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Goals and Objectives - Geriatrics
From the lecture:
# of 65+ millions by state: 1. CA, 2. FL, 3. NY, 4. PA
% of 65+ millions by state: 1. FL, 2. WV, 3. PA
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Elderly are 13% of the population
36% of hospital stays
49% of all days of hospital care
50% of all physician hours
Average 75 year old
Has at least 3 chronic conditions
Uses 4.5% of all prescription drugs
1 in 4 has at least one disabling condition
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Chronic disease results in 70% of all hospital stays and 60% of all Medicare costs
17% of all hospital admissions are caused by inappropriate drug prescribing
1 out of 5 elderly receive inappropriate prescriptions (in notes under slide)
by age 80 3 of 4 elderly have at least 1 disability (in notes under slide)
Ger 2: Nutrition
1. Understand physiologic and biologic changes in the digestive system
● Neurodegeneration of enteric nervous system → dysphagia, GI reflux and
constipation
● Gastric motility is impaired (small intestine unaffected)
● Reduced gastric acid secretions: due to chronic gastritis, proton pump inhibitors,
vagotomy and gastric resections
○ Reduction of gastric acid predisposes to bacterial overgrowth (71% of pt),
which is linked to reduced body weight and reduced intake of micronutrients
● Structural changes of pancreas: secretagogue-stimulated lipase, chymotrypsin and
bicarbonate concentration decline
● Liver declines in size
● BMI and body weight increase until 50-60 then declines
● Cachexia is involuntary loss of fat free mass (muscles, tissue, organ, skin, and bone);
wasting is involuntary loss of weight
● Sarcopenia is the major age related physiological change (loss of skeletal muscle
mass) - decreased exercise level, increased cytokines, and neuron loss in the spinal
cord
● aging is associated with a impairment of receptive relaxation of the gastric fundus→
rapid antral filling → early satiety (related to increased levels of PPY and CCK)
● higher levels of leptin are found in older people (singal for adequate body fat). Reduced
glucose tolerance can exacerbate this
● Small intestine: decline in number of villi and crypts, loss of villi and enterocyte height
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○ no clear association w/ intestine morphology and nutrient uptake w/ aging
unintentional weight loss is one of the best predictors of worse clinical outcome,
significant morbidity and mortality assoc..
2.
Understand specific signs and symptoms of nutrient deficiencies
“a wasted, thin individual w/ dry scaly skin and poor wound healing”
● Hair is thin (def protein and zinc)
● Nails are spooned (def iron) and depigmented (def albumin)
● Complaints of bone and joint pain (def Vit D, C), muscle tenderness (def thiamine)
and wasting (def protein, selenium, Vit D)
● Edema (def protein)
3.
Understand causes of weight loss
● Mechanism: cause
● Wasting: “involuntary loss of weight”, commonly due to poor dietary food intake
● Cachexia: “involuntary loss of fat-free mass (muscle, organ, tissue, skin, bone) or body
cell mass”, Cytokines (IL-1,-6, TNFa) cause increased resting energy expenditure,
increased gluconeogenesis, shift of albumin production to acute phase proteins
causing a negative nitrogen balance
● Sarcopenia: “decline in muscle mass”, reduced physical activity, hormonal (sex
horm), glucocorticoids, and catecholamines → increase pro-inflammatory
cytokines), neural (neuron loss → m atrophy), cytokines (increase acute phase
reactants which break down muscle)
● Other causes (pathological and non-pathological) causes of wt loss mentioned in
article
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Medical: CHF, COPD, malabsorption syndrome, H. pylori infection, endocrine
diabetes, stroke, Parkinson’s, pneumonia, UTIs, malignancy, rheumatoid arthritis,
alcoholism, poor dentition, drugs
Psychological: dementia/Alzheimer’s disease, depression, anxiety, alcoholism,
bereavement
Social: poverty, isolation, inability to shop, prepare, or cook meals
Ger 3: Alzheimer's disease
1.
Understand the risk factors and prognosis for Alzheimer's disease
● Risk factors: age,
● Death w/in 3-9yrs after dx
2.
Understand the pathology of AD
“accumulation of misfolded proteins in the brain results in oxidative and inflammatory
damage, which in turn leads to energy failure and synaptic dysfunction”
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B-amyloid peptide:
○ amyloidgenic mechanism initiated by beta-site amyloid precursor proteincleaving enzyme (BACB-1) a B-secretase
○ severity of AD correlates to levels of oligomers in brain (soluble oligomers and
intermediate amyloids are the most neurotoxic), not total B-amyloid
○ Neprilysin- protease, degrades B-amyloid mono/oligomers
○ Insulin-degrading enzyme: a thiol metalloendopeptidase, degrades B-amyloid
and other small peptides
○ THEREFORE, decreased neprilysin or insulin-degrading enzyme → B-amyloid
accumulation
■ INCREASED amounts of neprilysin or insulin-degrading enzyme →
prevents plaque formation
Dystrophic neurites:
Neurofibrillary tangles in medial temporal-lobe structures: filamentous inclusions in
pyramidal neurons. The number of tangles is a marker of severity of AD. The major
component of the tangles is an abnormally hyperphosphorylated (insoluble) and
aggregated form of tau. Elevated amino acids T181, T231 and tau in the CSF predict
incipient AD in patients with MCI.
