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Flashcards in geriatrics Deck (105):
1

Characteristics that protect you when you are young may not protect you when you are past your reproductive years

(antagonistic pleiotropy)

2

theories of aging

mutation acculumation (loss of proofreading), mitochondrial dysfunction (extra free radicals from oxidation), telomere shortening, dysregulation of cell cycle (loss of cell cycling and uncontrolled cycling)

3

reduced ability to maintain homeostasis

Homeostenosisis

4

physiologic changes in CV system of aging

o Basement membranes thicken around capillaries→ impaired diffusion
o Decreased compliance of aorta=HTN, increased pulse pressure and SVR
o Decreased sensitivity of baroreceptors
o Decreased CO and EF→ decrease coronary flow
o Decreased efficacy of Frank-Starling mechanism

5

physiologic changes in respiratory system of aging

o Decreased elastin and elastic recoil, early airway closure, can’t get air=obstruction
o Enlargement of alveoli →increased residual volume, decreased vital capacity
o Increased mucus, decreased cilia→ pneumonia
o More V/Q (vent/perfusion) mismatch→ slightly increased Pc02 and lowerd pH

6

physiologic changes in electrolyte system of aging

o Decreased GFR and can’t concentrate as well=peeing in middle of night
o Decreased thirst drive→ dehydration
o Decreased renal excretion of magnesium and increased laxatives causes hypermagnesemia→ too much membrane stabilization→ dysrhythmias, hypotension, drowsiness, decreased breathing, muscle weakness, constipation, polyuria

7

physiologic changes in renal system of aging

o Decreased GFR from atrophy of neurons d/t decreased blood flow→ overmedicated
o Decreased tubular reabsorption→ more urine→ nocturia
o Decreased drinking and decreased innervation of bladder→ incontinence

8

oral heaalth changes in aging

o Loss of enamel→ tooth loss
o Decreased saliva→ dry mouth and bad breath
o Decreased taste buds→ decreased taste, less eating → malnutrition

9

GI changes in aging

o Decreased replication of cells that secrete digestive enzymes, decreased mucosal cells→ decreased absorption
o Loss of muscle tone→ difficulty swallowing, delayed emptying, constipation, fecal incontinence

10

liver changes in aging

o Decreased enzymes→ decreased drug metabolism
o Alcohol dependency→ decreased liver function

11

metabolism changes in aging

o Less ability to burn glucose and secrete insulin→ DM
o Decreased Basal metabolic rate
o Decreased ability to sweat and thermoregulate

12

immune changes in aging

o Decreased T cell function→ increased infections

13

neuro changes in aging

o Decreased cerebral blood flow→ brain atrophy
o Decreased # of neurons→ decreased reaction time and decreased muscular coordination
o Decreased neurotransmitters→ tremor
o Altered sleep→ insomnia

14

special senses changes in aging

o Decreased high pitched hearing
o Decreased smell and taste
o decreased lens accommodation→ presbyopia and dryness

15

pain changes in aging

o More disease process→ more pain

16

skeletal system changes in aging

o Decreased deposition and increased resorption→ osteoporosis
o Dehydration of intervertebral discs→ decreased stature
o Erosion of cartilage→ joint pain, osteoarthritis

17

muscle changes in aging

o Atrophy→ decreased strength and endurance

18

sex changes in aging

o Don’t assume they aren’t interested!
o Prostate enlargement
o ED
o Vaginal dryness

19

factors affecting driving in older aduls

• Poor visual acuity and contrast sensitivity
• Dementia
• Impaired neck and trunk rotation
• Limitations of shoulders, hips, ankles
• Foot abnormalities
• Poor motor coordination and speed of movement
• Medications and alcohol that affect alertness

20

important aspects of social hx in older adults

support system, caregiver burden, economic well being, mistreatment, advance directives, spirituality, home safety

21

3 components of why people fall

biomechanical, neuromotor, sensory (sensation, vestibular, visual)

22

3 components of sensory component of why people fall

vision, sensation, vestibular

23

evolution of falls

history: circumstances, meds, fear of falling, comorbidities
PE: orthostatic BPs, eval of sensory systems--vision, sensation, vest., neuro assessment, cognitive assessment, timed up and go test

