Possible signs of loneliness include: 1. 2. 3. 4. body language with a ‘defeated’ demeanour 5. prolongation of visit including holding on to one’s hand

1. verbal outpouring 2. drab clothing 3. dependence on television

The Elderly Patient Flashcards by MA CARMELA CONCEPCION SALES

The ageing ________ are the fastest growing
section of the Australian population. The number of
‘old-old’ _______ is increasing at an even faster
rate.1

(over 65 years)

over 85 years

How well did you know this?

Not at all

Perfectly

Life expectancy has risen to _____ years for women

and _____ for men

79. 7

How well did you know this?

Not at all

Perfectly

The over-65s in 2001 made up ______of the Australian

population (13.4% in the US)

12.7%

How well did you know this?

Not at all

Perfectly

The over-65s use twice the number of health services
per head of population. They account for____ of all
hospital costs and 75% of all _______ costs

25%

nursing home

How well did you know this?

Not at all

Perfectly

Ageing is characterised by the following:

decrease in______
reduction in the _______ of organs
reduced capacity to adapt to______
increased vulnerability to disease
increased probability of death

metabolic mass

functional capacity

stress

How well did you know this?

Not at all

Perfectly

Degenerative cardiovascular disease emerges with ageing
according to the following approximate guidelines

40 Obesity
50 Diabetes
55\_\_\_\_\_\_\_
65 Myocardial infarction
70 \_\_\_\_\_\_\_\_\_
75 Heart failure
80 \_\_\_\_\_\_\_\_\_\_\_\_

Ischaemic heart disease

Cardiac arrhythmias

Cerebrovascular accident

How well did you know this?

Not at all

Perfectly

What is the classic triad of aging

confusion, falls, incontinence

How well did you know this?

Not at all

Perfectly

The classic triad often represents:

infection

How well did you know this?

Not at all

Perfectly

A clinically signifi cant feature in some elderly patients
is the raising of the pain threshold and changes in
homeostatic mechanisms, such as _______

Consequently, these patients may have an abnormal
response to diseases such as appendicitis, pyelonephritis,
internal abscess, pneumonia and septicaemia

temperature control.

How well did you know this?

Not at all

Perfectly

One of the best ways to generate a good relationship with the aged is through

home visits

How well did you know this?

Not at all

Perfectly

Home visits can be considered in three categories:

1 an_______ visit (especially to a new patient)
2 a patient-initiated but routine request for a ‘check-up
and tablets’
3 the_______—usually 2 to 4 weeks

‘unexpected’

regular call

How well did you know this?

Not at all

Perfectly

Forbes points out that at least _________elderly
people feel lonely. It is more likely to affect the_____
widows and widowers, and those affected by disability.

one in three

‘old-old’,

How well did you know this?

Not at all

Perfectly

Possible signs of loneliness include:

2.
body language with a ‘defeated’ demeanour
prolongation of visit including holding on to one’s hand

verbal outpouring
drab clothing
dependence on television

How well did you know this?

Not at all

Perfectly

Doctor behaviour that can irritate
and confuse elderly patients:

• having a consulting room with slippery steps, poor
lighting and inadequate handrails
• non-attention to______ by reception staff
• keeping them waiting
• having________in the waiting room and surgery
• being overfamiliar, with addresses such as ‘Pop’ or fi rst
names for elderly females

simple courtesies

low soft chairs

How well did you know this?

Not at all

Perfectly

Doctor behaviour that can irritate
and confuse elderly patients:

• shouting at them on the assumption that they are_____
• appearing _____and keen to get the consultation over
quickly
• forgetting their ________ and
concentrating only on their physical problems (i.e. not
treating the whole person)
• forgetting that they have several things wrong with
them and using a different ______ from theirs

deaf
rushed

psychosocial problems

priority list

How well did you know this?

Not at all

Perfectly

Doctor behaviour that can irritate
and confuse elderly patients:

being unaware that they may have seen other
practitioners or may be _________
• failing to ask patients to give their understanding of
what is wrong
• omitting to give printed _______
about their problems and medications

taking additional medication

patient education handouts

How well did you know this?

Not at all

Perfectly

Doctor behaviour that can irritate
and confuse elderly patients:

omitting to explain __________
• treating them as though they would have little
comprehension of their health and treatment
• failing to respect their privacy, such as__________
• failing to provide appropriate advice on various social
services such as ________ and other support
groups

how the medication will work

not knocking
before entering the examination room

meals on wheels

How well did you know this?

