Geriatrics Exam 1 - Highlighted/Bolded areas (L1-L4)

"normal", "typical"

The range of ____________ or ___________ increases as populations age.

Senescence

The process of deterioration with age which includes change in physiologic rhythms, loss of complexity and Homeostenosis

Homeostenosis

Diminished reserves to allow return to homeostasis after challenges.

Geriatric Syndromes

Term used to refer to common health conditions in older adults such as cognitive impairment, delirium, falls, etc...

1. Complexity, mulitmorbidity and physiologic reserve

2. Importance of cognition and function

3. Goals and Prognosis in clinical decision making

What are the guiding principles to care?

low, slow

With deliberate medicine it is best to start ______ and go ______

1. Mind - delirium, dementia, depression

2. Mobility - perform ADLs/IADLs, ambulation aids, hx of falls

3. Medications - any causing more harm than good

4. Multi - complexity - impact of therapeutics on pt as a whole

5. Matters most - align to what is most important to patient

What are the geriatric 5M's Framework?

knowledge of background of cultures and their values

concrete set of facts, impartial

could result in stereotyping

What is cultural competency?

promotes interpersonal sensitivity through partnerships with and learning from patients

ongoing curiosity and self reflection

requires attitude of openness with provider in "learning mode"

What is cultural humility?

1. Team structure

2. Mutual support

3. Communication

4. Team Leadership

5. Situation Monitoring

What are the 5 TeamSTEPPS?

SBAR technique

Situation

Background

Assessment

Recommendation

Under TeamSTEPPS concept 3 for communication, which technique is used to facilitate effective communication?

I PASS the BATON

Introduction

Patient

Assessment

Situation

Safety concerns

Background

Actions

Timing

Ownership

Next

Under TeamSTEPPS concept 3 for communication, which technique is used for improved communication during care transitions?

Informal Caregivers

Caregivers that are unpaid and are usually family/friends/neighbors, that are often a vital part of helping older adults maintain independence

Increased rates of emotional distress, financial strain, depression/anxiety, social isolation and negative effects on their own health.

What are risk factors for caregivers?

Caregiver Advise, Record, and Enable (CARE) Act

What Act was put in place to offer support for caregivers?

Misunderstandings of diagnoses and plans

Medication discrepancies

Confusion among patient and caregivers

Complications

Hospital readmissions

Patient dissatisfaction

During transitions in care, handoffs can lead to what?

Care Transition Intervention

What program has researched transitional care and offers insights and tools to improve quality and manage risk during handoffs?

That it is the real topic the patient wants to discuss.

What do we NOT want to assume about the listed chief complaint?

Have there been any recent ER visits/hospitalizations

What is important to ask about when receiving HPI on a patient?

Family History

What part of the history is not as pertinent to obtain from older adults, but may offer insight into their support system?

Support System

Home Safety

In the social history for geriatrics, we are adding in 2 additional S's in FEDTACOS, what are they?

Shared decision-making

For transgender health, what should be used to determine exams/screening tests that the patient is comfortable with?

1. No clear consensus or guidelines on continuing hormone therapy in older adults

2. Estrogen carries increased risk of venous thromboembolic events

3. Testosterone carries increased risk of polycythemia

What are 3 things to discuss with a geriatric patient concerning gender affirming therapy?

Each encounter

When should an updated medication list be completed?

What system do they use to organize meds?

During medication review, what is important to ask the patient?

Goals of care

What are important to reassess often and with any changes in health status?

Direct questions

When going over the ROS, what type of questions should you ask the patient?

Depression screening

When evaluating the patient mood, what screening should be done in all patients?

Pathology - Impairments - Functional limitations - Disability

What are the 4 parts of the disablement process?

Look for a cause.

(ex - difficulty with ADLs may be early sign of dementia)

What should be done if there is an unexpected change in functional status?

subsequent disability and mortality

When assessing functional status, gait speed is highly correlated with what?

Short Physical Performance Battery (SPPB)

During assessment of functional status, what test can be performed that will show better function with higher scores?

Balance, Gait Speed, Chair Stand

What 3 tests are done during the SPPB?

Systolic BP

While reviewing a patients vitals, what tends to rise with age due to arteries becoming less distensible?

widened pulse pressure

While reviewing vitals, what type of pulse pressure is more common?

