Exam 1 Flashcards
(218 cards)
1
Q
Is urinary incontinence a normal change with aging?
A
- No
2
Q
Most likely pathogen to cause septic arthritis in elderly. Management
A
- S. Aureus - Aggressive abx therapy combined with serial arthrocentesis in uncomplicated case. Surgical drainage required when conservative strategy fails.
3
Q
Prevalence of dementia
A
- In patients over 65: between 10-50% of community dwelling have it, in nursing home > 50% - Over 85: up to 50%
4
Q
Nail changes in elderly
A
- Slower growth - Dull appearance - Brittle, flake, fragmented tips - Color changes to yellow/opaque - Longitudinal ridges
5
Q
Define diffuse Lewy body dementia. Treatment
A
- Lewy bodies = intraneuronal inclusions contains alpha-synuclein, phosphorylated neurofilament proteins and ubiquitin - Features = a.) dementia b.) fluctuating cognition (very good and very bad days – unique to this disease) c.) recurrent visual hallucinations d.) motor features of PD (later in dz, bent over, mask like face, shuffle) - Tx: AchE inhibitor (Aricept or exalon), can add Namenda (stabilizes glut NMDA-R antagonist)
6
Q
Describe the antagonistic pleiotropy theory of aging
A
- Aging is an adaptive trait in which genes influence several traits are selected for and affect fitness in opposite ways at different stages of life
6
Q
Signs of financial exploitation of elderly
A
- disparity bw pt’s living condition or appearance and his/her assets - inability of pt to account for money, property or pay for essential care - reports of demands for money or goods in exchange for caregiving - unexplained loss of SS, pension checks - statements about exploitation by pt
7
Q
Cure for lymphedema?
A
- none, managed
8
Q
Pillars of geriatric medicine
A
1.) Evaluation of confusion, dementia 2.) Falling 3.) Urinary incontinence 4.) Altered homeostasis 5.) Iatrogenesis 6.) Psychiatry 7.) Derm 8.) ID 9.) Interdisciplinary collaboration 10.) Preventive medicine and wellness
8
Q
Types of treatments of psych patients
A
- SSRIs (work equally well, pick per side effects) - TCAs (work as well as SSRIs, challenging side effects) - Stimulants that augment NE/Epi pathways in brain - Bupropion - MAO inhibitors - SNRIs - ECT (effective and safe in geriatric population in tx life threatening and psychotic depression)
9
Q
2 mortal sins with depression
A
- Not reaching the diagnosis of depression - Not treating it • Depression is worst of all human suffering
10
Q
Cross-linkage theory of aging
A
- Damage via free radicals, glucose, UV which promote nicks in adjacent molecules + formation of bonds (cross-linkages) resulting in altered molecules and function. This damage accumulates in aging.
10
Q
What are delusions? Interventions.
A
- False beliefs, occur frequently in dementia patient, often paranoid and accusatory, may simply result from misidentification or misinterpretation of environment - Intervention: 1.) Non-pharm: reassurance, distraction, benign neglect, validation therapy, remove objects being misidentified 2.) Pharm: newer atypical antipsychotics
10
Q
Minimum criteria for initiating abx therapy for respiratory infection
A
1.) Fever > 102 AND RR > 25 or productive cough 2.) Fever bw 100-102 AND RR > 25, pulse > 100, rigors, or new-onset delirium 3.) If afebrile, but with COPD: new or increased cough with purulent sputum 4.) If afebrile, without COPD: new or increased cough AND either RR ? 25 or new-onset delirium
11
Q
How can patient leaving AMA be an area of liability for physician?
A
- Physician must be involved in AMA process, nurse/front office cannot administer - Pt not warned about medical condition and risks - No documentation of AMA process - No family involvement - Patient not competent to sign - Inadequate or failure to provide aftercare instructions
11
Q
Management of UI patients
A
- non pharm: decrease caffeine, etoh, evening fluid, Kiegel exercises, timed toileting, biofeedback, PT referral, pessaries - pharm: E replacement for women with stress or urge UI. Alpha stimulant with Sudafed for stress ui (increases tone of external sphincter). Anticholinergic for urge incontinence - silver alloy hydrogel catheters (reduces UTIs) - surgical: last resort
12
Q
Consequences of immobilization in geriatric population
A
- Stiffness/contractures - Loss of muscle strength - Confusion, sensory loss, depression - Dependence and institutionalization - Instability and loss of confidence - Dehydration and electrolyte imbalance – esp in hot water - Malnutrition - Pressure sores
12
Q
What is Fregoli syndrome?
A
- Everybody looks familiar and like family member / friend etc.
13
Q
What is the most common and frustrating behavioral difficulty in dementia? Intervention?
A
- Resistiveness to care - intervention: 1.) non-pharm: limit goals, used gentle, slow approach avoiding too many directions at once, some patients cooperate for reward 2.) pharm: pre-care administration of low dose benzo
14
Q
What is the single most effective method of maintaining homeostasis in geriatric population?
A
- Healthy lifestyle, which in seniors = socialization, exercise, stress reduction, use of talents for self and others (Freudian), avoidance of accidents on road and in home, nothing in excess, rest one day per week, have a good health care team, maximize one’s spiritual life
14
Q
Unusual causes of UI
A
- Bladder-sphincter dyssynergia, fistula, reduced detrusor compliance, recurrent cystitis
14
Q
Risk factors for poor adherence to abx regimen
A
- Poor cognitive function, impaired hearing/vision, multiple meds, financial constraints
15
Q
What has research showed about maintaining social life and friendships when it comes to aging?
