Geriatrics Final PDF

Geriatrics Final Yellow = things he said to know or there was a sound effect with it in class. Lecture 1: Theories of aging: EXAM QUESTION à WHICH OF THE FOLLOWING ARE THEORIES OF AGING = FREE RADICAL THEORY o Neuroendocrine pacemakers § Hypot...

Geriatrics Final Yellow = things he said to know or there was a sound effect with it in class. Lecture 1: Theories of aging: EXAM QUESTION à WHICH OF THE FOLLOWING ARE THEORIES OF AGING = FREE RADICAL THEORY o Neuroendocrine pacemakers § Hypothalamic-Pituitary Gonadal axis: Menopause, Dopamine , Human Growth Hormone § Hypothalamic-Pituitary Adrenocortical axis: Truncal obesity, glucose intolerance, osteopenia, cataracts o FREE RADICAL THEORY OF METABOLISM à KNOW THIS!!!! § Damage of DNA/ RNA antioxidants (vitamin C and E) § UV light: may also induce DNA mutations § EXAM QUESTION: WHICH OF THE FO o Errors in protein synthesis § usually caused by amino acid sequence error Biology of cell death o Apoptosis: Appears to be lack of proliferation of healthy T-lymphocytes § Gene transposition affecting immune system - Stress no good § AGING IS A DEVELOPMENTAL PROCESS NOT ACCUMULATION OF DISEASE!! KNOW IT! Normal age related changes in organ system à KNOW THESE!!! o Shorter (P.P. spine) & Lighter (more fat vs muscle) o Eyes: Lens changes – Less Elastic § Yellow Pigments: 3HK § Night Driving : Sensitive to glare o Ears: Cerumen impaction o Skin: Less elastic o Musculoskeletal: Muscle mass, Tendons and Ligaments, Tensile strength o Lungs: Harder to recuperate after Surgery or Disease o GI / GU: Low Fiber / Reduced Fluids & Exercise, Tissue Laxity, Impotence o CNS: Reaction times, Sleep Vision – Sensory Impairment o Visual impairment affects 20-30% of people over the age of 75. o Visual impairments that occur with greater frequency as people age include: glaucoma / macular degeneration (screen them for these) o NOT NORMAL PROCESS OF AGING à GLAUCOMA AND MACULAR DEGENERATION § Macular degeneration (Women) à Sxs: no pain, blurred vision, drusen What we can do: healthy diet, smoking, maintain BP / heathy weight, exercise § Glaucoma (men) à Sxs: no early warning sxs, can present without pain, loss of SIDE VISION What can we do: meds (eye drops), laser or conventional surgery, annual exams for prevention. o PRESBYOPIA: old ppl vision à BAD VISION BC OF NORMAL PROCESS OF AGING § Lens: increases rigidity of lens and ciliary muscles lead to presbyopia o Cataracts (women) : clouding of eye’s lens that causes loss of vision (usually related to age (smoking, DM, sunlight exposure))  § Sxs: cloudy or blurred vision, COLORS THAT MAY NOT APPEAR AS BRIGHT AS THEY ONCE DID, glare, poor night vision § What can we do: eat a healthy diet, wear sunglasses and brimmed hat when outdoors, don’t smoke. Hearing: o Presbycusis à Normal process of ageing (M>F), starts at age 30 § Cerumen becomes drier and impacted, TM thicker & looks duller, ossicular joints get DJD (can get arthritis in ear) o Etiologic Factors in the Development of Age-Related Hearing Loss: § KNOW THESE: Heart Disease, Diabetes, Alcohol, Exercise (lack thereof), Hypertension, Smoking o Costs of ignoring hearing loss: Reduction in quality of life (sum of EVERYTHING) § Depression, dementia(is it causative, shared origin, exacerbative or all 3?) Sensorineural Hearing loss (NPA) Conductive hearing loss (NPA) Retro-Cochlear hearing THE MOST COMMON CAUSE THE MOST COMMON CAUSE OF loss (Neurological) OF SENSORINEURAL HEARING CONDUCTIVE HEARING LOSS à § MC à CNS 8TH LOSS à LOSS OF HAIRS OF AUDITORY CANAL ATROPHY NERVE TUMOR CORTI!!! Other causes: infection, fluid, arthritis, (SCHWANNOMA!!) Other causes: Loss of cochlear hole in ear drum (not common in elderly), neurons, inner ear issues Pagets disease of bone § Presbyosmia: normal age-related change in smell in taste § Presbyesophagus: tension in the upper esophageal sphincter decrease (NPA) Lecture 2: § Frailty- defined as age-related increased vulnerability to adverse outcomes when exposed to stressors (either intrinsic or extrinsic) o Prevention of increasing frailty and its outcomes is at the core of geriatric medicine § Urination requires central and peripheral control o Bladder capacity declines (normal is 300 – 600) à IN ELDERLY CAPACITY IS 250 – 300 & URGE AT 150 (bladder comfortably holds 150-300cc of urine before the urge to void) à KNOW THE NUMBERS I BOLDED! § Elderly àIncreased in Residual urine (INCREASED