Exam 2 Flashcards
(222 cards)
1
Q
Is the following ok: Opening the discussion with CPR/DNR, ask separately about every part of resuscitation.
A
- Not ok - Guide patient by developing the big picture (We are in a different place now.), talking about the care plan, making a recommendation
2
Q
Treatment of chronic venous insufficiency?
A
Compression hose 20-30mmHg*** with open toe (older pts CANNOT tolerate heavier pressure compression!)
3
Q
2 reason for failure of geriatric rehab efforts
A
- Poor communication
3
Q
Delirium contributing factors: common and treatable
A
Medications (e.g., opioids, benzos…) Infection (UTI, Pneumonia) Constipation, Urinary Retention Uncontrolled Pain
4
Q
Ratings of USPSTF
A
- A&B = eligible for screening, discuss and offer them to patients - C = clinicians may provide for selected patients - D = discourage use - I = evidence lacking
4
Q
With what medication(s) is PTSD more highly associated?
A
- Benzodiazepines, esp in ICU. Patients report frightening memory of what happened to them during visit.
5
Q
Value of gratitude in aging
A
- Find meaning in past, today’s peace, vision for tomorrow
6
Q
Predictors of suffering
A
- Regret for past - Current marital problems - Little social support - Pessimistic attitude
7
Q
Does implantable cardioverter reduce risk of mortality in geriatric population?
A
- In patients with LBBB, mortality reduced by ~30% - CRT with defib = increase in mortality
7
Q
Pain, fatigue, depression, anorexia, early satiety, and delirium are always evaluated properly.
A
False. Often underevaluated and therefore undertreated.
8
Q
Role of medical director in nursing home
A
- Setting quality standards - Ensuring compliance - Working with admin and director of nursing
8
Q
Contributors to total pain
A
- Uncontrolled pain - Depression - Loss of hope and meaning - Loss of important roles - Terror re: death - Existential distress - Inability to trust - Unresolved guilt - Financial - Family conflict - Deep wounds from childhood
9
Q
Beers criteria
A
- Improve drug selection and reduce exposure to inappropriate meds with older adults - Categories: drugs to avoid, drugs to avoid in pts with specific diseases, drugs to use with caution
9
Q
Describe rehab process
A
- Physician or self-referral 2. Therapist: exam, eval, diagnosis/prognosis, plan of care, discharge 3. Communication: conference
9
Q
3 treatment options at end of life. Describe characteristics of each.
A
1.) Comfort care: quality of life > quantity of life, maximal comfort, minimal side effects 2.) Limited medical care: selected interventions balancing benefit/burden 3.) Life prolonging care: maximize length of survival; quantity of life > quality of life
10
Q
Difference between bunion and hammertoe?
A
Transverse plane deformity (bunion) vs. sagittal plane deformity (hammertoe)
10
Q
Eye changes at EOL
A
- Loss of retro-orbital fat pad - Insufficient eyelid length - Conjunctival exposure =dryness, pain
11
Q
ICF model
A
- Use model when deciding on managing and treating health conditions, which looks at interplay bw: - Body function and structures - Activities - Participation - Contextual factors
11
Q
Components of functional assessment in elderly for geri rehab
A
- ADLs - IADLs - Mobility
12
Q
USPTF recommendation for osteoporosis screening
A
B: women >=65
I: men
12
Q
Principles of rx drugs in older patients
A
- Start with low dose - Titrate upward slowly as tolerated - Avoid starting 2 drugs at the same time
13
Q
What is the story about acid suppression and pneumonia?
A
Ek weet ‘n bliksem nie
13
Q
True/False. Acute care should occur while palliative care is occurring.
A
- True
13
Q
Signs/symptoms that require diligence (prevention/treatment) day or two before death
A
- Respiratory tract secretions - Pain - Dyspnea - Restlessness - Agitation
13
Compare and contrast features of body shutting down vs starvation
1.) Body shutting down - Loss of body fluid, electrolyte changes - Decreased blood flow/o2 to GI - Absence of hunger sensation 2.) Starvation - Lack of nutrition - Physiological homeostasis - Hunger
14
USPTF recommendation for colon cancer screening
- A: 50-75 using FOBT, sigmoidoscopy, colonoscopy - D: \>=85
15
3 responses by patient to transition conversation. Strategies for physician?
1.) Accept transition is occurring: specified EOL planning 2.) Want to negotiate: discuss with family, look at disease progression, limited time trial 3.) Decline the clinician’s assessment: prospect is too sad/frightening/threatening for patient – pay attention to emotional data here, help explore feelings (“More time”)
15
General measures for dyspnea treatment
-Reposition the patient (upright or compromised lung down) -Provide skin care for the buttocks -Improve air circulation with draft, properly adjusted humidity, and avoidance of strong odors -Address anxiety and provide reassurance -Consider rehabilitative strategies such as relaxation and retraining breathing -Discuss any patient, family, or staff concerns about using opioids
16
Conversational approach to assessing spirituality
1.) Individual’s sense of crisis: disruption, discomfort, disfigurement, disability, death 2.) Spiritual connections: connected, unconnected, disconnected 3.) Care gates: awareness of holy, sense of providence, sense of faith, sense of grace, sense of repentance, sense of communion, sense of vocation – this is opened by patient
17
Does suffering need to be fixed?
