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Flashcards in Geriatric Deck (105):
1

decreased cutaneous vasoconstriction/sweat production

impaired response to heat

 

2

delayed recovery of dehydration

declining thirst

 

3

Impaired response to shock

physiologic drop in CO, LV filling and max HR

 

4

Primary aging not induced by diease but may be affected by:

periods of stress, exposure to fluctuating temperatures, dehydration or shock

5

Optimal aging

Occurs when people don't have debilitating disease and starts in late 80's-90's.

6

VS: BP

Ao stiffens d/t atherosclerosis, less distensible, SV causes greater rise in BP, esp SBP. Systolic HTN with widened pulse pressure. DBP stops rising in 60th decade.

Other extreme is postural hypotension(orthostatic)- drop in BP upon standing

7

VS: HR & Rhythm

resting HR unchanged. Pacemake cells decline in SA node, as does mas HR, affecting response to physiologic stress. Elderly more likely to have abn heart rhythms such as atrial/vent ectopy. Asymptomatic rhythm changes usually benign. May cause syncope or temp LOC.

8

VS: RR and Temp

RR unchanged. Changes in temp regulation lead to suseptibily to hypothermia.

9

Skin & Nails

skin wrinkles, lax, loses turgor. Vasc of dermis decreases, skin paler and more opaque. Nails lose luster, may yellow and thicken- esp toes.

10

Actinic purpura

purple patches/macules that fade over time. Come from blood leaked through poorly supported capillaries and spread through dermis.

11

Hair

scalp loses pigment. Hair grays. Men's hairline recede- as early as 20's. Women less sever hair loss. Generalized loss of scalp hair, diameter of each hair smalled. Hair loss on rest of body. As women reach 55, coarse facial hair appears on chin and upper lip, but doesn't increase further. Mostly applies to light skinned caucasian

12

Head and Neck: Eyes

Eyes, ears and mouth bear the brunt of old age.

Eyes: fat around eyes atrophy- eyeballs may recede, skin of eyelid may wrinkle- haging loose fold, fewer lacrimal secretion- dry eyes, fat may pusj fascia of eyelids forward- soft bulges, cornea lose luster. Pupils smlaller- harder to see fundus, pupils may be irregular- still repsond to light.

Visual acuity fairly constant. Lens loses elasticity- presbyopia in 5th decade. Increased risk of cateracts, glaucoma, mad degen.Thickened yellow lens impairslight passage- need more light to read.

Color vision diminishes, light adaption slows. Visual fields- by 7-8th decade lose 20-30% peripheral vision.

13

Head & Neck: Ears

Ears: hearing loss, may start in young adulthood, starts with high pitched sounds. Loss extends to middle and lower ranges. Distorts hearing.

 

14

Presbycusis

Normal aging hearing loss

15

Narrow angle glaucoma

lens grows, pushes iris forward, narrowing angle between iris and cornea- increasing risk

 

16

Head & Neck: Mouth

Mouth: dim salivary secretions, decreased sense of taste. Maybe affected by meds or diseases. Decreased olfaction, increased sensitivity to bitter/salt affect taste. Teeth wear down, abraded, lost to caries or other conditions over time.

Dental health reflects bone health. Affects ability to digest some complex nutrients. Blunted taste decreases sense of smell by 50%

17

Periodontal disease

Chief cause of tooth loss. If no teeth, lower face looks small and sunken, purstring wrinkles. Bony ridges of jaws become reabsorbed, esp lower jaw. Frequency of palpable cervical nodes diminish, but submandibular easier to feel.

18

Angular Cheilitis

Overclosure of mouth leads to maceration of skin at corners

19

Thorax & Lungs

Decreased exercise capacity. Chest wall stiffer, harder to move, resp muscles weaker, lose elastic recoil, lung mass declines, residual volume increases. Speed of breathing out with max effort gradually diminishes, cough less effective(dec mucociliary clearance). Skeletal- accentuated dorsal curvature ot thoracic spine= kyphosis- OP vertebral collapse and inc AP diameter of chest. Barrel chest- little effect on function. # Alveoli decrease. Muscle weaker- dec VC, FVC, FEV. Dec resting pO2, Dim chemoreceptor.

