Exam Flashcards
(137 cards)
1
Q
Geriatric Syndromes
A
Sensory Impairment (Visual and Hearing) Gait Impairment Falls B & B of Aging -Incontinence/constipation Dementia/Delirium Depression Poly-pharmacy Sleep Problems Sexual Dysfunction Skin changes/Pressure Ulcers
2
Q
ERICKSON stage during old age
A
EGO INTEGRITY vs DESPAIR:
Sense of whole and satisfaction with one’s life
3
Q
UNIVERSAL CHANGES w/aging
A
Decreased night vision Decreased muscle mass Loss of hair pigment Decreased lung vital capacity Decreased height Decreased gait speed/reaction time
4
Q
Functional Reserve Theory
A
As people age, FUNCTIONAL RESERVE (body’s organ system redundancies to handle acute insults) DIMINISHES
5
Q
Increasingly common changes in aging (NOT inevitable)
A
Hearing loss Macular degeneration Hypertension Heart disease Diabetes Cancer Parkinson’s disease Dementia
6
Q
Peck’s late adult development
A
Ego differentiation vs work role preoccupation:
Achieving identity apart from work
Body Transcendence vs Body preoccupation:
Adjusting to and accepting normal aging processes
Ego Transcendence vs Ego preoccupation:
Adjusting to the finality of death and living each day to its fullest without preoccupation with “normal” lifespan
7
Q
Most Common cause of blindness in whites v blacks in aging
A
whites: macular degeneration
blacks: cataracts
8
Q
leading cause of death from injury among those >65
A
complications from falls
9
Q
reversible causes of dementia
A
B12 def, sensory def., depression, thyroid disease
10
Q
The only well-researched, effective means of reliably slowing the aging process and increasing avg max lifespans in a number or organisms
A
The Caloric Restriction Theory/ Hypothesis
High nutrient, low calorie diet
CRON – Caloric Restriction, Optimal Nutrition
Coupled with moderate use of vitamin and mineral supplements as well as regular exercise
Dr. Roy Walford
11
Q
The Free Radical (Oxidative Damage) Theory/Hypothesis
A
Free radicals are molecules that contain “free electrons” (unpaired & unstable) which become destructive in biological systems
Attack and split apart other paired electrons
Free radicals attack cell membranes generating metabolic waste products such as lipofuscins (implicated in the development of age spots, etc.)
Also attack collagen, elastin, proteins, DNA, etc.
12
Q
The Hayflick Limit Theory(Replicative Senescence Hypothesis)
A
Cells are genetically preprogrammed to divide a set number of times (typically 40-60 cell divisions) and then die
Loss of cells leads to aging → death
13
Q
Life expectancy in US
A
78.7 years overall
Males: 76.2 years
Females: 81.2 years
14
Q
most common type of incontinence in geriatric population
A
urge incontinence: urinary bladder contracts when it shouldn’t, causing some urine to leak through the sphincter muscles holding the bladder closed; have sudden urge to urinate
15
Q
hydrodynamics of incontinence
A
normal: urethral pressure > bladder
incontinence: reverse (void when detrusor pressure > urethral pressure)
16
Q
sympathetic stimulation via hypogastric plexus (T11-L2) via beta-adrenergics
A
bladder relaxation and filling (200-400mL)
closure of bladder neck & sphincter
inhibits parasympathetic tone
17
Q
parasympathetic (cholinergic) stimulation via the sacral complex (S2-4)
A
bladder contraction (ACh release)
18
Q
somatic control via pudendal nerve
A
relaxation of pelvic floor musculature (ext. sphincter)
19
Q
common causes of acute incontinence
A
fecal impaction and urinary tract infections
20
Q
DIAPPERS (Transient Causes of incontinence)
A
D= delirium I = infection A= atrophic urethritis or vaginitis P= pharmaceutical P= psychiatric E= excessive urine output R= reduced mobility S= stool impaction
21
Q
urge incontinence
A
detrusor contractions at low volumes; detrusor overactivity or instability
causes: CNS lesions, CVA, increased bladder sensory stimulation from BPH, UTIs
22
Q
Stress incontinence
A
incompetent internal sphincter causes leakage w/ abd. pressure (coughing, sneezing, lifting)
23
Q
overflow incontinence
A
loss of detrusor contractility or sensation: neuropathies CVA, MS, SC injury, DM, or nerve damage w/ surgery or trauma, interferes with contraction & emptying
bladder outlet obstruction creates distension: BPH, bladder neck contracture, or drugs
24
Q
functional incontinence
A
refers to situations in which physical, functional, or mental disability makes it impossible to void independently, even though the urinary tract may be intact
25
basic test for urge incontinence
Cystometry:
| measures the bladder's ability to retain urine at different capacities and pressures
26
Postvoid Residual Urine Volume
the amount of urine left after urination-always valuable to know!
