POM 3 Geriatrics: chronic disease

what are the 4 Ms of age-friendly care?

what matters, medication, mind, mobility

incidence of hypertension

2/3+ of adults 65 and up

What are the 2 key geriatric groups at risk for HTN?

females and black patients

black patient's HTN characteristics

earlier onset, more severe cases, less controlled

leading etiology of HTN

arterial stiffness

lifestyle factors for HTN

smoking, ETOH, obesity

clinical presentation of HTN

most asymptomatic; dizziness, palpitations, headache, end organ damage, stroke, HF, renal failure, new onset A-fib

diagnostic workup of HTN

CBC, BMP, lipid panel, TSH, UA

ECG, home BP log, orthostatic readings

complications of HTN

CAD, CVA, CHF, LVH, arrhythmia, cognitive impairment, vascular dementia, CKD

risks of overtreating HTN in elderly

orthostatic hypotension, medication side effects

What BP is associated with increased mortality in elderly patients being treated for HTN?

<110/60

ACC/AHA guidelines for starting treatment for HTN in 65 years or older

start drug therapy for systolic >130; no diastolic threshold

incidence of T2DM

29% with DM in geriatric population

clinical presentation of T2DM

asymptomatic, hyperglycemia, increased adiposity, complications

What are the complications of T2DM in elderly?

micro/macrovascular issues, increased ASCVD, functional disability, depression, falls, incontinence, cognitive impairment, hypoglycemia

diagnosis of T2DM

A1C, fasting plasma glucose, random plasma glucose

What should be monitored in T2DM?

cholesterol, liver, BP, eyes, kidneys, feet

goals for T2DM management in elderly

AIC <7%, if multiple comorbidities <8%, fasting flucose 90-130, avoid hypoglycemia

A 76-year-old patient with PMH of CHF has an A1C of 8.5%. He currently takes metoprolol, spironolactone, and metformin. Which of the following would be the most appropriate to add on to their regimen to control his diabetes?

a. glyburide

b. empaglifozin

c. basal insulin

d. semaglutide

b.

What is the key risk factor of COPD?

smoking

clinical presentation of COPD in elderly

chronic cough, dyspnea, diminished or distant breath sounds, hyperresonance, prolonged expiratory phase, expiratory wheezing, increased AP diameter

complications of COPD

respiratory infections, cardiac involvement, deconditioning, depression

COPD work-up

spirometry - reduced FEV1/FVC ratio (<0.7); CXR

FEV1 values for mild, moderate, severe, and very severe COPD

mild: >80%

moderate: 50-80%

severe: 30-50%

very severe: <30% or <50% plus chronic respiratory failure

COPD management

smoking cessation, inhalers (LAMA +/- LABAs daily, PRN SABAs, +/- ICS if severe, supplemental oxygen, pulmonary rehab

What is the alorithm for pharmacological treatment of COPD?

Group A (bronchodilator): 0-1 moderate exacerbations (not leading to hospitalization)

Group B (LABA + LAMA): mMRC 2 or more, CAT 10 or more; no hospitalizations

Group E (LABA + LAMA +/- ICS): if 2 or more exacerbations or 1 or more hospitalizations

CKD definition

reduced GFR or evidence of kidney damage for at least 3 months

risk factors for CKD

dibetes, HTN, ASCVD, CVA, obesity, family history, smoking, age, medications

clinical presentation of CKD

asymptomatic until advanced, then nonspecific

complications of CKD

fluid/electrolyet abnormalities, bone and mineral disease, anemia, poor nutrition

CKD workup

GFR < 60; UA/UACR, monitor BP, CBC, imaging

GFR categories for CKD

G1: >90

G2: 60-89

G3a: 45-59

G3b: 30-44

4: 15-29

5: <15

When should a patient be referred to nephrology?

stage 4

CKD management

advanced care planning, ACEI/ARB, SGLT2, dialysis, kidney transplant, palliative care for all patients

When is dialysis recommended?

GFR < 30

average age of patients with peripheral vascular disease

70

risks for carotid artery stenosis

male, age, smoking, family history

What is a AAA?

dilation of the abdominal aorta >50% (above 3.0 cm)

risk factors for AAA

smoking, male gender, age >65

What imaging is go to for AAA?

US first, CT

treatment of AAA

repair for large, observation if smaller

screening recommendations for AAA

patients 65 and up

complications of peripheral arterial disease

wound healing, disability, critical limb ischemia, critical limb threatening ischemia

Two main signs of peripheral arterial disesae

loss of hair, decreased temperature, discoloraiton of skin

PAD diagnostic workup

ABIs, imaging (US) then angiography for intervention, evaluate comorbidities

PVD management

local - minimally invasive - balloon, stenting

systemic: high dose statin, HTN management, smoking cessation, antiplatelet for more severe

70% of all cancer diagnoses will be in adults < age ______ by 2030.

65

most common cancer in US

breast cancer

risk factors for breast cancer

age, family history, genetics, dense breast tissue, diet, obesity, HRT

clinical presentation of breast cancer

lump, skin changes, nipple changes, LAD

incidence of colon cancer

4th most common, 4th leading cause of cancer mortality

risk factors for colon cancer

age, family history, weight, DMT2, red meat diet, smoking, alcohol, personal history of polyps

clinical presentation of colon cancer

change in bowel habits, rectal bleeding, blood in stool, abdominal pain

prognosis of colon cancer

individualized evaluation, prevention and early diagnosis key, surgical candidates have best prognosis

incidence of prostate cancer

2nd most common cancer, 3rd leading cuase of cancer mortality

risk factors for prostate cancer

age (men over 65), race/ethnicity (black patients with highest risk), family history, genetics

clinical presentation of prostate cancer

increased PSA, asymptomatic, urinary complaints, hematuria

incidence of lung cancer

3rd most common cancer, #1 leading cause of cancer mortality

risk factors of lung cancer

age (median age of diagnosis 70), smoking, secondhand smoke, exposure to radon or asbestos

clinical presentation of lung cancer

cough, dyspnea, chest pain, hemopytsis

prognosis of lung cancer

generally poor, worsens with age