Not at all

Perfectly

Assessment of the elderly patient

At all times concentrate on a general
assessment of the patients’ _________ by
evaluating mental status, comprehension, hearing,
vision, mood and speech.

ability to communicate

How well did you know this?

Not at all

Perfectly

Physical examination

The elderly patient expects to
be examined adequately (especially having ___________measured) but requires appropriate dignity

blood pressure

How well did you know this?

Not at all

Perfectly

Physical examination

Practice nurse
• Prepares for \_\_\_\_\_\_\_
• Helps with questionnaire
• Records \_\_\_\_\_\_
• Takes temperature, pulse and respiration
• Checks audiometry (if hearing problem)
• Checks \_\_\_\_\_\_\_\_\_ (if appropriate)
• Prepares cervical smear tray for female patient (if
relevant)

examination

weight and height

ocular tension

How well did you know this?

Not at all

Perfectly

_______ for assessment of the

non-coping elderly patient

‘Rules of 7’

How well did you know this?

Not at all

Perfectly

‘Rules of 7’ in elderly assessment

1 Mental state: _________ Bereavement, incl. pets, Elderly abuse/bullying
2 Eyes: Visual acuity,________
3 Ears: Deafness, e.g. wax Tinnitus
4. Mouth: _____, _________, Malnutrition

Confusion/dementia Depression
Cataracts/glaucoma
Dentition Xerostomia

How well did you know this?

Not at all

Perfectly

‘Rules of 7’ in elderly assessment

5 Medication: _________
6 Bladder and bowels: ____________

Polypharmacy Adverse reactions

Incontinence Retention Urinary infection

How well did you know this?

Not at all

Perfectly

‘Rules of 7’ in elderly assessment

Locomotion: Gait—\_\_\_\_\_\_\_\_ movement disorder, esp. \_\_\_\_\_\_\_
Arthritis—hips/knees
Back/sciatica
Feet—\_\_\_\_\_\_\_\_
Circulation
Leg ulcers

antalgic;

Parkinson disease

nails; neuropathy

How well did you know this?

Not at all

Perfectly

The quick 10-step cognitive impairment test 1. 2. 3. 4.

1 When were you born? 2 What year is it? 3 What month is it? 4 What is the date today?

The quick 10-step cognitive impairment test 5. 6. 7. 8. 9. 10.

5 What is your telephone number? (or if no telephone) What is your street address? 6 What time is it (to nearest hour)? 7 Who is the Prime Minister of Australia? 8 What year did World War II end? 9 Count backwards from 20 to 1. 10 Repeat the memory test I gave you

The quick 10-step cognitive impairment test _____ not signifi cant _____ probably signifi cant ______ signifi cant Scoring: questions 1 to 8: correct—0, incorrect—2; questions 9 and 10: correct—0, 1 error—2, >1 error—4

0–8 9–12 13–24

_________ This relatively simple test provides a ready qualitative screening test to differentiate normal elderly from patients with cognitive impairment, particularly dementia

The clock-face drawing test

Scoring system for CDT Scoring system • _____________—3 points •______________—2 points • All correct numbers are included—2 points • Clock hands are placed in the correct position—2 points

Numbers are in the correct position A closed circle is drawn

The clinical features of early dementia include: • poor _______ memory • impaired acquisition of new information • mild _____ (cannot remember names) • ________ (e.g. withdrawn, irritable) • minimal visuospatial impairment (e.g. tripping easily) • inability to perform ___________

recent anomia personality change sequential tasks

Even apparently minor problems—such as the onset of deafness (e.g. wax in ears), visual deterioration (e.g. cataracts), _______ poor _______ and diet, urinary tract intercurrent infection, _______ and ________—can precipitate abnormal behaviour.

diuretic therapy, mastication boredom and anxiety

Mnemonic for dementia ``` D drugs and alcohol _____ E ears, eyes M _____, e.g. hyponatraemia, diabetes mellitus, hypothyroidism E __________ N ________ T tumours, trauma I infection A ________ ```

depression metabolic emotional problems (e.g. loneliness) nutrition: diet (e.g. vitamin B group defi ciency, teeth problems) arteriovascular disease → cerebral insuffi ciency

It is important to keep in mind the possibility of abuse | of the elderly, especially where there is ______

a family history | of abuse of members

Over one million elderly people are estimated to be the victims of physical or psychological abuse each year in the US.3 We should keep in mind the occasional possibility of______

Munchausen syndrome | by proxy.

