geriatrics exam #1

gerontology

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

geriatric medicine

focuses on medical care of the elderly

when is a person geriatric?

- NO set age

- most 65+ yo

- 65 set bc it is retirement age

- bc of increased life expectancy, considering increasing to 70 yo

rule of fourths

- disease: medical treatment is indicated

- disuse: can be cured with activity regimen

- misuse: prior damage cannot be revered, steps can be taken to prevent/preserve fxn

- physiologic aging: adapt and compensate

musculoskeletal system with aging

- osteoporosis: bone mineral content decreased by 10-30%

- arthritis

circulatory system with aging

- blood vessels narrow and less elastic

- heart works harder

- maximum HR decreased from 195 to 155

nervous system with aging

- less accommodation, markedly decreased after 40-50 yo

- hearing acuity decreased beginning ~12 yo, decline steepest in high pitches (>5000 hertz)

- number of taste buds declined by 70%

digestive system with aging

- weight decreased by 7%

- peristalsis decreased

- liver function decreased

urinary system with aging

- decreased circulation to kidneys

- perfusion to kidneys decreased by 50%

- creatinine clearance decreased, 10 ml/decade

endocrine system with aging

- postprandial glucose tolerance impaired, decreased 10 mg/dl/decade

- decreased DHEA

functional reserve

- all systems tend to have fxn ability > what is used during daily activities

- significant impairment from dz, disuse, misuse, or aging is needed to result in impaired fxn during normal activity

- clinically significant impairment in fxn occurs when demands > function reserve

stamina and fatigue with aging

insidious decrease in stamina occurs beginning in 20s

frailty

decreased in stamina and fatigue so great they define pt's physiological status

frailty is the occurrence of 3 or more

- unintentional weight loss (10 lbs in past yr)

- self reported exhaustion

- weakness (decrease in grip strength)

- slow walking speed

- low physical activity

environment and function with aging

- environment in which one lives and functions

- can make the difference between being independent and being unable to carry out basic everyday activities

- physical: setting in which a person lives

- social (caregiving): people who interact directly with patient

- organization: rules and regs that affect a person's life

immobility and aging

- older persons needs to "move it or lose it"

- various studies show that immobility is BAD for older pts

- as soon as an older person can get up, they should

ageism

- systematic stereotyping and discrimination bc a person is old

- origins can be older (esp if they have a condition) as well as younger people

key elements of successful psych adjustment include

- developing a sense of satisfaction w one's accomplishments

- life review: active reflection on one's life

- adjusting to losses: requires continual psych adjustment

disengagement theory

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

activity theory

staying active and engaged was the key to healthy aging (superior to disengagement)

relationships and family with aging

- changes occur throughout life, in elderly may occur more rapidly

- geriatrics hx more focused on relationship hx

- w/o bonds, older pts are at increased risk for isolation, depression, and institutionalization

geriatric syndromes

- falls

- frailty

- dizziness

- gait problems

- weakness

- incontinence

- confusion

role of PCP to ID in geriatrics

- functional deficits that adversely affect prognosis and quality of life

- most important issues = what pt can and cannot do

activities of daily living

- bathing and showering

- continence

- dressing

- mobility

- feeding (excluding meal preparation)

- toileting

instrumental activities of daily living

- cleaning and housekeeping

- doing laundry

- managing money

- managing medications and taking as directed

- preparing meals

- shopping

- transportation

- using communication devices

geriatric "icebergs"

- prominent: depression, CI, incontinence, MS problems, and alcohol use

- to avoid missing: conduct systematic case, specific screenings

cognitive impairment in geriatrics

- dementia or worry about memory is reason for 50% of consultations

- dementia is MC reason for nursing home placement

confusion in the elderly can also be due to undetected

alcohol use

3 common iatrogenic problems in geriatrics

- adverse drug effects

- acute kidney injury

- adverse surgical outcomes

slow medicine

aggressive medicinal tx in older pt, more often leads to adverse consequences than to improvements. "start low, go slow"

having many providers and services leads 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

- misunderstanding of diagnosis and plans

- med discrepancies

- confusion on the part of pt and family

essential elements of teamwork in geriatrics

- coordination of services

- shared responsibility

- communication

managing patients as a team approach leads to

- better continuity

- enhanced care coordination

- improved pt safety

- better chronic illness care

- enhanced med adherance

- fewer adverse drug rxns

- preserved function

- reduced hospital readmissions

emphasis of geriatric care

restore and maintain the pt's function and independence

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

what used to be called normal aging are largely explained by processes that are not normal

