Introduction to Geriatrics/Geriatrics Assessment

1. HER TEST Qs ARE VERY CLINICAL, APPLY CONCEPTS OF SIMPLE INFO

2. MYTHS-alone, all in poor health, more religious, dont have sex, all live in nursing homes/long-term care facilities, are poor
3. MORTALITY-Heart dz, Malignancy, Stroke
4. MORBIDITY-Arthritis, HTN, Hearing Problems
5. Women live longer
a. Estrogen is protective
b. Men smoke more, less likely to seek medical attn., work dangerous jobs
6. Pt Plan-consider environment (think about IPE type team involvement)
a. Elderly have more comorbidities, have atypical presentations, physical impairments
7. Geriatric Giants: Disabilities from end stages of chronic dzs
a. Incontinence
b. Immobility
c. Instabilityfalls
d. Intellectual Impairment
8. Caregivers and Adult daycare costs fall on pt/fam mostly
9. Assisted living-cant live alone, but dont need constant care
10. Nursing Home (Skill Nursing Facility)-24 hr care for pts who cant care for themselves
a. RNs, PT, OT, Speech Therapist, Supervising Physician
b. Custodial (Personal) Care includes help w/ activities of daily living
11. Caregiver burnout is #1 reason for pt needing careinstitutionalized
12. Medicare Part A-covers facilities and is free if paid SS taces for 40 quarters (10 yrs)
a. Less time has monthly premium
13. Medicare Part B-monthly premium covers medically necessary doctors services, tests, equipment, mental health, a few
Rxs, etc
14. Medicare Part D-covers Rxs, is optional, costs
a. Never directly from gov, only via private insurance companies
15. Goal: Improve function, make mgmt plan
16. Geriatric assessment includes nonmedical domains (functional capacity and quality of life).
a. Should keep in mind target areas
b. Incorporates a multidiscipline team
c. Changed function can be illness presentation, tx efficacy
i. Determine impact in HPI
d. Hx, PE, MENTAL STATUS exam
i. Meds-OTC, borrowed, out of date Rx, WHY being used
ii. Vaccination status and any adverse reacions
iii. Social Hx-isolation, safety, substance abuse, support
e. Katz scaleActivities of daily Living-concrete activities (not much planning)
i. Bathing (ok if only needs help w/ one body area)
ii. Dressing (ok if need help tying shoes)
iii. Toileting (okay to use walking assistance, bedpan, catheterization)
iv. Continence (no accidents)
v. Transferring (ok to use cane/walker/electric lift chair)
vi. Feeding (plate to mouth)
f. Instrumental Activities of Daily Living (planning, need higher mental and physical capacity)
i. Ex: Taking Rx, managing money, prepping meals, living life
g. ROS: falls, special sense changes, GI, incontinence, sexual function (might be embarrassed, so ASK), gait, psych
(might need to ask spouse/caregiver)
h. PE: minimize repositioning, check orthostatic changes in vitals, special sense changes, CV, Resp, Ab, Hernias, DRE,
Pelvic exam, SORES/ULCERS, timed get up and go test (walk 3 meters)
i. Mental Status Exam
i. MMSE<24progressive cognitive impairment
ii. Depression screen (may present w/ confusion/dementia sx)
j. Functional Assessment
i. Observe ability to dress, move, walk
ii. Assess home environment (home health agency can do this)
k. Tests-High Yield=CBC, BMP, ESR, Vit B12, TSH

Palliative Medicine-Dauwalder
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Giving a med is a treatment, but not a cure

Palliative care is not just for the actively dying
a. Is very integrative in its approach
i. Need a team to get psycho-social stuff beyond ROS
b. Goal of making it part of standard care
i. Can plan future medical interventions and give comprehensive care
c. Area of medicine with the most delegation to meet pt needs
d. Trained in planning required for dying pt and their fam
Quality of Life w/ severe dz happens w/ continuity of care
a. Linking care from acute setting to pt, pts family, community
Collaboration allows for shorter length of stays and more effective stays
Acknowledging death is imminent doesnt hasten it
You need to explain the trajectory of a dz (prognosis) to pts in context of choices and pt education
Hospice requirement
a. prognosis of <6months
b. covers all medical needs associated w/ terminal dx
c. is a Part A benefit of Medicare
d. Involves an inter-disciplinary team
PEG feeding tube insertion doubles the risk of new pressure ulcer
a. They do NOT promote healing of existing pressure ulcers
Tx may have physical/pharmacological restraintsimmobilitysacral edemaseparation of skin from blood
supplyischemiadecubitus uclers
a. Malnutrition is NOT the main cause
Osmolality of tube feedings and low albumindiarrhea
Workup for N/V, retching
a. Abdominal exam, look for signs of sepsis, liver failure, renal failure, hypercalcemia, neurological problems
b. Imaging, labs for organ failure, sepsis, hypercalcemia
c. Think about the cause
d. First line Tx of Metoclopramide (D2 antagonist) or Haloperidol (inverse dopamine agonist)
e. Second line Tx of Olanzapine (Inverse 5-HT2A agonist, D2 antagonistatypical antipsychotic) or Chlorpromazine (D2
antagonist)
f. -Third line Tx of Ondansetron (5-HT2A antagonist)
Clinical Skill of giving prognosis
a. Hard because of factors like comorbidities, overestimating, low research priority, emotions
b. Accuracy affected by frailty, dementia, organ system failure
c. There is some wisdom in fresh eyes, can have clouded vision from experience in this area.
d. Global trajectory is very important for formulating prognosis/care
i. NHPCO Guidelines made to be used WITH clinical judgment, but they are not validated or effective
Karnofsky Scale is 100-0
a. -50 being pt needs considerable assistance + frequent med care
b. -<40 has median survival of 3 mos
c. -0 is dead
Eastern Cooperative Oncology Group (ECOG) Score is 0-5
a. -3 is limited self care/bed or chair during a majority of waking hrs
i. -This is median survival 3 mos
b. -5 is dead