A
- Extends your life - Recovery times go down - Immunity boosted - Mental health: reduces anxiety, protects against mental decline
16
Q
Four greatest causes of dementia in industrialized countries
A
- Alzheimer’s dz (most common, as much as 80%) - Diffuse Lewy body dz - Vascular dementia - Frontotemporal dementia
16
Meds to sleep disorders
- Avoid benzos (except restoril). - Sonata, ambien, low dose atypical antipsychotic like Seroquel - Trazadone - Melatonin
17
What alterations are seen in geriatric musculoskeletal system? Clinical implication
1.) decreased bone mass, muscle mass, lean body mass, repair of microfractures 2.) flattening of foot arch - Clinical consequences: osteoporosis, decreased strength, loss of height, increased curvature of spine, strength of breathing, gait impairment
17
What distinguishes dementia from delirium?
- Dementia is persistent (chronic) and stable
17
How to evaluate elderly patient with fever of unknown origin?
1.) Confirm fever, conduct through H&P, discontinue non-essential meds 2.) Labs: CBC, liver ez, ESR, blood cultures, PPD testing, TSH, ANA, consider antineutrophilic cytoplasmic ab or HIV ab testing 3.) Imaging, biopsy 4.) BM biopsy OR liver biopsy 5.) Nuclear scan 6.) Laparoscopy / laparotomy 7.) Empiric trial: antiTB therapy in rapidly declining host or high suspicion for TB
18
Define young old, middle old and old-old
- Young old: 65-74 - Middle old: 75-84 - Old-old: 85+
18
NT changes involved in aging
- Decrease in dopamine - Decrease in ACh - GABA changes?
19
Calcium theory of aging
- Abnormal Ca movement results from: ROS damage, inadequate energy supply from damaged mt, increased glucocorticoids - Abnml Ca = abnml cell function esp in muscle, nerves and BVs
19
What happens to DNR order during surgery?
- suspended
20
What is the iceberg phenomenon seen in elderly?
- Underreporting/minimizing of issues by elderly for fear of hospitalization, unpleasant investigations, tx, fear of removal from home, low expectations for health, failure to recognize a problem
21
Is decreased muscle mass / strength considered normal in geriatric population?
- No. Maintain with regular resistance training throughout ROM
21
Urge urinary incontinence. What is it? Treatment?
- sudden urge to urinate, frequent intervals, detrusor muscle responds to small urinary volumes, post void residual is
23
Nutritional model theory of aging
- Animal fed ~50% less than it eats on own, lives longer. Lean mass results in greater health and age.
24
Intervention in sundowning patient
- Similar approach to other psych treatments. - Keep living area well lit decreasing gradually before bedtime - Give some meds 30-60 mins before anticipated behaviors. Trazadone, benzos and antipyschotics can be tried.
24
Minimum criteria for initiating abx therapy for skin/soft-tissue infection
- Fever OR one of following: redness, tenderness, warmth, new or increasing swelling at site
25
What is apathy? Intervention?
- Lack of interest, decrease in activity, decreased efforts at personal hygiene. Can be part of depression - Intervention: a.) Non-pharm: lower expectations set by caregivers b.) Pharm: Provigil and Ritalin
26
Minimum criteria for initiating abx therapy for UTI infection
1.) UTI without cath: Fever + one of following: new/worsening urgency, frequency, suprapubic pain, gross hematuria, CVAT, incontinence 2.) UTI with cath: Fever OR one of following: new CVAT, rigors, new-onset delirium
27
What alterations are seen in geriatric CNS? Clinical implication
- cerebral atrophy and decrease in blood flow to brain = cognitive decline
28
Why are the elderly afraid of talking about the difficult subjects with healthcare providers?
- Fear of losing independence
29
What is a living will?
- Competent patient documents medical treatment options or a health care proxy. Health care team gets clear directions on what pt wants and / or who they want to decide. Person whose living will it is, must discuss with decision maker and family so those individuals know what the patient wants. - In IA it is just for life-sustaining procedures.
29
What is the concern with glomeruli # decrease in elderly?
- Glomeruli decreases = GFR decrease = risk of overdosing with medication.
29
Why do many long-term care facilities have such a high rate of PPD positive tests?
- Prevalence of reactivity is 30-50% d/t high exposure in 1900s
30
Stress urinary incontinence. What is it? Treatment?
- loss of urine when intraabdominal pressure increases (laughting, coughing etc), failure of sphincter mechanisms d/t often insufficient pelvic support in women and secondary to trauma from prostate surgery in men - Tx: Kiegel exercises, alpha stimulation with agents like sudafed, E replacement in women is considered (even topical E)
31
Treatment of lower UTIs (cystitis)
- 3-7 days of fluoroquinolones for uncomplicated case - Some settings, give amoxicillin and first-gen cephalosporin if patient has fluoroquinolone intolerance - Not required to culture prior to treating.
32
Is health literacy an issue in older adults?
