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
–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
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?
–Decreased lens accommodation
–Poor dentition/false teeth
What are some things to be aware of regarding the lung and chest exam?
• 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?
–Vaginal and labial atrophy
•Squamous cell cancer
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
•Quality vs. quantity of life
Falls, or gait disturbances are multifactorial in etiology. How do we evaluate this functional impairment?
- Gait and balance
- Neuro Exam
- Cardiac exam
- lab tests
- 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?
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.
»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
»Treat underlying infections
How do we manage stress incontinence?
»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
–Prostatic enlargement – the prostate is always growing in men under the influence of testosterone
» Treatment Medication
•Alpha adrenergic antagonists
– Treatment with augmented voiding maneuvers
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)
–Electrolytes, BUN, creatinine, TSH, calcium
–Colonoscopy – carcinoma?
–CT of the abdomen
What are good treatments for constipation?
•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?
•Spoiled food in refrigerator
•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
•Parkinson’s disease related dementia
•Alzheimer’s dementia (SDAT)
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)
•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