The main differential diagnosis of dementia is depression, especially major depression, which is termed ________

pseudodementia

The _______ is one way in which it may be possible to distinguish between depression and dementia

mode of onset

Those with dementia ________ while | those with depression ___________ and readily give up tasks

have no insight have no insigh

In response to cognitive testing, the typical response of the depressed patient is _________, while making an attempt with a near-miss typifi es the patient with dementia

‘don’t know’

It is vital to detect depression in the elderly as they | are prone to_____

suicide

The incidence of dementia increases with age, affecting | about 1 person in 10 over _______ and 1 in 5 over ____

65 years 80 years.

dementia or pseudo? Worse in evening or night Orientation is reasonable

dementia pseudo

In _____ the earliest manifestations are personality change and alteration of behaviour, including social dysfunction

frontal dementias

______ is characterised by any two of visual hallucinations, spontaneous motor Parkinsonism and fl uctuations in the mental state

Dementia | with Lewy bodies

In patients with dementia, _____ judgment, verbal fl uency and the ability to ________ also become impaired.

Abstract thinking, perform complex tasks

The many guises of dementia can be considered in terms of four major symptom groups: 1. _______: due to loss of cognitive abilities 2. ______: based on personality change, 3. __________based on disturbed mood and personal distress 4. ________—causing distress and disturbance to others

Defi cit presentations— Unsociable presentations— Dysphoric presentations— Disruptive presentations

In patients with dementia, Driving is a problem, especially as many are reluctant to give up their licence. Those with ______ are more likely to cause road accident

mild dementia

If uncertainties arise in drivign or a patient is recalcitrant, refer to the _________

local Road Traffi c Authority

``` Demented patients are vulnerable to superimposed delirium, which is often due to: 1. 2. 3. 4. ```

* urinary tract infection * other febrile illness * prescribed medication * drug withdrawal

The best | option for PD and AD appears to be the administration of:

* levodopa to maximum dose | * quetiapine at night

The cholinesterase inhibitors _________, ____, ________ appear to delay progression of dementia to a modest extent only.

donepezil, galantamine, and rivastigmine

Available drugs for Alzheimer disease Cholinesterase inhibitors * donepezil (Aricept) ______ * galantamine (Reminyl) prolonged release ______ * rivastigmine (Exelon) rivastigmine (Exelon) 4.6 mg transdermal daily for 4 weeks, then______

5 mg (o) nocte for 4 weeks, increase to 10 mg nocte as tolerated 8 mg (o) daily for 4 weeks, increase to 16 mg daily 1.5 mg (o) bd for 2 weeks, increase gradually up to 6 mg bd 9.2 mg daily

Aspartate (NMDA) antagonist | • memantine (Ebixa) _______

``` 5 mg (o) mane for 1 week → 5 mg bd week two → 10 mg bd from week 4 ```

True about RCTs on donepezil and riva * only ______ improvement overall * greatest improvement with _____ doses

modest higher

True about RCTs on donepezil and riva: 1. higher doses less well tolerated 2. long-term effi cacy ______ 3. clinical effectiveness in ______ has not been demonstrated

unknown severe disease

In AD Tx, the evidence shows that ________ must be treated with rivastigmine 6–12 mg/day for 6 months for one patient to display clinically meaningful improvement