○ tau mutations do not occur in AD
○ oxidative stress, impaired protein folding by the ER and deficient
proteasome/autophagic mediated clearance are assoc. with aging and drive
amyloid accumulation.
Loss of neurons and white matter: observed in patients at all stages
Congophilic (amyloid) angiopathy:
Inflammation:
Oxidative damage: B-amyloid is a potent mitochondrial poison, especially affecting
synaptic pool
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B-amyloid inhibits key enzymes in brain and mitochondria, specifically
cytochrome C oxidase → electron transport, ATP-production, oxygen
consumption and mitochondrial mem potential all become impaired
Increased mitochondrial superoxide radical formation and conversion into
hydrogen peroxide cause oxidative stress, release of cytochrome c and
apoptosis
Alcohol dehydrogenase is targeted by B-amyloid
The antihistamine dimebolin hydrochloride is a putative mitochondrial
stimulant, reported to improve cognition and behavior in pts with AD
Dysfunctional mitochondria release oxidizing free radicals
Markers of oxidative damage precede pathological changes
B-amyloid is a potent generator of reactive oxygen species and reactive nitrogen
species
Stimulated microglia are a major source of highly diffusible NO radical
Peroxidation of membrane lipids yields toxic aldehydes
Increased permeability of Ca impaired glucose transport and aggravate energy
imbalance
Zinc, typically thought to be toxin in AD, might at lower concentrations protect
cells by blocking B-amyloid channels or compete with copper for Bamyloid binding.
3.
Understand the mechanisms of synaptic failure in AD
● AD may be a primarily a disorder of synaptic failure
● In mild AD, there is about a 25% reduction of presynaptic vesicle protein
synaptophysin and with advancing disease there’s a disproportionately large loss of
synapses compared to neurons **and this loss best correlates w/ dementia
● synaptic loss particularly affects the dentate region of the hippocampus
● “long-term potentiation”, an experimental indicator of memory formation at synapses are
impaired in mice with plaque-bearing disease after B-amyloid was applied to brain
● Disruptions of the release of presynaptic neurotransmitters and postsynaptic
glutamate-receptor ion currents occur partially as a result of endocytosis of Nmethyl-D-aspartate (NMDA) surface receptors and endocytosis of a-amino-3hydroxy-5-methyl-4-isoxazole (the ladder further weakens currents synaptic currents
after a high-frequency stimulus train) **intraneuronal B-amyloid triggers these synaptic
deficits even earlier
○ Endocytosis of receptors → disrupts Presyn release of NTs and postsyn GLU
receptor ion currents
● Depletion of neurotrophin and neurotransmitters
○ Neurotrophin- promote proliferation, differentiation and survival of neurons
and glia, mediate learning, memory and behavior. Normally high levels in
receptors in cholinergic neurons and are reduced in late-stages of AD
○ Deficiency of cholinergic projections in AD is linked to buildup of B-amyloid
and tau
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Presynaptic a-7 nicotinic acetylcholine receptors are essential for cognitive
processing. Levels are initially elevated in AD, then decrease. B-amyloid
binds to a-7 receptor, impairing the release of acetylcholine and maintenance of
“long-term potentiation”
■ Activation of nicotinic acetylcholine receptors or M1 receptors limits
tau phosphorylation
○ Muscarinic receptors are also reduced in AD: normally activate protein kinase
C, favoring amyloid to be processed into a non-amyloid molecule
Summary: B-amyloid triggers endocytosis of crucial surface receptors and impairs the
release of AcH resulting in synaptic failure. The reduction of synaptophysin best
correlates with dementia.
4.
Understand risk factors for progression to AD
● Age: incidence of dx doubles every 5 yrs after 65yo, exceeding ⅓ of people over 85
● Strokes and white matter lesions contribute greatly to cognitive decline
● APOE genetic risk (APOE4 specifically exponentially increases the risk).
○ major determinant of late-onset AD.
○ apolipoprotein J is a newly discovered that deposits AB
● Sortillin-related receptor being reduced
● General anesthesia
Ger 4: Mild Cognitive Impairment
1.
2.