- Yes, 7 out of 10 have trouble using everyday health info - Persons over 65 have smallest percentage of ppl with proficient health literacy skills
34
Physiologic theories of aging
1.) DNA damage: cumulative deletions, mutations and translocations 2.) MtDNA damage: efficiency of respiration/ATP production changed, more free radicals produced 3.) Telomere: loss of activity + length 4.) Developmental genetic: genetically programmed induction into aging 5.) Error catastrophe: cumulative errors in RNA and protein synthesis 6.) Free radicals (most well known): ROS damage proteins, lipids and DNA 7.) Accumulation: abnml proteins not removed 8.) Endocrine: levels of secretion of hormones? Decrease / increase 9.) Immunologic: deficits in immune response and T-cell function
34
Compare and contrast features of delirium vs dementia in terms of development, progression, duration, altered consciousness, onset
1.) Delirium - Abrupt, nonprogressive, short duration, fluctuating consciousness, precise time onset 2.) Dementia - Slow, progressive, many years, rare to have altered consciousness, uncertain date/time onset
35
Signs and symptoms of physical abuse of elderly
- Anxiety, nervousness in presence of caregiver - Excessive deference to caregiver - Bruises/welts at various healing stages especially bilateral inner arms or thighs - Fractures at various healing stages - Cigarette, rope, chain or chemical burns - Lacs and abrasions of face, lips, eyes - Repeated falls or injuries requiring ED visits - Head injuries, hair loss, hemorrhages beneath scalp as a result of hair pulling - Unusual discharges around genitalia or rectum - Delays in seeking tx, inconsistent f/u - Statements about abuse by pt
37
Physical and physiologic manifestations of aging
- Thinning, graying of hair - Deterioration of teeth - Body weight loss and redistribution - Loss of nerve cells - Loss of muscle mass - Increased cellular inclusion of aging pigments - Decline in motor activity - Impaired homeostasis
38
Factors that contribute to iatrogenic disease in elderly if not done properly
- Communication: set positive tone for medical intervention - Diagnosis: gently, tactfully, radiology is a wealthy third world nation, ask if proposed exam or test will reveal enough info to outweigh inconvenience and risk to patient - Therapy (med, surg): greatest opportunity for iatrogenesis is here, ask if potential benefits outweigh risks - Environment: ~40% chance that something bad will happen just because pt is in the hospital – delirium, falls, nosocomial infections, restraints, foley cath, unnecessary testing - Cost, Quality of life
39
Is AAMI part of dementia or normal change with age?
- No known
39
How to evaluate a demented patient?
1.) Comprehensive H&P, including accurate time of problem to assess delirium vs dementia 2.) Folstein’s mini-mental exam (nml = 26-30) – note: full scores can still mean you get diagnosed with dementia 3.) Lab tests: electrolytes, BUN, mag, cal, gluc, TSH, cre, CBC, B12, folate, VDRL, consider homocysteine level (reflective of B12) 4.) Neuro imaging: start with CT w/o, or MRI. PET, SPECT scans for difficult cases.
39
What is representative payee?
- Appointed when beneficiary is incapable of managing his/her benefits and it is in best interest
39
Psych problems commonly seen in geriatric population
- dementia - delirium - depression - agitation and aggressive behavior
39
What is agitation?
- Nonspecific umbrella term referring to: anxiety, irritability, restlessness, aggression, screaming, rummaging, sundowning and catastrophic reactions.
39
General treatment plan for lymphedema using OMM
1.) open thoracic inlet and treat down from it 2.) treat central to distal
40
Why treat herpes zoster in elderly?
- Postherpetic neuralgia is most disabling complication
41
During what phase of growth/development in the 2nd half of life are the elderly more vulnerable to external forces strong-arming them into making changes
- Phase 3: recapitulation, resolution and contribution
41
What type of hallucinations are common in dementia patients? Intervention.
- Visual, other senses can be involved. - Intervention: 1.) non-pharm: reassurance, distraction, benign neglect 2.) pharm: atypical antipsychotics
42
Factors affecting aging rate
- Cell wear/tear - Free radicals - DNA damage - Hormonal changes - Immune system changes - Programmed longevity - Glycation
43
How to take care of dry skin in geriatrics population?
- Wet it and lock in moisture with eucerin or Vaseline
44
Treatment of influenza in elderly
- Oseltamivir within 48 hours of symptom onset. Sooner the better.
45
In order to reduce risks of polypharmacy in the elderly, what tool can be used by healthcare providers
- BEERS criteria
45
Define Alzheimer’s disease. Treatment
- Gradual decline that is steady - Neuritic plaques and neurofibrillary tangles are pathologic hallmarks – causative nature not well understood - Features = a.) amnesia: short term memory b.) agnosia: difficulty recognizing things c.) apraxia: inability to carry out motor functions d.) aphasia: difficulty naming familiar items - Tx: AchE inhibitor (Aricept or exalon), stabilize glutamate (Namenda, NMDA-R antagonist)
46
How to pharmacologically treat osteoporosis?
1.) Give 1500 mg of elemental Ca per day 2.) Normalize vit D3 3.) Normalize PTH
46
Should a pt with CHF receive lymphedema treatment?
- No
47
Types of surrogate decision makers
- Durable power of attorney: patient is competent when they signed a document (power of attorney) designating a person (attorney in fact) to make decisions for them in patient’s best interests and according to patient’s wishes - Guardianship: court-appointed person (Guardian ad litem, at law) limited to set powers - Family hierarchy: spouse, adult children, parents, special friend - Health care provider: with best interests of patient
48
Compare and contrast: life span, longevity, mean longevity and maximum longevity
- Life span: length of life - Longevity: number of years of life - Mean longevity: life expectancy - Maximum longevity: maximum life span
50
Psychological changes with aging
- Attitude towards life - Self-image/worth - Value to society - Changes with retirement
51
Meds that affect memory in elderly if not used appropriately
- Diphenyhydramine - Loratidine - Lorazepam - Zolpidem - Triazolam - Paroxetine
51
Forms of elder mistreatment
- Physical - Psychological - Neglect - Self-neglect - Financial exploitation - Abandonment
52
Facial nerve palsy (Bell’s) associated with what infectious causes
- HSV, VZV, Borrelia burgdorferi (Lyme)
53
Extrinsic factors that lead to falls
- Home hazards: loose rugs, slippery floors, uneven door thresholds, poor lighting, inappropriate fixtures and furnishings.
55
Geriatric patient comes in and presents with diarrhea-like symptoms. Does this patient have diarrhea?
- Common presentation of constipation is seepage around fecal impaction. Before you make the diagnosis of diarrhea, do a rectal exam. Take a radiograph to make sure it is not impacted.
56
Treatment of TB in geriatric patient
- Similar to that in younger adult – 3 different drugs - Anyone with positive PPD should be treated with isoniazid for 9 months if: they have never been treated in past, active disease is excluded.
