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Geriatrics > Falls in Elderly > Flashcards

Falls in Elderly Flashcards

1
Q

What are the common causes of provoked falls?

A

Pushed
Syncope
Seizure related
Icy walkway

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2
Q

What are the unintentional falls

A

Loss of balance

Weakness

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3
Q

What are the risk factors of falls?

A

Advanced age

Medications

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4
Q

What medications are associated with falls?

A

Drugs that cause:
Sedation
CNS/cognitive effects
Psychoactive medications

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5
Q

What number of medications is independently associated with falls

A

4 or more

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6
Q

What is the definition of dizziness?

A

Spinning/light-headedness, w/o loss of consciousness, and may or may not be associated with falls

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7
Q

What are the different classifications of dizziness?

A

Vertigo - sensation of movement
Light headedness - common in COPD/hypoxia
Disequilibrium - lower extremities or trunk
Presyncope - associated with nausea, sweating, or weakness

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8
Q

What is the definition of syncope?

A

“Transient loss of consciousness almost always associated with falls” associated with central hypoperfusion

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9
Q

What is syncope associated with?

A 
Seizures
TIAs
Metabolic disorders
Intoxication
Orthostatic hypotension
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10
Q

What are the most common causes of dizziness/syncope are attributed to?

A

CV or neurological conditions

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11
Q

What is the definition of orthostatic hypotension?

A

Symptomatic decline in BP after standing

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12
Q

For orthostatic hypotension, how is SBP and DBP reduced?

A

greater than or equal to 20 SBP or greater than or equal to 10 DBP within 3 minutes of standing

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13
Q

How much blood is in the lower extremities when standing during orthostatic hypotension?

A

500-1000ml

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14
Q

How does the body return blood to the heart and maintain blood pressure?

A

CNS increases sympathetic and decreases parasympathetic outflow

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15
Q

Why is orthostatic hypotension more common in the elderly?

A

Blunted baroreceptor response

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16
Q

What are sx of orthostatic hypotension?

A 
Weakness
Dizziness
Light-headedness
Blurred vision
Possible syncope
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17
Q

What are other etiologies for orthostatic hypotension?

A

Autonomic failure (Lewy bodies, neuropathies)
Volume depletion
Reflex syncope

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18
Q

Which medications can cause orthostatic hypotension?

A 
Antihypertensive agents (BB, diuretics, CCBs, vasodilators, alpha blockers)
Sedative hypnotics
Antidepressants
PDE-5 inhibitors
Antipsychotic agents
Muscle relaxants
Narcotic analgesics
Antiparkinsons agents --> but also Parkinson's disease
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19
Q

What are some management strategies for orthostatic hypotension?

A 
Hydration
Reduction of medication offenders
Elastic stocking/ab binders
Exercise
Medications
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20
Q

When are medications used for orthostatic hypotension?

A

Last line
Typically someone would not be on any antihypertensive agents at this point but would still not be able to maintain adequate blood pressures

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21
Q

When are medications more commonly used for patients with orthostatic hypotension?

A

Pts w/autonomic dysfunction or neuropathy

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22
Q

What are the commonly used agents for orthostatic hypotension?

A

Fludricortisone

Midodrine

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23
Q

What is fludrocortisone?

A

Synthetic adrenocrotical steroid with potent mineralcorticoid activity

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24
Q

What is the MOA of fludricortisone?

A

Mimics aldosterone
An endogenous mineralcorticoid
Promotes resorption at the distal renal tubule

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25
Q

What do larger doses of fludricortisone do in the body?

A

Endogenous adrenal cortical secretion
Thymic activity
Pituitary corticotropin execretion

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26
Q

What is the dose of fludrocortisone in orthostatic hypotension?

A

0.1-0.2 mg PO once daily

Max 0.2mg daily, no dosage adjustments are needed for renal or hepatic impairment

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27
Q

What are the AEs of fludricortisone in orthostatic hypotension?

A 
Edema
Electrolyte abnormalities (K wasting, hyperglycemia)
Ab distension
PUD
Myopathy
HA
Vertigo
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28
Q

What is midodrine?

A

Prodrug hydrolyzed to desglymidodrine

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29
Q

What is midodrine’s MOA?

A

Binds to alpha-1 receptors on arteries and veins to increase vascular tone and elevate blood rpessure

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30
Q

Can midodrine pass the BBB?

A

Limited which means no central action

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31
Q

What is the dose of midodrine?

A 
10mg TID (4 hours between doses; no later than 6pm)
Max daily 30mg
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32
Q

What are the dose adjustments in midodrine?

A

No adjustment for hepatic impairment

In renal impairment, start with 2.5mg per dose TID

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33
Q

What are the AEs for midodrine?

A 
Pruritus
Shivering
Parasthesias
Dysuria
HTN
Bradyarrhythmia
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34
Q

What is the new orphan drug for orthostatic hypotension?

