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Flashcards in Geriatrics Potpourri 3 Deck (51):
1

What is the leading cause of adult blindness in the developing world?

Age-Related Macular Degeneration (AMD)

2

Impacts of Age-Related Macular Degeneration (AMD) on the elderly?

1. Ability to drive
2. Increased rates of falls
3. Ability to live independently

3

1. What is AMD?

2. Early AMD usually presents how?

3. Results in the loss of what?

1. Degenerative disease of the central portion of the retina (macula)

2. Early AMD is often asymptomatic

3. Results in loss of central vision primarily

4

Classifications of AMD? 2

1. Dry (atrophic)*

2. Wet (neovascular or exudative)

5

Describe the following types of AMD:
1. Dry (atrophic)*? 2

2. Wet (neovascular or exudative)?
2

1. Dry (atrophic)*
-Ischemia

-Retinal epithial cell apoptosis/activating inflammation

2. Wet (neovascular or exudative)
-Balance between substances that promote or inhibit blood vessel development

-Vascular endothelial growth factor (VEGF)

6

AMD Risk factors?
7

1. Age
2. Smoking
3. Genetics
4. CVD
5. Diet?
6. Cataract surgery?
7. Possibly alcohol

7

AMD Hx questions? 4


Vision loss occurring over days or weeks requires what?

1. Rate of vision loss
2. Whether one or both eyes involved
3. Loss near or far vision or both
4. Acute distortion of loss of central vision—may be wet AMD


urgent ophthalmic referral

8

Ophthalmologic Evaluation
for Dry? 3

For wet? 3

Dry:
1. Drusen appears as bright yellow spots
2. Atrophy appears as areas of depigmentation
3. There may be increased pigmentation

Wet:
1. Subretinal fluid/and or hemorrhage
2. Neovascularization—appears as grayish-green discoloration
3. Often require fluorescein angiogram

9

Treatment for dry? 1
-To slow progression? 3

Wet? 3

Tool for detecting AMD?

Dry:
1. None
2. For slowing the progression:
-Antioxidants with Vitamin C, E;
-beta carotene,
-zinc & copper (in smokers NO beta carotene)

Wet:
1. VEGF inhibitors
2. Photocoagulation
3. Surgery

Tool for detecting disease progression: Amsler Grid

10

What are the types of glaucoma?
4

Most common?

1. Acute angle glaucoma

2. Secondary glaucoma
3. Congenital glaucoma

4. Primary open-angle glaucoma: most common

11

Subtypes of secondary glaucoma?
3

: many subtypes
1. Uveitis
2. Old trauma
3. Steroid therapy

12

Characteristics of POAG?
3


Disease must be screened for

1. Optic neuropathy—optic disc described as “cupping”

2. Peripheral visual field loss followed by central field loss—cannot be recovered

3. No symptoms initially


Disease must be screened for

13

POAG—Risk Factors
4

1. Elevated IOP:

2. Increasing age w/ increased risk of blindness

3. African Americans have 4-5 times greater risk

4. Family history

14

What is a normal IOP?

Normal range 8-22 mg Hg


Exact relationship between elevated IOP & cupping not well understood

15

1. POAG screening?
-Done by who?
-How?

2. Tx? 3

1. Screening:
-Generally done by specialist with specialized equipment
-Can examine optic disc for cupping—cup > then 50% of the vertical disc diameter is suspicious

2. Treatment:
-Topical and systemic medications
-Laser therapy
-Surgery

16

Angle-Closure Glaucoma
What is the difference between primary and secondary?