3 multiple choice options

which one of the following is most true about aging changes

stage 3 and 4 sleep decreases

3 multiple choice options

well functioning teams with good communication skills, team leadership may

shift based on the care topic being addressed

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

social workers make diagnostic decisions about the patient's clinical symptoms

3 multiple choice options

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

the PCP is always the leader of an interprofessional team

3 multiple choice options

anal cancer risk in gay men

- HPV related cancer

- more common in MSM, 20x more likely than heterosexual men

- HIV is an important risk factor

prostate cancer in LGBT

no specific changes in screening guidelines

WSW cancer screening

- breast cancer: screening with MMG follows current society guidelines for general pop

- cervical cancer: screening w PAP follows population wide guidelines

An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg, pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to make medical decisions for her in case she becomes unable to make decisions for herself. She reports that she and her partner are not married. She asks if she needs any further documentation to ensure her goals of care are followed.

Which one of the following would be the most appropriate recommendation for this patient and her partner?

advise them to file and advanced directive

3 multiple choice options

An 81-year-old transgender female with history of depression and hyperlipidemia presents to your clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin 20 mg and subcutaneous estrogen therapy.

Which of the following is the most important next step in this patient's primary care?

counseling on smoking cessation

3 multiple choice options

An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2 diabetes presents to clinic for follow-up. He is independently living in a retirement community and still works part time on a golf course. He

currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago, with no abnormality. He reports he is sexually active with men and

women, engaging in receptive oral, receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with intermittent condom use.

What sexually transmitted infection testing should be offered?

urine testing, blood testing, anal swab, and oropharyngeal swab

3 multiple choice options

autonomy

clinician's duty to respect a patient's right to self determination (to choose for themselves)

beneficence

clinician's responsibility to provide benefit/help to pt (to do good), the essence of the patient provider relationship

nonmaleficence

provider shall do no harm

justice

the duty to treat patients fairly

ethical dilemmas

- often have more than one morally permissible alternative

- generally, falls to health care team and pt to determine which alt will be followed

informed consent

- foundation for the exercise of autonomy

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

disclosure should allow pt to weight benefits and risks of

- proposed intervention

- comparative alternatives

- status 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 (dementia does not necessarily indicate that pts lack this)

standards for assessing decision making capacity

- understanding info disclosed during informed consent

- appreciation of the info and how it applies to the pts situation

- reasoning with the info

- expressing a choice

assessing capacity

- ability to choose

- ability to understand relevant information

- ability to appreciate the situation and its consequences

- ability to reason

disclosure of medical errors

- commission or omission error

- widely accepted as an ethical obligation

ordinary care treatments include

- pain relief

- antibiotics (may be extraordinary in terminally ill pts)

extraordinary care treatments are

- very expensive

- possibly painful or uncomfortable

- may provide an equivocal chance of success and not routinely used (pic line, ventilation)

advanced directives

verbal or written directions provided by individual outlining what medical decisions are to be made on their behalf when that person no longer possesses decisional capacity. best done before an acute illness or crisis

categories of advanced directives

- appointment of surrogate: to make medical decisions if pt loses decision making capacity

- living will: written statement of preferences for care if decision making capacity is lost

- advisable to periodically review directives to ascertain concordance w pts wishes

the federal patient self determination act requires health care orgs to

- ask pts if they possess advanced directives

- provide written info regarding rights

- educate staff and community about advanced directives

the physician order for life sustaining treatment

- summarizes pt's wishes for life sustaining treatment AND

- combines prefs that may have been expressed on a DNR, living will, proxy, etc

- designed to be transferred from one setting to another

futility

- when proposed tx is unlikely to provide benefit or is clearly pointless

- age alone rarely provides a rationale for determining an intervention is futile

DNR

- initiation of CPR inevitable in institutions if specific orders to w/hold CPR have not been entered

- in absence of DNR, it is presumed that pt consents to CPR. attempt will be initiated

- "resuscitative effort" should be used vs "resuscitation"

- only applies to cardiac arrect, not equivalent to "do not treat"

double effect

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

double effect must be approached like other circumstances

- requires informed consent

- should NOT be presumed ethically acceptable in absence of consent

- dont forget state laws

during withdrawal of nutrition and hydration, it may be more appropriate to

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

culture and religious considerations

- keep an open mind to alt values stemming from unfamiliar culture and religious traditions

- do not make assumption's about the pts moral preferences based only on the religion stamped on the chart

clinicians need to carefully examine clinical practice guidelines for conflicts of interest before

implementing their recommendations into their practices

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?

appreciation

2 multiple choice options

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?

