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What are the definitions of geriatrics?

Over 65 per social security act of 1935

Young old 65-74

Middle old 75-84

Old old beyond 85 and up


What are some unique aspects of taking a geriatric history?

–Always review medications
–Assess activities of daily living
–Often have concomitant and complex medical problems
–Cognitive impairment
–Difficulty with communications


What are some reasons that the elderly patient might have trouble communicating?

•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


What things should we be on the look out for regarding pulse and BP?

–Atherosclerosis and tissue perfusion
–Often have orthostatic changes


What are some things to be aware of as far as HEENT exam goes?

–Temporal arteritis
–Decreased lens accommodation
–Poor dentition/false teeth
–Decreased olfaction


What are some things to be aware of regarding the lung and chest exam?

–Kyphotic changes
         • Decreased lung capacity
–Increased incidence of breast cancer


What percentage of octogenarians have a systolic murmur?


•Aortic stenosis, aortic sclerosis , mitral regurgitation, atrial septal defects, tricuspid regurgitation


What should we be looking for in the abdominal exam?

–Often present atypical/asymptomatic
•Perforation, ischemia, inflammatory


Genitourinary exam of the elderly should look for what?

–Prostatic hypertrophy
–Vaginal and labial atrophy
•Squamous cell cancer
•Vaginal bleeding


What problems related to the musculoskeletal exam are common in the elderly?

–Deformities related to arthritis
–Compression fractions and kyphosis


What are some elements of the neuro exam that are high points for the elderly patient?

–Gag/speech – aspiration


What are the focuses of geriatric care?

•Reduce nursing home placement
•Reduce hospitalization
•Quality vs. quantity of life
•Socio-economic issues


Falls, or gait disturbances are multifactorial in etiology.  How do we evaluate this functional impairment?

  1. HP
  2. Gait and balance
  3. Neuro Exam
  4. Cardiac exam
  5. lab tests
  6. PT evaluation


To test gait and balance, what do you do?

"get up and go test"


What are the consequences of falls?

•Subdural hematoma – mental decline
•Fracture (hip fractures are associated with up to a 50% mortality at 1 year)
•Nursing home placement


Urinary incontinece is more common in females (short urethra, child birth), it increases with age, common factor leading to institutionalization/social isolation.


What are the four types?

»Stress incontinence
»Urge incontinence
»Overflow incontinence
»Functional incontinence


How do you evaluate urinary incontinence?

»Functional alertness/capacity, CHF, abdominal exam (distention), genital exam
»CBC, U/A, blood sugar, imaging (Renal U/S), culture
»Post void residual – evaluation of emptying


What are the coping strategies for urinary incontinence?

»Pads, hand-held urinals, bed pans, bedside commodes, etc.
»Social isolation
»Foley (indwelling) catheters are a poor choice for management – a last resort


What are the downsides to the foley catheter?

•Limits mobility and is a safety risk
•Significant cause of infection


How do we treat urge incontinence?

–Bladder training/toileting schedule
»Anticholinergic medication - detrusor muscle instability
»Reduce/eliminate caffeine
»Treat underlying infections


How do we manage stress incontinence?

–Kegel exercises
»Estrogens – some data reveal that oral estrogens make the condition worse
»Alpha adrenergic agonists
–Surgery urethropexy or pubovaginal slings
–Pessary – uterine prolapse


How do you manage overflow incontinence treatment?

–Post void residual urine volume is elevated

–Fecal Impaction

–Prostatic enlargement – the prostate is always growing in men under the influence of testosterone
» Treatment Medication
•Alpha adrenergic antagonists

– Treatment with augmented voiding maneuvers
»Suprapubic pressure
»Valsalva maneuver
»Intermittent catheterization


Constipation is patient specific, decreased frequency of bowel movements for the particular individual, but usually fewer than three evacuations a week.  

What does this include?

–impaction that requires

manual disimpaction, incomplete elimination, painful elimination, dry/hard stool


What are some of the etiologies of constipation?

•Medication - opiates, anticholinergics, antidopaminergic, calcium channel blockers
•Mechanical obstruction – tumor, prolapse, adhesions
•Neurological – CVA, MS
•Systemic – hypothyroid, diabetes, inflammatory, electrolyte disorders
•Dehydration and inactivity


How should we evaluate for constipation?

–Medications,  fluid intake,  disease history
–Abdominal distention and pain
–Rectal exam – tone, impacted stool, hemorrhoids, strictures, or fissures
–Neurological exam – rectal tone (spinal cord impairment)
•Lab test
–Electrolytes, BUN, creatinine, TSH, calcium
–Colonoscopy – carcinoma?
–Abdominal X-ray
–CT of the abdomen


What are good treatments for constipation?

•Bulk laxatives
•Osmotic agents
•Stool Softeners
•Maintaining physical activity


When are bulk laxatives not adviseable?

–The exception is for treatment opiate-induced constipation, need to use peristaltic stimulants


What are risk factors for pressure ulcers?

–immobility, poor nutritional status, incontinence, vascular insufficiency, altered level of consciousness 


What are pressure ulcers?

ischemic soft tissue injury usually over a boney prominence


The Braden scale is a risk assessment tool.  What are the stages of pressure ulcers?

•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


How do we prevent pressure ulcers?

•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


How do we treat pressure ulcers?

•Moist dressings (allow for a healing environment), antibiotics for infection, surgical debridement, enzymatic debridement, consider osteomyelitis – non-healing wounds


People may have benign senescent forgetfulness.  What is this?

•mild recall/memorizing inability


What does dementia include?

•loss of memory, language, visuospatial orientation, executive functions


What are causes of depression in the elderly?

–Inadequate finances, loss of spouse/significant other/children, functional decline
–Widely under recognized due to its non-specific presentation


What kind of dangers does sensory impairment present to elderly patients?

–Olfaction loss
•Spoiled food in refrigerator
–Vision loss
•Presbyopia, cataracts, open-angle glaucoma, macular degeneration, diabetic retinopathy
–Hearing loss leads to isolation, frustration of others
•Presbycusis – high frequencies followed by speech frequencies
–Decrease in thirst perception 


How does dementia present initially?

–Presents as a slow, progressive disease
•Impaired memory and new learning
•Behavior and personality changes


What are the types of dementia?

•Multi-infarct (vascular) dementia
•Lewy Body dementia
•Alcoholic  dementia
•Parkinson’s disease related dementia
•Alzheimer’s dementia (SDAT)
•Pseudo-dementia (depression)
•Pick’s disease


Some underlying etiologies of potentially reversible  dementia include?

•B-12 deficiencies, normal pressure hydrocephalus, neurosyphilis, hypothyroidism, seizure disorder


What are some management strategies for dementia?

•Lab test/ Evaluation – Rule out reversible causes
–Imaging of the brain, CBC, BMP, TSH, VDRL, B-12 level, EEG, GDS
•Cholinesterase inhibitors and/or NMDA receptor antagonists
•Antidepressants (SSRIs,  SNRIs)
•Structured day
•Simple, calm and direct communication
•Realistic goals (caregiver denial)
•Attention to safety
•Agitated or aggressive
–Antipsychotics, benzodiazepines, anticonvulsants, and serotonergic compounds
–Contributes to physical deconditioning, pressure sores, depression, disorientation


What qualifies as polypharmacy?

More than 5 medications