Geriatrics Exam 1 [Bolded info from PACO 2021]

Gerontology

The scientific study of aging and the problems of the old

Geriatric Medicine

Focuses on the care of the elderly

Whats different about people over 65+?

● Heterogeneity of health status

● Age-related physiologic changes

● Increased incidence of comorbidity

● Atypical disease presentations

● Increased incidence of iatrogenic illness

● Higher need of social support

● Different goals of therapy

Rule of Fourths

Disease, Disuse, Misuse, Physiologic Aging

Decreased exercise tolerance in a chronic smoker is an example of which rule of fourths?

Disease-related disability

Shortness of breath on minimal exertion in a largely sedentary older person is an example of which rule of fourths?

Disuse-related

-Often cured with activity regime

Knee arthritis in former football player is an example of which rule of fourths?

Misuse-related disability

-Prior damage cannot be reversed, but care and education can prevent deterioration and preserve function

Trouble reading the fine print in a 50 yo is an example of which rule of fourths?

Physiological Aging related disability

-Take steps to compensate for disability

Osteoporosis

Bone mineral content decreases by 10-30%

Arthritis

Due to RA, overuse in youth, injuries

Circulatory System

Blood Vessels narrow and become less elastic

The changes make the heart work harder

Maximum heart rate decreased from 195 to 155 beats/ minute

Vision

Lens accommodation markedly reduced after age 40-50

Hearing

Acuity declines beginning beginning at age 12

Taste

Number of taste buds reduced by 70%

Digestive System

1. Weight decreases by 7%

2. Peristalsis decreases

3. Liver function is reduced

Urinary System

Decreased circulation to kidneys-perfusion decreases by 50%

Creatinine clearance declines at 10mL per decade

Endocrine System

Postprandial glucose tolerance is impaired and declines 10mg/dl per decade

Decrease in DHEA

Functional Reserve

Clinically significant impairment in function occurs when demands exceed function reserve

Reduced Stamina & Fatigue

Insidious slow reduction in stamina occurs beginning in the 20s

Frailty

The reductions in stamina and fatigue are so great that they become the defining feature in ones physiologic status

Frailty requires the occurrence 3 of more of these

Unintentional weight loss,

self-reported exhaustion,

weakness,

slow walking speed,

low physical activity

Environment and Function

Environment in which one lives and function can make a difference between being independent and being unable to carry out basic everyday activities

Enviro & Fxn-Physical

setting in which a person lives

Enviro & Fxn-Social (caregiving)

people who interact directly with your patient

Enviro & Fxn-Organization

Rules and Regulations that affect one's life

True/False

Immobility is bad for older persons

TRUE

Ageism

Systematic stereotyping of and discrimination against people because they are "old"

Why is ageism a concern?

Lower self esteem, reduce opportunities, lead to isolation, loneliness, depression

What is Life Adjustment

Key elements of successful psychological adjustment include developing a sense of satisfaction with one's accomplishments

-Life review, adjusting to losses, continual psychological adjustment

Disengagement Theory

posited that letting go of the trappings of earlier life was the key to successful aging.

Ex. The icon - old man in a rocking chair on the front porch.

Activity theory

that staying active and engaged was the key to healthy aging

**Activity theory is the healthier theory

Attitudes Changing Towards Aging Population

-More work needs to be made for older generations

-More older people need to engage in volunteer and entrepreneur activity

-Need to integrate into society instead of isolated

**Will decrease the number of people dependent on social welfare

Without ________, older persons are at a high risk for isolation, depression, and institutionalization

BONDS (relationships)

Most Important Geriatric Syndromes

Falls, frailty, dizziness, gait problems, weakness, incontinence, confusion

Role of the Primary Care Provider

Identify functional deficits that adversely affect the pts and quality of life

Activities of Daily Living

Tasks that people need to do every day, often multiple items each day.

Ex- Dressing, bathing, eating, changing positions, going to the toilet.

If the patient is dependent in __________________ ADLs, pt will qualify for nursing home, or will require daily assistance if living at home.