Contrast the clinical features between mild cognitive impairment and dementia
Contrast the clinical features between MCI and normal aging
Mild Cognitive
Impairment
(amnesic)
Normal Aging
Dementia
Signs/Symptoms
more prominent
forgetfulness – forget
important
information or
appointments and
conversations
Misplacing
objects or
difficulty recalling
words
Cognitive deficits
affect daily
functioning = loss of
independence in
community
Tests To Run
Short Test of Mental
Status and Montreal
Cognitive Assessment
3.
Functional Activities
Questionnaire
According to the reading, identify treatments that have potential benefit
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4.
Cognitive rehabilitation programs
○ Using mnemonics, association strategies and computer assisted
training programs has shown some improvement
Since a risk factor for progressing to dementia include cardiovascular risk
factors, brisk walking of 150 min per week showed that the exercise
group had better cognitive function than the group that did not exercise
high dose vitamin E or donepezil (reduced progression in up to 24
months, at 36 no significant effect; vitamin E did not significantly reduce
the risk of progression)
Understand the types of MCI
o 2 Subtypes of MCI:
● Amnestic (memory impairment)
○ Clinically significant memory impairment that does not meet criteria for
dementia
○ Pt. is aware of increasing forgetfulness
○ Other cognitive capacities are preserved with only mild inefficiencies
● Non-Amnestic (no memory impairment)
○ Subtle decline in functions not related to memory, or affecting attention,
language or visual-spatial function
○ Less common
○ May be forerunner for dementias other than Alzheimer’s
Ger 5: Depression
1.
Understand diagnostic criteria for depression
● major depression can be made if a patient has five or more of the following symptoms during
the same 2-week interval with at least one of the symptoms being either depressed mood or
loss of interest or pleasure in activities that were previously pleasurable:
○ 1 sx must be depressed mood and loss of interest or pleasure in previously pleasurable
activities
○ 2nd sx can be: Significant weight gain or loss, in/hypersomnia, psychomotor agitation or
retardation, fatigue, feelings of worthlessness or inappropriate guilt, impaired
concentration, recurrent thoughts of death.
● dysthymia - less severe but longer lasting than depression (chronic low mood)
○ dx requires 2 (or more) of the following: poor appetite/overeating, in/hypersomnia,
fatigue, low self esteem, impaired concentration, hopelessness
○ chronicity is an essential element; specifically,for the majority of the time they must
exhibit the above sxs over 2 years and not be asx for more than 2 mos. (during those 2
years)
2.
Understand risk factors for depression
a. Increased chronic conditions = increased depression (both can affect each other)
b. Living environment, nursing homes have higher depression rates
c. Inability to perform ADLs
3.
1.
Understand how depression affects comorbidities
a. depression is not the most prevalent in the elderly but has the highest impact on
their health when it is present. So, an elderly person is more likely to commit
suicide when depressed.
b. depression is an independent risk factor for ACS (SSRIs have been shown to be
beneficial for both depression and ACS)
c. depression is an independent risk factor for mortality
Ger 6: Delirium
Identify risk factors for delirium
Predisposing Factors (chronic):
Precipitating Factors (acute that initiate)
• Advanced age
• Preexisting dementia
• History of stroke
• Parkinson disease
• Multiple comorbid conditions
• Impaired vision
• Impaired hearing
• Functional impairment
• Male sex
• History of alcohol abuse
• New acute medical problem
• Exacerbation of chronic medical
problem
• Surgery/anesthesia
• New psychoactive medication
• Acute stroke
• Pain
• Environmental change
• Urine retention/fecal impaction
• Electrolyte disturbances
• Dehydration
• Sepsis
An Old Alcoholic Male with parkinson,
strokes, and dementia who can’t see, hear or
be functional.
2.
CBC
Chem-7
BUN/Cr
UA
CXR
ECG
Understand use of lab work, imaging and other studies in evaluation of delirium
a. the Dx is based entirely on the H&P: evaluation confirms and identifies causes
i.
Key aspects of hx: acute onset more common with delirium as well as
fluctuations in mental status
ii.
Key aspects of PE: evaluation of mental status, most importantly,
inattention and abnormal level of consciousness
b. labs and imaging are for etiology and correctable factors
infection/severe anemia
hyper/hyponatremia
dehydration
UTI is common in frail elders
Pneumonia/CHF
MI/Arrhythmia
ABG
Drugs
Tox Screen
CT/MRI
Lumbar Puncture
EEG
Glucose
LFT/INR*
COPD (hypercarbia)
even with normal levels of some drugs (Meperidine has a high risk factor for delerium)
for younger pts usually
younger pts
younger pts
diffuse slow wave activity
hypo/hyper and hyperosmolar state (Type II DM)
rare
3.
Understand use of medication for agitated delirium
● non-pharm is the cornerstone of tx
● All drug tx is off label. Must be used cautiously and having someone to console the pt
may be preferable.