Asp, PNA, Hypoxia, DOE

20

Arcus Senilus

pt over 60yo deposit of calcium and cholesterol salt- appear grey-white ring at edge of cornea

21

Macular Degeneration

can have no fovea refelx. Drusen(yellow spots) can appear in/around macula- deposits are EC material.

causes poor central vision and blindness

22

Cerumen Impaction

most common in elderly d/t overgrowth of hair. Most often cause of tinnitus and hearing loss. Cerumen is drier and lore likely to accumulate d/t decrease in sweat glands.

23

Tinnitus

more prevalent in elderly, can be caused by cerumen, meds, vasc disorders and impair blood flow.

24

Hearing Loss

Conductive/ Sensorineural( most common in elderly)

Reason d/t decreased blood flow, dec vestibular conduction, loss of acuity.

First signs hearing loss refer to audiologist

25

Cardiovascular: Neck Vessels

Lengthening/tortuosity of Ao- kinking/buckling of carotid artery. Results in pulsatile mass, mainly in women with HTN, may be mistaken for aneurysm. Torturous Ao- raise L jugular vein pressure, imp drainage within thorax, into RA.

Carotid bruit in middle/upper portion of carotid arteries- suggests part art occlusion( in younger people usually innocent). Warrant investigation-possible stenosis d/t risk for possible ipsilateral stroke

26

Cardiovascular: S3 S4

Middle/Older aged adults commonly have systolic Ao murmurs. After age 40 S3 suggests dilation of LV from CHF/CMO from volume overload of LV (CAD, VHD)

S4 can be in healthy people, but may suggest dec ventricular compliance/imp vent filling, accompanied by HTN.

Heart sounds are diminished

27

Cardiovascular: Murmurs

Middle/Older adults commonly have Ao systolic murmur. Detected in 1/4 adults over 60yo. Aging thickens base of aortic cusps with fibrous tissue, calcification follows. Mostly fibrosis/calcification does not impede blood flow(Ao scleoris) but can cause turbulent flow. AS leaflets calcified and immobile, outflow obstruction- has delayed carotid upstroke(aortic sclerois has normal upstroke). Increased M/M with both. Crescendo/decrescendo M at 2RICS- AS/sclerosis. Delay during simultaneous palp of brach/rad art=AS

Sim changes to mitral valve, usually one decade later than Ao, leads to MR- systolic murmur- may become pathologic as volume overload increases in LV. Harsh holosystolic M at apex=MR

28

Cardiovascular Implications

LVH

Dec CO- dec peripheral perfussion/oxygenation

Dec sens to anything that stim B-adrenergic(SNS, PNS, hormones, drugs, exercise, stress response)

Inc arrhythmias- ICD

syncope- falls/injury

Need for pacer

HF

Heart block

 

29

CV musculature

mod-marked hypertrophy(LVH- sustained PMI, CHF- diffuse PMI)

Inc wall thickness LV

Inc myocardial wall thickness in general d/t inc myocytes

Inc fibrous tissue

Inc size LVand LA

walls less pliable, thick, stiff

vessles become dilated and elongated

deposits form matrix- lead to atherosclerotic changes- damage intima- inflammation- injury- occlusion

Leads to PVR, PAD, thrombosis, ischemia

30

Barorecptors

dec in elderly

regulate HR and MAP

Imp BP response to standing- volume depletion

Higher incidence orthostatic changes with position changes

31

Peripheral Vascular System

Atherosclerosis- not normal aging but occurs more in elderly

Vesesls dilate and lengthen, torturous, hard

Changes in skin, nails and hair are not specifically d/t arterial insuff- but are often symptoms of.

