Geriatrics

Question 1

leading causes of death >65 y/o

Answer 1

coronary heart disease 31%
cancer 20%
CVA
COPD
pneumonia/flu

Question 2

leading cause of disability >65 y/o

Answer 2

arthritis
HTN
hearing impairments
heart impairments
catcalls and chronic sinusitis
orthopedic impairments
diabetes and visual impairments

Question 3

aging changes: cell, tissue, organ

Answer 3

cellular changes:

• increase in size
• decrease in cell capacity to divide and reproduce
• arrest of DNA synthesis and division

tissue changes:

• accumulation of pigmented materials, lipofuscins
• accumulation of lipids and fat
• CT changes: decreased elastin, degradation of collagen

Organ changes:

• decrease in functional capacity
• decrease in homeostatic efficiency

Question 4

primary regulators of aging:

Answer 4

hypothalamus, pituitary gland, adrenal gland

Question 5

muscular changes of aging

Answer 5

**may be due more to decreased activity levels (hypokinesis) and disuse than from aging process

loss of muscle strength

• peaks at age 30-50
• accelerating loss (20-40% by 65 in non-exercising adult)

loss of power (force/unit time)
-significant losses in speed of contraction, changes in nerve conduction and synaptic transmission

loss of skeletal muscle mass (atrophy)

• both size and # of muscle fibers decrease
• by age 70 loss of 33% muscle mass

changes in muscle fiber composition

• selective loss of fast twitch fibers
• increase proportion of slow twitch

changes in muscular endurance

• decreased muscle tissue oxidative capacity
• decreased peripheral blood flow, oxygen delivery to muscles
• altered chemical composition; decreased ATPase, glycoproteins and contractile protein
• collagen changes: denser, irregular, loss of water content and elasticity- affects bone, tendons, cartilage

Question 6

skeletal changes of aging

Answer 6

cartilage changes:

• decreased water content, becomes stiffer, fragments and erodes
• by age 60 >60% have degenerative joint changes, cartilage abnormalities

loss of bone mass and density::

• peak bone mass at age 40
• between 45-70, bone mass decreased (in women by 25%, 15% in men)
• loss of calcium and bone strength, especially trabecular bone
• decreased bone marrow RBC production

intervertebral discs:
-flatten, less resilient due to loss of water content (30% loss by age 65) and loss of collagen elasticity; trunk length, overall heigh decreases

senile postural changes:
-FHP
- kyphosis of thoracic spine
flattening of lumbar spine
with prolonged sitting, tendency to develop hip and knee flexion contractures

Question 7

Neurological changes with age

Answer 7

atrophy of nerve cells in cerebral cortex

• overall loss of cerebral mass/brain weight of 6-11% between 20-90
• accelerated loss after age 70

changes in brain morphology

• gyral atrophy
• ventricular dilation
• generalized cell loss in cerebral cortex
• presence of lipofuscins, senile or neuritic plaques, and neurofibrillary tangles: significant accumulations associated with pathology (alzheimer’s)
• more selective cell loss in BG (substantia nigra and putamen), cerebellum, hippocampus, locus coeruleus

decreased cerebral blood flow and energy metabolism

changes in synaptic transmission

• decreased synthesis and metabolism of major neurotransmitters (ACh, dopamine)
• slowing of many neural processes, especially in polysynaptic pathways

changes in SC/peripheral nerves

• neuronal loss and atrophy: 30-50% loss of AHC, 30% loss of posterior roots by age 90
• loss of motoneurons results in increase in size of remaining motor units
• slowed nerve conduction velocity: sensory> motor
• loss of sympathetic fibers: may account for diminished, autonomic stability, increased incidence of postural hypotension in older adults

age related tremors (essential tremor)

• isolated symptoms- hands, head, voice
• exaggerated by movement and emotion

Question 8

sensory changes with age

Answer 8

Vision:

Hearing:

