Exam One Flashcards
(94 cards)
1
Q
How many phases of development are involved in the growth and development of people in the 2nd half of life?
A
four
2
Q
What is dementia?
A
- An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient
- Progressive and disabling
- Not an inherent aspect of aging
- Different from normal cognitive lapses
3
Q
List 5 possible protective factors for dementia
A
NSAIDs Antioxidants Intellectual activity Physical activity Statin
4
Q
List 4 definite risk factors for dementia
A
Age
Family history
APOE4 allele
Down syndrome
5
Q
List 4 possible risk factors for dementia
A
- Head trauma
- Fewer years of formal education
- Late-onset major depressive disorder
- Cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, obesity)
6
Q
How many people (%) have Alzheimer dementia?
A
6-8%
prevalence doubles every 5 years
nearly 45% of those aged 85+ have AD
7
Q
How many patients have vascular dementia?
A
co-occurs with an estimated 15-20% of AD cases - “Mixed dementia”
8
Q
2nd most common cause of dementia is what?
A
Lewy body dementia (LBD): related to deposition of lewy bodies throughout the CNS
9
Q
2 major traits of the etiology of Alzheimer disease
A
Amyloid plaques/oligomers
Tau neurofibrillary tangles
10
Q
Etiology of Lewy body and Parkinson dementia
A
Cytoplasmic α-synuclein inclusion bodies
11
Q
Etiology of frontotemporal dementia
A
Tau or ubiquitin proteins
12
Q
General etiology of dementia
A
Most neurodegenerative disorders appear to result from an accumulation of proteins or protein aggregates that creates a cascade of cellular-extracellular events in a disease-specific pattern.
13
Q
What are the two greatest risk factors for AD?
A
The two greatest risk factors for AD are age and family history. Studies that account for death from other causes suggest that by 90 years of age, nearly half of people who have first-degree relatives (ie, parents, siblings) with AD develop the disease themselves.
14
Q
What 2 things are responsible for early onset dementia (
A
Amyloid precursor protein (APP)
Presenilin proteins (PS1 and PS2)
15
Q
Two major causes of late onset dementia
A
Apolipoprotein E gene (APOE 2/3/4) ― chromosome 19
Single-nucleotide polymorphisms
16
Q
5 general things to include in a history regarding dementia
A
- Date of onset of current condition and nature of symptoms
- Medical history
- Current medications & medication history
- Patterns of alcohol use or abuse
- Living arrangements
17
Q
Describe the general work-up for a patient who possibly has dementia
A
Comprehensive h and p
Lab work: cbc, elecrtolytes, bun, creatinine, calcium, rpr (syphilis), B12, folate, ALT, AST, free T4, TSH
CNS visualization
Neuropsych testing
18
Q
Differential Diagnoses for Dementia Patients
[DEMENTIAS]
A
Drugs Emotional (psych.) disorders Metabolic disorders Endocrine problems Nutritional/Neurologic disease Trauma and Tumor Infection, ischemia, inflammation Anemia, arrythmia Social, Sensory, Spiritual isolation
19
Q
Give a general description of the physical assessment of a patient with dementia
A
Examine:
Neurologic status
Mental status
Functional status
Include:
Quantified screens for cognition (Folstein’s MMSE, Mini-Cog, SLUMS, MoCA
Neuropsychologic testing)
20
Q
Description of normal aging when it comes to cognitive ability
A
- No consistent, progressive deviations on testing of memory
- Some decline in processing and recall of new information: slower, harder
- Reminders work—visual tips, notes
- Absence of significant effects on ADLs or IADLs due to cognition
21
Q
Differentiate between delirium and dementia
A
Delirium is any acute change in mental status; acute onset, fluctuating level of consciousness
Dementia is chronic with a constant level of consciousness
22
Q
4 distinguishing signs of delirium
A
Acute onset
Cognitive fluctuations over hours or days
Impaired consciousness and attention
Altered sleep cycles
23
Q
4 overlapping symptoms of depression and dementia
A
- Impaired concentration
- Lack of motivation, loss of interest, apathy
- Psychomotor retardation
- Sleep disturbance
24
Q
Describe 6 characteristics of Alzheimer Disease including onset, cognitive symptoms, motor symptoms, etc.
