CMS II Final: Geriatrics

What are the 5 M's of in the framework of friendly care?

Mobility

Medication

Matters

Mentation

Multi-complexity

which lobes of the brain have the most prominent loss in aging?

frontal and temporal

which sections of the brain have the greatest neuronal loss due to aging?

cerebellum and cerebral cortex

how much does the blood flow to the brain decrease due to aging?

5-20%

which cognitive and behavioral changes are the most affected by aging?

- episodic and working memory

- executive function

which 2 primary CV disease increase with age?

HTN and CAD

what are the cardiovascular structural changes assoc. with aging?

- RA, LA volume increase

- LVH

- decreased SVC/IVC flow, myocytes

- aortic valve and mitral annulus thicken and calcify

- loss of stretch d/t hypertrophy

how is CO affected by aging?

does NOT change at rest

max CO and aerobic capacity are reduced

which heart sound is a normal finding for age >75 if in NSR?

S4 atrial gallop → secondary to rigid ventricle

how does HR change with aging?

resting HR unchanged

max HR decreased (220-age)

what causes increased CCB sensitivies in the elderly?

SA node function declines and leads to arrhythmias and increased CCB sensitivities

chest wall compliance, resp muscle strength and FEV all _____________ due to aging

decrease

how is cough power altered due to aging?

diminished d/t decreased muscle strength and increased closing capacity

how is mucociliary clearance changed due to aging?

slow and less efficient; delayed recovery after infection →increased tendency for infection

how is air/gas exchange changed due to aging?

lung tissue loses elasticity bc muscles aren't as strong/coordinated

how is the chest wall affected by aging?

- increased stiffness

- compliance decreases by 1/3 from age 30-75

- abd muscles play greater role than intercostals in chest expansion→ less effective supine and sitting, full expansion when standing

how is the diaphragm affected by aging?

- flattens and less efficient

- contributes to increased work of breathing during exercise

- increased breathing effort → difficulty weaning from ventilator

why is the elderly population at increased risk for aspiration?

- oropharynx thins → dec salivary production

- impaired strength/tongue coordination

- dec. mastication/gag reflex

- impaired food tolerance

why can reflux esophagitis become so severe in the elderly?

decreased sensation →severe reflux esophagitis despite minimal sx

(kinda like peripheral neuropathy in diabetics preventing sensation of ulcers)

what are the esophageal changes seen in the elderly?

- skeletal muscle of upper third hypertrophies

- muscle lose compliance and increases resistance to food passage

- decreased LES tone and strength of contractions →inc gastric acid exposure

- decreased sensation

what are the changes seen in the large intestine d/t aging?

- mucosal atrophy

- cellular and structural mucosal gland abnormalities

- colonic motility reduced

what conditions are increased in the elderly due to changes seen in the large intestine?

- chronic constipation

- risk of colon CA

- diverticula

- predisposition to fecal incontinence d/t dec in anal sphincter tone and thinning of the external sphincter

What happens to the renal mass, functional glomeruli, renal plasma blood flow and creatinine clearance in the aging population?

- renal mass dec by 30%

- glomeruli dec by 50%

- renal BF dec by 40%

- crcl decreases

what changes are seen in the bladder d/t aging?

- Dec. detrusor muscle contractility

- Dec. maximum bladder capacity

- Dec. maximum flow rate

- Dec. ability to withhold voiding

- Inc. in postvoid residual (retaining)

how does urinary incontinence affect the aging population?

11-34% of men

17-55% of women

what is sarcopenia?

loss of muscle mass, strength and performance

what is the normal rate of decline of mass of aging bones?

0.5% per year starting at 40

what is the normal change of aging bones?

trabecular # decreases, distance between trabeculae increases, osteoblasts DECREASE in # and activity progressively decreases.

osteoclasts are unchanged

what factors contribute to osteoporosis?

menopause

Vit D def

weight bearing activity reduced

what causes increased skin fragility seen in the elderly?

epidermis thins and dermoepidermal junction flattens → plays a role in wounds from shear stress and bleeding between dermis/epidermis occurs more often

what leads to delayed wound healing in the elderly?

thinning dermis and decreased vascularity →delayed wound healing

what are the ocular changes seen in the elderly?

