Upload
mariah-lloyd
View
232
Download
0
Tags:
Embed Size (px)
Citation preview
Alycia Cleinman MD
Assistant Professor
Geriatric Medicine
77 yo man with few months of anorexia, weight loss (10-15 #), nausea and diarrhea, malaise, fatigue, and falls.PMHx: paroxysmal Afib, HTN, glaucomaMeds: Digoxin, lasix, lopressor, quinidine, ASA
VS stable except pulse 42, regular. Otherwise unremarkable exam.
What could be cause of anorexia, wt loss, GI upset?
Adverse drug reactions are increased 2-3x in elderlystrongly correlates with polypharmacy increased comorbidity
drug-disease interactionaltered pharmacokinetics related to body
composition changes and hepatic/renal alterations
Adverse drug effects may be subtleFallsAnorexiaCognitive ImpairmentFatigue Urinary IncontinenceConstipation
Body composition changes↑ body fat↓ body water↓ serum albumin
Changes in body composition can alter drug distributionLarger volume for distribution
Lipophilic eg Diazepam, trazodone Longer half life & duration action
Smaller volume for distribution Hydrophilic
Eg PCN Shorter half life & duration action
Physiological changesDelayed gastric emptyingSlowed GI motility
Drug Absorption Slowed rate of absorptionLower peak concentrationsVariable transdermal absorption
CNSAge related changes
↓ blood flow & O2 ↑ BBB permeability
Increased sensitivity Anti-cholinergics & sedating medications
Hyponatremiathiazide diureticsSSRI’shigh-dose narcotics
HyperkalemiaPotassium- sparing diuretics
eg spironolactoneACE inhibitors, ARBsNSAIDs
86 yo female with Alzheimer disease, GERD, and arthritis is admitted to hospital after a fall resulted in a hip fracture. She is very lethargic on your exam and her family reports this is a change from her normal mental statusMedications: donepezil, memantine, pantoprazole,
tylenol Plus inpatient meds – morphine, promethazine,
diphenhydramine, cyclobenzaprine
Which medications could be resulting in altered mental status?
What is best option for her pain?
Potential Side effects confusion, gait instability, dry mouth, constipation,
urinary retentionMedications with anti-cholinergic properties
Anti-depressants (amitriptyline) Anti-spasmodics (oxybutynin, dicyclomine) Anti-histamines (diphenhydramine, hydroxyzine) Anti-emetics (phenergan)
Anticholinergic drugsNarcoticsBenzodiazepinesL-dopa, bromocriptineprednisoneNSAIDscimetidine
WarfarinAntibiotics (FQs), herbals, and other meds
may increase bleeding risk and increase INR
SSRIs, SNRIs, tramadol, zyvoxCombination can increase risk for serotonin
syndrome
86 yo man with CHF, AFib, and Parkinson Disease is under your care in a NH. The nursing staff asks you to write an order for a physical restraint while he is in a wheelchair. They report that over the last 2 weeks he has become more confused at night with restlessness and that his gait is more unsteady. When he tries to walk, he needs the assistance of a nurse’s aide.
Medications: Furosemide, Digoxin, Levodopa-Carbidopa, Bromocriptine, Nitrate Patch, Diazepam
What could be contributing to his gait instability?
PUD NSAIDsBPH anticholinergicsCKD NSAIDs Syncope or falls Benzos, antidepressants,
neuroleptics, BP meds, oral hypoglycemicsProlonged QTc fluoroquinolones,
azithromycin, SSRIs, antipsychotics
ScreeningHearing handicap inventory for the elderly
10 item questionnaire - Impact of loss on daily activities
Handheld otoscope with tone generatorPresentation
Tinnitus – can be early symptomCognitive impairment
Examine ear canals for impactionHo TM sx or perforation – refer to ENT for
removalCerumenolytics – 40% effectives
Medication reviewLasix, salicylates, aminoglycosides, vancomycin
Asymmetrical lossmore concerning for a tumor
Comprehensive audiologic assessment
Personal amplifier/Adaptive equipmentHearing aids Bone anchored hearing aids
Use if:Unilateral hearing lossUnable to tolerate hearing aid in canalConductive/mixed hearing loss
Cochlear implantsSevere to profound hearing loss
with little/no benefit from aidPossible complication
Meningitis
A 78-year-old F with PMH HTN is seen in clinic for her medicare wellness visit reports falling once in past year. She tripped over her cat while going to the toilet at night in poor lighting. She denied injuries, LOC, preceding symptoms.