A
Onset: gradual
Cognitive symptoms: memory impairment core feature with difficulty learning new information
Motor symptoms: rare early, apraxia later
Progression: gradual, over 8–10 yr on average
Lab tests: normal
Imaging: possible global atrophy, small hippocampal volumes
25
Describe 6 characteristics of Vascular Dementia including onset, cognitive symptoms, motor symptoms, etc.
Onset: may be sudden/stepwise
Cognitive symptoms: depend on anatomy of ischemia, but dysexecutive syndrome common
Motor symptoms: correlates with ischemia
Progression: stepwise with further ischemia
Lab tests: normal
Imaging: cortical or subcortical changes on MRI
26
Describe 6 main characteristics of Lewy Body Dementia including onset, motor symptoms, etc.
Onset: gradual
Cognitive symptoms: memory, visuospatial, hallucinations, fluctuations
Motor symptoms: parkinsonism
Progression: gradual, but usually faster than AD
Lab tests: normal
Imaging: possible global atrophy
27
Describe 6 main characteristics of Frontotemporal Dementia including onset, motor symptoms, etc.
Onset: gradual, usually age
28
5 Goals for dementia patients
1. To make sure the patient is safe and happy
2. To make a clear diagnosis
3. To initiate best interventions
4. To answer any questions from patient and loved ones
5. To help initiate plans for the future so that the patient will always be safe and happy.
29
primary goal of treatment for dementia patients
To enhance quality of life and
maximize functional performance by
improving cognition, mood, and behavior
30
7 aspects of non-pharmacologic management for dementia patients
Cognitive rehabilitation
Supportive individual and group therapy
Physical and mental activity
Regular appointments every 3–6 months
Family and caregiver education and support
Attention to safety
Making the environment safe
31
General definition of aging
"processes in an organism that increase the mortality risk as a function of time”.
characterized by progressive and broadly predictable changes that are associated with increased susceptibility to many diseases.
32
Changes with NORMAL aging as relate to brain neurons, max breathing capacity, liver weight, GFR, and lower esophageal failure
brain neurons: 0 to 50% decrease
liver weight: 20% decrease
max breathing capacity: 80% decrease
GFR: 50% decrease
lower esophgeal failure: 50% decrease
33
Describe 9 cardiovascular changes that occur in normal aging
By age 70 cardiac output reduced up to 70%
Left atrium dilates, while left ventricle stiffens
Ventricular myocytes hypertrophies – secondary to increased afterload
LVEF is not changed in healthy older people
There is a negligible age-related decrease in the resting heart rate, but a marked decrease in the maximum heart rate in response to exercise or other stressors.
Can have more arrhythmias
Arteries become more rigid
Veins dilate
No significant change in resting heart rate, but a marked decrease in the maximum heart rate in response to exercise or other stressors.
34
MOST COMMON VALVULAR LESION (HEART MURMUR) IN ELDERLY IS:
aortic stenosis
35
Describe 6 respiratory changes that occur with aging
Alveoli dilate – decreased gas exchange
Loss of elastic tissue
Lungs become more rigid - more anatomical dead space
Age increases ventilation-perfusion mismatching
Major factor in decreased arterial PaO2 (alveolar PO2 does not change) - INCREASE IN ALVEOLAR-ARTERIAL O2 GRADIENT
Carbon dioxide excretion is not impaired with age; changes in PaCO2 are d/t disease and should not be associated with age
Chest wall stiffens
Pulmonary function decreases
Cough is less vigorous
And mucociliary clearance is slow and less effective
36
Describe 5 major GI changes that occur with aging
50 % reduction of saliva production from parotid glands
Impacts chewing and swallowing
Esophagus: hypertrophy of the skeletal muscle at the upper third and decrease in myenteric ganglion cells that coordinate peristalsis
Secondary esophageal contractions (induced by esophageal distention) appear to be greatly reduced
Small intestine undergoes modest anatomic changes, including moderate villus atrophy and coarsening of the mucosae
Problems with absorption of nutrients.
Hepatobiliary: standard liver function tests are minimally affected with age.
