Older adult Flashcards
Delirium
- Abrubt onset - hours to days
- rapidly progressive change in mental status
- memory imapired but variable recall
- Duration hours to days
- Usually reversal to baseline with treatment of underlying cause
- sun downing, sleep disturbance
- change in psycomotor activity
- perceptual disturbance - hallucinations
- speech incoherant, confused
- infection, medication, fracture - most common cause
- Screening tool CAM - confusion assessment method
Dementia
- insidous onset that cannot be related to a precise date
- memory loss, especially for recent events
- durration months - years
- chronically progressive - irreversable
- disturbed sleep wake cycle, no variability, day night reversal
- no psychomotor changes until late disease
- no perceptual changes unitl late
- word serching progressing to sparse speech to mute
- Standard therapy - minor/time-limited effects will not reverse disease
1. cholinesterase inhibitor: mild to mod disease - donazapril (Aricept), rivastigmine (Exelon)
2. Mod to severe disease - memantine (Namenda) - Screening: MMSE mini mental State Exam
Depression in Elderly
- onset can be gradual with exacerbation in times of stress
- difficulty concentrating - able to express what is forgotten
- lasts months to years without treatment
- reversible with proper tx
- poor sleep quality with early morning awakening
- decreased activity, lack of motivation
- no perceptual disturbance
- speech slow, flat, low
- Intervention: antidepressants
- Screening: Geriatric depression scale
MOst common contributors to development of delerium
DELERIUMS Mnemonic
* Drugs - new or adjusted dose- prblematic drugs: systemic anticholinergics (TCA, 1st gen antihistamine), 1/2nd gen antipsycotics, opioids, benzo, alcohol
* Emotional/Electrolyte disturbance - mood disorders (loss/grief), Hyponatremia
* Low PO2/lack of drugs - hypoxemia from CAP, COPD, MI, PE; lack of drugs (withdrawl from alcohol
* Infection: UTI, CAP
* Retention/reduced sensory input: urinary or fecal retention; reduced sensory input ( loss of glasses, hearing aids)
* Ictal or postictal phase
* Undernutrition: protein/calorie malnutrition, B12, folate, dehydration
* Metobolic/myocardial problems: poorly controlled DM, thyroid disease, MI/ACS, HF, dysrhythmia
* Subdural hematoma
Eval of New onset Altered Mental Status
Routinely indicated:
* UA, C&S : UTI common cause
* CBC w/diff: anemia, infection
* Serum electrolytes
* glucose
* BUN/Creatine
* Serum B12
* thyroid function
* liver function
* depression screen
Possibly indicated based on risk factors and presentation
* Brain imaging
* PET scan
* Toxic screen
* CXR if tachypnea
* ESR
* HIV
* RPR/VDRL - tertiary syphilis
* ECG - atypical presentation of ACS
* Genetic testing
Academy of nerology Standards of Alzheimer-type-dementia care
Slow decline
* Vit E 1000 IU BID or selegiline 5mg BID
Mild to mod stage
* cholinesterase inhibitor - increases availability of ACH
* donazapril (Aricept), rivastigmine (Exelon), glantamine (Razadyne)
Moderate to severe
* NMDA receptor antagonist - effect on glutamate
* use with cholinesterase inhibitor is helpul in early disease
* memantine (Namenda)
Treat agitation and depression:
* 40% with demential also have depressoin
* standard antidepressant therapy
Consider non AD resons for behavioral issues
* evaluate for pain, infection, and other clincal conditions
persistant agitation or psycosis- consider psycotropic meds
* 2nd gen atipsycotics: risperidone, however increased risk of stroke and MI, worsens insulin resistance, leading to weight gain and elevated TG
Fragility syndrome
- Syndrome of age-associated decline, characterized by increased vulnerability to advers health outcomes, increased risk of falls, delerium and disability
Dx meets 3 or more of the following
* unintentional weightloss at least 10lbs or >5%
* muscle weakness, as measured by reduced grip strength
* physical slowness - time to walk distance of 15 ft
* Poor endurance - self reported
* low physical activity - using standard assessment questionnaire
1st Line intervention
* treat underlying cause to avoid frailty, typically irreversible
* regular physical activity/exercise
* Caloric and protein support
* Vit D
* reduction of polypharmacy
Medications to avoid in frail elderly
- TCAs: amitryptyline - sig risk of orthostatic hypotention
- Sedatives: zolpidem (Ambien) - increased fall and fracture risk
- NSAIDS: naproxen (aleve) - potential to promote fluid retention and minimize effect of anti-HTN meds
- SSRI - sertraline (Zoloft) - Increased risk of hyponatremia, especially when used with diuretic
- Sysemic Anticholinergic: Oxybutynin (ditropan) - sig systemic anticholinergic effects when compared to other meds in class
Dizziness
- Sense of disturbed relashionship to space, but surroundings not moving
- feeling of lightheaddedness
- multiple causes including circulatory or neurologic disorders
- hypotension, parkinsosn’s, certain meds, axiety disorder, hypoglycemia, hyperthermia, dehydration
- treat underlying cause
Vertigo
- Surroundings are moving; sensation of motion with eyes closed
- Described as room spining
- usually inner ear disturbance - small crystals within the inner ear become displaced and incorrectly stimulate nerve cells within the semicircular canal
- Causes: inflammation of inner ear, meniere’s disease, head trauma, stroke, MS, tumors, certain types of migraine HA
- treat underlying cause
Syncope
- transient loss of consciousness characterized by loss of postural tone, typically sudden in onset, with not warning and spontaneous recovery
- passed out woke up on floor
- neurologic - fear, pain, anxiety
- situational - cough, defication
- cardiac - cardiomyopathy, outflow obstruction, dysrythmia,
- circulatory - medications, orthostatic hypotension, dehydration
- treat underlying cause
Peripheral Artery Disease
Presentation
* Leg pain and numbnessduring activities (intermittent claudication)
* persistant infections or soress on the leg and feet
* skin pale or bluish color
* some may be asymtomatic
Etiology
* * systemic build-up of plaque in arteries limiting blood flow
* smoking is the main risk factor, other factors: age, HTN, hpercholesterolemia, elevated blood sugar
Dx:
* ABI <0.9: doppler US, or MRI to assess blood flow;
* tredmill test to evaluate severity of symptoms
* arteriogram to id blockages
Tx
* lifestyle mods: smoking cessation, weightloss
* manage HTN, Cholesterol, blood sugar
* antiplatlets to prevent clots
* Cilostazol and pentoxifylline to reduce claudication pain
* surgery improves blood flow
Venous Insufficiency
Presentation
* symptoms include burning, swelling, throbbing, cramping, aching, heaviness in the legs
* restless legs and leg fatigue
* telangiectasias
Etiology
* Congenital absence of or damage to venous valves resulting in reflux through superficial veins
* thrombus formation can also cause valve failure
Dx
* physical exam of vein apearance
* Duplex US can be used to assess blood flow and r/o other casues
Tx
* Lifestyle changes physical activity, weight loss
* compression stockings to decrease swelling
* sclerotherapy or ablation of refluxing superficial veins
Peripheral Neuropathy
Presentation
* gradual onset of numbness and tingling in hands, feet
* burning pain, sharp electric like, muscle weakness
* exteme sensitivity to touch
Etiology
* damage to nerves extending peripheral system
* DM most common cause
Dx
* nerve damage ID by nerve function test, or nerve Bx
* H &P to id underlying cause
Tx
* mild pain - NSAIDS
* anti-sezure and antidepressants meds, lidocaine patch
* Tanscutaneous nerve stimulation
