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Geriatrics

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Title: Geriatrics


1
Geriatrics
Geriatrics
2
Demography Key Indicators
  • Population
  • Baby boomers (1946-64) will dramatically change
    the aging demographics
  • In 2000, 35 million persons 65 lived in the US.
    By 2030, this will double to 70 million
  • The 85 age group is growing faster than any
    other age group
  • Women make up 58 of those 65, but 70 of those
    85
  • In 1998, 41 of older women lived alone, compared
    to 17 of older men

3
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4
Life Expectancy
5
US Census Data and Projections
6
Key Indicators of Well-Being
  • Economics
  • Older persons living in poverty declined from 35
    in 1959 to 11 in 1998
  • In 1998, Social Security provided gt80 of income
    for older Americans with the lowest levels of
    income. For those in the highest income
    category, SS accounted for 20 of income
  • Households headed by older black persons had
    median net worth of 13K in 1999, compared with
    181K headed by older white persons

7
Percent Distribution by Income 2000
8
Key Indicators of Well-Being (Contd)
  • Health Status
  • The leading causes of death for older Americans
    are heart disease, cancer, and stroke
    (respectively). Mortality rates for heart
    disease and stroke have declined by about a third
    since 1980. Mortality rates for cancer have
    risen slightly over the same period
  • In 1995, 58 of persons over 70 reported having
    arthritis, 45 reported hypertension, and 21
    reported heart disease
  • In 1998 4 of persons 65-69 had moderate to
    severe memory loss compared to 36 of persons 85
  • 23 of persons 85 reported severe symptoms of
    depression

9
Key Indicators of Well-Being (Contd)
  • Health Risks and Behaviors
  • The majority of persons 70 reported engaging in
    some form of social activity during a 2-week
    period. 2/3 age 70 reported satisfaction with
    their level of social activities
  • In 1995, 1/3 of older Americans reported a
    sedentary lifestyle
  • Self-reporting re diet 21 good, 67 need
    improvement, 13 poor
  • Older persons are much less likely to be victims
    of both violent and property crime than persons
    age 12-64

10
Key Indicators of Well-Being (Contd)
  • Health Care
  • Older persons of all ages are generally satisfied
    with their health care and few report difficulty
    obtaining health care services
  • In 1996 average annual expenditure on health
    care age 65-69 5,864 age 85 16,465
  • In 1997, 4 of population 65 resided in nursing
    homes ¾ were women
  • Older persons receiving home care in 1994 64
    relied exclusively on informal (unpaid) care, 8
    received only formal care and 28 received a
    combo of informal and formal care

11
General Principles of Aging Old Foks Are
Different
  • Atypical presentation of acute illness
  • Multiple concurrent problems
  • Non-specific symptoms
  • Hidden illness
  • Under-reporting
  • Multiple losses condensed into a short time
    span
  • Expected physiologic aging changes

12
Atypical Presentation of Acute Illness
  • Only 40 of elderly fit the classic one
    symptomone disease model
  • Acute myocardial infarction without chest pain
  • Acute hyperthyroidism without tachycardia, weight
    loss, etc.
  • Acute infection without rising WBC count or
    typical fever
  • Fatigue as chief presenting complaint of CHF

13
Non-Specific Symptoms
  • Confusion
  • Self-neglect
  • Falling
  • Incontinence
  • Apathy
  • Anorexia/weight loss
  • Dyspnea
  • Fatigue
  • Taking to bed

14
Hidden IllnessYou Must Ask, They Wont Tell!
  • Sexual dysfunction
  • Depression
  • Incontinence
  • Musculoskeletal stiffness
  • Alcoholism
  • Hearing loss
  • Memory loss

15
Under-Reporting Due To
  • Belief that symptoms are due to old age
  • Fear or denial
  • Concern about cost
  • Embarrassment
  • Mental impairment
  • Concern about ill spouse
  • Previous bad experience with health care system
  • Fear of institutionalization

16
Multiple Concurrent Losses
  • Loss of physical health
  • Loss social contacts friends/family die
  • Loss of familiar roles mother, wife, employed
    person
  • Loss of financial security retirement, widowhood
  • Loss of independence and power
  • Loss of mental stability

17
Normal Aging vs. Disease
  • Aging is NOT a disease
  • Learn to separate pathologic processes from the
    aging process
  • Concentrate on how physical problems interfere
    with the ability of the person to remain
    independent (functional in their usual
    environment)

18
Normal Aging vs. Disease (Contd)
  • Normal aging
  • Crows feet
  • Presbycusis
  • Seborrheic keratoses loss of skin elasticity
  • Benign forgetfulness
  • Decreased blood vessel compliance
  • Increase in body fat
  • Disease
  • Macular degeneration
  • Tympano-sclerosis
  • Basal cell CA
  • Dementia
  • Athero-sclerosis
  • Hypertension
  • Obesity

19
Laboratory Values that Do Not Change with Aging
  • Hepatic function (ALT, AST, GGPT, Bilirubin)
  • Coagulation tests
  • Chemistries electrolytes, total protein,
    calcium, phosphorus
  • ABGs pH, PaCO2
  • Hemoglobin, RBC indices, platelet count

20
Laboratory Values that Do Change with Aging
  • Decreases Serum albumin , magnesium, PaO2, T3,
    T4, Creatinine clearance, white blood cell count
  • Increases Alkaline Phosphatase, uric acid,
    blood sugar, TSH, BUN/Creatinine