Home Medications: lisinopril.
On physical examination, BP 138/85 mm Hg, negative orthostatics.
Which of the following is the next step in the management of this patient?
A Assess gait and mobility
B Discontinue lisinopril
C Prescribe an exercise program
D Provide a standard walker
E Order Hip protectors
Consequences
Functional decline
Fracture (10-15%)
Head trauma/serious soft tissue injury (5%)
MCC of injury-related death
Increased use of medical services & NH
placement
Inquire about falls annuallyTake detailed history
Circumstances, frequencyAssess risk factors
Home hazard, sensory impairment, dz, meds, etoh, pets
Perform physicalGait assessment, orthostatics, visionStrength, ROM, sensation, proprioception, reflexes
Focused Labs/ImagingVitamin D, TFTs, Chemistry, B12MRI (Cervical, lumbar spine); Head CT Nerve conduction studies/EMG
Timed Get-Up-and-Go testGet up from chair, walk 10ft, turn around & sit
Less than 10 sec normal10-20 sec moderate fall risk>20 sec high fall risk
Balance assessmentPull testSemi-Tandem stanceTandem (heel-to-toe) walk
POMA (Tinetti)Balance + Gait
Antalgic gaitFestinationFoot dropFreezing of gait
PropulsionRetropulsionSteppage gaitTurn en bloc
Medication reviewAppropriate footwearAssistive devicesTreat vision impairment Life Alert systemsHome safety evaluation (OT)
Exercise Balance & resistance training
Tai chi - ~50% reductionVitamin D replacement/supplementationOsteoporosis evaluation and treatment if
necessary
A 76 yo man with PMH mild dementia, macular degeneration is seen in clinic for follow-up. His daughter reports she has concerns over his driving, as he confuses the gas & the brake sometimes and has hit the mailbox. The patient reports he is a good driver and denies these events. He has not had any recent traffic tickets or accidents with other vehicles. He scores 22/30 on the Mini–Mental State Examination. He lives in an area with nearby stores and his family is able to drive him to places he needs to go.
Which of the following is the most appropriate recommendation regarding driving for this patient?
A Limit driving to daytime and local roadsB Allow patient to continue driving without restriction C Instruct patient to immediately stop drivingD Recommend a driving evaluation
Vision impairmentRestricted mobility
Arthritis, foot drop, cervical dzCognition (ie judgement)NeuropathyParkinsonian diseases
RigidityMedication side effects
Sedation (decreased reaction time), dizziness
Office assessmentVision
Fields & acuityCognition
Visuospatial, Executive functionMusculoskeletal exam
Strength; ROM of neck, trunk, & extremitiesSensation & proprioception
Driving assessmentDriving rehabilitation specialistDMV
65 y/o F with PMH HTN c/o being more forgetful over the past 6 mo. She is losing items and forgetting names of distant friends, which is new for her. She no longer is interested in attending church or lunch with her girlfriends. She reports only sleeping 4 hours a night and has lost 10lb over this time period. She denies depressed mood, hallucinations, or gait changes.
Her physical exam is unremarkable; Mini-Mental State Examination (MMSE) score 23/30; Geriatric depression screen (GDS) 15/30
Results from basic blood work, including thyroid function studies, are normal. An MRI of the brain shows no abnormalities.
