2- Geriatric ENT and Dermatology

What are the physiologic age related changes that occur to the nose?

↓ smell

↑ mucosal thinning and/or capillary fragility

What are the physiologic age related changes that occur to the ears?

Loss of high-frequency hearing

What are the physiologic age related changes that occur to the eyes?

↓ lens flexibility

↑ time for pupillary reflexes

↑ incidence of cataracts

How does age related changes to the nose present?

↓ taste and ↓ appetite

↑ incidence of nasal bleeding

How does age related changes to the ears present?

↓ ability to recognize speech

How does age related changes to the eyes present?

Presbyopia

↑ glare and difficulty adjusting to changes in light

↓ visual acuity

State some of the vision changes related to aging.

· Decreased retinal illuminance

· Decreased visual acuity

· Decreased contrast sensitivity

· Decreased peripheral vision

· Presbyopia à impairment of depth perception

· Decreased ability to adapt to changes in light

· Increased sensitivity to glare

What ocular conditions are common with aging?

•Age-related macular degeneration

•Cataracts

•Glaucoma

•Diabetic retinopathy

•Transient Monocular Blindness

What do 30-50% of all geriatrics experience due to aging?

hearing impairment (presbycusis)

What is the term for the impairment of depth perception?

presbyopia

What are some common otic conditions that arise due to aging?

•Presbycusis

•Hearing loss-- Mainly high-pitched

•Vestibular imbalance

•Tinnitus

What is the term for hearing impairment?

presbycusis

What occurs when less sound moves through the ear canal causing the decreased ability to hear certain voices that might cause pts to need a longer period to process sounds?

hearing decline

What presents as bilateral symmetric, high frequency sensorineural hearing loss that results from cumulative degeneration of the auditory system?

presbycusis

What does the American Speech-Language-Hearing Association recommend for screening for hearing loss?

screening by an audiologist every 3 years after age 50 years or more frequently in those with known exposures or risk factors associated with hearing loss

What are some reasons to refer to otolaryngology (ENT)?

-Chronic ear infections

-Ototoxic medication use

-Otosclerosis

-Head trauma related to onset

-Sudden loss < 72 hours

-Acute, chronic dizziness

-Deformity of ear

-Blood, pus, foreign body in ear canal

-Unilateral loss > 15 dB

-Pulsatile tinnitus

-Bilateral speech discrimination loss

What are some treatment options for hearing loss?

Apps to Amplify sound or hand-held devices

Cochlear implants for severe hearing loss (directly stimulates auditory n.)

Hearing aids

What are the age related changes to smell?

•Decrease in sense of smell

•Lining of nose becomes thinner and dryer

•Nerve endings in the nose deteriorate

What are the age related changes to taste?

•Decrease in sense of taste

•Decreased taste bud sensitivity

•Affects sweet and salt more than bitter and sour

What are the RFs associated with oral candidiasis?

•Immune suppression

•Extremes of age

•Immunocompromising diseases

•Chronic steroid use

•Chronic antibiotic use

What causes oral candidiasis?

C. albicans

What type of oral candidiasis is MC seen and has White patches that are easily removed?

acute pseudomembranous

RFs associated with acute pseudomembranous candidiasis?

•Steroid use

•Decreased salivary flow

What type of oral candidiasis presents with Slightly raised well-circumcised white plaques that start on the buccal mucosa and spread to the labial commissures are are NOT easily removed?

hyperplastic

What type of oral candidiasis presents with a Pt complain of burning of tongue or mouth and is generalized to oral mucosa?

acute atrophic

What is the RF associated with hyperplastic candidiasis?

smoking

What type of oral candidiasis can lead to malignancy?

hyperplastic

What are the RFs associated with acute atrophic candidiasis?

•Antibiotic use

•Steroid use

•IDA

•Vitamin B12 anemia

•Uncontrolled diabetes

What type of oral candidiasis presents with Localized erythema of oral mucosa under dentures?

chronic atrophic

What are the RFs associated with chronic atrophic candidiasis?

•Poorly fitted dentures

•Prolonged use of dentures

•Poor oral hygiene

What type of oral candidiasis presents with Fissured patches in one or both commissures of the mouth, typically bilateral?

angular chelitis

What are the RFs associated with angular chelitis?

•Denture use

•Licking lips

•Facial wrinkling

What is the 1st line therapy for mild oral candidiasis?

topical antifungal therpay:

· Clotrimazole 10 mg PO five times daily, dissolve over 20 minutes x 7-14 days

· Nystatin oral suspension (10,000 U/mL) 5 mL PO four times daily, swishes for several minutes then swallowed x 7-14 days

· Nystatin (oral rinse) and clotrimazole (troches) = are high in sucrose (alt Fluconazole for diabetics!)

