GERI Flashcards
(242 cards)
1
Q
What is the approach to life expectancy in Geri pts
A
> 10 years: Appropriateness of tests and treatments is generally the same as for younger persons.
<10 years: Test choice should be made on ability to improve patients prognosis/quality of life.
Prognosis <12 months: Consider Palliative Care Services
Prognosis <6 months: Consider Hospice Care
2
Q
What is the “get up and go” test
A
It’s a functional evaluation exam
Record the time that it takes for a patient at risk to get up from a chair, walk 10 feet, and return to the chair. If this takes more than 15 seconds, they have impaired mobility and are at greater risk for a fall.
3
Q
Intrinsic risk factors for falls
A
Visual impairment Postural Hypotension Medications (Hypnotics, anxiolytics) Muscle Atrophy (Vitamin D? 800IU daily)
4
Q
Primary care screening for impaired vision
A
Near vision: Jaeger card
Far vision: Snellen eye chart
Referal: Optometrist/ Ophthalmologist
Periodic screening is reasonable (DM, glaucoma)
5
Q
What is the geriatric screening for cognition
A
Mini Cog:
- 3 item recall + clock drawing exercise: 2 minutes
Dementia unlikely if both portions normal.
Patients who fail the mini-cog should be followed up with a more in-depth mental status examination.
-Mini Mental Status Exam (MMSE): 10 minutes
-MOCA; specific: 30 minutes
6
Q
Screening for depression
A
PHQ 2 screen: 2 questions.
One positive response requires more in depth interview/screening tool. (PHQ 9)
7
Q
<35 on the mini mental exam =
A
Cognitive impairment
8
Q
NML value for a Montreal Cognitive Assessment
A
NML: >26
9
Q
What are the two questions in the PHQ-2
A
“Over the past 2 weeks, have you felt down, depressed, or hopeless?” (depressive mood)
AND
“Over the past 2 weeks, have you felt little interest or pleasure in doing things?” (anhedonia)
10
Q
Is incontinence a normal part of aging?
A
NO!
11
Q
What is the screening acronym for incontinence
A
DIAPPERS
(Delirium, Infection, Atrophic Urethritis, Pharmaceuticals, Psychological, Excessive excretion, Restricted mobility, Stool Impaction)
12
Q
What level of wt loss requires further eval
A
Unintentional weight loss >5% in one month or 10% in 6 months requires further evaluation
13
Q
Leading cause of vision impairment in the United States
A
Cataracts
14
Q
A Geri pt presents with blurred yellowed vision, with an increased sensitivity to glare
Suspect
A
Cataracts
S/s: central opacity, diminished red reflex
15
Q
What are the two types of Age related Macular Degen
A
Non-neovascular (“Dry”) 90%
- gradual blurring of central vision
- increased difficulty reading fine print, recognizing faces or seeing street signs.
- RX: dry AMD specific formulation of antioxidants and zinc in supplements
Neovascular (“Wet”)
- rapid loss of central vision
- RX: With prompt recognition and referral to a retinal specialist ophthalmologist, many patients treated with anti-VEGF (vascular endothelial growth factor) intravitreal injections will maintain or even have mildly improved vision
16
Q
What is the screening for DM retinopathy pts
A
All diabetic patients should have an annual dilated, funduscopic examination
17
Q
Do we routine screen for Glaucoma ?
A
NO!
USPSTF does not recommend routine screening, if concerned send to optometry for a tonometer
18
Q
What is the vision loss assoc w/ glaucoma
A
Periphery loss and extends inward
19
Q
Is hearing loss a NML part of aging?
A
NO!
Hearing loss is independently associated with
- incident dementia
- accelerated cognitive decline
- poorer neurocognitive functioning
- increased falls
- gait disturbance
20
Q
What ABX is associated with hearing loss
A
Aminoglycosides
Gentamicin
21
Q
Define NMLL cognitive impairment of aging
A
In Normal aging the patient typically:
- Remembers the information later
- Has intact learning
- Any deficits in memory function are subtle, relatively stable over time, and do not cause functional impairment.
22
Q
Define Mild Cognitive impairment
A
MCI is characterized by:
-subjective cognitive complaints, preferably corroborated by someone else
-evidence of objective cognitive impairment in 1 or more cognitive domains (memory, language, executive function, etc.)
intact functional status.
MCI is a disorder in which cognitive function is below normal limits for that patient’s age! and education! but is not severe enough to qualify as dementia!
23
Q
What should be ruled out in dementia w/u
A
Delirium and depression
24
Q
When should we screen pts for dementia
A
The effectiveness of screening asymptomatic patients for dementia is controversial.
However, for patients with a high risk of dementia
(e.g., patients age 80 years and older)
or for those who report memory impairment, screening with a standardized and validated tool is recommended.
Like the Mini mental status exam
25
What is the rate of decline for Alzheimer’s on the MMSE
3 points of decline per year
26
What is the rate of decline for moderate cognitive impairment on the MMSE
Decline of 1 point per year
27
Which is more sensitive for detecting Cognitive impairment
The MMSE or the MoCA (Montreal)
Montreal
28
Specific labs to R/o causes of dementia
Specific (high index of suspicion):
- Vit B12
- TSH
- Calcium levels
- ETOH
- evaluation of CSF
- Drug levels
- toxicology screen
- RPR (latent syphilis)
- HIV.
