Week 10 Geriatrics, Parkinsons, Alz Flashcards
(79 cards)
1
Q
behavioral risk factors to reduce CVA risk?
A
- balanced diet (fresh fruits, veggies, low fat dairy, fiber, whole grains, proteins, decrease salt)
- exercise
- healthy weight (BMI: 18.5-24.9)
- smoking cessation
- alcohol in moderation (1-2 drinks per day max)
2
Q
recommended BP goal if had stroke/TIA?
A
< 130/80
3
Q
which medications reduce recurrent strokes significantly?
A
diuretics alone or WITH ace but NOT with BB or ACE alone
4
Q
AHA/ASA recommendations on statin treatment
A
- use high intensity statin if:
- have ischemic stroke or TIA who have atherosclerosis
- LDL > 100
- want 50% LDL reduction or < 70
- known CAD
5
Q
cardiac causes and extra cardiac causes of stroke
A
- cardiac: atrial fibrillation and patent foramen oval
- extracardiac: intracranial and extracranial large vessel atherosclerotic disease (carotid artery and vertebral basilar disease)
6
Q
anticoagulant target INR in pts with ischemic stroke / TIA
A
- target INR: 2.5, range 2-3
- fi can’t take oral, aspirin alone recommended. NO clopidogrel + aspirin = bleeding risk and not recommend for pts with a contraindication to warfarin
7
Q
post stroke depression
A
- common in 40% of pts post stroke
- a/s with poor functional recovery, poor social outcomes, reduced QOL
- give SSRI!
8
Q
most common sx of a TIA (acute stroke)
A
lasts a few minutes to 1 hr
unilateral paresis and dysarthria (paralyzed speech)
9
Q
highest risk reduction to prevent stroke in pts that have had a TIA?
A
- high intensity physical activity at 64%
- BP reduction is 40%
- antiplatelets 37%
- statins 33%
10
Q
Transient ischemic attack sx’s
A
- few minutes
- Facial droop
- L sided weakness
- Coming from carotid arteries or vertebral arteries bc of stenosis and emboli to block blood = ischemia
- Embolus will dissolve once blood flow is restored in 24 hrs
- stroke risk of 10% up to 90 days
11
Q
pts with TIA examination
A
- close observation x 24 hrs in ER or inpt
- use ABCD2 score for TIA [1-3 pts: output, 4-5: inpt, 6-7 pt: inpt beneficial)
- 1 pt
- Age: 60 yrs old
- BP > 140/_>_90
- Clinical presentation:
- Speech changes
- Duration:
- < 1 hr
- Diabetes
- 2 pts:
- unilateral weakness
- > 1 hour
- 1 pt
12
Q
intracranial hemorrhage stroke sx’s
A
- vomiting
- SBP > 220
- severe headache, unilateral facial sag, slurred speech, weakness in an arm and leg, and eye deviation away from the paretic limbs
- no warning or prodromal sx’s
- Majority of cases, pts are up and active
13
Q
subarachnoid hemorrhage
A
- c/b aneurysm, AV malformation, bleeding disorder
- Abrupt onset of a severe headache
- *worst headache of my life”* + n/v + signs of meningitis (meningeal irritation) + neurological irritation
- Can have LOC at event
- Risk factors: smoking, HTN, family hx, PCOS, connective tissue disease
- require neurosurgical intervention
14
Q
stroke diagnostics
A
-
STAT head non contrast CT *gold standard
- differentiates from ischemic or hemorrhagic stroke
- ECG
- chest radiography
- pulse ox
- ABG
- CBC with platelets, prothrombin time
- PTT
- gluocse
- creatinine
- BUN
- e- values
15
Q
administer IV thrombolytics within
A
45 to 60 mins arrival to ED
for ischemic stroke
16
Q
optimal SBP for acute ischemic stroke is
A
121 -200 SBP optimal
, if lower with meds, brain already ischemic and lowering BP would worsening hypo perfusion and injury. after acute period of stroke, BP will gradually return to baseline w/o any treatment
if have to use antihypertensive, labetalol and nicardipine used to gradually reduce BP
17
Q
when is tPA given
A
indications: 18+, ischemic stroke, onset less than 3 hours (180 mins) to 4.5 hrs