*trouble with word finding

*Use of assistive devices

*Appropriate dress for weather

*How clothes fit (too tight/loose could indicate wt changes)

What are 4 things to assess/document regarding the general survey of the patient?

actinic or "senile" purpura

purple patches on the skin from blood that has leaked through poorly supported capillaries

Pressure ulceration

What is important to look for early signs of on the skin of at risk patients?

whisper test

During HEENT exam, what test is used to evaluate hearing acuity?

True

T/F: Atherosclerosis is more common in older patients but is not considered a normal part of aging

Timed Up and Go (TUG) Test

Gait assessment

Cognitive testing

During the MSK and Neuro exams, what are 3 tests/assessments to complete?

Increased fall risk

If the TUG test takes longer than 12 seconds to complete, what is the patient at risk for?

Intact Mobility

Indicates high risk

During a gait assessment what does being faster then 1.0 m/s suggest?

What does it mean if they are between .6 and 1.0 m/s?

3 item recall

MMSE or MoCA if indicated

What is performed during the cognitive test?

During all routine visits

When should immunization history be reviewed with the patient?

Covid-19 - currently 2 doses for 2024-2025

Influenza - yearly

Tdap - q10 years

Zoster - 2 dose series, 2-6 mos apart

Pneumococcal - once after 65 years old

Inactivated poliovirus - complete 3 dose series if incompletely vaccinated

RSV - for all adults ≥75 years, or for 60-74 y/o if they have an additional risk factor or another indication

What immunizations should be administered in geriatrics and when?

metabolism slows, physical activity declines, nutrient absorption may decrease

Why would dietary needs change from aging?

loss of appetite

poor dentition

decreased gastric mobility

mobility challenges

What would cause food choices to be more limited?

Look for BMI <20 or unintended weight loss >10 lbs within 6 month period

In a patient with under-nutrition, what is important to look for?

1-1.5 g/kg/day

14 g per 1000 calories consumed/day

64 ounces daily - water, juice, milk

Five servings of fruits/vegetables daily for potassium and vitamin A/C/E

What are daily intake recommendations for the following?

Protein

Fiber

Water/fluids

Vitamins and Minerals

Individualized

Decisions to screen patients for cancer should be ____________.

Every 2 years for females aged 40-74

What is the USPSTF recommendation for screening mammogram?

Every 10 years for people aged 45-75 for people of average risk.

What is the USPSTF recommendation for colon cancer screening?

Recommends against if they have had adequate screening.

2 consecutive neg HPV tests within past 10 years (last 5 years ago)

2 consecutive neg Pap/HPV tests within past 10 years (last 5 years ago)

3 consecutive neg pap tests within past 10 years (last 3 years ago)

What is the USPSTF for cervical screening in females older than 65?

perform pap/HPV every 3-5 years until at least age 70

If past cervical screening is unknown/inadequate, what is recommended?

Individualized screening for males who are average risk and between ages 55 and 69.

What is the USPSTF recommendation for prostate cancer screening?

annual screening with low-dose chest CT scan for high-risk individuals ages 50-80 years. (at least 20 pack-year smoking history or current smokers or former smokers who quit within the past 15 years)

What is the USPSTF recommendation for lung cancer screening?

Ethics committees

A required presence in hospitals, nursing homes and other healthcare organizations.

Disclosure

In what part of the informed consent do patients require enough info to make clinical decisions in a language and educational level they understand to weigh the risk/benefits of proposed intervention?

Voluntariness

In what part of the informed consent is it important to confirm the patients decision is not coerced?

Competence

What is often used as a legal term to refer to soundness of mind to make most routine decisions and may require a court ruling?

Decision-making capacity

What is often used as a clinical term where a patient may be able to make some decisions but not others and is applied on a case by case basis.

Decision-making capacity

What should providers determine as part of the process of obtaining informed consent?

1. Understanding (understanding of info and can repeat in own words)

2. Appreciation (for own circumstances)

3. Reasoning with the information (infer consequences of choice)

4. Expressing a choice (ability to make and state decision - do not confuse with refusal to make a choice if other standards are met)

What are the 4 decision-making capacity set of standards?

Healthcare proxy (mPOA, surrogate, rep, agent)

Living Will

Physician order for life sustaining treatment (POLST) - Medical Orders for Scope of Treatment (MOST) in NC

What are parts of the advance directives?

Healthcare Proxy

What portion of the advance directives appoints a surrogate or agent to make medical decisions should a patient lose decision making capacity

Living Will

What is the written statement of preferences for care when decision-making capacity is lost?

preferences to the conditions listed in the document

What does the living will limit?