- Does not
18
% of individuals 65+ with chronic condition
- \> 80%
18
Strategies to support/build hope
- Effectively control pain - Develop relationships - Set attainable goals - Support spirituality - Affirm pts worth - Humor - Reminisce
19
Steps in communicating serious news
- ASK-TELL-ASK - Establish patient understanding, determine how much patient wants to know - Deliver info (include warning shot) - Respond to feelings, ascertain understanding, organize plan/follow-up
19
Numbness and tingling might suggest…
DM B12 deficiency Thyroid disease Alcoholism
19
Common signs and symptoms of imminent death 1-2 weeks
- Altered state of consciousness - Dreams, visions, conversing with seen/unseen - Restless, agitated, wanting up/down - May want to remove clothing - Maybe quiet, resting deeply - Eyes appear unfocused/dreamy - Sleeping, waking hours prolonged - Not eating, maybe drinking - May request an occasional meal
20
How to reassure families when they say we are dehydrating their loved one at end of life?
- Dehydration does not cause distress - Dehydration may be protective - Parenteral fluids harmful (fluid overload, breathlessness, cough, secretions) – wet death worse than dry death
22
Components of CGA. What does each address?
1.) Medical assessment: problem list, comorbidities, disease severity, med review, nutritional status 2.) Assessment of function: ADLs, IADLs, activity/exercise status, gait/balance 3.) Psychosocial assessment: cognitive testing, mood/depression testing 4.) Social assessment: support needs and assets 5.) Environmental assessment: home safety
22
Risk factor for colon cancer
- AA men
23
Where do most deaths in America occur?
- At home
23
Suffering and meaning per Frankl
- Meaning central to suffering. Pain and privation insufficient to explain suffering and can be endured if for a purpose.
23
Clinical treatment of loss of ability to swallow at EOL
- Scopolamine to dry secretion - Postural - Positioning - Suctioning (rarely) – secretions come back and injury possible
24
Percent of peripheral neuropathy that does not have identifiable etiology? Percent of DM neuropathy causes by something other than hyperglycemia?
40% 10%
25
USPTF recommendation for breast cancer screening, AGS recommendation
1.) USPTF - B: biennial mammography (film) women 50-74 - D: BSE teaching - I: 75+, clinical breast exam in women 40+, digital or MRI 2.) AGS - Annual or biennial mammography until 75 - After 75, q 2-3 years with no upper age limit with estimated life expectancy of 4+ years - No evidence to support CBE or BSE
25
Ramification of weakness/fatigue in dying
- Increase risk of pressure ulcers, need for care (ADLs)
25
The usual vs difficult road to death
- Usual: sleepy – lethargic – obtunded – semicomatose – comatose – death - Difficult: restless – confused – tremulous – hallucinations – mumbling delirium – myoclonic jerks – seizures – semicomatose – comatose – death
26
Recommendations from home assessment visit
1.) Re-assign rooms 2.) Movement and removal of furniture/appliances 3.) Purchase and installation of adaptive / assistive equipment 4.) Suggestion of outside services
28
Risk factors for prostate cancer
- First degree relative hx - AA
29
What is Xerosis highly likely to be in the elderly? Test to dx?
Chronic athlete’s foot (tinea pedis) infection. KOH test, look for diagnostic fungal hypha (filament).
30
What is hyperkeratosis? Complications?
Intermittent pressure over prominent bones (due to shoes) leads to thickened skin. Only hard stratum corneum can reproduce. Dermis breaks down into ulcer. Bones become prominent due to toe contractures and/or loss of fat padding on ball of foot. Pressure on bone leads to skin b/d. Complication: deeper skin ulcerations may develop if pressure becomes continuous. Corns on tips of toes with ulcer underneath are close to nails; bacteria jump on bone osteomyelitis.
31
Three main areas of non-pain symptoms
Disease process Treatment of disease process Symptoms from co-morbidities
32
True or false: Palliative medicine patients are polysymptomatic.
True. Advanced cancer patients have 10-13 symptoms.
33
Obstacles to hospice
- Late referral = main obstacle - Difficulty with prognosis - Lack of family support - Limited access
34
Relationship between activity and function. Result of bedrest?
- Cornerstone of rehab, decreased activity = decreased function - B: bladder/bowel incontinence, bedsores - E: emotional distress - D: deconditioning, depression, demineralization - R: ROM loss - E: energy depletion - S: sensory deprivation - T: trouble
34
Suffering according to Cassell
- Suffering occurs when threat to integrity of person is perceived, persists till integrity of person reestablished
34
Thick, yellow nails can be due to (8)? (KNOW THESE)
TOE CLYPT acronym T: trauma O: onychomycosis E: eczema C: circulatory problems L: lichen planus Y: yellow nail syndrome P: psoriasis T: tumor
34
Symptom distress is not always in proportion to severity.
