Geriatrics Flashcards
(54 cards)
1
Q
Definition and History
A
- Bismark (Germany 19th century); Old age and Disability Insurance Bill 1889 - Eligibility at 70
- Older than 65: Social Security Act 1935
- Medicare: Social Security Act 1965
- Series of Losses; frail and less well-functioning; multiple concurrent disease processes
2
Q
Setting
A
- Home
- Small Group home
- Assisted Living
- Nursing Home (sub-acute and long term)
- Long term acute care (LTAC)
- Acute hospital care
- Hospice
3
Q
Unique aspects of the geriatric history
A
- Always review medications
- Assess activities of daily living
- Often have concomitant and complex medical problems
- Depression
- Cognitive impairment
- Difficulty with communications
4
Q
Difficulty with communication
A
- Hearing, vision, speech (CVA)
- Inability to afford physician visits
- Underreporting: intimidated by a busy practice
- Fear: afraid to find out something is wrong
- Slower to respond
- Atypical presentations
5
Q
PE: Weight
A
Asses Diet and Fluid Status
6
Q
PE: Pulse and Blood Pressure
A
- Atherosclerosis and tissue perfusion
- Often have orthostatic changes
7
Q
PE: HEENT Exam
A
- Temporal arteritis
- Decreased lens accommodation
- Presbycusis
- Poor dentition/false teeth
- Decreased olfaction
8
Q
PE: Chest and Lung Exam
A
- Kyphotic Changes: decreased lung capacity
- Increased Incidence of Breast cancer
9
Q
PE: CV Exam
A
- Thrills and Bruits
- 1/3 octogenarians have systolic murmur:
- Aortic stenosis, aortic sclerosis , mitral regurgitation, atrial septal defects, tricuspid regurgitation
10
Q
PE: Abdominal Exam
A
- Compression fractures: altered contour
- Often present atypical/asymptomatic:
(1) Perforation, ischemia, inflammatory
(2) Bleeding
11
Q
PE: GU Exam
A
- Prostate hypertrophy
- Vaginal and Labial atrophy: (1) squamous cell cancer, (2) Vaginal Bleeding
12
Q
PE: MSK
A
- Deformities related to arthritis
- Compression fractions and kyphosis
13
Q
PE: Neuro Exam
A
- Olfaction
- Cognition
- Gag/speech: aspiration
- Gait
14
Q
Focus of Geriatric Care
A
- Reduce Nursing Home Placement
- Reduce Hospitalization
- Quality vs Quantity of Life: ask pt what their goals of care are
- Socio-economic issues: aging in place, limited income, spend down
15
Q
Falls - Gait Disturbance
A
- Multifarious in etiology
- Evaluation
1. H&P
2. Gait and Balance
3. Neuro exam
4. CV exam
5. Lab tests
6. Physical and Occupational therapy eval
16
Q
Gait Dist. - H&P
A
- full med history w/ medications review (include OTC)
2. LE weakness, gait/balance probs, decreased vision, arthritis, hx of falling, pain
17
Q
Gait Dist. - Gait and Balance
A
Get up and go test
18
Q
Gait dist. - Neuro exam
A
- mental status
- Proprioception