● high-potency antipsychotics (haloperidol is best in young AIDS pts) are considered
the treatment of choice for agitation in delirium because of their low anticholinergic
potency and minimal risks for hypotension or respiratory depression
● Table 3 summary:
○ Haloperidol is typical but CI in parkinson/Lewy body disease bc of Sx (EPS).
ALso has QT prolongation.
○ Lorazepam is second line (also used in alcohol withdrawal/neuroleptic malignant
sx)
○ Olanzapine/Quetiapine can be substituted in pts with parkinson/lewy body
disease as they have less EPS.
○ If sedation is an issue with other txs use Risperidone.
● Meperidine - high risk for delirium
● Benzos - high risk for delirium
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Ger 7: AGS Beers Criteria
1. Understand the intent of Beers Criteria
● Intended for use in all ambulatory and institutional settings for patients 65 years and
older in U.S.
● Primary target audience is the practicing physician
○ also used by researchers, pharmacy benefit managers, regulators, and policy
makers
● INTENT:
○ Improving the selection of prescription drugs
○ Evaluating patterns of drug use w/in populations
○ Educating clinicians and patients on proper drug usage
○ Evaluating health-outcome, quality of care, cost and utilization data
● The goal is to improve care of older adults by reducing their exposure of PIMs
(potentially inappropriate medications)
● Accomplished by the use of both educational tools and quality measures
● Some individuals are exempt, when benefits > potential harm
2. Understand clinical application of the criteria
● PIMs are placed into three groups: 1) Drugs to avoid in elderly (ex, megestrol,
glyburide, sliding-scale insulin), 2) Drugs to avoid in elderly w/ certain diseases or
syndromes (ex. thiazolidinediones or glitazones with heart failure, acetylcholinesterase
inhibitors with history of syncope, and selective serotonin reuptake inhibitors with falls)
and 3) Drugs to be used with caution in elderly
● not meant to supersede clinical judgment or a patient’s values and needs.
● the list can be used for prescribing medications and monitoring drug effects in older
adults.
Geri 7a: Prescribing in elderly people 2: The challenge of managing drug interactions in
elderly people
1. Describe categories of
drug interactions that
may occur in elderly
patients
● Drug-Drug
Pharmacokinetic (what
the body does to the
drug) involves what a
drug does to absorption,
distribution, metabolism
or excretion of another
drug. Results: changes in
serum drug
concentrations and might
change clinical response
● Drug-Drug
Pharmacodynamic (what
the drug does to the
body) related to the
pharmacologic activity of
interacting drugs. Results: amplification or decrease in the therapeutic effects of a
specific drug
● Drug-food
● Drug-EtOH
● Drug-herbal product
● Drug-nutritional status
● Drug-disease - take place when a drug has a potential to exacerbate an underlying
disease or medical disorder
○ most common is CCB + HF, Beta-blockers + diabetes and aspirin + PUD
○ more frequent than drug-drug interactions according to australian researchers
2.
Identify considerations for prescribing medications for elderly patients
● Drug-drug interactions are frequent when drugs with a narrow therapeutic index are
used such as digoxin, phenytoin or warfarin.
○ drugs that affect CYP450 are also common causes of drug-drug interactions
○ diseases and disorders, such as constipation, dementia, and postural
hypotension are also frequently involved in drug-disease interactions
● Complex interactions - nine or more drugs and five or more comorbidities are frequently
have issues (must consider total combination of drugs and their potential interactions)
● Cascade interactions- misinterpretation of ADV drug rxn as a new medical disorder
results in prescribing of an new drug that may bring even more ADV rxns
○ ex. Dx is dementia → cholinesterase inhibitor is prescribed→ urinary
incontinence develops as ADVR → anticholinergic drug is prescribed
● Use Lexi-Comp !
● Be involved in an multidisciplinary team (geriatrician, physician, nurse)
3.
Describe elderly patients that may be at a higher risk of drug interactions
● increased risk due to pt. factors, prescriber factors or difficulties in the healthcare system
such as bad communication
● Higher risk with more drugs prescribed
● Atypical presentations of diseases
● An elderly person who has several
physician and multiple pharmacies
They reported that 15–40% of patients had a
potential drug–disease interaction, the most
common being calcium-channel blockers in
patients with heart failure, beta blocker in
diabetes, and aspirin in peptic ulcer disease
Ger 8: Falls
1. Identify causes and risk factors for falls
● Weakness, unsteady gait, confusion and
certain medications
● Increased age (>75) have a greater risk of falling and their associated symptoms
● Persons living in a long term care institution have a much higher rate of falling as well as
more serious complications
● Wrist fractures are due to FOOSH (backwards or forwards) while hip fractures are due to
falls to the side
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Epidemiology trends: 65-75 wrist fractures are more common and over 75 hip
fractures are more common due to reflex slowing also overcautious fear of falling
Slow recovery from falls (as seen in the elderly) increase risk of subsequent falls through
deconditioning
Post-fall anxiety syndrome - down regulate activity, being over cautious of falling →
can lead to deconditioning, weakness, and abnormal gait which increase risk of falling
Accidental/environmental related falls #1 cause
Steppage height, muscle tone and strength, posture control, and body orienting reflexes
all decline as we age; age-associated memory, vision, and hearing impairments
Maintaining balance strategy changes from using the hips to using the step strategy
seen in elders. Eventually there is total loss of ability to prevent a fall.
