Geriatrics Final Study Guide.pdf

● ● ● Geriatrics Final Study Guide This doesn’t include Alex 5 Qs – will be short answer, unknown if pharm Qs No pharm Qs from Megatron-so look but don’t memorize specific rx Question types: MC, T/F, matching, select all that apply 3Ds: Delirium, Depression, Dementia ● Types of dementia and their...

● ● ● Geriatrics Final Study Guide This doesn’t include Alex 5 Qs – will be short answer, unknown if pharm Qs No pharm Qs from Megatron-so look but don’t memorize specific rx Question types: MC, T/F, matching, select all that apply 3Ds: Delirium, Depression, Dementia ● Types of dementia and their prevalence ○ #1 – Alzheimers (60-70% of cases) ○ #2 Vascular dementia, #3 Lewy body dementia, #4 Frontotemporal dementia ● Factors that predispose an individual to develop Alzheimer’s ○ Down’s Syndrome, age, family hx, genetics, lifestyle factors ● Modifiable and non-modifiable risk factors for Alzheimer’s ○ Mod: HTN!! T2DM, smoking, depression, sedentary, isolation, head trauma, hearing loss ○ Non-Mod: age, family hx, genetics (APOE epsilon 4 gene), downs syndrome ● Risk factors and comparisons of depression in older adults vs general population ○ Common in older adults (10-15%) ■ may present with cognitive impairment, somatic complaints, social withdrawal ○ Risk factors: CV disease, diabetes, chronic pain → contribute to depressive symptoms ■ Neurotransmitter imbalances, genetic predisposition, comorbidities ■ Social isolation, bereavement, caregiver stress, life transitions, decreased ADLs ● Work up of depression ○ Geriatric Depression Scale (GDS) - score of 5+ indicates → PHQ-9 ○ Pharm: SSRIs first line, regular monitoring ○ Non-pharm: psychotherapy, physical activity, social intervention, sleep hygiene & nutrition ○ Collaborative care involving a multidisciplinary team is crucial for the effective management of depression in older adults ● CAM, when to use, what is its purpose ○ Confusion Assessment Method – used to diagnose delirium ○ Evaluation of acute onset and fluctuating course, inattention, disorganized thinking, ALOC ○ Also used in post-discharge visits, make sure the pt is at their baseline when they leave ● Pharmacologic interventions for delirious patients ○ Pharm: Antipsychotics, Benzos (avoid; only for severe agitation that poses a safety risk) ○ Non-pharm: ID underlying cause, environment (clocks), mobilization and engagement, sleep hygiene (minimize noise & disruptions) ● Interventions in managing delirium in the hospitalized patient ○ “Depending on pt, what are things we can look at to potentially bring them out of the delirious state?” ○ Adequate lighting, minimal noise, familiar personal belongings, orientation cues (clocks, calendar), clear signage Urinary Incontinence – Common in elderly, but not normal ● Requirements to maintain continent of urine ○ Intact cognitive, neuro, muscular, and urinary systems ○ Consciousness, motivation, comprehension, & attention to recognize the need to void ● Post void residual volumes for various pathologies ○ Post-void residual (PVR) increases w/ age bc thinning, atrophy, weakness of tissues ○ Most people: 75-100 ml ○ First urge to void at lower PVR: 150-300 ml ○ Bladder capacity decreases: 300-600 ml ● Consequences of incontinence ○ Medical–sleep deprivation, rashes/skin infections, pressure ulcers ○ Functional–mobility issues, falls ○ Social–limited social activities, avoidance of sex ○ Emotional–depression, anxiety ● ● ● When are pelvic floor exercises (Kegels) used ○ May help in mild-moderate stress or urge incontinence When is catheterization appropriate for patient care ○ Overflow incontinence ■ Obstructive-decompression or Atonic Bladder-intermittent/indwelling ○ Use in urinary incontinence ■ Relieve obstruction, monitor output, keep pt dry, manage sx (if no surg/pharm) ■ Cons: ↑risk UTI/uro-sepsis, bladder stones, bladder cancer, periurethral abscess First line and refractory treatment for UI ○ Functional: loss of urine in setting of a normal structural and functional urinary system ■ PT, exercise, assistive devices (bedside commode) ○ Stress: detrusor instability or urethral sphincter laxity → MCC in women ■ Nonpharm: lifestyle modifications, Kegels, pessary (device), surgery (bladder neck vs mid urethral sling; surgery is most effective definitive tx) ■ Pharm: topical estrogen (for vaginal atrophy), Duloxetine (off label use) ○ Urge: uninhibited detrusor activity at inappropriately low urinary volumes → MCC elderly ■ Nonpharm: bladder training (timed void), pelvic floor PT (+kegels), pads, weight loss, diet changes (↓etoh, caffeine, carbonation, excess fluids), smoking cessation ■ Pharm: antimuscarinics, beta 3 agonists, topical vaginal estrogen (if postmeno) ○ Overflow: excessive bladder volume as result of impaired bladder wall contraction or urinary sphincter relaxation ■ Nonpharm: ● Obstructive - decompression (cath), surgery, intermittent/indwelling cath ● Atonic - remove