- periorbital tissue atrophies, eyelids relax → ectropion/entropion

- conjunctiva atrophies and yellows

- cornea sensitivity declines by 50%

- arcus senilis from cholesterol/fat

- rigid iris →slow pupillary response

- presbyopia

- slower adaptation to low light, more sensitive to glare

what is the primary cause of conductive hearing loss? how do you eval?

cerumen impaction → whisper test evaluation

what instrument can be used to asses for hearing loss in the office?

audioscope →most accurate

what are the 5 MC chronic conditions in ppl >75?

hearing loss

cataracts

arthritis

HTN

Heart dz

what are the 10 topics used on the Barthel self-care index to assess functional independence?***

feeding

moving

personal toilet use

transfers (on/off toilet)

bathing self

walking

mobility ease

stairs

dressing

continence

what screening tools are used to assess delirium?

confusion assessment method (CAM) and 4 AT rapid clinical test

what screening tool is used for attention?

digital span memory test → quick assessment for attention

what is delirium defined as?

acute disturbance in attention, awareness, and baseline cognition that is not better explained by an underlying neurocog disorder

what are the 4 features assoc. with the CAM?

1. acute onset and fluctuating course

2. inattention

3. disorganized thinking

4. altered LOC

what are the hyperactive sx of delirium?

- restless

- agitated

- refusing care

- emotional lability

- can be mistaken for psychosis or mania

what are the mixed sx of delirium?

can be normal or fluctuating activity

what are the hypoactive sx of delirium?

- sluggish, lethargic

- can be mistaken for depression

MC and poor prognosis!

what is the strongest RF for development of delirium?

dementia

what is the primary neurotransmitter of the RAS system? how is this affected in the elderly?

Ach = responsible for regulating alertness and attention→ elderly pts are hypocholinergic → disruption of RAS leads to deficiencies in all domains of cognition

what are the predisposing factors of delirium?

- cognitive impairment/dementia

- prior episode

- medical comorbidities

- functionally dependent

- sensory impairment

- malnutrition/dehydration

- advanced age

- male sex

what are the precipitating factors of delirium?

- acute cardiac or pulm events

- bed rest

- drug withdrawal

- fecal impaction

- fluid/electrolyte disturbances

- infections

- meds

- restrains

- severe anemia

- uncontrolled pain

- urinary retention

what meds are precipitating factors for delirium?

sedatives

opiates

H2 blockers

anticholinergics

polypharmacy

what is the MCC of REVERSIBLE delirium?

drugs → benzos, opioids

what are the causes of reversible delirium?

D- Drugs

E - Electrolytes

L - Lack of drugs/water/food

I - Infection

R - Reduced sensory input

I - Intracranial causes

U - Urinary infection/fecal impaction

M - myocardial →MI, CHF, arrhythmia

what is the peak post op timeframe an individual can develops delirium?

2-7 days post up

peak inflam mediators on day 2

how do you manage a pt with delirium?

- management →tx underlying cause, give antipsychotics

- environment →lighting, orientation, sensory deprivation

- address behavioral issues

- anticipate and prevent complications

- restore function

what are the high risk drug categories assoc with delirium?

Benzodiazepines

Opioid analgesics

Nonbenzodiazepine sedative hypnotics

Antihistamines (esp first gen)

Alcohol

Anticholinergics

Anticonvulsants

TCAs

H2 blockers

Antiparkinsonian agents

Antipsychotics

Barbiturates

which 2 antipsychotics are appropriate and commonly used to tx delirium?

haldol and seroquel → avoid in old pts w/ parkinsonism (+ alcohol use for seroquel)

how is dementia defined?

decline in intellectual functioning significant enough to affect daily life and independence

what are the 6 cognitive domains of dementia?

1. learning and memory

2. language

3. executive function

4. complex attention/concentration

5. perceptual motor/visuospatial

6. social cognition/emotion

what is the MC form of dementia?

alzheimer's

what is the DSM-5 criteria for major neurocognitive disorders?

- evidence of significant cognitive decline from a previous level of performance in 1+ category

- cognitive defects interfere with independence in everyday activities

- cognitive deficits do not occur exclusively in the context of a delirium

- cognitive deficits are not better explained by another mental disorder

what is vascular dementia?

dementia caused by CV dz or impaired cerebral blood flow; progression is typically sudden or stepwise

what is the DSM-5 criteria for vacular dementia?

- criteria met for major/mild neurocog disorders

- clinical features consistent with vascular etio →onset related to CV event, evidence for decline in complex attention

- evidence of CV disease

- sx not explained by another dz

what is mixed dementia?

dementia that is secondary to coexistence of more than 1 dementia- producing condition → alzheimer's, vasc. dementia, alcohol-related dementia, normal pressure hydrocephalus, chronic subdural hematoma, HIV

what is cognitive impairment without an overall decline in function?

mild cognitive impairment (MCI) → precursor to dementia or secondary to reversible condition

what is dementia that onsets alongside or within 12 months of motor sx?

dementia w lewy bodies

what is dementia that is onset >12 months AFTER appearance of motor sx?

parkinson's disease dementia →motor sx first!!

who does Pick's disease (frontotemporal dementia) typically present in?