24

cut off for "falls risk" with timed up and go test

>13. 5 seconds

25

4 ds of aging

dementia, delirium, depression, dying

26

older adults that are at risk of abuse

• Female
• Advanced age
• Dependent
• Problem drinker
• Intergenerational conflict
• Internalizes blame
• Excess loyalty
• Past abuse
• Stoicism
• Isolation
• Impairment
• Provocative

27

high risk caregivers

• Problem drinkers, med abuse
• Mental illness
• Caregiving inexperience
• Economically troubled
• Stressed
• Socially disengaged

• Blames others
• Abused as child
• Unsympathetic, hypercritical
• Unrealistic

28

signs ofabuse

• Frequent unexplained crying
• Unexplained suspicion or fear
• Physical findings
• Pattern bruises
• Genital, breast or anal bruising
• Contractures

29

T or F: you need to prove elder abuse to report it

F--adult protection will investigate

30

or which situations should screening tests for older adults not be followed?

low life expectancy or high comorbid conditions: • CHF (Class III, IV), ESRD, Severe COPD (home O2), Severe dementia (MMSE

31

rec'd breast cancer screening

every 2 years 50-74 +/- clinical breast exam (not hard evidence for it in this age group)

32

how to decide life expectancy of an older adult?

if many comorbidities "below average" if no comorbidities or few and high functional status "above average"

33

colorectal cancer screening in older adults

50-75 every 10 years with one of the 7 methods. after 75 perform screening on individual basis with RFs

34

cut off for cervical cancer screening

65 with 3 normal paps and not high risk

35

osteoporosis screen

at least once after 65 for women, 70 for men

36

BG screen in those over 65

every 3 years in those with BP > 135/80

37

AAA ultrasound in those over 65

Once for men 65–75 years who ever smoked

38

cholesterol screen in those over 65

Every 5 years, more often in CAD, DM, PAD, prior CVA

39

what health screens should be done every year in those > 65?

height, weight, BP, TSH in women, physical activity, smoking cessation, sexual activity, falls, incontinence, cognition, depression, vision and hearing, BMI, safety and preventing injury (including health care directives), influenza

40

when to screen for alcohol abuse in > 65 years?

initially and then when suspect abuse

41

T or F: there are no RCTs demonstrating a beneficial effect of multivitamins in the elderly

T

42

is hormone therapy recommended in those >65?

no

43

T or F: most biochemical measures are normal in older adults and aren't a good measure of nutrition

T

44

T or F: serum proteins (albumin) are a good measure of nutritional status in older adults

F. albumin affected by many things

45

t or F: chronic medical problems usually have a concurrent nutritional problem

T! see percentages of malnourished by disease in geriatric nutrition lecture

46

diseases that have risk of malnutrition

RA, COPD, renal failure, heart failures, stroke, dementia, hip fx, cognition issues

47

psychosocial issues that impair good nutrition intake in older adutls

depression, substance/etoh abuse, loneliness, isolation, decreased function, moving, poverty, end of life

48

how medications can impair intake in older adults

dry mouth, nausea, effect taste perception, decreased appetite

49

causes of significant rapid weight gain in older adults

renal or heart failure, ascites, edema

50

goal for obese older adults

maintain rather than gain (not lose--will lose lean muscle instead of fat)

51

T or F: in older adults BMI 25-30 is most protective

T! esp with chronic dz like HF or COPD

52

components of frailty syndrome (need 3 or more)

Weight loss >4.5 kg in past year
Exhaustion – often or most of the time
Very low to no physical activity
Low walking speed (6-7 sec)
Low hand grip strength

53

benefits of protein in older adults

decreased bone loss and muscle loss, increased bone density

54

4 RFs of failure to thrive

impaired physical function
malnutrition
depression
cognitive impairment

55

evaluation of FTT

 Lab / diagnostics
 MMSE, ADL, IADL, “Up & Go Test”
 Geriatric depression scale
 MNA ®
 Rx review
 Chronic disease evaluation
 Assess environment

56

hx and pe examination of FTT

Hx & Clin Dx
•Medical / surgical history
•Current Dx …including Rx
Clin. Signs & Phys Exam
•Inflammation present? fever, hypothermia, tachycardia, etc.
•Edema, wt gain/loss, nutrient deficiency symptoms
Anthropo-metrics
•Height, weight, BMI, waist circumferences, skin-folds…. body composition
Lab
•Serum albumin, prealbumin
•CRP, WBC, BG
•Neg N+ balance, ↑REE
Diet
•Diet history; 24-hour recall
Function Outcomes
•Strength and physical performance (gait, grip, stand/sit….)