- Sensory and Cerebellar Exam
19
Q
Gait dist. - CV exam
A
- dysrhythmia
- postural hypotension
- murmurs
20
Q
Gait Dist. - Lab tests
A
- CBC
- blood chemistries
- EKG
- HBA1C
- Holter monitor
- vitamin D (muscle weakness and function impairment in addition to increased incidence of osteoporosis)
21
Q
Gait Dist. - PT and OT Evaluation
A
- Home and hazard assessment/environmental safety
2. Berg Balance Scale
22
Q
Gait Dist - Treatment
A
- PT/OT
- Brain Imaging (after falls)
- Medication review (reduction)
- Pacemaker
- Treat underlying conditions - infections, normal pressure hydrocephalus
- Murmurs (aortic stenosis)
23
Q
Gait Dist. Consequences
A
- Subdural Hematoma - mental decline
- Fracture (hip fractures associated with up to 50% mortality at year 1)
- Nursing Home Placement
24
Q
Urinary Incontinence (UI)
A
- more common in females (dt short urethra and child birth)
- increases with age
- common factor leading to institutionalization/social isolation
25
UI Types
1. Stress incontinence
2. Urge incontinence
3. Overflow incontinence
4. Functional incontinence
26
UI Evaluation
1. H&P
2. Functional alertness/capacity, CHF, abdominal exam (distention), genital exam
3. CBC, U/A, blood sugar, imaging (Renal U/S), culture
4. Post void residual - evaluation of emptying
27
UI Treatment
= Coping Strategies
1. pads, hand-held urinals, bedside commodes etc
2. social isolation
3. foley (indwelling catheters) = poor management choice/last resort dt (a) limits mobility and is a safety risk, (b) significant cause of infections
28
UI - DIAPERS
```
Drugs
Infection
Atrophic Vaginitis
Psychiatric
Endocrine
Restricted Mobility
Stool Impaction
```
29
Urge Incontinence Treatment
1. Bladder Training/toileting schedule
2. Medication: Anticholinergic medication for detrusor muscle instability, Reduce/eliminate caffeine, Treat underlying infections
30
Stress Incontinence Treatment
1. Kegel exercises
2. Medications:(A) Estrogens – some data reveal that oral estrogens make the condition worse, (B) Alpha adrenergic agonists
3. Surgery urethropexy or pubovaginal slings
4. Pessary: uterine prolapse
31
Overflow Incontinence Treatment
= Important for preservation of renal function
1. post void residual volume is elevated
2. fecal impaction
3. prostate enlargement (tx = finastride or alpha adrenergic antagonist)
4. Treatment w/ augmented voiding maneuvers (a) suprapubic pressure (b) valsalva maneuver (c) intermittent catheterization
32
Constipation Def
- Patient specific, decreased frequency of bowel movements for the particular individual, but usually fewer than three evacuations a week
- Includes impaction that requires manual disimpaction, incomplete elimination, painful elimination, dry/hard stool