```
Imaging:
MRI or CT to rule out treatable causes of dementia:
-subdural hematoma
- normal pressure hydrocephalus, -tumor
-vascular dementia
```
29
What is the key finding that should alert the provider to possible underlying depression in the dementia pt
Patient’s memory complaints that are disproportional to objective deficits should alert a provider to the possibility of depression
30
What is the classic triad of Alzheimer’s
Memory impairment: manifested by difficulty learning and recalling information
(especially new information)
Visuospatial disorientation; getting lost
Progressive language impairment
31
Do Alzheimer’s pt have insight to their deficits?
No
32
What are the features of Lewy Body dementia
Parkinsonism (Bradykinesia)
Fluctuant Cognitive Impairment
Hallucinations
(but are aware of them)
REM sleep disorder
(Thrashing, punching, kicking)
Syncope and falls are common
33
What defines vascular dementia
SUDDEN ONSET of dementia!
Hx of or evidence of cerebrovascular dz (Series of strokes)
Stepwise decline
34
What is PICKS dz
Young pt dementia
(Younger than 50) !
Changes in personality and behaviors
Changes in food preference
Early loss of social awareness
Compulsive and repetitive behaviors
OFTEN MISSDX AS PSYCH D/o
+Progressive aphasia and semantic dementia
35
What is the mainstay tx for AD
Cholinesterase Inhibitors (ChEIs)
- Donepezil
- rivastigmine
- galantamine
36
What are the ADE Of Cholinesterase Inhibitors
Side effects: GI distress
(nausea, vomiting, diarrhea), syncope, bradycardia
Slow titration (8-12 weeks) to prevent.
37
How do you know Cholinesterase Inhibitors are working
Stable or improved MMSE or MOCA scores over 6–12 months suggests the drug may be effective
->Continued indefinitely
38
What is the role of memantine
NMDA antagonist
FDA approved for Mod/Severe Alzheimer's Disease.
Typically added to ChEI when dementia reaches moderate severity.
Side effects: Headache
39
What are the tx for Vascualr dementia
No specific drug therapies
Treat risk factors of stroke:
HLD, smoking, DM, Atrial Fibrillation.
HTN treatment is somewhat controversial
->Permissive HTN ( SBP 150s) may be better for cognitive function!
ChEIs and memantine may be of benefit in VaD
40
What Rx have the best evidence of effectiveness for treating dementia
Antipsychotics
(Olanzapine/risperidone).
->Best evidence of effectiveness.
BLACK BOX WARNING (increased risk of mortality and cerebrovascular events and tardive dyskinesia in patients with dementia).
->Risk vs Benefit discussion.
41
What SSRI can be used to tx dementia
Citalopram
42
When counseling a pt with dementia
What medications should you advise the pt to avoid
Gingko Biloba
NSAIDS
Estrogens
Vitamin E
43
What does SIGECAPS stand for
Helps DDX MDD
1. must be present x 2 weeks
```
S-sleep
I-interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P-Phsycomotor
S-SI/HI
```
44
Tx for MDD in Geri Pts
SSRI, SNRI, TCAs, or Mirtazapine
45
Side effects of SSRI: Citalopram
QT prolongation/torsade de pointes (max dose 20mg).
46
ADE of SSRI: Fluoxetine
LONG half life, inhibition of P-450 System.
47
What class of Rx is venlafaxine, and duloxetine
SNRI
48
What Rx class are amitryptyline and imipramine and Doxepin
TCAs
49
What is the role of mirtazapine
Stimulant of appetite in a depressed pt
ADE: Insomina
50
What is the approach of Depression Rx for Geri pts specifically
Start at ½ normal dose and titrate up to reduce side effects
Older patients frequently undertreated
(provider fails to titrate).
Can at times take 8-12 weeks to see full effect.
If side effects tolerable and no benefit: Titrate.
At therapeutic w/o response: switch or “AUGMENT” with additional agent.
51
ADE of SSRIs in Geri pts
May increased BP
Increased risk of falls (on Beers list)
May increase bleeding risk with anticoagulants
Hyponatremia
```
Beware Serotonin syndrome includes AMS (HA, confusion, agitation)
Autonomic hyperactivity (diaphoresis, HTN, tachycardia, nausea, diarrhea)
```
neuromuscular abnormalities (tremor, myoclonus, hyperreflexia)
52
What are the ADE of TCAs in Geri
(lethal in overdose)
Orthostatic hypotension, arrhythmias
Cognitive impairment (anticholinergic effect)
53
What is the approach to Dc MDD rx
Continue regimen 6 months if S/s resolve
High risk of relapse: 1-2 years vs indefinitely
D/C? – taper down over 3 month period.
54
When should MDD Geri pts be referred
Concomitant Mania/psychosis
No response to 2 medicines
SI risk factors
->hx of SI, drug/alcohol abuse, severe anxiety/stress, SI plan, access to firearms/lethal means
(stockpiled medications).
