Study Guide Q's: Medically Complex Older Adults Flashcards

Question

Non rebreather mask LPM and FiO2

Answer 1

LPM: 10-15 FiO2: 60-80%

Answer 2

LPM: Up to 15 FiO2: 54-75%

Answer 3

* Observations for the PT * Respiratory rate * Average is 12-20/min * Inspiratory: expiratory ratio * Normally 1:2 * 1:1 suggests hyperventilation and decreased PaO2 (anxiety, uncontrolled DM) * 1:3 suggests hypoventilation, increased PaCO2 (hypoxia) * Observe expansion of chest walls in all directions * Speech * Should have 12-15 syllables per breath at rest * Pulse ox * Up to 5-6% error rate * Accuracy decreases in dark pigmented patients * Earlobe is the most accurate placement * Auscultation * Normal vs. adventitious sounds

Answer 4

* Accounts for 1/3 of infections in nursing home residents * Causes * Primary cause: urinary stasis * Older women * Decreased pelvic floor strength * Decreased estrogen levels * Older men * Decreased bladder emptying due to BPH * Indwelling catheter How does this often present in an older adult? * S&S not always the same as in younger patients * Big change in older adults is acute delirium

Answer 5

* **Definition**: life threatening organ dysfunction caused by a deregulated host response to infection * Leading cause of hospitalization and most expensive inpatient condition

Answer 6

* Differentiated from infection by a dysregulated host response that results in **organ dysfunction** * Loss of **adaptive homeostasis in response to infection** * High degree or mortality risk with organ dysfunction * Urgency for early recognition of sepsis and prompt restraint * **Anti-inflammatory response** fails to develop * **Proinflammatory process becomes unregulated** * Results in a cascade of dysfunction * Increased microvascular permeability with transduction into the organs * Platelet sludging --\> capillary blockage, ischemia * Reperfusion injury * Dysregulation of vasodilatory and vasoconstrictive mechanisms * **Maldistribution of blood flow --\> shock** * **Immunosuppression from excessive anti-inflammatory response** Organ failure --\> multiple organ dysfunction syndrome

Answer 7

* Lactate \>18mg/dL * Hypotension * Fever \>103 degrees * HR \>90 BPM * RR \>20 breaths/min * Often confirmed infection from culture

Answer 8

* _Cardiovascular_ 1. Hypotension 2. Tachycardia 3. Elevated CO (drops with septic shock) 4. Systemic vascular resistance drops with septic shock 5. Hypoperfusion exacerbated -\> lactate accumulation * _Pulmonary_ 1. Tachypnea 2. Hypoxemia (VQ mismatch) 3. Respiratory alkalosis 4. Pulmonary edema and respiratory failure -\> ARDS * _CNS_ 1. Altered mental status 2. Encephalopathy 3. Polyneuropathy * _Renal_ 1. Oliguria (abnormal low urine production) 2. Azotemia (elevation in BUN & serum creatinine) * _GI_ 1. Impaired motility 2. Stress ulceration * _Hepatic_ 1. Elevated serum transaminase 2. Hyperbilirubinemia 3. Final stages: hepatic insufficiency * _Hematologic_ 1. Leukocytosis 2. Multifactorial edema 3. Thrombocytopenia and coagulation abnormalities 4. Disseminated intravascular coagulation (DIC) is a late stage manifestation that carries poor prognosis

Answer 9

sepsis --\> severe sepsis --\> septic shock

Answer 10

* **Definition:** abnormal circulatory and cellular metabolism profound enough to significantly increase mortality * Criteria * Persisting hypotension that requires vasopressors to maintain MAP at 65mmHg or greater * Blood lactate \>2mmol/L despite volume resuscitation * Mortality is 4x greater than when these criteria are met

Answer 11

* Sufficient evidence shows PT can be initiated in ICU/acute care once patient is medically stable (patients can safely respond to increased vascular and oxygen demands of physical exam and treatment) * Patient status can fluctuate daily, hourly, and by the minute * Response dependent management * Required moment to moment interpretation of patient response * Delivery of oxygen must match oxygen consumption

