KC Geriatrics

Question 1

*2 reasons why it is hard to get an abdominal pain history in elderly patient

Answer 1

• Vague symptoms
• Cognitive deficits (e.g. dementia, increased risk of delirium)
• Physical deficits (e.g. hearing)

Question 2

*3 reasons why the physical exam may be unreliable in geriatric patients

Answer 2

S

Question 3

*End of life symptom management re: secretions

Answer 3

Glycopyrrolate, Octreotide, Atropine

Question 4

*End of life symptom management re: anxiety

Answer 4

Benzos

Question 5

*Criteria for MAID

Answer 5

18 years old and mentally competent
Resonable foreseeability of natural death
Make a volunarty reqyest for main that is not under duress or influence

As per the latest updates you do NOT need to have a fatal or terminal condition to be eligible for MAID (opens it up to those with mental disorders)

Question 6

*What are 5 environmental risk factors for falls in the elderly?

Answer 6

Clutter, lack of stair railings, loose rugs or other tripping hazards, lack of grab bars in the bathroom, and poor lighting, especially on stairs.

Question 7

*What are 4 patient-specific risk factors for falls?

Answer 7

Weakness, balance or gait deficit, visual deficit, mobility limitation, cognitive impairment, impaired functional status, and postural hypotension

Question 8

*1 med that increases mortality with falls/trauma

Answer 8

Warfarin

Question 9

*3 meds that alter the trauma exam

Answer 9

Sedatives - alter GCS
BB - alter HR
CCB - decrease BP

Question 10

*75 year old lady with rheumatoid arthritis falls from standing height and has midline neck tenderness without LOC or paresthesias. On methotrexate. What are two reasons that she is at high risk from this injury?

Answer 10

• Age
• Rheumatoid arthritis (prone to rupture of C2 transverse ligament)

Question 11

*What are two c-spine fractures commonly seen in elderly patients with falls?

Answer 11

• Chance fracture (flexion-distraction injury, flexion fracture of vertebral body, distraction injury of posterior elements)
• Odontoid fracture (type 2)

Question 12

*What are the 2 most common UE fractures in the elderly?

Answer 12

Distal radius, proximal, humerus, elbow (distal, proximal, middle)

Question 13

*What is the most common LE fracture in the elderly?

Answer 13

Ankle, Hip and pelvis, tibial plateau (distal, proximal, middle)

Question 14

*What are 2 changes with aging that increase the risk of C-spine injury?

Answer 14

Cervical stenosis, osteopenia/porosis

Question 15

*Describe the radiologic findings in a Type II odontoid fracture & is it stable or unstable?

Answer 15

Type II odontoid fractures, at the base of the dens at its attachment to the body of C2, are the most common C-spine fracture in older trauma patients. Could be considered unstable.

Question 16

*List 4 strategies that may be employed to prevent overuse of medications in the geriatric patient

Answer 16

Stepwise Approach to prescribing for older adults
- periodic review of current drug therapy
- discontinue unneccary medications
- consider non-pharmacological alternative strategies
- consider safer alternative medications
- use lowest possible dose
- simplify dosing schedule
- Dosette/dispill

Question 17

*List one change that occurs in aging for each of the following categories and the pharmacodynamic effect it has on medications
i. Metabolism
ii. Absorption
iii. Distribution
iv. Elimination

Answer 17

i. Metabolism Decreased, increases drug potency
ii. Absorption Decreased, may decrease drug potency
iii. Distribution Increased, elderly have higher adipose tissue → dynamics depends on drug (if higher Vd then higher potency)
iv. Elimination Decreased, increases drug potency

Question 18

*List 4 Elder RF for elder abuse

Answer 18

Functional dependence or disability
Poor physical health
Cognitive impairment/dementia
Poor mental health
Low income/socioeconomic status
Social isolation/low social support
Previous history of family violence
Previous traumatic event exposure
Substance abuse

Question 19

*List 4 types of elder abuse

Answer 19

Physical abuse
Sexual abuse
Emotional abuse
Neglect
Self neglect
Abandonment
Financial/material exploitation

Question 20

*List 4 Caregiver RF for elder abuse

Answer 20

Mental illness
Substance abuse
Caregiver stress
Previous history of family violence
Financial dependence on older adult

Question 21

List the diagnostic criteria for delirium

Answer 21

1. Acute change of mental status or fluctuating course AND
2. Inattention AND
3. Disorganized thinking or 4. altered LOC This is according to Bcam the actual DSM differential is
4. Acute and fluctatuting
5. Abnormality in attention and awareness
6. Alteration in cognition such as perception or disorganzed thinking
7. Not dementia not coma

Question 22

List 5 ADLs and 5 IADLs

Answer 22

Basic ADLS (DEATH) - dressing, eating, ambulatory, toileting, hygiene
Instrumental ADLs (SHAFT) - shopping, housekeeping, accounting, food prep/meds, transportation. These are higher level societal functions

Question 23

List 5 age related cardiovascular changes

Answer 23

Box 183.2 Decreased arterial compliance, myocardial cell hypertrophy, apoptosis of pacemaker cells, decreased responsiveness to beta stimulation, fibrosis and calcification of heart cells

Question 24

List 5 reasons diagnosis can be challenging in an geriatric patient

Answer 24

altered pain perception, aging effects on the immune system, medications that limit tachycardic response to stress, decreased ability to mount a febrile response to infection, presentation with more generalized or vague symptoms, delayed presentation due to transportation barriers, lack of abnormal laboratory values