INCIDENCE OF BLADDER SPASM): increase pressure in bladder to point where of overcoming bladder sphincter § Leakage: If intra-vesicular pressure rises above max. urethral sphincter pressure increases. § Valsalva: Intravesicular pressure can rise from increased intra-abdominal pressure § Men: enlarged prostate ax with RETENTION not overflow incontinence. § ABOUT LIKE 5 QUESTIONS ON DIFFERENT TYPES OF URINARY INCONTIENCE! à know the difference between each / causes / management! o Stress Incontinence: Involuntary loss of small amounts of urine due to increased intra- abdominal pressure, cough, laugh, sneezing (VALSALVA) à most common in women § Causes: Laxity of pelvic floor § Management: Kegel exercises, alpha adrenergic agonists, bladder training, surgery § More common in women o Urge Incontinence: Inability to delay voiding after sensation of bladder fullness § Causes: Detrusor muscle hyperactivity caused by cystitis, urethritis, tumors, stones, outflow obstruction, impaired contractility or stroke, dementia, Parkinsons, cord pathology  § Management: Treat infection, bladder relaxants, bladder training, electrical stimulation, surgery o Overflow Incontinence: Leakage of urine from mechanical forces on an overdistended bladder (Dribbling, weak stream, hesitancy, nocturia) § Causes: Anatomical obstruction from prostate or cystocele, non-contractile bladder from DM or cord injury, Detrusor underactivity causes retention then overflow incontinence § Management: Surgical removal of obstruction, catheterization (intermittent or indwelling o Functional Incontinence: Leakage of urine due to cognitive and/or physical impairment, unwillingness, or environmental barriers § Causes: Dementia, immobility, restraints, inaccessible toilets, or toileting assistance, depression, catheters § Management: Behavioral therapy, environmental change, incontinence undergarments, external collection devices, bladder relaxants o Mixed Incontinence: Features of both urge and stress incontinence Common in older women § Management: Bladder retraining, pelvic muscle exercises, other pelvic muscle, pharmacologic agents o Evaluation of Urinary incontinence à ASK IF ANY CURRENT HX OF à Frequency, urgency, nocturia, leakage with valsalva, hesitancy, dysuria, constipation, bladder diary (timing and amounts) of normal voids vs. incontinence o Medications: “there may be one question about medications ur giving and ax with incontinence I don’t remember” § Sedatives: Reduced awareness & detrusor activity = Urge / Obst UI § Loop diuretics: Diuresis overwhelms bladder capacity = Urge / Obst UI § Alcohol: Polyuria, Reduced Awareness = Urge & Functional UI § Caffeine: Polyuria, Increased detrusor activity = Urge UI § Cholinergics (donepezil): Increased detrusor activity = Urge UI o Treatment: IDK IF THESE ARE IMPORTANT BUTTTTT THE SIDE EFFECTS WERE IN RED! § Anticholinergic: Darifenacin (Enablex), Oxybutynin, Mirabegron (Myrbetriq ) à Increase bladder capacity, decrease involuntary contractions Urge / Stress incontinence w/ detrusor instability Side Effects: Dry mouth, >IOP, delirium, visual changes, constipation § Alpha – adrenergic agonist: Phenylefedrine, Pseudoephedrine à urethral smooth muscle contraction Stress incontinence from sphincter weakness Side Effects: HA, tachycardia, > BP § Conjugated estrogens: > peri-urethral blood flow, strengthen local tissue Stress/urge related to atrophic vaginitis Side Effects: Endometrial Ca, > BP § Cholinergic agonists: Urocholine à Stimulate bladder contractions Overflow incontinence secondary to atonic bladder Side Effects: Bradycardia, hypotension, bronchospasm, >gastric acid secretion § Alpha adrenergic blockers: Tamulosin (Flomax), Hytrin (Terazosin) à Relaxes smooth muscle of urethra and prostate Overflow and urge from > prostate size Side Effects: Orthostatic Hypotension § Renal NPA:  o Creatinine Clearance decreases by 7.5-10% per decade after 50 o Potential major effect on drug clearance o Erythropoietin - EPO levels rise with age in healthy, nonanemic individuals § Those with anemia also had a lower slope of rise, suggesting that the anemia reflected a failure of a normal age-related compensatory rise in EPO levels o Renal mass decreases by 25-30% by age 75 o Less able to concentrate or excrete excess water. o Glucose, protein, and sodium retention thresholds are diminished o Potassium Handling: Potassium excretion increases with GFR à So Big reductions