57

decreased fluid needs in

CHF / COPD
SOB, pulmonary edema
Edema
Fluid overload
Hepatic ascites
Renal failure
Significant HTN
Third spacing fluid

58

increased fluid needs with...

Anabolism
Constipation/Diarrhea
Dehydration
Emesis
Fever
Fistulas / draining wounds
Hemorrhage
Hyperventilation
Heat
Medications
Hypotension
Polyuria
Use of air-fluidized mattress

59

#1 cause of dysphagia

stroke--always follow up and make sure they are eating OK

60

drugs that increase K excretion (risk of hypokalemia)

thiazide and loop diurectics

61

drugs that decrease K excretion

ACE, ARB

62

indications for enteral tube feeding

swallowing dysfunction, not alert, not expected to eat for 5-7 days,pancreatitis (can insert after the pylorus)

63

CI for enteral tube feedings

dysfunctional GI tract, hemodynamic instability, comfort care, refusal

64

causes of medication overuse

increasing comorbid conditions, multiple providers and poor communication, treating side effects of other meds, patient saving meds for later use

65

problems of polypharmacy

adverse drug reactions, drug-drug interactions, errors in taking meds

66

how do adverse drug reactions present in older adults?

usu a non-specific reaction, usu a loss of cognition or function

67

opiods to avoid in older adults

meperidine (risk of metabolite), pentazocine (CNS side effects), tramadol (increases seizure risk, don't use if personal hx of seizures or seizure RFs)

68

T or F: long term use of opioids is safer in older adults than NSAIDSs

true! see dr. alexanders handout

69

for which types of pain should opioids be used in older adults?

funcitonal impairment b/c of pain, decreaseD QOL b/c of pain, moderate to severe pain

70

good analgesic adjutants for neuropathic pain in older adults

antidepressants (TCAs, SNRIs) or anticonvulsants (GABA)

71

adjuvant meds for pain control of localized neuropathic pain

topical lidocaine

72

adjuvant pain control for inflammation/bone pain in older adults

corticosteroids

73

which drug is good at the end of the life to decrease discomfort from SOB?

morphine

74

criteria for hospice admission for alzheimers

Specific diagnosis: Alzheimer's, Lewy Body
•PPS of 30% and FAST of 7c or worse
•Documented history of significant decline in the prior 6-12 months and Medicare wants to see a 10% weight loss
•Lost the ability to ambulate and to make sensicalconversation
Need assist with 6/6 ADLs (eating, bathing, dressing, toileting, transferring and continence) and be incontinent of bowel and bladder
•History of pressure ulcers, skin breakdown and repeated infectionssupports admission
•Having multiple co-morbid chronic conditions also helps to justify admission

75

hospice eligibility for CHF and COPD

CHF should be NYHA class IV.Dyspnea at rest and O2 dependence.Medicare wants a history of multiple hospitalizations and exacerbations

76

hopsice eligibility for renal failure dx

For renal failure the GFR should be <15 or <10 with hyperkalemia and symptoms of renal failure: fatigue, nausea.