21
Health Maintenance in the Elderly
  • Recommend primary and secondary disease
    prevention screening
  • Review all medications
  • Control all chronic medical problems
  • Optimize function
  • Verify the presence of an adequate support system
  • Discuss and document advanced directives

22
Prevention
  • Primary
  • Preventing the occurrence of disease or injury
  • Examples Immunizations, Safety Equipment or
    Clean water
  • Secondary
  • Early detection and intervention preferably
    before the condition is clinically apparent
  • Screening programs
  • Breast cancer screening
  • BP screening
  • Tertiary
  • Minimizing the effects of disease and disability
    by surveillance and maintenance aimed and
    preventing complications

23
Primary and Secondary Preventions
  • BP screening
  • Influenza, pneumonia, tetanus immunizations
  • Obesity (height and weight)
  • Smoking cessation
  • Consider ASA to prevent MI/CVA
  • Cholesterol screening
  • Diabetes Mellitus screening
  • Osteoperosis screening - females

24
Primary and Secondary Preventions (Contd)
  • Cancer Screening
  • Breast
  • Cervical usually not gt65
  • Colorectal
  • Prostate-discussion
  • Skin (Risk-based)
  • Hearing/visual impairment screening
  • Cognitive impairment screening
  • Consider TSH in women

25
Iatrogenesis A Definition
  • Any illness that results from a
    diagnostic/therapeutic intervention or the
    omission of such intervention that is not a
    natural consequence of the patients disease

26
Caring for Hospitalized Elderly
  • 20-36 of older patients have their
    hospitalization prolonged by major adverse events
  • One study compared those under 65 to those over
    65 complication rate was 29 vs. 45
  • Another study showed hospital related
    complications in 40.5 of those gt 70, and 8.5
    of those lt 70

27
The Hospital Cascade of Disasters
  • Hospitalization? new environment and new
    medications ?acute delirium ? more new drugs
    and/or restraints ? more agitation Foley
    inserted ?poor oral intake? dehydration? IV
    fluids increased and/or NG tube placed for
    feeding
  • We now have the potential for congestive heart
    failure, thrombophlebitis, pulmonary embolism,
    aspiration pneumonia, falls and fractures,
    pressure sores, urosepsis, septic shock, etc . .
    .

28
The Hospital is aHazardous Place...
  • Drugs
  • Polypharmacy
  • Alterations in drug disposition and tissue
    sensitivity
  • Drug-to-drug interactions
  • Changes in renal/hepatic elimination
  • Medications errors
  • Medication side effects (expected)

29
The Hospital is aHazardous Place... (Contd)
  • Bed rest and immobility
  • General cardiac and muscle deconditioning
  • Postural lightheadedness, hypovolemia,
    hypotension
  • Pressure sores
  • Constipation/fecal impaction
  • Atelectasis and pneumonia
  • Thrombophlebitis and thromboembolism
  • Urinary incontinence

30
The Hospital is aHazardous Place... (Contd)
  • Therapeutic and diagnostic procedures
  • Angiography
  • GI endoscopy and its preparation
  • TUBES IVs, NGs, Foleys, restraints, dialysis
    and transfusions
  • Surgery and anesthesia
  • Nosocomial Infections
  • Pneumonia, C. difficile, MRSA

31
The Hospital is aHazardous Place... (Contd)
  • Under nutrition
  • Cognitive impairment
  • Social isolation
  • Poor dentition
  • Impaired thirst perception
  • Limited access to food and fluids
  • Chronic disease

32
Keys to PreventionA Checklist to Monitor the
Hospitalized
  • Diagnosis
  • Medications
  • Nutrition
  • Continence
  • Cognition
  • Emotional status
  • Mobility
  • The Caregiver

33
Diagnosis
  • Keep accurate medical and surgical diagnosis
    lists
  • Prioritize medical therapies, addressing
    reversible problems first
  • Clarify the specific medical goals of the
    hospitalization
  • Carefully select diagnostics Is this procedure
    necessary and how will it change my management?

34
Medications
  • Make an accurate list of all medications on
    admission, including OTCs and herbals
  • Always consider adverse drug effects as the cause
    of new symptoms
  • Monitor appropriate blood levels (Digoxin,
    dilantin)
  • Try to control pain without narcotics first
  • Monitor/review need for medications daily

35
Nutrition
  • Avoid long NPO periods if possible
  • Albumin and total cholesterol signal poor
    nutritional state
  • Provide vitamin supplementation
  • Adjust fluid therapy on an individual basis
  • Ask about nausea/anorexia, food satisfaction
    daily
  • The hospital is an excellent place to obtain a
    professional nutritional consultation

36
Continence
  • Maintain mobility and cognitive function to avoid
    incontinence
  • Reduce IV fluid rates at night
  • Avoid anti-cholinergic medications
  • Reassure the patient that new urinary
    incontinence is usually temporary
  • Monitor bowel function early and daily to prevent
    incontinence, constipation and food refusal

37
Cognition
  • Premorbid cognitive disorders lead to a very high
    incidence of delirium--expect it, prevent it
  • Carefully monitor fluids and electrolytes
  • Minimize psychoactive medications
  • Use acetaminophen around the clock to manage
    fever and/or pain
  • Use environmental strategies (lights, family
    sitters during the night)
  • Address hearing and vision problems