in GFR result in inability to excrete K+, And increased plasma potassium/ cardiac arrythmias. o Calcium metabolism: Failure to activate vitamin D decreases calcium absorption in the gut. Causes breakdown of bone due to erroneous PTH elevation § Hematological NPA: o ANEMIA IS NOT NORMAL IN THE ELDERLY!! (Relative à HEMOGLOBIN CAN BE SLIGHTLY REDUCED (normal 13 – 15 but in elderly can be 11 – 12) § Actual number of RBC and correspondingly H&H are reduced but not significantly. o Bone Marrow function: function remains intact but reserve capacity under stress is reduced o Platelet function unchanged. § Cardiovascular system: Normal process of aging: Less able to react to Catecholamine and Sympathetic Responses Energy Metabolism § Cellular Level - Impaired mitochondrial capacity to increase ATP o BP & recovery time increase (systolic more so then diastolic), HR & baroreceptor sensitivity decrease à increase chance of postural hypotension § The Elderly: Have less exercise tolerance & are more prone to hypotension when changing positions § NOT A NORMAL PROCESS OF AGING: Coronary Artery Disease, Arteriosclerosis and Hypertensive Heart Disease à These are all Common disorders found in the elderly (also HF) but they’re not NPA!! o HTN: Elevated blood pressure in the elderly is ABNORMAL à Consider atherosclerotic disease, valvular disease, renal disease, vascular disease, DM § Structural changes with age = decreased functional capacity of the heart § Treatment: START LOW AND GO SLOWWW!!!!! à rapid reduction of blood pressure in the elderly can lead to serious secondary effects (more likely to die from hypotension rather then HTN so don’t drop too fast) Consider potential side effects of medications Lifestyle Modifications Very Important o Cerebrovascular disease: MOST COMMON FORM OF CVA IS NON-HEMORRHAGIC CVA (thrombotic or atherosclerotic) § Signs/ Symptoms: Acute unilateral facial and/or extremity weakness, garbled speech § Management: Complete neurologic exam, Neuro imaging, Aspirin (non-hemorrhagic only), control of blood pressure thrombolytics o Heart failure: HF is the most frequent hospital discharge diagnosis in the U.S. § Signs/Symptoms: Usually subtle, easy fatigability, ankle edema, SOB/DOE, cough ECG, echocardiography, BNP § Treatment: Lifestyle modifications- salt reduction, fluid restriction, Beta blockers, diuretics, ACE/ARB, nitrates, digitalis o PAD: (RF = Age, DM, smoking Hyperlipidemia, hypertension, elevated homocysteine levels) § Sxs: LE pain, Exercise intolerance/ Quality of Life reduction, Pain resolves with rest/ no pain at rest, Reduced blood pressure in the LE (abnormal ankle-brachial index)  § TX: Smoking cessation, control of BP and lipids, Anticoagulation (clopidogrel, aspirin), Cilostazol, surgery Respiratory system components: § Lungs: Stiffening of elastin and the collagen connective tissue supporting the lungs, stiffening of chest wall / diaphragm (loss of muscle tone) o Basically everything decreases in lungs (alveoli / alveolar surfaces), and airway (antibodies / effectiveness of cilia) Lecture 3 § Age related changes in endocrine o Most Apparent: Glucose homeostasis, Reproductive function (W HYPERTHYROID Drug interaction distorts thyroid function tests: Calcium, iron, bile acid sequestrants, coffee, sucralfate (PUD), aluminum hydroxide, and sevelamer TSH is an acute phase reactant: so TSH lvls are not reliable in inflammatory state! TSH can be as high as 6- 8 in the elderly and be safe § Pancrease: The Islets of Langerhans usually show little age-related change o NOT A NPA à decreased islets response to high blood glucose (decrease in glucose tolerance) § Other possibilities: Inadequate Insulin production, Increased insulin level in response to oral glucose (in some affected elderly) § Blood Glucose: Levels tend to rise (body less responsive to insulin) o Most patients older than 65 years with diagnosed DM have type 2 DM (INSULIN RESISTANCE), and a small minority has type 1 DM (autoimmune to pancreatic B cells). § Tx Type 2 DM: 1ST LINE TREATMENT / BEST TREATMENT: LIFESTYLE MODIFCATION (diet, exercise, weight loss) Medication: metformin à check liver function (BUN Creatine) if elevated then hydrate them and retest if still raised then stop metformin We want HbA1c 60k) § Complication: COLONIC PERFORATION, Sepsis, hypotension, dehydration § Tx: VANCO,(binds toxins not absorbed – taper as 2nd line), metronidazole (Flagyl), fidaxomicin, QUESTRAN, rifaximin (last resort) Questran nullifies vanco o Constipation: three bowel movements or less per week § EXAM: CAUSES OF CONSTIPATION à Lack of fiber in diet, Slower Motility, Decrease in body water, Cancer, Metabolic and endocrine disorders, Muscular dystrophy, Neurologic disorders, Obstructive disorders, Recent abdominal surgery, Opoids § TREATMENT: OSMOTIC LAXATIVES (LACTULOSE – can use in DM), Fiber supplementation, Metamucil, Prune Juice, Bulk laxative, Stool softeners, Magnesium containing laxatives, Senna End stage renal disease: Don’t use Magnesium based laxatives or Phosphorus Enema (Use Tap Water) § GERIATRIC GIANTS à FTT ,GAIT DISORDERS / FALLS, PRESSURE ULCERS, URINARY INCONTINENCE, CONSTIPATION / DIARRHEA Lecture 4 Osteoporosis: T score à Osteopenia: -1.0 to -2.5 (-)/ Osteoporosis: > -2.5 / normal: +1 and -1 o >10% mortality rate for hip fx o Tx: Bisphosphonates (Alendronate (Fosamax)) à decrease osteoclast activity, must be taken on empty stomach § BOARD QUESTION: CAN CAUSE JAW NECROSIS (reduced chances if taken before eating) § Others: Etanercept (Enbrel) – TNF inhibitor, calcitonin (nasal spray), HRT (increased risk of CA / DVT), Hip protectors (reduce fall injury) Falls: Inadvertently coming to rest on the ground or a lower-level w/o LOC o Injuries from falls: Largest single cause of preventable restricted activity in elderly o Fall at home: Much higher incidence within 1 month of hospital discharge § F > M, bedroom / bathroom MC, environmental factors are common cause § Balance dysfunction: Peripheral Sensory Disorder (input issue), CNS Structural Pathology, effector organ problems § Drugs: ETOH, Analgesics , Antihypertensives § HX: SPLAT à Symptoms, Previous falls, Location, Activity, Time § Gait examination à Get (Time) up and go test (3 meters) should be performed < 10 sec Watch them standing (heel to toe / reaching for target), ambulate (always guarded – with stress / with obstacles) o Treatment / Intervention: LOWER BED HEIGHT!!!!!!  Pressure ulcers: o Pressure on capillary beds greater than 32mm Hg will cause necrosis in as little 2 hours + Add shearing forces and moisture from incontinence = PRESSURE ULCERS o BONY PROMINENCES: Greater trochanter, Heels, Sacrum, Scapula, Occiput o Wound types: KNOW THISSS! § Stage 1: Non-Blanchable erythema that typically is painful § Stage 2: Partial skin loss usually epidermis & dermis (Blister, Abrasion, Superficial crater) § Stage 3: Full thickness loss with damage to not through underlying fascia à surgery PRN § Stage 4: Full thickness loss through fascia to supporting structures (Bone, tendons, joint capsule) à Billing stage only to Stage IV Usually managed by surgeon § Unstageable: Any wound that you cannot see the base, Usually needs surgical intervention If its dry, ie: eschar à Local care, Just cover, Iodine à unstageable until eschar is debrided!! § Treatment: Keep wound clean, moist not wet, and well protected from pressure and outside environment Numerous commercial products: Calcium Alginate, Santyl, Xeroform, Unaboot, Hydrogen NEED HIGH PROTEIN DIET TO HEAL à 1 gm / kg of body weight & stay hydrated (30 mL / kg of H2O) o Arterial leg ulcers: results of arteriosclerosis obliterans and/or atherosclerosis causing ischemia (sx of claudication) à dry well defined borders, pale with minimal exudate, covered w. black eschar § ABI (ankle-brachial index) good screening test à >1.4 = PAD § Angiography is diagnostic o Venous stasis ulcers: MOST COMMON TYPE (75%), results from venous HTN à Valve disease, Obesity, Phlebitis, Trauma, Infection, Diabetes à large, shallow, moist, granulating rarely necrotic, accompanied by edema § PUNCHED OUT APPEARANCE § Stasis dermatitis (usually brown, scaly), varicosities § Confirm with: Duplex doppler § Cornerstone treatment: COMPRESSION BANDAGES (not surgery) o Diabetic foot ulcers: very similar to arterial but with peripheral neuropathy (sensory / autonomic / motor) à infection more common from poor glucose control à small ulcers on plantar or lateral surface Malnutrition: Commonly associated with acute illness à Can present as confusion or hypotension o Hypoalbuminemia: Check Albumin / Pre-Albumin, Total Protein (LFT) o DELIRIUM!!!!! ON EXAM Lecture 5 Depression = under diagnosed in elderly o Social integration: IMPORTANT IN GOOD MENTAL HEALTH OF ELDERLY Prefrontal cortex: undergoes cell shrinkage & cell loss with age (working memory is reliant on