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Geriatrics: Study Guide

STUDY
PLAY
What age is considered elderly?
Age 65 or older
What are the major causes of DEATH?
4 C's
Coronary artery disease (CAD)
Cancer
Cerebrovascular disease (CVD)
COPD
What are the most common chronic conditions in the elderly?
HHVAC
HTN
Hearing impairment
Vision impairment
Arthritis
CAD
What are the environmental factors that affect lifespan?
Increased caloric intake
Smoking
Sedentary lifestyle
Alcohol use
What is the normal GFR of age 30 compaired to age 80?
Age 30: 140 ml/min
Age 80: 97 ml/min
Drug dosage adjustment in elderly should be based on what?
Creatinine clearance (best way to asses renal function!!!)
But serum creatinine level ALONE is not an adequate indicator of renal function
Decreased muscle mass + decreased GFR = stable serum creatinine level
What serum creatinine level in the elderly typicall indicated renal pathology?
Serum creatinine level more than 1.5 mg/dl
What type of test may become a new and better way to assess renal function?
Cystatin-C
More reliable in pts w/ high risk of CV dz who have a normal serum creatinine level
Protein found in blood that is filtered by kidneys
NOT affected by age, rafe, gender, or lean muscle mass
What labs increased with aging?
Decrease?
Increase: ESR, alkaline phosphatase, autoantibodies
Decrease: PaO2, albumin, vit B12
What are the RF for adverse drug reactions (ADRs) in elderly?
Increasing age
Gender (women)
Small body size
Duration of therapy
Patient non-compliance with therapy
Underlying disease states
What lipophylic drugs can penetrate the CNS due to changes in CNS function of the elderly?
TCA, barbiturates, opiates
What electrolyte is affected when kidney changes occur in the elderly?
Sodium - hyponatremia
Decline in active renin/aldosterone = sodium loss
Inability to excrete large volumes of free water = dilutional hyponatremia
What host factors can increase risk of infection?
Associated diseases: Type II DM, PVD, valvular heart dz
Prosthetic devices
Nutritional deficiences
What is a type of primary prevention? Secondary? Tertiary?
Primary- prevent disease (immunization)
Secondary- early detection before it becomes symptomatic (colonoscopy)
Tertiary- optimize health once disease is detected (medication)
What are the 5 aspects of behavioral counseling that optimize the pt's interest and adherence to lifestyle changes that promote health?
Assess
Advise
Agree
Assist
Arrange
Elderly over age 65 that have received a pneumoccoccal vaccination prior to age 65 should receive a re-vaccination when?
6-7 years after initial vaccination
How do you dose Tetanus vaccinations?
3 doses if never vaccinated
Previously vaccinated = booster every 10 yrs
*Most cases of tetanus in US occur in unvaccinated older persons
What are some different statins that can treat hyperlipidemia?
Lipitor - atorvastatin
Lescol - Fluvastatin
Mevacor - Lovastating
Crestor - Rosuvastatin
Zocor - Simastatin
What is the most common cause of secondary HTN in the elderly?
Renovascular disease (RAS)
50% of men who undergo treatment for prostate cancer will suffer what side effects?
3 I's
urinary "I"ncontinence
"I"mpotence
rectal "i"njury
What are some ADLs?
Simple task
Bathing
Dressing
Eating
Transferring
Continence
Toileting
What are some IADLs
More complex task
Transportation
Shopping
Cooking
Using the telephone
Managing money
Taking meds
Cleaning
Laundrey
New or subtle declines in IADL function may indicate what?
Presence of disease (CAD, CVD)
Loss of vision or hearing
Fear of falling
Depression and/or dementia
How do elderly pts present differently than younger pt when it comes to ACS?
Acute MI more likely to present W/O chest pain
Asymptomatic ischemia found more often on ECG
Conduction defects signal onset of CAD in almost 2x more often in elderly
SOB, pulmonary edema, CHF, cardiac rupture, and shock are common complaints related to acute MI
Delirium may be presenting symptom after an MI in elderly
CHF is most commonly associated with what?
Proonged systolic HTN
Presence of CAD second most common
What drugs do what in CHF?
Afterload reduction = ACEI
Volume overload = diuretics
Digoxin = reduces frequency of CHF exacerbations
BB should be prescribed unless CI
What is the second most common indication for heart surgery in the elderly?
Second MC = Aortic stenosis (AS)
MC = CABG
What is the MC valvular disorder in the elderly?
Mitral Regurgitation
Mod-severe = ACE inhibitors
How do you diagnose and treat A-fib/flutter?
Echo to dx
Rate/rhythm control and thrombolytic for tx
Hyperthyroidism imitates what other non-endocrine diseases?
Delirium
CHF
Classic eye findings are less common
Tremor- may be a benign finding
What medication may cause hyperthyroidism?
Amiodarone
Contains iodine and may cause iodine excess
What drug is recommended for an elderly pt with the flu?
Tamiflu (Oseltamivir)
Symmetrel (Amantadine) - Influenza A only
What are some medications that may cause constipation?
Opoid analgesics
Antacids
CCB
Diuretics
Iron supplements
Anticholinergics
What are some transient causes of urinary incontinence?
DIAPPERS
Delirium
Infection
Atrophic vaginitis/urethritis
Pharmologic therapy
Psychological (depression, pyschosis)
Excess fluid output (many factors)
Restricted mobility
Stool Impaction
What medications are used to treat acute renal failure?
Aminoglycoside antibiotics
NSAID
ACEI
Hyperkalemia is a complication
How does gout present and what is the tx?
Polyarticular and UE involvement
Indomethacin is not well tolerated
Another NSAID or prednisone are alt txs
What are some treatments for BPH?