38
Emotional Status
  • Address anxiety, pain and insomnia early
  • Depression common 20-60 of hospitalized
    elderly treat it
  • Frequently update family hold patient/family
    conferences to allay fears and clarify the plan

39
Mobility
  • Avoid physical restraints including Foleys
  • Encourage patient range of motion activities and
    resistive exercises in bed
  • Expect self-sufficiency
  • Enlist PT/OT therapists early for those with poor
    mobility and transfer skills
  • If bed immobile, inspect for skin pressure areas
    daily

40
The Care Giver
  • Is there a competent, willing and acceptable
    caregiver?
  • Assess care giver burden/burnout
  • Identify patients at risk for skilled nursing
    facility placement
  • Anticipate post-hospital needs such as medical
    equipment, oxygen and home care services

41
Drug Therapy in the Elderly
  • Prescription drug expenses make up 7 of total
    health care spending in elderly
  • 65 of Americans age 65 use at least one
    prescription medication
  • Elderly (65) use 30 of Rx drugs and 40 of OTC
    drugs
  • Elderly with drug coverage average-18
    prescriptions per year
  • Elderly in nursing homes receive an average of 7
    different medications

42
Pharmacokinetics Absorption
  • Clinical significance
  • Little to none
  • Physiologic change
  • No significant change in gastric pH decreased
    absorptive surface and splanchnic blood flow
    generally preserved gastric emptying time

43
Pharmacokinetics Distribution
  • Increased body fat
  • Significance Fat soluble drugs cross membranes
    more easily and spread widely (diazepam)
  • Decreased lean body mass
  • Significance Water soluble drugs cross barriers
    less easily and are largely confined to lean body
    tissue (cimetidine, digoxin, ethanol)

44
Pharmacokinetics Distribution (Contd)
  • Decreased serum albumin and lower protein binding
  • Significance Lower protein binding in elderly
    (theophylline, warfarin, cimetidine)
  • Exception lidocaine binds primarily to
    alpha-1-acid-glycoprotein and it shows higher
    binding in the elderly

45
Pharmacokinetics Hepatic Metabolism
  • Physiologic change
  • Decreased liver mass and hepatic blood flow
  • Clinical significance
  • Phase 1 reactions altered (oxidation, reduction,
    hydrolysis)
  • Phase 2 reactions (conjugation) not significantly
    affected

46
Pharmacokinetics Renal Elimination
  • Physiologic change
  • Creatinine clearance reduced with aging or disease
  • Clinical significance
  • Dose adjustments required for drugs predominantly
    excreted by the kidneys (digoxin, LMWH)

47
Contributors to Noncompliance in Older Adults
  • Complex treatment regimens and dosing schedules
  • Medication side effects
  • Physical disability (dysphagia, arthritis)
  • Cognitive impairment
  • Poor communication
  • Inadequate understanding of therapy
  • High cost of medications

48
Contributors to Polypharmacy
  • Patient
  • Borrowing or sharing medications
  • Failing to understand instructions
  • Saving medication for later use
  • Combining Rxs with OTCs and Herbals
  • Visiting more than one physician
  • Doctor
  • Failing to review the patients medications
  • Prescribing medications for common and non-life
    threatening symptoms
  • Treating multiple symptoms or illnesses with
    several drugs

49
Principles of Appropriate Drug Prescribing
  • Be alert to the possibility of drug interactions
    and adverse drug reactions
  • Consider efficacy, cost (generic vs. brand), and
    ease of administration
  • Avoid using multiple drugs with similar actions
    and toxicity
  • Do not prescribe drugs longer than necessary
    discontinue if no longer indicated

50
Principles of Appropriate Drug Prescribing
(Contd)
  • Keep the drug regimen simpleonce or twice daily
    dosing
  • Be aware that patients may visit other prescibers
  • Initiate therapy with the lowest recommended dose
    and increase slowly (Start low, go slow)
  • Justify the use of each drugwhat is the active
    problem you are treating??
  • Understand the pharmacokinetics and
    pharmacodynamics of drugs prescribed

51
Principles of Appropriate Drug Prescribing
(Contd)
  • Psychotropic drugs (all of them) and
    cardiovascular drugs (all of them) cause
    undesirable side effects. Use them with caution
  • Review all meds at each patient visit (brown bag
    test) including indications and dosing
  • Ask about the use of OTCs and herbals
  • Involve the patient in decision making and
    maintain open communication
  • Encourage the patient to report any new or
    unusual symptoms

52
Goals of Geriatric Assessment
  • Improve diagnostic accuracy
  • Define functional impairment
  • Limit iatrogenesis
  • Prevent cascade of disasters
  • Recommend optimal living situation
  • Predict outcomes
  • Monitor clinical change over time

53
Data-Gathering
  • Listen to patient but verify with competent
    observers
  • May be very time intensive--use two or more
    sessions if necessary
  • Chief complaint may be misleading
  • Medication history is pivotalbrown bag
  • Tailor the review of systems
  • Family history often unhelpful
  • Always seek data regarding functional abilities

54
Review of Systems/(Function)
  • Appetite/weight change
  • Fatigue
  • Falling/gait/balance
  • Sleep
  • Depression
  • Hearing/visual loss
  • Alcohol use
  • Joint pain, stiffness, ROM
  • Cough/Dyspnea
  • Constipation/laxative use or abuse
  • Incontinence
  • Frequency/Nocturia
  • Memory loss/confusion
  • Headache
  • Transient weakness or visual symptoms (TIAs)