Which of the following is the most appropriate next step in management?A Start remeronB Start amitriptylineC Start paroxetineD Start donepezilE Start quetiapine
Prevalence – 6-10% primary care clinic12-20% NH residents
Presentation in Elderly -Less frequently report depressed mood “Pseudo-dementia”Overlap with chronic illness in somatic
symptoms
Clinic setting -Initial visit then annual
Nursing home -Within 2wk of admission then every 6 months
Screening Instruments – PHQ-9GDS
Evaluate for co-morbid conditionsHypothyroidism Substance abuse
1st line – SSRI Preferred – sertraline, citalopram, escitalopram
Paroxetine, fluoxetine (long half life) Beers criteria –
TCA – anticholinergic, sedating, OH Preferred TCAs – nortriptyline, desipramine
Weight loss or insomnia Mirtazapine QHS
Aggressive acute phase treatment to bring about remission Follow-up in 4 weeks to re-assess
Continuation tx to prevent relapse Additional 6mo after symptom remission
Maintenance tx to prevent recurrence 3 or more years for depression with psychosis,
suicidality, or recurrent episodesAddition of psychotherapy if psychosis or suicidal
A 65 y/o F with severe COPD is referred to palliative care clinic with persistent complaints of dyspnea. She wears her oxygen at all times . On exam – oxygen saturation 94%, clear lung fields bilaterally. An acceptable quality of life for her would be to spend time with her dogs and husband outside, without having constant dyspnea.
What should be done next in the management of this patient’s dyspnea?
a. Explain to her that oxygen saturation is in the mid 90’s and she does not need to worry
b. Recommend addition of spironolactonec. Recommend morphine immediate release elixir 2.5-5 mg
every 4 hours as neededd. Recommend she increase her oxygen from 2 to 4 liters
Palliative careGoals
Relieve physical/emotional suffering, optimize function, assist with MDM for pts with advanced dz
May be provided regardless of whether the patient is receiving curative or disease-modifying treatment
HospiceComprehensive care for pts with life
expectancy ≤6 months
Dyspnea Opioids*
Oral & parenteral effectiveNebulized morphine not shown to be helpful
Supplemental oxygen, cool air (fan)Benzo – if anxiousDiuretics - if volume overloaded
Increased respiratory secretionsAtropine drops, glycopyrrolate, scopolamine,
Hyoscyamine
Painopioidsalternative routes of delivery
suppositories, transmucosal formulations, SC
Bone pain NSAIDs*, steroids*Bisphosphonates, calcitonin, radiation (mets)
Nausea/vomitingHaldol*, ondansetron, steroidsReglan (dysmotility), PPI/H2 Blocker (gastritis)Anti-histamines, antivan, phenergan – with
cautionDiarrhea
Check for impactionCholestyramine, octreotide
ConstipationProphylactic bowel regimen if receiving opioids
fecal softener (eg, docusate) + bowel stimulant (eg, senna, bisacodyl)
Can addosmotic laxative (eg, sorbitol, lactulose, or
polyethylene glycol) Lubiprostone
If no bowel movement for ≥4 days – check for impaction/obstruction & consider enema
opioid-induced constipation Methylnaltrexone
A 94 y/o F with moderate dementia, vision/hearing impairment was hospitalized for CAP. She was started on Levaquin and 2 days into her admission began “talking out of her head” according to her family, which is a change from her baseline.
On exam - T 37.3C, BP 108/56 mmHg, HR 95/min, RR 16/min, O2 sat 94% on ambient air, thin, inattentive, lungs with rhonchi over posterior right base (unchanged from admit), no focal deficits. All home meds were continued on admission including: omeprazole, rivastigmine, lorazepam PRN.
LABS - normal serum electrolytes/glucose Cr 1.4 (up from 1.2 on admission)CBC with WBC 10 (down from 14 on admission) UA negative
Which of the following would be the best next step?