57
Lyme dz tx
- Amox, doxy or IV ceftriaxone
58
Presentation of TB in older pt
- Fatigue, anorexia, decreased functional status, or low-grade fever instead of classic symtpoms - 75% = lung involvement, can involve any tissue though
59
Neuro-aging theory
- Cells undergo NS degeneration resulting in changes in hormonal release leads to decline in cell function
60
Is DNR order signed by patient or physician?
- Physician order, exception = out-of-hospital DNR which according to Iowa law applies to adults with terminal illness, requires order or identifier (Medic Alert) - Same with full code
60
Treatment of nursing home/hospital-acquired pneumonia
- Broad initially - If MRSA-colonized or in unit where MRSA rates high, tx with vanc or linezolid until MRSA is excluded.
60
Compare contrast symptoms of lower UTI and upper UTI
- lower: dysuria, frequency, urgency - upper: fever, chills, nausea, flank pain
61
Code green
- Elopement
62
Reversible causes of urinary incontinence
- Mnemonic = DRIPP - D: delirium - R: restricted mobility - I: infection, inflammation, impaction of stool - P: polyuria secondary to DM, caffeine, volume overload - P: pharmaceuticals (diuretics, ANS agents, psych meds)
63
Do L16 cases
Do L16 cases
64
What alterations are seen in geriatric pulmonary system? Clinical implication
1.) Alteration of collagen and elastin 2.) Collapse of small airways with no change in TLC 3.) VQ mismatch 4.) Vital capacity decreases - Clinical implication = decreased lung elasticity, arterial saturation and maximal o2 uptake. When patients become ill with anything, risk for low o2 goes up. With decrease in vital capacity, difficulty clearing secretions and prone to aspiration and infections.
64
What alterations are seen in geriatric immune system? Clinical implication
1.) Involution of thymus with decreased new T lymphocytes, decreased capability of T lymphocytes to proliferate in response to antigens, decreased suppressor T lymphocytes, decreased humoral immunity, trouble differentiating self/non-self - Clinical consequence = anergy to various skin tests, inadequate response to extrinsic antigens like in vaccine, decreased T cell function, decreased antibody response, infection more likely, self-non-self issues = auto immunity
66
Procedure for AMA
- Determine patient’s capacity to understand conditions and risk. If no capacity, don’t let them leave. - Review chart, explain diagnosis, condition, risks of leaving and alternatives - Involve family, friends or hospital personnel to help convince pt to stay - Have pt sign AMA for and document in chart, best with witnesses. If patient refuses, witnesses - Send with aftercare instructions and invite to return
68
Is osteoporosis considered normal finding in geriatric population?
- No. Remain active and change nutrition to maintain normal bone mass/strength
69
What is disinhibition? Interventions?
- Patients say or do things that they would not have done. Commonly in patients with frontotemporal dementia, but seen in AD and other diagnoses. - Interventions: 1.) Non-pharm: examine triggers, avoid situations where pt more likely to act out, if sexually disinhibited consider restrictive clothing, caregivers should carry info card to explain to others what is happening without talking in front of patient 2.) Pharm: anticonvulsant, beta-blocker, SSRIs (depoprovera and Lupron)
70
Most common cause of iatrogenesis in geriatrics
- Medications (diuretics, pain meds, psychotropes, anti-arrhythmics, abx, NSAIDs, anticoags, corticosteroids, regland)
72
Define frontotemporal dementia. Treatment
- Heterogenous group of disorders much less common than AD, DLBD and vascular dementia. - Focal atrophy of frontal, temporal lobes with microscopic findings of argyrophilic inclusions and swollen achromatic neurons in Pick’s dz (most common FTD) - Features = a.) Do well on initial memory test b.) Patients are disinhibited (social disturbances, lack of social tact, hypersexuality) c.) Personality changes d.) Usually underdiagnosed/misdiagnosed until social disturbance occurs e.) Early and progressive change in language function f.) Poor personal hygiene - Tx: no specific tx, tx the disinhibition
72
Fever is hallmark sign of infection in older adults. T/F.
- False. Fever may be absent in 30-50% of frail older adults with serious infections. Also chills, sweating is less common.
74
Compare and contrast elopement and wandering
- Elopement: patient is aware that he/she is not permitted to leave, but does so with intent - Wandering: patient strays beyond view / control of staff without intent of leaving d/t cognitive impairment potentially
75
Treatment of community-acquired pneumonia
- Beta-lactam/beta-lactamase combo or advanced generation cephalosporin +/- macrolide OR - one of newer fluoroquinolones
77
Is constipation a normal change with aging?
- No, but very common. Should have BM every day or every other day
78
Physiological processes/factors that contribute to bone changes in elderly
- Osteogenesis decreases - Osteolysis increases - Absorption of free Ca in GIT decreases - Excretion of free Ca increases - Reabsorption of Ca in kidney decreases - Hormonal changes (PTH, E, GH, insulin, calcitonin and Vit D3)
79
What is the best thing to prevent aging?
- Exercise
80
Examples of quasi-advanced directives
- IPOST - DNR
81
What is IPOST?
- Iowa Physician Order for Scope of Tx - Complementary document to other advanced directives - Allows patient/proxy to discuss wishes with physician and have them execute with a medical order that travels with patient. Insures patient wishes are clearly communicated in medical terms – extraordinary, invasive, comfort care etc.
82
Do L15 cases
Do L15 cases
83
What violence must physicians report in IA besides child and dependent adult abuse?