Dizziness is most non-specific cause of falls
Drop attack : sudden falls without loss of
consciousness or dizziness.. IN true reality
these are not common.
Most important risk factors are muscle
weakness and problems with gait and
balance.
2. Understand evaluation of a fall patient
● When assessing a patient who has fallen, obtaining a full report (may be from witness) of
the circumstances and symptoms surrounding the fall is crucial
● on the post fall exam note direct contributors to the fall, risk factors, orthostatic
changes, arrhythmias etc.
○ considering reproducing the possible cause (e.g.positional changes)
○ gait and stability exam (Tinetti balance and gait instrument is useful)
3. Understand recommendations for fall prevention
● Fall risk assessments tied to interventions, exercise, environmental inspection and
modification, and combined interventions.
● Detect and ameliorate risk factors and causes.
○ ex. for orthostatic causes advise using more pillows at night and getting up
slower in the mornings.
Ger 8: Frailty Syndrome
1. Discuss the pathophysiology of frailty
● Age-related changes to multiple physiological systems are fundamental to the
development of frailty, particularly the neuromuscular, neuroendocrine and
immunological systems.
● A loss of homeostatic reserve; functionally independent but close to a threshold that
once surpassed by even a minor nudge could result in a severe health change.
● Phenotype includes: sarcopenia, anorexia, osteoporosis, fatigue, risk of falls , poor
physical health.
● Treatment effectiveness : Physical Activity > Nutrition > Pharmacologic
2. Understand the frailty
cycle
● Increased frailty gives
rise to increased risk of
further decline towards
disability and greater
frailty.
● Sarcopenia is a key
component of frailty,
characterised by a
progressive loss of
skeletal muscle mass
and strength.
● another major target for
tx is chronic
undernutrition
3. Understand indicators and
measures of frailty
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The five Fried Model
Indicators:
○ 0 out of 5 = robust
older person
○ 1-2 out of 5 = prefrail
○ 3+ out of 5 = frail
○ Mnemonic: a
Weak SLEW?
Edmonton frail scale: Id
frailty in clinical settings
and acute hospital
inpatient setting.
Ger 9: Osteoporosis
1. Understand indications
for measuring bone
mineral density
● women and men over 50
and those over 50 who
have experienced a fragility
fracture.
● history of falls in the past
year
● presence of vertebral
fractures
● DEXA > 2.5 SD below the
peak bone mass for young
adults = Osteoporosis
● prior fragility fracture after
40
● GCs at least 3 mos in
preceding year @ >7.5mg
daily
2. Understand pharmacologic options for treatment of osteoporosis
● Calcitonin and teriparatide may decrease the pain associated with vertebral fractures
● 1st line for hip, nonvertebral and vertebral in menopausal women: Alendronate,
Risedronate, Zoledronic acid and denosumab (grade A)
● 1st line for menopausal women req. tx of osteoporosis : Raloxifine for prevention of
vertebral fractures (grade A)
● Menopausal women + osteoporosis + vasomotor symptoms : Hormone therapy for
prevention of hip nonvertebral and vertebral (grade A)
● Menopausal women intolerant of first line therapies : calcitonin or etidronate for vertebral
(grade B0
● Men req. tx for osteo : alendronate, risedronate zoledronic acid (grade D)
● Testosterone is NOT recommended for osteoporosis tx in men.
● Overall benefits far outweigh the risk
3. Understand adverse effects of pharmacologic treatments
● High dose Ca → renal calculi CV events.
● Bisphosphonates → self limited flu like sx, esp after 1st dose and atypical femur
fractures; atypical femur fractures; esophageal cancers
● Denosumab → cellulitis
● Raloxifene → thromboembolic events, including PE
● Teriparatide → hypercalciuria/emia (usually resolves spontaneously)
● Glucocorticoids → bone loss develops quickly (within 3 to 6 months)
4. Understand risk stratification for falls (should this say fracture ? )
● HIgh absolute risk for fracture :
○ >20% probability for a major osteoporotic fracture over 10 years
○ over 50 with fragility fractures ( 1 or more) of hip/vertebra
○ pharmacologic tx recommended
● Moderate Risk (10-20%)
○ MORE osteoporotic fractures occur in this group than high risk solely because
there are more individuals in this group.
