Geriatrics Exam #1

geriatrics

the medical care for older adults

gerontology

studies aspect of aging on social, cultural, psychological, cognitive, and biological aspects

geriatric medicine

medical care of the elderly

when is a person geriatric?

-no set age

-most 65 yrs +

why is 65 considered geriatric?

because it is retirement age

the rule of fourths

of the decline in normal function seen as people age:

-1/4 due to disease

-1/4 due to disuse

-1/4 due to misuse

-1/4 due to physiologic aging

rule of fourths ex: decreased exercise tolerance in chronic smoker

-disease related disability

-treated medically

rule of fourths ex: SOB on minimal exertion in sedentary older person

-disuse related disability

-often cured with activity regime

rule of fourths ex: knee arthritis in former football player

-misuse-related

-prior damage cannot be reversed

-care and education can prevent detrioration and preserve function

rule of fourths ex: trouble reading fine print in 50 YO

-physiological aging

-take steps to compensate for disability

musculoskeletal system changes with aging

-muscles lose tone, volume, and strength

-osteoporosis

-arthritis

osteoporosis

bone mineral content decreases by 10-30%

circulatory system changes with aging

-blood vessels narrow and less elastic

-heart works harder

-maximum heart rate drops from 195 to 155

vision changes with aging

lens accommodation markedly decrease after 40-50 YO

hearing changes with aging

-acuity decreases beginning around 12 YO

-decline steepest in high pitches (>5000 hertz)

taste changes with aging

number of taste buds decrease by 70%

digestive system changes with aging

-weight decreases 7%

-peristalsis decreases

-liver function decreases

urinary system changes with aging

-decreased circulation to kidneys

-perfusion to kidneys decreases 50%

-creatinine clearance decreases 10 mL/decade

endocrine system changes with aging

-postprandial glucose tolerance impaired, decreases about 10 mg/dl/decade

-decreased DHEA

when does clinically significant impairment in function occur?

when demand is greater than the functional reserve

stamina changes with aging

insidious decrease in stamina occurs beginning in 20s

frality

-decrease in stamina and fatigue so great they define patient's physiologic status

-occurrence of 3 or more: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity

how can environment in which one lives affect their function?

can make the difference between being independent and being unable to carry out basic everyday activities: physical, social, and organization

what do older persons need to do involving mobility?

move it or lose it

ageism

systematic stereotyping and discrimination because a person is old

what do key elements of successful physiologic adjustment include?

a sense of satisfaction with one's accomplishments: life review and adjusting to losses

what does adjusting to losses require?

continual psychological adjustement

disengagement theory

letting go of trappings of earlier life way key to successful aging

activity theory

staying active and engaged was the key to healthy aging

how do relationship change occur in the elderly?

occurs more rapidly

what are older pts more at risk for without bonds?

isolation, depression, institutionalization

what does delivery of primary health care to older persons require?

in-depth knowledge of clinical medicine

geriatric syndromes

multiple multisystem deficits

-falls

-frailty

-dizziness

-gait problems

-weakness

-incontinence

-confusion

role of PCP is to ID functional deficits that:

adversely affect prognosis and quality of life

ADLs

-bathing and showering

-continence

-dressing

-mobility

-feeding (excluding meal prep)

-toileting

instrumental ADLs

-cleaning and housekeeping

-doing laundry

-managing money

-managing meds

-preparing meals

-shopping

-transportation

-using communication devices

prominent icebergs

depression, CI, incontinence, MS problems, alcohol use

how do you avoid icebergs?

specific screenings

what is the reasons for about 50% of consultations in geriatric assessment clinics?

dementia or worry about memory

what is the MC reason for nursing home placement?

dementia

what can confusion also be due to?

undetected alcohol use

3 common iatrogenic problems in geriatrics

-adverse drug effects

-acute kidney injury

-adverse surgical outcomes

aggressive medicinal treatment in older pts, more often leads to _____ than to ______

adverse consequences; improvements

what increases the amount of drug-drug interactions or drug-disease interactions?

increased number of meds

what does having many providers and services lead to?