normal: 50mL or less
27
Estrogen replacement therapy in incontinence
helps restore the urethral lining which is a cause of stress incontinence, and estrogen cream particularly desensitizes the bladder, helping those with urge incontinence
28
Anticholinergic agents effect on incontinence
```
inhibit the involuntary contractions of the bladder and increase the capacity of the bladder
ex: oxybutynin (Ditropan)
propantheline (ProBanthine)
hyoscyamine (Levbid, Cytospaz)
tolterodine (Detrol)
Festerodine (Toviaz)
```
29
Overflow Incontinence Drug Rx
cholinergic agonists:
bethanechol (Urecholine)
alpha1-adrenergic antagonists:
terazosin (Hytrin) qhs
doxazosin (Cardura) qhs
tamsulosin (Flomax) qhs
30
Antispasmodic drugs
help relax the bladder muscle (analgesic, anesthetic, and smooth muscle relaxant) are used for urge incontinence
flavoxate (Urispas)
dicyclomine (Bentyl)
31
Male overflow due to prostate obstruction Tx
Terazosin (Hybrin)
| Finasteride (Proscar)
32
Most common Sx of DM in elderly
INCONTINENCE AND CONFUSION (change in mental status)**
50% asymp, most not diagnosed
glycosuria not seen at usual levels (higher renal threshold), dehydration more common
33
prominent characteristic of type 2 diabetes in older adults
post-prandial hyperglycemia
34
Latent Autoimmune Diabetes in Adults (LADA)
subtype of type 1 diabetes that occurs in adulthood. Similar to type 1 diabetes, LADA is an autoimmune disorder in which the body’s immune system mistakenly attacks cells in that make insulin
adults with LADA are often thin and may lack a family history of diabetes. People with LADA typically need to take insulin within 6 months of diagnosis.
35
When does glucose normally start spilling into urine?
When the blood glucose level exceeds about 160–180 mg/dl
36
Most common symptoms of hypoglycemia in elderly
dizziness/visual disturbances (may not have typical hypoglycemic symptoms such as tremors or tachycardia)
37
Hypoglycemia in elderly pathology
Decline in beta-adrenergic receptor function: so no tremors or tachycardia
Autonomic neuropathy: blunted epinephrine response as a counter-regulatory hormone (hypoglycemia unawareness)
Growth hormone and glucagon: response diminished
38
Severe hypoglycemia
May precipitate stroke
Myocardial infarction
Significant injury resulting from trauma during syncope
39
What history questions to ask in evaluating DM/hypoglycemia in elderly
```
coronary artery disease
hypertension
peripheral vascular disease
renal disease
Incont, confusion, visual disturbance
```
40
Better tests to monitor renal function in elderly
BUN, CREAT, microalbumin
| glycosuria not a good indicator
41
Hyperglycemic Hyperosmolar Nonketotic Syndrome
Most common in the elderly, 30-40% initial presentation
Younger more DKA
Associated with dehydration and severe electrolyte disturbances
Often triggered by illness or infection
Hyperglycemia (generally > 600 mg/dL)
Impaired mental status
Elevated plasma osmolality (> 320mOsm/kg)
Profound dehydration
No ketosis
Normal PH
can cause hallucination and coma
42
cause of Hyperglycemic Hyperosmolar Nonketotic Syndrome
Underlying kidney problems: decrease in glucose clearance
Decreased sensation of thirst
Decreased access to water
43
Tx of Hyperglycemic Hyperosmolar Nonketotic Syndrome
Aggressive fluid resuscitation, IV insulin, and electrolyte correction (potassium, phosphate, magnesium) are the mainstays of treatment. Patients with HHS are very ill, and many are elderly; therefore, slower correction of osmolality may be required to limit cerebral edema.