Confusional States
1. Delirium-disturbed consciousness, cognition over a short time (DSM-IV)
a. AKA acute confusional state, acute mental status change, altered mental status
b. Significant increase in hospital death, nosocomial complications, and poor functional recovery
c. DDX-depression, Werrnicke-Korsakoff, HIV, Neurosyphilis, Vit B12 deficiency, normal pressure hydrocephalus, Rx
SE, hyperthyroidism, subdural hematoma
d. Delirium is often not recognized by physicians/nurses
e. Confusion Assessment Method (CAM) allows Dx with high sensitivity and specificity
i. Requires acute change in mental status that fluctuates

ii. AND inattention

iii. ALSO EITHER disorganized thinking OR altered lvl of consciousness
iv. 10 letter sequence, squeezing hand on Asmore than 2 errorsFAIL (inattention)
v. Yes/No Qs, finger commands (disorganized thinking)
f. Delirium may present hyperactive/agitated, hypoactive, mixed
g. Neuropathophysiology-cholinergic deficiency, irregular serotoin, cytokines, other NTs (GABA, DA, ETOH)
h. Predisposing Factors-AGE, dementia, medical probs, ETOH abuse, male sex, special sensory impairment)
i. Precipitating Factors-basically anything that sends an older pt to the hospital
i. Explains high prevalence of delirium in hospitals
j. Post opespecially cardiac surg and hip fracture repair
i. Peak 2nd post op day
ii. Pain, anemia, benzos, opiods can cause delirium
k. Hx should focus on the timing of sxs and other sx associations
i. -Review meds, ETOH, drugs, etc
1. Drug withdrawal affects appropriate dose of Rxs
2. Appropriateness of Rx based on age, kidney function
3. Drug interactions-glucose, electrolytes, ABs
4. When you get older your body makes less ACh already, so avoid anticholinergics if possible to
prevent even lower ACh
l. Vital signs are most important on physical exam
m. Labs-CBC, electrolytes, RFT
i. Cerebral imaging rarely helpful
1. Exception: head trauma or new focal neuro findings)
ii. EEG and CSF rarely helpful
1. Exception: seizures or signs of meningitis
n. Management should be interdisciplinary b/c multiple factors contribute to delirium
i. Tx underlying dz, address contributing factors, monitor pain/urine retention/fecal impaction
ii. Give social restraints, sitter/family to stay in room
iii. Avoid day naps, physical/pharm restraints
iv. Rehabilitation-orienting stimuli, socialization, sensory aids, mobilization ASAP, nutrition, fluids, and
education to pt and family
v. The best management is prevention
1. Nonpharm sleep aids (Ex: warm milk)
2. Limit/avoid psychoactive or high-risk Rx
o. Agitated Delirium-is a MEDICAL EMERGENCY that stresses the CV systemlonger hospital stay and worsens
outcomes
i. Low-dose haloperidol and monitor for torsades de pointes
ii. Avoid continuous IV sediation
iii. Avoid benzos as a first-line (useful as adjuncts)
2.

Dementia-an acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert
pt.
a. Progressive, disabling, and NOT an inherent part of aging
i. Ex: not recognizing family, forgetting to serve just prepared meal, getting lost in own neighborhood
b. May occur along with delirium.
i. Alzheimers (MOST COMMON)-memory impairment, gradual onset, progressive, difficult learning new
things, aphasia, apraxia, agnosia, changed exutive function
ii. Not do to CNS/physical condition or Axis I d/o
c. Vascular (2nd MOST COMMON)-focal neuro sx and signs of cerebrovascular dz w/ the AD sxs (see above)
d. Lewy Bodies-visual hallucinations, Pakinsonian signs, attention/alertness changes
e. Family bears financial and emotional burden
i. Nearly half of caregivers suffer clinical depression
f. Risk factors-AGE, Fam Hx, head injury, less education (less coping mechanisms have developed)
g. Genetics
i. Chromosomes 1,14,21early onset (before 60)
ii. APOE*4 on chromosome 19late onset
1. APOE*2 may be protective allele
h. Protective factors-Estrogen replacement (post-menopausal pts), NSAIDS, AOs, physical activity