Screen for Ao anuerysm with back/abd pain- esp men who smoke and have CAD. measure Ao diameter and feel for pulsatile mass

Art occlusion- dim/abs pulses

 

32

Temporal Arteritis

Over 50 yo, temporal arteiries become subject to giant cell- loss vision 15%, c/o HA, jaw claudication

33

Breasts/Axillae

May become granular, nodular or lumpy. Aging- less grandular, more fatty- total amount decreases. Breast flaccid, pendulous. Nipples- ducts may be more palpable as firm stringy strands. Axillary hair diminished

Lumps/mass- check for malignancy

34

Abdomen

Fat accululates lower abd, hip- more pronouced abd.

Aging may blunt acute abd- pain may be less severe, fever less, signs of peritoneal inflam reduced/absent

check for bruits and Ao diameter/pulsatile mass

35

GI

dec motility

dec vasc flow

dec gastric acidity

gastric emptying slowsfeels full longer

dec appetite

inc diverticulosis

inc polyps

inc NSAIDS- affects lining- inc PUD,GERD,esophagitis

36

GI: Stomach

inc gastric pH

dec blood flow

dec absorption calcium vit d

 

37

GI Implications

constipation

dec absorption Vitamins, esp B12

dec calcium absorption- OP

Rectal mass found with colon CA

38

GI: Liver

dec blood flow

dec metabolism toxins

dec size

protein synthesis dec

dec hepatic drug elim

Cytochrome P450 less efficient/effective 50%

dec excr of drugs met in liver

POLYPHARM concerns

 

39

GI: Gallbladder

inc cholelithiasis

bile acid syntheisis dec

Ask id cholecystectomy- important

40

GU: Incontinence

Stress- weak sphincter- cough,sneeze,laugh

Urge- sudden urge, muscles contact inappr

Overflow- Men, nocturnal- unable to full empty- leakage, no urge

Functional- mental physical interference

Inc residual volume

 

Inc not normal aging but causes can be d/t atrophyof muscles or dec sensation

41

Male Genitalia

Sex interests remains intact, freq of sex declines. Dec testosterone level- erection dependant on tactile stim, less cues. Penis size decr, testicles drop lower in scrotum. Protracted illness may lead to dec teste size. Pubic hair dec,gray. ED affect 50%- usually d/t hypogastric cavernous art insuff or ven leakage through subtunical venules

 

42

Female Genitalia

Ovarian Fxn dim 5th decade. Estrogen falls, hot flashes- up to 5 years- sweating, palpitations, chills, anxiety. Sleep/mood swing problems. Vag dryness, urge incont, dyspareuria. Pubic hair gray, sparse. Labia, clitorus smalled, vagina narrows, shortens, mucosa pale,thin,dry loss of lube. Within 10 yrs of menopause, ovaries nonplapable. Sexuality unchanged

Atrophic vaginitis

Freq UTI

Vulvovaginitis

urge/stress incont

Check for masses, Paget's disease, erythema

43

BPH

begins 3rd decade- hyperplastic prostate

overflow incont, esp nocturnal

dec blood flow to penis- ED

44

GU implications

freq UTI

nocturia

incont

skin breakdown

embarrassment

social isolation

45

Renal

function dec

Cr Cl dec 10ml/decade

dec Na exc/conserv

dec concentrating capacity

dec blood flow

dec GFR

Consider kidney function when ordering renally excreted drugs

46

Muscuoskeletal

Subtle loss in Ht d/t intervertbral discs thin, bodies shorten or collapse from OP. Kyphosis, inc AP diameter esp women. Muscles decrease in bulk, power, ligaments lose tensile strength. ROM dim, partly d/t OA.

Immobility- leads to rapid muscle loss

Age 40yo- can see OA changes on xray

DJD- changes in OA

Joint inflam- RA, gout

 

47

Sarcopenia

decrease muscle mass 1% per year after age 25yo

48

Osteopenia

loss of skeletal bone mass

49

MS Implications

OP- fractures

falls/injuries

dec flexibility, balance, stamina, endurance, strength

enc reg exercise routine

PT/OT after hopsitalization

50

MS: Joints

art cart loses thickness

d/t dehydration of cart, also wear and tear.