55
Areas of Assessment
  • Functional assessment
  • Mobility, gait and balance
  • Sensory and Language impairments
  • Continence
  • Nutrition
  • Cognitive/Behavior problems
  • Depression
  • Caregivers

See Appendix A at End of Chapter
56
Functional Assessment
  • Activities of Daily Living (ADL)
  • Feeding, dressing, ambulating, toileting,
    bathing, transfer, continence, grooming,
    communication
  • Instrumental ADL (IADL) Cooking, cleaning,
    shopping, meal prep, telephone use, laundry,
    managing money, managing medications, ability to
    travel

57
(No Transcript)
58
Mobility, Gait and Balance
  • Get up and go test rise from a sitting position
    with arms crossed, walk in a straight line for
    15-20 feet, turn, return to chair and sit down
  • Maintain standing balance when receiving a slight
    sternal nudge
  • Bend down and reach as if to pick up an object
  • Shoulder/hand function
  • Feet structural problems, neuropathy, proper
    foot wear

59
Sensory Impairments
  • Visual testing
  • Read a sentence from the newspaper
  • Pocket Snellen chart
  • Diabetics need annual dilated eye exam by
    ophthalmologist
  • Auditory Testing
  • Assess hearing during history-taking
  • Whisper words behind the back
  • Finger Friction rub your thumb and index finger
    in front of ear
  • Formal audiometric evaluation

60
Continence
  • A hidden disease you must ask
  • Simple screening questions
  • Office evaluation often adequate to make a major
    difference
  • Incontinence section to follow

61
Nutrition
  • Assess any patient admitted to the hospital or
    nursing home
  • Assess for weight change, anorexia, chewing or
    swallowing problems
  • Questions about alcohol a MUST (use CAGE)
  • Low albumin and total cholesterol may be clues
  • 2-3 day diet journal may be the most helpful
    screening tool
  • Establish and record serial weights (minimum
    yearly) and heights (minimum Q3Y)

62
Cognitive Problems
  • Goals of cognitive screening
  • Detect unsuspected mental impairment
  • Provide baseline for future encounters
  • Discover those at risk for delirium
  • Provide concrete data for competency/decision-maki
    ng opinions
  • Dementia section to follow

63
Depression
  • Commonly missed
  • Somatic complaints often predominate
  • Many, many drugs should be suspected
  • Suicide in elderly males is high
  • Target your search recent bereavement,
    psychosocial losses, dementia, functional
    impairment, severe illness or surgery
  • Yesavage Geriatric Depression Scale

See Appendix B at End of Chapter
64
Care Givers
  • Lack of a willing or capable care giver is a
    prominent reason for ECF placement
  • Is the care giver acceptable to the elder?
  • Is the care giver evidencing burn-out?
  • Is there evidence of elder abuse or neglect?
  • Zarit Burden Interview is a short instrument that
    can introduce the topic of caregiver stress in a
    non-threatening way

65
Putting it All Togetherthe Care Plan
  • List all problems (physical, social, functional)
  • List the strengths you find in the present
    situation and build on them
  • Reduce the list to those problems that are out of
    control and/or you can remedy
  • Treat acute medical problems with appropriate
    aggressiveness
  • Manage chronic problemscontrol, not cure
  • Address routine health maintenance
  • Do the medications relate 11 to an active
    problem?

66
The Care Plan (Contd)
  • What functional problems are most amenable to
    intervention?
  • Is there evidence of chronic uncontrolled pain?
  • Is there evidence of dementia or depression?
    Treat it
  • Are there any geriatric syndromes to address?
  • Is the living situation appropriate?
  • Is there evidence of a willing, capable,
    appropriate and acceptable care giver?
  • Would any community resources benefit the
    situation?

67
Mistreatment of Elders
  • Elder abuse shall mean an act or omission which
    results in harm or threatened harm to the health
    or welfare of an elderly person. Abuse includes
    intentional infliction of physical or mental
    injury sexual abuse or withholding of necessary
    food, clothing and medical care to meet the
    physical and mental needs of an elderly person by
    one having the care, custody or responsibility of
    an elderly person

68
Types of Abuse and Neglect
  • Physical abuse Intentional infliction of
    physical discomfort, pain or injury
  • Hitting, slapping, inappropriate use of
    restraints, sexual assault
  • Psychological abuse Intentional infliction of
    mental anguish or provocation of fear of violence
    or isolation
  • Name-calling, chronic verbal aggression,
    intimidation, threats of institutionalization,
    withholding security and affection, withholding
    contact with family or friends

69
Types of Abuse and Neglect (Contd)
  • Material abuse misappropriation or misuse of
    funds or possessions
  • Fraud, theft, extortion/use of undo influence to
    persuade elderly to relinquish control, use or
    ownership of funds or possessions
  • Neglect withholding of physical, material, or
    emotional necessities of physical and mental
    health whether intentionally or unintentionally

70
Risk Factors for Maltreatment
  • Female, living alone, over age 75
  • Poor health/functional status
  • Cognitive impairment
  • Abuser suffers substance abuse/mental illness
  • Dependence of abuser on victim (such as shared
    living arrangements)
  • Elders needs exceed caregivers abilities
  • Social isolation
  • History of family violence/antisocial behavior