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Assess w/ detailed Hx, Physical (Neuro, mental status, functional

status)
MMSE-not created for dementia, copyrighted, cultural/educational/language biases
i. ->25 is normal, 9 or less is severe dementia
k. Mini-Cog-3 words given, draw clock @ 11:10, recall 3 words
i. Clock drawing incorrecttest positive for cog impairment, (unless you get all 3 words)
ii. Clock drawing correctjust need 1 word to test neg
l. Labs-CBC, FLT, test serum for syphilis, TSH, Vit B12 lvl
m. Brain Imaging-noncontrast CT, MRI, PET if suspect normal-pressure hydrocephalus, asymmetric neuro signs, early
onset, or sx for less than 2 yrs
n. Management goal-enhance quality of life, max functional performance (improved cognition, mood, and behavior)
i. Work on routine, appropriate stimuli lvl, safe environment, communication/education for
caregivers/family
ii. Community resources should be used to support patient, family, caregivers
o. Pharm-cholinesterase inhibitors, cognitive enhancers, antidepressants (reduced size of hippocampus),
antipsychotics (last resort)
i. Avoid benzos or antihistamines
p. Sundowning reduced by daytime stimulation/light, bedtime ritual, avoiding stimulants/smoking near bedtime,
giving diuretics/laxatives early in the day, and familiar bedside objects
q. Aggression reduced by distraction, routine, Rx
r. Wandering (AD) addressed by enhancing socialization, structured physical activity, and providing a safe place to
wanter
i. Vest or wrist restraints are NOT effective
1. Lead to increased falls/injuries
s. Hypersexuality reduced by tx underlying syndrome, modification in approach to pt, antiandrogens
t. May refer to psych, geriatrics, neruo, social work, PT, nurse
u. Preemptively manage dementia by completing attorney for will
Stroke Online Module
1. Most stroke older than 65yo
rd
2. 3 leading cause of death, #1 cause of disability in USA
3. 80% are ischemic
a. tPA is only approved tx for acute ischemic stroke
i. CBC/PTT/PT/INR/tells if tPA is indicated/contradindicated
ii. Falls/injuriesdont give tPA
iii. Weight establishes correct dosage of tPA
4. L/R handedknow where language center is
5. Hypoglycemia mimics strokecheck glucosetx w/ glucose/thiamine
6. Head CT to rule out hemorrhagic stroke
7. NIH Stroke Scale-measures severity, determines tx/prognosis, gives baseline to monitor response to tx
a. LOC, lvl of consciousness, lvl of consciousness questions, face, arms, legs, ataxia, aphasia, dysarthria, sensory loss,
and neglect are scored
8. Complications-DVT, aspiration pneumonia, arrhythmia
a. After acute phase, perform neuro exam
b. Determine if pt has a living or durable power of attorney in place
9. Following tPA administration, hold antiplatelets/anticoags/NSAIDS, give TED stockings (prevent DVT), control BP, keep NPO
(prevent brain edema)
10. After 24 hrWarfarin/Aspirinstroke prevention if not contraindicated
11. After discharge, can prevent w/ ACE inhibitor, warfarin, statin
a. Careful w/ risk of falling or D-D interactionsbleeding
b. Recommend outpatient speech therapy, Dysphagia II diet, and mobilization exercises
Elder Abuse
1. Neglect
a. Active Neglect-caregiver intentionally fails to meet obligations
b. Passive Neglect-caregiver unintentionally fails (lack of training)
c. Signs of malnourishment, exacerbated chronic health problems
2. Physical Abuse-physical harm, restraints
a. Unexplained/undisclosed injuries, doctor shopping, time lags between time of injury and medical tx

3.

