GERIATRICS EXAM 1

agee342

WHat is the study of aging and the problems of the old?

Gerontology

WHat is the medicine focused on the care of the elderly?

Geriatric medicine

When is a person geriatric?

NO SET AGE**

- Most 65+ (65 bc of retirement,but bc of incre life expectancy considering now 70 yrs old)

What are some differences about people >65+ yrs?

- Heterogeneity of health status

- Age related physio changes

- Incre incidence of comorbidity

- Atypical disease presentations

- Incre incidnce of iatrogenic illness

- Higher need of social support

- Diff goals of therapy

WHat is the rule of fourths?

Decline in norm func seen as ppl age d/t: Disease, DIsuse, Misuse, Physio aging (1/4)

*used to determine whether/ what extent new Sx are caused by etiological categories

How do you treat disease?

Medical tx

eg. Decre exercise tolerance in a chronic smoker

How do you treat disuse?

Cured w/ activity regimen

eg. SOB on minimal exertion in a largely sedentary older person

How do you treat misuse?

Prior damage cannot be reversed

- steps taken deterioration and preservation

Eg. Knee arthritis in former football player

How do you tx physiological aging?

Adapt & Compensate

eg. Trouble reading the fine print in a 50 yr old?

How is the musculoskeletal sys affected in geriatrics?

- Osteoporosis (bones decre 10-30%)

- Arthritis

How is the circulatory sys affected in geriatrics?

- Blood vessels narrow and become less elastic

- Hypertrophy

- Max HR decreases from 195 --> 155bpm (Catecholamine and exercise induced HR increases are blunted-- acts like heart on B-blockers)

How is the nervous sys affected in geriatrics?

-Lens accommodation decre after 40-50 yrs

- Hearing Acuity declines starting age 12 yrs old (decline steepest in HIGH pitches >5000Hz)

- # of taste buds decre by 70%

How is the digestive sys affected in geriatrics?

- Weight decre by 7%

- Peristalsis decre

- Liver func decre

- Adaptive mechs less effective

How is the urinary sys affected in geriatrics?

- Kidneys decre in size and less efficienct

- Decre kidney perfusion 50% **

- Creatinine clearance decre at 10mL per decade**

HOw is the endocrine sys affected in geriatrics?

- Postprandial glucose tolerance impaired and decre 10mg/dl per decade **

- Decre in DHEA

The reductions in stamina and fatigue are so great in geriatrics that they

become the defining features of physio status (frailty)

- Insidious decre in stamina occurs beginning in 20s

- Occurrence of >3: unintentional weight loss (10 lbs/yr), self reported exhaustion, weakness, slow walking speed, low physical activity

What does it mean when geriatrics have incre physio diversity?

The range of normal becomes wider

- Age related protocols and guidelines almost non existent (individualized care**)

T/F: Immobility is bad for older persons.

TRUE -- older ppl need to move it or lose it (need to get up and walk as soon as they can)

What is systematic stereotyping of and discrimination against people bc they are "Old"?

Ageism

-lowers self esteem

- Decre opportunities

-Isolation , loneliness, depression

How should you make successful psychological adjustments in changing one's life status (aging)?

- Develop sense of satisfaction and accomplishments

- Life review

- ADjusting to losses (KEY PART = needs CONTINUAL psych adjustment; starts w/ midlife crisis)

WHat is the disengagement theory?

Letting go of the trappings of earleir life - key to successful aging (no longer accepted by social scientists)

-icon= old man in rocking chair on front porch

What is activity theory?

Staying active and engaged is the key to healthy aging

*the HEALTHIER theory vs. disengagement

Delivery of primary health care to older persons

- Functionally oriented approach

- Focused on the social hx of pt

- Mult problems are normal (geriatric syndromes)

- Most important geriatric syndromes= falls, frailty, dizziness, gait probs, incontinence, confusion

- Focus on function (what pt can/cannot do) vs medical dx that adversely affect day-day life**

WHat are "geriatric syndromes"?