Question 25

List 10 features of a geriatric friendly ED

Answer 25

Staffing: geriatric nurse manager, interdisciplinary geriatric assessment team (physiotherapy, occupational therapy, social work) Education: for staff physicians and nursing Policies: standardized screening for delirium and dementia, approach for identification of elder abuse, pain protocol, medicine reconciliation protocol, order sets for common ED presentation (ex. delirium) Quality improvement initiatives with outcome measures on repeat ED visits, hospital admissions Equipment: walkers, canes, non slip socks, pressure ulcer reducing mattresses, hearing devices Physical space: natural light, noise reduction, non slip floors, handrails, wheelchair accessible toilets, large analog clocks, easy access to food and drinks See ACEP policy for full details See Rosen's e.8 for more

Question 26

Describe modifications to ATLS in the geriatric patient

Answer 26

Airway: potentially difficult BVM/intubation (toothless, cervical arthritis). Use 1/2 doses RSI drugs Breathing: less reserve, more likely to tire Circulation: medications (ex. beta blockers) may blunt tachycardic response (vitals may be insensitive for shock), systemic hypertension is common so normotension may indicate hypovolemia, more likely to be anticoagulated and are at a higher risk of hemorrhage Disability: higher risk of head and C spine injuries; more liberal imaging Exposure: Increased risk of fractures due to osteoporosis, more likely to develop hypothermia, more likely to develop skin ulcers

Question 27

What are 3 risk factors for MVCs in the elderly? 

Answer 27

Cognitive impairment Decreased hearing and vision Slow reaction time

Question 28

 Mention 3 reasons why elderly are more vulnerable to injury?

Answer 28

Osteoporosis —> higher risk of # Thin skin and subcutaneous tissue —> Lacerations Anticoagulation/ASA —> bleeding comorbidities/meds (BBs) —> Blunted physiologic response to injury Brain atrophy and bridging veins —> SDH Osteophytes/spinal stenosis —> hyperextension spine -> central cord syndrome

Question 29

What is the difference between pharmacokinetics and pharmacodynamics

Answer 29

Pharmacokinetics is the metabolism of the drug: absorption, distribution, metabolism, elimination Pharmacodynamics is the actual effect of that drug

Question 30

List 5 pharmacokinetic changes in the older adult

Answer 30

Table 185.1 Absorption is unpredictable. Decreased with increase in gastric pH, increased c/o decreased gastric/bowel motility and prolonged transit time Distribution is affected by decreased muscle mass and increased fat stores. Higher volume of distribution and accumulation for lipophilic drugs ex. opioids. Lower volume of distribution for hydrophilic drugs ex. digoxin Metabolism is decreased due to decreased hepatic function Elimination is decreased due to decreased creatinine clearance Polypharmacy may alter drug metabolism

Question 31

List 5 reasons why geriatric patients are more prone for adverse drug reactions

Answer 31

altered pharmacokinetics and pharmacodynamics (see list above), more medications, more comorbidities, physiologic changes of aging

Question 32

List 1 drug that elderly patients have decreased sensitivity to

Answer 32

beta adrenergic receptors agonist and antagonists

Question 33

List 5 drugs that elderly patients have increased sensitivities to

Answer 33

calcium channel blockers, benzos, propofol, opioids, neuroleptics, warfarin

Question 34

How do you calculate creatinine clearance

Answer 34

[(140-age)*weight/(72*creatinine) * 0.85 if female 

Question 35

For each of the following drugs list another that can interact with it: ACE/ARB, theophylline, phenytoin, digoxin, warfarin

Answer 35

ACE/ARB: Septra -> hyperkalemia Theophylline: Cipro Phenytoin: Septra Digoxin: Macrolides Warfarin: NSAIDs, most antibiotics

Question 36

List 3 common ED medications in the BEERs list

Answer 36

Diphenhydramine, Diazepam, Clonidine [Box 185.3]

Question 37

List 5 medications that should be STOPPed in the ED

Answer 37

[Table 185.4] Benzos, NSAIDS w hypertension, NSAIDs + warfarin, NSAIDs + renal failure, opioids (long term), antihistamines/anticholinergics, beta blockers + COPD

Question 38

List 5 signs on history that may suggest elder abuse

Answer 38

Poor living conditions (collateral from paramedics) Frequent/unexplained injuries, delay in onset in care, repeat ED visits, multiple physicians involved 'Doctor Hopping' Strained interaction with caregiver, inconsistent history between caregiver and patient, caregiver unable to give details on the patient's medical history, caregiver answers all questions on behalf of the patient, abandonment of the patient in the ED by caregiver Elderly patient referred to as 'accident prone'

Question 39

List 5 physical signs that may suggest elder abuse

Answer 39

Bruising in atypical locations, patterned injuries, burns/immersion patterns, multiple injuries of different ages, intraoral lesions, wrist or ankle lesions (suggests restraints), scalp hematomas Genital, rectal, or oral trauma, evidence of STIs Cachexia/malnutrition, dehydration, pressure sores, poor body hygiene, dirty clothing, elongated toenails, poor oral hygiene

Question 40

When is reporting of elder abuse required

Answer 40

When the patient lives in a LTC facility