Vestibular/balance control

somatosensory

taste and smell
-gradual decrease in taste sensitivity
-decreased smell sensitivity
(smokers, chronic allergies, respiratory infections, dentures, CVA -hypoglassal involvement)

Question 9

vision changes with age

Answer 9

decline in visual acuity, accommodation, color discrimination, cornea reflex

Additional vision loss with pathology:

• cataracts
• glaucoma
• senile macular degeneration
• diabetic retinopathy
• CVA- hemianopsia

meds: impaired or fuzzy vision may result with antihistamines, tranquilizers, antidepressants, steroids

Question 10

hearing changes with age

Answer 10

Outer ear:
-build up of cerumen (earwax) results in conductive hearing loss- common in older men

Middle ear:
-min degenerative changes of bony joints

Inner ear:
-significant changes in sound sensitivity, understanding of speech, and maintenance of equilibrium may result with degeneration and atrophy of cochlea and vestibular structures, loss of neurons

Types of hearing loss

• conducting hearing loss
• sensorineural hearing loss
• presbycusis hearing loss

Hearing loss with pathology:

• Otosclerosis: immobility of staples results in profound conductive hearing loss
• Paget’s disease
• Hypothyroidism

Question 11

Vestibular/balance changes with aging

Answer 11

• degenerative changes in otoconia of utricle and saccule
• loss of vestibular hair-cell receptors
• decreased # of vestibular neurons
• VOR gain decreases

begins at age 30, accelerated decline 55-60

• diminished acuity, delayed reaction times, longer response times
• reduced function of VOR; affects retinal image stability with head movements, produces blurred vision
• altered sensory organization: older adults more dependent on somatosensory inputs for balance
• less able to resolve sensory conflicts when presented with inappropriate visual or proprioceptive inputs due to vestibular losses
• postural response patterns for balance are disorganized: characterized by diminished ankle torque, increased hip torque, increased postural sway

Additional loss of vestibular sensitivity with pathology:

• Meniere’s disease
• BPPV
• meds
• CVA
• cerebellar dysfunction
• migraine
• cardiac disease

Question 12

Somatosensory changes with age

Answer 12

decreased sensitivity of touch associated with decline of peripheral receptors, atrophy of afferent fibers; LEs more affected than UE

proprioceptive losses, increased thresholds in vibratory sensibility (beginning around age 50); greater in LEs than UE

loss of joint receptor sensitivity; losses in LE, cervical joints may contribute to LOB

cutaneous pain thresholds increased: greater changes in upper body areas (UEs, face) than in LEs

Additional loss of sensation with pathology:

• diabetes, peripheral neuropathy
• CVA, central sensory losses
• peripheral vascular disease, peripheral ischemia

Question 13

cataracts

Answer 13

opacity, clouding of lens d/t changes in lens proteins; results in gradual loss of vision- central first than peripheral

• increased problems with glare
• general darkening of vision
• loss of acuity
• distortion

Question 14

glaucoma

Answer 14

increased intraocular pressure, with degeneration of optic disc

• atrophy of optic nerve
• results in early loss of peripheral vision (tunnel vision)
• progresses to total blindness

Question 15

senile macular degeneration

Answer 15

loss of central vision associated with age related degeneration of the macula, compromised by decreased blood supply or abnormal growth of blood vessels under the retina

• initially patients retain peripheral vision
• may progress to total blindness

Question 16

diabetic retinopathy

Answer 16

damage to retinal capillaries

• growth of abnormal blood vessels and hemorrhage leads to retinal scarring and finally retinal detachment
• central vision impairment
• complete blindness is rare

Question 17

homonymous hemianopsia

Answer 17

loss of half of the visual field in each eye

• nasal half of one eye and temporal half of other eye
• -produces an inability to receive info from R or L side
• corresponds to side of sensorimotor deficit

Question 18

impaired or fuzzy vision may result with which common meds?