Multiple multisystem deficits

-falls

-frailty

-dizziness

-gait probs

-weakness

-incontinence

-confusion

What can decrease the number of people dependent on social welfare?

- Work made specifically for older generations

- Engaging in volunteer and entrepreneur activity

- Integration into society instead of isolation

Without _____, older person are at a high risk for isolation, depression, and institutionalization.

BONDS (relationships)

When is it appropriate to admit to a nursing home?

deficient in >2 activities of daily living (bathing, continence, dressing, mobility, feeding, toilet)

What are tasks that people need to do every day, often mult items each day?

Acitvities of daily living

- Bathing & showering

- Continence

- Dressing

- Mobility

- Feeding (excluding meal prep)

- Toileting

WHat are tasks that are needed to maintain a household but do not need to be done every day?

Instrumental activities of daily living (cleaning, housekeeping, laundry, managing money, manage meds, communciation devices)

*need help sev times a week if deficient in >2 IADLs

WHat are icebergs?

Frequently unreported Sx

eg. Depression, incontinence, MS, ALCOHOL USE***

How do you avoid missing "icebergs"?

- Conduct systematic case

- ROS

- Specific screenings= cog func, depression, depressive Sx, physical func

WHat is the MC reason for nursing home placement?

Dementia

Confusion can also be d/t

undetected alc use

WHat is the leading cause of death from unintentional injury in the rnage of 65-74 ys?

Motor vehicle accidents (MVA)

What do we use to assess driving capability in elderly?

AMA Physician Guide for assessing and counseling older drivers

*every 6 months

* VISION

WHat are the 3 MC iatrogenic diseases in geriatrics?

1. Adverse drug effects

2. Acute kidney injury

3. Adverse surgical outcomes

WHat is the rule of giving meds to the elderly?

Start low, go slow

(aggro tx in elderly usu has bad results)

*must be aware of polypharmacy

Handoff of pts to other providers can lead to

- Misunderstandings of dx

- Med discrepancies

- Confusion by pt

Having many providers and services leads to

- Tx duplication

- High cost

- Fragmentation of care

- Access barriers

- Probs when pt transitions from 1 settting or provider to another

What is the clincians duty to respect a pts right to self determination, right to give adequate and truthful info to exercise self determination?

Autonomy

What is the essence of the pt-Dr. relationship; Clinician's responsibility to give benefit or help to the pt "to do good"?

Beneficience

What is the rule to do no harm?

Nonmaleficence

The 4 topics model

Case based approach that allows an organized review of the facts and issues in a given case, acccording to 4 topics

1. Medical indications (Beneficience, Nonmaleficience)

2. Patient preferences (Autonomy)

3. Quality of life ( BEneficience, Nonmalficience, Autonomy)

4. Contextual features (Loyalty and Fairness)

What is ordinary care?

- Pain relief

- Anitbiotics

What is extraordinary care?

- Very expensive

- Possibly painful or uncomfy

- May give equivocal chance of success and not routinely used

Which is most true of the following about rule of fourths

A. 1/4 geriatric problems are iatrogenic

B. Little can be done to prevent 3/4 probs of aging

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

D. What used to be called normal aging are largely explained by processes that are not normal

E. Good geriatric assessment uses 4 categories: Mental, Physical, Psychosocial, Environ

D. What used to be called normal aging are largely explained by processes that are not normal

Which is the most true about aging changes?

A. Stage 3 and 4 sleep decreases

B. Renal perfusion is not decre, but renal func is reduced

C. Hearing acuity declines beginning in middle age

D. Prostatic enlarge,ent occurs only in a minority of men

A. Stage 3 and 4 sleep decreases

T/F: Dementia by itself indicates that a pt lacks decision-maaking capacity.

FALSE

What is the reason for 50% of consultations in geriatric assessment clinics?

Dementia/ memory problems

WHat is the 3rd MC prevalent PSYCH disorder among elderly?

Alcohol use (after dementia and anxiety)

What is binge drinking?

5+ drinks on same occassion

What is heavy drinking?