A

Droxidopa (Northera)

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35
Q

What is the MOA of droxidopa?

A

Synthetic precursor to NE, use results in peripheral vasoconstriction

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36
Q

What is droxidopa indicated for?

A

Neurogenic orthostasis (Parkinson’s disease)

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37
Q

What is the dose for droxidopa?

A

100mg TID

Titrate by 100mg TID every 24-48 hours until 1800 mg/day max

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38
Q

Is there efficacy beyond using droxidopa for 2 weeks?

A

Nope

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39
Q

What are the AEs for droxidopa?

A 
HTN
Nausea
HA
Dizziness
Neuroleptic malignant syndrome
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40
Q

What drugs are considered to be added if the first line therapies are not effective in orthostatic hypotension?

A 
Pyridostigimine
NSAIDs
Caffeine
Erythropoietin
Dihydroergotamine
DA (metoclopramide, domeperidone)
Amulatiory NE infusions
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41
Q

If the patient is in an urgent, emergent or critical settings, what medications are used for orthostatic hypotension?

A

Vasopressors

IV fluids

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42
Q

What are sources of vitamin D?

A

Sunlight (cholecalciferol)
Diet
Supplementation

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43
Q

What parts of the diet contain cholecalciferol?

A

Oily fish
Eggs
Fortified dairy

44
Q

What parts of the diet contain ergocalciferol?

A

Fungi

Eggs

45
Q

Why is vit D deficiency common in older adults?

A

Inadequate dietary intake
Low sun exposure
Northern hemisphere residence
Age related changes of the liver and kidney

46
Q

What are s/sx of vit D deficiency?

A

Muscle weakness
Bone impairment
Potentially neuromuscular impairment

47
Q

What is the normal and goal 25(OH) vitamin D level?

A

greater than or equal to 30

48
Q

What is the level for 25(OH) vitamin D insufficiency?

A

21-29

49
Q

What is the level for 25(OH) vitamin D deficiency?

A

less than or equal to 20

50
Q

How long should clinicians wait to check the patient has reached appropriate levels?

A

4 months

51
Q

What is the order for most to least common fractures in elderly?

A

Vertebral > wrist > hip

52
Q

How does WHO classify Osteoporosis?

A

BMD T-score

53
Q

What are the classifications for BMD T-score?

A

Normal T > -1
Osteopenia T= -1 to -2.5
Osteoporosis T= -2.5 or worse

54
Q

How do hip fractures affect the elderly?

A

Increase in anxiety and depression
Decrease independence/confidence
Increase mortality - 25% 1 year mortality

55
Q

How do falls affect the elderly?

A

Increase hospital stays and increase chance of being institutionalized
Hasten functional decline

56
Q

How often is the human skeleton replaced?

A

Every 7-10 years

57
Q

What are the steps in remodeling of bone?

A

Resorption
Reversal
Formation
Quiescence

58
Q

What is predmoninant mineral in the bone?

A

Hydroxyapatite

59
Q

What do osteoblasts do?

A

Bone formation

60
Q

What do osteoclasts do?

A

Bone resorption

61
Q

What are basic multicellular units (BMU) made of?

A

Team of osteoclasts and osteoblasts

62
Q

What do BMUs perform?

A

Performs the remodeling process

63
Q

What are the four largest predictors of fracture risk?

A

Low BMD
Prior fragility fracture
Age
FH of osteoporosis

64
Q

What are factors associated with low bone mass?

A 
Famle
Caucasian/asian
Sedentary lifestyle
Immobility
Low body weight (<125lbs) 
Low Ca intake
Smoking
Excessive alcohol
Low sun exposure
Medications
65
Q

What medications can cause low bone mass?

A 
Usually chronic meds
Glucocorticoids at 7.5 mg prednisone for 3 months
Heparin (15,000 units/d for 3-6 months)
Phenytoin
Phenobarbital
Thyroid supplements
Aluminum
Lithium
Loops
66
Q

What are osteoporosis risk factor classifications?

A

Modifiable

Nonmodifiable

67
Q

What are nonmodifiable RFs for osteoporosis?

A 
Age
Race
Sex
FH
Early menopause/oophoerctomy
68
Q

What are modifiable RFs for osteoporosis?

A

Sex hormone deficiency
Ca and Vit D intake
Physical activity
Cigarette smoking

69
Q

What is the pathophysiology of osteoporosis?

A

Characterized by low bone mass and microarchitectural deterioration of bone tissue

70
Q

What are non pharmacologic interventions for falls and fractures

A

Exercise programs - tai chi is well studied and recommended
Evaluations and modifications of environment
Visual correction procedures
Medication reduction/withdrawal
Adequate calcium and Vit D intake to develop and maintain healthy bones
Smoking cessation, moderation of EtOH and caffeine

71
Q

What is the recommended dietary allowance of calcium?