- GSW - Stab wound - Other serious bodily injury - May report: if pt commits or threatens to commit a crime on the premises or against personnel, may release info surrounding the incident and patient’s name, address and last known whereabouts
84
What alterations are seen in geriatric skin and CT systems? Clinical implication
1.) Decreased vascularity of dermis 2.) Altered epidermal turnover time 3.) Decreased melanocytes 4.) Low dermis density and eccrine function - Clinical implication = dry skin, decreased sweating response, prolonged wound healing, poor insulation, uneven tanning
85
Intervention for wandering
- Daytime exercise and outdoor time - Sleep disturbances should be treated - Door locks and security systems - Dark tape across floor of doorway may help, apparently no crossing of imagined threshold - Pharm: dopaminergic therapy (some promising results), generally ineffective and can lead to falls, enroll in wander alert program
86
Drugs to build up bone mass in osteoporotic patient
1.) Anti-resorptive drug 2.) PTH analog 3.) Selective estrogen receptor modulator 4.) Calcitonin
86
UTI in older man typically arises from what?
- Obstructive prostate disease or functional disability
87
Most common type of chronic urinary incontinence
- Urge.
88
What is Capgras syndrome?
- Demented pt has delusion that family members look like person they know (husband/spouse), but are not them.
88
Define what fever in older nursing-home residents is
- Temp \> 2 degrees over baseline - Oral temp \> 99 deg (37.2) - Rectal temp \> 99.5 deg (37.5)
89
Types of chronic urinary incontinence
- Urge: sudden urge to urinate, frequent intervals, detrusor muscle responds to small urinary volumes, post void residual is
90
What is asymptomatic bacteuria? Is treatment recommended.
- Up to 15% of women in community and 40% of women in nursing homes have a bacteruria without other signs / symptoms of UTI. - No treatment recommended. Associated with adverse effects.
92
Health risks with excessive etoh use
- Liver problems - GI problems - Sleep problems - Short term memory problems - Heart dz - CA - Drug interactions
94
When determined whether or not to code a patient, what levels of law should be looked at?
- Federal law (medicare, patient self-determination act), state law (advanced directive, professional licensing), standard of care (AHA std, common law) - Error on side of coding
95
Examples of ADLs that geriatric population loses which leads to diminished quality of life
- personal hygiene, feeding, dressing, toileting - instrumental activities: money, shopping, preparing meals, taking meds
97
Are physicians required to report unsafe drivers
- May report person who has been diagnosed with condition that would render a person physically or mentally incompetent to operate a MV in a safe manner. If making a report, immune to liability (civilly or criminally).
98
Informed consent
- Patient must have enough information (risks, benefits, alternatives in terms patient understands, by answering questions, engaging in two-way conversation, providing more info if requested) to say either yes or no, provided they have MDM capacity (ability to be understand and be informed) - Consent cannot be given where information is absent, patient is incompetent, or is being coerced.
99
Patient with well-established history of dementia develops a new cognitive a new symptom. Is it necessary to do a careful evaluation of this patient?
- Yes, these patients have more difficulty communicating exactly what they are experiencing. Concern in this patient is for neuropsychiatric complication.
100
How to evaluate UI in elderly patient?
1.) History - Urgency precipitating event typically suggests detrusor overactivity - Loss of urine with cough/strain = stress UI - Continuous leakages = sphincter weakness or overflow 2.) Physical - Functional status, mental status, orthostatic BP and HR - Bladder distention and impaction - Neuro exam looking for signs of cord compression (atrophy), Hoffman and Babinski signs - Sacral root integrity: rectal tone, perineal sensation - Signs of fluid overload - Pelvic and rectal in women, prostate exam in men - Have patient perform standing full bladder test. Relax followed by coughing with resultant loss of urine = stress UI - Post void residual: nml
101
Can a geriatric patient with UTI problems present with cognitive issues?
- Yes - Remote stressor = loss of reserve
102
Risk factors for elder mistreatment
- Poverty - Dependency for caregiving - Age - Race - Functional disability - Frailty - Cognitive impairment
103
Causative factors of lymphedema
- Genetically sparse LNs/channels - Ongoing dz causing direct / indirect effects on lymphatic system – eg. filiariasis - Damaged nodes/channels - Surgical reduction - Tissue damage (scarring, radiation) - Compartmentalization d/t soft tissue strains
104
What alterations are seen in geriatric endocrine system? Clinical implication
1.) Increased NE, ADH (vasopressin), ANP and PTH - clinical consequence: impaired EC volume regulation, higher risk for hyper/hyponatremia 2.) decreased plasma renin and aldosterone = predisposition to hyperkalemia 3.) resistance to insulin = glucose intolerance
106
Criteria for diagnosis of AAMI (age-associated memory impairment)
1.) complaint of gradual memory loss in patient \> 50 2.) objective evidence of memory impairment 3.) evidence of adequate intellectual function 4.) absence of clinical dementia
107
Define aging
- Decreased homeostatic reserve, ie. decreased ability to return to baseline function after insult
108
Management of prosthetic device infections in elderly
- Device removal usually required - Early prolonged abx intervention combined with aggressive surgical drainage may be successful if symptoms have been present only for a brief duration.
109
Biological changes in female repro system
- Decline in E and P - Ovulation ceases - Vaginal atrophy, shorter and drier - Uterus smaller - Breast tissue loses elasticity
110
Signs of possible elderly mistreatment
- Clothing that is inappropriate, soiled or in disrepair - Poor hygiene - Deficient nutritional status - Compromised skin integrity
111
Objective of lymphedema treatment
- Promote terminal lymphatic drainage - Promote regional lymphatic drainage - Treat soft tissue strains
113
Mean longevity (life expectancy) in US
- 78.3. Ideally 85 + 4
114
Treatment of upper UTIs (pyelonephritis)
- Consider 7-21 days of abx therapy with suspect urosepsis or infested with resistant bacteria - Must culture
115
Presentation of GI infection in elderly
- Classic presentation or in absence of fever or elevated WBC counts. If latter, high index of suspicion is necessary. Use imaging of some kind.