Financial Abuse-misuse/exploitation of assets/possessions

a. Incapacitated but signing papers, signatures not matching, someone not authorized to sign is signing
b. Promises of lifelong care in exchange for assets/property/$$$
4. Psychological Abuse-threats, isolation, violation of basic rights
a. Acting differently/strangely around caregiver
b. Psychological sxs
5. Sexual Abuse-no consent, or unable to consent
a. Trauma to genitals, VD, psychological abuse indicators
6. Self Neglect-competent, but choosing to not meet their own health and safety needs
a. This is the most common type of case reported to APS (40-50%)
b. Patter of this type of behavior throughout life
c. Mental health problem or dementia that is not dx or tx
i. Hypothyroid, anemia, infections, malnutrition, overmedicationcognitive impairment if not tx
ii. Depression sx of maintaining self-care
1. Tx ASAP b/c very treatable, high risk of suicide
d. Escalates w/ other stressors
e. May be resistant to intervention from past negative experiences
i. Build rapportincrease trustget pt to accept intervention
f. Substance abuse-long term addicitons, exacerbated from other medical
conditions/depression/anxiety/stress/overprescription
7. Possible indicators of abuse
a. If the elder is not given opportunity to speak w/o caregiver
b. Caregiver is indifferent or angry towards pt
c. Pt is overmedicated/oversedated
8. Physicians are MANDATED REPORTERS of abuse to APS
9. Caregiver stress/burnout is the #1 reason for instituationalization of pt
a. Lack of sleep, dont have care skills/info, frustration w/ care
b. External stress has a correlation w/ abuse
i. $$$/Job/Sandwich Generation (care for parents AND kids)
ii. Alcoholism/Drugs/Emotional disorders
10. Pts w/ poor health are more likely to be abused
a. Dependencecaregiver resentment/stressburnout
11. If caregiver is financially dependent, they are more likely to abuse
a. May feel powerless, not in control
12. Prevent abuse w/ social support/checks, setting up future legal things now, arrange simplified finances, and assess
resources/situation of care
a. Isolation is a risk factor for all forms of elder abuse
Incontinence Online Module
1. Diminished quality of life b/c emotional disturbances, poor sleep, isolation, decreased mobility/recreation
2. Can cause skin problems like infections and ulcers
3. Often goes unreported
4. Bladder Diary and Incontinence Impact Questionnaire
5. Length of time since onsetacute or chronic
6. Frequency, volume, activating activitiesquality of life and what type
a. Activities that increase ab pressurestress incontinence
b. Activities like sleepoverflow incontinence
7. Ask about UTI hx, caffeine/ETOH intake (diuretics)
8. Associated bowel difficulties may indicate a neuro problem cause
9. W/ females, atrophic vaginaincreased urinary incontinence risk
a. Vaginal births have association too
10. W/ males, ask about prostate
11. Important to get medication hx
12. Post-Void Residual Urine-checks for obstruction or neuromuscular prob
a. Normal is 50cc or less, more than 200cc is distinctly abnormal
13. Urinalysis to check for UTI, hematuria (possible malignancy)
14. Abdominal PE always should be included, as well as genital and rectal
15. Pseudoephedrine/Imipraminemore ext. urethral sphincter pressure

16. Anticholinergic drugs (like Haloperidol)urine retention

17. Chronic mixed-most common cause of urinary incontinence in elders
18. Need to ask b/c might not volunteer this info on their own
Independent Readings
1. Dementia and the Family: Intrapsychic and Interpersonal Issues
a. Dementia tx is complex w/ conflicts (family and community/gov)
b. Psychotherapeutic therapy for caregiversrelief of burden
i. Clarification of what is actually occurring to fix passivity that comes from guilt
c. 5 areas of concern
i. Refusal to accept role reversal need
1. Stronger if dementia pt was strong authority figure
2. Conscious and unconscious problem
3. Decisions may conflict w/ pts stated wishes
ii. Cant distinguish b/t innate personality and impaired behavior from cognitive change
1. Dismissed as being stubborn
2. Caregivers may respond w/ anger fueled by the past
iii. Family conflict complicated from pt decline
1. Sibling rivalries, differential treatment of children by the parent w/ dementia, intergenerational
discord, financial expectations, and even family myths
2. May try to split health care or threaten legal action
3. Use soundest/safest tx plan
- Should serve as the essence of the message to all sides of the issues.
iv. Over/underinvolvement in care and decision-making
1. Can exhaust caregivers
2. Abuse
v. Guilt and other factors interfering with an effective interface with potential support systems.
1. Fear, depression, discomfort w/ caregiving
2. A Look at Diogenes Syndrome
a. Goal of elders receive needed health care, independent lives w/ dignity
i. Diogenes Syndrome aka Senile Squalor Syndrome-behaviors in people living reclusivelyextreme selfneglect w/ compulsive hoarding and denial of surroundings or sxs
1. Risk to selves and the public
2. Forgotten population
ii. Named after Greek philosopher who lived/acted like this
iii. Often single or widowed, live alone, lengthy decline
1. Underdiagnosed
b. Independent of socioeconomic class
c. Tx primarily as dementia (APS is notified)
d. Paranoid/Schizoid personality d/o, cant relate to others
e. Suggested Hypotheses
i. OCD, obsessive personality d/o
ii. Paranoid psychoses, mood d/os
iii. Frontal lobe dementia
f. Establish trusting relationship w/ a caseworkerbest tx
i. Day/community care
ii. SSRIsmanage paranoid sxs
iii. Regain control of environment w/ living space intervention
g. Nearly half of DS pts die within 5yrs from complications
i. Often noncompliance w/ tx and f/u
h. Area of needed research (biological, environmental, social)
2.

Vulnerable Elders-When It Is No Longer Safe to Live Alone

a. Most common report to APS
b. Often discounted as part of getting older or lifestyle choice
i. Adults are presumed to be autonomous
c. Social Security Act protects against abuse from others, but self abuse is not as well understood
d. VAST-Vulnerable Adult Specialist Team

3.