○ pharmacologic tx should be considered in many of these patients
● Low Risk (< 10%)
○ pharmacologic tx is not usually required
○ address lifestyle issues (exercise, falls, calcium/vit D and smoking cessation)
Ger 12: Deficits in Communication and Information Transfer
if there is one article you need/want to skip make it this one….
1. Identify ways to improve communication between hospital and outpatient setting
● most common intervention was a comparison of PC generated and manually created
discharge summaries.
○ PCPs preferred the computer generated summaries
● changing mode of delivery (hand delivery is best)
● changing format of the document (discharge summary from a hospital database is best)
○ however, dictated summaries were more likely to include Social Hx and info
about consultations.
● enhanced discharge planning
○ included a telephone call to the PCP, follow-up appointment scheduled for
patient, and educational booklets for pt and PCP
● standardized template
● use health information technology
● give a copy of the most pertinent data to a newly discharged pt.
2. Identify adverse events that may occur due to poor communication
● lower quality of care and adverse clinical outcomes...do we need research to state the
obvious
● greater risk of readmission
● physicians are unaware of test results patients had when hospitalized, even though
these sometimes require action
● erroneous information sometimes enters into discharge communications and it is rarely
questioned → leads to faulty medical decision making or failure to adequately monitor a
patient’s condition during follow-up
3. Understand benefit of efficient communication between providers
● reductions of information deficits
● higher quality care with regards to timeliness and quality of discharge
Ger 12: Elder Maltreatment
Definition: an act or omission that results in harm or threatened
harm to the health or welfare of an elderly
person.
1. Identify physical findings abuse -->
2. Understand mimickers of abuse (BFT =
blunt force trauma in table)
● Skin and soft tissue
○ Senile Purpura - seen on the flexor
surfaces (minor pressure increase)
■ can be due to chronic steroid
use and Cushing Disease
○ Ulcers are usually found on sacral and
lumbar region
● Bleeding
○ Many forms of acquired bleeding
tendencies that have non-abuse
etiologies.
○ Examples
■ spontaneous antibodies to
factor V or VIII can result in
soft tissue hemangiomas
■ platelet disorders cause
mucous membrane bleeding
and cutaneous bruising
■ drugs can often times cause
thrombocytopenia
○ keep in mind some areas are more prone to bleeding by nature (nose)
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intracerebral hemorrhages are more commonly due to elder disease/disorders
(where intracranial hemorrhages are more indicative of abuse)
○ Cerebral atrophy → predispose to subdural hemorrhage of the bridging veins
Fractures
○ decreased bone mass and impaired proprioception predispose
○ common sites of accidental fracture → femoral neck, proximal humerus,
vertebrae. Rib fractures secondary to CPR.
Malnutrition and Dehydration
○ normal decreased in basal metabolic rate and adipose tissue, and muscular
atrophy, elders can appear malnourished
○ dehydration can be a result of: decreased thirst sensation, renal disease,
diabetes, diuretic use, etc
Anogenital
○ Lichen sclerosis (friable easy to bleed), excoriations from incontinence,
tetracycline (penis), IBD (anal fissures) can all mimic abuse
3. Understand types of abuse
● physical abuse: Physical abuse is an act carried out with the intention of causing
physical pain or injury physical abuse is generally considered the most extreme form of
elder maltreatment.
○ Subdural hemorrhage is a common cause of death due to elder abuse
○ chemical restraint is most often seen with haloperidol
● sexual abuse: Sexual abuse, or molestation, consists of contact with the genitalia, anus,
breast, or mouth.
○ most underreported
○ a significant amount of trauma can also be seen in the nongenital areas (bite
marks, blunt force trauma, hard and soft palate trauma, injuries secondary to
restraints and signs of asphyxia
● neglect: failure of the caregiver to proide basic care to a paitent and to provide
goods and services necessary to prevent physical harm or emotional discomfort
○ most common form
○ active = intentional and passive = unintentional
○ decubitus ulcers
■ common finding in cases of elder neglect
■ can be the source of fatal sepsis
○ psychological abuse financial/material exploitation violation of rights are other
types of abuse.
○ medical neglect - when the caretaker does not seek medical tx for the elder,
undermedicaiton, etc
4. Identify those at risk of being abused
● Inherent factors in the elder that appear to put him or her at risk include cognitive
impairment, dementia, physical impairment, functional debility, incontinence, provocative
actions of the elder, guilt, fear of nursing home placement, and a fear of retaliation.