33
Constipation Etiologies
1. Medication - opiates, anticholinergics, antidopaminergic, calcium channel blockers
2. Mechanical obstruction – tumor, prolapse, adhesions
3. Neurological – CVA, MS
4. Systemic – hypothyroid, diabetes, inflammatory, electrolyte disorders
4. Dehydration and inactivity
34
Constipation H&P
1. Medications, fluid intake, disease history
2. Abdominal distention and pain
3. Rectal exam – tone, impacted stool, hemorrhoids, strictures, or fissures
4. Neurological exam – rectal tone (spinal cord impairment)
35
Constipation Lab tests
1. Electrolytes, BUN, creatinine, TSH, calcium
2. Colonoscopy – carcinoma?
3. Abdominal X-ray
4. CT of the abdomen
36
Constipation Treatment
1. Bulk laxatives- The exception is for treatment opiate-induced constipation, need to use peristaltic stimulants
2. Osmotic agents
3. Enemas
4. Stool Softeners
5. Hydration
6. Maintaining physical activity
37
Pressure Ulcers def and risk factors
Def: ischemic soft tissue injury usually over a boney prominence
Risk factors: immobility, poor nutritional status, incontinence, vascular insufficiency, altered level of consciousness
38
Braden Scale
Risk assessment tool for pressure ulcers
39
Pressure ulcer staging
* repeated inspection is fundamental to prevention and the ongoing treatment
Stage 1 - intact skin with non-blanchable redness
Stage 2 - partial thickness loss, open ulcer or blister with a pink wound bed
Stage 3 - full thickness tissue loss, subcutaneous tissue present, tunneling and slough
Stage 4 - full thickness with exposed underlying structures, bone, muscle, tendon
Unstageable - covered by slough and/or eschar and underlying structures cannot be visualized
40
Pressure Ulcers Treatment
1. Prevention – pressure relieving devices/mattresses, turning and barrier creams while avoiding shearing forces, reduce moisture – diapers (catheters can be used in as a last resort; can they lead to UTIs)
2. Moist dressings (allow for a healing environment), antibiotics for infection, surgical debridement, enzymatic debridement, consider osteomyelitis – non-healing wounds
41
Cognitive Impairment
1. Benign senescent forgetfulness - mild recall/memorizing inability
2. Dementia - loss of memory, language, visuospatial orientation, executive functions
42
Depression
- Inadequate finances, loss of spouse/significant other/children, functional decline
- Widely under recognized due to its non-specific presentation
- Pseudo-dementia
43
Sensory Impairments
* increased safety risks
1. Olfaction loss - Spoiled food in refrigerator
2. Vision loss- Presbyopia, cataracts, open-angle glaucoma, macular degeneration, diabetic retinopathy
3. Hearing loss leads to isolation, frustration of others
- Presbycusis – high frequencies followed by speech frequencies
4. Decrease in thirst perception
44
Dementia Presentation
- presents as a slow, progressive disease
1. impaired memory loss and new learning
2. behavior and personality changes
3. hallucinations
- Chronic and progressive loss of memory and cognitive function resulting in social and safety decline
1. Wandering/high injury risk
45
Dementia Etiology
Identify the underlying etiology if possible – potentially reversible
i.e. B-12 deficiencies, normal pressure hydrocephalus, neurosyphilis, hypothyroidism, seizure disorder
46
Types of Dementia
1. Multi-infarct (vascular) dementia
2. Lewy Body dementia
3. Alcoholic dementia
4. Parkinson’s disease related dementia
5. Alzheimer’s dementia (SDAT)
6. Pseudo-dementia (depression)
7. Pick’s disease
47
Dementia H&P
- Med/substance hx
- living/safety arrangements
- Basic Activities of daily living (ADLs)
- Instrumental Activities of Daily living (IADLs) = executive functions
- weigh loss, missed apts, DRIVING, repeatedly wearing same clothes, inappropriate phone calls
- MMSE, GDS
48
Dementia Management
- Lab test/ Evaluation – Rule out reversible causes
- Cholinesterase inhibitors and/or NMDA receptor antagonists
- Antidepressants (SSRIs, SNRIs)
- Structured day
- Simple, calm and direct communication
- Reorientation
- Realistic goals (caregiver denial)
- Attention to safety
- Agitated or aggressive
- *Restraints = Contributes to physical deconditioning, pressure sores, depression, disorientation
49
Polypharmacy
= greater than five medications
- consider drug interactions, med errors, altered phamacodynamics and pharmacokinetics
- **Geriatricians are often best known for the number of medications they discontinue, rather than how many they prescribe
50
Polypharmacy considerations
- Beers List: Safe geriatric drug list
- loss of lean body mass (altered vol of distribution)
- decreased cytochrome P450 activity w/ age
- decreased renal/tubular function w/age
- Multiple DRs and pharms
- Brown bag rounds - comprehension of meds = poor
- prophylactic meds in hospitalized pts
51
Polypharmacy - Management Strategies
- risk to benefit ratio
- start one new med at a time
- START LOW AND GO SLOW
- Review OTC and herbals/supplements for interactions
- duplicate meds
- provide detailed, plain English instructions w/ reasons for taking
- pill box reminders
- review prescribers and their roles
52
Care Settings: Hand - offs
- readmission to hospital
| - Reimbursement
53
Nursing Homes
- OBRA 1987 = highly regulated
- Team approach to care
- Two focuses of care= Short stay rehab and long term care
- Variable expertise
- Limitations of type of care
- Pharmacy/diagnostic limitations
54
Advanced Directives
1. Goals of individual care?
- Five wishes
- Durable Med Power of Attorney
2. Capacity - do they understand the consequences of their decisions?
3. DNR
- poor outcomes of resuscitation rates
- not the same as do not treat
- MOST = Med Orders for Scope of Treatment; POLST = Physician's Orders for Life Sustaining Treatment