Answer 12

* Vestibular * Vertigo is the most common cause in older adults * BPPV * Cardiac origin * Syncope is more often the symptom than dizziness * ECG and Holter to monitor cardiac dysfunction * Echocardiogram to monitor blood flow * Orthostatic hypotension * Take positional BP to rule in or out OH * Medications * Antihypertensives * Diuretics * Sedatives

Answer 13

* How to determine * Ask the right questions * What brought on the dizziness? * What were you doing when you got dizzy? * Has it happened before? * Did you fall? * Comorbidities * DM * Cardiac * Medications * Anything that causes dizziness * Vitals * Check positional BP * Sensory assessment * Vision * Somatosensory * Vestibular * Nutritional status * Malnutrition * Dehydration

Answer 14

* Blunted thirst mechanism * Reduced total body fluid (decreased muscle mass, including body fat) * Decreased renal function * Physical/mental decline

Answer 15

1. Advanced age 2. Female gender (including % body fat) 3. BMI \<21 and \>27 4. Dementia 5. History of CVA, UI, infections 6. Use of steroids 7. Polypharmacy 8. Decreased functional independence

Answer 16

* Confusion * Lethargy * Rapid weight loss * Functional decline

Answer 17

Hypertonic dehydration Isotonic dehydration Hypotonic dehydration

Answer 18

water \> Na+ loss caused infection or hot temp

Answer 19

water = Na+ loss caused by vomitting or diarrhea

Answer 20

water \< Na+ loss caused by diuertics (most common cause in the older adult)

Answer 21

* Insulin resistance syndrome * **Definition**: Vicious cycle of obesity, decreased insulin sensitivity, higher levels of blood glucose, release of more insulin, elevated free fatty acids, reduced glucose oxidation, increased production of LDLs (elevates triglycerides and decreases HDLs) * 3 or more CV risk factors * Abdominal obesity * High triglycerides * Decreased HDLs * Increased BP * High fasting glucose

Answer 22

* Affects 30% of the US population * Increased incidence of **T2DM and CV events**

Answer 23

1. Weight loss 2. Fatigue 3. Low physical activity 4. Slow gait speed 5. Weakness

Answer 24

lost greater than 10 lbs uninentionally measured via scale or self report

Answer 25

exhaustion with regular activity measured by series of questions, 0-6 scale with higher score indicating fatigue

Answer 26

sedentary behavior \< 383 kcal/week for men, \<270 kcal week for women measured by sedentary activity pattern captured via series of questions

Answer 27

usual pace over 15 feet generally: less than 0.8 m/s 0. 65 m/s or less (W\<159 cm or M\<159 cm or M\>173 cm)

Answer 28

grip strength less than 30 kg for men and less than 20 kg for women sit to stand: less than 8 in 30 seconds

Answer 29

* Considers the number of deficits accumulated over time * Disability * Diseases * Physical and cognitive deficits * Psychosocial risk factors * Geriatric syndromes (falls, delirium, UTI, etc.) * 70 items * **Score of \>0.5: 100% dead in 20 months**

Answer 30

* Self report * Scores * 0 yes answers = no frailty * 1-3 yes answers = frailty risk * ≥4 yes answers = frailty risk * 3 criteria: gait speed, grip strength, and repeated chair stands * All predictive for frailty and 6 month mortality * Gait speed greatest indicator for multidimensional frailty * Scores * Gait speed * Grip strength \<25kg = 6x more likely to be frail * Chair stands \<7x in 30 seconds = 14x more likely to be frail

Answer 31

more than 10 seconds

Answer 32

less than 0.8 m/s

Answer 33

\<60 points indicates 4.4 higher risk of SNF placement during subsequent 6 years

Answer 34

physically active no restrictions few chronic conditions, if any

Answer 35

Gait speed \> 1.0-1.2 m/s 30s CRT with 15 reps or more independent floor transfer

Answer 36

adaptions to mobility life space mobility restricitons start impaired recovery from illness/injury

