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Older adults or elderly over the age of? Are considered geriatric popula7on 65 years
- they have a weaker immune system, so they do not mount a strong immune response
- this weaker immune system, health problems may be present, but present in an atypical manner not with the usual symptoms Unique to geriatric pa7ents No evidence of fever in elderly? Ex) an elder may have an overwhelming infec7on, but not have normal reac7ons
- oFen they can have sepsis and have a low or norma l temperature. What are the other signs of illness in our >65 yoa popula7on? Decreased appe7te, decreased ac7vity, or changing mental status Polypharmacy The use of many different drugs concurrently in trea7ng a pa7ent, who oFen has several health problems. Elders Have an increased risk of skin breakdown and pressure sores due to the fact that they have decreased subcutaneous fat
NURS 5333 FAMILY 1 TEST 3
GERIATRICS PART 1,2,3,
QUESTIONSAND CORRECT
ANSWERS (LATEST UPDATE
A geriatric assessment
- a thorough health assessment at least annually. These can be done by the primary care providers, but oFen are not because of the 7me involved
- medical, social, and environmental factors that affect the wellbeing of the geriatric pa7ent
- medicare actually allows for an annual health wellness visit
- studies have shown that pa7ents who par7cipate in this annual health wellness visit actually have a lower mortality rate The goals of the geriatric assessment are Iden7fy problems early, to intervene, to improve the quality of life for pa7ents, to op7mize their health outcomes and through iden7fying problems early. When developing plans, they should be pa7ent-centered collabora7ve plans of care.
- nutri7on needs to be a part of every geriatric assessment The components of a geriatric assessment are Func7onal status, fall risk, medica7on review, nutri7on, vision and hearing, cogni7on, mood or mental status, and ability to care for oneself as well as toile7ng and immuniza7on needs. Screening vision in the elderly A simple snellen test can be done in the office. A formal vision exam does not need to be done unless the snellen result is abnormal or the pa7ent complains of visual changes Elderly and bmi: normal bmi is 23 to 30. A bmi less than 22 kilograms per meter squared is associated with increased mortality and a sign of malnutri7on.
- they have enough money to actually purchase food?
- do they have someone who can help them with the shopping? Do they have
back to the chair and then si^ng down again not using their arms. They should be able to complete this ac7vity in less than 12 seconds. Func7onal assessment: adls
- func7onal ability is to ask them if they're able to dress themselves, do they need help with bathing and do they need help with toile7ng?
- included in the func7onal assessment is the use of any assis7ve devices, such as canes, walkers, or wheelchairs
- medica7on review Assessment on any geriatric pa7ent.
- should be done at least once a year.
- medica7on should be reviewed always when a pa7ent establishes care with a new provider, and it's important to also repeat the medica7on review aFer a hospitaliza7on
- the pa7ent should be instructed to bring a bag with all of their medica7ons to their ini7al visit or to their annual health wellness visit
- those seniors at highest risk for polypharmacy are the ones that see mul7ple providers, see mul7ple specialists in addi7on to their primary care provider and have had a recent hospitaliza7on or self-treat with mul7ple over-the-counter medica7ons that may interfere or interact with their prescribed medica7ons Inappropriate medica7ons for older adults. Some medicines that are safe for children and adults are not safe for geriatric pa7ents
- geriatric pa7ents may have decreased renal func7on and that affects clearance of medica7on and would necessitate an adjustment in dosing. The beers criteria & stopp and start &. Choosing wisely website
- you should never start a new medica7on without knowing all of the current medica7ons the pa7ent is on
Geriatric assessment, one should address the fact that a pa7ent needs advanced direc@ves.
- it should always be ins7tuted prior to a pa7ent actually having a deteriora7on of mental status or a sudden illness that requires major decisions ask them if they have completed those advanced direc7ves and if they have, does their primary care provider or your office have a copy Suspicion of a cogni7ve change or deteriora7on, then a cogni7ve evalua7on should be done.
- mini-cog and the mini-mental status exam are both licensed, and so you need approval or payment before using these
- a mini-mental status exam or through a mini-cog. The mini-cog is quicker. It only takes about five minutes or less and improves detec7on of cogni7ve changes to about 83%.
- encourage to exercise Two simple ques7ons you can use to assess
- one, in the past year, have you lost urine or goden wet? If the answer is affirma7ve,
- then if so, has it happened at least on six separate days? If both answers are posi7ve, then one would want to proceed with treatment of urinary incon@nence. Urinary incon7nence is that it can lead to skin breakdown and also is associated with social isola7on.
- an annual influenza vaccine in the fall of the year.
- prevnar 13 to preven t pneumonia is indicated at age 65 with a follow- up pneumovax 23 one year later.
- shingrix , the shingles vaccine, should be given to all adults over the age of 50. This immuniza7on is a two-dose vaccine that's given two to six months apart.
Absorp7on. With aging There's also decreased ac7ve transport of some drugs, so it can decrease bioavailability. The rate of absorp7on also slows with age. There's an increase in total body fat, and a decrease in subcutaneous fat. Frail, older adults don't have very much subcutaneous fat to absorb rx such as? This decreases the absorp7on of transdermal drugs. This can be important if you're trying to manage pain with transdermal patches.