True. Example given was “if they have a lot of nausea and vomiting, they are less likely to complain about a lesser symptom such as fatigue”
35
Recommendations for lung cancer screening of geriatrics patients
- USPTF recommends annual low-dose CT scan for high-risk (30 pack-years) smoking, current smoker or those who quit smoking within the last 15 years. - Age group 55-80 - 74 upper age for Natl Lung Screening Trial
36
Reframing requests for ANH – go over it
Do it
37
Components of health care responses to suffering
- Self-assessment - Self-reflection - Self-care
39
Protein family involved in drug interactions
- Cytochrome P450
40
Patient types with regards to receptiveness to information regarding prognosis. Strategies for physician?
- Want explicit discussion with info: provide info, acknowledge rxn to news explicitly, check for understanding - Don’t want info: elicit and understand why patient doesn’t want to know, acknowledge concerns, ask to revisit topic, make private assessment about this info changing their decision making - Ambivalent: name ambivalence, explore pros/cons knowing, acknowledge difficulty of situation, consider outlining options for discussion and consequences
42
Medical care challenges in a nursing home
- Heterogenous residents = individualized approach - Atypical presentation of illness - Limited access to biotech - Non-physician dependence for pt evals - High prevalence of cognitive impairment - Need to involve families in education and psych support - Ethical concerns (EOL, hydration, feeding etc) - Regulatory oversight
43
Factors associated with nursing home placement
- Increasing age - Low income and low social activity - Poor family support - Accepting attitude toward nursing homes - Cognitive and functional impairment
43
What is the national consensus project?
- 12 key elements of palliative care
43
What is paronychia? Cause, treatment?
Infected nail border. Cause: Staph aureus is the most common pathogen. Assume methicillin sensitive. Conservative treatment: 5-7 days of soaking in warm, soapy water. Betadine solution + Band-Aid. Antibiotic: Cephalexin (Keflex) Surgical treatment: I &D – Anesthetize first!, Bid soaks and Betadine solution. Cephalexin.
43
Reversible causes of anorexia (mnemonic)
Aches and Pains Nausea and gastrointestinal dysfunction Oral candidiasis Reactive (or organic) depression Evacuation problems (constipation, retention) Xerostomia (dry mouth) Iatrogenic (radiation, chemotherapy, drugs) Acid-related problems (gastritis, peptic ulcers)
43
Physiological changes during the dying process
- Increasing weakness, fatigue - Decreasing appetite, fluid intake - Decreasing blood perfusion - Neurological dysfunction - Pain - Loss of ability to close eyes
44
% of individuals 65+ with difficulty with ADLs
- \> 50%
45
From where (what location) do most nursing home admits take place?
- Acute care hospital
46
Dyspnea: definition, general characteristics
Definition: discomfort in breathing, breathlessness, shortness of breath, work of breathing General characteristics: can be a subjective sensation (many different factors), shows up in at least 50% of cases of most diseases, tends to worsen as death approaches
47
Value of forgiving
- BP reduction - Sleep improvement - Stress reduction - Fight off illness - Decrease risk of chronic dz - Helps control anger - Understand others action
48
Malignant bowel obstruction: general characteristics
Found in up to 50% of patients with ovarian and GI patients; median survival of 3 months, high symptom burden (N/V, colic, and abdominal pain)
49
Cases of dyspnea (mnemonic)
BREATH AIR: Bronchospasm, Rales, Effusion, Airway obstruction, Thick secretions, Hemoglobin low, Anxiety, Interpersonal issues, Religious Concerns (last 3 nonphysical)
50
With what virus is temporal arteritis possibly associated in elderly?
- VZV
51
Goals of care with serious illness
- Control pain and other distressing symptoms - Alleviate psychosocial problems - Communicate effectively - Provide empathetic presence - Foster realistic hope
52
Most common cause of geriatric trauma
- Falls - Low speed MVA (usually left hand turn into oncoming traffic about 1 mile from home)
53
Anorexia treatment
Appetite stimulants (serious side effects), artificial nutrition and hydration (ANH) such as enteral feedings (tube) or parenteral feeding (TPN) – benefits hard to identify with ANH
55
Percentage of elderly with nutrition problems? What is red flag to look for during H&P?
- up to 30% - Weight loss \> 10% in previous 6 months
56
What period of time is most common for nursing home stay?
- \> 90 days = ~80%
56
Death rates of breast cancer in women over 65
- More than half of breast cancer deaths occur in women over 65
56
What is a hammertoe? Treatment?
Buckling of the toe at the PIPJ and/or DIPJ of lesser toes. Due to tendon imbalance around the lesser toe joints. Causes one bone to dorsiflex and those distal to it to plantar flex. Common in flat and high arched feet. Treatment: debridement of hyperkeratotic tissue, paddings to limit pressure, splints to passively plantar flex toe, extra-depth or custom molded shoes
57
Name 3 similar-looking causes of dry skin.