71
Presentations Suggesting Abuse
  • Delay between injury/illness and seeking care
  • Disparity in history from patient and suspect
  • Implausible or vague explanations provided by
    either party
  • Frequent visits to the ER for exacerbations of
    chronic disease despite a plan for medical care
    and apparently adequate resources

72
Presentations Suggesting Abuse (Contd)
  • Numerous injuries at various stages of healing
  • Elder presents with poor nutrition, hygiene, or
    misses appointments
  • Presentation of impaired elder without a
    caregiver

73
Abuse/Neglect Indicators
  • No food, or rotten food in the house
  • Clothes extremely dirty or uncared for
  • Not dressed appropriately for the weather
  • Utilities cut off
  • Gross accumulation of garbage, papers and clutter
  • Large number of pets with no apparent means of
    care
  • Signs checks over to others out of money by
    second week of the month

74
Abuse/Neglect Indicators (Contd)
  • Swollen eyes or ankles, decayed teeth or no teeth
  • Bites, fleas, sores, lacerations
  • Untreated pressure sores
  • Broken glasses frames or lenses
  • Medication non-compliance
  • Refusal to accept presence of visitors
  • Unjustified pride in self-sufficiency
  • Vague health complaints

75
AMA Proposed Screening Questions
  • Has anyone at home ever hurt you?
  • Has anyone ever touched you without your consent?
  • Has anyone ever made you do things you didnt
    want to do?
  • Has anyone taken anything that was yours without
    asking?
  • Has anyone ever scolded or threatened you?

76
AMA Proposed Screening Questions (Contd)
  • Have you ever signed any documents that you
    didnt understand?
  • Are you afraid of anyone at home?
  • Are you alone a lot?
  • Has anyone ever failed to help you take care of
    yourself when you needed help?

77
Documentation is Essential
  • Use quotations or verbatim comments made by the
    patient in describing an event or situation
  • Detail descriptions of all injuries, using body
    charts and/or color photographs

78
Management of Confirmed Mistreatment
  • Two pivotal questions
  • Does the patient accept or refuse intervention?
  • Does the patient retain decision-making capacity?

79
Intervention
  • Currently there is no therapy of choice
  • Many victims refuse help
  • Victims often deny abuse
  • Most elderly persons would rather receive
    inadequate care living with their family than
    excellent care in an institution
  • Do not attempt or initiate individual heroic
    rescues

80
Intervention (Contd)
  • Hospitalize if emergency intervention is required
  • Report incident to Adult Protective Services
  • Decompress the situation Adult day care,
    respite housing, counseling, support groups
  • Legal aid
  • Home Health Assistance

81
Medical Care in the Nursing Home
  • Skilled nursing beds 1.5-2 million in US
  • 5 of those over 65 live in a NH
  • 45 of NH residents are over age 85
  • 75 of NH residents are female
  • 60 have moderate-to-severe dementia
  • 50 admitted to NH die there
  • Cost 20-45K per patient per year

82
Types of NH Residents
  • Short-stayers 1-6 months
  • Terminally ill
  • Short term rehabilitation
  • Debilitated post-acute care hospitalization
  • Long-stayers 6 months to years
  • Primarily cognitively impaired
  • Significant impairments of both cognitive and
    physical functioning
  • Primarily physically impaired

83
Factors Precipitating NH Placement
  • Care requirements exceed the ability of care
    giver
  • Behaviors due to dementia nocturnal wandering,
    aggressive behavior,etc
  • Bed bound status requiring total ADL support
  • Bowel and/or bladder incontinence
  • Recurrent falling
  • Insufficient financial resources to maintain help
    at home

84
Physician Duties in the NH
  • Verify transfer or admission orders from the
    transferring facility
  • Perform history and physical within 48 hours of
    admission
  • Schedule regular reassessments (frequency
    mandated by the government q30d x 3, then q60d
    thereafter
  • Comply with multiple OBRA (1987 Omnibus Budget
    Reconciliation Act) regulations

85
Admission Checklist
  • History, physical, labs as needed
  • Tuberculin test
  • Determine functional status ADLs, IADLs,
    Mini-Mental Status, Geriatric Depression Scale
  • Identify medical problemsreview old records
  • Medication review each must correlate to an
    active medical problem

86
Admission Checklist (Contd)
  • Assess for presence of pain
  • Establish relationships patient, family, and
    staff
  • Establish advance directives
  • Formulate the problem list
  • Formulate the care plan

87
Sources of Payment for Nursing Home
  • Medicaid47
  • Private pay46
  • Medicare---lt4
  • Long term care insurance ??

