CMS II Geriatrics: E2

1. Pressure Injury (Ulcers)

1. Pressure Injury (Ulcers)

What is the pathophysiology of pressure injuries?

Pressure → Friction (breaks in skin surface) → Shearing forces (demoepidermal junction separates resulting in decreased tissue perfusion) → moisture (tissue breakdown)

What are the 4 most susceptible bony prominences for pressure injuries?

- Sacrum

- Heel

- Greater trochanter

- Ischial tuberosity

What are the normal changes in elderly skin?

- Thinning dermis and decreased vascularity

- Decreased elastin

- Loss of subQ fat

- Dec dermis/epidermal turnover

Qhat is included in wound assessment for pressure injury?

Location

Class/stage

Size

Base tissues

Exudates

Odor

Edge/perimeter

Pain

Infection evaluation

A ___% reduction in size over 2 weeks is a reliable predictive indicator of healing

20%

Which stage of pressure injury:

Intact skin with localized area of non-blanchable erythrema

Stage 1

ID a Stage 1 Pressure Ulcer

Which stage of pressure injury:

Partial thickness skin loss, no subQ exposure

Note: May include intact/ruptured blisters

Stage 2

ID a Stage 2 Pressure Ulcer

Which stage of pressure injury:

Full thickness skin loss that extends to the subQ tissue

Stage 3

ID a Stage 3 Pressure Ulcer

Which stage of pressure injury:

Full thickness skin loss w/ extensive destruction exposing muscle, tendon, cartilage, or bone

Stage 4

ID a Stage 4 Pressure Ulcer

What is a reliable predictor of healing for stage 3/4 pressure injuries?

Granulation tissue

What is a Deep Tissue Pressure Injury?

Persistent non-blanchable deep red or purple skin which can be intact or non-intact → can present as blood filled blisters

What is an unstageable ulcer?

Localized area of tissue necrosis covered with slough or escar

What is a collection of viscous fibrinous dead tissue (pale, yellow to tan)?

Note: soft, moist avascular tissue

Slough

What is a collection of dead tissue that presents as a dry, dark scab?

Eschar

Deep Tissue Pressure Injury vs. Unstageable Pressure Injury:

Appearance:

→ Persistent localized area of non-blanchabledeep red or purple skin.

→ Can also present as blood-filled blisters. (Can have epidermal separation → dark wound bed or blood-filled blister.)

→ Can be intact or non-intact.

Features:

→ Pain/temperature changes oftenprecede skin color changes.

→ Can evolve rapidly to reveal the actual extent of tissue injury -or- may resolve without tissue loss.

Cause:

** Caused by damage to underlying soft tissues.**

Intense and/or prolonged pressure and shear forces at the bone-muscle interface.

Deep Tissue Pressure Injury

Deep Tissue Pressure Injury vs. Unstageable Pressure Injury:

Appearance:

→ Localized area of tissue necrosis covered with slough or eschar.

(AKA: debris/eschar covers the pressure ulcer.)

NOTES:

→ NEVER debride stable lesions.

→ The base of the ulcer needs to be visible in order to properly assess the stage… but it is not visible in this case, thus unstageable.

→ (It is possible for skin edges to be rolled w/ these, seen with the example photos.)

→ Slough = collection of viscous fibrinous dead tissue (pale yellow to tan in color).

→ Eschar = a collection of dead tissue that presents as a dry, dark scab.

Unstageable Pressure Injury

What is pink/red moist tissue comprised of new blood vessels, collagen fibers, and fibroblasts?

Note: Appears Shiny and Moist

Granulation tissue

What is shiny, new, pink tissue/skin that grows in from the edges or as islands on a wound surface?

Epithelium

What is a dead space in a wound caused by erosion under the wound edges?

Note: Large wound with small opening

Undermining

What effects the fascial planes and is a narrow passageway deep within a wound?

Tunneling

What is the recommended solution when irrigating a pressure injury?

Normal Saline

What is thin, watery, clear/straw colored fluid?

Serous

What is thin, pale red/pink colored fluid?

Serosanguinous

What is thick, opaque, yellow/green fluid with an offensive odor?

Purulent

What amount of exudate: Small amount in center?

Slight

What amount of exudate: Contained within dressing?

Moderate

What amount of exudate: Extends beyond dressing on onto clothes?

Copious

What is defined as multiplication of organisms without invasion but interfering with wound healing?

Note: Wounds stagnate without obvious signs of infection

Critical colonization

Why is critical colonization concerning?

Can result in failure to heal, poor quality tissue, increased friability and increased drainage

What are the 4 phases of wound healing and their timing?