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Elders with a family who has a history of abuse, caretakers with substance abuse and
mental illnesses or excessive dependence on the elder are more likely to maltreatment
the elder
Ger 13: Pressure Ulcers
1. Understand Braden Scale
● Braden scale is the most commonly used tool for predicting pressure ulcer risk
○ assess sensory perception, moisture, activity, mobility, nutrition, and
friction/shear (http://www.bradenscale.com/images/bradenscale.pdf)
● Intrinsic risk factors - limited mobility, poor nutrition, comorbidities, aging skin; Extrinsic
risk factors - pressure from hard surface, friction from pts inability to move well in bed,
shear from invol muscle movements, moisture
2. Understand etiology of pressure ulcers
● caused by unrelieved pressure, applied with great force over a short pd (or with less
force over a longer pd)
● the pressure disrupts blood supply to the capillary network, impeding the blood flow and
depriving tissues of oxygen and nutrients
● the external pressure must be greater than arterial capillary pressure to lead to inflow
impairment and resultant local ischemia and tissue damage
● most common sites for pressure ulcers are the sacrum, heels, ischial tuberosities,
greater trochanters, and lateral malleoli.
3. Understand ulcer staging system
● the stage of an ulcer cannot be determined until enough slough or eschar is removed to
expose the base of the wound
4. Understand pressure ulcer management
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basic components: reduce or relieve pressure on the skin, debride necrotic tissue,
cleanse the
wound, manage
bacterial load
and colonization,
and select a
wound dressing
wounds should
be cleansed
initially and with
each dressing
change - use of
normal saline is
preferred
dressing that
maintain a moist
wound
environment
facilitate healing
urinary catheters or rectal tubes may be needed to prevent bacterial infection from feces
or urine
trial of topical antibiotics (ex: silver sulfadiazine cream aka Silvadene) should be used for
up to 2 wks for clean ulcers that are not healing properly
systemic antibiotics are NOT recommended unless there is evidence of advancing
cellulitis, osteomyelitis, or bacteremia
Ger 14: Palliative Care
1. Understand the role of palliative care
● Aims to relieve suffering and improve the quality of life for pts with advanced illnesses
and their families through specific knowledge and skill, including:
○ communication with pts and family members
○ management of pain and other symptoms such as psychosocial, spiritual, and
bereavement support
○ coordination or an array of medical and social services
● palliative care should be offered simultaneously with all other medical treatment
2. Understand approaches to common symptoms of terminally ill
● Relief of suffering begins with routine and standardized symptom assessment
● Improved treatment of symptoms has been associated with the enhancement of patient
and family satisfaction, functional status, quality of life, and other clinical outcomes
Symptom
Assessment
Treatment
Anorexia and
cachexia
Is a disease process causing the
symptom, or is it
secondary to other symptoms (e.g.,
nausea and
constipation) that can be treated? Is the
patient
troubled by the symptom?
Consider megestrol acetate or
dexamethasone
Anxiety
Does the patient exhibit restlessness,
agitation,
insomnia, hyperventilation, tachycardia,
or
excessive worry?
Recommend supportive
counseling and consider
prescribing benzodiazepines
(in the elderly, avoid
benzodiazepines with long halflives).
Constipation
Is the patient taking opioids? Does the
patient have
a fecal impaction?
Prescribe a stool softener
(ineffective alone) plus escalating
doses of a stimulant; if escalation
of the dose is ineffectual, agents
from other classes (e.g., osmotic
laxatives and enemas) should be
added.
Depression
How does the patient respond to the
question “Are
you depressed?” Does the patient
express or exhibit
any of the following feelings:
helplessness,
hopelessness, anhedonia, loss of selfesteem,
worthlessness, persistent dysphoria, and
suicidal
ideation? (Somatic symptoms are not
reliable indicators
of depression in this population.)
Recommend supportive
psychotherapy, cognitive
approaches, behavioral
techniques, pharmacologic
therapies, or a combination
of these interventions; prescribe
psychostimulants for rapid
treatment of symptoms (within
days) or selective serotonin
reuptake inhibitors, which may
require three to four weeks to take
effect; tricyclic antidepressants
are relatively contraindicated
because of their side effects.
Delirium
Was the onset of confusion acute? Is the
patient disoriented
or experiencing changes in the level of
consciousness or minute-to-minute
Identify underlying causes and
manage symptoms; recommend
behavioral therapies, including
avoidance of excess stimulation,
fluctuations?
Is the condition reversible?
frequent reorientation, and
reassurance; ensure presence of
family caregivers; prescribe
haloperidol, risperidone, or
olanzapine. (Chlorpromazine can
be used for agitated or terminal
delirium,
but benzodiazepines have been
found to exacerbate delirium
and should be avoided.)
Dyspnea
Does the symptom have reversible
causes?
- Prescribe oxygen to treat
hypoxia-induced dyspnea or to
provide symptomatic relief, when
hypoxia is absent, through
stimulation of the V2 branch of the
trigeminal nerve.