Tinea pedis (athlete’s foot) Psoriasis Eczema
57
Signs/symptoms of neurological dysfunction at EOL
- Decreasing LOC - Communication with unconscious patient - Terminal delirium - Changes of respiration - Loss of ability to swallow, sphincter control
59
Omnibus budget reconciliation act (OBRA)
- Set training and staffing requirements for nursing homes - Resident’s rights: limit use of restraints, limit use of psychoactive meds - Initiated MDS: minimum data set (periodic clinical assessment of all residents – quality measures for pain, ulcers, weight loss etc.) - Meds: Documentation of all meds, particularly psychoactive; monthly eval by pharmacist; no unnecessary drugs; gradual reduction of psychoactive drugs unless contraindicated and well documented
60
How can one assess function by observation during CGA?
- Did patient fill out questionnaire? - Observe patient walk, getting on exam table - What detail does patient give in history? Do they give the history themselves?
61
Most important skill for physician to acquire when giving serious news
- Ability to recognize and respond to the patient’s emotions
61
What is onychocryptosis? Cause, symptoms, tx?
Ingrown nail. Sometimes with secondary bacterial infection. Cause: improper nail trimming, trauma, heredity, systemic or local disease. \*Nails should be cut straight across only if nails are normal to begin with. Tx: Remove distal corner. Some pts do okay with leaving in-grown nails left longer than normal.
62
Types of vascular disease in the elderly? What happens? Where do we see it first?
Deterioration in the structure of arteries and veins leads to atherosclerosis in arteries and malfunctioning of valves in veins (chronic venous insufficiency). Veins lose elasticity, valves don’t work, can’t prevent backflow, leads to hypoxia in vessels, tissue ischemia, ulcerations, foot breakdown, gangrene. (\*accelerated by DM) Foot shoes arterial disease. Ankle shoes venous diseases. (Because circulation is worst.)
63
Malignant bowel obstruction treatment
Dependent on functional status, goals of care, expected survival Treatment options include surgical (limited evidence of benefit at end of life), endoscopic techniques such as stents, medical management
65
Common areas where information transfer breaks down between acute and long-term care facilities
- Missing/illegible transfer summaries - Omission of rx meds - Advanced directives not documented - Psychosocial issues and behavior problems not reported
66
Respiratory changes at EOL
- Diminished TV - Apnea - Cheyne-Stokes respiration - Accessory muscle use - Last reflex breaths + gasping in some patients
67
Dysphagia: definition, general characteristics
Definition: difficulty swallowing General characteristics: have to discern whether neurologic or non-neurologic – obstruction (do solids progress to liquids?) or neurologic (simultaneous issue with solids and liquids); conservative management can ameliorate dysphagia for majority of patients (emphasize good oral hygiene or other specific measures)
68
Delirium assessment and treatment
Use Hx and PE to identify potentially reversible causes, treat underlying cause, use low dose non-sedating antipsychotic (or sedating with actively dying pts), AVOID BENZOS
69
Common non-pain symptoms of palliative care
Constipation, nausea and vomiting, diarrhea, bowel obstruction, anorexia and cachexia, delirium, depression, and dyspnea
70
What is onychomycosis? Cause – and pathology, symptoms?
Fungus that causes tinea pedis can also infect toenails. Fungus produces keratinase which destroys nail plate keratin. Nail becomes thick, discolored, loose, and collects subungual debris. \*symptoms are not unique to fungal nails.
71
Define universal design
- Design of products and environments to be usable for all people to greatest possibly without need for adaptation or specialized design
73
Which race is more likely to be admitted to a nursing home?
- Black 65-74
73
Delirium: general characteristics
-Acute onset, fluctuating, altered level consciousness (hyperactive, hypoactive, or mixed), cognitive impairments -Very distressing to patients and family members, high incidence, cause of discord between family and healthcare professionals, aggressive preventative measures
74
Who can complete home assessment?
- PT or OT
76
Four IADLs that serve as predictors of one-year incident dementia.
- Telephone, transportation, meds, finances - At 3 years, # of IADL impairments was strong predictor of incident dementia - 1 impairment, OR =1 - 2, OR = 2.5 - 3, OR = 5
77
Cervical cancer severity risk in elderly women
- Less likely to present with advanced disease
78
Challenges of geri pharmacotherapy
- More drugs each year - FDA and off-label indications expanding - Formularies change frequently - Knowledge of drug-drug interactions - Drug change from rx to OTC - Nutraceuticals
79
Loss of sphincter control implications at EOL
- Incontinence
81
According to new research, is there any relation between exercise/balance training and the number of falls in geriatric population?
- These might not decrease the number of falls, but bounce-backs and recovery times appear to be improved.
82
Signs/symptoms of decreasing blood perfusion at EOL
- Tachycardia, hypotension - Peripheral cooling, cyanosis - Mottling of skin - Diminished urine output - Parenteral fluids will not reserve
83
Saying there is nothing more I can do for you is ok and will never elicit a haunting by Dr. Hirsch?
- False.