Cytochrome p450 content decreases with age
Pancreas: Minor atrophic and fibrotic changes have essentially no impact on pancreatic exocrine function
37
Describe 6 major changes in renal systems that occur with normal aging
50% decrease in glomeruli
Renal plasma blood flow is 40% lower
GFR decreases by almost 50%
Decreased urine concentrating ability
Fluid and electrolyte homeostasis are maintained relatively well with aging
Bladder: increased incidence of urinary incontinence after age 80
38
5 major changes in the male repro system that occur with normal aging
Reduced testosterone
Testes atrophy and soften
Decrease in sperm production
Seminal fluid decreases and more viscous
Erections take more time
39
5 major changes in the female repro system that occur with normal aging
Declines in estrogen and progesterone
Ovulation ceases
Vagina atrophies, shorter , drier
Uterus becomes smaller
Breast tissue lose elasticity
40
Describe the major NT changes that occur with normal aging
Decrease in dopamine (parkinsonism)
Acetylcholine decreases (dementias)
GABA – slowing of sensory info
41
List some of the changes that occur in the nervous system with aging
Brain can lose up to 10% in weight
Cerebral blood flow – by age 70 up to a 20% decrease
Age-related neuronal loss is most prominent in the largest neurons in the cerebellum and cerebral cortex.
42
Describe some of the motor function changes that occur with normal aging
Impaired balance – posture
Slow widened gait
Jerky , clumsy coordination
Resting tremor (parkinsonism)
43
Describe 4 major cognitive changes that occur with normal aging
Certain memory performances on cognitive testing, like procedural, primary, and semantic memory are well-preserved with age
The ability to recognize familiar objects and faces, as well as to maintain appropriate visual perception of objects remains stable over the lifetime.
Episodic and working memory and executive function are the specific domains of cognition most affected by "normal" aging
Executive function declines with age, and more dramatically after age 70
44
list 6 major changes of the eyes that occur with normal aging
Periorbital tissues atrophy; eyelids become more relaxed.
Conjunctiva thinner and more yellow
Lacrimal gland function and tear production decreases.
Changes in lens and iris lead to "presbyopia.”
The pupil becomes rigid and the lens more opaque.
Impaired color vision – decreased cone cells
45
list 3 major changes of the ears that occur with normal aging
Irreversible sensorineural loss with age (presbycusis)
Affects men more than women
By age 60 most adults have trouble hearing above 4000Hz
46
Describe 3 major changes of taste and smell that occur with normal aging
Loss of taste in older patients is in large part due to decreased olfaction rather than taste itself
Acuity of olfaction declines significantly with age.
Decreased taste and smell sensation may result in decreased enjoyment of food
47
describe 3 major changes in muscle that occur with normal aging
Muscle mass decreases in relation to body weight by about 30 to 50 percent in both men and women.
Muscle quality decreases with infiltration of fat and connective tissue into the old muscle.
The loss of muscle mass is not uniform; in general, the loss from the legs is greater than from the arms.
48
describe 2 major changes in bone that occur with normal aging
There is a progressive decline in osteoblast number and activity but osteoclasts remain unchanged with age.
Weight bearing exercise is frequently reduced in older adults, contributing to a negative calcium balance and loss of bone mineral
Increasing weight bearing time or increasing loading forces may result increase bone mineral and prevent age-related bone loss.
49
describe the traits of height change in normal aging
Between age 20 and 80 average loss in height is 1 – 4 inches
Flattening of arch in feet
Increased spinal curvature
50
describe the traits of weight change in normal aging
Increase in percentage of body fat
Decrease in size of arms and legs
Increase in size of trunk (redistribution).
51
number one cause of blindness in the US and a major condition of older people
macular degeneration
52
Describe 6 major changes that occur in the immune system when patients age
Overall decline in function
Trouble differentiating between self and non-self (auto – immune problems)
Decreased antibody response
Fatty marrow replaced red marrow
Extended duration of stress
Exercise improves immune system!!!
53
list 3 possible changes that occur in the joints with normal aging
Can have osseous growths (bone spurs)
Decreased cartilage
Osteoarthritis can occur
54
Patients 65 and older comprise what percentages of the various patient populations?
```
29% primary care
32% surgery
44% emergency dept. visits
43% specialists
48% hospital
```
55
Tell me the age ranges for various populations of the geriatric community - i.e. old, young old, etc.
```
≥ 65 geriatric
65-74 young old
75-84 middle old
≥85 old old
≥100 centenarian
```
56
What was life expectancy in 1900? What about 2000?