88
Social Security Act of 1965
  • Established Medicare and Medicaid
  • Medicare health insurance for elderly (65)
    amended in 1970s to cover end-stage renal
    disease (any age) and certain patients on
    permanent disability administered by federal
    government
  • Medicaid medical insurance covering low income
    persons of all ages jointly administered by the
    federal and state governments

89
Medicare Part A Hospital Insurance
  • Most people do not pay a premium because they
    have (or spouse) 40 quarters of credit
    (employment)
  • Inpatient hospital care
  • Nursing home care
  • Home health care
  • Hospice care
  • 840.00 deductible per benefit period
  • Begins day of hospital/NH admit
  • Ends when no hospital/NH services for 60 days
  • Co-insurance after 60 days of care
  • Limited nursing home coverage skilled only
  • Medicare certified
  • After qualifying 3 day hospitalization

90
Medicare Part B Supplementary Medical Insurance
  • Physician services
  • Laboratory tests
  • Durable medical equipment
  • Ambulance services
  • Selected preventive services
  • Premium - 58.70/monthly
  • Deductible 100.00/year
  • Patients pay 20 of Medicare approved amount

91
Medicaid
  • Covers approximately 2/3 of all nursing home
    patients 39 billion in 1997
  • Persons pay out of pocket (spend down) until
    income/asset criteria are met criteria set by
    each state
  • No national program covers chronic custodial care
    for elders who remain in the home
  • Some commercial long term care insurance policies
    now available to cover nursing home care

92
Falling A Geriatric Syndrome
  • 30 of persons 65 fall at home each year
  • 50 of persons 80 fall at home each year
  • 66 of fallers will fall again in six months
  • If an elder is hospitalized due to a fall, only
    50 will be alive in a year
  • Falls are common in the hospitalized, most on the
    night of admission
  • Falls result in 250,000 hip fractures per year

93
Complications of Falls
  • Medical
  • Fractures
  • Subdural hematoma
  • Sprains, bruises, hematomas, lacerations
  • Psychological
  • FFF (3F syndrome) Fear of further falling
  • Decreased confidence ? isolation and withdrawal ?
    depression ? reluctance to go outdoors

94
Complications of Falls (Contd)
  • Social
  • Loss of independence
  • Risk of nursing home placement
  • Increased immobilization
  • Further loss of muscle tone and strength
  • DVT/pulmonary embolism
  • Hypothermia
  • Dehydration
  • Osteoporosis
  • Pulmonary infections

95
Medical Risk Factors for Falls
  • Poor vision cataracts, glaucoma,macular
    degeneration
  • CV postural hypotension, syncope, arrhythmias,
    drop attacks
  • Lower extremity dysfunction arthritis, weakness,
    foot problems, peripheral neuropathy
  • Gait and Balance CVA, Parkinsons, myelopathy,
    cerebellar disorders

96
Types of FallsIntrinsic vs. Extrinsic
  • Intrinsic factors
  • Changes in postural control
    Decreased proprioception, righting reflexes,
    muscle tone and strength increased postural sway
  • Decreased foot swing height, slower gait
  • Decreased depth perception, clarity, dark
    adaptation, color sensitivity, visual fields
    Increased sensitivity to glare

97
Types of Falls (Contd)
  • Extrinsic factors
  • Poor lighting
  • Objects on the floor (clutter, pets,
    throw rugs)
  • Unstable furniture
  • Poor or absent railings
  • Low beds or low toilet seats

98
Take a Fall History
  • Inquire about the circumstances of the fall
  • Inquire about injuries or loss of continence
  • Medication history
  • Are there any risk factors?

99
Fall-Related Physical Exam
  • Vital signs (postural blood pressure)
  • Assess mobility Get-up-and-go test
  • MMSE
  • Visual exam
  • Cardiac evaluation
  • Neurologic evaluation
  • Musculoskeletal (including feet) exam

100
Management and Prevention of Falls
  • Treat immediate medical problems
  • Assess and alter environment as necessary
  • Attempt to modify any risk factors
  • Consider rehab (strengthening exercises)
  • Prescribe assistive devices, if necessary
  • Teach patient how to get up if they do fall
  • Consider a personal emergency response system
    (Help, Ive fallen..)
  • Hip protectors reduce fracture incidence by 50

101
Urinary IncontinenceA Geriatric Syndrome
  • The involuntary loss of urine sufficient in
    amount or frequency to be a social or health
    problem. Urinary incontinence (UI) is a symptom,
    not a specific disease

102
UI Prevalence
  • 15-30 in community dwelling elders (only half
    report so this is an estimate)
  • 30-35 of elderly in acute care hospitals
  • 50 of those living in nursing homes
  • UI is never a normal part of aging, despite
    ubiquitous advertising for absorbents

103
UI Risk Factors
  • Females 21
  • Age
  • Parity
  • Dementia
  • Polypharmacy
  • UI is independently and positively associated
    with poor self-rated health

104
Basic Bladder Anatomy and Physiology
  • Functionally, urinary incontinence is due to
  • Failure to store urine (because of bladder OR
    because of the urethra)
  • Failure to empty urine (because of bladder OR
    because of the urethra)

105
Physiology
  • Emptying the bladder involves stimulation of
    cholinergic receptors and inhibition of alpha and
    beta adrenergic receptors
  • Filling the bladder involves inhibition of
    cholinergic receptors and stimulation of
    adrenergic receptors
  • Stimulation of alpha adrenergic receptors
    increases sphincter and urethral tone, and
    inhibition decreases it

106
Causes of Transient UI-DIAPERS
  • D Delirium/confusional states
  • I InfectionUTIs
  • A Atrophic urethritis/vaginitis
  • P Pharmaceuticals (hypnotics, diuretics,
    anticholinergics, alpha-adrenergic agents,
    calcium channel blockers)
  • P Psychological
  • E Excessive urine production
  • R Restricted mobility
  • S Stool impaction

107
General Principles of Diagnosing UI
  • Basic history and physical
  • Urinalysis
  • PVR (post-void residual) determination
  • Voiding diary
  • Labs BUN, Cr, Glucose, Ca
  • Imaging tests
  • Urodynamic and endoscopic tests rarely needed to
    diagnose