83
Flatfoot symptom and cause? Symptoms it causes? Tx?
Collapse of the medial longitudinal arch due to progressive ligamentous laxity of the joints. AKA pronation or pronated foot type. Symptoms: leg and low back pain, capsulitis of MPJs (pain on ball of foot), DJD of foot/ankle joints, tendonitis (tib post), inflammation of plantar fascia at insertion (plantar fasciitis) Treatment: arch support (orthosis) to life arch and limit stress on tendons, ligaments, joints.
85
According the 2013 State of Aging and Health in America, what goals have we not met?
- Flu vaccine - Pneumonia vaccine - Reduction in smokers
86
Changes in kidney that affect clearance of drug
- Low GFR d/t: o Smaller size of kidney o Decreased renal blood flow o Decreased # of functioning nephrons o Decreased renal tubular secretion
86
Most symptoms are volunteered by patients.
False. Many patients will not volunteer their symptoms so it’s important to ask them what they want to address.
88
Purpose and value of CGA
- Prevention decline of performance in ADLs and IADLs - Screen for functional impairment - Screen for preventable diseases - Value = improve function and quality of life, decrease hospitalizations
89
Factors affecting drug metabolism in elderly
- Decrease liver flow, size and mass = reduced clearance - Age - Heart failure = hepatic congestion = reduced metabolism - Smoking
89
Common signs and symptoms of imminent death days to hours
- Maybe surge in energy - Breathing grows shallower in chest - Maybe apnea (up to 60 seconds) - Gurgling - Eyes teary or dry/shinny - Eyes remain open/no blinking - Skin dusky/blotchy - Little observable response to outside environment
90
Barriers to palliative care?
- Awareness of services - Tendency of clinicians to equate palliative care with EOL care. Introducing this care would interfere with therapy aimed at extending life, reimbursement, shortage.
91
Most common drug-drug interactions signs/symptoms
- Confusion/delirium - Cognitive impairment - Hypotension - Acute renal failure
92
Elements of total pain according to Cicely Saunders
- Physical pain - Mental anguish - Spiritual suffering - Emotional distress
93
Examples of cognitive-behavioral techniques in alleviating psychosocial problems
- Info and education - Cognitive distractions - Relaxation and imagery - Self-monitoring
93
Chronic venous insufficiency? Cause, complications?
Damage to vein valves prevents efficient pumping of blood back to heart. Result: congestion of blood in veins which leaks to peripheral tissues, limits arterial inflow, and thus causes have hypoxia. Complications: edema, hemosiderin deposition in skin, ulcerations, predisposition to DVT and PE. Varicose veins.
94
OTC treatment of Xerosis (5)? What might you add if the patient has cracked, inflamed skin? Other home remedy?
Lanolin Water + petrolatum Urea Lactic acid Oatmeal If patient has redness and deep fissuring, add OTC mild steroid and combine with above agent. Occlude skin with Saran wrap at night under sock/glove to promote penetration. Apply after bath/shower. Gel socks
95
Cognitive impairments
Altered orientation, altered organization of thought, altered perceptions (hallucinations, delusions, especially visual auditory), emotional labiality, disruption or reversal of sleep-wake cycle, psychomotor agitation or retardation, memory impairment
96
Treatment of tinea pedis?
OTC Lamisil (terbinafine) cream.
97
Purpose of elderly functional assessment
- Current functioning level - Need for intervention - Determine discharge / placement
98
FICA model of spiritual assessment
- F: faith and belief - I: importance of belief in life - C: community (part of) - A: address/action in care (how beliefs influence care)
98
Main principle of management of non-pain symptoms
Identify the cause of the symptom whenever possible and treat the cause of the symptom (also choose treatment strategies that support the patient’s goals of care considering age, functional status, overall needs, rate of change of disease, and life expectancy)
98
Common signs and symptoms of imminent death 1-3 months
- Withdrawal from world - Turning inward - Less communication with the world - Increased reflection - Decreased nutritional intake
100
RR that is concerning for higher risk of death in geriatrics patient
- 10 BPM
100
Number of days longer patients who transfer to hospice live
- 29
101
Depression screeners during CGA
- Geriatric depression scale (GDS) - Patient health questionnaire (PHQ-9)
103
How is pain related to suffering?
- When pain persists without meaning it becomes suffering (split bw self and now malfunctioning body, isolation, fear about continued pain, sense of separation from transcendent truth, loss of control/self/relationship)
105
What is a CGA?
- Comprehensive geriatric assessment = multidisciplinary eval in which multiple problems for older individual are uncovered, described and explained, resources and strength of person catalogued and coordinated care plan developed
106
What is consider tachycardic in geriatric population?
- Pulse of 90+
108
True/False. Poor prognosis destroys hope.
- False. Not about prognosis, about delivery of it.
110
True/False. Age is a predictor of performance
- False.
112
Palliative medicine is only necessary towards the end of a serious illness. True/False.
- False. Any age at any stage. Provided along with curative tx.
114
How is absorption of drugs different in elderly?