1900 - age 49
| 2000 - age 78
57
Major causes of mortality in the geriatric population (7)
```
Heart disease
Cancer
COPD
Stroke
Alzheimer’s disease
Diabetes
Renal disease, injuries, pneumonia
```
58
What 4 major organ systems involve age related changes in the feet
dermatologic, musculoskeletal, vascular, neurologic
59
List some dermatologic changes/conditions that are very evident in the geriatric population
```
Dry skin (xerosis)
Dystrophic toenails
Onychomycosis (fungal nails)
Onychocryptosis: (ingrown nails)
Hyperkeratosis (corns, calluses)
```
60
What is xerosis? What causes it? When is it most common? How do we diagnose it for sure?
Dry, flaky skin
Skin dry and flaky due to decrease in epidermal filaggrin (binds keratin into macrofibrils)
Eccrine glands decline by 15% leading to decrease in spontaneous sweating
Hydrophobic substances well absorbed, hydrophilic are not
Delayed recovery of stratum corneum’s barrier function and decreased lipids leads to more water loss
Due to autonomic dysfunction in diabetics, there is a decrease in skin moisturization
More common in winter due to low humidity
Xerosis in the elderly is highly likely to be chronic athlete’s foot (tinea pedis) infection-perform a KOH whenever possible
KOH is used to dissolve skin scrapings and release the diagnostic fungal hypha (filament)
61
What % of people 85 and older need personal assistance with everyday activities?
50%
62
Is geriatric care just like adult care but with older patients?
NO
Often multiple chronic diseases present concomitantly
Diminished “health literacy"
There may be little evidence-based treatment
Encounters may be lengthy
Presenting symptoms are often absent or blunted in the elderly
Emphasis is on control and secondary/tertiary prevention, not cure
Your patient will end up dying on you
63
What % of geriatric patients have three or more chronic illnesses?
50% - clinical practice guidelines usually focus on best management of single diseases
64
What are the 5 main multimorbidity guiding principles?
Elicit and incorporate patient preferences
Interpret best evidence, recognizing limitations of the evidence base visavis the older age group
Frame decision within context of risk, benefit, and prognosis
Feasibility (complexity)
Optimize benefit, minimize harm, enhance QOL
65
Treatment options for xerosis
- creams and hydrocortizone
- Can occlude skin with Saran wrap at night under sock to promote penetration
- Apply after bath, shower, or soak to limit evaporation of water
- gel socks
66
Onychomycosis
Fungus that can cause tinea pedis can also infect the toenails
Fungus infects nail bed first, and through the production of keratinase, destroys the keratin of the nail plate and allows the nail to become thick, discolored, loosened, and collect subungual debris
67
Thick, yellow toe nails can be due to what things? (TOE CLYPT)
```
Trauma
Onychomycosis
Eczema
Circulatory problems
Lichen planus
Yellow nail syndrome
Psoriasis
Tumor
```
68
Onychocryptosis
Usually the result of improper nail trimming, trauma, heredity, systemic or local disease
Nails should be cut straight across ONLY if the nails are normal to begin with
If there is a chronic problem with ingrown nail, need to remove some of the distal
Some patients do better with in-grown nails if left longer than normal
Some, but very few, need a central “V” cut into the end of the toenail
corner
69
Examples of ADLs in geriatric patients
Transferring
[Functional mobility
“Get up and go”
Sit, stand, walk 3 m, return, sit,
70
Examples of IADLs in geriatric patients
```
Housekeeping
Meal preparation
Managing medication
Checkbook (managing money)
Shopping (groceries)
Telephone
Transportation
```
71
List some of the considerations of mobility in geriatric patients
```
Movement defines us as humans
Loss of strength
Loss of muscle mass (sarcopenia)
Stiffness, contractures, pain, fatigue
Loss of confidence
Dependence, institutionalization
Hydration, electrolyte, nutrition imbalance
Pressure sores
Death
```
72
paronychia - what is it, what causes it, how do you treat it?
Infected nail border(s)
S. aureus most common pathogen, although gram- rods frequent contaminant, but rarely the primary pathogen
[Derm literature usually equates the term “paronychia” with candida (yeast) infection]
Conservative treatment (5-7days):
* 10 min. bid warm, soapy water soak
* Betadine solution and band aid
* Cephalexin (Keflex®) @ 500 mgs. bid
Need to get rid of the offending part of the nail
Surgical treatment:
* I&D
* Bid soaks and Betadine solution
* Cephalexin @ 500 mgs bid (?)