Might not apply to the specific circumstances a patient finds themselves in.

What is a risk of stipulations listed in the living will?

POLST/MOST

A set of orders based on a patients current condition and anticipated trajectory and stipulates which interventions should be provided or withheld if need arises.

resuscitation, antibiotics, fluids, nutrition

What does the POLST/MOST often address?

Medical aid in dying (MAID)

Physician-assisted dying (PAD)

Practice in which they physician provides a qualified patient, at their explicit request, with a prescription for lethal medication that they can take on their own.

VAE - voluntary active euthanasia - MD administers lethal med at patients request usually by IV injection

What is not currently legal in the US?

Referral to palliative/hospice care

What is appropriate when a patient is requesting MAID/PAD?

Concern that the dosages of narcotics used to treat pain and discomfort will also hasten death

What is the "double effect"?

like any other treatment that requires informed consent

How should providers approach the "double effect"?

Voluntary Stopping Eating and Drinking (VSED)

In regard to nutrition and hydration, patients may choose this as a way of hastening death and may be written into the living will.

Pts who have ESRD or ALS or receive Social Security Disability Insurance

What pt's other than those 65 or older, can receive Medicare benefits?

Part A

Which part of Medicare?

Most people do not pay a premium

Hospitalization

Post acute rehab

Home Healthcare

Hospice

Durable Medical Equipment (DME)

False

T/F - Medicare covers long term nursing home/assisted living communities.

ordered by a provider as medically necessary

certified as "homebound" needing only part-time or intermittent skilled services

What must be done for Medicare Part A to cover home healthcare?

When two clinicians certify that life expectancy is less than 6 mos

When is a patient eligible for hospice?

Part B

What Medicare part?

Visits to clinicians and services that occur on outpatient basis (outpatient hospital services, ambulatory surgery, same-day procedures, labs/diagnostic tests)

Part C

What Medicare Part?

Created as alternative to traditional fee-for-service

Medicare pays an organization a risk-adjusted sum per member per month that covers all medicare-reimbursed services for enrolled members.

Part D

What Medicare part?

Prescription coverage

The "donut hole"

Provided coverage up to a limit but then started again once drug cost reached a "catastrophic level"

ADL disability

What is there a 30% chance of an older adult developing during a hospitalization?

Acute Care for the Elderly (ACE) units

Units incorporated changes in both physical environment and overall care approach.

Aimed for home like setting, added safety features

65 and older

experienced a fall

multiple admissions in past 6 mos

frail on admission

Some hospitals do continue to have designated ACE units for what patients?

Cognitive impairment

Depression, EToH, hearing/vision loss

Use of anticholinergics or >3 new meds during hospital stay

Dehydration or malnutrition

What are some risk factors for delirium?

4-6 hours uninterrupted sleep each night

keep clock/calendar in room

encourage family to bring personal items

avoid anticholinergics/benzos when possible

manage pain and constipation appropriately

What are ways to prevent delirium?

poor coordination, tremor, weakness, sensory changes

orthostatic hypotension

joint pain/effusions, antalgic gait

abnormal time up and go test

Risk factors for falls.

immobility >3 days

HF or severe COPD

Anesthesia/Surgery

Cancer or Stroke

Sepsis/critically ill

Smoking

Prior VTE

Risk factors for Venous Thromboembolism

Low molecular weight heparin (LMWH)

What VTE prophylaxis is used for moderate/high risk patients unless risk of bleeding outweighs benefit?

Mechanical prophylaxis (pneumatic compression, compression stockings, venous foot pump, limit activity and increase risk for falls)

What can be used as an alternative for VTE prophylaxis in low risk patients?

use proper protective dressings and consult wound care as needed

use pressure reducing supports for bed-bound or immobile patients (bony prominences, reposition q2 hours)

What skin care is provided for pressure ulcers?

incentive spirometry

deep breathing

encouraging mobility

continue inhalers for preexisting pulm disease

sit in a chair for meals

What can respiratory illness prevention include?

Judicious use of IV/urinary catheters and other invasive monitoring devices.

What is one way to prevent infection while in the hospital?

assistance with meals if needed

consider consistency of solids/liquids in pts with dysphage

speech therapy or nutrition consults prn

What are ways to maintain nutrition while in the hospital?

limit restricted activity orders and hospital equipment (IV lines, catheters)

Early referral to OT/PT

What are ways to help maintain mobility and function while in the hospital?