Once glucose is no longer significantly improving with fluids alone, reassess patient’s fluid status and initiate IV insulin.
44
Dx of DM
1. Fasting glucose ≥126 mg/dl
2. OGTT with 2-hr value ≥ 200 mg/dl
3. Glycosylated hemoglobin (HbA 1c ) ≥6.5%
4. Random plasma glucose of ≥ 200 mg/dl
45
Tx of DM
Diet and exercise: mainstay
| Pt education, smoking cessation
46
Metformin in elderly
GI side effects, weight loss, lactic acidosis
47
Sulfonylureas in elderly
Cheaper
| Risk of hypoglycemia (glyburide), weight gain
48
Metaglinides in elderly
Risk of hypoglycemia and weight gain (less risk of hypoglycemia than sulfonylureas)
High cost, frequent dosing
49
Glucagon like peptide 1 agonist
Good for postprandial hyperglycemia, low risk for hypoglycemia
Nausea and weight loss, injection therapy, dose reduction for renal dysfunction
50
Insulin
Hypoglycemia, weight gain
| Vision/manual dexterity (consider pen devices: cost), glucose monitoring
51
aging effect on thyroid
thyroid gets smaller and smaller, T3/4 production declines
| no effect on TSH
52
most common thyroid condition in elderly
subclinical hypothyroidism: normal frT4, elevated TSH
| hypothyroidism affects women more than men
53
hypothyroidism delay in Dx
4 year delay
54
Most common cause of hypothyroidism in elderly
Hashimoto's
55
Hashimoto's
Autoimmune disorder
Normal thyroid tissue replaced with lymphocytic and fibrous tissue
Progressive fibrosis, appearance of lymphocytes, decrease in follicle size
Leads to reduction in function of thyroid and decline in hormone production
56
Iatrogenic post surgical or ablation/medications causes og hypothyroidism
Lithium therapy
Amiodarone-induced
Phenytoin, Carbamazepine, Gleevac (chemotherapeutic)
57
myxedema coma
```
Life threatening hypothyroidism, Rare
Often associated with systemic illness
infection, stress, surgery
Meds: Beta Blockers, Amiodarone
Rapid:
stupor, seizures, coma
Hypothermia
Respiratory depression: hypoxia and carbon dioxide retention
Low BP, low hr --> features of shock
```
58
Hypothyroidism SxS
```
Subtle in elderly:
Fatigue and weakness**
Weight gain
Cold intolerance
Paresthesia
Abdominal cramps
Dry skin
Nodular/firm thyroid: Hashimotos Disease
Mental slowing, depression, lethargy & dementia
Behavioral disturbances, confusion
Hearing impairment
Delayed relaxation of DTR’s
unsteady gait (cerebellar)
depressed resp drives
leaky capillaries: pleural, cardiac effusions
Sinus bradycardia typical
Generalized nonpitting edema: Periorbital
Decreased peristalsis: Constipation, Distension
```
59
Most common paraesthesias in hypothyroidism
Commonly mononeuropathy:
| especially median nerve (carpal tunnel syndrome)
60
Lab values of myxedema coma
high TSH, low Free T4
| Hyponatremia
61
What should be included in the DDx of every case of hyponatremia*
hypothyroidism
62
Mortality of myxedema coma
Mortality rate > 50% if not prompt treatment
| 25% even w/prompt Tx
63
Overt Hypothyroidism Tx
Thyroid replacement therapy: Levothyroxine
25 mcg initially
Increase in increments of 25 mcg Q 4-6 weeks (follow TSH) - Monitor for atrial fibrillation and loss of bone mineral density (inc risk of fractures)
(start low and go slow, 20% can get subclinical hyperthyroidism)
64
Anti-TPO antibodies
the most common anti-thyroid autoantibody, present in approximately 90% of Hashimoto's thyroiditis, 75% of Graves' disease and 10-20% of nodular goiter or thyroid carcinoma
65
Who to treat w/subclinical hypothyroidism
TSH level that is consistently elevated above 10 μU per mL
Also, patients who complain of symptoms: fatigue, dry skin, constipation, muscle cramps or other common symptoms of hypothyroidism may possibly benefit from treatment