- delayed gastric emptying can also occur, and reduced splanchnic blood flow, also. With distribu7on There's also an increased percentage of body fat. Lipid-soluble drugs, such as benzodiazepines, have a higher tendency to accumulate in the adipose 7ssue, resul7ng in lower serum concentra7ons, but it also increases the dura7on of ac7on, due to an increased half-life, because the drugs tend to hang around there in the adipose 7ssue.
- lean muscle mass decreases about 20%, in total body water by 10-15%, causing changes in the distribu7on of many drugs Pharmaceu7cal agents primarily distributed in lean body mass or body water reach higher serum concentra7ons in older adults
- lean muscle mass decreases about 20%, in total body water by 10-15%, causing changes in the distribu7on of many drugs Normal aging also results in a decrease by as much as 20% of serum albumin levels. Albumin is the primary drug-binding protein in the plasma. The consequence of this lowered serum albumin level is fewer protein molecules available for binding to the drug, and higher levels of the free or unbound drug.
Metabolism of rx with elderly Metabolism, this brings up the hepa7c metabolism, and this declines with age. This is your cyp Metabolism:decreases with age, causing a decrease with the drug clearance and an increased half-life. So=this alters drug-drug interac7ons, as well. First-pass metabolism also decreases, and so drugs that undergo the first-pass metabolism have an increased bioavailability and decreased amounts of the prodrugs Most drugs are eliminated through the kidney Generally about a 50% decline in renal func7on. This decreases tubular secre7on and decreases the renal clearance of drugs. Because of the decrease in kidney func7on, this is the most important cause of adverse drug reac7ons in the older adult popula7on.
- the decrease in kidney func7on, this is the most important cause of adverse drug reac7ons in the older adult popula7on
- examples of drug classes that there's evidence of age-related reduc7on in clearance include your an@hypertensives, your fibrates, your seda@ves and hypno@cs, and your anxioly@c medica@ons Crea7nine clearance is evaluated best with the cockcroF-gault equa7on Renal func7on needs to be assessed, what the best method? Altera7ons in receptor proper7es may underlie sensi7vity to some drugs such as
- there's a reduc7on in the number of beta-receptors, and there's a reduc7on in the affinity of beta-receptors for beta-receptor blocking agents Drugs with more intense effects are warfarin and cns depressants. Beta- blockers in the elderly are? Reduced thermoregulatory ability, and this increases hypothermia risk
- is taking five or more medica@ons , and more drugs given or taken that are relevant to a pa@ent's chronic condi@on Pims Are those without an evidence-based indica7on, those that have poten7al for adverse effects with other medica7ons the pa7ent may be taking, those that are con7nued beyond therapeu7c benefit, or those given in place of less expensive op7ons. Appropriate pharmacology Op7miza7on of medica7ons in pa7ents with complex and/or mul7ple condi7ons, where medicine usage agrees with best evidence Deprescribing The systema7c process of iden7fying and discon7nuing drugs in instances which exis7ng or poten7al harms outweigh exis7ng or poten7al benefits within the context of an individual pa7ent's care goals, current level of func7oning, life expectancy, value and preferences Risk factors, and polypharmacy Older pa7ents also tend to have mul7ple subspecialist providers and no primary care providers, and this makes them par7cularly vulnerable to polypharmacy
- living in long-term care facility
- have mul7ple medical and cogni7ve issues Healthcare system issues that contribute to polypharmacy
- such as poor record keeping
- not reconciling meds at every visit, and auto refills.
- pa7ents should be asked to bring all medica7ons, including over-the-counter medica7ons, in their original containers to every office visit. Automa7c refills
They may not know to stop the medica7on if the pharmacy is con7nuing to refill them. Overmedica7ng wrong medica7ons and should have stopped Age-dependent changes in body composi7on: is one of the problems with polypharmacy because as we age
- there is a substan7al ---- in body fat, with
- a commensurate ------- in lean body mass,
- plasma volume levels =------ slightly, total body water-----, and this is in part due to ------ in lean body mass, and --------extracellular fluid decreases up to 40%.
- increase
- decrease
- decrease
- decrease
- a decrease Ramifica7ons of polypharmacy
- adverse drug events, an increase in falls, a decrease in the quality of life, an increase in hospitaliza7ons, increase in noncompliance
- increased cost burden, and increased mortality, and ades in the elderly may not be recognized because the signs may mimic disease processes Does polypharmacy cause the disease process? Benefits of deprescribing Number one is decrease in drug costs, and with government financing of medica7ons being on the rise, deprescribing can actually reduce drug costs,
- And are there clinically significant drug-drug interac7ons?
- Are there clinically significant drug-disease or condi7on interac7ons?
- And is there unnecessary duplica7on with other drugs?
- Is the dura7on of therapy acceptable?