Answer 18

antihistamines
tranquilizers
antidepressants
steroids

Question 19

conductive hearing loss

Answer 19

mechanical hearing loss from damage to external auditory canal, tympanic membrane, or middle ear ossicles

results in hearing loss (all frequencies), tinnitus, may be present

Question 20

sensorineural hearing loss

Answer 20

central or neural hearing loss from multiple factors

• noise damage
• trauma
• disease
• drugs
• arteriosclerosis

Question 21

presbycusis hearing loss

Answer 21

sensorineural hearing loss associated with middle and older ages

characterized by bilateral hearing loss, especially at high frequencies first, then all
-poor auditory discrimination and comprehension, especially with background noise; tinnitus

Question 22

presbyopia

Answer 22

visual loss in middle and older ages characterized by inability to focus properly and blurred images due to loss of accommodation, elasticity of lens

Question 23

Meniere’s disease

Answer 23

episodic attacks of characterized by tinnitus, dizziness, and a sensation of fullness or pressure in the ears

also experience sensorineural hearing loss

Question 24

Benign paroxysmal positional vertigo

Answer 24

BPPV

brief episodes of vertigo (

Question 25

common meds with vestibular side effects

Answer 25

antihypertensives -postural hypotension anticonvulsants tranquilizers sleeping pills aspirin NSAIDS

Question 26

cognition changes with age

Answer 26

changes typically >mid 60s significant declines 80s *most significant in years preceding death decreased perceptual speed impaired numerical abilities memory: short term first, task specific

Question 27

cardiovascular changes with age

Answer 27

* may more more d/t inactivity and disease than aging degeneration of heart muscle with accumulation of lipofuscins (characteristic brown heart); mild cardiac hypertrophy, L ventricular wall decreased coronary BF cardiac valves thicken and stiffen changes in conduction system: loss of pacemaker cells in SA node changes in blood vessels: arteries thicken, less distensible; slowed exchange through capillary walls; increased peripheral resistance resting BP rise: SBP>DBP decline in neurohumoeral control: decreased responsiveness of end organs to beta adrenergic stimulation of baroreceptors decreased blood volume, hemopoietic activity of bone increased blood coagulability decreased SV d/t decreased myocardial contractility max HR declines with age CO decreases 1% per year after age 20 d/t decreased HR and SV orthostatic hypotension: common in elderly d/t reduced baroreceptor sensitivity and vascular elasticity possible ECG changes: longer PR and QT intervals, wider QRS, increased arrhythmias

Question 28

pulmonary changes with age

Answer 28

chest wall stiffness- declining strength of respiratory muscles results in increased work of breathing loss of lung elastic recoil, decreased lung compliance changes in lung parenchyma: alveoli enlarge, become thinner; fewer capillaries for delivery of blood changes in pulmonary blood vessels: thicken, less distensible decline in total lung capacity: RV increases, VC decreases forced expiratory volume (airflow) decreases altered pulmonary gas exchange: oxygen tension falls with age blunted ventilatory responses of chemoreceptors in response to respiratory acidosis: decreased homeostatic responses -blunted defense/immune responses: decreased ciliary action to clear secretions, decreased secretory immunoglobilins, alveolar phagocytic function *clinical signs of hypoxia are blunted; changes in mentation and affect may provide important cues cough mechanism is impaired gag reflex is decreased, increased risk of aspiration prolonged recovery from respiratory illness

Question 29

integumentary changes in age

Answer 29

changes in skin composition: - dermis thins with loss of elastin - decreased vascularity; vascular fragility results in easy brushing (senile purpura) - decreased sebaceous activity and decline in hydration - appearance: skin appears dry, wrinkled, yellowed and inelastic; age spots appear - general thinning and graying of hair due to vascular insufficiency and decreased melanin production Loss of effectiveness as protective barrier: - skin grows and heals more slowly, less able to resist injury and infection - inflammatory response is reduced - decreased sensitivity to touch, perception of pain and temp; increased risk for injury - decreased sweat production with loss of sweat glands results in decreased temp regulation and homeostasis