66
Most common causes of hyperthyroidism in elderly
Multinodular goiter and Graves disease most common
67
Hyperthyroidism in elderly
15-20% over 60 y/o
Anxiety, tremors, palpitations, weight loss, heat intolerance (However elderly present usually with only 1-2 symptoms)
Lid lag frequently seen
Clinically detectable goiter more common in younger population
68
Hyperthyroidism Problems
```
Atrial Fibrillation
CHF
Hypertension
Exercise intolerance
Exacerbation of angina in those with pre-existing CAD
Osteoporosis
```
69
Hyperthyroidism Tx in elderly
Recommended therapy is medication in elderly then radioactive iodine for definitive therapy
Methimazole*
propylthiouracil*
70
Subclinical hyperthyroidism Tx
Medication if:
TSH less than 0.1 mU/L (milliunits/liter) or
TSH 0.1-0.5 mU/L with afib, weight loss, osteoporosis
71
Thyroid storm
Acute hyperthyroidism
Occurs after operation, trauma, infection, or exposed to iodinated IV contrast, radioactive iodine therapy
Usu caused by some type of stressor
72
Thyroid storm SxS
Fever, confusion, agitation can lead to coma and death
Tachycardia, afib, CHF, diarrhea, vomiting
IF Cardiac disease= high risk for acute HF or MI
Life threatening
15-20% mortality rate
less common than myxedema coma in elderly
73
How is the heart affected by aging?
Increase in intimal media thickness --> reduced compliance** --> increased vessel stiffness**
This increases systemic vascular resistance or afterload
Systolic pressure increases
Pulse pressure widens
Decreased ability to respond to the nervous system (sympathetic & parasympathetic)
Ventricles become enlarged, stiffer and therefore work less efficiently (Diastolic dysfunction “STIFF wall”) --> can lead to A fib*
74
Isolated Systolic Hypertension*
SBP >160 mmHg with DBP <90 mmHg --> Increase in pulse pressure (SBP – DBP)
accounts for 60-80% of hypertension in the elderly***
due to Diminished arterial compliance*
75
Tx of BP in elderly
Initial treatment is still trial of non-pharmacologic: 2gm Na, weight loss, exercise
Start LOW, go SLOW (half normal initial dose)
common to see Increase in orthostatic hypotension --> Falls!
76
Orthostatic Hypotension
with 2 to 5 minutes of quiet standing: at least 20mmg Hg drop in systolic BP
At least 10mmg drop in DBP
77
Most common cause of sick sinus syndrome
```
replacement of sinus node tissue by fibrous tissue
Generally older (7th or 8th generations of life)
```
78
Signs of sick sinus syndrome
Bradycardic, Hypotensive, Orthostasis
| ECG Changes: Sinus Bradycardia, Sinus pauses, Sinus arrest
79
Drug-induced causes of SSS
CCB*
Aricept/Donepezil*
bb, digoxin, antiarrhythmics
80
most common underlying disorders in patients with AFib*
Hypertensive heart disease and CAD
81
Atrial Fibrillation: Management
Rate Control:
Chronotropic Agents: BB, non-dihydropyridine CCB (verapamil, diltiazem), digoxin
Rhythm Control:
Anti-arrhythmics: Amiodarone, Sotalol
Cardioversion, Ablation
Prevention of Emboli --> Anticoagulation
Coumadin/Warfarin
Xarelto, Pradaxa, Eliquis
82
Atypical ACS presentation
increases with age
Fatigue, nausea, syncope, confusion
NSTEMIs increase with age
DM and HTN increase incidence of silent MI
83
Risk of hemorrhagic CVA
increases w/age!
| weight Benefit vs. risk of any any thrombolytic therapy
84
risk of cardiac cath and PCI in elderly
Risk of GI bleed
85
most common valvular disease in old age
```
Aortic Valve disease
Aortic Sclerosis (thickening/stiffening) affects up to 1/3 of all elderly patients
```
86
When is surgery considered in aortic stenosis?