i. Referral for lack of utilities, poor hygiene, unsafe environment, cognitive disorders, questionable Rx
adherence, needed capacity evaluation
1. Possibly multiple reasons
e. Consequence of untreated medical dzs (hypothyroidism, DM, CA
i. Also health hazards in conditions
f. Limited access to tx or denial of tx (poor judgment ability)
g. Poor living conditions are not always easily apparent, so pts will be discharged back to unsafe conditions
h. Is very common (prevalence of 50.3% to 39.1% or higher)
i. Increasing awareness AND reports of self neglect
1. Demographic shift to more elders
- Qualify of life and economic consequences
i. Change in ability to pts and carry out taskscant take steps needed for appropriate self-care
j. It is wrong to impose medical or social remedies on eccentric elders who have capacity, but should not allow living
in extreme squalor (ex: no utilities)
k. There is not much evidence to guide intervention w/ APS
i. Public health, legal, medical, nursing problem to address
ii. Research has cost-containment potential and could improve overall quality of life for elderly pts
The ETHNIC(S) Mnemonic: A Clinical Tool for Ethnogeriatric Education
a. Large health disparities among older people from different racial and ethnic groups
b. Cultural competency involving awareness and acceptance of cultural difference, self-awareness, knowledge of pts
culture, and adaption of medical skills.
i. Training for this has been proposed at every level of healthcare professional training
c. Real-time availability of language services is important and remains problematic
d. Illness Explanatory model (EM)negotiate acceptable tx
i. LEARN-Listen, Explain, Acknowledge, Recommend, Negotiate
ii. BATHE-Background, Affect, Trouble, Handling, Empathy
iii. ESFT-Explanatory model, Social and environmental factors, Fears and concerns, Therapeutic contracting
e. ETHNIC-addresses cross-cultural healthcare in 15-minute visits in a variety of healthcare settings
i. EXPLANATION-Why do you think you have this?
1. What do others say about these sx?
2. Do you know anyone w/ this kind of problem?
3. What have you learned about this in the media?
4. What concerns you about this problem?
ii. TREATMENT-What have you tried for this?
1. Pt might only share what they think would be acceptable to the provider, so ask explicitly w/o
judgment
2. What do you eat/drink/do/avoid to stay healthy?
3. What tx are you seeking from me?
iii. HEALERS-Who else have you sought help from for this?
1. Have you consulted alternative/folk healers, friends, other non-doctors?
iv. NEGOTIATE-How best do you think I can help you?
1. Find options that are mutually acceptable and incorporate pts beliefs
- Try to not contradict pt beliefs
2. Focus on functional outcomes and sx relief
v. -NTERVENTION-This is what I think needs to be done now
1. May also incorporate alternative tx, spirituality, healers, and cultural practices
vi. COLLABORATE-How can we work together on this?
1. Who else can we work with?
- Family members, healers, community resources
vii. SPIRITUALITY SENIORS-What role does faith, religion, spirituality plays in helping you with this?
1. What is your spiritual life like?
2. Can be very effective as establishing trust/rapport
f. ETHNIC is not a scoring sheet nor detection scheme, but a tool for eliciting and negotiating cultural issues during
healthcare encounters
i. Does not address a lot of other barriers like sensory disabilities, discrimination, and bias.
g. It is important to avoid stereotyping, maintain respectful communication, and foster empowerment in
relationships w/ elderly pts

4.

Geriatric Pharmacology
a. Individuals 65 and older are leading consumers of medications
i. Might herbals/OTC or Rx
ii. More are taken in nursing homes (9 avg) than community (4 avg)
b. #1 reason for nursing home admittance is urinary incontinence
c. More doctors, more prescription errors
i. Error is they are allergic (looking at algorithm, not pt)
ii. Error is the wrong dose
d. Any sx in an elderly pt should be considered a drug SE until proven otherwise
i. An easy fix
e. Noncompliancemedication related problemsmajor health care costs
f. Elderly at greater risk for medication problems
i. Multiple chronic diseases
ii. Multiple Prescribers (lack of geriatric trained)
iii. Multiple medications, types
g. Aging changes the special senses, oral health (dry mouthinfection), CV, GI (hypochlordydriahigher pH and
constipation), and metabolism
h. Aging affects pharmacokinetics
i. Decreased 1st pass effectmore bioavailable in plasmamore SEs
ii. More keratinized skin, less skin lipids/circulation/hydration decreased absorption from transdermal
patch
iii. Slow GI, less blood flow, higher gastric pHdelayed onset/peak but NO change in quantity absorbed.
iv. Less m. mass and blood flow, more CTless IM absorption
v. Less body water, more body fat (think about lipo/hydrophilic Rx
vi. Less albuminless Rx bindingmore free Rxmore SE
1. Have to decrease Ca doseavoid kidney stones/CV problems
vii. Have less liver mass/blood flowless phase-I metabolismless clearance and longer H/L
1. Phase II metabolism and CYP 450 activity are unchanged
- CYP 2D6 increases w/ age (2 even numbers=more)
- CYP 1A2, CYP 2C19 decrease (1 odd, 1 even=less)
viii. Lifestyle can induce/inhibit enzymes (Smoking/ETOH/Drugs/etc)
1. Hx is important, change dosing
ix. Creatnine clearance is an important measure of physiologic changes that need to be accounted for w/
doseprevent toxicity
x. -CrCl decreases starting at 25yo (50% by 85)
i. Aging affects pharmacodynamics
i. Increased receptor sensitivity to benzos, warfarin, opioids
ii. Decreased receptor sensitivity to beta blockers
iii. Decreased baroreceptor sensitivity
1. Ortho HoTN w/ vasodilators, tricyclic anti-depress, BP meds
iv. Antipsychotics are NOT tx for dementia
v. Decreased renin/ALD levelsmore risk for hyperkalemia
j. No apparent pharmacogenomics issues in terms of changes as adults
Ethnicity plays a role in speed of metabolizing Rxs
k. Clinical response=Pharmacokinetics + Pharmacodynamics + Individual Variance
i. Interpatient variability makes it difficult
1. Dz, nutrition, adherence, other meds
l. Non-adherence from not filling Rx, used not as intended
i. Costincreases/decrease use (cant pay, use if perceived as better b/c expensive)
ii. From dementia, cant read, in denial, cant open containers, too large to swallow, complicated regimens,
dont understand instructions
m. Avoid using another medication to tx a SE of another agent
n. Adverse effects
i. Most commonly confusion, cognitive impairment, falls, GI probs
1. benzosfalls
ii. Anticholinergic Effects: Cant see, spit, pee, and poop
iii. The Beers Criteria-criteria for determining meds bad for elderly
1. High Severity=adverse outcome likely, clinically significant