108
Types of UI
Overflow
Urge (Detrusor instability)
Functional
Stress (Urethral insufficiency)
Involuntary loss of urine, usually small amounts
with increased intra-abdominal pressures
Leakage of small amts. resulting from mechanical
forces on an overdis-tended bladder
Leakage, usually large amts, due to inability to
delay voiding after sensation of fullness
Urine loss due to inability to toilet impaired
cognition or physical functioning Environmental
barriers
109
Symptoms
Functional
Stress
Urge
Overflow
Loss of small amts of urine. PVR gt 100 cc
Urine loss with coughing, sneezing, etc.
Sudden urge to urinate. Loss of moderate amts.
PVR lt 100 cc
Loss of small to large amounts PVR minimal
110
Cystometric Findings
Stress
Functional
Urge
Overflow
Little or no detrusor contractions despite high
bladder volume
Involuntary detrusor contractions that can not be
suppressed
Normal
Normal
111
Common Causes
Stress
Functional
Urge
Overflow
Outlet obstruction (BPH, fecal impaction),
urethral stricture, anticholin-ergic meds,
diabetic neuropahy, multiple sclerosis
Local GU conditions (UTI, stones, diverticuli),
decreased cortical inhibition (CVA, dementia,
Parkinsons tumor)
Obesity, laxity of pelvic floor,
spondylosis Peripheral (pudendal) neuropathy
Post-radiation
Physical restraints, dementia, sedative use,
diruetics, arthritis, muscular weakness,
cluttered home, poor lighting, neglect of
bedbound
112
Primary Treatments
Stress
Functional
Urge
Overflow
TURP, intermittent cath timed voidings trial of
cholinergic drugs trial of alpha-blocker agents
urologic referral
Bladder training scheduled toileting trial of
antispas-modics Kegel exercises
Kegels, weight loss, various surgical
proceduresestrogens, alpha-adrenergic agents
pessaries
Remove or replace offending drugs improve
patient mobility night-time urinal or bed side
commode scheduled toileting
113
Delirium
  • An acute confusional state
  • Transient reduction in the clarity of awareness
    of the environment
  • Fluctuating level of consciousness
  • A syndrome, usually referable to an underlying
    disease process

114
Risk Factors for Delirium in Hospitalized
  • Four strong predictors of delirium
  • Age gt 80
  • Prior cognitive impairment
  • Fracture on admission
  • Institutionalization prior to admission
  • Other predictors Systemic infection, narcotic or
    neuroleptic use

115
Causes of Delirium
  • Organ Failure
  • Respiratory failure
  • Congestive heart failure
  • Hepatocellular failure
  • Infections
  • Acute bronchitis/Bronchopneumonia
  • Bladder infection
  • Septicemia
  • Metabolic
  • Dehydration
  • Hypo/hypernatremia
  • Hypoxia, uremia, hypo/hyperglycemia

116
Causes of Delirium (Contd)
  • Drugs ANY, ANYTHING NEWLY ADDED
  • Anticholinergics (including anticholinergic
    antidepressants, and antihistamines)
  • Antibiotics
  • Narcotics
  • Neuroleptics
  • Anticonvulsants
  • Digoxin other antiarrhythmics
  • Alcohol/alcohol withdrawal

117
Causes of Delirium (Contd)
  • Neurologic causes
  • Subdural hematoma
  • CVA
  • Cerebral infections
  • Raised intracranial pressure
  • Miscellaneous
  • Postoperative delirium
  • Sensory deprivation
  • Recent institutionalization
  • Change of living arrangement

118
Assessment of Delirium
  • History
  • Prior functional status ADLs/IADLs
  • Alcohol use they wont tell you
  • Prior cognitive function
  • Time course of changes in consciousness
  • Medications used, both RX and OTC
  • Physical examination
  • Neurologic examination (including mental status)
  • Rectal (fecal impaction)

119
Assessment/Treatment (Contd)
  • Initial labs
  • Chem profile
  • CBC w. diff
  • UA
  • CXR
  • EKG
  • Pulse ox or ABGs
  • Serum albumin
  • Consider
  • Ammonia level
  • Blood/urine cultures
  • CT/ MRI of head
  • Drug levels
  • Serum/urine drug screens (alcohol)
  • Thyroid function
  • PVR urine
  • CSF exam
  • Folate/B12 levels

Treatment See Psychiatry slides 27-30
120
Dementia
  • Memory impairment
  • Cognitive impairment as evidenced by one of the
    following aphasia, apraxia, agnosia,
    disturbance in executive functioning
  • The cognitive deficit causes significant
    impairment in social or occupational functioning
  • Does not occur exclusively during the course of
    delirium

121
Types of Dementia
  • Alzheimers disease (AD)-- gt 60
  • Vascular (multi-infarct) dementia-- 15-20
  • Mixed dementia AD vascular features
  • All others rare AIDS, Parkinsons, Lewy-body
    dementia, Downs syndrome
  • Reversible dementias depression, thyroid
    disease, vitamin deficiency, infections, normal
    pressure hydrocephalus

122
Alzheimers Disease
  • Pathologically deposits of plaques (amyloid) and
    neurofibrillary tangles (tau protein)
  • Average time between diagnosis and death 10
    years
  • Early personality changes, irritability,
    anxiety, depression
  • Late 50 develop agitation, delusions,
    hallucinations, or paranoia