1. Hemostasis → immediately

2. Inflammatory → wound development up to 6 days

3. Proliferation → 4-24 days

4. Maturation (remodeling) → 21 days-2 yrs

Which phase of wound healing is characterized by local vasoconstriction, formation of a platelet plug, clot formation and retraction, and fibrinolysis?

Note: Immediately after injury- minutes - hours

Hemostasis → when bleeding stops

Which phase of wound healing is characterized by redness, swelling, warmth, phagocytosis and stimulation of growth factor?

Note: Beginning immediately, last up to 6 days

Inflammatory → chronic wounds can get stuck in this phase

Which phase of wound healing is characterized by granulation formation, angiogenesis, collagen synthesis, epithelialization, and contraction of wound edges?

Note: Day 4-24

Proliferation

Which phase of wound healing is characterized by scarring, reorganization of collagen, and improvement of tensile strength?

Note: Begins - Day 21, can last up to 2 years

Maturation

Which dietary recommendations should be made to pts with wounds?

Encourage protein, calorie-dense foods and fluids

2. Dizziness and Syncope

2. Dizziness and Syncope

Vertigo vs. Pre-Syncope vs. Disequilibrium vs. Syncope:

Rotational Sensation

Vertigo

Vertigo vs. Pre-Syncope vs. Disequilibrium vs. Syncope:

Impending faint

Pre-Syncope

Vertigo vs. Pre-Syncope vs. Disequilibrium vs. Syncope:

Feeling of imbalance of standing or walking

Diseuilibrium

Vertigo vs. Pre-Syncope vs. Disequilibrium vs. Syncope:

Sudden, transient loss of postural tone & consciousness (not d/t trauma); spontaneous full recovery

- Loss of postural tone and consciousness with spontaneous recovery

Syncope

What is the MC Peripheral Vestibular Disorder?

Benign Paroxysmal Positional Vertigo (BPPV)→ brief spells brought on by changes in position

calcium debris (canalithiasis) within semicircular canals causes movement of endolymph and results in spinning sensation

How is Benign Paroxysmal Positional Vertigo (BPPV) diagnosed and treated?

Diagnosis → Dix-Hallpike

Treatment → Epley maneuver

What is a positive Dix-Hallpike?

Nystagmus

Vertigo

Fatiguing of sx

Confirming BPPV

What is a positive Head Thrust?

Eyes cannot remained fixated

What is a positive Fukunda?

Sway >30 degrees toward affected side indicates unilateral vestibular lesion or acoustic neuroma

Which dx is characterized by repeated episodes of tinnitus, fluctuating hearing loss with sensation of fullness in ears, and severe vertigo?

Meniere's disease → tx w salt restriction and diuretics

Which stage of Meniere's:

Sudden unpredictable vertigo, hearing loss and tinnitus with hearing returning between attacks?

Early

Which stage of Meniere's:

Vertigo attacks are less severe, hearing loss and tinnitus worsening with periods of remission?

Middle

Which stage of Meniere's:

Less frequent vertigo with worsening hearing loss and tinnitus and problems with balance?

Late

What is the MC brain tumor associated with dizziness?

Acoustic Neuroma

What are the s/sx of Acoustic Neuromas?

Unilateral cochlear symptoms (tinnitus and hearing loss)

What are the MCC of presuncope?

Cerebral Ischemia secondary to:

-Orthostatic hypotension

-Cardiac causes

-Dehydration

-Medications

-Vasovagal attack

-Autonomic dysfunction secondary to diabetes

-Parkinsonism

Postprandial hypotension

What are the MCC of syncope?

- Cardiac

- Electrical

- Structural

- Vascular causes

- Postural change

- Post-prandial hypotension → decreased in systolic BP >20 mmHg 1-2 hrs after a meal

What factors are associated with Disequilibrium?

- Proprioceptive disorders → Peripheral Neuropathies

- Visual probs → cataracts, macular degeneration

- MSK disorders → RA, OA, weakness

- Gait disorders → Stroke, Parkinson's

What med classes are most associated with dizziness in the elderly?

Antihypertensives

Psychotropic meds

Aminoglycosides

NSAIDs

What are the 3 provocative tests of the vestibular system?

1. Dix-Hallpike

2. Head-thrust test

3. Fukuda stepping test → difficult if weakness or gait disorder present

Other than provocative tests should always be performed on PE when evaluating dizziness?

BP

Cardiac exam

Balance and gait

Audiometry

Tilt table test

Lab testing

If dizziness is long-standing and lasts more than several months, what other conditions should you consider?

Psychological

How does aging affect the baroreflex?

Decreased ability to increase HR in response to sympathetic stimulation → Syncope

What is the pathophys of syncope?

reflex mechanisms are less responsive → decreased ability to increase HR in response to sympathetic stimulation and increased sensitivity to effects of dehydration and vasodilator drugs

Which comorbidities affect postural responses?