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Sliding Scale Insulin was added in 2012

Screening Tool of Older Persons potential inappropriate Prescriptions (STOPP) is a better
predictor
o. Common Drug-Drug Interaction players: Warfarin, ACE Inhibitors, Digoxin, NSAIDS, ETOH
i. ETOH-7 standard drinks/wk (Max 2 drinks per occasion )
p. Avoid polypharmacy by thinking about SEs, risk factors, risk: benefit, compliance
q. Start w/ low dose and titrate up
r. Use one Rx that will tx more than one problem
s. ARMOR-emphasizes quality of life in medication regimes
i. Assess
ii. Review
iii. Minimize
iv. Optimize
v. Reassess
t. Choose the ADR w/ least trouble for the Doctor, Pharmacist and Pt
i. Geriatric pts are the most complicated pts.
ii. Ways to Enhance Adherence/Compliance
1. Clear written and verbal instructions
2. Simple dosing schedule daily when possible
3. Decrease number of medications
4. Use adherence aids (Pill box, Calendar, iPad apps)
5. Reminder calls from family member or friends
iii. Behavior modification
Do a medication check up regularly and discuss and agree all changes with patient/ caregiver
a. Ask allergies, history ADRs, use of tobacco, alcohol or recreational drugs (specific drugs; marijuana, cocaine, meth,
etc.)
Dose should Start Low, Go slow aka titrate
Recommend dosage reduction when appropriate
Stop all medications that are no longer indicated
Prescribe new medications only if it has a clear indication
If possible, avoid medications that have deleterious effects in older patients (e.g. Beers list)
Limit the number of prescribers if possible
Herbal Products are not regulated, are inconsistent
a. Vary by when picked, light exposure, temp
Herb=A flowering plant or plant part valued for its medicinal, savory or aromatic qualities.
Botanical Medicine/Phytomedicine=A substance derived from plants. A vegetable drug especially in the crude state that has
a medicinal use.
Think about interactions w/ herbals, Rx, OTC
Dont stop Rx abruptly for herb replacements
Avoid herbals during pregnancy and lactation (exception of ginger)
Some herbals have bad adverse effects (ex: Kava) so check
Avoid giving herbals to infants/children
Black Cohosh-like estrogen, for menopausal hot flashes, may induce miscarriage (DONT use if pregnant)
Cranberry-has anthocyanininhibits E. Coli adherence, tablets can cause urinary stones (oxalate)
Echinacea-immune stimulant, prevent/tx colds, only active if HOT, cross sensitivity w/ sunflower seeds
Garlic-tx lipids/HTN/PAD/DM, prevents some CA
a. Has alliincoverted to allicin (pungent aroma)bad odor/breath
Ginkgo Biloba-memory/anxiety/stress, D-D interaction w/ ASA, Coumadin, AntidepressantsBLEEDING
Ginseng-memory, SEs of HA, BP, Tachy, Bleeding, vag bleeding
Milk Thistle-gallbladder and liver probs, SHORT shelf life (3mo), cannot be given as a tea.
Saw Palmetto (Serenoa Repens)-Tx for BPH, sex hormone probs, inhibits 5-alpha-reductase, only for men
Soy-phytoestrogens, prevents CA, menopausal sx, osteoporosis, CV dz
St Johns Wort-for depression/pain/anxiety/insomnia

Fall Prevention
1. Falls are the leading cause of death and disability in the elderly
a. Small % die, large % go to EDlots of cost
b. Downward spiral from fall injury

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3.