What is the alternate treatment of choice for a diabetic pt that developed mild oral candidiasis?

fluconazole bc nystatin and clomitrazole are high insucrose

What is the tx for moderate/severe oral candidiasis?

Fluconazole 200 mg PO once, then 10 mg PO daily x 7-14 days

what describes this vision in a geriatric pt:

unsafe driving at night

glaucoma

what describes this vision in a geriatric pt:

Blurred vision; glare

cataracts

what describes this vision in a geriatric pt:

Central vision loss; Unable to see faces or read

macular degeneration

what describes this vision in a geriatric pt:

blurring and patchy loss; severe retinopathy- difficult to reverse

diabetic retinopathy

What type of age related cataract:

located under the shell Fibrous metaplasia of lens epithelium

subcapsular

What type of age related cataract:

outermost layer,youngest layer --Cortical hydration between lens fibers

cortical

What type of age related cataract:

innermost, oldest layer of the lens--- deposition of pigments

nuclear

What is the MC type of cataract?

nuclear

What type of cataract do pts notice progressive vision loss with decreased perception of colors, particularly blues?

nuclear

What type of cataract is 4x more common in African Americans and diabetics where patients have vision loss, halos, and glare that are particularly noticed with night time driving?

cortical

What type of cataracts are associated with diabetes, radiation, smoking, long term steroid use and progress more rapidly than other types and are usually more noticeable to the patient?

subscapular

What type of color vision do cataracts degrade?

blue yellow

What are the RFs associated with cataracts?

•Age

•Trauma

•Smoking

•Alcohol use

•Exposure to x-rays

•Infrared exposure

•System disease (ex: diabetes)

•Uveitis

•Systemic drugs (ex: corticosteroids)

•Undernutrition

•Chronic UV light exposure

What diagnosis is described as any opacity in the lens causing it to lose transparency and scatter light?

cataracts

This is the presentation of what dx:

· Decreased or blurred vision

· Diplopia or polyopia

· Colored halos around the light

· Sensitivity to glare

· Increased frequency of changing refractive glasses

· Disturbances in color vision

cataracts

What are the PE findings for a pt with cataracts?

· Visual acuity decreased

· Fundoscopic exam dependent on type of cataract- absent red reflex

How are cataracts diagnosed?

Fundoscopic exam --> slit lap exam

What is the tx for cataracts?

•Surgical removal of cataract

•Placement of intraocular lens

What is the leading cause of blindness for black and Hispanic pts and the 2nd MCC of legal blindness?

glaucoma

What diagnosis is characterized by elevated IOP leading to vision loss over time?

glaucoma

What is the primary RF associated with glaucoma?

high IOP

What type of glaucoma:

•increased resistance to aqueous outflow

open angle

In a pt with glaucoma what is the level of intraocular pressure related to?

retinal ganglion cell death

What type of glaucoma:

access to drainage pathways obstructed

angle-closure

How does glaucoma present?

•Patients are typically unaware until it is detected during routine eye exam

•Gradual loss of peripheral vision

What are the PE findings associated with glaucoma?

· Abnormal optic disc

· Visual field defects

· Elevated IOP

What are the diagnostics for glaucoma?

REFER to opthalmo

· Exam of optic disks

· Tonometry

· Measurement of central corneal thickness

· OCT

Gonioscopy

How is screening done for glaucoma?

•Checking visual fields with frequency-doubling technology (FDT)

•Ophthalmoscopic evaluation of the optic nerve

What is the tx for glaucoma?

Decrease IOP via

•Medications (from PPP CLOSED topicals- timolol, PO- acetazolamide OPEN= prostaglandins- Latanoprost)

•Laser

•Incisional surgery

State the differences related to vision changes in glaucoma vs. macular degeneration.

Glaucoma- loss of peripheral vision, keep central vision

ARMD- loss of central vision, keep peripheral vision

What is the normal IOP value and what is considered an abnormal tonometry value?

normal- 10-21

abnormal >21

This is the pathophys for what type of diabetic retinopathy:

•Develops first

•Most Common

•Causes increased capillary permeability, microaneurysms, hemorrhages, exudates, macular ischemia, and macular edema

nonproliferative

This is the pathophys for what type of diabetic retinopathy:

•More severe

•May lead to vitreous hemorrhage and traction retinal detachment

proliferative

What are the PE findings for nonproliferative DR?

•Capillary microaneurysms

•Retinal hemorrhages

•Hard exudates

•Cotton-wool spots (soft exudates)

•Late findings: macular edema, venous dilation, intraretinal microvascular abnormalities

What are the diagnostic tools for DR in these areas:

______= makes dx !

______________- determines grade

___________- determines extent

__________- severity of macular edema and tx response

Fundoscopy= makes dx !