55
What are the essential tools to use to evaluate Rx excretion in GEri pts
ESSENTIAL to make GFR-related dosage adjustments
| Use MDRD or CKD-EPI and not Cockcroft-Gault
56
Rsk factors for increased ADE in Geri pts (RX)
Risk factors for ADRs include:
- Increasing age
- Gender (women)
- Small body size
- Duration of therapy
- Poor compliance with therapy
- Underlying disease states
57
Beers list
1st gen antihistamines
Digoxin >0.125 mg/day
TCAs (amitryptyline)
Antipsychotics (unless pt is a risk to others)
Benzos
Zolpidem and Eszopiclone
(Similar to Benzos)
Testosterone (men)
Glyburide, and chlopropamide
(DM drugs)
Meperidine (neurotoxicity)
Non selective NSAIDS
Skeletal Muscle Relaxants
58
What is the STOPP criteria
Screening Tool of Older Persons' Prescriptions
59
What is the stopp criteria for Loop Diuretics
Stop:
Leg elevations and stockings more appropriate
60
STOPP criteria for diltiazem or verapamil
MAy worsen HF
61
STOPP criteria for Aspirin for Afib
No benifits
62
STOP criteria for Acetylcholinesterase inhibitors (eg donepezil) with history of persistent bradycardia, heart block, recurrent unexplained syncope, or concurrent treatment with drugs that reduce heart rate
Risk of cardiac conduction failure, syncope, injury
63
STOP criteria for SSRIs with HypoNA+
Risk of exacerbating or precipitating hyponatremia
64
STOP criteria for Drugs likely to cause constipation (e.g., antimuscarinic/anticholinergic drugs, oral iron, opioids, verapamil, aluminum antacids) in patients with chronic constipation where nonconstipating alternatives are available
65
STOP criteria for Bladder antimuscarinic drugs with dementia or cognitive impairment
Risk of increased confusion, agitation
66
When to use anticoagulants in Geri
Anticoagulants in the presence of chronic atrial fibrillation
(Not aspirin)
67
When to use antiplatlet tx in Geri
Antiplatelet therapy with a documented history of coronary, cerebral, or peripheral vascular disease
68
When to use ACEI in Geri
Angiotensin-converting enzyme (ACE) inhibitor in heart failure with reduced ejection fraction and/or documented coronary artery disease
69
When to use B2 agonists in Geri
Regular inhaled β2-agonist or antimuscarinic bronchodilator for mild to moderate asthma or chronic obstructive pulmonary disease
70
When to use L-Dopa in Geri
L-DOPA (levodopa) or dopamine agonist in idiopathic Parkinson disease with functional impairment and resultant disability
71
When to use Antidepressants in Geri
Antidepressant (other than tricyclic antidepressant) in the presence of persistent major depressive symptoms
72
When to use PPI in Geri
Proton pump inhibitor with severe gastroesophageal reflux disease or peptic stricture requiring dilatation
73
When to use Bisphosphonates in Geri
Bisphosphonates, vitamin D, and calcium in patients taking long-term systemic corticosteroid therapy
74
What is the recommendation for AAA screening
USPSTF recommends that men between the ages of 65 and 75 with any current or past history of smoking undergo a one time screening for AAA with an abdominal ultrasound.
75
Recommended screening for falls
Annually
76
Recommended screen for depression
Annually
77
Recommended screen for nutrition
Wt at each visit
78
Recommended screening for vision
Initial the q2yrs
79
Recommended IMRs in the Geri population
Influenza yearly
Pneumococcal one after age 65
Tetanus booster every q10yrs
Herpes zoster: two shots after age 50
80
Recommended screening for DM
Initially if hypertension, hyperlipidemia, or obese, and then every 3 years
81
Recommended screening for osteoporosis
Initially women >65 years, consider men >70 years
82
Recommended screening for HLD
Initial than q5yrs
83
Recommended screening for HTN
Initial then pts driven
84
recommended screening for Aortic Aneurysm
Once in men age 65–75 years who ever smoked
85
recommended screening breast cancer
Mammo q2yrs
86
Recommended screening for colorectal cancer
Fecal immunochemical test (FIT) annually or colonoscopy q 10 years
87
Recommended screening for cervical cancer up to what age
65
88
Recommended screening for lung cancer
Annually (age 50–80 with 20-pack-year smoking or quit in past 15 years)
89
What are the 2 phases of Cerebrovascular Dz
1. Acute triage: Noncontrast brain CT, MRI, EKG, cardiac markers, CBC, CMP, INR
Uncertainty: Lumbar puncture, ABG, toxicology screen, blood alcohol.
2. Investigations into etiology after stroke is established as the diagnosis
90
What is a lacunae stroke
Ischemic stroke from small vessel occlusion
91
Exclusion criteria for TPA for INR and aPTT
Great than 1.7 INR and greater than 15 seconds aPTT
92
Should BP be dropped rapidly in ischemia stroke
Avoid rapid reduction in acute ischemic stroke (helps maintain perfusion to ischemic brain tissue).