73
What does dependency in geriatric patients really mean? What does it entail?
Reliance on someone or something else
Vulnerability = the state of being open to injury
Risks of neglect, abuse, exploitation
Function, not age should be top criterion in medical decision making
74
Name the 3 functional classifications of age groups
young adult, middle age, old age
75
Young adult
(20-39) 1st half of working life - 90 – 100% of function
76
middle age
(40 – 64) 2nd half of working life – 10-30% decreased function
77
old age
(65 – 74) – immediate post retirement period – significant loss of function but maintain homeostasis
78
hyperkeratosis
Thickened skin is the result of intermittent pressure over prominent bones
May hide deeper skin ulcerations which will develop if pressure becomes more continuous
Bones become prominent as a result of toe contractures and/or a loss of fat padding on the ball of the foot
The skin thickens in response to this pressure to form a cushion against the shoe or walking surface, but only the hard stratum corneum can reproduce hard, thick skin then causes pain as it presses against sensory receptors in the underlying dermis.
79
How do we treat hyperkeratosis?
debridement, padding, shoe modifications (Queen mary shoes)
80
Is dementia a normal aspect of aging?
no
81
Prevalence of dementia
5.4 million (63K in IA)
5th leading cause of death in seniors
$236 billion for care in US
82
What is homeostenosis?
o As age increases, our level of performance starts to diminish
o When you get old enough, if your level of functioning is bad enough, you may not have enough “reserves” to get you back to normal >> leads to “catastrophic” events and those sorts of injuries that keep a person from ever getting back to normal functioning ability
o When you get older, your functioning is diminishing and those reserves are diminishing (double hit)
o The narrowing of the gap between reserves available and functioning ability is termed stenosis
83
What are the 3 main types of theories on aging
evolutionary (why), psychosocial (who), physiologic (how)
84
Loss of homeostasis in geriatric patients
A breakdown in maintenance of specific molecular structures and pathways
This breakdown is the inevitable consequence of the evolved anatomy and physiology of an organism
Some are unique to the specific cellular and tissue context of a specific organ
Some are due to the overall organ system being stressed
85
Musculoskeletal conditions in the foot of geriatric patients
Digital deformities: bunion (hallux valgus), hammertoe
Flatfoot (pes valgoplanus)
Heel pain (plantar fasciitis)
86
Bunion
Prominent medial aspect of 1st metatarsal head due to actual medial migration of 1st metatarsal and lateral migration of great toe (hallux)
Usually, the result of a tendon imbalance around the joint in a person with a flatfoot
87
Bunion treatment
extra depth shoes (SAS), bunion shield, toe separator, surgery*
88
Hammertoe
Buckling of the toe at the PIPJ and/or DIPJ of the lesser toes due to a tendon imbalance around the lesser toe joints that causes one bone to dorsiflex and one or more bones distal to it to plantarflex
Common in flat- and high-arched feet
89
Treatment options for hammertoe
Debridement of hyperkeratotic tissue
Paddings to limit pressure: Foam, silicone, moleskin, lamb’s wool
Splints to passively plantarflex toe
Extra-depth or custom molded shoes
90
flatfoot
Common to develop a collapse of the medial longitudinal arch as one ages due to progressive ligamentous laxity of the joints
Also known as pronation or pronated foot type
91
things that can cause flatfoot
Leg and low back pain
Capsulitis of MPJ’s (pain on ball of foot)
DJD (“wear-and-tear” arthritis) of foot and ankle joints
Tendonitis (tibialis posterior)
Inflammation of the plantar fascia, usually at or near its insertion into the plantar calcaneus (plantar fasciitis)
92
Treatment for flatfoot
arch support (orthosis) helps to lift arch and limit stress on tendons, ligaments, and joints
93
Vascular disease progression in geriatric patients
The normal aging process will cause deterioration in the structure of arteries and veins
This can lead to atherosclerosis in arteries and malfunctioning of valves in veins (chronic venous insufficiency)
The end result can be tissue ischemia leading to foot and leg pain, ulcerations, and gangrene
The increased incidence of diabetes in the elderly accelerates the aging process of vessels, particularly, arteries
94
What are the waist measurements that provide 80% positive predicative value of diabetes in women and men
males > 40 inches
| females >35 inches