-treatment duplication

-high cost

-fragmentation of care

-access barriers

-problems when a pt transitions from 1 setting or provider to another

handoffs to other providers can lead to:

-misunderstandings of diseases and plans

-med discrepancies

-confusion on the part of pt and family members

what are essential elements of teamwork?

-coordination of services

-shared responsibility

-communication

what do managing pts as a team approach lead to?

-better continuity

-enhanced care coordination

-improved pt safety

-better chronic illness care

-enhanced med adherence

-fewer adverse drug reactions

-preserved function

-dec hospital readmissions

which one of the following is most true about the rule of fourths?

A. 1/4 of geriatric probelms are iatrogenic

B. little can be done to prevent 3/4 of problems of aging

C. for every medical complaint a pt has, a careful assessment can ID 3 other dx

D. what use to be called normal aging are largely explained by processes that are not normal

E. good geriatric assessment uses 4 categories

D. what use to be called normal aging are largely explained by processes that are not normal

which one of the following is most true about aging changes?

A. stage 3 and 4 sleep decreases

B. renal perfusion is not reduced, but renal function is reduced

C. hearing acuity declines beginning in middle age

D. prostatic enlargement occurs only in a minority of men

A. stage 3 and 4 sleep decreases

which of the following statements is false regarding the role of the medical social worker in the health care team?

A. social workers frequently are the translators between patients/family and the rest of the team

B. social workers are trained to conduct cognitive and psychological assessments of pts

C. social workers provide care management assistance to pt/families

D. social workers make diagnostic decisions about the pts clinical syndrome

D. social workers make diagnostic decisions about the pts clinical syndrome

which one of the following statements is false regarding the role of the primary care provider in the health care team?

A. the PCP is responsible for assessing and managing the pt's medical problems

B. the PCP has the responsibility to inform other team members of the pt's medical condition

C. the PCP is always the leader of an interprofessional team

D. the PCP plays an important role in the discussion of advance care planning with the pt and family

C. the PCP is always the leader of an interprofessional team

autonomy

a pt's right to self-determination (to choose for themselves)

beneficence

clinician's responsibility to provide benefit/help the pt; to do good

what is the essence of the pt-dr relationshp?

beneficence

nonmaleficence

provider shall do not harm

justice

the duty to treat pts fairly

generally, ethical dilemmas falls to the _______ and ______ to determine which alternative will be followed

health care team and patient

what is the foundation for the exercise of autonomy?

informed consent

what does informed consent require?

disclosure and comprehension of information as well as voluntary and competent decision making

what should disclosure allow?

the pt to weight benefits and risks of proposed intervention, comparative alternatives, and staus quo or doing nothing

voluntariness

ascertain that decision is not coerced; truly represents free will of pt

decision making capacity

ability to cognitively process provided information appropriately and render a decision

standards fro assessing decision making capacity

-understanding info disclosed during informed consent

-appreciation of the info and how it applies to the pt's situation

-reasoning with the info

-expressing a choice

ordinary care

treatments that include pain relief, antibiotics, etc

extraordinary care

treatments that are very expensive, possibly painful or uncomfortable, may provide an equivocal chance of success and not routinely used

eg. Pic line, ventilation

advanced directives

verbal or written directions provided by individual outlining what medical decisions are to be made their behalf when that person no longer possesses decisional capacity

2 common categories of advanced directives

-appointment of surrogate or agent

-living will

appointment of surrogate or agent

appointing a person to make medical decisions if pt loses decision-making capacity

living will

written statement of preferences for care if decision-making capacity is lose

The Federal Patient Self-Determination Act

requires health care organizations:

- to ask pts if they possess advance directives

- to provide written information regarding individual's rights under state law

- to educate the staff and community about advance directives

The Physician Order for Life-Sustaining Treatment

-summarizes pt'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

-designed to be transferred from one setting to another

futility

when proposed treatment is unlikely to provide benefit or is clearly pointless

in the absence of DNR order, it is presumed that:

-pt consents to CPR

-a resuscitative attempt will be initiated

when discussing DNR orders with elderly pt, what is it important to differentiate?

