determine bone density
- T-score > -1.0 = normal
- T-score -1.0 - -2.5 = low bone mass or osteopenia
- T-score < -2.5 = osteoporosis
80
what is DEXA
- Estimates fracture risk
- Identifies candidates for intervention
- Assesses changes in bone mass over time
- **Indicated in women +65 years**
- Use in _younger perimenopausal women with risk factors for fragility fx’s_
- Medicare covers cost in all women >65 for initial
dx and for f/u after 2 yrs
- Includes _results for hip, spine, and wrist_
- _Bone density values_ = T scores and Z scores
- **Each standard deviation change increases fracture risk by 2 - 2.5 times**
81
categories with DEXA
- _Normal_ - BMD within **1 standard deviation (SD)** of young normal adult (T score is greater than −1.0)
- _Osteopenia_ - BMD **1-2.5 SD** below a young normal adult (T score −1 to −2.5)
- _Osteoporosis_ - BMD **>2.5 SD** below a young normal adult (T score is less than −2.5)
- _Severe/established osteoporosis_ - BMD **>2.5 SD** below young adult **+ 1 or more fragility fractures**
82
what is the FRAX algorithm?
_fracture risk assessment tool for osteoporosis_
- Uses clinical risk factors, BMD measurements, and country-
specific fracture data to calculate a **10-yr probability of a fragility fracture**
- Applicable to _men and postmenopausal women ages 40 – 90_
83
labs for osteoporosis
1. Tests used to rule out or find common secondary causes of osteoporosis
2. Preliminary testing: CBC, CMP
3. More specific testing for secondary causes: Hypogonadism, Primary hyperparathyroidism, Secondary hyperparathyroidism, Multiple myeloma, Hyperthyroidism
4. labs to order
- Secondary hyperparathyroidism
- 25-Hydroxy vitamin D
- PTH
- Serum testosterone
- prolactin PTH
- ionized calcium
- Serum and urine protein electrophoresis
- Thyroid-stimulating hormone, thyroxine (T4)
84
management for osteoporosis
1. Treat
- T-score of less than -2.5 at the femoral neck, hip, or spine
- Low bone mass (T score between -1.0 - -2.5)
- 10-year probability of hip fracture of >3% (determined by FRAX)
2. Two types of medications: Antiresorptive & Anabolic
3. Antiresorptive inhibits osteoclast function
- Bisphosphonates such as Alendronate (Fosamax)
- Hormone Replacement Therapy (HRT)
- Selective estrogen receptor modulators (SERMs)
- Denosuman
- Calcitonin
4. Anabolic: PTH is the only US approved anabolic agent
85
complications with osteoporosis
1. _hip fractures_
- Incidence increases with age; peaks +85 y/o
- Injured leg is shortened, externally rotated, and abducted when the patient is lying flat
- **Plain radiographs are diagnostic**
- Surgery
2. _wrist fractures_
- Incidence increases in white women ages 45 – 60 years
- associated with a fall from outstretched arm
3. _vertebral fractures_
- _Incidence estimated to be **3x that of hip fractures**_
- Multiple vertebral fractures = **thoracic kyphosis (hunchback)**
- **Lateral thoracic and lumbar radiographs standard tool**
86
what is the osteoporosis procedure that involves A small balloon is inflated at the site of a compression deformity
kyphoplasty
87
what osteoporosis procedure involves cement placed at the site of a compression deformity
vertebroplasty
88
Osteoporosis
Prevention
* Exercise
* Fall prevention
* Hip protectors (hard/soft shell with padding that covers the area over greater trochanter)
* Calcium supplements
* Vitamin D supplements
* Smoking cessation
* Avoidance of heavy alcohol use
89
The risk of developing DM type 2 increases with:
* Obesity
* Lack of physical activity
* Loss of muscle mass
All 3 commonly occur with aging
90
Epidemiology of DM
The prevalence in the U.S. population of older adults has been estimated at 10.9 million, or **27%** of people **+65 y/o**
91
DM management of an older patient must account for their certain impairments
Decision making should be:
1. Individualized
2. Focused on patient factors
- Duration of the diabetes
- Presence of complications
- Comorbid conditions
- Life expectancy
- Patient goals and preferences
- Functional abilities
92
Some geriatric pts cannot effectively manage their DM because of
* Cognitive impairment
* Visual impairment
* Functional impairment
93
how is Glycemic control different for geriatrics with DM?
1. ADA - recommends <7% HbA1c for healthy adults with extended life expectancy
2. AGS (American Geriatric Society)
- 7.5-8% for healthy adults
- 8-9% for older adults with extensive comorbidities
94
complications of DM for geriatrics
DKA
HHS
Macrovascular and Microvascular complications
Cognitive impairments
Depression
Falls
Functional Decline
95
Optimal body mass index (BMI) in the older adult is considered to be __ to ___ kg/m2
24 - 29 kg/m2
96
Frailty is defined by the features of ?
weight loss
exhaustion
weakness
slow gait
decreased physical activity
97
what 3 factors often play a role in weight loss
Medications
medical comorbidities
socioeconomic factors
98
difficulty in performing tasks necessary for self-care (ADLs) and independent living (IADLs)
what is this term
disability
99
A multidisciplinary team approach is recommended for patient assessment and might include who?
a speech therapist
dietitian
physical therapist
occupational therapist
social worker
100
what is present when insufficient energy and/or protein is available to meet metabolic demands?
how does this happen? (starred)
Protein-energy malnutrition
- poor intake
- increased metabolic demands from illness/trauma
- increased nutrient losses
Deficiencies in macronutrients and micronutrients are very common
100
Energy intake declines significantly with age, what are the results? (2)
decrements in lean body mass
decline in physical activity
101
Poor nutritional status and weight loss are also associated with: (5)
- altered immunity
- impaired wound healing
- reduced functional status
- increased health care use
- increased mortality
102
Failure to thrive (FTT) may be considered to result from interaction of 4 components:
1. Physical frailty
2. Disability
3. Impaired neuropsychiatric function
4. Inability to obtain foodstuffs
103
be suspicious with wt loss when it is what %?
>= 5%
104
how to approach FFT when they are meeting adequate caloric intake? (hint: flow chat)
Malabsorption?
1. yes - tx specific cause
2. no - altered metabolism/catabolism
- endo
- malignancy
- infection
- Low-output heart disease
- hypoxemic lung disease
- everything EXCEPT endo may be associated with anorexia
105
how to approach FFT when they are NOT meeting adequate caloric intake? (hint: flow chat)
1. see if they have access to food
- no - social factors: needing assistance
- yes - see if they have difficult in swallowing or have oral problems
--- possible denture problem
--- possible anorexia - find cause and tx
106
management (non-Rx) for FFT?
any factors to consider? (4)
1. _Enhance oral intake_
- Frequent meals, snacks
- Provide favorite foods, fortified foods, minimize/remove dietary restrictions
- Feeding assistance, company at meals
- Protein-calorie supplements
- Multivitamins
- Appetite stimulants
2. Factors:
- Degree of baseline protein-calorie depletion
- Current intake relative to requirements
- Expected duration of inadequate nutrition
- Effect of intervention on clinical outcomes
107
available Rx options for FFT management? factors to consider?
1. anabolic - potential for reversibility
2. enteral - quality of life
3. parenteral - patient care preference
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The normal urge to void is when bladder is at what volume?
what is the capacity of the bladder?
150-300mL
capacity - 300-600mL