medications causing problem, intermittent/indwelling cath ■ Pharm: ● Obstructive - Doxazosin (alpha 1 blocker) ● Atonic / post-op - Urecholine Wounds & Infections ● Areas prone to developing pressure injuries ○ Bony prominences ○ Elbows, heels, ear, back of head, sacrum, scrotum (not an answer, but just know) ● Intrinsic vs. extrinsic risk factors for development of pressure injuries ○ Immobile = unrelieved pressure ○ Intrinsic - nutritional status, age, immobility, sensory impairment, incontinence, dry skin, body temp ○ Medical - DM, kidney failure, PVD, chronic steroid use ○ Extrinsic - pressure, shearing forces, friction, moisture, incontinence ● Staging of pressure injuries Stage 1 Stage 2 Stage 3 Stage 4 Suspected deep tissue injury Unstageabl e Erythema does not blanche Partial thickness, involving epidermal & dermal layers Full thickness loss involving all layers of the skin Full thickness involving muscle & bone Purple or maroon area, blood filled blister underlying tissue Base covered by slough or eschar ● ● ● ● ● Markers to assess nutritional status of a patient ○ Protein → Albumin Common organisms that affect this population ○ Institutionalized older pts ■ MRSA, vanco-resistant enterococci (VRE), FQ-resistant strep pneumoniae, resistant gram (-) bacilli ○ Pneumonia ■ MC is strep pneumoniae ■ COPD/nursing home → H.flu, legionella pnuemophila, M. catarrhalis, Klebsiella ○ Infections mentioned in lecture – Norovirus (long-term care facilities), C.diff (abx use, age, PPI use), MRSA, HIV Assessing pneumonia/treating pneumonia ○ May present w/o fever or cough → low grade fever, hypoxia, confusion, falling, anorexia ○ Older adults more commonly have tachypnea ○ MC organism → strep pneumoniae ○ Tx → same as general population; cover atypicals in nursing home settings ■ Amoxicillin + doxy or azithromycin ○ Indications for hospitalizations: CURB65 ■ Confusion, Uremia – BUN > 20, RR > 30, SBP < 90, age > 65 ■ If 2+ → admit, if 3+ → ICU UTI assessment/treatment ○ Order UA if: acute dysuria, new or worsening urgency/frequency, new incontinence, hematuria, suprapubic/CVA tenderness, fever, new unexplained falls, AMS, VS changes or signs of acute illness ○ RF – BPH, menopause, neurogenic bladder (CVA/DM), indwelling catheters, nursing home ○ Only use abx if pt has sx → if asymptomatic but “dirty urine” DO NOT use abx ■ Broader empiric coverage, take into account GFR, monitor for toxicity MRSA risk factors/assessment/treatment ○ High risk individuals – underlying health conditions, abx use, medical implants, prior hospital/nursing home admission ○ Dx → clinical appearance and location of SSTI, swab from lesion ○ Tx: I&D for large abscesses is crucial, abx (TMP-SMX, clinda, doxy, minocycline) Elder Abuse and Neglect ● Types and prevalence of mistreatment ○ Most common type: FINANCIAL ○ Physical: hitting, kicking, burning, dragging, over/under medicating ○ Sexual: unwanted sexual contact, exploitation, forced viewing of porn ○ Financial: theft, misuse of funds/property, extortion, duress, fraud ○ Neglect: failure to provide food, clothing, shelter, healthcare ○ Mental suffering: verbal assaults, threats, causing fear ○ Abduction: removal from this state and restraint from returning to the state ○ Abandonment: desertion or willful forsaking by caretaker ○ Isolation: preventing from receiving mail, calls, or visitors ● What to do when mistreatment is suspected ○ Mandated reporters → report to APS vs Ombudsman (abuse in a SNF) ○ Witnessed active abuse and people are in danger → Police ● Common perpetrators of abuse/neglect ○ Family members serving as caregivers ● Hallmarks of abuse of the elderly ○ Explanation of injury inconsistent w/ possible cause, caregiver angry/indifferent/aggressive towards elder, personal belongings missing, elder is hesitant to talk openly, lack of necessities, caregiver has hx of substance abuse/mental illness/criminal behavior/family violence, another persons name added to clients bank account/important docs Palliative/Hospice/Death and Dying ● Provider accuracy with assessing prognosis ○ If w/in a year: normally within a 3 month range ○ Typically: overly optimistic – not very accurate ● Delivering bad news appropriately (Textbook p. 172 and IPC discussed) ○ Six steps ■ 1. Decide who the key participants are, obtain necessary background info, and arrange for an appropriate time and place for the meeting. ■ 2. Determine what the patient already knows, remember that although information may have been presented to the patient, it may not have been well understood. ■ 3. Determine how much the patient wants to know. Patients have the right to know as much—or as little—as they want about their medical illness and their prognosis. ■ 4. Communicate the results. Deliver “warning shot” so pt will be prepared. Phrases “I’m afraid I have bad news” or “the results are not what we would like them to be” can alert patients and families that they are about