NO: active bleeding, on oral anticoagulant, hx diabetes or previous stroke, > 80 yrs old
18
Q
ischemic stroke sx’s
A
MILD headache
visual field defect, ataxia, and dysarthria
resolves w/in few hours
amaurosis fugax (transient, painless loss of vision)
19
Q
ischemic stroke prevention
A
aspirin 81 - 325 mg QD
warfarin (Coumadin), Eliquis, Xarelto for pts with risk for cardiac embolism & hypercoaguable states (atrial fibrillation, L ventricular dysfunction with CHF, artificial cardiac valves)
20
Q
surgical interventions for stroke
A
mechanical thrombectomy (up to 24 hrs post sx onset)
neurosurgical consultation for SAH, ICH, IICP = carotid endarterectomy for symptomatic carotid stenosis
21
Q
patient education in stroke
A
- 1: Focus on risk factor reduction (BP, cholesterol, OSA)
- 2: stroke sx recognition and emergency treatment!
- HTN is most important independent and modifiable risk factor
- Atrial fib → 5x risk of stroke, need anticoagulant
22
Q
5 domains to assess in an older adult
A
- physical health
- cognition and mental health
- functional status
- social and environmental circumstances
- advanced care planning
23
Q
geriatric assessment
A
- screens for risk factors that can affect health and independence
- starts age 75 if healthy (start < 75 if have multiple comorbidities)
- after major illness requiring hospitalizations
24
Q
components of pt’s physical assessment
A
- nutrition
- hearing
- vision
- urinary and bowel incontience
- balance / hx of falls
- osteoporosis risk
- polypharmacy
25
**immunizations for older adults**
* PCV 13 (Prevnar 13) & PPSV 23 (Pneumovax 23)
* after 65 yrs - 1 dose
* flu annually
* **Shringrex/zoster**
* **everyone after 50 yrs old - 2 doses, 2-6 months part**
* tetanus (Tdap) once
* Td every 10 years
26
cardiovascular screening for older adults
* abdominal aorta ultrasound: once in males who have ever smoked after 65 yrs
* hypertension at EVERY visit (no age restriction)
* height / weight every visit
* glucose in overweight/obese until age 70
* fasting lipid panel every 5 years unless levels are high or other CV risk factors present
27
cancer screening in older adults
* colorectal cancer: start age 50 - 75 (76-85 individualized)
* cervical cancer screening: STOP after age 65
* breast mammogram: every 2 years until 74 yrs old
* NO prostate specific antigen screening (individualized)
28
bone mass screening in older adults
* women: once at 65 yrs
* men: once at 70 yrs
29
elderly and driving
* Assess memory, judgment and executive function (dementia), arthritis, neuropathy, hypoglycemia, adverse drug reactions
* moderate dementia should NOT drive
* **visual and spatial perception (cataract, glaucoma, poor night vision) - predictors of impaired driving**
* **vision, hearing**, balance, gait, range of motion, and strength of hips and knees
* recommend to DMV if:
* new traffic impairments
* impairments in attention, executive function, visual, spatial perception
* mild dementia
30
other screenings in older adults
insufficient evidence: dementia, hearing, vision, glaucoma
31
screening for hearing in older adults
* USPSTF recommends asking patient and caregivers about hearing loss
* Whisper test
* most common: presbycusis (gradual loss/sensorineural hearing loss) and cerumen impaction (conductive hearing loss)
32
urinary incontinence in the geriatric population
* Key deciding factor for placement in nursing home
* Evaluation – fluid intake, medications, cognitive functions, mobility, urologic surgeries
* Screen:
* Urge: Do you have a strong and sudden urge to void that makes you leak before reaching the toilet?