Inc in arthritis, need OR

Nonarticular cart grows with aging- ears, nose

51

Endocrine: Thyroid

atrophies

nodules inc

hypo/hyper subtle- harder to Dx

most freq cause of afib in elderly

52

Endocrine: Pancreas

Inc Insulin resist

Imp glucose homeostasis

Post prandial gluc tol inc by 10mg/dl per decade

Inc gluc in resp to illness

53

Neurologic

Intelligence dec after 40yo

slowing process takes longer

mild forgetfullness not pathological

Loss of nerve cells dec- hippocampus- short term

Brain atrophy

Dec cortical brain cells

54

Motor

less speed, dec skeletal muscle

May dev benigh tremor- often a/w Parkinson. Benigh tremors are faster and disappear at rest, no muscular rigidity.

Lose vibratory sense in feet/ankles

Position sense may dim

Abd and ankle reflex dim/absent

If assymetrical- search for another reason

55

Immune Response

dec humoral antibody resp

dec T cell fxn

inhibitory effect on immune system

dec immune system

By the time the elderly are showing symptoms, they could be septic

Dec immune- inc suseptibilty for infections/malignancy

 

56

Hematolgy

H&H dec slightly

MCV inc

Anemia most common in elderly

ESR inc significantly

Clotting inc(fibrinogen, coag factor V, VII, IX)

57

polypharmacy

58

Tips for Interviewing Elderly

Face patient, eye level

talk low pitch, quiet room

50% HOH

allow extra time

Allow reminiscense

Go slow, don't rush

bright light

use aidess

59

ADL's

capacity to perform

Also ask about Instrumental ADL's- higher level of functioning

60

Medications

thorough medication history

Polypharmacy dangerous

common, fatal

seeing more than one practitioner

D/T: dec liver met, dec GFR, often takes several doses to build up, some meds inh/enh other drugs, hypnotics=danger, alpha blockers=hypotension, anticholinergic meds more evident

61

Nutrition

take history

those with chronic disease at risk

esp GI, poor dentition, depression, other psyche, drugs.

In under wieght elderly albumin is independant risk factor for maortality

62

Pain

80% visits for pain

Usually MS

Older less likely to report

ask with every visit

acute vs chronic

 

 

63

Functional Assessment Tools

Tinetti Balance and gait eval

Get up and go test

timed walking test

GARS

64

Smoking/ETOH

Smoking bad any age

ETOH abuse rises with age

Dec detection/treatment with elderly

Lots of drugs interact with alcohol

Chronis drinkers: cirrhosis, GIB, GERD, gout, HTN, DM, insomnia, gait DO, depression

65

Advanced Directives/ Palliative Care

End of Life wishes

66

Screening

Vision/hearing

Exercise

Immunizations

Household safety

Cancer

Depression

Dementia/ Mild Cognitive Impairment

Elder Mistreatment

67

Immunizations

Flu annually

Pneumococcal good for life after 65, Q5yrs prior

Zoster- over age 60yo

Tetanus every 10 years

68

Depression Screening

affects 10% elderly

nder diagnosed

Men over 85 at higher risk of suicide

69

Dementia

Slow, insidious onset. Hard to detect initially. MCI- mild cognitive impairment

Amnesic MCI- affects memory

Non amnesic MCI- not memory but language or visuospatial.

AACI- age associated cognitive impairment- mild cognitive changes in late life

70

Alzeheimer's Dementia

amnesic memory impairment, deter language, and visuospatial defects. Initial loss of high ADL. Mood change or apathy apparent. Psychosis/agitation late.