the term resuscitation vs resuscitative effort

what do DNR orders apply to?

only to cardiac arrest

double effect

principle that says it is morally allowable to perform an act that has at least 2 effects, one good and one bad

what is appropriate to focus on with withdrawal of nutrition and hydration?

palliative interventions that will provide comfort to the pt and prepare the pt and family for end of life (rather than offer false hope)

when a religion is stamped on the chart, what should you not do?

do not make assumptions about the pt's moral preferences

clinicians need to carefully examine clinical practice guidelines for conflicts of interest ____ implementing their recommendations into their practices

before

Dr. Smith is obtaining informed consent from Mr. Jones to perform a

colonoscopy, because the patient had blood in his stool and Dr. Smith is

concerned that this might indicate the presence of carcinoma of the colon. Mr. Jones is able to recite back to Dr. Smith what a colonoscopy is, how it is done, and that a colonoscopy is performed to look for cancer. He then tells Dr. Smith that he is refusing the procedure because he knows he does not have cancer because he has not experienced any bleeding. Of the following required elements for Mr. Jones's decision-making capacity, which is impaired?

A. Understanding

B. Appreciation

C. Ability to express a choice

B. Appreciation

George Hall is a 91-year-old man visiting his physician to receive the results of a recent computed tomography scan of his abdomen. He is cognitively intact and still works 2 days a week. He is accompanied by his daughter Eleanor. She takes the doctor aside before the appointment and says, "Please do not tell my father any bad news. It would just kill him." If the physician were to agree, which ethical principles might this violate?

A. Paternalism

B. Autonomy

C. Authenticity

D. None of the above

E. All of the above

B. Autonomy

what is the 3rd most prevalent psychiatric DO among elderly men?

substance abuse (surpassed only by dementia and anxiety)

alcohol use=

at least 1 drink in past 30 days

binge drinking

5+ drinks on same occassion

heavy drinking

5+ drinks on same occasion for 5+ days in the past 30 days

4 classification patterns for elderly pts with alcoholism

-chronic

-intermittent

-late onset: after age 65 (1/3)

-reactive: impaired use after psychosocial stressor

moderate use of alcohol

1 or more drinks per day

heavy use of alcohol

2 or more drinks per day

excessive use of alcohol

3 or more drinks per day

what is the most appropriate alcohol screening for the eldery?

24-item MAST-G (geriatric MAST)

most useful labs for assessing substance use in older adults

-GGT (elevated in excessive alcohol drinkers)

-MCV

-CDT

what illnesses are alcoholism related to in older adults?

-dementia

-depression

-falling

meds for alcohol abuse in older adults

-Disulfiram

-Naltrexon 50 mg PO qd

-acamprosate

The diagnosis and treatment of alcohol dependency is best facilitated by using the model that defines alcoholism as a:

A. Moral issue

B. Psychological issue

C. Disease

D. Habit

E. Response to social stresses

C. Disease

An 81-year-old woman is being evaluated for dementia. She describes no more than two drinks per day during the week and slightly more on the

weekends. Which one of the following is true?

A. At this level of intake, she does not have alcoholism.

B. This quantity of use is safe.

C. Quantity of use is a good screen for alcoholism.

D. Alcoholism may be present if there are negative consequences.

E. This report clearly defines how much ethanol is being ingested.

D. Alcoholism may be present if there are negative consequences.

what is the leading cause of death from unintentional injuries in 65-74 YOs?

MVAs

A key component of older driver assessment is:

A. Vision screening

B. Motor reflex testing

C. Back range of motion

D. Extremity strength testing

A. Vision screening

Counseling regarding driving retirement

plans should include:

A. Reducing all social activities to minimize driving

B. Identifying alternative transportation options

C. Advising the patient to drive at night when there is less traffic

D. Informing the patient that it will be less stressful for everyone after

driving retirement

B. Identifying alternative transportation options

4 domains of assessment

-mental: cognitive/mood

-physical: hearing, vision, mobility

-functional: ADLs, IADLs, mobility

-social/economic: nutrition