Answer 37

gait speed 0.8-1.2 m/s 30s CRT, 8-15 reps Modified floor transfer

Answer 38

loss of independence evident, needs assistance, life space restrictions

Answer 39

gait speed 0.5-0.8 m/s 30s CRT \<8 reps assistance for floor transfer

Answer 40

dependent ADL's/mobility inactive/dying life expectancy 6-12 months

Answer 41

gait speed \<0.5 m/s 30s CRT unable floor transfer unable

Answer 42

* Pro-inflammatory state * Blunted immune response * Autonomic dysfunction * Kidney dysfunction * Anemia * Malnutrition * Endocrine dysfunction

Answer 43

* Multifactorial * Genetic * Environmental * Metabolic * Lifestyle stressors * Acute and chronic diseases * Result in multisystem impairments across multiple physiologic systems * Impaired homeostatic mechanisms

Answer 44

* Progressive resistance exercise is a key component for treating frailty * Reduces biological age * Addresses sarcopenia * 12 week programs can show significant gains * High intensity effort is key * 40-80% 1RM * 8 reps for 1 set , working up to 3 sets * LE exercises are a priority over UEs * Also include core * Don’t forget power and agility

Answer 45

* Floor transfers * Learning to get up from the floor requires practice * Every patient returning home should learn this skill * Reduces risk of serious adverse health outcomes

Answer 46

nutrition hormone therapy pharm

Answer 47

* Mini Nutritional Assessment * Screen for weight loss * Screen for underlying cause * EEA supplementation * Vitamin D supplement

Answer 48

* SARMS and testosterone may treat sarcopenia * Results still inconclusive

Answer 49

* Medication review essential * Deprescribing * Statins * Glucocorticoids * Anticholinergics * Benzodiazepines * Vitamin D: 800-1000 IUs/day

Answer 50

* Regular engagement in moderate to vigorous physical activity * Cognitively stimulating activities * Healthy diet and supplementation as needed * Ideal sleep * Maintaining proper body weight * Metabolic control (blood sugar, blood pressure, blood lipids)

Answer 51

* Use assessment tool to identify key underlying deficits * Implement a multimodal approach * Medication management * Falls prevention * Nutritional support * Social/psychological support * Exercise program

Answer 52

* Prevalence * 12.6% of older adults over 50 * 10 million affected in the US * Causes * Primary: postmenopausal or idiopathic * Secondary: following disease condition * Risk factors * Post menopausal (estrogen deficiency) * Other hormonal factors * Hyperparathyroidism * Cushing syndrome * Sedentary lifestyle * Vitamin D deficiency * Cigarette smoking * Asian or Caucasian * Excessive caffeine consumption

Answer 53

* Osteopenia: low bone density that compromises the bone’s ability to absorb loads (lower than normal, but not as low as osteoporosis)

Answer 54

* T scores * WHO diagnostic classification in postmenopausal women or men over 50 * Cannot be applied to young population * *From Google: Your T-score compares your bone mass to that of a healthy young adult. The “T” in T-score represents the number of standard deviations, or units of measurement, your score is above or below the average bone density for a young, healthy adult of your same sex.*

Answer 55

* Vitamin D + calcium * Ca+ at least 1000mg * Postmenopausal 1500mg * Vitamin D 800-1000 IU * Fluoride supplements * Promotes bone deposition * Bisphosphonates * E.g. alendronate (Fosamax) * Calcitonin * Secreted by a thyroid gland to lower blood calcium * Injected human parathyroid hormone * Decreases bone resorption * Raloxifene (Evista) * Selective estrogen modulators * Other: surgery to reduce kyphosis, realign vertebrae

Answer 56

* Regular weight bearing activities * Appropriately dosed strength training * Exercises to build bone strength * Standing / WBing exercises * Strengthening, flexibility, and balance activities * \*Dosage depends on degree of bone loss and level of fitness * Exercises to avoid * Trunk flexion and excessive rotation * High impact exercises * Joint mobilizations/manual percussion * Patient education * Customized exercise program to promote strength while minimizing the risk of injury * Nutrition: calcium and vitamin D * Fall reduction * Appropriate use of AD * Home assessment * Medication review