1. Primary:
-patients anatomically predisposed
-No identifiable secondary cause

2. Secondary:
-Secondary process responsible for closure of the anterior chamber angle

17

Examples of secondary angle closure glaucoma? 2

1. A fibrovascular membrane grows over the angle

2. A mass or hemorrhage in the posterior segment pushes the angle closed

18

ACG—Risk Factors
6

1. Family history
2. Age older then 40-50 years
3. Female
4. Hyperopia (farsightedness)
5. Pseudoexfoliation
6. Race:

19

What races are most at risk for ACG? 2

Least? 2

1. Highest in Inuit and Asian populations

2. Lower in African and European origins

20

ACG—Presentation
1. Pressure rising acutely: symptoms? 5


2. Signs? 4

1.
-Decreased vision
-Halos around lights
-Headache
-Severe eye pain
-N/V

2. Signs:
-Conjunctival redness
-Corneal edema or cloudiness
-Shallow anterior chamber
-Mid-dilated pupil (4-6mm); reacts poorly to light

21

ACG
1. Severity?
2. Management?
3. In how long or else what?
4. Guided by what?
5. Tx aimed at doing what?

1. Ophthalmologic emergency

2. Immediate referral for further evaluation and definitive treatment:
3. If there is an hour or more delay to treatment empiric therapy should be started
4. This should be guided by the consultant
5. It is aimed at lowering IOP

22

What is the leading cause of blindness in the world?

Cataract

23

Cataract—Risk Factors
7

1. Age: predominant
2. Smoking: two-fold increase
3. Alcohol
4. Sunlight exposure
5. Metabolic syndrome
6. DM
7. Systemic corticoid steroid use*

24

Cataract presentation? 3

PE findings? 2

Presentation:
1. Painless, progressive process
2. Patients usually complain of problems w/ night driving, reading road signs or difficulty w/ fine print
3. Often increase in nearsightedness (myopic shift)

PE:
1. Lens opacity can be confirmed by fundoscopic exam
2. May see darkening of the red reflex, opacities or obscuration of ocular fundus detail

25

Cataract Treatment?

Surgery

26

Cataract Surgery Pre-op evaluation should include? 3

Complications? 2

Pre-op: Extensive evaluation not necessary
1. HTN should be controlled
2. Endocarditis prophylaxis not needed
3. Risk of bleeding w/ aspirin or warfarin (coumadin) is low so meds can usually be taken

Complications:
1. Endophthalmitis
2. Retinal detachment

27

Hearing Loss in the Elderly
Most common presentation presbycusis?
3

1. Sensorineural
2. Bilateral
3. Beginning in the high frequency range (4000-8000Hz)

28

Presbycusis—Risk Factors
9

1. Lifetime exposure to noise
2. Genetics
3. Medications
4. Older age
5. DM
6. Cerebrovascular disease
7. Smoking
8. HTN
9. White race

29

Presbycusis
Presentation? 3

Associated symptoms? 2

1. Presentation:
-Complain of inability to hear/understand speech in crowded or noisy environment
-Difficulty understanding consonants
-Inability to hear high pitched voices or sounds

2. Associated symptoms:
-Tinnitus
-If hearing a pulsatile noise in one ear should further assess w/ MRA or MRI to R/O glomus tumor or AV malformation

30

Screening for Hearing loss should begin when?

Screening for hearing loss > age 60

31

Hearing Amplification
1. Should be done through who?

2. Describe the efficiency of hearing aids?

1. Should be done through a licensed audiologist!

2. Hearing aids do not restore hearing to normal!
-For example a 60 dB loss could be improved to a 30 dB range

Sometimes two hearing aids are better, sometimes one

32

Subclinical Hypothyroidism
Defined how?

Data link subclinical hypothyroidism w/ what? 2

1. Defined as a normal T4 with a elevated TSH

2. atherosclerosis and MI

33

Subclinical Hypothyroidism: Tx Recommendations?
3

1. TSH =/> 10 mU/L treat
2. TSH between 4.5 – 10 mU/L in persons less than/= 65YO with sx suggestive of hypothyroidism
3. Treating persons >/= 65YO increase risk of cardiac arrhythmias
4. 4.5 to 8 in those over 70 then they should not be treated

34

COPD
1. What is it?
-two types?