- Amount absorbed unchanged - Peak serum concentrations may be lower and delayed - Exception = drugs with first pass effect (less extracted by liver) – availability increases
115
Screening criteria for palliative care
1.) Primary: not be surpised if pt died within 12 mos, frequent admissions, admission prompted by difficult-to-control symptoms, complex care requirements, decline in function 2.) Secondary: admission from long-term care, older patient, cognitive impairment with acute hip fracture, metastatic or locally incurable cancer, chronic home o2 use, out of hospital arrest, current or past hospice enrollee, limited social support, no hx of advance care planning
117
Risk factors for ADEs in elderly
- 6+ concurrent chronic conditions - 12 or more doses of drugs/day - 9+ meds - Prior ADE - Low body weight or BMI - Age 85+ - CrCl
118
What are reasons for good communication between members of geriatric rehab team members?
- Collaborative interventions - Monitor progress and lack of progress - Reimbursement
119
Trajectories of death
1. Walking well, sudden death 2. Serious illness (see L26 graphs) a.) Steady decline, short terminal phase – typical in cancers b.) Slow decline, periodic crises, sudden death – in CHF, COPD c.) Prolonged dwindling – in generalized frailty, dementia
120
Difference between arterial and venous ulcers?
Venous ulcers: red base (adequate arterial flow) Arterial ulcers: white/black/gray base
121
Purpose of home assessment
- Prevention of injury - Increase function - Facilitate return to home
122
Hyperkeratosis treatment?
Debridement Padding Shoe modifications (Queen Mary shoes/SAS shoe)
124
Physician strategies regarding prognosis
- Realist - Optomist - Avoider
126
USPTF recommendation for cervical cancer screening
- A: 21-65 = pap q3 years, 30-65: combo pap + HPV q5 years - D: \> 65 years with adequate prior screening, not otherwise high risk - D: hysterectomy with removal of cervix w/o hx of high grade precancerous lesion
128
Goal of palliative medicine
- Improve quality of life for patient and family. It is specialized care for people with serious illnesses.
129
Locus of sensation: thirst, taste, hunger
- Thirst: mouth - Taste: mouth - Hunger: stomach
131
Who is the gate keeper to palliative care access?
- Health care provider. Patient and family readily accept referral.
132
Most important thing to do in a clinical symptom assessment
Thorough history and physical – including chief complain, symptom characteristics, medication history, medical history, systems review, psychosocial screen, physical examination, investigations, document, reassess
133
Medications commonly involved in ADEs in elderly
- CV drugs, diuretics, NSAIDs, hypoglycemics, anticoagulants - Be aware of NSAID use in CHF patients.
134
Manage pain in last hours of life
- Stop routing dosing, infusions - Breakthrough dosing as needed (prn) - Least invasive route of meds administration (not IM)
136
Physician’s responsibilities in nursing home
- Comprehensive admission assessment - Development of care plan - Periodic monitoring of chronic health problems - Prompt assessment of acute med problems - Interdisciplinary involvement - Review meds periodically - Optimize quality of life and function - Physical attendance to each resident
137
Risk of using benzos in elderly
- Cause more sedation and poorer psychomotor performance. Don’t use as sleep aid. Addicting in the matter of days.
138
Vascular disease tx?
Proper shoes, shoe inserts to offload pressure areas, very tight regulation on blood sugars. Therapeutic shoe bill for diabetes: custom molded shoes for diabetics with physician letter.
139
What is the most beneficial thing to determining probable cause?
Detailed history and physical
141
Palliative setting assessment tools
- Karnofsky scale - Palliative performance scale (PPSv2)
142
Nausea and vomiting treatments
-Select antiemetic agent based on likely cause, pathway mediating symptoms, and NTs involved -Small and frequent meals -Frequent small sips of fluids -Avoid strong odors or unpleasant tastes -Address nonphysical factors (psychological, social, and spiritual)
144
When does CDC recommend that geriatric patient be transferred to trauma center?
- Anyone over 65 with BP
145
Most common drug-drug interactions in elderly
- CV and psychotropic drugs
146
Cause (4 major aging changes), symptoms of xerosis.
Symptoms: dry, flaky skin. Cause: Decrease in epidermal filaggrin (which binds keratin into microfibrils) leads to skin flaking. 15% decline in eccrine glands leads to decrease in spontaneous sweating. Delayed recovery of stratum corneum’s barrier function. Decrease in skin moisturization due to autonomic dysfunction in diabetes
148
Is palliative care only available in hospital?
- No. Hospital (consultation, inpatient, comanagement), non-hospital and hospice
150
ADEs in geriatric population resulting in hospital admissions
- up to 30% of acute geri hospital admissions
151
Nausea and vomiting: general characteristics
Very common symptoms that cause significant distress but can be controlled in more than 90% of patients
152
Is vitamin E supplementation helpful in patients with Alzheimer dementia?
- Slower time to functional decline compared to placebo – best results in mild to moderate AD - No studies show an improvement in cognitive function
154
Tool used to reduce acute hospital admissions from nursing homes
- Interact II
155
What medications are a risk factor for osteoporosis?