93
What is the MGMT for Acute ischemic stroke
IV tPA
->3 hours of symptom onset.
Can be extended up to 4.5hr (patients <80 y/o). BP <185/110
Intra-arterial thrombolysis or mechanical thrombectomy.
->Carefully selected patients.
94
What is the 1st Line anti platelet tx in non-cardioemboic stroke
Aspirin
Clopidogrel
Aspirin and dipyridamole
95
What is the threshold for a Carotid endarectomy
Carotid Stenosis- Carotid Endartectomy (CEA) effective when >70-90% stenotic
may benefit if >50% but balance with risks
96
What is the time frame of tiA
brief episode of neurologic dysfunction caused by focal brain, spinal or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction.
97
What is the MGMT for coronary Dz
Anti-platelet
Statin
B blocker
ACE/ARB: HFrEF
98
A Geri pt presetns with Exertional dyspnea, fatigue, orthopnea, lower extremity swelling.
Think
HF
99
What is the tx for HFrEF
```
HFrEF: <40%.
->Beta blocker and Neprilsyn inhibitor (Sacubitril-valsartan- first line)
or
ACE/ARB, mineralocorticoid antagonist
(Spirinolactone/Eperenone) for EF <35%.
```
Cardiac resynchronization: EF <35%. Biventricular pacing.
100
What is the tx for HFpEF
Aggressive management of HTN
NA restriction
Loop diuretics
101
What is the sodium and fluid restriction for HF pts
Sodium limit: 2g daily.
Fluid limit: 1-1.5L daily.
Daily weights.
102
What are the comments of a CHAD2VASc score
CHA2DS2VASc >2:
| (CHF, HTN, Age>75 (2), DM, Stroke, Vasc dz, 65-74)
103
What is the Tx for Tachyarythmmias in Geri
1) Anticoagulation.
2) Rate vs Rhythm Control.
(BB) -> Cardioversion, Radiofrequency ablation, Watchman.
104
What does the HASBLED score predict
score estimates risk of bleeding, history of falls does not increase score
105
Stage I HTN
Stage 1 HTN : Systolic between 130-139 or diastolic between 80-89
106
Four common conditions in older patients complicate diagnosis/management HTN
“White coat hypertension”, orthostatic hypotension, post prandial hypotension, pseudohypertension.
107
most common indication for major cardiac surgery in older adults after coronary bypass surgery
Aortic Stenosis
108
How do you DDX PAD vs spinal stenosis
PAD: Leg discomfort with ambulation, rest pain, non-healing ulcers, gangrene
(distinguish from spinal stenosis- worse with standing/walking, better sitting/knees to chest)
109
What is the Rx for PAD/VTE
Cilostazol
General: Good skin/foot care. Podiatry (DM). Daily foot inspection. PT
Reduction of CVD: Anti-platelet, high intensity statin. HTN mgmt., DM mgmt., tobacco cessation.
110
What is the MGMT for VTE
Massive PE- Thrombolysis
DOAC or Heparin/VKA compression stockings
Treatment length estimate is for minimum of 3 months if a discrete cause, 6-12 months if no cause.
111
A geri pt with an unprovoked VTE
Think
CANCER
112
What does HASBLED score stand for
HTN
Abdominal Liver or Kidney Dysfunction
Stroke
Bleeding
Labile INRs
Elderly >65
Drugs or Alcohol
Score greater than 2 consider risk
113
What is the only approved anti Xa inhibitor approved in older pts with renal failure
only enoxaparin has approved dose reduction in older patients with renal impairment
114
What is the tx for chronic Venus insufficiency
Treatment:
Conservative: weight loss, Skin/ulcer care, foot/nail care, leg elevation, compression stockings, PT, diuretics, Laser ablation.
115
Ulcers from chronic venous insufficiency appear where
Severe disease presents with ulceration typically located above the medial malleolus.
116
Ulcers from arterial insufficiency appear where
Over the toes, foot and heals
117
Which is painful
Venous or arterial insufficiency
Arterial
118
MGMT for acute COPD exacerbation
1. Beta agonist (albuterol)
2. Anticholinergic (Ipatropium)
3. Prednisone
4. NIPPV
5. ABX
119
Dx for chronic bronchitis
Chronic bronchitis: Cough and sputum for at least 3 months during 2 consecutive years
120
Tx for Chronic COPD
: SABA prn (albuterol)
(mild symptoms, up to 2 puffs bid).
LABA/Inhaled corticosteroids, (formoterol/ Budesonide )
Anticholinergics ( Ipatropium)
Pulmonary Rehab.
Oxygen: for patients with resting SpO2 <88% Room air
121
Late onset asthma is assoc with
Obesity and Tobacco
122
What is the recommendation from the CDC for Geri pts with asthma
The CDC recommends patients 65 years of age or older receive both pneumococcal conjugate vaccine-13 and pneumococcal polysaccharide vaccine-23 to decrease risk of pneumonia.
123
A geri pt presents with Velcro-like/”rice crispy”-like rales; lymphadenopathy, hepatosplenomegaly, uveitis, and skin rashes in sarcoidosis; right heart failure with lower extremity edema.