* Stress; Is your incontinence caused by coughing, sneezing, lifting, walking, or running?
33
leading cause of hospitalization/injury in 75+ adults? screen?
* Falls!
* Screening: Get Up and Go Test
* Observing a patient get up from chair without using arms, walk 10 feet, turn around, walk back, sit down (should not take longer than 16 seconds) → anything concerning needs further evaluation
* if have 1 fall w/o major injury and normal get up and go test → no further eval needed
* home assessment by family or OT
34
geriatric syndromes
* polypharmacy
* cognitive impairment
* dehydration
* falls
* failure to thrive
* elder abuse
35
polypharmacy
use or misuse of multiple drugs (5+ meds) but rx and non rx + interactions
most prevalent consequence: adverse drug reaction → change in mental status, sedation, falls
36
polypharmacy management
* Beers criteria, IPET (improved prescribing in elderly tool), START (tool to alert doctors to right treatment), STOPP
* is med still indicated?
* Once a day dosing best
* Carry up to date med list and review every visit
* order drugs with computerized drug data
* pharmacodynamics and adverse effects more heavy in older adults
37
how to discontinue meds in polypharmacy
* Without clear indication (leftovers from acute conditions or transitions of care)
* High-risk medications (warfarin, digoxin, hypoglycemic medications)
* One drug at a time if condition is stable, more aggressive discontinuation if experiencing side effects that may be due to drugs
* Taper down medications at the rate that you would taper them up (opioids, BB, clonidine, gabapentin, antidepressants)
* Educate patients on side effects of tapering or discontinuation
* Communicate with other providers that may be prescribing
38
barriers to med adherence in older adults
* forgetting to take → organize with pill counters, put someone in charge
* pt doesn't think it helps → educate or stop med
* difficulty taking or too expensive → substitute med
39
depression screening
* Depression 2 Q screen:
1. During the past month, have you been bothered by feelings of sadness, depression, or hopelessness?
2. Have you often been bothered by a lack of interest or pleasure in doing things?
* if+ → do 2nd assessment or refer to psychiatry
* Geriatric Depression Scale
* Hamilton Depression Scale
40
FNP role in financial capacity
* Education need for advance care plan (ACP)
* Durable power of attorney for finances (DPOAF)
* is none, existing DPOAF or conservator/guardian is appointed by state
* Discuss at time of diagnosis of dementia
* Recognizing and assessing signs of impaired financial capacity
* Recommend interventions for financial independence (automatic deposits or withdrawals)
* Knowing when and to whom to make medical and legal referrals
* Report suspected elder abuse including financial abuse
41
Cognitive impairment
* Alzemiers and dementia
* short term memory loss
* disorientation
* disturbance in executive functioning (planning, organizing, abstract thinking)
* ADL problems
* aphasia (impaired language), apraxia (impaired motor; can't tie shoelace) , agnosia (can't understand info from senses ie can't understand smell)
* delirium - acute onset, fluctuations in orientation and attention esp if hospitalized
42
dehydration in older adults
* sodium imbalance
* most common cause: fever, poor intake, drug, NGI fluid loss
* check: orthostatic hypo, pulse, temp
* labs: e-, BUN/Cr, osmolality, H&H (concentrated)
43
Dementia DSM 5
* Evidence of decline 1 or more:
* Learning and memory
* Language
* Executive function
* Complex attention
* Perceptual-motor
* Social cognition
* cognitive deficits interfere with independence in daily activities, and needs help with complex activities of daily living (paying bills)
* not due to delirium
* not another mental disorder (schizophrenia or major depressive disorder)
44
Falls
* assess sensory, central/peripheral nervous system
* **most important risk factors: vision and hearing**
* contributing factors:
* lower extremity weakness
* ortho hypo
* CNS condition
* unsafe environment (throw rugs)
* balance exercises
* tai chi
45
post fall assessment
DDROPP
* Diseases
* Drugs
* Recovery (how long take to improve)
* Onset
* Prodrome
* What sx did they have prior to fall
* precipitating factors
* Were they sick before this happening? fever/flu like sx’s?