Question 30

GI changes in age

Answer 30

decreased salivation, taste and smell -inadequate chewing (tooth loss, poorly fitting dentures), poor swallowing reflex may lead to poor diet, nutritional deficiencies esophagus: reduced motility and control of lower esophageal spincter; acid reflux and heartburn, hiatal hernia common stomach: - reduced motility, delayed gastric emptying - decreased digestive enzymes and hydrochloric acid - decreased digestion and absorption - indigestion common decreased intestinal motility -constipation common

Question 31

Renal system changes with age

Answer 31

kidneys - loss of mass and total weight with nephron atrophy, decreased renal BF, decreased filtration - blood urea rises - decreased excretory and reabsorptive capacities bladder: - muscle weakness - decreased capacity, causing urinary frequency - difficulty with emptying, causing increased retention - urinary incontinence common - increased likelihood of UTI

Question 32

osteoporosis

Answer 32

disease process resulting in reduction of bone mass - failure of bone formation (osteoblast) to keep pace with bone reabsorption and destruction (osteoclast) - high risk of fractures - trabecular bone more than cortical; common areas: vertebrae, femoral neck, distal radius/wrist, humerus osteoporosis= BMD >2.5SD below young, normal mean osteopenia= BMD between 1-2.5 SD below the mean Etiology: - hormonal deficiency associated with menopause and hypogonadism (estrogen and androgen) - age related deficiencies - nutritional deficiency: calcium, excessive alcohol & caffeine - decreased physical activity/mechanical loading - diseases that affect bone loss: hyperthyroidism, diabetes, hyperparathyroidism, rheumatic disease (lupus), celiac disease, gastric bypass, pancreatic disease, multiple myeloma, sickle cell, end stage renal disease, Paget's disease, cancer, and chemotherapeutic drugs - meds that affect bone loss: corticosteroids, thyroid hormone, anticonvulsants, catabolic drugs, some estrogen antagonists, chemotherapy - additional risk factors: family history, caucasian/asian, early menopause, thin/small build, smoking

Question 33

common pathological conditions associated with the elderly

Answer 33

MS: - osteoporosis - fractures - degenerative arthritis (osteoarthritis) Neurological: - stroke - degenerative diseases: PD Cognitive disorders: - delirium - dementia - depression Cardiopulmonary disorders: - HTN - CAD - PVD - chronic bronchitis - COPD - asthma - pneumonia - lung cancer Integumentary: -pressure ulcers Metabolic pathologies: -Diabetes

Question 34

Fractures

Answer 34

*high risk associated with low BMD, age, comorbid diseases, dementia, psychotropic meds Hip fracture: ~50% won't resume pre-morbid level of function 95% are femoral neck fractures or intertrochanteric vertebral compression fractures: * T8-L3 - typically from routine activity: bending, lifting, standing - child complaint: immediate, severe local spinal pain, increased with trunk flexion Stress fractures: - in elderly common in pelvis, proximal tibia, distal fibula, metatarsal shafts foot - observe for local tenderness and swelling UE fractures: humeral head, Colle's fracture

Question 35

Degenerative arthritis

Answer 35

osteoarthritis noninflammatory, progressive disorder of joints - typically hips, knees, fingers and spine - pain swelling and stiffness (>AM) or with overuse - muscle spasm - loss of ROM and mobility; crepitus - bony deformity - muscle weakness secondary to disuse

Question 36

delirium

Answer 36

fluctuating attention state causing temporary confusion and loss of mental function -acute disorder, potentially reversible Etiology: - drug toxicity and/or systemic illness, oxygen deprivation to the brain - environmental changes and sensory deprivation S&S: - acute onset, often at night; fluctuating course with lucid intervals; worse at night - duration: hours to weeks - may be hypo or hyper alert, distractible; fluctuates over course of day - impaired orientation - illusions/hallucinations - memory deficits: immediate and recent - disorganized thinking, incoherent speech - sleep/wake cycles always disrupted