77

signs of active dying

cheyne-stokes respirations, signs of organs shutting down (no urine, jaundice, edema), cool extremities ,mottling of extremities from small capillary clots, low BP, fever, decreased consciousness, fatigue, restlessness, anorexia

78

advance directives are only for the end of life

F: they can be for at any other time in the persons life that they can't make a decision

79

health care agent or health care power of attorney

can make decisions about health care for the patient

80

living will aka health care instructions

set of instructions about a patients wishes of medical care esp that care intended to sustain life

81

DNR order

instructions not to do life sustaining measurs

82

good resource for end of life resources

honoring choices minnesota

83

5 D's to review your health care directives

decade, death, divorce, diagnosis, decline

84

intrinsic risk factors of falls for older adults in hospitals

Gait, balance issues
Peripheral neuropathy
Vestibular dysfunction
Muscle weakness
Vision impairment
Impaired ADLs
Advancing age
Dementia

85

extrinsic risk factors of falls in older adults

Environment Hazards
Poor footwear
Restraints/Tethers
Medications for sleep she recommends trazodone or melatonin

86

modifiable risk factors of delirium

Sensory impairment
Immobilization
Medications
Acute neurologic disease
Concurrent illness
Metabolic derangements
Surgery
Pain
Emotional distress
Disruption of sleep pattern

87

non modifiable risk factors of delirium

Dementia or cognitive impairment
Age >65yo
Hx of delirium, stroke, neurologic disease
Multiple comorbidities
Male sex
Chronic renal or liver disease

88

medications to avoid in delirium

opioids, anticholinergics: scopolamine, diphenhydramine, atropine, muscle relaxants (baclofen and cyclobenzaprine), benzos, barbituates, corticosteroids (ramp you up, can't sleep), dopamine agonists (bromocriptine, levodopa, pramipexole), H2 blockers

89

delirium dx

inattentive, and acute and fluctuating + either altered consciousness or disorganized thinking

90

work up of delirium

Review medications !!
Perform focused history and physical exam
Basic labs / studies:
CBC, glucose, lytes, Cr, BUN, Ca, UA, pulse ox, ekg
Offending drug? Remove it
Trauma or focal neuro finding? Head imaging
Infection? Treat it
No obvious etiology? Consider B12/folate, TSH, toxin screen, eeg, etc

91

supportive tx of delirium

Maintain hydration
Mobilize patient, avoid restraints
Reduce noise, limit staff changes
Orienting stimuli (glasses, hearing aides)
Maintain day/night cycle, sleep protocol
Manage pain
Reassurance
Bedside sitter
Feed them

92

T or F: fever may not be present in older patients with an active infection

T

93

indications for catheter use

acute urinary retention, to help a perineal sore heal, need for accurate Ins and outs in critically ill pt, periop use, requiring prolonged immobilization, end of life for comfort

94

6 ways to prevent pressure ulcers

Pressures ulcer assessment on admission
Reassess all patients for risk daily
Inspect skin of at-risk patients daily
Manage moisture
Optimize nutrition/hydration
Minimize pressure

95

Intrinsic RFs for ulcers

immobility, poor nutrition, incontinenc,e circulatory compromise,neurologic deficits (dementia, spinal cord injury)

96

scales to assess risk for pressure ulcers

norton scale, braden scale

97

ways to relieve prevent pressure ulcers in immobile older adults

reposition every 2 hours, remind people in wheelchairs to move every 15 minutes, use lifting devices not transfers when possible, , keep head of bed at lowest elevation, use foam or dynamic surfaces, keep good nutrition, change briefs at least every 2 hours, check skin daily, cleanse daily

98

when an ulcer is healing--do you decrease its stage?

no, a stage 4 is always a stage 4, just document state of healing

99

signs of wound healing

granulation tissue

100

scale to assess ulcer healing

PUSH (pressure ulcer scale of healing)

101

main RFs for osteoporosis

incrreasing age, prior fx, low BMI, female, smoking, etoh

102

DEXA scan rec'ds

>65 and <65 with FRAX >9.3%

103

when can you skip DEXA scan?

can make dx clinically by fragility fx: a fx in Spine, hip, wrist, humerus, rib, and pelvis
◦Occur from a fall from a standing height or less, without major trauma such as a motor vehicle accident

104

ways dz can present non specifically in older adults

Weakness/ Fatigue
Weight loss/ Failure to Thrive
Falls
Immobility
Incontinence
Cognition Change
Mood Change
Social Crisis

105

when do we treat bacteria in urine?

when they are symptomatic, many of them have bacteria in their urine all theme