- Steroid, chronic use
157
At what age do majority of colon cancers occur?
- 90% after age 50
158
Conditions that interfere with eating and suggested interventions
Dentures fit poorly – Adjust or replace dentures, offer pureed foods Poor dental hygiene – Encourage brushing and flossing two to three times a day Taste disorders – Treat sinusitis or other infections, provide supplemental vitamins, including zinc and other minerals (although a stage-III trial on high-dose zinc demonstrated equivocal benefit) Weakness or neuromuscular problems – Offer soft or pureed foods, cut food into bite-sized pieces, provide small, frequent meals, moisten food with gravy, sauce, sour cream or mayonnaise, avoid hard, dry or sticky foods, help the patient into an upright position and stabilize his head, use aids for easier drinking and eating (i.e. a drinking glass with a cut-out for the nose), use crushed, liquid or rectal-suppository forms of medications, encourage the patient to chew thoroughly and to remain upright for 15 minutes after eating Stress and tension – Provide a calm, unhurried environment
159
Would a more educated person want more or less info regarding prognosis?
- Desire for more info - More advanced illness corresponds with wanting less illness though
160
What would you say to someone who says we are starving their loved one at end of life?
- Food nauseating - Anorexia protective - Risk of aspiration - Clenched teeth expressing desires
161
Musculoskeletal pathologies in the elderly? (4)
Digital deformities: bunion (hallux valgus) and hammertoe Flatfoot (pes valgoplanus) Heel pain (planter fasciitis)
163
True/False. It is not illegal to hospice to require DNR.
- False, it is.
164
Questions to ask when setting goals
Are the goals achievable? Are the goals beneficial to the patient as the patient sees it? Does it extend their life or improve comfort? How will the results be measured, and what is the timeframe to reassess? Continue or stop the intervention
166
Screening is what form of disease prevention
- Secondary - Primary = immunizations
168
Are care gates opened by physician or patient?
- Opened by patient
169
USPTF recommendation for prostate cancer screening
- D: PSA-based screening
170
Delirium preventative measures
Prevent dehydration, remove unnecessary catherers/IVs, restraints, decrease environmental stimuli, reduced light and sound at night, minimal interventions, hearing and visual assessment, reorientation and cognitive stimulation (let pt know they’re safe), induce sleep with music or massage
172
Calls to action per the 2013 Stage of Aging and Health in America (by CDC)
- Healthy brain initiative - Improving health literacy - Address LGBT aging and health issues - Address mental distress in elderly - Develop more culturally aware health care providers
173
Name four common dermatologic geriatric pathologies.
Xerosis (dry skin) Onychomycosis (fungal nails) Onychocryptosis (ingrown nails) Hyperkeratosis (corns, calluses)
174
Cognitive function assessment tools during CGA
- Folstein mini-mental status exam (MMSE) - Montreal cognitive assessment (MOCA) - Clock draw test (CDT) - Verbal fluency (VF) or animal naming - Mini-cog
175
Tests for gait/balance during CGA
- Get up and go test: pt sits in chair, get up and walk 10 feet and return. Fail if it takes more than 20 sec
176
What is the most dangerous room in the house for elderly patient?
- Bathroom
177
PT vs OT
- PT: focus on mobility and movement – ie. balance, gait transfer - OT: focus on function – ie. for completion of ADLs and IADLs
178
What is a bunion? Treatment?
Prominent medial aspect of 1st metatarsal head, due to an actual medial migration of 1st metatarsal and lateral migration of hallux. Result of a tendon imbalance around the joint in a person with a flatfoot. Treatment: extra depth shoe (SAS), bunion shield, silicon toe separator, surgery
179
New paradigm in successful aging
- Prolonging life towards prolonging life worth living
180
What major organ systems are involved in age related changes in the feet?
Dermatologic Musculoskeletal Vascular Neurologic
181
Delirium contributing factors: less common and treatable
Electrolyte disturbance Unfamiliar Environment Isolation Hearing/Visual Impairment Emotional Distress
182
What onychocryptosis remedy is outdated and not recommended? (Works rarely?)
Old midwives’ tail to cut a central “V” into the end of the toenail to relieve pressure on the sides.
183
Route of administration of meds
- Buccal mucosal or oral first - Subcut rarely - IM never
184
Characteristics of typical deaths in US?
- Slow decline, associated with chronic dz with comorbidities, increased dependency needs
185
Diagnoses addressed with geriatric rehab
- CVA, PD, osteoporosis, fractures, generalized deconditioning, amputations
186
Principles of universal design
- Equitable use - Flexibility in use - Simple, intuitive - Perceptible information - Tolerance for error - Low physical effort - Size and space for approach and use
187
Factors affecting drug absorption in drug
- Route - What is taken with drug - Comorbid illness - Divalent cations affect absorption of many fluoroquinolones - Enteral feedings interfere with some drugs - Increased gastric pH - Drugs affecting GI motility
189
Team members on geri rehab team
- Patient - Caregiver - Physician/PA - Nurse - Social worker - PT, OT - Speech therapist - Psychologist - Other
190
What percentage of the nursing home population has impairment in decision making?