this area of the brain) o slowing of reaction time (the time it takes to respond to an event), Somewhat slower on “simple associative” tasks (e.g., hitting brakes in response to red light), more pronounced  slowing on “complex choice” tasks (e.g., deciding whether to accelerate or brake at a yellow light), take longer to make a decision o Processing speed à affect the ability to hold information in mind (the time one part of a problem has been completed; other aspects of the problem may have been forgotten) § Making more Gut decisions o Slowing of neurotransmission speed also is reduced in prefrontal cortex Long term memory (minutes to years) à hippocampus o Learn info à attend to info à process meaning of info (using strategies to make info meaningful / organizing info / reducing amount of stress improves memory) o Aging enhances the ability to remember information that is emotionally positive and personally relevant o Remote memory (many years) & semantic memory: These memories tend to be more resilient, and are less affected by brain damage, aging, or the initial stages of Alzheimer’s disease § Over time memory no longer dependent on hippocampus à lots of repetition spread out over many yrs causes this transition o Semantic memory (factual knowledge): reliant on temporal lobe (preserved with aging) § Older adults tend to have much better semantic memory than young adults, so they perform better on tasks of vocabulary & World knowledge o Perceptual memory: 1 – 2 sec maximum o Working (short term memory): ~45 sec maximum Dementia: Multiple acquired cognitive deficits that occur in the absence of acute confusions o Memory, Orientation, Language, Praxis (skilled action) Construction, Executive control, Prosody (The patterns of stress and intonation in a language). o NO GAIT DISTURBANCE o ½ of all the cases are AD (Cortical neurodegenerative disorder): Insidious and progressive decline in cognitive function à Immediate and delayed memory recall (early), aphasia § Disinhibited behaviors (frontal lobe): actions which seem tactless, rude or even offensive - SPO-SPOA § Later: childlike, apathetic, labile, tantrums § Rarely exhibits Motor Deficiencies in early stages § Affects neurons in the cortex affecting neurotransmitters: acetylcholine, serotonin and norepinephrine (NOT GABA) § Dx: ONLY ON AUTOPSYYY!! à Excessive amyloid plaques, neuritic plaques and neurofibrillary tangles o Dementia with Lewy Bodies (frontal dementia): abundant Lewy bodies in cortex and brainstem à confusion w/ delirium and always progresses o Vascular Dementia: Multi-infarct, Lacunar state (localized sub-cortical infarcts), § Sporadic changes in mental Status, mild recovery, but not to baseline § TOXIC / METABOLIC AS POSSIBILITY Metabolic: patients with severe, end stage systemic disease Toxic: Medication toxicity, ETOH, Polypharmacy, Heavy Metal intoxication (lead/ mercury / cadium) o Frontal dementias: Picks disease, Creutzfeldt-Jacob & Lewy body dementias § Picks: Early aphasia, personality changes, insight and judgment, memory somewhat later, very active and disinhibited (familial) § Creutzfeldt-Jacob & Lewy body dementias: Rapidly progressive, Parkinsonian features CJ may be transmissible  o Normal pressure hydrocephalus: gait disturbances, dementia, incontinence (wet/ wacky/ wobbly) o Dx: NO SPECIFIC DIAGNOSTIC TEST!!! But need an accurate H&P § R/O: Delirium, depression (pseudodementia), any other reversible cause!!! o TX: anticholinergic inhibitors Delirium: Disturbance in consciousness, Change in cognition, Develops over short period of time, fluctuates, Caused by physiological consequence of a medical condition o Functional change rather than structural change in the brain § RISK FACTORS: NEW RXX!! ALWAYS ASK!!! Highest risk group: ill elderly, impaired physical function, post op pts and dementia (dementia raises the risk by 25 – 50%) o Common causes: Dehydration, Infections, Hypoxia, Hypoperfusion, Constipation, Fecal impaction, Sensory impairment, A wide variety of medications o Major cause: anticholinergic intoxication: Anticholinergic drugs are often administered for the treatment of gastrointestinal & respiratory disorders, insomnia, and even motion-sickness § Antihistamines, cold medicines, TCAs, Heroin § SYNERGISTIC EFFECT: Taking combo of anticholinergic drugs § Sxs: Amnesia, confusion, constipation, disorientation, dry skin, fever, High BP, Pupil dilation slurred speech