<60

gradual but faster onset than alzheimers

what are the s/sx of Pick's disease?

cognitive = executive → disinhibition, apathy, behavior changes

motor = none

which dx shows atrophy in frontal and temporal lobes on imaging?

pick's disease

what is the triad of sx seen in normal pressure hydrocephalus?

progressive dementia

urinary incontinence

gait instability

which genetic disorder has a strong correlation with an early onset of Alzheimer's?

down syndrome, trisomy 21

what dx should be on your differential assoc with dementia?

- normal cognition

- mild cognitive impairment

- major depressive disorder

- delirium

- specific learning disability

- normal pressure hydrocephalus

- b12 deficiency

- hypothyroidism

- parkinson's

what MMSE score warrants further testing?

<24

which drugs are acetylcholinesterase inhibitors and have been shown to provide some benefit for mild/moderate dementia?

donepezil

rivastigmine

galantamine

what are the MC side effects of anticholinesterase inhibitors?

GI

which drug is an NMDA inhibitor approved for moderate/severe dementia?

Memantine (Namenda) → indicated for more advanced dz

reduces glutamate-mediated excitotoxicity

what are the common side effects of Namenda?

constipation

dizziness

HA

what are the 4 types of incontinence?

1. urge → leak when you gotta go

2. stress →laughing/coughing/sneezing

3. overflow →continuous leakage bc not emptying bladder

4. mixed →stress and urge

what are the 4 main drug classes assoc. with elderly hospitalization d/t adverse effects?

warfarin

insulin

oral antiplatelet (ASA)

hypoglycemic drugs

what are the RF of osteoporosis?

- asian/caucasian

- increasing age

- small body size

- family hx

- post menopause/hypogonadism

- smoking

- excess alcohol consumption

- low physical activity

- glucocorticoid use >3 months

what may you see on PE in a pt with osteoporosis?

- low body weight; BMI <19

- loss of height

- localized vertebral pain

- kyphosis

what is the recommended dose of calcium and vitamin D for osteoporosis?

1000-1500 calcium daily

400-800 IU Vit D daily

what is the first line tx for osteoporosis?

Bisphosphonates

what is the MCC of elder abuse?

self neglect

what are teh 3 MC osteoporotic fracture sites?

wrist

hip

vertebrae

what is failure to thrive? what are the MC indicators?

FTT = weight loss >5%, decreased appetite, poor nutrition, inactivity, dwindling physical function, malnutrition, cognitive impairment

1. depression

2. cognitive impairment

3. malnutrition

4. functional impairment

what exams can check cognition?

mini-cog

clock drawing

MMSE

what exams can check affect?

depression screening

>5 = sus depression

> 10 = def depression

what exams can check mobility?

timed up and go (TUG) test→stand, walk, turn, sit

>12-14 = inc. risk of falling

>20 = warrants comprehensive eval

what are the 7 domains involved in a geriatric rapid assessment?

1. functional status

2. mobility

3. nutrition

4. vision

5. hearing

6. cognitive function

7. depression

how do you screen for functional status, mobility, and nutrition?

functional status = ansewr yes to needing help w ADLs

mobility = TUG test >12

nutrition = answers yes to "have you lost more than 10 lbs in 6 months without trying" or BMI <20

how do you screen for vision?

vision = unable to read newspaper headline and sentence w corrective lenses, use Snellen chart. unable to read greater than 20/40

how do you screen for hearing, cognitive function, and depression?

hearing = unable to hear 40 dB at 1000 or 2000 Hz in one or both ears

cognitive function = 3 item recall

depression = answers yes to " do you often feel depressed"

which gait: pain-induced limp with shortened phase of gait on painful side?

antalgic

which gait: outward swing of leg in semicircle from hip?

circumduction

which gait: excessive plantar flexion and inversion of ankle?

equinovarus

which gait: acceleration of gait?

festination

which gait: loss of ankle dorsiflexion secondary to weakness of ankle dorsiflexors?

foot drop

which gait: early, frequent audible foot-floor contact with steppage gait compensation?

foot slap

which gait: hyperextension of knee?

genu recurvatum

what is the tendency to fall foward?

propulsion

what is the tendency to fall backward?

retropulsion