- ~80%
191
Organ(s) where must drugs are metabolized? Cleared?
- Liver = metabolism - Kidney = clearance
192
Body composition changes in elderly affecting drug distribution
- Low body water = VD (volume of distribution) lower - Low lean body mass = lower VD - High fat stores = increase VD for lipophilic drugs - Low plasma protein = higher % of drug unbound
194
Purpose of geriatric prevention
- Increase function (ADLs and IADLs) - Improves health quality of life
196
Does dementia change drug interactions
- May increase sensitivity inducing paradoxical rxns
197
Should geriatric patients be screened for AAA?
- No significant reduction in all-cause mortality, less than 3% of deaths - Screening didn’t decrease AAA-related or all-cause mortality in women
198
Vital components to successful aging
- Engage with life - Maintain relationships - Stay connected with community - Good health a priority: eating, weight, medical care, listening to body, no smoking
199
How to provide empathetic presence?
- Atmosphere encouraging questions - Body language - Listen - Presence and gentle touch
200
What percentage of the nursing home population needs assistance with 3+ ADLs? 1-2 ADLs?
- 3+ = ~80% - 1-2 = ~20%
202
What percentage of the nursing home population has dementia?
- ~50-70%
203
Goals of clinical symptom assessment
-Elicit most distressing symptoms for patient and family -Determine underlying pathophysiology, cause, and contributing factors for each symptom -Screen for common distressing symptoms -Review current and past treatments, their effectiveness, and side effects (sometimes caregiver is more truthful about this) -Document assessment and plan -Reassess at regular intervals
204
Patient presents with pain on the bottom of heel, mostly when they get out of bed. Dx and Tx?
Plantar fasciitis. Get OTC arch support and go home
205
Delirium contributing factors: less common and less treatable
Renal Failure Hepatic Failure Neurologic Dysfunction (stroke, seizures, metastases)
207
Ways to determine creatinine clearance
- Measure with 24-hour urine collection - Cockrof-Gault equation: weight, age, serum cre, sex (limitations: significant decline in renal function = underestimates; muscle mass reduced beyond normal = overestimates)
208
Compare and contrast palliative medicine and hospice
- PM: all stages of dz, concurrent with acute care, any location, physicians and nurses - Hospice: primarily last 6 months of life, typical to forgo concurrent acute care unless open access, at location patient feels is home, more inclusive providers
209
Which sex is most represented in nursing home?
- Widowed women
210
HOPE model of spiritual assessment
- H: hope sources (meaning, comfort, peace…) - O: organized religion - P: personal spirituality and practices - E: effects on medical care and end-of-life issues
211
How to assess pain in last hours of life?
- Persistent vs fleeting expression - Grimace vs physiologic signs - Incident vs rest pain - Distinction from terminal delirium
212
ICHABOD syndrome
- I: immobility - C: confusion/coma - H: homeostatic failure (temp, BP, circulation) - A: anorexia - B: breathing changes - O: oral intake decreased/observation (facial, personality changes) - D: dyspnea/detachment
213
What is the current approach to BP management in acute phase of ischemic stroke?
- Current approach to avoid excessive lowering of BP within first 24 hours
214
Goals of geriatric rehabilitation
- Best answer = function and independence - Attainment of maximal, not necessarily normal functional abilities - Living in most satisfying environment - Maintain social engagement
215
Pathophysiology of nausea and vomiting
Intracranial pressure/anxiety and memories --\> cerebral cortex Motion sickness/vestibular disease --\> vestibular apparatus Uremia/hypercalcemia/drugs --\> chemoreceptor trigger zone Gastric irritation/intestinal distension/gag reflex --\> GI tract All cause vomiting from there
216
Do elderly patients have the capacity to increase their muscle strength, balance, walking and aerobic function?
- Yes
217
Bodies – do they experience pain, do they suffer?
- A body experiences pain - A person experiences pain and suffers - Therefore when suffering, one must acknowledge that a person is involved.
218
Dyspnea treatment
Oxygen – may not always be beneficial (caution if CO2 retention) but is more helpful for patient and families to feel like something is being done Opioids – first line of defense for dyspnea, usually start with morphine at a low dose and ALWAYS prescribe meds for constipation Anxiolytics (for anxiety, not dyspnea) General measures, alternative therapies, or complimentary medicine Noninvasive ventilator support (CPAP, BiPAP)
219
Dyspnea assessment
Subjective, so self-report is GOLD standard; oxygen saturation/RR/signs of increased WOB do not correlate with report; Rx dependent on prognosis, goals of care, risks and benefits of tests/interventions
220
Palliative care service
- Establishing goals of care - Treatment of symptoms (pain and non-pain) - Psychosocial support/spiritual care
221
Single best predictors of low bone density
- Weight
222
Employee turnover rates in nursing home
- \>50% per year