Think
ILD
124
Honeycombing on CT
Think
ILD
125
Pulm HTN groups
Group 1: Pulm arterial HTN
Group 2: HTN 2/2 Left HDz
Group 3: HTN 2/2 Lung Dz
Group 4: HTN 2/2 embolism
Group 5: Mulitfactorial
126
How do you Dx Pulm HTN
echocardiogram: estimated systolic pulmonary arterial pressure of 35 to 40 mm Hg (usually higher in older adults) is suggestive of pulmonary hypertension
right cardiac catheterization if suspicious for pulmonary arterial hypertension.
127
What are sisters Mary Joseph’s nodes
PERIumbilical lymphadenopathy seen in pancreatic cancer
128
What are typically the only S/s of appendicitis in geri pts
In some cases, a low grade fever and general abdominal pain are the ONLY symptoms
129
A geri pt presents with absent bowel sounds, tenderness and rigid dirty
Think
Peritonitis
Hypotension and cardiovascular collapse will occur if untreated or the cause is not identified and treated rapidly
130
How does cholecystisis present in geri pts
Abdominal tenderness and peritoneal inflammation is absent in > 50% of patients
Normothermia and a normal WBC count are found in a significant number of elderly patients
Gangrene and perforation are commonly discovered at surgery
131
What are the alarm features of dysphasia in geri pts
Alarm features such as unintentional weight loss, anemia, and odynophagia should be solicited and warrant endoscopy for evaluation.
132
MGMT for dysphagia
Behavior modification (eating/swallowing)
Balloon dilatation
Medications
-> PPI, H2
133
How does PUD present in Geri Pts
Perforation is more common in geriatric population and less likely to have significant pain and/or abdominal rigidity
Chronic PUD can present with symptoms of gastric outlet obstruction (early satiety, nausea, vomiting), anemia and possible melena
134
Acute vs chronic diarrhea
Acute diarrhea is defined as symptom duration for ≤4 weeks, whereas chronic diarrhea occurs when persistent for >4 weeks
135
A pt presents with painless hematochezia
What is the next step
(may require inpatient management in elderly)
136
Should we use docusate for constipation
NO (lol)
| Use methylcellulose
137
MGMT for Constipation
BIG 3: FLUID – FIBER - FITNESS
Take advantage of “morning gastrocolic reflex”
138
Grade A recommendation for Constipation
Psyllium (Metamucil) & Methyl cellulose (Citrucel)
139
What is the threshold for dis impaction in Geri pts
Pain, bloating, 5 or more days without a BM, or no longer eating
140
What is the age to begin colorectal screening
NLT than 50
141
When can colorectal screening be stopped
Guidelines recommend that patients may stop screening at age 75 or when life expectancy is <10 years if:
->up to date with screening & negative prior screening tests
142
What is the acute vs chronic tx for hypoNA+
Acute (< 48 hrs) – 3% hypertonic saline
Chronic (> 48 hrs or unknown) – -slow correction
->Prevent Osmotic Demyelination Syndrome
(formerly Central Pontine Myelinolysis)
->Water restriction, demococycline
143
Acute vs Chronic Tx for HYPO NA+
Acute (< 48 hrs) – 3% hypertonic saline
Chronic (> 48 hrs or unknown) – ->slow correction
- >Prevent Osmotic Demyelination Syndrome (formerly Central Pontine Myelinolysis)
- >Water restriction, demococycline
144
What is the acute vs chronic tx for Hyper Na+
Acute (< 48 hrs) – hypotonic solutions (0.5% saline)
Chronic (> 48 hrs or unknown) – slow correction
145
Dx for CKD in Geri
Abnormal urinalysis
(proteinuria, hematuria)
or
Structural abnormality
(by ultrasound)
or
GFR < 60 mL/min
For ≥ 3 months
146
Mod-Severe CKD
Gfr30-59 : Moderate
GFR 15-29: Severe
<15 super severe
147
HTN goal in pts with CKD
Less than 130/80
ACEI/ARBS are first line in pts with Protineuria to a goal of <0.2 Ratio
148
LDL goal in Geri pts
Less than 100 mg/dl
149
MGMT of CKD in GEri Pts
ACE/ARB to slow progression of proteinuria and CVD
Potentiates hyperkalemia
repeat serum creatinine & potassium in one week
Consider a statin
Diuretics to avoid fluid overload
150
What is the Threshold to treat Subclincal Hypothyroidism
Subclinical hypothyroidism: TSH 5-10, normal T4
RX: If symptomatic, or TSH >10
151
What is the tx to sub clinical hyperthyroidism
Medication induced?
-> Decrease Levothyroxine.
RX: Iodine-131 ablation
152
What is the MGMT for symptomatic hypothyroidsm
```
Primary: High TSH, low t4
->Rx: “low and slow”
Start at 12.5 (cardiac hx)- 25 mcg,
f/u q4-6wks.
End: Euthyroid w/o SE
```
Secondary: Low TSH, low t4
(brain tumor?)