Question 37

dementia

Answer 37

loss of intellectual functions and memory, causing dysfunction in daily living Criteria: - deterioration of intellectual functions - disturbance in higher cortical functions: language (aphasia), motor skills (apraxia), perception (agnosia) - memory impairment: recent and remote - personality changes: alteration or accentuation of premorbid traits - alertness is usually normal - sleep often fragmented - mini-mental

Question 38

Alzheimer's disease

Answer 38

10-20% of >65 y/o population generalized atrophy of brian with decreased synthesis of neurotransmitter, diffuse ventricular dilation Types: - senile dementia, alzheimer's type (SDAT): onset >60 y/o - presenile dementia (PDAT): onset 40-60 y/o S&S: - dementia: insidious onset, with generally progressive deteriorating course - periods of agitation and restlessness, wandering - sundowning syndrome: confusion and agitation increases in late afternoon

Question 39

multi infarct dementias

Answer 39

20-25% of dementias etiology: small and large vascular infarcts in both gray and white matter of brain, producing loss of brain function S&S: - sudden onset rather than insidious; step wise progression - spotty and patchy distribution of deficits; areas of preserved ability along with impairments - gait and balance abnormalities, weakness, hyperreflexia - emotional lability common - associated with history of stroke, cardiovascular disease, HTN

Question 40

depressive symptoms

Answer 40

nutritional problems sleep disturbances psychomotor changes: inactivity with resultant functional impairments, weakness or agitation fatigue or energy loss feelings of worthlessness, low self esteem, guilt inability to concentrate, slowed thinking, impaired memory, indecisiveness withdrawal from family and friends, self neglect recurrent thoughts of death, suicidal ideation decline in cognitive function

Question 41

CAD

Answer 41

40% of ppl 65-74 y/o and 50% >75 Angina: not always a consistent indicator of ischemia in elderly -SOB and ST segment depression may be more reliable Acute MI: - clinical presentation may vary from younger adults - may present with sudden dyspnea, acute confusion, syncope - double mortality rate conduction system diseases: pacemaker dysfunction results in low CO

Question 42

pneumonia

Answer 42

initial symptoms may vary | -instead of high fever and productive cough, may see altered mental status, tachypnea, dehyrdration

Question 43

diabetes

Answer 43

aging associated with deteriorating glucose tolerance -type 2 affects as 10-20% over age of 60 associated with obesity and sedentary lifestyle

Question 44

adverse drug reactions for elderly

Answer 44

confusion/dementia sedation/immobility weakness postural hypotension depression drug induced movement disorders - dyskinesias - akathisia - esstential tremor - parkinsonism incontinence

Question 45

meds that can cause confusion/dementia in elderly

Answer 45

``` tranquilizers barbiturates digitalis antihypertensives anticholinergics analgesics antiparkinsonians diuretics beta blockers ```

Question 46

meds that cause sedation/immobility in the elderly

Answer 46

psychotropics | narcotic analgesics

Question 47

meds that cause weakness in elderly

Answer 47

``` antihypertensives vasodilators digitalis diuretics oral hypoglycemics ```

Question 48

meds that cause postural hypotension in the elderly

Answer 48

``` antihypertensives diuretics antidepressants tranquilizers nitrates narcotic analgesics ```

Question 49

meds that cause depression in elderly

Answer 49

``` antihypertensives antiinflammatories antimycobacterials antiparkinsonians diuretics vasodilators ```

Question 50

drugs that induce movement disorders in elderly

Answer 50

Dyskinesias: - long term use of neuroleptic and anticholinergics - levodopa Akathisia: motor restlessness - antipsychotics Essential tremor: - antidepressants - adrenergic drugs Parkinsonism: - antipsychotics - sympatholytics

Question 51

drugs that cause incontinence in elderly

Answer 51

barbiturates benzothiazides antipsychotics anticholinergics