5+ dirnks on same occassion for 5+ days in the last 30 days

What are 4 patterns for elderly alcoholics?

1. CHronic

2. Intermittent

3. Late onset (after 65 yrs)

4. Reactive (after psch stressor)

How do you screen for alc in elderly?

24-item MAST-G (most age approp questionnare)

-Labs: GGT (most sensitive, incre in alcoholics), MCV, DCT

How should you tx alcoholism in geriatrics?

Naltrexone

- prevents relapse and decre alc cravings

WHat are advanced directives?

Verbal or written directions given by indiv outling what med decisions are to be made on that indiv behalf wehn that person no longer has decisional capacity

1. Surrogate / agent that makes med decisions if pt loses capacity

2. Living Will

What determines capacity for medical decisions?

1. Understanding

2. Appreciation (application)

3. Reasoning

4. Expression of choice

What is the Federal self determination act?

Requires health care orgs to ask pts whether they possess advance directives and to provide written info regarding indiv rights under state law, and educate staff and community about advance directives

What is the physician Order for Life Sustaining treatment (POLST)?

Summarizes pts wishes for life sustaining tx and combines pref of DNR, Will, Health care proxy (can be trasnferred bw settings)

What is futility?

When proposed tx is UNLIKELY to give benefit or is clearly pointless

*age is NOT the sole reason for futility

What is entailed in DNR?

Applies ONLY to cardiac arrest and not the same as "do not treat"

- Need to use "Rescuscitative effort"

(w/o DNR order, CPR will be initiated)

What is the principle that says its morally allowable to perform an act that has at least 2 effects, 1 good, 1 bad?

Double effect

-NEEDS informed consent

- Should not presume ethically acceptable w/o consent

- STATE LAWS**

Withdrawal of nutrition and hydration

Palliative interventions

T/F: Do NOT make assumptions about pts moral preferences based only on the religion stamped on the chart.

TRUE

What are the 4 domains of assessment?

1. Mental (Cog/ mood)

2. Physical (hearing, vision, mobility)

3. Functional (ADLs, IADLs, mobility)

4. Social/economic (nutrition)

What are some aspects of care unique to older adults?

- Co-managed by mult providers

- Mult comorbidities (>2 organ sys w/ overlapping Sx)

- Geriatric syndromes affecting Functional status

- Ill-defined Sx (fatigue, dizziness)

- No complaints or atypical complaints (common dz markers for younger pts abset om geriatrics)

- May be unablr to effetively communicate

What is a potential sign of new or worsening underlying condition?

Functional status (ability to perform tasks needed to participate in daily life)

How should older adults bring in their current meds?

In the ORIGINAL bottles to EVERY visit, document update, reconcile meds every visit

- Make sure to ask pt to bring in any assistance devices

How do you screen for functional status?

1. Self report

2. Performance based measures: Confirm self report / assess for depression, cog assessment, quick screen of atetntion and concentration

- get up and go test

- shoulder func: pt touch back of head then placing haands together behind back

- Hand func: Pick up pencil

- Balance: Modified Romberg

- Put on socks/shoes

- OT

**NEVER FORGET TO CHECK EARS

Loss of smell maybe an early sign of what?

Alzheimers

What are 5 things to focus on in f/up visit (4-6 weeks after initial visit)?

1. Things that have changed since last visit

2. Typing up loose ends from prev visits

3. Aspects that are most important to pt func (esp cognition, mobility, hearing)

4. Review meds

5. Review func status

How often should geriatrics get influenza vax?

1 per yr

How often should geriatrics get Td/Tdap vax?

1 time initial dose and booster every 10 yrs w/ Td

How often should geriatrics get varicella vax?

2 doses needed if indiv never had varicella

How often do geriatrics need Zoster vac?

1 dose (around 60 yrs) but can give earlier if comorbidities present

How often do geriatrics get pneumococcal vax?