- And is this the drug that is the least expensive alterna7ve compared to others of equal u7lity? Is the new medica7on necessary? Will this medica7on benefit the pa7ent? Are there other op7ons, such as nonpharmacologic therapies or preventa7ve measures? What are the goals of therapy? What are the risks of the therapy? Are there drug interac7ons with current medica7ons? If you prescribe this medica7on, do you need to discon7nue another medica7on? +++one of the most important is, can the pa7ent afford the medica7on?+++ Ques7ons to ask about prescribing: Pa7ents are more likely to agree with? Deprescribing if the provider recommends Neurocogni7ve disorders Demen7a and delirium: systems affected can be learning and memory
- have very poor short-term memory but may have excellent long-term memory
- do not recognize family members, also can affect language skills and the ability to speak clearly or appropriately
- have difficulty coping with unexpected events or unplanned things or changes in plans Demen7a
- difficulty handling complex tasks
- difficulty with execu7ve func7oning, which is decision-making and ability to carry out plans
- problems with spa7al ability and orienta7on( get lost in familiar places)
- personality changes disorienta7on What does demen7a look like? S/s Differen7als of demen7a are: Depression, delirium, acute infec7on forgequlness u pneumonia medica7on effects( an7cholinergic medica7ons) Schizophrenia or any other psychiatric Differen7al for demen7a The disease with no survivors...it's chronic, pa7ents can be confused, forgequl, maybe less interac7ve, but they do not have an altered level of consciousness or focal deficits Alzheimer disease is the most common type of demen7a
- there's impaired synthesis of (low levels) acetylcholine and norepinephrine
- deposi7on of amyloid plaques within the cerebral cortex. There are neurofibrillary tangles in the brain and loss of neurons What neurotransmiders are affected in alzheimer's? What would be an early sign of alzheimer's? Pa7ents have difficulty learning and retaining informa7on and complex tasks are very difficult for them to perform Rule out what neurocogni7ve disorder when dx of alzheimers is? Depression B- 12 brain ct
A>d>d>nv>h>av Side effects of cholinesterase inhibitors. Anorexia, diarrhea, dizziness nausea /vomi7ng headache, and rarely these drugs can cause av block in the heart. Pt already at risk for falls??
falls w cholinesterase inhibitors. Pt cachexic? Cholinesterase inhibitors > not ea7ng Cad...bit of cau7on with a beta blocker and prescribing these medica7ons with the risk of further av block. Galantamine or reminyl, exalon?? Nmda receptor blocker, meman7ne, 7trate up to: 10 mg twice daily Namenda is used for moderate to severe symptoms of alzheimer's- or if they're unable to tolerate cholinesterase inhibitors +++do not give if pt has renal impairment+++ Both the aricept and namenda Improve cogni7on and actual func7on, and there are some studies that support dual therapy with? Has been shown to improve overall cogni7on & ssri, such as celexa or lexapro Include exercise, because exercise &vitamin e 1000 interna7onal units daily Vitamin e 1000 interna7onal units daily But watch out w/pts on an7coagulants....>risk of bleeding Vascular demen7a (vad)
A form of demen7a characterized by sporadic, and progressive, loss of intellectual func7oning caused by repeated infarcts, or temporary obstruc7ons of blood vessels, (cerebral vascular disease)which prevent sufficient blood from reaching the brain. (also called mul7-infarct demen7a.) Risk factors for vascular demen7a go along with: Cerebrovascular disease, right, hypertension, hyperlipidemia, cigarede smoking, and diabetes mellitus Ct or an mri of the brain can show the focal infarcts. In addi7on, you want baseline lab studies such as a complete blood count, a metabolic panel, b and folate, rpr, and thyroid studies. Helps to ro other causes of demen7a Decreasing the risk factors to prevent future infarcts in vascular demen7a Controlling their blood pressure, smoking cessa7on, trea7ng dyslipidemia, although studies have shown that sta7ns alone have lidle benefit in vascular demen7a, but s7ll trea7ng the dyslipidemia to prevent further cardiovascular disease, and also control of diabetes mellitus to avoid further vascular problems. ++++no benzos++++++ Lewy body demen7a Lewy bodies are found in parkinson's disease, but then they also can cause lewy body demen7a, a form of demen7a characterized by an increase in lewy body cells in the brain. Symptoms include visual hallucina7ons( lewy bodies are found in the brain cortex mood and memory centers, and they can also be responsible for the
of effort, so they try to do well. Depression, memory will improve with cues, whereas in demen7a giving the pa7ent cues does not help improve their memory Dx of demen7a or depression Pa7ents with depression usually give you a very detailed history, whereas demen7a pa7ents will give you a vague history with few details Differen7al of pseudodemen7a Underlying infec7ons such as a urinary tract infec7on or pneumonia can cause symptoms similar to pseudodemen7a or depression dehydra7on malnutri7on Malnutri7on is a bmi less than 22 kilograms per meter squared can cause for any over-the-counter and herbal medica7ons as contribu7ng to the symptoms. Can look like demen7a How do we treat pseudodemen7a? An7depressants most oFen the ssris, such as celexa, lexapro, prozac cogni7ve behavioral therapy is helpful and social ac7vi7es social ac7vi7es or day programs are good for this popula7on formal exercise, which we talked about, can improve cogni7on but it can also improve the release of serotonin which helps in depression