->Myxedema Coma- alteration of cognition, lethargy, seizures, psychosis, confusion
Refer to SRGRY
153
What is the tx for hyper calcemia
| Stones, bones, groans, overtones
NS
Bisphosphonates
Steroids
Calcitonin
Parathyroidectomy
Dialysis
154
Primary Hyperparathyroidism
common disorder in post menopausal women
->50% no
or minimal symptoms- incidental hypercalcemia found on routine labs
usually from an adenoma- tx surgery
Stones, bones, groans, and moans/ psychiatric overtones
155
Secondary Hyperparathyroidism
Due to hypocalcemia from renal failure, vit D insufficiency, malabsorption, bisphosphonates/lasix
156
Typical cause of Cushing Syndrome in Geri’s
usually iatrogenic
->Iatrogenic, ACTH neoplasm (small cell lung/carcinoid)
Cushing disease less common
Establish hypercortisolemia
157
W/u for finding an incidentaloma
Should be evaluated for excess cortisol, aldosterone, and catecholamine production
158
MUDPILES
Methanol
Uremia
Diabetic Ketoacidosis
Paraldehyde
Iron, Isonazid
Lactic Acidosis
Ethylene Glycol
Salicylates
159
Dx for DM
Hemoglobin A1c ≥6.5
or
Fasting (no caloric intake for ≥8 hours) ->plasma glucose ≥126 mg/dL (7.0 mmol/L),
or
Symptoms of hyperglycemia plus random plasma glucose ≥200 mg/dL (11.1 mmol/L),
or
2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test .
160
Treatment goal for DM Geri pts
RX: Patient guided. <7 for younger and healthy.
| Short life expectancy <8-9
161
What are the Thresholds for anemia
<13g/dL in men; <12g/dL in women
162
Work up for central lung cancer
Sputum Cytology
| Bronch Biopsy
163
W/u for peripheral lung cancer
CT guided transthoracic biopsy
164
Recommendations for screening lung cancer
annual screening for lung cancer with low-dose CT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years
165
Screening for Breast cancer
Biennial screening mammo for age 50-74
166
Screening for colorectal cancer
q10 yr C-scope up to 75 (q5 for high risk)
167
Tx duration of prostatitis
4-6 weeks
Use TMPX/SMX or Fluoroquinolones
168
MGMT for UTIs
1st Line: TMP/SMX, nitrofurantoin
2nd Line (allergy/resistance): ->Fluoroquinolones
Duration: Female: 3-5 days; 10-14 days male or female with severe symptoms-> (pyelonephritis).
169
What is the criteria to Dx UTI in a pt with a urinary catheter
Fever >100 or an increase in 1.5*F over baseline
New CVA tenderness
Rigors
New onset of delirium
170
What is the criteria for Dx of UTI without a catheter
Acute dysuria
Fever >100*
+ Urgerncy, Frequency, supapubic pain, gross hematuria, CVA tenderness, Urinary incontinence
171
Threshold for transudative effusion
Pleural: serum protien <0.5
Plearal:seurm LDH <0.6
172
Prevention of RTI in Geri pts
Yearly influenza vaccine. Pneumococcal vaccine. COVID
173
Tx for influenza
Oseltamivir (Tamiflu)
| 72hrs or if Severe
174
MGMT for PNA
CAP: Macrolide (azithromycin) or doxycycline.
Comorbidities (chronic lung or renal disease, DM):
->Respiratory quinolone or beta-lactam plus macrolide.
Hospital Acquired and skilled nursing acquired:
->IV abx (Vanc, Pip-tazo, etc).
CURB 65 or Pneumonia Severity Index for disposition/mortality estimation
175
MGMT for PNA pt with renal dz
Respiratory quinolone or beta-lactam plus macrolide.
| Floxacin+Azithromycin
176
What is the most common health care assoc diarrhea
C. difficile - most common health-care associated diarrhea
Volume repletion and stop inciting antibiotics
Rx: Oral Vancomycin or Fidaxomicin
->Avoid metronidazole in frail or >65 years
Hand hygiene key in prevention
177
What are the ABX for Staph and Strep MSSA and MRSA
Strep/MSSA: 1st generation cephalosporin, dicloxacillin
Staph: MRSA?; Clindamycin; Doxycycline, TMP-SMX
178
Rash q with target like lesions
Erythema multiforme
179
A new mole in a Geri pt
Benign Nevi uncommon: New mole should be suspicious for malignancy
180
Tx for SKs
Remember stuck on papules
Rx: Cryotherapy or curettage
181
MGMT for stasis dermatitis
DDx: Pigmented purpuric dermatosis, contact dermatitis
RX: Leg elevation, compression stockings.
Class 5 steroids BID for plaques. ->Diuretics for edema
182
Tx for Zoster and post herpetic neuralgia
Zoster Rx: Anti-viral.
(acyclovir, valacyclovir), within 48 -72hrs of rash onset.
Dermatome heals in 3-4 weeks.
Post Herpetic Neuralgia.
Rx: Gabapentin, Tylenol, topical lidocaine
183
Tx for Scabies
Permethrin 5% cream
Or oral ivermectin 0.2mg/kg
->Class 1 steroid bid for pruritus, 3-4 weeks.