A Haloperidol, restrain for safety B Change antibiotics, bedside observerC Olanzapine, head CT D Risperidone, EEGE Short acting benzodiazepine, head
CT
~1/3 hospitalized elders have delirium50% present on admission
Prevalence increased in ICU & hospice settings
May persist for weeks to months in subsetOlder, dementia, functional impairment,
multiple co-morbidities; restraint use & delirium severity
Independently associated with poor patient outcomesIncreased risk of death, institutionalization, &
dementia
Confusion Assessment Method (CAM) Most useful bedside assessment tool Requires presence of 1 + 2 + (3 or 4)
1. Acute change in mental status & fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness
CAM - ICU Designed for non verbal/vent dependent pts Sensitivity lower than traditional CAM
Under-recognition is HUGE Standardized screening of ICU, post-op, very
elderly pts Daily; aids in recognition of hypoactive delirium
Baseline riskAdvanced ageDementiaImpairment with ADLsHigh medical comorbidityLab abnormalities
Dehydration, sodium, thyroidSome evidence
Males, sensory impairment (hearing, vision), depression, alcohol abuse
Acute riskMedications
sedating, anti-cholinergic
withdrawlSurgeryUncontrolled painAnemiaBed rest
Indwelling devices & restraints
InfectionStrokeMIUrinary retentionFecal impaction
FIRST STEPTake a history – patient, support staff, family
Includes chart reviewFull physical exam THEN Targeted labs, imaging, other
diagnosticsREMEMBER
Typically multiple contributing factors
MedicationsBEERS CriteriaEffect OR withdrawl
InfectionsFluid balance
Dehydration, heart failureElectrolyte Disturbances
Sensory deprivationEyeglasses, hearing aids/amplifiers
Elimination issuesFecal impaction, urinary retention
Impaired CNS oxygenationAnemia, hypoxia, hypotension
Severe pain
ALLCBC, chem8
ConsiderUA, UDS, LFTs, ABGCXR, EKG, cultures, troponinEEG if seizure activityLP if meningitis suspectedHead CT/Brain MRI
if head trauma suspected or focal findings on neuro exam
Behavioral InterventionsFamily visitationDaily reorientationSleep-wake schedule
Avoid unnecessary interventions at nightLimit tethers & ties
Pharmacologic InterventionLow dose, short term antipsychotics
Haldol, risperidone, olanzapine, seroquelRemember to check EKG to evaluate QT interval
What do I do if they have prolonged QT interval??Remember to taper off as soon as possibleAvoid 1st generation antipsychotics in LBD & PD
Opt for seroquel Ativan – IF benzo or ETOH withdrawl
Urinary incontinenceScheduled toileting program
Immobility/FallsPhysical therapy – MOBILIZE THAT PATIENTAvoid restraints – they are NOT your friend
Opt for 1:1 sitter
Pressure ulcersMobilization – can I hear it again?!Repositioning if immobileMonitor pressure points
Sleep disturbanceSleep hygiene is your best option
Feeding disordersAssist with mealsAspiration precautionsNutritional supplements at snacks
EnvironmentNoise reduction, lighting, familiar objects
Cognitive reconditioningReorientation TID
ADL performanceFamily education/supportTime for discharge
Providing support services at home or facility
Hospital Elder Life Program (HELP) Interventions/Risk factors
Cognitive impairmentSleep deprivationImmobilityVisual/Hearing impairmentDehydration
A 75-yo M is admitted to rehab after having a stroke 2 wk ago. He has residual right-sided paralysis, aphasia & urinary incontinence. He spends most of the day in bed or in a chair and needs assistance with all ADLs. The patient has a poor appetite, cannot use his right arm to feed himself, and is eating only half his meals. He also has intermittent urinary incontinence.
Which of the following is the most appropriate intervention for preventing pressure ulcers in this patient?