Color fundus photography- determines grade

Fluorescein angiography- determines extent

Optical coherence tomography (OCT)- severity of macular edema and tx response

What is the screening for DR?

annually dilated opthalmologic exam

What is the tx for DR?

•Control of glucose

•Control of blood pressure

•Macular edema: Intraocular injections of anti-VEGF medications, intraocular corticosteroid implants, focal laser and/or vitrectomy

What is the Most common cause of irreversible central vision loss in older patients?

ARMD

What are the RFs associated with ARMD?

•Age

•Genetics

•FHx

•Smoking

•CVD

•HTN

•Obesity

•Sun exposure

•Poor diet

What type of AMD:

•Causes changes of the retinal pigment epithelium

•Accumulation of waste products from rods and cones --> drusen

•No elevated macular scar, edema, hemorrhage or exudation

dry

What type of AMD:

•Occurs when new abnormal blood vessels develop under the retina--> Process = choroidal neovascularization

•Localized macular edema or hemorrhage --> elevate areas of macula or cause localized retinal pigment epithelial detachment

•When left untreated -> disciform scar under the macula

wet

____ are 4x more likely to develop AMD.

smokers

What are some sx of AMD?

· Distortion of straight lines in your field of vision (metamorphopsia)

· Difficulty adapting from bright lights to low lights

· Blurry vision

· Blank spot in central vision

Sx of what type of AMD:

•Insidious, painless central vision loss

•Scotomas = late finding

•Bilateral presentation

dry

Sx of what type of AMD:

•Rapid vision loss

•First symptom = visual distortion

•Peripheral vision and color vision unaffected

•Unilateral presentation

wet

What are the fundoscopic findings for dry AMD?

changes in retinal pigment epithelium, drusen, chorioretinal atrophy

What are the fundoscopic findings for wet AMD?

subretinal fluid, retinal edema, discoloration of macula, exudates, detachment of retinal pigment epithelium, subretinal hemorrhage around/in macula

What are the diagnostics for ARMD?

fundoscopic exam

Color fundus photography- when wet is suggested

Fluorescein angiography- when exam suggests wet

OCT- assess response to treatment

What is the tx for ARMD (wet vs. dry)?

Supportive care

Dry AMD = support nutrition and slow progression

Wet AMD = same as dry AMD + intravitreal anti-VEGF or laser therapy

What diagnosis occurs with an acute episode of ischemic origin in which one eye has profound visual loss, followed by full recovery within one hour?

transient monocular blindness (amaurosis fugax)

What are the RFs associated with transient monocular blindness (amaurosis fugax)?

•Advanced age

•Diabetes

•CVD

•Smoking

•HTN

•HLP

•Use of cocaine

How does transient monocular blindness (amaurosis fugax) present?

Unilateral, painless, transient vision loss

•Partial or complete vision loss

•"Curtain coming down"

What are the diagnostics associated with transient monocular blindness?

Labs- CBC, CMP, lipid panel, PT/INR, PTT, ESR/CRP

Carotid doppler

EKG

NONcontrast CT of head

What is the tx for transient monocular blindness?

tx and control underlying RFs (DM, HTN, HLD)

What changes occur to the skin due to aging?

•Thinning of the epidermis and dermis

•Loss of subcutaneous fat

•Loss of skin elasticity

•Increased dryness

•Diminished sensation

•Decreased number of sweat glands and blood vessels à decreased ability to respond to heat exposure

•Decreased number of melanocytes à decreased protection against UVR

What are the common skin conditions associated with aging?

•Pressure injuries

•Pressure ulcers

•Actinic keratosis

•Skin cancer

What diagnosis occurs with areas of necrosis and often ulceration where soft tissues have been compressed between bony prominences and hard surfaces?

pressure injuries/ulcers

What are the RFs associated with pressure injuries/ulcers?

•Age >65

•Decreased mobility

•Exposure to skin irritants

•Impaired capacity for wound healing

•Impaired sensation

How do pressure injuries/ulcers present?

Painful or pruritic skin lesion or wound

· Due to blunted sensations some patients may be unaware that they have a pressure injury or ulceration

What stage of pressure injuries/ulcer:

Skin is unbroken but inflamed

1

What stage of pressure injuries/ulcer:

Skin is broken to epidermis or dermis

2

What stage of pressure injuries/ulcer:

Ulcer extends to subcutaneous fat layer

3

What stage of pressure injuries/ulcer:

Ulcer extens to muscle or bone

4

What is the tx for pressure injuries/ulcers?

Pressure reduction

Direct wound care

Management of pain

Infection control

Nutritional supplementation

Adjunctive therapy

What diagnosis is precancerous skin changes that increases the incidence with age and occurs due to changes in keratinocytes?

actinic keratosis