All clothes worn within 2 days of treatment, towels, and bedsheets should be machine washed in hot water or dry cleaned
184
Geri pt with sandpaper texture skin
What is the Dx and Tx
AKs
```
Tx: Cryotherapy, or ‘field’ treatment with imiquimod (Aldara)
or fluorouracil (Effudex)
```
185
MGMT for BCC and SCC
Excision
186
ABCDE for Malignant melanoma
asymmetry, border irregularity, color variegation, diameter >6 mm and an evolving lesion
187
Screen for sleep D/o
Polysomnography.
AHI >30 per hour denotes severe OSA,
16–30 per hour that of moderate OSA,
5–15 per hour for mild OSA
188
What should be ruled out in pts with periodic leg movement D/o in sleep
Iron deficiency anemia
189
DDx for lower urinary tract symptoms
Prostatitis
malignancy
bladder stone
medication side effect (anticholinergic/urinary retention) UTI
190
Obstrucive Urinary S/s
Hesitancy*
Decreased force and caliber of stream*
Sensation of incomplete bladder emptying
Double voiding
Straining to urinate
Post-void dribbling
191
S/s of irritative urinary tract d/o
Frequency*
Urgency*
Nocturia*
Dysuria
192
MGMT for BPH
```
Alpha blockers
(prazosin/doxazosin/terazosin)
```
Alpha-1a blockers
(tamsulosin/alfuzosin)
5-alpha reductase
(finasteride)
->Reduces PSA by 1/2
Surgery: Transurethral resection of the prostate (TURP), Transurethral incision of the prostate (TUIP )
193
What is the NSAID of choice for pain in Geri pts
Diclofenac Gel
194
MGMT to Gout
Acute: Colchicine, NSAIDs, Steroids.
Chronic: Allopurinol/febuxostat (xanthine oxidate inhibitors), probenecid (uricosuric).
195
MGMT for CPPD/ Pseduo Gout
Rx: NSAIDs, colchicine, steroids.
196
MGMT for Polymyalgia Rheumatica
RX: Steroids.
197
Dx for Polymyalgia Rheumatica
One month of bilateral aching shoulders/proximal arms/hips.
Worse in AM, up to 1hr.
Neg RF/joint erosions.
Elevated ESR/CRP
198
MGMT for RA
NSAIDs, DMARDs, steroids
199
Red flags for Osteoporosis Fx
Hx
Use of steroids
Older age 75
Recent trauma
200
Acute, subacute and chronic back pain
acute (lasts less than 4 weeks)
subacute
(lasts between 4 and 12 weeks)
chronic (lasts longer than 3 months).
201
S/s of Lumbar spinal stenosis
Lumbar spinal stenosis- radiates to legs, worse with standing/walking
202
ASAP referral criteria for Lower Back Pain
Indications for ASAP referral to a surgeon include cauda equina syndrome, suspected cord compression, and progressive or severe neurologic deficits.
203
Tx for Giant Cell
Get a ESR or CRP
Then treat with Prednisone
204
A pt presents with falls
What is the red flags for syncope
history of loss of consciousness with the fall
unexplained non-accidental fall
recurrent falls despite adherence to a multi-factorial targeted treatment program
205
MC sites for pressure ulcers
```
Iliac crests
Sacrum
Greater trochanters
Ischial tuberosity
Lateral malleoli
```
206
Optimal order for pressure ulcer prevention
q2 turns
Bedridden patients should have there head positioned no more than 30 degrees or maintained at the lowest level needed to prevent complications to prevent shearing of the skin.
207
Stage 1 ulcer
non-blanching erythema of intact skin
Warmth, edema, and induration are also indicators, particularly on persons with dark skin
208
Stage 2 ulcer
partial thickness involving the epidermis and dermis, superficial
Appears as a blister or abrasion
209
Stage 3 ulcer
full thickness, deep crater involving necrosis of subcutaneous tissue that may extend to the underlying fascia
210
Stage 4 ulcer
tissue necrosis and destruction that includes damage to bone, muscle, and/or supporting structures with or without full thickness skin loss
211
Documentation for Ulcers
```
Size
Location
Eschar and granulation tissue
Exudate
Odor
Sinus Tracts
Signs of infection
```
Undermining: Separation of skin/mucosa from the stroma, it can stretched over the defect of wound
Staging (I-IV)
212
Tx for stage 1-2 ulcers
Only clean with normal saline.
Apply a protective, transparent dressing
Avoid “skin cleaners” or antiseptics (destroys granulation tissue).
Remove necrotic tissue
->Ulcers with stable, dry eschar do not need debridement, if there are no signs of infection.
213
MGMT for Stage 3-4 ulcers
Prolonged and expensive treatment by irrigation, debridement of necrotic tissue, healing by secondary intention, appropriate dressings, or surgical closure
Perform mechanical, enzymatic, autolytic debridement
Maintain appropriate wound moisture and remove excessive external moisture
Wound care nursing
214
What is the Tx for cellulitis, osteomyelitis, bacteremia, or sepsis 2/2 to ulcers
Topical antibiotic should be considered if no healing is achieved after 14 days of conservative interventions (Silver Sulfadiazine)
May need surgical debridement, as appropriate
Systemic antibiotic are used with advanced cellulitis, osteomyelitis or systemic infection.