1 dose of PCV13/ PPSV23 / PCV20 at 65 yrs old (sooner if high risk)

* PPSV23= repeat after 5 yrs if pt received <65 yrs

How often do geriatrics get Hep A and Hep B vax?

Vaccinate only at high risk (nursing home, T2DM)

Do older adults have similar smoking quite rates to younger adults?

YES but LESS likely to recieve counseling about it

What are the 4 A's in pts >50 yrs?

- ASk

- Advise

- Assist

- Arrange f/up

What do you need to remember when prescribing meds for older ppl?

- DO behavioral changes before turning to meds

- Combo of both may allow lower dosing

- Give both WRITTEN + VERBAL instructions

- Review meds at each visit

What can incre risk of worseining disease processes?

Inactivity

What is a low BMI for geriatrics?

<20 or unintentional weight loss >10lbs in 10 months

=poor nutrition (although decline in caloric needsm the nutritional requirement stays same)

How many fats should geriatrics get?

20-30% of daily intake (change to monounsaturated and decre LDL)

How much protein should geriatics get?

12-20% of daily intake

WHat should you always check for in geriatrics when checking nutritional status?

B12 deficiency

(tx: IM B12)

What is an obese BMI in geriatrics?

>30

How should you anticoag in geriatrics (ABCs)?

A = antiplatelet/ anticoag agents (ASA- decre stroke in women and men)

B= BP Control (B-blockers prevent 1st events of nonfatal MI in pts w/ HTN; nonspecific BB in astham and COPD)

C= CHol management (Statins)

WHat is the most effective prevention of stroke caused by Afib?

Warfarin

T/F: It is NEVER too late to initiate habits to augment musculoskeletal health, incorporating exercise.

TRUE

When do you begin a bone density screening (DXEA)?

65 yrs for all women

Osteoporosis= >2.5 standard deviations below young adult peak bone density

Osteopenia= 1-2.5 SD below; weakening of bones that will progress to osteoporosis

How to tx/ prevent osteoporosis in females

- Ca 1200-1500mg QD (Ca citrate >Ca carbonate)

- Vit D 600-1000 QD (sunlight!)

- Bisphosphonates

Decisions about cancer screening should be

individualized

Breast cancer screening

Every 2 yrs for women 50 - 74 years

Cervical cancer screening

Not screening in >65 yrs who have had adequate prior screening and not at high risk

Colon cancer screening

50+ annual colonoscopy (can stop after 76-85; no further screening >86 yrs)

What are 7 steps to motivate older pts to engage in healthy behaviors?

1. Educate

2. Assess needs

3. ID goals

4. Elim barriers

5. Provide role models

6. Supply verbal encouragement

7. Cont verbal reinforcement and rewards

What is advanced cultural competency?

Pt and communitys expectations ride from shared life experiences regarding doctors and medical sys

-Physicians treat the patient primarily (not the disease/ illness)

What is the 3rd MC chronic disorder in older adults?

Hearing loss (cerumen impaction?)

- Bilateral earing loss incre w/ age 75% >80yrs

Dx: *ALWAYS CHECK EARS W/ OTOSCOPE

- Hearing Handicap inventory for the elderly screening (HHIE-S)

Mild-mod loss= Inability to understand words rather than inability to hear

Mod-Severe loss= HEaring disability, communication probs, social withdrawal, depression

Sensorineural (inner ear involvement)

*Presbycusis= MC CAUSE OF Age related hearing loss [bilateal symmetric, high freq hearing loss]

- Noise induced hearing loss= 2nd mc

-Meniere disease (vertigo + tinnitus)

- Acoustic Neuroma = MC benign tumor in inner ear (CN 8- unilateral HL , HA, dizziness)

-Meds that are ototoxic (antibiotics, antimalarials, antineoplastics, loop diuretics)

conductive hearing loss (middle to external ear)

1. Cerumen impaction

2. TM perforation

3. Disruption of ossicular chain

4. Cholesteatoma = epithelial overgrowth in ear that needs chronic drainage

5. Otosclerosis (bony overgrowth on stapes - low freq conductive loss)