DM

Arrhythmia

AS

MI

Which drugs can impair postural reflexes?

Vasodilators

Antidepressants

Alpha/beta blockers

TCAs

Which cause of syncope:

Sudden, occurs in any position, no precipitant, blue/ashen skin, faint/absent pulses, rapid recovery?

Syncope caused by Arrhythmia

Which cause of syncope:

Aborted if person lies flat, nausea/diaphoresis precipitant, visual changes, pale and motionless, fatigue/nausea/diaphoresis on recovery without retrograde amnesia?

Vasovagal Syncope

Which cause of syncope:

Occurs in any position without warning, rigid tone, rapid pulse and high BP, tonic eye deviation, frothing at mouth, incontinence, slow recovery?

Seizure

Why do we obtain an EKG in all adults with syncope?

Assess for:

- Acute or remote MI

- Conduction abnormalities and pre-excitation

- Sinus bradycardia

- Prolonged QT

What is the tx for syncope caused by Orthostatic HypOtension?

Adjust meds

Ensure adequate volume

Other conservative measures (stockings)

What is the tx for vasovagal syncope?

Avoidance of triggers; medical therapy is somewhat controversial (BB, clonidine, paroxetine, midodrine)

What is the tx for Carotid Sinus Hypersensitivity induced syncope?

Avoid stimulating factors (tight collars or rapid neck movements); pacemaker

What is the tx for syncope due to Post Prandial Hypotension?

Avoid alcohol and high carb meals

Remain recumbent after meals

What is the tx for syncope due to ventricular tachyarrhythmia?

Implanted defribrillator or medical tx

What is the tx for syncope due to bradyarrhythmia?

Pacemaker

3. Urinary Incontinence

3. Urinary Incontinence

What is the sympathetic control of normal micturition?

Urine storage → inhibits detrusor contraction and increases sphincter contraction

What is the parasympathetic control of normal micturition?

Voiding → induces detrusor contraction and sphincter relaxation

What are the age-related urinary tract changes?

Detrusor muscle function decreases → fibrosis of bladder wall and increased sensitivity to neurotransmitter

Leads to →

Decreased bladder capacity

Detrusor instability

Decreased urinary flow rate

Decreased voided volume

Increased PVR

What are the transient causes of urinary incontinence?

Hint: DIAPPERS:

- Delirium

- Infection

- Atrophic vaginitis/urethritis

- Pharmaceuticals

- Psych probs

- Excessive urine output

- Restricted mobility

- Stool impaction

What is the MC type of incontinence in the geriatric population?

Urge incontinence

What is the leakage of urine along w/ or before the urge to void (MC in older population)?

Urge incontinence

What is the leakage of urine w/ increased intra-abdominal pressure in absence of bladder contraction?

Stress incontinence

What is the continuous leakage of urine, dribbling, incomplete emptying, "bedwetting"?

Overflow incontinence

What type of incontinence is where the patient is physically unable to toilet themselves in a timely fashion despite intact storage and emptying function?

Functional incontinence

What nonpharm treatments for incontinence have high rates of satisfaction?

- Bladder training

- Biofeedback

- Pelvic muscle exercises

What are the primary causative mechanisms associated with Stress incontinence?

- Weak pelvic floor muscles

- ntrinsic sphincter deficiency

Who is Overflow Incontinence MC in?

Men → due to outlet obstruction and detrusor underactivity

PVR > 200 mL = inadequate emptying

Which Antimuscarinic needs dose adjustment in renal insuff?

Trospium

Which drugs are Antimuscarinincs? What are their side effects?

- Oxybutynin

- Tolterodine

- Trospium

- Darifenacin

- Solifenacin

- Fesoterodine

- Dry mouth, blurry vision, constipation, dental caries, cognitive

Which drug is a Beta 3 agonist? What are common SE?

Mirabegron (Myrebetriq)

Constipation, Diarrhea, HA, Dizziness, Nausea, Tachycardia, HTN, UTI

Urine storage is under what control?

Sympathetic

Voiding is under what control?

Parasympathetic

What is indwelling catheterization reserved for?

1. Short term decompression of acute urine retention

2. Chronic retention not surgically/medically remediable

3. Patients with wounds that must be kept clean of urine

4. Very ill/end of life pts

Why should catheterization be done with caution?

Significant morbidity → polymicrobial bacteriuria

4. Palliative Care

4. Palliative Care

Which protocol provides a framework for difficult discussions?

SPIKE

What is the main goal of palliative care? Which dx is it used for?

improve quality of life

Cancer, Failure to thrive, COPD/emphysema/ILD/IPF, advanced liver dz, stroke, CHF 3+, dementia, HIV/AIDS, parkinsons, ALS