123
Vascular Dementia
  • Dementia is present
  • Two or more of the following are present
  • Focal neurological signs on physical exam
  • Onset was abrupt, step-wise or stroke-related
  • Brain imaging shows multiple strokes
  • Diagnosis requires presence of cardiovascular
    disease, dementia and a definite temporal
    relationship between the two

124
Lewy Body Dementia
  • Dementia present
  • Two of the following core features
  • Fluctuating cognition with pronounced variation
    in attention and alertness
  • Recurrent well-formed visual hallucination
  • Spontaneous motor features of Parkinsonism
  • Supportive features repeated falls, syncope,
    transient LOC, neuroleptic sensitivity,
    systematized delusions

125
Reversible Dementias
  • Chronic infections
  • Chronic heart failure
  • Chronic obstructive pulmonary disease
  • Drug-induced cognitive impairment
  • Thyroid disease
  • Normal pressure hydrocephalus (cognitive
    impairment, gait disturbance and urinary
    incontinence)
  • Alcohol related dementia
  • Vitamin B12 deficiency

126
Depression vs. Dementia
  • Depression can look like dementia
    (pseudodementia)
  • Duration is weeks to months, not months to years
  • Islands of recent and long term memory loss
  • Language preserved
  • History of depression usually positive
  • Responds to questions with I dont know
  • Patients impression of disability exaggerated
  • Screen with Yesavage Geriatric Depression Scale

127
Diagnostic Tools
  • Focused medical and family history
  • Physical examination and laboratory tests
  • Functional status examination
  • Mental status examinations
  • Assessment for Depression
  • Brain scans (CT or MRI)
  • Neuropsychological testing usually not needed

128
Common Laboratory TestsRule Out Reversible
Causes
  • CBC
  • Comprehensive chemistry profile
  • Thyroid function tests
  • Vitamin B12 Folic acid
  • ESR
  • VDRL
  • HIV if high risk

129
Mental Status Screening Tests
  • Mini Mental Status Exam (Folstein)
  • Considered the gold standard screen
  • Maximum score of 30, cut-off of 21-23 for
    dementia
  • Requires verbal and written responses
  • No time limit
  • Reproducible over time
  • Specificity goes down, sensitivity rises with
    higher educational levels

130
Mental Status Screening Tests (Contd)
  • CAST Cognitive Assessment Screening Test (AFP
    54 1957-62)
  • Written, self-administered test
  • No time limit
  • Set Test
  • Category fluency name 10 colors, towns, fruits,
    animals
  • 80 of demented score less than 15/40
  • Considered a measure of executive,i.e., frontal
    lobe functioning

131
Mental Status Screening Tests (Contd)
  • Clock Drawing
  • Person is presented a paper with a 4-6 circle
    drawn and is asked to write the numbers and draw
    hands of a clock to show 10 past 11
  • Use as a qualitative, not quantitative screen
  • Yesavage Geriatric Depression Screen
  • Previously described

132
Dementia Management(YES, Dementia is Treatable)
  • Maximize function and independence
  • Maintain safe and secure environment
  • Maintain adequate nutrition and hydration
  • Enhance cognition (medications available)
  • Treat mood and behavior problems
  • Educate/support care givers
  • Expect regular physician office visits

133
Cholinesterase Inhibitors
  • Widespread use and multiple trials confirm that
    these drugs offer a plateau in functional decline
    and positively influence behavioral
    manifestations
  • Cognitive decline is postponed, but these drugs
    do not influence neuronal decline
  • All patients in whom AD is clinically confirmed
    and categorized as mild to moderate should be
    offered a long term therapeutic trial
  • Probably help vascular and Lewy body dementia
    too, though not labeled

134
Cholinesterase Inhibitors (Contd)
  • Donepezil (Aricept) HS dosing, 5-10 mg.,
    metabolized by P-450 system
  • Rivastigmine (Exelon) 1.5-6 mg BID with meals
    available in liquid form
  • Galantamine (Reminyl) 4-12 mg BID with food
    avoid with hepatic impairment

135
Other Non-Traditional Drugs
  • Antioxidants (Vitamin E) Ginkgo Biloba extract
    benefit supported by a single clinical trial
  • NSAIDs and estrogen replacement therapy
    benefit supported by epidemiologic evidence but
    not confirmed by prospective trials

136
Behavioral Modifications
  • Create a predictable schedule active day, quiet
    night
  • Maintain a familiar, calm environment
  • Foster reminiscence photos, music, objects
  • Keep life simple reduce choices
  • Match activities to capabilities and preferences
  • Avoid overwhelming situations (family reunions)
    and challenges (shopping)
  • Learn dementia speak dont reason or argue
    with a demented person

137
Drug Therapy for Behaviors The Last Resort
  • Behavior must present clear danger to self or
    others
  • Behavior prevents necessary care (feeding,
    hygiene, wound care)
  • Discuss indications in progress notes and with
    patient advocate
  • Use time-limited medication trials
  • Antipsychotics, benzodiazepines,mood stabilizers

138
End Stage Care
  • Palliative management of medical problems
  • Focus on quality of life
  • Be firm about aggressive medical
    interventionsthese are rarely indicated
  • Institute and follow DNR instructions
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