46
fall labs
* CBC
* electrolytes
* BUN/Cr
* cult stool (GI bleed - anemia)
* ECG
47
Frailty (FTT) and tx
* unplanned 10% + loss body weight in \< 1 year
* progressive loss of energy, strength, and stamina leading to decreased function and general physical and cognitive deterioration resulting in a physiologic vulnerability
* look at irreversible causes (depression)
* **increase protein and caloric intake → boost plus (protein)**
* **daily multivitamin**
* **800 IU of vitamin D**
* weight training
* get family involved
48
sus for elder abuse
* Bruises in the breast, or genitalia
* sudden withdrawal from me that i know or change in behavior = psychological abuse
* Change in financial situation or checks signed by other = financial exploitation
* Bed sores, poor hygiene, nutritional deficiencies, hoarding or inappropriate clothing for season = neglect
49
dementia screening
* Dementia screening:
* 3-word recall and clock face.
* If abnormal, administer MMSE (Mini Mental Status Exam) or MOCA (Montreal Cognitive Assessment)
* Offer neuropsychiatric evaluation or perform further primary care evaluation of cognitive impairment such as comorbid medical problems, medication adverse effects, or mood disorder.
50
dementia diagnostics
* no single test
* CBC, CMP, TSH, B12, folate
* UA drug test (r/o cancer, infection)
* baseline brain imaging with CT
51
delirium hallmarks
* Clouding of consciousness, inability to focus, sustain, or shift attention, and a change in cognition
* Impairment, perception disturbances
* Prominent deficit of environment
* **Sx develop rapidly and vary in severity**
52
**pt has TIA, send to ED or outpatient?**
* ABCD score for acute cerebral vascular syndrome:
* **A**ge, **B**P, **c**linical presentation, **d**iabetes
* 1-3 pts: outpatient
* 4-7: hospitalization
* 1 pt for:
* _\>_ 60 yrs
* BP _\>_ 140/_\>_ 90
* speech changes (no unilateral weakness)
* _\<_ 59 mins duration
* diabetes
* 2 pts for:
* unilateral weakness
* _\>_ 1 hour duration
53
how is dementia diagnosed?
* Mini Mental Status Exam :orientation, registration, attention and calculation, recall, language
* good for moderate dementia (not mild)
* memory impairment screen
* tests Recall Ability: say nouns in 4 groups (animal, city, vegetable, musical instrument), then give task, recall nouns. 2 pts if no hints, 1 pt for hints
* clock drawing test
* put #'s on face of clock and make the clock say 10 minutes to 11
* general practitioner assessment of cognition
* modified mini mental state exam
* severity of dementia
* Hopkins Verbal Learning Test or Word List Acquisition Test4
* More helpful for mild cognitive impairment or highly educated patient
* Cognitive Assessment Screening Test
* Psychogeriatric Assessment Scales
* Screens for depression and stroke
* Clinical Dementia Rating Scale
* Assesses functional and cognitive performance
54
dementia meds
* Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
* mild to moderate AD
* Side effects include nausea, vomiting, diarrhea, dizziness, and weight loss.
* Gastrointestinal (GI) side effects may be worse with rivastigmine, less with galantamine, least with donepezil.
* Donepezil - muscle cramps and sleep disturbance.
* Contraindicated in patients with cardiac conduction abnormalities or gastric ulcer disease with a history of bleeding.
* N-Methyl-D-aspartate (NMDA) receptor antagonist (memantine)
* moderate to severe dementia
* May be added to cholinesterase inhibitor as dementia progresses.1,5
* Side effects include headache, sedation, constipation, and agitation.2
55
what nonpharmacologic interventions have been studied in patients with mild dementia?