2 or more

Instrumental Activities of Daily Living

Tasks that are required to maintain a household but do not need to be done every day.

Ex- Talking on the phone, shopping, making the bed

**Need help several times a week if dependent in 2 or more IADLs

What are Icebergs?

Frequently unreported symptoms

Give examples of Icebergs

depression, CI, incontinence, MSK problems, ALCOHOL USE

Driving

Driving is a skill and its loss has a HUGE impact

What is the leading cause of death from unintentional injury in the range of of 65-74?

-Motor Vehicle Accidents

What do we use to assess driving capability in an elderly person?

-AMA's Physician Guide for Assessing and Counseling Older Drivers

**Evaluation/physical (vision, cognitive, etc) every 6 months

3 Most Common Iatrogenic Diseases in Geriatrics

1. Adverse drug effects

2. Acute kidney injury

3. Adverse surgical outcomes

What is the rule of giving medicine to the elderly?

-Start low, and go slow

-Aggressive treatment in the elderly usually has bad results

Cognitive Impairment

Dementia or worry about memory is reason for nearly 50% of consultation in geriatric assessment clinics.

What is the most common reason for nursing home placement?

DEMENTIA

What is the 3rd most common prevalent psychiatric disorder among the elderly?

-Alcohol Use (Behind dementia and anxiety)

Alcohol Use

At least one drink in the last 30 days

-Binge= 5+ drinks on the same occasion

-Heavy= 5+ drinks on the same occasion for 5+ days in the last 30 days

4 Patterns for Elderly Alcoholics

1. Chronic

2. Intermittent

3. Late Onset (After age 65)

4. Reactive (After a psychological stressor)

Screening for Alcohol in Elderly

-24-item MAST-G (Geriatric MAST)

-Labs: GGT (Most sensitive, will be elevated in alcoholics), MCV, CDT

Alcoholism Treatment

Naltrexone (Revia)

- Safe, effective in preventing relapse and reducing alcohol cravings in the elderly

Autonomy

The duty to respect a patient's right to self-determination

-The right to be provided with sufficiently adequate and truthful information to exercise self-determination

Beneficence

The clinician's responsibility "to do good".

-Clinician should promote health and interventions should benefit to the patient

Nonmaleficence

DO NO HARM (Benefits need to outweigh risks of treatment)

Justice

The duty to treat patients fairly

Individual Dignity

Refers to treating the individual with a quality or state of being worthy of esteem or respect

Authenticity

Refers to the ability to choose a lifestyle consistent with one's own values, beliefs, and habits

Advanced Directives

Are verbal or written directions provided by an individual outlining what medical decisions are to be made on that individual's behalf when that person no longer possesses decisional capacity.

2 Common categories of written advance directives

1. Appointment of a surrogate or agent to make medical decisions if the patient loses mental capacity

2. Living Will = Written statement of preferences for care when decision making capacity are lost

Federal Patient Self-Determination Act

Requires health care organizations to ask patients -

Whether they possess advance directives

To provide written information regarding the individual's rights under state law, and

To educate the staff and community about advance directives.

The Physician Order for Life-Sustaining Treatment

Summarizes the patient's wishes for life sustaining treatment and combines preferences that may have expressed separately on a DNR form, living will, health care proxy, or other advance directives

-Can be transferred from one setting to another

Futility

When a proposed treatment is unlikely to provide benefit or is clearly pointless

-AGE SHOULD NOT BE THE SOLE REASON FOR FUTILITY

DNR

applies only to a cardiac arrest and is not equivalent to "do not treat."

Double Effect

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

-Requires Informed Consent

-Should not be presumed to be ethically acceptable in the absence of consent

-STATE LAWS

Religious Considerations

Do not make assumptions about the patient's moral preferences based only on the religion stamped on the chart.