116
Define dementia
- Syndrome characterized by an impairment in two or more intellectual or cognitive functions desire a state of clear consciousness
118
Intrinsic factors that lead to falls
- Decreased vision, decreased contrast sensitivity, decreased hearing, decreased height of step, narrow waddling gait in women and wide short step gait in men, diseased states, DEMENTIAS
119
Signs/symptoms of neglect of elderly
- contractures - dehydration or malnutrition - depression - diarrhea, fecal impaction or urine burns - failure to respond to obvious dz - med use that is inadequate, inappropriate or excessive - pressure ulcers - repeated falls - repeated hospital admissions - statements about neglect by pt
121
Reversible causes of delirium
- Mnemonic = DELIRIUM - D: drugs (new, increased dosage, OTC, etoh) - E: electrolyte disturbances (dehydrated, thyroid abnml) - L: lack of drugs (withdrawal, poorly controlled pain) - I: infection (UTI, resp) - R: reduced sensory input (poor vision, hearing, lack of glassing/hearing aid) - I: intracranial (infection, stroke, tumor) - U: urinary (retention, fecal impaction) - M: myocardial, pulmonary – MI, CHF, COPD, hypoxia
122
What is overflow urinary incontinence?
- outflow obstruction or impaired detrusor contractility d/t B12 deficiency, DM, tabes dorsalis, alcoholism and spinal disease – also outlet obstruction (prostatic hypertrophy, urethral stricture, neoplasia, constipation, large cystocele); intervals not predictable, not urge, but gush of urine
124
Are small decrements in learning and retrieval of knowledge normal changes with aging?
- Yes
125
What alterations are seen in geriatric cardiac system? Clinical implication
1.) Decreased diastolic function = decreased CO 2.) Decreased response to SNS = decreased in max HR with exercise and stress 3.) More reliance on atrial kick = difficulty maintaining CO in A fib 4.) Heart smaller, less elastic. 5.) Valves sclerotic. 6.) Heart muscle more irritable d/t hypoxia = more arrhythmias 7.) Arteries rigid, veins dilate
126
Factors affecting longevity
- Diet - Personal habits - Geography - Marital status - Psych influences - Local environment - Parental age at conception - Diseases
127
Dementia differential mnemonic
- Mnemonic = DEMENTIAS - D: drugs - E: emotional dz - M: metabolic disorder - E: endocrine dz - N: nutritional and degenerative neurologic dz - T: trauma and tumor - I: ischemia and infection - A: anoxia, anemia, arrhythmia - S: Sjögren’s syndrome, social, sensory (isolation) and spiritual deprivation
128
Mandatory abuse reporting
- Child and dependent adult abuse cases are mandating by IA law to be reported by physicians - Must have 2 hour training in identifying - If knowingly and willfully fails to report is guilty of simple misdemeanor and potentially liable for damages.
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Risk for acquiring pneumonia
- No vaccine - Smoking - Comorbidities
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Bacterial meningitis treatment in elderly
- Ceftriaxone OR cefotaxime, plus vanc for empiric tx - Amp drug of choice for Listeria spp - More resistant gram neg rods require ceftazidime or extended-spectrum pen +/- intrathecal aminoglycoside
131
Three areas AMA form needs to address/cover
- liability - informed process - choice of patient to leave/refuse treatment
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According to IA law, what should happen if pt doesn’t have a living will and is in a terminal condition and proceeding with care information is requested by healthcare team?
1.) Attorney in fact (durable HC POA) 2.) Guardian 3.) Spouse 4.) Adult children 5.) Parents 6.) Adult sibling
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What is mixed urinary incontinence?
- Combined urge and stress incontinence common in older women
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Evolutionary theories of aging
1.) Disposable body theory: born, survive, reproduce, mature, die 2.) Mutation accumulation theory
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What alterations are seen in geriatric auditory system? Clinical implication
1.) Loss of cochlear neurons = hearing loss (sensorineural loss – presbycusis) for pure tones and higher frequencies more than lower. Tinnitus. Men worse than women.
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What is lymphedema?
- Swelling in one or more extremity caused most commonly in US by removal of or drainage to LNs as part of cancer. Most common cause worldwide = filiariasis infection. - Lymph is prevented from draining and fluid buildup leads to swelling.
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What is functional urinary incontinence?
- inability or unwillingness to toilet d/t physical, cognitive, psychological or environmental factors – seen in advanced dementia patients
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Define mistreatment
- intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in trust relationship to elder
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Natural memory loss in geriatric population is accelerated d/t what problems
- Sleep apnea - HTN - Depression - Anxiety - DM - Hypothyroidism - Medication - Deficiency in vit B12
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Geriatric competency areas for medical students
- Med mgmt. - Cognitive and behavioral disorders - Self-care capacity - Falls, balance and gait disorders - Health care planning and promotion - Atypical presentation of dz - Palliative care - Hospital care for elders
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Which patients are at risk for elopement?
- Court-appointed guardian - Danger to self/others - Legally committed - Lack of cognitive ability - History - Physical or mental impairments that increase their risk of harm to self or others
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What happens to Hg and Hct with aging?
- Decrease
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What class of medication cannot be given to someone with heart failure?
- NSAID
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An individual with a lower amount of plaques and tangles in their brain will have higher cognitive reserve and function than someone with a higher amount. True/False.
- False. Nun Study – 2 people with same amount of plaques/tangles may have very different presentations.