Symptomatic
| LV EF <50%
87
usually the best valve choice in elderly patients
Bioprosthetic: 10-20yrs; advantage: pt doesn’t need long term anticoagulation w/warfarin; best for elderly
88
Systolic HF*
HFrEF
89
Diastolic HF*
HFpEF
90
Tx of systolic HF*
BB, ACE: cornerstone of therapy
91
What is common in diastolic HF patients?
A fib
92
Chronic or Persistent pain
>3-6mon
| Pain that goes beyond the expected time of healing
93
“Pain Signature"
the parameters affected by pain and the severity of their impact
94
Pain rating tools for cognitively intact patients
numeric rating scale: 0-10
pain thermometer scale
comparative pain assessment scale
neuropathic pain tool: 3 or >
95
Pain rating tools for cognitively impaired patients
PainAD tool: Pain Assessment IN Advanced Dementia
| PACSLAC: Pain Assessment Checklist for Seniors with Limited Ability to Communicate
96
Screens for Depression
PHQ-2, then PHQ-9
97
What should you focus on in PEs
Focus on neuromuscular systems:
Impairments, weakness, hyperalgesia/hypoalgesia, hyperpathia, allodynia, numbness, and tingling
Trigger points, bony deformities, or local inflammation at certain sites that may suggest certain pathologies
Mobility/Balance- range of motion testing, gait, and balance testing
98
Mental Status Exams
Montreal Cognitive Assessment (MoCA): >26 is normal
| MMSE
99
Conditions that may cause pain in the elderly
```
Myofascial pain syndrome*
Chronic low back pain*
Lumbar spinal stenosis*
Fibromyalgia*
Generalized osteoarthritis
Cancer pain
Peripheral neuropathy
Ischemic pain
```
100
4 most common and misdiagnosed conditions that cause persistent pain in older adults.
Myofascial pain, chronic low back pain, lumbar spinal stenosis and fibromyalgia syndrome
101
Drug Sensitivity in elderly
Response to benzodiazepines are increased
Response to warfarin is increased
Response to Opioid analgesics is increased
Alpha-2 receptor responsiveness is decreased (response to clonidine and methyldopa)
Beta 1 & 2 receptor responsiveness is decreased (response to salbutamol and terbutaline)
102
Pharmacokinetic changes in Older adults*
increased body fat & decreased water and muscle mass*
Water soluble drugs become more concentrated and have higher initial concentrations
Fat soluble drugs have longer half-lives due to slower release from the body’s fat stores
103
Lipophilic drugs
fentanyl and lidocaine
104
Somatic pain comes from*
skin, muscles and soft tissues**
105
Visceral pain comes from*
internal organs**
106
Topical NSAIDs
Diclofenac topical gel/solution
for Tx of musculoskeletal pain and osteoarthritis of superficial joint
Minimal systemic absorption
107
ADR of Celebrex (Celecoxib)
not used anymore in elderly bc of risk of CV events
108
NSAIDS worsen
HTN, CHF & renal impairment
and CV risks
only used in rare circumstances
109
Ask every pt about
OTC medication use
110
are TCAs used in older populations?
not used much due to many SEs (anticholinergic, CV)
111
Good starting medication in elderly*
acetaminophen*
opioid for mod to severe
adjuvant in neuropathic pain
112
best Tx for older adults w/sleep problems
cognitive behavioral therapy (over meds)
113
Advanced Sleep Phase Syndrome
Go to bed much earlier in the evening and wake up much earlier
114
sleeping aids in pts w/OSA
Benzos, Opioids, barbiturates not recommended
| Eszopiclone (Lunesta®) or zolpidem (Ambien®) safe but pt must have CPAP!
