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Flashcards in Geriatrics Deck (51)
1

leading causes of death >65 y/o

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

2

leading cause of disability >65 y/o

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

3

aging changes: cell, tissue, organ

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

4

primary regulators of aging:

hypothalamus, pituitary gland, adrenal gland

5

muscular changes of aging

**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

6

skeletal changes of aging

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

7

Neurological changes with age

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

8

sensory changes with age

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)

9

vision changes with age

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

10

hearing changes with age

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

11

Vestibular/balance changes with aging

-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

12

Somatosensory changes with age

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

13

cataracts

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

14

glaucoma

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

15

senile macular degeneration

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

16

diabetic retinopathy

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

17

homonymous hemianopsia

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

18

impaired or fuzzy vision may result with which common meds?

antihistamines
tranquilizers
antidepressants
steroids

19

conductive hearing loss

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

20

sensorineural hearing loss

central or neural hearing loss from multiple factors
-noise damage
-trauma
-disease
-drugs
-arteriosclerosis

21

presbycusis hearing loss

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

22

presbyopia

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

23

Meniere's disease

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

also experience sensorineural hearing loss

24

Benign paroxysmal positional vertigo

BPPV

brief episodes of vertigo (

25

common meds with vestibular side effects

antihypertensives -postural hypotension

anticonvulsants

tranquilizers

sleeping pills

aspirin

NSAIDS

26

cognition changes with age

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

27

cardiovascular changes with age

* 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

28

pulmonary changes with age

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

29

integumentary changes in age

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

30

GI changes in age

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

31

Renal system changes with age

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

32

osteoporosis

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

33

common pathological conditions associated with the elderly

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

34

Fractures

*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

35

Degenerative arthritis

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

36

delirium

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

37

dementia

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

38

Alzheimer's disease

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

39

multi infarct dementias

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

40

depressive symptoms

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

41

CAD

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

42

pneumonia

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

43

diabetes

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

associated with obesity and sedentary lifestyle

44

adverse drug reactions for elderly

confusion/dementia

sedation/immobility

weakness

postural hypotension

depression

drug induced movement disorders
-dyskinesias
-akathisia
-esstential tremor
-parkinsonism

incontinence

45

meds that can cause confusion/dementia in elderly

tranquilizers
barbiturates
digitalis
antihypertensives
anticholinergics
analgesics
antiparkinsonians
diuretics
beta blockers

46

meds that cause sedation/immobility in the elderly

psychotropics
narcotic analgesics

47

meds that cause weakness in elderly

antihypertensives
vasodilators
digitalis
diuretics
oral hypoglycemics

48

meds that cause postural hypotension in the elderly

antihypertensives
diuretics
antidepressants
tranquilizers
nitrates
narcotic analgesics

49

meds that cause depression in elderly

antihypertensives
antiinflammatories
antimycobacterials
antiparkinsonians
diuretics
vasodilators

50

drugs that induce movement disorders in elderly

Dyskinesias:
-long term use of neuroleptic and anticholinergics
-levodopa

Akathisia: motor restlessness
- antipsychotics

Essential tremor:
-antidepressants
-adrenergic drugs

Parkinsonism:
-antipsychotics
-sympatholytics

51

drugs that cause incontinence in elderly

barbiturates
benzothiazides
antipsychotics
anticholinergics