o Dx / Assessment: requires 1 & 2, and either 3 or 4 (can use RASS score or CAM – ICU flow sheet) § 1) Acute change in mental status that fluctuates § 2) Inattention: difficulty focusing, distracted, following a conversation § 3) Disorganized thinking: rambling, irrelevant conversation, illogical flow ideas, rapid subject changes § 4) Altered mental status o Tx: tx / ID illness, review medications, eliminate risk factors (catheters, constipation, sleep deprivation), avoid restraints (chemical or physical) Major Depressive Disorder- depressed mood or marked loss of interest experienced most of the day or every day for 2 weeks or longer along with at least four of the following: o Sxs: >5% loss of body weight/1 month, loss of appetite, insomnia, hypersomnia, psychomotor agitation or retardation, Feelings or worthlessness or guilt, diminished concentration, Thoughts of suicide, loss of interest o Depression in the elderly can be missed due to patients not reporting symptoms, patient can’t report symptoms (aphasia) à may also have unusual presentation (agitation) o Tx: same as non-elderly (Pharm / psychotherapy) § CAUTION WITH PHARM MEASURES (ALTERED RESPONSE IN ELDERLY) o Dx: can be times where its impossible to dx but it doesn’t mean its not there!!! § Screening tool: geriatric depression scale Lecture 6 **15.8% of all hospital admission are from Adverse Drug Reactions - (ADR) o Drug use increases with age due to higher prevalence of disorders à Rise in adverse drug reactions Criteria for POLYPHARM: Medications w/o diagnosis, Duplication of medication in same class, Using medications that interact with each other, Use of contraindicated medication, Treatment of ADR’s with other medication, Improvement is noted after medication is stopped / discontinued  o All heightened with polypharm: Drug to Drug Reaction, Drug to Disease Reaction, Drug to Nutrient Reaction o CAREFUL WHEN USING MORE THAN 5 DRUGS!!! o PREVENTION: PRIMARY FEATURE = PATIENT EDUCATION across all care settings at every encounter!! § PATIENTS MUST BE AWARE THAT ALL DRUGS HAVE AE POTENTIAL EVEN OTC!! § Medication review: Do I have an diagnosis to medication match?, Adverse drug reactions?, Is a medication necessary? (Lifestyle Modification), What are my therapeutic goals from this drug?, Risk to benefit ratio?, Am I duplicating drug use? Can one drug treat two different conditions?, LENGTH OF PRNNNN USEEE!!!! § HEIGHT AND WEIGHT!!!!! à a lot of elderly are frail and may not require ADULT DOSING!!!! (90 yo buddy 65 lb à back to peds with mg / lb) BEERS CRITERA: o List of meds to avoid / consider use of older adults: § 1st Generation Antihistamines (diphenhydramine) : clearance reduced with advanced age, increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity o List of medications that are Inappropriate to use in the elderly § Antihypertensive Drugs: Alpha1 blockers (Peripheral) à orthostatic hypotension Alpha blockers(Central) à adverse CNS effects § Antiarrhythmics: Studies show that rate control works better than rhythm control in older adults with arrhythmia Antiarrhythmic drugs (Class Ia, Ic, III) à Avoid o Cardiac drugs: § Digoxin >0.125 mg/day à increased risk of toxicity at higher dosages with no additional benefit, monitor renal clearance § Nifedipine (immediate release) severe orthostatic hypotension à May precipitate MI (due to Hypotension) § Spironolactone >25 mg/day à increased risk of hyperkalemia when used in patients with heart failure o Antihyperglycemics: § Insulin: sliding scale- increased risk of severe hypoglycemia § Sulfonylureas: long acting drugs have increased risk of hypoglycemia o Pain Medications: § Meperidine: may cause neurotoxicity § Non–COX- selective NSAIDs: Increases risk of GI bleeding/peptic ulcer disease in high- risk groups, including those >75 years old § Skeletal muscle relaxants: increase risk of severe anticholinergic effects § Tertiary TCAs: alone or in combination à Highly sedating, severe anticholinergic effects § Antipsychotics, first generation and atypical drugs (Haloperidol): increased risk of CVA and mortality in patients with dementia § Benzodiazepines (short and medium-acting): increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Long acting- decreased metabolism of the drug Nonbenzodiazepine hypnotics: Similar to benzodiazepines, avoid usage > 90 days Pain:  o Type 1: Nociceptive (localized / direct damage to normally functioning