2. Periodic exacerbations are characterized by what?

1. Slow progressive irreversible airway obstruction:
-Chronic bronchitis
-Emphysema

2. Periodic exacerbations:
-Increased dyspnea
-Infections
-Respiratory failure

35

Pathophysiology—Air Flow Obstruction: from what? 3

1. Increased mucous in bronchioles

2. Inflammation

3. Decreased ciliary movement

36

What is the definition of chronic bronchitis?

Chronic bronchitis is when a cough with mucus persists for most days of the month, for at least three months, and at least two years in a row.

37

Characteristics of Chronic Bronchitis?
4

1. Overweight and cyanotic
2. Elevated Hemoglobin
3. Peripheral edema
4. Rhonchi and wheezing

38

What is Emphysema?

Pathologic dx, permanent enlargement and destruction of airspaces distal to the terminal bronchoiles

39

Characteristics of Emphysema? 4

1. Older and thin
2. Severe dyspnea
3. Quiet chest
4. On x-ray, hyperinflation and flattened diaphragm

40

COPD: Air flow obstruction leads to? 3

1. Increase residual volume and functional capacity
2. Total lung capacity often increased
3. Vital capacity decreased

41

What is the main tx for COPD?

Treatment additions for COPD? 3

1. O2

2.
-Short acting beta-agonists

-Short acting anti-cholinergics

-Glucocorticosteroids

42

Complications COPD
5

1. Cor Pulmonale
2. Pneumonia
3. Pneumothorax
4. Polcythemia
5. Arrhthymias

43

Chronic Therapy for COPD
Usually involves what?

long term inhaled glucocorticoids

44

Long term inhaled glucocorticoids:
1. Local deposition effects? 3

2. Systemic SE? 3

1. Dysphonia
2. Thrush
3. Cough/throat irritation/reflex bronchoconstriction

1. Osteoporosis
2. Adrenal suppression
3. Increase intraocular pressure/cataracts

45

Signs of Worsening COPD
4

1. Decrease in BMI

2. Decrease in FEV1

3. Increased dyspnea on exertion

4. Need for O2

46

End Stage COPD
What should be involved in management? 5

1. Hospice
2. Control any pain
3. Usually bedridden
4. Support family
5. Get living will in ADVANCE from patient—don’t want to put them on a ventilator they can’t come off of!

47

Community Acquired Pneumonia: Predisposing conditions?

8

1. Smoking
2. Alcohol consumption
3. Pulmonary edema
4. Malnutrition
5. Administration of immunosuppressive agents
6. Being >/= 65 years of age **
7. COPD
8. Previous episode of pneumonia

48

CAP
Pathogens? 4

Risk factors for drug resistance? 5


Tx?

Complicated—comorbidities/recent antibiotic use? 2

Pathogens?
1. Strep Pneumo
2. H. influenzae
3. Chlamydia
4. Viruses 10-31%

Risk factors for drug resistance:
1. Age > 65 years
2. Antibiotic therapy within the last 3-6 months
3. Alcoholism
4. Medical comorbidities
5. Immunosuppressive illness or therapy


-Azithro

-Respiratory fluoroquinolones (minimum of 5 days)
-Amoxacillin-clavulanate

49

CAP: Indications for hospitalization?
4

Use CRB-65:
1. Confusion
2. Respiratory rate > 30
3. BP (systolic less than 90 mmHg or diastolic less than 60 mmHg)
4. Age >65 years


Scores:
0-1—treated as outpatient
2—hospitalized
3-4—consider ICU care

50

Residents of LTCF w/ pneumonia have a higher mortality then elderly patients in the community

Patients in LTCF have underlying factors? 4

1. COPD
2. Left heart failure
3. Aspiration
4. Use of sedating medications

51

Parameters for clinical tx in LTCF rather then hospitalization?
6

1. Able to eat and drink
2. Pulse less than/= 100
3. Respiratory rate less than/= 30
4. Systolic BP >/= 90 or decrease of less than/=20 from baseline if /=92% or if pt has 6. COPD >/= 90%