A

1000-1200 mg daily

72
Q

What is the recommended dietary allowance of vitamin D?

A

600-800 units daily, some recommend 800-1000 units daily

73
Q

What are the side effects of calcium supplementation?

A

Constipation, gas, upset stomach
Kidney stones (uncommon)
Food sources of calcium may be better tolerated

74
Q

What are the available calcium products?

A

Calcium carbonate
Calcium citrate
Calcium phosphate tribasic

75
Q

What are the Calcium carbonate supplements?

A

Tums
Caltrate w/vit D, OsCal w/vit D
OsCal +/- vit D

76
Q

What are the calcium citrate supplements?

A

Citracal +/- vitamin D

Cal-Citrate

77
Q

What is the calcium phosphate tribasic supplement?

A

Posture

78
Q

What is the calcium supplement daily dose for men 50-70 years?

A

1000mg daily

79
Q

What is the calcium supplement daily dose for women 50+ and men 71+?

A

1200mg daily

80
Q

What is the max intake of calcium per the IOM?

A

2000mg daily

81
Q

What is the max intake of calcium per the NOF?

A

1500mg daily

82
Q

What are DDIs with calcium?

A

PPIs (decrease Ca absorption)
Ca decreases absorption of iron, tetracycline, quinolones, bisphosphonates when given concominantly
Fiber laxatives decrease Ca absorption if given concomitantly

83
Q

What are the side effects of Vitamin D?

A

Hypercalcemia (weakness, HA, somnolence, Nausea, cardiac rhythm disturbance)
Hypercalcuria
Kidney stones, especially when combined with Ca
Toxicity is very rare

84
Q

What are the available Vitamin D products?

A

D3 (cholecalciferol)

D2 (ergocalciferol)

85
Q

Which vitamin D is more potent and has better bioavailability?

A

D3 - 3 times more potent than D2

86
Q

Which vitamin D is available OTC?

A

D3

87
Q

In a patient with regular absorptive capacity, 100IU will increase 1,25 (OH) vitamin D level by how much?

A

0.6 - 1.0 ng/ml

88
Q

What is the dosing of ergocalciferol?

A

50,000 IU capsules

8,000 IU/mL liquid

89
Q

What are the repletion dosing for patients with Vit D insufficiency/deficiency?

A

50,000 IU weekly
4000-6000 units daily
Obese patients 6000-10000 units daily

90
Q

How long is a patient on repletion dosing for VitD insufficiency/deficiency?

A

6-12 weeks, then the patient is converted to the maintenance dose

91
Q

What are the maintenance doses for vitamin D insufficiency/deficiency?

A

800-1000 IU daily or 50,000 monthly in those w/o deficiency
1500-2000 units daily in those with a h/o deficiency
Obese patients 3000-6000 units daily with a h/o deficiency

92
Q

Who is calcitriol reserved for?

A

Patients with late stage kidney disease or who aren’t having adequate results from D3/D2

93
Q

What form of Vit D is calcitriol?

A

Active vitamin D

94
Q

When do we use vitamin D analogs?

A

Primarily in patients with advanced kidney disease for vitamin D replacement and hyperparathyroidism

95
Q

What does the use of cod liver oil to treat vitamin D deficiency expose patients to?

A

Vitamin A that results in greater osteoporosis, hip fracture, and malignancy risk

96
Q

Why are combination Ca and Vit D products not recommended for primary supplementation of vit D?

A

Relatively low doses (of vit D)
Multiple daily doses required
Low adherence with Ca supplements

97
Q

Vitamin D should not be given at the same time as what products?

A

Binding resins
High-fiber cereals
Fiber stool softeners d/t poor absorption

98
Q

What does the USPTF say about the routine supplementation of vitamin D?

A

No longer recommends supplementation for community dwelling elders 65 or older

99
Q

According to the AGS, what vitamin D dose does not prevent falls in those 65+ yo?

A

< 600 IU

100
Q

What does the AGS recommend for vitamin D daily dose?

A

4000 IU

101
Q

Which drugs are used for prevention of osteoporosis?

A 
Alendronate
Ibandronate
Risedronate
Zoledronic acid
Conjugated estrogens
Raloxifene
102
Q

What are the preventative doses for alendronate?

A

5mg daily

35mg weekly

103
Q

What is the preventative dose for ibandronate?

A

2.5mg daily

150mg monthly

104
Q

What is the preventative dose for risedronate?

A

5mg daily

105
Q

What is the preventative dose for zoledronic acid?

A

5mg IV Q24mo

106
Q

What is the conjugated estrogens dos?

A

0.625mg daily

107
Q

What is raloxifene’s dose?

A

60mg daily

Geriatrics (15 decks)

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