4 Domains of Assessment

1. Mental

2. Physical

3. Functional

4. Social/Economic

*All contribute to overall health

Aspects of Care Unique to Older Adults

-Co-Managed by multiple providers

-Multiple Comorbidities

-Geriatric Syndrome Function Status

-Ill defined Symptoms (fatigue, weakness, dizziness, not feeling well)

-No complaints or atypical complaints

-May be unable to effectively communicate

Change in____________________is a potential sign of new or worsening underlying condition

Functional Status

Functional Status

the ability to perform tasks necessary to participate in daily life

How should older patients bring in current medications?

-In the ORIGINAL bottles to EVERY visit

-Also make sure to ask patient to bring in any assistance devices

Functional Screen

2 Methods:

-Self Report

-Performance Based Measures (Confirms self report)

Functional Screen Performance Tests

-Get up and Go test

-Shoulder Function: pt. touch back of head and then placing hands together behind back

-Hand Function: Pick up pencil

-Modified Romberg

-Put on shoes and socks

-OT

-Also assess for depression, cognitive assessment, and quick screen of attention and concentration

**Never forget to check the ears on the elderly

Loss of smell may be an early sign of what?

Alzheimer's

Five things to focus on in Follow-Up Visit

(4-6 weeks after initial visit)

1.Things that have changed since last visit

2.Tying up loose ends from previous visits

3.Aspects that are most important to patient function (esp.. cognition, mobility, hearing, vision)

4.Review medications

5.Review Functional status

Immunizations

influenza, Td/Tdap, Varicella, Zoster, Pneumococcal, Hep A & B, MMR

Influenza

1 Dose per Year

Td/Tdap (tetanus, diphtheria, pertussis)

1 time initial dose and a booster every 10 years with Td

Varicella

Two doses are needed if the individual has never had varicella

Zoster

1 dose (around 60), but can give earlier if comorbidities are present (2 may be needed)

Pneumococcal

1 dose of 13 valent pneumococcal conjugate (PCV13) or 23 valent pneumococcal polysaccharide vaccine (PPSV23)

Hepatitis A

Vaccinate only at high risk/seeking protection against hepatitis A

Hepatitis B

Vaccinate if at high risk (nursing home, DM2, etc)

Prevention of Disease

1. Smoking

2. Polypharmacy

3. Inactivity Increases RISK OF WORSENING of MANY DISEASE PROCESSES

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

YES! BUT they are less likely to receive counseling about it

The Four "A's" in patients 50 years and up

1. Ask

2. Advise

3. Assist

4. Arrange Follow-Up

Polypharmacy

-Implement behavior changes (diet, exercise,etc.) before turning to medications

-Combo of behavior plus meds may allow lower dosing

-Provide both WRITTEN AND VERBAL instructions

-Review meds at each visit

Inactivity increases/decreases the risk of worsening of many disease processes.

increases

Nutrition

Low BMI (<20) or unintentional weight loss of >/= 10lbs in 10 months suggest poor nutrition & should be evaluated

Nutrition breakdown - Fats

20-30% of daily intake-Change to monounsaturated & decreases LDL

Nutrition breakdown-Proteins

12-20% of daily intake (Form antibodies to promote healing, most older adults are deficient in protein)

Nutrition breakdown-Fat Soluble Vitamins

A, D, E, K (5 servings of fruit and vegetables)

**Always check for B12 deficiency and supplement with IM form if needed!!!

Obesity is a BMI great than _______________

30

What is the most effective prevention of stroke caused by atrial fibrillation?

Warfarin

Musculoskeletal Health

Bone Density Screen beginning at age 65 for all women

What supplements are recommended for bone density and what are the doses?

Calcium: 1200-1500 daily

(No more than 2500 mg daily-Calcium Citrate is better)

Vitamin D: 600-1000 daily >70 yo (Sunlight!!)

Cancer Screening

breast, cervical, colon

Breast Cancer Screening

every 2 years for women 50-74

Cervical Cancer Screening

women >65 who have adequate prior screening and not at high risk

Colon Cancer Screening

50+ annual colonoscopy (Stop after 76-85)