- Opioids relieve breathlessness
without measurable reductions in
respiratory rate or oxygen
saturation; effective doses are
often lower than those used to
treat pain.
- Consider anxiolytics (e.g., lowdose benzodiazepines) and use
reassurance, relaxation,
distraction, and massage therapy
Nausea
Which mechanism is causing the
symptom (e.g., stimulation of the
chemoreceptor trigger zone,
gastric stimulation, delayed gastric
emptying or “squashed stomach”
syndrome, bowel obstruction,
intracranial processes, or vestibular
vertigo)?
Prescribe an agent directed at the
underlying cause. Multiple agents
directed at various receptors or
mechanisms may be required.
Pain
How severe is the symptom (as assessed - Prescribe medications to be
with the use of validated instruments)?
administered on a standing or
regular basis; as-needed or
rescue doses should be available
for breakthrough
pain or pain not controlled by the
standing regimen;
start a regimen to prevent
constipation for all patients
receiving opioids.
- For mild pain: use
acetaminophen or a nonsteroidal
antiinflammatory agent (consider
opioids in older adults). For
moderate pain:
titrate short-acting opioids. For
severe pain: rapidly titrate
shortacting opioids until pain is
relieved or intolerable side effects
develop; start long-acting opioids
(e.g., sustained-release morphine
or oxycodone and transdermal
fentanyl) once pain is well
controlled; use methadone only if
experienced in its use.
- Rescue doses: prescribe
immediate-release opioids
consisting of 10% of the 24-hour
total opioid dose to be given every
hour (orally) or every 30 minutes
(parenterally) as needed.
Concomitant analgesics (e.g.,
corticosteroids, anticonvulsants,
tricyclic antidepressants,
and bisphosphonates) should be
used when applicable
3. Understand coordination of care in each stage of serious chronic illnesses
Early Stage
Goals of care-Discuss diagnosis, prognosis,
likely course of the illness,
and disease-modifying therapies;
talk about patient-centered
goals, hopes, and
expectations for medical
treatments.
Programmatic support- Advise patient to sign up for
visiting nurse and home
care services and case management
services
(if available).
Financial planning- Advise patient to seek help in
planning for financial, longterm
care, and insurance
needs and to begin transfer
of assets if patient is considering
a future Medicaid
application; refer patient to
a lawyer who is experienced
in health issues.
Family support- Inform patient and family
about support groups; ask
about practical support
needs (e.g., transportation,
prescription-drug coverage,
respite care, and personal
care); listen to concerns.
Middle Stage
Goals of care- Review patient’s understanding of
prognosis; review efficacy and
benefit-to-burden ratio for diseasemodifying treatments; reassess
goals of care and expectations;
prepare patient and
patient’s family for a shift in
goals; encourage paying attention
to important tasks, relationships,
and financial affairs.
Programmatic support- Advise patient to sign up for visiting
nurse and home care services;
consider palliative care program
in hospital or at home, hospice,
subacute rehabilitation, case management
services, and
PACE.
Financial planning- Advise patient to reassess adequacy
of planning for financial, medical,
home care, prescription,
long-term care, and family-support
needs; consider hospice referral
and Medicaid eligibility.
Family support- Encourage support or counseling for
family caregivers; ensure that
caregivers have information
about practical resources, stress,
depression, and adequacy of
medical care; identify respite and
practical support resources; recommend
help from family and
friends; raise the possibility of
hospice and discuss its benefits;
listen to concerns.
Late Stage
Goals of care- Assess patient’s understanding of diagnosis,
disease course, and prognosis;
review appropriateness of diseasemodifying treatments; review
goals of care and recommend appropriate
shifts; help patient explicitly
plan for a peaceful death; encourage
completion of important tasks and
increased attention to relationships
and financial affairs.
Programmatic support- Advise patient to sign up for a palliative
care program in hospital or at home,
case-management services, hospice,
or PACE; consider nursing home
placement with hospice or palliative
care if patient’s home caregivers are
overwhelmed.
Financial support- Advise patient to review all financial resources
and needs; inform patient
and family about financial options
for personal and long-term care (e.g.,
hospice and Medicaid) if resources
are inadequate to meet needs; explicitly
recommend hospice and review
its advantages; consider Medicaid
eligibility.
Family support- Encourage out-of-town family to visit;
refer caregivers to disease-specific
support groups or counseling; inquire
routinely about health, wellbeing,
and practical needs of caregivers;
offer resources for respite
care; after death, send bereavement
card and call after one to two weeks;
screen for complicated bereavement;
maintain occasional contact after
patient’s death; listen to concerns
1. Understand the elegance of the following Haiku.
Geriatrics
Thin, dry and scaly
More Christmas cookies for me
Old age, not hungry