13 patients

Tx of Psychotic Sx of AD 1. 2. 3.

``` olanzapine 2.5–10 mg (o) daily or risperidone 0.5–2 mg (o) daily or haloperidol 0.5 mg (o) nocte up to 2 mg bd ```

To control symptoms of anxiety and agitation use: | ______

oxazepam 15 mg (o) one to four times daily

benzodiazepines should be used only for short periods________ as they tend to exacerbate cognitive impairment in dementia

(maximum 2 weeks)

In AD, Defi ciencies of ______, ________, ______should be treated.

folate, | vitamin B12 and vitamin D

This ‘popular’ term is also referred to as ‘age-related | memory loss’ or ‘mild cognitive impairment’ of ageing

Benign senescent forgetfulness

Features of Benign senescent forgetfulness 1. 2. 3.

* short-term forgetfulness * inability to fi nd the right word * embarrassment about shortcomings

Features of Benign senescent forgetfulness 4. 5. 6

* feeling dithery * inability to fi nd items stored away * forgetting to pay accounts

The risk factors for late life | suicide are:

* male * single * recent bereavement * social isolation * recent relocation * poor pain control * feeling helpless/hopeless * anhedonia * indicating a wish to die * recent alcohol abuse

________ is that condition where the symptoms and signs of paranoid psychosis appear for the fi rst time in the elderly

Paraphrenia

In patients with Paraphrenia, it is usually an elderly female, presents with ______, such as a feeling of being watched or persecuted and even _______

paranoid delusions hallucinations.

Tx of paraphrenia

Treatment is with an anti-psychotic agent e.g. risperidone or olanzapine.

Falls in the elderly are a major problem as _____of people over the age of 65 experience at least one fall per year, with 1 in 4 of these having ______

30% signifi cant injury

The ________ test: a brief test of | postural competence

‘get up and go’

Steps for get up and go: 1 Get up from chair without ____ 2 Observe normal gait and ______ 3 Carry out the _________ (slight push with eyes closed). 4 Observe _______ (heel toe, straight line).

use of arms 360° turn. Romberg test tandem walking

Ageing is associated with increased rates of adverse drug reactions.1 The rate of adverse drug reactions for a single medication rises from about ______ at age 20 years to about ______at age 70 years.

6% 20%

For fewer than six medications taken concurrently, the | rate of adverse drug reactions is about______.

For more than six medications taken concurrently, the rate of adverse drug reactions jumps to _____

20%.

Approximately ______of elderly patients admitted to hospital are suffering adverse drug reactions.

15%

Most adverse drug reactions are ______ rather than type B (idiosyncratic).

type A (dose related)

The fi ve mechanisms of adverse drug reactions in | the elderly are

1. Drug–drug interaction 2. Drug–disease interaction 3. Age-related changes leading to increases in drug plasma concentration 4. Age-related changes leading to increased drug sensitivity. 5. Patient error

The fi ve mechanisms of adverse drug reactions in the elderly __________ For example, beta-blockers given concomitantly with digoxin increases the risk of heart block and bradycardia

Drug–drug interaction.

______ For example, in the presence of kidney impairment, tetracyclines carry an increased risk of kidney deterioration

Drug–disease interaction.

______. Decreased kidney excretion can extend the half-life of medication, leading to accumulation and toxicity

Age-related changes leading to increases in drug plasma | concentration

____________ For example, there is some suggestion that the pharmacological response to warfarin, narcotics and benzodiazepines is increased in the elderly

Age-related changes leading to increased drug sensitivity.

______Multiple medications can lead to this. The incidence and prevalence of dementia also increases with age. Other problems include failing eyesight and reduced manual dexterity.

Patient error.

``` In a study on adverse drug reaction in elderly patients the drugs most frequently causing admission to hospital were: 1. 2. 3. 4. 5 ```

* digoxin * diuretics * antihypertensives (including beta-blockers) * psychotropics and hypnotics * analgesics and NSAIDs

The same study showed that drugs regularly | prescribed without revision were:

* barbiturates * benzodiazepines * antidepressants * antihypertensives * beta-blockers * digoxin * diuretics

The elderly may need much lower doses of ______ and ________than younger patients to produce the same effect, thus rendering them more susceptible to adverse effects and toxicity

anxiolytics and hypnotics

The elderly | are especially liable to accumulate the _____

longer-acting | benzodiazepines

In particular, any drug or combination of drugs with anticholinergic properties (e.g. tricyclic antidepressants, anti-Parkinsonian agents, antihistamines, phenothiazines and some cold remedies) can precipitate a ____

central | anticholinergic syndrome.

Both ___ and ______ have been shown to produce a greater fall in blood pressure in elderly compared with younger subjects, presumably related also to a reduced homeostatic response

ACE inhibitors and calcium-channel blockers

SE in the elderly Confusion, falls, psychomotor impairment

BZD

SE in the elderly Confusion, falls, asthma, insomnia

β-blockers

SE in the elderly Confusion

Cimetidine

SE in the elderly Nausea, confusion

Digoxin

SE in the elderly Incontinence, falls, hyponatraemia, hypokalaemia

Diuretics

SE in the elderly Confusion, falls, dystonia, hallucinations, agitation, postural hypotension

Levodopa

Confusion, extrapyramidal | symptoms

Metoclop

Confusion, postural hypotension, falls, constipation

Phenothiazines

SE in the elderly Confusion, falls, ataxia, Parkinsonism, urinary problems

Phenytoin

SE in the elderly Postural hypotension, incontinence

Prazosin

SE in the elderly Nausea, agitation, insomnia

SSRI antidepressants

SE in the elderly Confusion, falls, postural hypotension, constipation, urinary problems, eye problems

Tricyclic antidepressants

SE in the elderly Constipation

Verapamil

The starting dose of a drug in the aged should be at the_____of recommended ranges. Dosage increments should be gradual and reviewed regularly.

lower end

The Elderly Patient Flashcards

(100 cards)