* Cognitive training and rehab programs
* improving functionality in everyday life
* may help with cognitive function in patients with MCI but NOT mild dementia
* Reminiscence therapy
* revisit memories and experiences
* Significant improvement in cognitive and depressive symptoms
56
behavioral disturbances of progressive dementia and tx
* Agitation with delirium or psychosis
* Atypical antipsychotics (risperidone, olanzapine, quetiapine) are commonly used
* May increase risk of metabolic syndrome and stroke
* Black box warning for atypical antipsychotics → increased rate of death
* to targeted at a specific symptom with plans to taper and remove medication within 6 months.
* Agitation and aggression
* Anticonvulsants (divalproex, carbamazepine)
* Depression or anxiety
* SSRIs = sertraline and citalopram or buspirone
* NO TCAs = worsen agitation and increase risk of falls.
* Benzodiazepines short-term treatment of anxiety but worsen confusion, increase risk of falls, and cause paradoxical agitation.
* Insomnia → trazodone
57
**DSM 5 for delirium**
Acute onset!
1. Decreased ability to direct, focus, and sustain attention and orientation to the environment
2. alt to lucid periods
3. Short = Hrs - days; fluctuating
4. Cognition changes or perceptual disturbance that is not explained by a preexisting condition (eg, dementia)
5. not caused by a severely reduced level of arousal, such as coma
58
key points of hx in delirium
* sx's of recent infection
* history of organ failure
* medication list
* history of substance use
* psychiatric history including recent evidence of depression
59
greatest risk factor for delirium
* **age**
* elderly most susceptible bc reduced capacity to handle change in surroundings, depression, med changes, acute stressors [surgery/hospitalization])
60
delirium mangement
medical emergency! send to ER
61
**what assessment tools confirm delirium and dementia?**
Confusion Assessment Method (CAM) for delirium
Mini mental status exam (MMSE) for dementia
**\*hx of sudden onset or fluctuation during the day = delirium**
also screen for depression, schizophrenia
62
interventions for prevention and tx of delirium
* primary interventions: environmental factors (reorientation, sleep hygiene, visual or hearing aids if impaired, maximizing mobilization, avoiding physical restraints)
* **interpersonal need of social interaction** important in delirious pts! have family member or staff present so there's no isolation
* if hyperactive/aggressive delirium: meds that are involved in acetylcholine, dopamine, serotonin, and GABA
63
**demential hospice requirements**
if 2 clinicians (referring clinician and hospice medical director) agree pt has \< 6 months to live if illness were to take natural course
need to be Stage 7C on Functional Assessment Staging Tool (FAST) - unable to move independently and at least 1 of:
* aspiration pneumonia
* pyelonephritis
* upper UTI
* septicemia
* pressure ulcer (stage 3 or 4)
* recurrent fever after tx with antibiotics
* eating problems (decrease intake, weight loss or albumin \< 2.5)
64
FTT labs
* CBC
* electrolytaes
* kidney and thyroid studies
* fasting blood glucose
* liver function tests
* Ca
* UA
* stool for occult blood x3
* chest xray
65
FTT focus on
sx's, organ failure, infections, cancer
66
most powerful risk factor for recurrent stroke ?