4.

i. Leading cause of traumatic brain injury in elderly

ii. Fractures
iii. Fear of falling againlimit activity
Risk factors-ask about these things during HPI/ROS
a. Demographics-Over 75yo, white, live alone, housebound
b. Hx-fallen before, use assistive device, acute illness, chronic conditions (esp neuromuscular, like PD), Rx, nutritional
deficiencies, depression
c. Physical-Cognitive deficits, special sense probs, foot probs, neuro changes (decreased w/ age), difficulty rising from
chair.
d. Environmental hazards
Assessing risk
a. I
Inflammation of joints (or joint deformity)
b. H
Hypotension (orthostatic blood pressure changes)
c. A
Auditory and visual abnormalities
d. T
Tremor (Parkinson's disease or other causes of tremor)
e. E
Equilibrium (balance) problem
f. F
Foot problems
g. A
Arrhythmia, heart block or valvular disease
h. L
Leg-length discrepancy
i. L
Lack of conditioning (generalized weakness)
j. I
Illness
k. N
Nutrition (poor appetite; weight loss)
l. G
Gait disturbance
m. Morse Fall Risk Assessment Score (MFS)
i. 51 or higher=high risk
ii. 25 to 50=low risk
iii. 0 to 24=no risk
n. Get up and go testmore than 10 secondsincreased fall risk
Prevention
a. Vit D/Cabetter bone density, nervous system, muscle strength better posturereduced falls
b. Exercise (at least 50 hrs of training)
i. Walking, tai chi, dance, physical therapy, community-based
c. OMT to help gait
d. Minimize high-risk Rx-(benzos, SSRIs, Tricyclics, anti-HTN, narcotics, neuroleptics, anti-epileptics, sleep aids)
e. Screen for depression (risk factor and comorbidity w/ falling)
i. Little interest/pleasure in doing things?
ii. Feel down/depressed/hopeless?
f. Safety evaluation of environment/living situation
g. Assistive devices

Osteoporosis
1. Fallsfracturesincreased mortality-20% (esp hip fx)
2. Most common osteoporotic fx=vertebral
3. Most devastating osteoporotic fx=hip
4. Measuring BMD
5. Risk Factors
a. BMD, age, prior fxstrongest predictors of fracture risk
b. Also glucocorticoid therapy, fam hx (1st degree relative), low BMI, cigarette smoking (esp currently), excessive
ETOH
c. RA, Lupus, IBD, Celiac, bariatric surg, CF, Hyperthyroidism, Hyperparathyroidism, DM, RD, Leukemia, Lymphoma,
Multiple Myeloma, PD, MS
6. Assessment-10 yr probability of major osteoporotic fx in untreated pt
a. T/Z-score and clinical risk
b. FRAX-T-score or total hip BMD
c. Measure BMD
i. Gold standard is Dual energy X-ray absorptiometry (DXA)
1. Not portable, expensive, low dose ionizing radiation
ii. Peripheral DXA (pDXA)-in forearm, calcaneus, finger

1.

Technical differences, variation in these bone regions, dont have stand reference database to
get T-scores
iii. Quantitative CT-measures volumetric BMD
1. Can isolate trabecular bone from cortical bone
2. -Less reproducible, higher radiation dose than DXA
d. Quantitative US
i. Does not measure BMD, but other parameters
ii. No studies showing reduced fx risk, cant measure tx response b/c changes are too slow
e. F/U BMD testing did not improve predictive value of fx risks
i. Interval testing-maybe some value, but only after 2 yrs
f. Bone turnover markers are associated, but varyconfounded use
7. Screening (BMD testing)
a. USPSTF recommends screen women older than 65 or younger w/ a risk equal to or greater than 65yo white
women w/ no additional risk factors
i. Younger postmenopausal women
ii. Men over 70yo
iii. Men over 50yo w/ that increased risk (ex: previous fx)
8. Prevention
a. Check for risks/causes
b. Advise Ca and Vit D
c. Regular weight bearing and muscle strengthening exercise
d. Avoid smoking and excessive ETOH
9. Treatment Recommended
a. Hip/vertebral fxs
b. T-score of -2.5 or more
c. Post-meno women or men over 50yo w/ T-score -1 to -2.5
d. FRAX greater than 3% risk
10. BMD AND clinical risk factors (together)best estimate of fx risk
11. Screen and tx early to reduce morbidity/mortality
Pressure Ulcers
1. Localized injury to skin/underlying tissue (pressure/shear)vascular inflow impairmentischemiatissue damage (decubitus
ulcers, bedsores, pressure sores)increased morbidity/mortality
a. Mostly elderly or younger pts w/ neuro impairment/severe illness
i. Common denominator=limited mobility
b. Higher the stagethe worse the healing within 6 mo
c. 2nd leading cause of litigation in long term care
2. #1 Sacrum, #2 Heels for areas of development
3. Intrinsic risk factors
a. Limited mobility
b. Poor Nutrition
c. Comorbidities-cognitive, CV, etc
d. Aging skin-thinner, drier, less elastic, w/ slow healing
4. Extrinsic risk factors
a. Pressure-hard surface
b. Friction-poor movement in bed
c. Shear-involuntary muscle movements
d. Moisture
5. Prevention
a. ID at-risk pts
b. Inspect skin daily
c. Wash with warm water (NOT hot)
d. Lubricate skin
e. Avoid bony prominence massage (added pressure, friction)
f. Reduce pressure-reposition, mattress overlays, heel protectors
i. Do NOT use donut cushions
g. Manage incontinence-reduce moisture
h. Positioning

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7.

