Geriatrics E2 Fien

PE findings in an elderly patient with Aortic Regurgitation.

• Aortic Regurgitation is usually asymptomatic typically until the 4th or 5th decade of life.
• The patient may experience dyspnea on exertion (DOE), orthopnea, and paroxysmal nocturnal dyspnea (PND).
• Significant cardiomegaly and LV dysfunction may occur.
• Other findings can include angina, which develops later and often during nighttime.
• Palpitations and head pounding, are common especially in the supine position, as the heart pounds against the chest wall.

Most frequent hospital admitting diagnosis in a Medicare age patient.

• Heart disease is the most common cause for hospitalization in older adults.
• Heart failure is documented as the most common cause of hospitalization in the Medicare age group.

Physical Exam findings in a patient with chronic venous insufficiency.

• Edema usually develops slowly and initially involves only the ankle.
• The skin can be dry, shiny, and atrophic with a reddish, cyanotic hue when dependent, which causes hyperpigmentation.
• The limb is warm, not cool, unlike arterial disease.
• Limb pain occurs with prolonged standing.
• Chronic edema may result in ulcer formation above the medial malleolus
• Venous ulceration is noted in the "gaiter" region of the legs, located circumferentially around the lower leg from approximately mid calf to just below the medial and lateral malleoli.

Normal physiologic changes that occur in the aging heart.

• Physiological changes of the cardiovascular system in aging may modify the presentation of heart disease.
• Peak physiological function occurs at 20-30 years of age.
• Myocardial reserve mechanisms maintain normal function causing older persons to be more vulnerable to developing dysfunction when disease is superimposed.
• Heart rate (HR) response to exercise decreases in older adults due to diminished beta-adrenergic responsiveness.
• Cardiac output (CO) is maintained by increasing cardiac volumes (end-diastolic and end-systolic volumes).
• Older persons depend more on atrial contraction for LV filling potentially leading to heart failure if atrial fibrillation (AF) occurs.
• Heart failure (HF) may occur in the absence of systolic dysfunction or valvular disease.
• Maximal HR response declines on stress testing and is attenuated at all levels of exercise.
• Vascular stiffness increases leading to a rise in afterload (SBP).
• Altered diastolic compliance leads to changes in the relaxation phase of the cardiac cycle, causing an increase in diastolic LV wall thickness
• Systolic function is preserved.
• Older patients do not respond the same as middle aged or younger adults to therapies.

CVS physical exam findings present in the elderly population.

• Softer S1 and S2 sounds occur due to increased distance between the heart and chest wall with age.
• Splitting of S2 is detected in 30-40% of the population and wide splitting increasing with inspiration suggests RBBB.
• A systolic ejection murmur (SEM) is detected in 50% but is short in duration, Grade 1-2, and does not radiate.
• An S4 heart sound is often present due to reduced LV diastolic compliance.
• Auscultation of a carotid bruit suggests but does not prove partial arterial obstruction.
• Hearing a carotid bruit is unlikely if stenosis is < 40% and may not be heard if stenosis is >90% because of low flow.

Most common cause of mortality in geriatric aged patients.

• Heart disease is a leading cause of death worldwide in older adults
• CAD causes 80% of deaths in adults > 65 years old.

Treatment of choice for a hypertensive patient with DM.

• Treatment, including those who with isolated systolic HTN, should follow same principles outlined for general care of HTN.
• Diuretics, diuretics plus beta blockers, and CCBs are often used as first-line therapy.
• Use lower initial drug doses to avoid symptoms, utilizing standard doses and multiple drugs to reach BP targets.
• There is no specific drug class that is contraindicated in older adults.

Presentation of AF in the elderly population.

• AF occurs in 5% to 10% of ambulatory older adults and more frequently in hospitalized patients.
• Associated with underlying heart disease but the causes are the same as in younger individuals.
• Symptoms include palpitations
• Patients can be asymptomatic, while others have fatigue, dyspnea, chest pain, hypotension, syncope, confusion, dizziness, or CHF.
• Characterized as paroxysmal, persistent, long-standing persistent, or permanent
• It is important to determine its underlying cause as well as defining associated cardiac and extracardiac disease and assessing thromboembolic risk.

Most common valvular heart disease present in the geriatric population.

• Presence of clinically significant aortic stenosis (AS) increases with age.
• Aortic and mitral valve (MV) calcification is common among older adults