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Epidemiology of TB in patients over 65
- 25% of active cases
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Primary mode of HIV infection in older adults
- Heterosexual activity
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Factors that aggravate institutional mistreatment of elderly
- poor working conditions - low salaries - inadequate staff training and supervision - prejudiced attitudes - disruptive or insulting behavior by older adult
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Most common microbe in UTI in elderly
- E. coli
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Intervention in agitated geriatric patient
- Reverse cause - Non-pharm: Avoid confrontation, remove triggers, create quiet/calm environment, structure daily routine, address pain/discomfort, consider aromatherapy - Pharm: buspar (anxiolytic), SSRIs, anticonvulsant, benzo, antipsychotics, cholinesterase inhibitors and namenda (this is for treatment of underlying dementia)
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Presentation of neurosyphilis in elderly and tx
- Underlying process in stroke or dementia, also consider in unilateral deafness, gait disturbance, uveitis, and optic neuritis - Pos VDRL test, not highly sensitive - Tx = pen G
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Signs/symptoms of psychological abuse of elderly
- Impatience, irritability, demeaning statements of caregiver - Ambivalence of pt to caregiver or high levels of anxiety/fear/anger - Unexpected depression, withdrawal - Lack of adherence to tx regime, frequently cancelled appointments - Frequent requests for sedating meds
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What is geriatrics population more vulnerable to drug effects?
- Altered liver, kidney and GI functions - Increased fat = drug stored in fat - Changes in body water
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Define vascular dementia. Treatment
- Decreased BF to brain with significant brain damage to cause cognitive impairment - Pts typically present with stepwise deterioration. Pts usually have hx of HTN, DM and hyperlipidemia – things that harden arteries. - Presentation similar to AD (amnesia, agnosia, apraxia, aphasia) - Tx: same as AD - AchE inhibitor (Aricept or exalon), stabilize glutamate (Namenda, NMDA-R antagonist)
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How to tx C. difficile infection?
- Metronidazole in mild-moderate - Vanc in severe dz
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Clinker’s theory of aging
- Potentially harmful substances accumulate in the body and interfere passively with body functions. Eg = amyloid accumulates in heart and brain
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Define sundowning
- Confusion, disorientation that increases in afternoon or evening. Common in patients with cognitive disorders such as dementia and tends to improve when pt is reassured and reoriented
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When is POA terminated?
- Upon principal’s death - Upon disability or incapacity unless documented otherwise - By principle at any time (verbally or in writing) - After event/transaction occurs
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True/False. Age is the best was to describe an older patient
- False, utilize function as part of MDM
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Two key features to maintain in an elderly person’s life
- Function - Independence
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Management of HIV/AIDS in elderly
- Untreated older adults progress to AIDS more rapidly than young adults, but respond to HAART similarly. Management similar except more aggressive CVD prevention is necessary. HIV is most treatable infectious cause of dementia and much more likely to reverse with therapy than syphilis.
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How to approach elderly when talking about difficult subjects such as urinary incontinence, sexuality, mental health?
- Many ppl your age… - Some people taking this med have trouble with… - Feel, felt, found (3 Fs) - I am going to ask you a lot of questions some that might seem silly, don’t be offended
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Management of bacteremia and sepsis in elderly patient
- Rapid admin of abx aimed at most likely source - Volume-resuscitation if necessary. - CSF if nothing found. - Similar to treating young peds patient.
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What alterations are seen in geriatric ocular system? Clinical implication
1.) Increased rigidity of iris = decrease in pupil size 2.) Accumulation of yellow substance in lens = alteration of color perception (eg. blue appears green-blue) 3.) Decreased size of anterior chamber = impaired adaptation to darkness, increased risk of glaucoma 4.) Decreased elasticity of lens = significant impairment of vision in presence of glare
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When should a geriatric patient get a Dexa scan?
- Every women after 65 - Every man after 70
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Wear-and-tear theory of aging
- Accumulation of injuries and damage to parts of body caused by use, accidents, disease, radiation, toxins combined with increased failure to repair damage = inability to maintain homeostasis
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Health risks for not being active
- DM - HTN - Obesity - ACS - Color CA - Osteoporosis
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Examples of advanced directives
- Living will - Durable healthcare power of attorney
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Types of guardianships
1. General or full (all court allows) 2. Limited (set powers) 3. Standby (decided in advance, triggered) 4. Temporary (limited time)
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Biological changes in male repro system
- Reduced T - Testicular atrophy and softening - Decrease in sperm production - Seminal fluid decrease and more viscous - Erections take more time
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What biological changes are seen in the nervous system in elderly?
- Impaired balance, postures - Slow widened gait, bow-legged - Jerky, clumsy coordination - Restring tremor
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Treatment of UTI in man vs women
- Longer treatment with same meds as females
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What is conservatorship?
- Court-appointed representative to make important financial decision, applies to minor children or someone with impaired decision making capacity (unable to make, communicate or carry out) - Lifetime appointment, must submit reports to court, ceases when ward turns 18, death of ward, court decides ward can make own decision or conservatorship is not necessary
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What are the results of excess stress?