nerves), somatic (bone, muscle, skin origin), visceral (cardiac, lung, bowl) o Type 2: neuropathic: may be peripheral or central (occurs in the absence of ongoing tissue damage) à complicated to tx § Common in hemiplegia / DM o Management: communicate, differentiate (acute/ chronic), EXPECTATIONS (level of pain relief), don’t allow mild/ moderate to become severe § Non-pharmacological therapies, Warmth/cold, Massage, Acupuncture, Transcutaneous Electrical Nerve Stimulation (TENS) § Pharmacological: Start simple and advance as needed – Tx depends on cause / severity Mild to Moderate Pain: Acetaminophen or NSAIDS (if one does not work try another, or add Tylenol) o Trending away from opoids but can be effective for moderate / severe somatic visceral pain Reproductive system: age related changes (WOMEN WORSE THEN MEN) o Females: Estrogen decrease, Vaginal pH increases, Mucous production decreases, atrophy of Ovaries / uterus / breast / vagina (Premarin cream) § Climacteric: beginning of the end à Loss of estrogen/progesterone, Increase in LH / FSH o Men: Still produce sperm (frequently be mutate), Testosterone can remain in normal range until age 80, Prostate enlarges in 90% males by 85, often results in compression of the urethra à inhibit the flow of urine. o MOST CAUSES OF IMPOTENCE AND LOSS OF LIBIDO ARE DUE TO PSYCHOLOGICAL ISSUES Geriatric assessment: Flexibility à do not approach the geriatric patient with chief complaint, HPI, PMH, PSH, ROS and social history, followed by a complete physical exam o The various components can be conducted over multiple encounters o Do not try to accomplish too much at one visit à USE MULTIPLE VISITS o Assessment: ADL’s (activities of daily living), Gait Impairment and Fall Risk, Cognitive Status, Incontinence, Psychological (Geriatric Depression Scale (PH-9)), Social (living condition, income, caregivers and visitors) à PROBLEM RECOGNITION IS THE FIRST STEP o ADLs: Activities that people tend do every day without needing assistance à KNOW THESE: § Bathing, Dressing, Toileting, Transferring, Walking, Feeding o IADLs: Activities that are not necessary for fundamental functioning, but they let an individual live independently in a community à KNOW THESE § Handling finances, Telephone, Shopping, Ability to travel, Driving, public transportation, Managing Medications o Support system à You need to identify who, how, and the capability of the patient’s support system (80% of the frail elderly rely on direct family support) o When assessment done answer questions about à acute issues, chronic illnesses, ADL’S, IADLS, support system Routine maintenance o Breast Cancer à The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. o Cervical Ca à No PAPs after 70 if prior PAPs have normal o Colon Ca: Colonoscopy vs Fecal à >45 (USPTF), History of Polyps, Familial Polyposis o Immunizations: Tdap, Flu Vax for life , Prevnar for life ( ??? PneumoVax), Covid LECTURE 7 o Hospitalization / preop assessment: 50% of people over 65 will have surgery before they die  o Major surgery places excessive stress on elderly because of fluid shifts and blood loss o CHF or MI within last six months are the only well documented contraindications for surgery o Hazards of hospitalizing the elderly à 75% of independent population over 75 years old are no longer independent after hospitalization § Despite cure or repair of the condition they were admitted, 58% suffered preventable iatrogenic complications § RISK FACTORS FOR FUNCTIONAL DECLINE WHILE ELDERLY ARE HOSPITALIZED à ADVANCED AGE, PRESENSE OF DELRIUM, MULTIPLE MEDICAL CONDITIONS o Common reason for hospitalization: Pneumonia, CHF, Femur Fx, UTI, Dehydration o Muscle mass and strength à DIMISHED (NPA) but bed red / muscle inactivity leads to further decrease in muscle mass / strength (in elderly 5% / day) o Vasomotor stability: Increased baroreceptor insensitivity is a normal age related change § Combine with age related depletion, Bedrest in supine position decreases plasma volume Orthostasis à syncope à falls à injury o Respiratory function: Normal Age Related Changes à Diminished chest wall expansion, Costochrondral calcifications, Increased closing volume, Decreased muscle strength, Decreased PaO2 à Bed Rest / Hospitalization decreases homeostatic mechanisms o Sensory deprivation/ stimulation à Elderly appear to have higher incidence of confusion during hospitalization à Visual or hearing