A-1 blockers - Minipress (prazosin), Cardura (doxazosin), Hytrin (terazosin), Uroxatral(alfuzosin)
5-a reductase inhibitor- Avodart (dutasteride), Proscar (finasteride)
Surgery -TURP or TUIP
What is the best test to dx CHF?
Echocardiography
What is the definition of delirium (2 of 6 required for dx)?
Disturbance of CONSCIOUSNESS
PERCEPTUAL disturbance
SLEEP-WAKE CYCLE disturbance
Increase/decrease in PYSCHOMOTOR activity
DISORIENTATION to person/place/time
MEMORY impairment
What four features are required for Confusion Assessment Method to dx delirium?
Acute onset and flutuating course AND
Inattention
Disorganized thinking OR
Altered level of consciousness
3 of 4
What medication sare used to treat delirious state of delirium?
Anti-psychotics
Typical = Haldol (Haloperidol)
Atypical = Quetiapine (seroquel)
Risperidone (risperdal)
What is the primary cause of PERMANENT cognitive impairment among older pts?
Dementia
Dementia is defined as memory impairment plus one of what 4 features?
Aphasia
Apraxia
Agnosia
Disturbed executive functioning
What are the two most common types of dementia?
Alzheimer's disease (MC) -progressive
Stroke-related -sudden
What are the two type of dementia?
Cortical - affects memory, language, problem-solving and reasoning (amnesia, aphasia, apraxia, agnosia)
Subcortical - affects attention, motivation and emotionality (amnesia, slowness of thought, apathy) - Movement and gait findings early
What are some diseases that cause cortical dementia?
Alzheimer's disease
Pick's disease- atrophy of cerebral cortex; frontal lobe findings like delusions, flat affect, loss of speech, progressive dementia
Stroke syndrome
Jakob-Creutzfeldt dz -"mad cow dz"- infectious prion
Lewy Body dementia - visual hallucinations, movement d/o assoc. w/ PD signs
What are some diseases that cause subcortical dementia?
Parkinson's disease
Huntington's disease
Normal pressure hydrocephalus (NPH)
Basal ganglia strokes
Brain tumors
What is the triad of sxs for normal pressure hydrocephalus?
Early gait ataxia
Urinary incontinence
Later progression of congitive changes
What are the two steps for dx of dementia?
Document decline in cognition from previous level
Delinate process causing decline- r/o reversible causes
What are the impairments of dementia?
Loss of independence
Progressive loss of ADLs and IADLs
What s/sx appears early in stroke-related dementia?
Asymmetrical motor signs such as unilateral extensor plantar response occur early
What medication is the mainstay of therapy for AD?
Anti-cholinergics
Aricept (donepezil)
Reminyl (galantamine)
Exelon (rivastigmine)
Mild to mod
Namenda (memantine) -AR is severe HTN
Mod-severe
What is used to tx depression in dementia?
SSRI - Zoloft
What do you treat pseudodementia with?
Antidepressant
SSRI - Zoloft (sertraline) or Lexapro (citalopram)
TCA -not used in elderly b/c anticholinergic effects
Lithium - bipolar
Remeron (mirtazapine)
What are the most common emotional disorders in the elderly?
Minor affective disorders
Major depression is dx when there is a dysphoric mood plus what two characteristic sxs?
Feeling of helplessness and worthlessness
Change in vitality
SIG E CAPS
What meds can treat the different causes of secondary depression?
Strokes of anterior L hemisphere- TCAs
PD, AD, HD - TCA and ECT
Even though infrequent, what can treat schizophrenia in the elderly?
Recommended: Clozaril (clozapine)
Risperdal (risperidone)
Zyprexa (olanzapine)
Phenothiazines class: Thorazine (chlorpromazine)
Haldol (haloperidol) - increase EPS
What is the most common physical d/o associated with erectile dysfunction?
DM
What is the most consistent predictor of falls in the elderly?
Sedative use
Tests of balance assess 2 of what three components of functional balance?
Ability to maintain position
Ability to respond to voluntary position changes
Ability to respond to anticipated or unanticipated disruption of balance
Clusterig of falls is associated with a high ___-month mortality.
High SIX-month mortality
What is the mnemonic for causes of falling?
IVE FALLEN
Illness
Vestibular
Environmental
Feet/Footwear
Alcohol or druges
Low BP
Low O2
Eyes/ears
Neuropathy
What are the most common sites of pressure ulcers from the waist down?
Iliac crest
Sacrum
Greater trochanters
Ischial tuberosities
Lateral malleoli
What are the critical factors that cause pressure ulcers?
Pressure
Friction
Shearing
Maceration of skin (due to excess moisture)
What are the four types of major sleep disorders?
Disturbance of initiating and maintaining sleep (DIMS)
D/o of excessive somnolence (DOES)
D/o of the sleep-wake cycle
Abnormal sleep behaviors (parasomnias)
Which type of major sleep d/o is associated with periodic limb movements and primary complaint is insomnia?
DIMS
Disturbance of initiating and maintaining sleep
What is the treatment for "restless leg" syndrome?
Requip
Believed to be related to dopamine dysfunction
What major sleep d/o is characterized by pathologic sleepiness that interferes with activities during wakefulness
DOES
D/o of excessive somnolence
*Narcolepsy
*OSA - primary cause
*PLM-primary cause
What is the number of episodes of disturbance per hour required to dx OSA?
More than 5 episodes/hr of sleep
What can cause a morning HA in pts with severe OSA?
Hypercapnia
What is the tx for RLS?
Benzos
Klonopin (clonazepam)
Requip (ropinirol HCl)
How long does a person have to live when considered for hospice?
< 6 mths