* blood pressure with HTN involved in 70% of all stroke cases
* 5% weight reduction can improve overall health with 10% being goal (reducing BP of 10/5 mmHg reduce stroke up to 42%)
* diabetes, smoking, HLD, obesity, nutrition, diet, physical inactivity
67
mild cognitive impairment
transition b/t normal aging (forgetfulness) and dementia
close monitoring bc it's a risk factor for dementia
68
3 types of dementia
* **Alzheimers (most common)** - amyloid plaques and neurofibrillary tangles and atrophy of the cerebral cortex (amount of atrophy does NOT correlate to degree of cognitive impairment)
* **Vascular dementia** - if pt has HTN, HLD, DB or occlusive dz (higher risk) for infarct in tiny arteries in the brain
* **Lewy body dementia** - Lewy body causes brain death and loss of dopamine and acetylcholine
69
Alzheimers stages & sx's
* prognosis: 9 years
* early:
* short term memory loss
* anxiety / depression
* personality changes
* middle/second stage:
* worsening of memory, language, judgment
* disorientation of place and time
* paranoia, hallucinations, delusional thinking
* urinary incontinence
* late stage:
* motor rigidity
* apraxia
* agnosia
* severe cognitive and language impairment
* date
70
Parkinson's cardinal features
* 3 cardinal manifestaions: **T.R.A.[P.]**
1. **Tremor - asymmetric/unilateral resting tremor**
2. **Rigidity: lead pipe rigidity**
* **cogwheeling rigidity**
* **resistance to passive movement in all directions**
**3. Akinesia: absent of movement, bradykinesia**
* Postural instability, pill rolling
71
Parkinsons diagnosis
if try dopamine therapy/Levodopa and have good response, confirms diagnosis
neuroimaging shows Lewy bodies (gold standard) BUT done after they're dead
no DaTScan if hx/exam suggests PD
72
Parkinson physical examinations
* postural reflexes = sudden, firm pull on shoulders from behind
* cog wheeling rigidity = grasp pt's elbow at antecubital region, slowly flex/extend elbow or pronate/supinate forearm
* festination = walks faster with short steps
* freezing phenomenon (motor block) can't do active movements, feet glued to ground
* kinesia paradoxa = move normally for short burst of motor activity when physically cued
73
Parkinson's non motor disorders
* depression, anxiety
* dementia
* psychosis / halluncations
* forced closure of eyelides
* orthostatic hypotension
* hypophonia speech/soft, excessive salivation but can't swallow
* aspiration pneumonia = death
* thicken up liquids
* increased sweating
* constipation
* micrographia handwriting
* urinary incontinence
* dopamine dysregulation syndrome
* manic sx's - don't stop meds abruptly
* RBD (REM sleep behavior disturbances)
* nightmares = give Clonazepam (Klonopin) every night
* daytime sleepiness/fatigue
74
parkinson hallucination med tx
* if delirium, treat underlying cause
* if not delirium, then give pimavanserin, 2nd line quetiapine/Seroquel
75
parkinson med treatment
* carbidopa - levodopa (Sinemet) gold standard
* 100-150mg/d
* \>60 yrs old
* selegiline (Eldepryl) [MAOI-B]: - use WITH Sinemet to allow easier entry and prolonged effects (not monotherapy)
* mirapex [Dopamine agonist]
* for \< 60 yrs early PD mono therapy
* \> 60, adjunct with Sinemet
* orthohypo
* amantadine (antiviral)
* WITH sinemet for advanced PD akinesia and rigidity
76
parkinsons non pharm tx
adjunct:
* OT, PT, speech therapy
* treadmill training, boxing, tai chi
* cognitive exercises: crossword puzzles/sudoku
* deep brain stimulation - surgery for advanced PD
* improves motor fluctuations
* depression = refer psychiatrist
* hospitalize if pneumonia, DVT, PE
76
parkinsons non pharm tx
adjunct:
* OT, PT, speech therapy
* treadmill training, boxing, tai chi
* cognitive exercises: crossword puzzles/sudoku
* deep brain stimulation - surgery for advanced PD
* improves motor fluctuations
* depression = refer psychiatrist
* hospitalize if pneumonia, DVT, PE
77
delirium hallmarks
Clouding of consciousness, inability to focus, sustain, or shift attention, and a change in cognition
* **Sx develop rapidly and vary in severity**
78
pseudomentia
* Due to depression which leads to memory loss, attention deficits, and problems with initiation
* **Depression can lead to memory loss, attention deficit, problems with initiation**