disturbances, Diminished/ slowed neurotransmitters, Neuroanatomic changes, Delirium § Increase in sensory incontinence à sleep deprivation a prominent factor o Urinary incontinence: 40-50% of hospitalized patients over 65 become incontinent within 36 hrs after admission o Recommendations: Minimize Bedrest!!, Low beds, Carpeting, Minimize “lines”, Clocks and Calendars, Newspapers, Dressing and Dining, Proper Lighting, Make sure they have Glasses, Hearing Aid and Dentures, Avoid hospitalization, promote early discharge o Elder Abuse o Warnings signs of abuse: EXAM § Physical: Unexplained bruises, repeated injuries, broken bones § Psych: crying, agitated, ashamed, depressed, afraid § Financial: large bank withdrawal, unpaid bills, missing items § Sexual: genital anal trauma, bleeding, STDs, bruising to breast, painful urination § Neglect: dehydration, poor hygiene, poor living conditions à ull see mostly in primary care settings § Abandonment: seeing a vulnerable elder left alone in distress o Perpetrators: § FAMILY MEMBERS (57%), Friends and neighbors 16.9%, Home Care Aides 14. o Call: adult protective services, ombudsman, police to make report or do welfare check o Home care services à Health care, such as having a home health aide come to your home or getting care from your provider through telehealth o Community services: § THE PROGRAM OF ALL – INCLUSIVE CARE FOR ELDERLY (PACE) à know the name! Comprehensive preventive, primary, acute, and long-term care services for older individuals with chronic care needs Eligibility: 55 years or older and certified by their state to need nursing home care but don’t need to live in a facility  § Home Health Agencies (HHAs) provide part-time nursing and medical care in patients’ homes à physical, speech / occupational therapy, social services, some medical supplies and equipment (wheelchairs, walkers) § Meals on Wheels (an HHA variation) - supplies one hot meal a day (usually lunch) to people who are confined indoors due to a mental or physical disability o Criteria: A physician must order Medicare home health services and must certify a patient’s eligibility for the benefit § MEDICAL PROVIDER MUST SEE THEM FACE TO FACE TO SIGN OFF ON THE ORDERS à based on physicians current knowledge of pts clinical condition! The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care à must also document date provider saw pt / pts condition during encounter, supports the pts homebound status and need for skilled services Can also be ordered by à NP, nurse specialist, midwife, PA PHYSICIAN MUST WRITE OR TYPE AND SIGN (Cannot verbally communicate the encounter to HHA to document) o Skilled services: must need à Skilled nursing care on an intermittent basis, or Physical therapy, or Speech-language pathology or continuing need for occupational therapy (this is different from home health aide) o Adult Day Care Centers: designed to provide care and companionship for older adults who need assistance or supervision during the day. Programs offer relief to family members and caregivers § Goals of the programs: Delay or prevent institutionalization by providing alternative care, to enhance self-esteem, and to encourage socialization o Advanced directives à know o Health Care Proxy: Designates a person to make medical decision for you if you lack capacity to do so o DNR / DNI: Whether to treat with antibiotics, and respiratory support, including intubation if necessary o Living Will, Power of Attorney o MOLST / POLST: Medical Orders for Life Sustaining Treatment, Provider Orders for Life- Sustaining Treatment o Palliative care: specialized medical tx for ppl living with serious illnesses à focused on relief from the symptoms and stress of a serious illness. o Goal: improve quality of life for both the patient and the family. o Shifting the focus à someone with HTN has a bad HA were tx the HTN not to cure it but were tx it to make the pt comfortable!!! à tx pain o SPIKES à § STEP 1: SETTING UP the Interview § STEP 2: Assessing the Patient’s PERCEPTION § STEP 3: Obtaining the Patient’s INVITATION STEP § STEP 4: Giving KNOWLEDGE and Information to the Patient § STEP 5: Addressing the Patient’s EMOTIONS with empathic responses § STEP 6: Strategy and Summary o Hospice: Provides a site of care for the dying, and a team of practitioners with knowledge of palliative care o INSURANCE PAYS FOR THIS à MEDICARE BENEFIT à PROGNOSIS NEEDS TO BE LESS THAN 6 MONTHS TO LIVE