to receive difficult information. ■ 5. Responding to feelings–important w/ communicating unfortunate information. ■ 6. Make a plan for follow-up. Patients and families have a basic need for education so guide them by explaining what the next steps will be ● ● ● What does palliative care offer – Holistic approach ■ Physical–pain, functional ability, sleep, fatigue, nausea, appetite, constipation ■ Psychological–anxiety, depression, enjoyment, fear, condition, total pain/distress ■ Social–financial/caregiver burden, sexual fx (indwelling dildo/anal beads), appearance, relationships & roles ■ Spiritual–hope, suffering, total pain (meaning), religion, existential distress Difference between hospice and palliative care ○ Hospice: a health care delivery system under which support and services are provided to a patient with a terminal illness where the focus is on comfort rather than curing an illness ■ Hospice is a model of palliative care that is offered to patients at the end of life when curative or life-prolonging therapy is no longer indicated or desired. ■ An estimated prognosis of <6 months is required. ○ Palliative care: Specialty care for people who have serious illness ■ Goal – prevent & relieve suffering and provide the best possible quality of life for both the patient and the family. ■ All palliative care is not hospice care, but all hospice care is palliative care POLST: sections and what they mean ○ Physician Orders for Life Sustaining Treatment (form for pt to fill out) ■ ● Legal tools meant to direct treatment decision-making and/or appoint surrogate decision makers ■ Not followed unless pt has lost the ability to make decisions ■ *Completed advanced directives does not always mean that ACP has been done. ACP does not always result in an AD* ■ “POLST is a document summarizing the patient’s wishes for life-sustaining treatment and combines preferences that may have been expressed separately on a DNR form, living will, health care proxy, or other advance directives.” ○ Usually a pink form to find easily & quickly in an event in emergency ○ PAs can sign the form. Know what the sections represent in POLST. ■ A: resuscitation preferences ■ B: if pts select resuscitation, they have to select full treatment ■ C: artificially administered nutrition ■ D: signature of pt and providers, including PAs PAs and their role in Death with Dignity ○ PAs are unable to write the medication for this. MD or DO ○ PAs have a role: counsel patients LGBTQHDTV Care in the Geriatric Population – textbook Chapter 4 (new edition, we don’t have it-sorry, I tried!) meghan posted this chapter in the final questions DB thread ● Important aspects to consider when providing care to different members of this community ○ Significant bias and discrimination throughout life. Historical mistrust of providers – fear of discrimination when seeking help → more likely to remain in closet w/ health care providers ○ Family rejection → increased suicidality, substance abuse, HIV infection, depression ○ No legal protections for gay couples → decline in economic stability when partner dies ○ More likely to be caregivers to friend/family, but often lack one stable caregiver ○ Less likely to be partnered, more likely to live alone → loneliness ○ Gender neutral pronouns, space for LGBTQ data, LGBT literature in office, display signs of allyship, do not assume all pt are heterosexual, promote stress reduction ● Consequences of social isolation in the LGBT community ○ Twice as likely to live alone, HIV even higher risk, less likely to have family care for them, community based care that often falls off, impacts are negative health outcomes and increased risk for decline in cognitive function due to isolation. ● Minority Stress ○ LGBTQ commonly experience distinct and chronic stressors related to their sexual orientation and/or gender identity ● Importance of open-ended questions ○ Allows patients to better explain their circumstances without preconceived notions. ○ Encourages patients to be more open with responses – facilitates a safe space ● Gender affirming care in the geriatric population ○ What are some unique factors that we have to think about in the geriatric population? ■ “Textbook has a few examples” (???) ○ Older adults may see “Queer” as an offensive term due to historical implications (avoid) Oregon Movie (Extra Credit) ● 1 ) What medication is used for life ending care? ○ Seconal and Nembutol ● 2) When was Cody's original date to end her life? ○ May 25th (memorial day) ● 3) What was the ballot measure number in Washington to legalize death with dignity? ○ i -1000 ● 4) How quickly does a patient need to consume their life-ending medication to ensure it has the desired effect? ○ 1-1.5 minutes ● ● 5) In what year did Oregon legalize the Death with Dignity Act? ○ 1997 What is required of a patient to be able to utilize Death with Dignity Act ○ Pt must be able to swallow medication within 1-1:30min