Test with MMSE

71

Elder Abuse

abuse, neglect, exploitation, abandonement

72

Functional Status

6th VS

10 min Geritric Screener

D- delirium,

I-Infection

A-Atrophic urethritis/vaginitis

P-Pharmaceuticals

E-Excess UOP- hyperglycemia, CHF

R-Restricted mobility

S-Stool Impaction

ask about ADL, IADL, Sex fxn, gait assessment

73

Falls Assessment

Assess with routine exams

Gait velocity

 

Widening of base, slowing and lengthening of stride, diff turning- correlated with risk for falls

 

74

GARS

Gait abn rating scale

sum of 16 facets, total score reflects fall risk

75

HPI

Disorientation/Confusion

onset, duration, associated problems, meds

76

Isolated systolic HTN

SBP >140 after age 50, CHD triples in men, inc risk of CVA

Widened PP >60- inc risk for CV, renal and stroke

 assess for LVH

77

Orthostatic Hypotension

10-20% elderly, 30% NH residents

causes: meds, autonomic DO, DM, prolonged BR, blood loss, CV DO

78

Tachypnea

>25 BPM, lower resp infection or CHF, COPD

79

Hypothermia

common in elderly

80

Wt/Ht/BMI

calculate for nutrition assessment

Undernourished seen with ETOH, depression, gog impair, malignancy, chronic organ failure, meds, social isolation, poverty

81

MMSE

Use for suspected cognitive impairment.

Tests for orientation, registration, attention, calculation recall, language

82

pseudoscars

white depigmented patches

83

Seborrheic keratoses

raised yellow lesions, greasy, velvety/warty

84

comedones

blackheads- on cheeks or around eyes

85

Herpes Zoster

inc risk with age, reactivation of latent varicella zoster virus

86

Senile Ptosis

eye atrophy from loss of fat, levator palpebrae

87

Arcus Senilus

white ring around limbus

88

Cataracts

leading cause of blindness in the world.

RF- smoking, UV b, high ETOH intake, DM, meds, trauma

89

Wide angle glaucoma

inc cup to disk size, caused by irreversible optic neuropathy and leading to loss of peripheral vision and central vision and blindness. 3-4X more prevalent in AA.

90

Drusen bodies

check fundi for colloid bodies causing alter in pigment

91

Oral Malodor

poor oral hygiene or periodontal disease

Gingivitis may arise from peridontal disease.

92

clitoral enlargement

Androgen-producing tumors or use of androgen creams

93

Estrogen stim cervical mucus with ferning

HRT, endometrial hyperplasia, estrogen producing tumors

94

Restricted mobilty of uterus

inflam, malignancy, surgical adhesion.

95

Leiomyomas

enlarged uterine fibroids.

Malignant leiomyosarcoma

Palp ovaries with Ovarian CA

96

Parkinson's

slow tremors, pill rolling, rigidity, bradykinesia, micrographia, shuffling gait, diff turning in bed, opening jars, rising from chair.

Aggravated by stress, inhibited during sleep or movement.

Persistent blinking and diff walking heel to toe also common

97

3D's of altered mental status

Dementia

Depression

Delirium

98

Dementia

Clinical syndrome of failing memory and impairment of other intellectual functioning- can have features of delirium

progressive and disabling

NOT inherent aspect of aging

 

99

Depression

Common psyche DO, mild to psychotic, variety symptoms

100

Delirium

acute confusional state accompaned by DO of perception

Alt MS, attention span, sleep patterns, affect

Behaviors vary from intense agitation to sluggishness

Hallucinations and delusions often experienced

 

may superimpose on dementia- may occur with acute illness like infection, stroke, med side effect

101

Symptoms that may indicate Dementia

learning/retaining new info

handling complex tasks

reasoning ability

spatial ability and orientation

language

behavior

 

102

Normal Lapse vs Dementia

Normal                                         Dementia

forget a name            not recogn a family member

leave kettle on           forget to serve meal just made

finding right word         subs inapprop word

forget date/day             getting lost in own neighborhood

UA to balance CHBK    not recogn #

lose keys/glasses          putting iron in freezer

getting blues in sad sit    rapid mood swings(unexpl)

grad changes with aging   sudden personality changes                                

 

103

other Cognitive areas to evaluate

insight/judgement

thought content

mood/affect

 

104

Social Assessment

caregiver

economic state

elder mistreat

sexual health

suicide

105