A An air-fluidized bed
B A doughnut cushion when seated
C A foam mattress overlay
D Bladder catheterization
E Massage of skin over pressure points
Any process rendering immobility for extended time period
Intrinsic risk factorsAge, poor nutritional status, decreased
arteriolar blood pressureExtrinsic risk factors
Friction, shear, moisture, urinary or fecal incontinence
Skin care (Limited evidence)Daily skin inspectionSkin cleaning with mild agent; MoisturizerDo NOT massage over bony prominencesAvoid skin exposure to wound drainage, urine,
feces, perspiration
Nutrition (inconsistent studies)Do NOT OVER-supplement pts with protein,
vitamin, mineral supplements evidence is lacking if no deficiency
Optimal nutrition is part of national pressure ulcer prevention guidelines
Mechanical off-loadingMinimize friction/shear Reposition q2HUse of bed positioning devicesDo NOT use seating cushions (ie doughnuts)
Support surfaces (pressure redistribution device) Use with any pt at risk No one surface superior but all superior to standard
mattress Two types of devices
Static: foam, static air, gel/waterDynamic: alternating air, low air loss, air fluidized
Which to use?Static is less expensive so used in most Use dynamic IF:
“bottoming out” (surface compressed to <1 inch) Reactive hyperemia despite static support use
Dynamic airflow potential adverse effectsDehydration, sensory deprivation, difficulty with
mobilization
Suspected Deep Tissue Injury Purple with intact skin/blister
Stage I Non blanching erythema
Stage II Partial thickness loss of dermis
Stage III Full thickness tissue loss
Stage IV Exposed bone, tendon, or muscle
Suspected Deep Tissue Injury Purple with intact skin/blister
Stage I Non blanching erythema
Stage II Partial thickness loss of dermis
Stage III Full thickness tissue loss
Stage IV Exposed bone, tendon, or muscle
A 77-year-old F is transferred to SNF after a 2-wk hospital stay for hip fracture repair. Her hospital course was complicated initially by a lower gastrointestinal hemorrhage and subsequent bacteremia from an intravenous line.
Her vital signs are within normal limits. She is alert and oriented to person and date. She appears thin. She has a 4 x 5 cm pressure ulcer over her presacral area that extends through the skin, but no muscle or bone is exposed. The ulcer is debrided with little exudates. There is minimal surrounding erythema.
Which of the following is indicated for the pressure ulcer?
A Calcium Alginate dressing
B Hydrocolloid dressing
C Short course of systemic antibiotics
D Silver sulfadiazine cream
E Vacuum-assisted closure device
Location
Stage
Area
Depth
Drainage
Necrosis
Granulation
Cellulitis
Transparent filmi.e. tegadermStage I & IIc/i if draining or suspected infection
Foam islandi.e. allevyn, lyofoamStage II & III; with lo-mod exudatec/i if excessive exudate or dry/crusted
Hydrocolloids i.e. duo-derm, tegasorbStage II & III; with lo-mod drainageGood for autolytic debridementremains in place 3-5 daysc/i poor skin integrity, infection, packing
Alginatei.e. AlgiDERM, Sorbsan, AlgosterilStage III, IV; excessive drainagec/i dry/min drainage, superficial with
maceration
Hydrogel Gel or sheet – Intrasite, vigilon, restore Stage II, III, IV c/i macerated, excess exudate
Gauze packing (moistened with saline) Stage III/IV c/i deep wounds, tunneling
Silver dressings ie aquacel Ag, silvadene Malodorous wounds; hi exudate; suspected local infection;
slow healing c/i systemic infection, cellulitis, fungus, skin necrosis,
leukopenia, interstitial nephritis
RecommendationsWet-to-dry discouragedHydrocolloid preferred
Require fewer dressing changes; block bacteria; maintain moist environment
Pick a dressing based on stage, amount of wound exudate, suspected infection
Performed if necrotic, devitalized tissue present – as it prevents healing
Four types Mechanical: wet-to-dry, hydrotherapy
Can remove vitalized tissue; painful Enzymatic: topical agent
Use if no infection present; damage surrounding skin Autolytic: synthetic dressings allow self digestion
Use if no infection present & no other method tolerated; takes longer for effect
Sharp: scalpel, scissors, forceps, laser Quick, effective; use if infection present
Biosurgery: Maggot or larva therapy Good for those who cannot tolerate surgery
Surgical Repair Viable option for stage III & IV ulcers Types
Direct closure, skin grafting, skin flaps, musculocutaneous flaps, free flaps
Diet/Nutritional Supplements Controversial; limited evidence Dietary recommendations –
30-35 calories/kg/d1.25-1.5g of protein/kg/d
Amino acids may assist Argine, glutamine, cysteine
New problem – blame a drugFalling elders – give vitamin D, order
PT, home safety evaluation (OT)Preferred drugs
Anti-depressants Citalopram, escitalopram, remeron, sertraline
Pain medicationTylenol, tramadol
InsomniaZolpidem, trazodone, remeron