115
Periodic Limb Movement Disorder
Brief muscle twitches, jerking movements or an upward flexing of the feet clustered into episodes lasting from a few minutes to several hours
usu benign
May be caused by kidney disease, DM or anemia (B12 or iron deficiency) – pt needs workup**
116
REM behavior disorder Tx*
Clonazepam 90% effective
117
Age-related alterations in drug metabolism
reduced renal and hepatic clearance, always monitor
118
Light Sleep
Stage 1 -Period between awake and early sleep
| Stage 2 – transition stage - Decreased heart rate, muscle relaxation, decreased body temperature
119
Deep Sleep (Delta)
Restful and restorative phase
Stage 3
Stage 4: elderly rarely or ever reach this stage
120
Rapid Eye Movement (REM)
Active dreaming
Increased heart rate, increased respiratory rate, increased brain activity.
Active muscle inhibition occurs to prevent reacting to the dreams
121
Treatment Options for OSA
Continuous Positive Airway Pressure (CPAP)
Dental appliances which reposition the lower jaw and tongue
Surgery to remove tissue in the airway:
Somnoplasty
UPPP, or UP3 – uvulopalatopharyngoplasty
Mandibular/maxillary advancement surgery
Nasal surgery
122
What makes a geriatric assessment different?
```
ASSESSING
THE NEED FOR CHRONIC MEDICAL TREATMENT
LEVEL OF PHYSICAL FUNCTIONING
LEVEL OF MENTAL FUNCTIONING
AVAILABILITY OF SUPPORT – FAMILY, SOCIAL, FINANCIAL
ENVIRONMENTAL & HOME FEATURES
ADVANCED CARE DIRECTIVES
```
123
Gait speed alone in older adults predicts..***
Functional decline
| Early mortality
124
most common (60-80%) form of dementia
AD
125
Anticholinergic Toxicity
```
Flushing
Dry skin and mucous membranes
Mydriasis with loss of accommodation
Altered mental status (AMS)
Fever
Sinus tachycardia
Decreased bowel sounds
Functional ileus
Urinary retention
Hypertension
Tremulousness
Myoclonic jerking
```
126
A1c of 7 is about how much in glu
150
Every 1 a1c, add 30 sugar; eg a1c of 8 is 180 sugar
shooting for an avg of 180-220
127
THE PRINCIPAL FACTOR ASSOCIATED WITH THE LACK OF SEXUAL PARTICIPATION IS DUE TO
Lack of appropriate partner
128
PHOSPHODIESTERASE 5BLOCKER
```
Inhibits cGMP-specific PDE5 smooth muscle relaxation corpus cavernosum inflow of blood
Tx erectile dysfunction
ex:
VIAGRA - sildenafil
LEVITRA -verdenafil
```
129
1st line depression Tx in elderly
SSRI
| SNRI 2nd line
130
Sarcopenia
Decline in lean body mass, often associated with a corresponding increase in total body fat
131
Leading causes of involuntary weight loss
Depression (especially in LTC facility): #1
| Cancer (especially lung and GI malignancy): #2
132
In the long term care setting, a clinically significant weight loss episode is defined by
loss of 5 percent of usual body weight in 30 days, or 10 percent in 6 months
133
9/10 ER visits in elderly*
UTI!
| don’t drink enough water, hold their urgency bc hassle
134
all pts on CHRONIC ASA >60yo should also be on**
PPI
| Prevents gi BLEED
135
Immunization for elderly
Tetanus (Tetanus diphtheria (Td) every 10 years )
Influenza
Pneumococcal (all adults aged ≥65 years receive 1 dose of PPSV23)
Herpes Zoster (All immunocompetent persons >= 50 yo regardless of varicella hx; Shingrix)
136
Karnofsky Performance Scale (KPS)
tests functional status
Excellent predictor of outcome, risk, mortality
<50 signif (100 max)
137
What opioid wost in elderly*
Morphine --> Metabolites are neurotoxic