- Decreased function of immune system - Heart disease - GI disorders - Depression/anxiety - Skin disorders
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Annual incidence of falls
- 30% in persons over 65 - 50% in persons over 80
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What alterations are seen in geriatric renal and urologic systems? Clinical implication
1.) decreased renal mass, GFR, renal tubular secretion, concentrating ability, bladder capacity - Clinical implication: decreased drug clearance, facilitation of incontinence, decreased creatinine clearance, higher risk for dehydration
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Define delirium
- Acute reversible state of agitated confusion marked by disorientation without drowsiness, hallucinations/delusions, difficulty focusing attention, inability to sleep/rest, and emotional, physical and ANS overactivity
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Hip fracture recovery statistics
- 1 in 5 dead within first year - 2 will be placed in a wheelchair/walker, losing initial mobility - 1 will get back 70-75% of function - 1 will fully recover
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Minimum criteria for initiating abx therapy for fever without source
- New onset delirium or rigors. - If abx instituted as diagnostic test, discontinue in 3-5 days if no improvement / negative eval
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Risk factors for abusive caregiving
- Cognitive impairment in pt and/or caregiver - Excessive dependency of caregiver on elder or of elder on caregiver - Family conflict - Family hx of abuse, etoh/drug misuse, mental illness, development disability - Financial stress, lack of funds - Isolation of patient and / or caregiver - Living arrangements inadequate for needs of pt - Stressful events in family
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Factors that exacerbate abx resistance issues in long-term care facilities
- Debilitated hosts - Close proximity of residents - Poor staff compliance with prevention strategies - Difficulties with infection control implementation
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Changes to joints in elderly
- Osseous outgrowths - Cartilage (thicker (except patella), decrease elasticity, decreased collagen) - Decrease in proteoglycans - Synovial fluid is more viscous
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List and describe functional classification of age groups
1.) Young adult: 20-39. Has 90-100% of function 2.) Middle age: 40-64. 10-30% decrease in function 3.) Old age: 65-74. Significant loss of function, maintains homeostasis 4.) Very old: 75-84. Likely impairment of function for ADLs 5.) Old old: 85+. High incidence for needing help with ADLs
196
A diagnosis of dementia can be made at the bedside. True/False.
- True
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Complications of dementia are known as. Why does this occur?
- Neuropsychiatric complications. Dementia patients put brain at higher risk for diffuse circuity dysfunction.
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Define iatrogenesis
- Set of illness and injuries induced by healthcare workers words or actions
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Intervention strategy for treating delirium
- Calm environment - Family presence - Tx underlying physiologic stress - Anxiolytic (Ativan) - Antipsychotic (haldon, Geodon)
200
Describe changes to trunk and arms/legs in elderly
- Decrease in size of arms and legs - Increase in size of trunk
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Health risk for tobacco use
- CA - COPD - Heart dz - Osteoporosis - Cataracts
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Liability for patient that elopes or wanders
- negligence - criminal (welfare of dependent adult, failure to call 911, falsifying records) - licensure - accreditation
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Most common psych diagnoses in geriatrics. Is it curable? How do diagnose? How to intervene/tx?
- Depression (at least 25% of patients with dementia have significant depression) - 100% curable - Diagnose with SigECaps (sleep, interest, guilt, energy, concentration, appetite, psychomotor function, suicidal ideation) – typically require 4 of these for longer than 8 weeks, not absolute. - Tx: 1.) Pharmacologically: meds (SSRIs, SNRIs, TCAs, [adjuvant therapy with psychostimulants lithium anxiolytic and antipsychotic agents], MAO inhibitors), ECT 2.) Non-pharmacologically: psychotherapy (specifically cognitive behavioral therapy), exercise, increased socialization, light therapy, pleasurable activities (humans need to work and love to be happy)
205
Most common cause of pneumonia in elderly
- Strep pneumo - S. aureus and resp viruses commonly cause community-acquired pneumonia in nursing-home residents
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Syndromes of premature aging
- DS, Werner, Progeria (Hutchinson-Gilford), Klinefelter’s, Turner’s, myotonic dystrophy
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Competency vs capacity
- Competency is legal definition determined by a judge whether or not a person can make decisions - Capacity to make a decision is a clinical definition determined by health care provider.
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Name and describe 4 phases of growth and development in 2nd half of life
1. ) Re-eval, exploration and transition (40s-late 50s) - confront mortality for first time - plans/actions shaped by sense of personal discovery - increased bi-lateral brain used supports more balanced perspective on life
2. ) Liberation, experimentation and innovation (late 50s-early 70s) - if not now, when feeling in terms of activities and plans - speaking one’s mind and acting according to needs - retirement gives time for trying new things
3. ) Recapitulation, resolution and contribution (late 60s-80s) - motivated to shared wisdom, legacy - plans/actions shaped by desire to find meaning in life/summing up - feeling compelled to attend to unfinished business or unresolved conflicts
4. ) Continuation, reflection and celebration (70s-end of life) - plans/actions shaped by desire to restate and reaffirm major life themes (initiate conversations surrounding EOL, person must be receptive) - desire to live well to end with positive impacts on family and community
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Can POA be revoked?
- Yes at any time orally or in writing (financial POA must be terminated in writing) by telling the person directly or other persons who acted upon the document
211
Define fever of unknown origin. Typical causes
- Temp \> 38.3 C (101F) for at least 3 weeks, undiagnosed 1 week after med eval - Intra-abdominal abscess, bacterial endocarditis, TB
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Distinguish between informed consent and advanced directive
- Informed consent: tx decisions in current clinical context that survive any subsequent incapacity, it is a present decision to consent/refuse treatment - Advanced directive: provides instructions regarding health treatment for medical conditions not current or present, it is future directed decision only effective after incapacity
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What is the most restricted substitute decision maker? Least?
- Most = guardianship - Least = self-directed - Health care power of attorney is in between
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Interventions to reduce risk and prevent falls in elderly
- Two biggest = improve lower extremity strength, exercises for balance - 3rd = inspection of home environment - Osteoporosis prevention and tx: Calcium, vit D, fosomax, estrogen, calcitonin, exercise, smoking cessation and caffeine limation. - External hip protectors
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Is Delirium a medical emergency?
- Yes. When untreated has mortality of about 40%. Evaluate with H&P, ensure airway, breathing and CV stability. - Why mortality? Physiologic stress typically underlies delirium.
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Leading causes of death in elderly
1.) Heart disease 2.) Cancer 3.) LRT diseases, chronic – COPD, emphysema 4.) CVA 5.) Alzheimer’s 6.) DM 7.) Influenza, pneumonia
217
What alterations are seen in geriatric GI system? Clinical implication
1.) Slowed colonic transit time = constipation 2.) Slower metabolism of etoh = decreased tolerance
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Most likely pathogen to cause osteomyelitis
- S. Aureus