Pending culture, antibiotic should cover MRSA, anaerobes, enterococci and gram negative bacteria
215
Causes of Urge incontinence
Detrusor over activity
Idiopathic or associated with neurologic disorders
(e.g., stroke, multiple sclerosis, Parkinson disease)
bladder irritants
stones
infection or tumors.
216
Causes of stress incontinence
Failure of the urethral sphincter mechanisms, insufficient pelvic support in women, or prostate surgery in men.
217
MGMT for urge incontinence
Anticholinergics
218
MGMT for stress incontinence
Topical estrogen
219
MGMT for overflow incontinence
Alpha Adrenergic blockers
220
MGMT for atonic bladder 2/2 stroke or severe DM neuropathy
intermittent catheter
221
DIAPPERS
Delerium
Infection
A trophic Vaginitis
Pharm
Psych
Excess UOP
Restricted mobility
Stool impaction
222
What should be R/o in Urinary Incontinence
r/o CHF, neuro/mental status, prostate/penis, pelvic, perineum
Do cough stress test
Post Void residual
223
What are the PCM recommendations for incontinence
Kegel (pelvic floor strengthening) exercises
Reducing caffeinated beverages
Reducing total fluid intake
Weight loss
Compression stockings instead of diuretics
Consider PT/increase mobility training
224
Rx for Urge incontinence
Estrogen
Oxybutynin
Mirabegron
225
Rx for overflow incontinence
alpha blockers (Doxazosin)
5-a reductase inhibitors (finasteride)
catheter, surgery
226
MGMT for osteoporosis
Nonpharmacologic
-> Weight loss, exercise, PT, heat and cold
Pharmacologic
-> Acetaminophen: Initial
NSAIDs: Prescribed if inadequate response to acetaminophen
Oral NSAIDSs: ADVERSE EFFECTS! Consider topical NSAIDs first
227
Type I and Type II oestoporosis
Type I: post menopausal
Type II: advanced age, lack of zinc or calcium
228
W/u for osteoporosis
```
CBC
CMP (inc LFT)
Phosphate
PTH
25-hydroxy vitamin D
Consider 24 hr urine Ca
```
229
Test for multiple myeloma (2nd cause of osteoporosis)
Serum and Urine protine electrophoresis and free light chains
230
What is the Screening for Osteoporosis
Per USPSTF:
DEXA for females 65 > y/o
Results interpretation:
Normal: BMD within one SD of young adult (T score greater than -1.0)
Osteopenia: BMD within 1 and 2.5 SD below a young normal adult (T score -1 to -2.5)
Osteoporosis: T score less than -2.5.
231
MGMT for osteoporosis
Bisphosphonates (dronates)
HRT
Raloxifene
(Increased risk of VTE, hot flashes, cramps)
Calcitonin
Denosumab
Teripoaratide
Romosozumab
232
What is the CAM w/u for delerium
Acute onset + Inattention
Or
Disorganized thinking + AMS
233
Specific test to w/u delerium
```
Thyroid Function Tests
Vit B12
Drug levels
toxicology screen
ABG
blood cultures
cortisol levels
evaluation of CSF
UA/Urine Culture
```
234
MGMT for delerium
Non-pharmacologic
->Sleep Protocol ; Sleep wake cycle
Avoid sedatives; Avoid restraints
Volume repletion
Frequent re-orientation
Taper and/or discontinue unnecessary Medications
->Beers Criteria (TCAs, anticholinergics, etc.)
Pharmacologic
->Last resort
Haldol, Olanzapine, Quetiapine, Risperidone, Benzodiazepines.
235
4 criteria for Parkinson’s dz
1. Resting tremor
2. Bradykinesia
3. Muscular rigidity
4. Postural instability
236
dopaminergic cell loss of substantia nigra
Parkinson’s
237
Red flags for 2ndary Parkinson’s
Think of secondary causes when certain red flags are seen
- >symmetric presentation
- >lack of tremor
- >and/or atypical features that are rarely seen early in PD
Lack of response to higher doses of dopaminergic medications should alert clinician to likelihood of secondary PD
238
2 MC causes of 2nd Parkinson’s
Vascular: From chronic ischemic damage/multiple infarcts
Drug induced: Anti-emetics and antipsychotics (dopamine receptor blocking agents)
239
Are anti HTN needed in pts with Parkinson’s Dz
Reduce medications as possible (antihypertensives no longer needed as PD progresses),
240
How do we treat Depression in Parkinson’s
SSRIs 1st line. Followed by SNRIs
241
MGMT for Parkinson’s
Levodopa is the drug of choice in patients >70 years
```
dopamine agonists
(pramipexole and ropinirole), amantadine, and anticholinergics are poorly tolerated in this age group
```
Dopamine agonists: Pramipexole, ropinirole (1st line if age<70)
242
MGMT for essential tremor
Beta blockers