Assessment
a. #, location, size, exudate (none/slight/moderate/copious and serous/serosanguinous/purulent), odor, necrosis,
infection, healing,
b. margins, sinus tracts, tunneling
c. Stage 1-non-blanchable redness over bony, compare elsewhere
i. Tx: protective dressing
d. Stage 2-shallow open ulcer (dermis lost) w/ red-pink wound or intact/ruptured blister
i. Tx: moist dressing, clean the wound
e. Stage 3-full thickness of skin lost, possibly exposing subcutaneous fat, may includes undermining and tunneling
i. Tx: most/absorbent dressing, surg consultation, clean at each dressing stage
f. Stage 4-exposed bone, tendon, or muscle, often includes undermining and tunneling
i. increased risk of osteomyelitis or osteitis
ii. Tx: same as stage 3
g. Unstageable if base of ulcer is covered by slough
i. Dont remove stable eschar
h. DO NOT REVERSE STAGE (once stage 4, always stage 4)
i. Keep original stage and add healing descriptors
Tx: clean, ABs (topical or systemic based on local or systemic infection)
a. DONT use antiseptic agents
i. They destroy granulation tissue
b. Debridement of necrotic tissue
i. For advancing cellulitis or sepsis
1. Sharp debridement: sterile scalpel or scissors
ii. Non-urgent
1. Mechanical debridement
2. Autolytic debridement
- complete wound healing not the main goal
3. Enzymatic debridement
4. Biological debridement: larval or maggot therapy
c. Transparent film: semi-permeable adhesive
i. not for infected or draining wounds
d. Hydrogel-fill dead space tissue w/ impregnated gauze, sooths pain, rehydrates wound bed, can be used w/
infected or deep wounds
i. Not for wounds w/ heavy exudate
e. Alginate-from brown seaweed absorbs a lot (heavy exudate)
i. Not for light exudate, dry, superficial woundsdehydrates
f. Foam-Nonadherent, absorbs exudate
i. Not for dry eschar
g. Hydrocolloid-semiocclusive dressing, facilitates autolytic debridement
i. Not for heavy exudate, sinus tracts, infection, packing
h. Moistened gauze-soaked in saline, but be remoistened often
i. Refer to specialists for skin flaps/grafts, wound vac, electromagnetic therapy, and vascular surgery

Choosing Wisely
1. More CA and CA deaths, CA acts differently in the elderly
a. Acute Myeloid Leukemia, ovarian CA, Non-Hodgkins Lymphoma have worse px
b. Breast CA has a more idle course
c. W/ CA screening, think about the pt, would they benefit?
d. Radiation is generally well-accepted in elderly
i. Caution w/ chemo-radiation
e. Age is not a contraindication of chemotherapy
i. Increased risks for myelosuppression, neuropathy, cardiac toxicity, mucositis, dehydration, electrolyte
abnormalities, malnutrition
1. Adjust dose or substitute drugs
2. Screen if
a. High prevalence, serious consequences, detectable preclinically, tx is better if applied before sxs
b. Tests should be simple, inexpensive, high sensitivity/specificity
3. Life expectancy-functional status AND comorbidities

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9.
10.

11.

12.
13.
14.
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16.
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18.

Colorectal CA
a. USPSTF-Screen all average-risk 50-75yos every 10yrs
i. Dont do routine screening 76-85yo
ii. Dont screen over 85yo
b. ACG 2008-colonoscopy every 10yrs start at 50yo (45 for AA)
i. If fam hx40yo or 10 yrs younger than youngest relative dx
Breast CA
a. USPSTF-every 2 yrs for women 50-74yrs
b. AGS-extends up to age 80
c. ACS and ACOG-every yr starting at 40yo
d. MRI is NOT recommended to screen w/ average risk pts
Cervical CA
a. Stop screening w/ 3 nml Paps in the last 10 yrs and pt over 65yo
Ovarian CA
a. Screen only w/ strong fam hx
b. Early sxsCa 125, TVUS (controversial)
Prostate CA
a. Screening indication is blurry (dont screen about 75yo though)
b. DRE for 50 yo (45 if fam hx, or AA pt)
Bladder CA
a. Evidence is insufficient to screen w/o sx
Lung CA
a. Screen w/ low-dose CT if 55-80yo and 30pk/yr smoking hx and currently smoke or quit within the last 15yrs
i. Discontinue if quitting date becomes more than 15yrs ago
DVT
a. Dont work up clotting disorder on 1st DVT episode
b. Dont repeat US DVT if no clinical change
Bacteriuria
a. No adverse outcomes w/ asymptomatic bacteriuria
Carotid A. Imaging
a. Focal neuro deficitsfainting (not occlusive a. dz)
Stress Cardiac Imaging
a. Dont perform w/o cardiac sx unless DM w/ pts over 40yo, PAD, greater than 2% yr risk for HD events
Low Back Pain
a. Dont do imaging for LBP within 6 wks unless red flags
i. severe/progressive neuro deficits, osteomyelitis
Sinusitis
a. Dont give AB unless sx 7 days or more
Feeding Issues
a. Dont recommend percutaneous feeding tubes w/ advanced dementia
i. Pressure ulcers, more restraints, no improvements
-End Stage Renal Dz
a. Chronic dialysis decision is an individual one (based on Px)