autonomy

2 multiple choice options

4 domains of geriatric assessment

- mental: cognitive/mood

- physical: hearing, vision, mobility

- functional: ADLs, IADLs, mobility

- social/economic: nutrition

aspects of care unique to older adults

- comanaged by diff specialists

- multiple comorbidities involving >1 organ system w overlapping symptoms

- geriatric syndromes affecting functional status

- common clinical entities present in uncommon fashion

- ill defined symptoms

- common disease markers for younger pt may be absent in geriatric

- change in functional status = alert

when should you document, update, and reconcile med list

every visit

functional status

ability to perform tasks necessary to participate in daily life

2 methods for functional screen

- self report

- performance based

performance based measures for functional screen

- useful to confirm self report

- get up and go test

- shoulder function

- hand function

- balance, modified romberg

- put on shoe and shocks

- OT consult for more extensive testing

mood and cognition geriatric screening

- depression often goes unrecognized, use PHQ-2

- know where to refer if results are positive, full eval by neuropsych is useful

- montreal cognitive assessment

- quick screen of attention and concentration

geriatrics ROS (cover all systems, direct questioning)

- visual impairment

- hearing impairment

- sleep disturbance

- loss of appetite/weight loss

- depression

- cognitive impairment

- constipation

- urinary incontinence

- falls

- dizziness

geriatric specific physical exam

- review vital signs carefully

- general appearance

- increased focus on systems that affect function

- note patients level of alertness, ability to answer questions appropriately

diminished olfactory sensitivity, loss of smell may be early

alzheimer's dementia

test only if result will

change treatment plan and benefits outweigh risks

geriatrics pt education/self management

- education is critical for successful pt management outside clinical setting

- assess pt's ability and willingness to self manage medical issues

- set reasonable goals, reiterate main points during visit and check for understanding

caregiver support

- more dependent pt = more demands on caregiver

- recognize importance of caregiver in overall well being of pt

focus following encounters on

- things that have changed since last visit

- tying up loose ends from previous visits

- aspects that are important to pt function

- review meds every visit

- review functional status every visit

which of the following is a basic rather than an instrumental activity of daily living

bathing

3 multiple choice options

Mr. C is an 86 yo male visiting your clinic to establish care. which of the following answers best describes your plan for the initial eval of Mr. C?

prioritize function and his chief complaint, focus on learning about his health care goals, and plan for follow up

3 multiple choice options

geriatric immunizations

- COVID

- flu 1 dose annually

- Tdap

- shringrix (zoster)

- RSV (arexvy)

- vaxneuvance (PCV15)

- prevnar 20 (PCV20)

- pneumovax (PPSV23)

- hepatitis A and B

- MMR

- varivax (varicella)

elderly have ___ quit rates as younger adults but are ___ likely to receive cessation counseling

similar, less

polypharmacy

- simultaneous use of multi meds for 1+ dzs

- at risk due to multiple comorb and providers

- must avoid unnecessary med use

- attempt behavioral intervention as 1st line

- combo of behavioral and meds may allow lower dosing

- provide clear instructions, written and verbal

- simplify drug regimens (combo meds)

- review meds at every visit, have pt bring them

geriatric maintenance of nutrition

- low BMI (<20) or unintentional weight loss of >10 lbs in 6 mos suggest poor nutrition

- although there is less caloric needs, nutritional requirements remain the same

antithrombotic meds

- antiplatelets: prevent platelets from clumping

- anticoagulants: slow down clotting through action on enzymes involved in clot formation

prophylactic aspirin use

- benefit: reduced ASCVD risk

- risks: brain or GI bleed, skin bruising

- prophylaxis against CVD must be balanced against bleeding risk

- many pts >75 yo, this means eliminating ASA

physical activity in geriatrics

- exercise is key to successful aging, functional independence, to control illness, and promotes brain health

- if fall risk, exercise that maintains/improves balance 3 days/wk

- if screen is needed, may use exercise and screening tool by Texas A&M

- never too late to initiate healthy habits that augment MSK health

- incorporate exercise into daily activities (esp weight bearing)

geriatrics bone health

- DEXA scans begin at 65 for all women

- USPSTF: at least once >65 and <65 postmenopausal w increase fracture risk

- osteoporosis: bone density 2.5 SD below

- osteopenia: bone density 1-2.5 SD below

fracture risk assessment tool

online calculator that est pts risk of a major osteoporotic fracture over next 10 years. uses bone density and 7 clinical RFs to calculate

calcium citrate vs calcium carbonate

citrate is better absorbed and does not have to be taken with food

geriatrics vitamin D supplementation

- sunlight exposure

- intake generally low, supplement often needed

- if >70 yo vit D 600-1000 IU/day (max 2000)