Exam (elaborations) NR 601 FINAL EXAM

Exam (elaborations) NR 601 FINAL EXAM How to conduct Mini-Cog-  The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE  The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function.  It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administer  The Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.  Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words.  A score of 0 to 2 is a positive screen for dementia Causes of delirium in elderly-  Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins.  Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of delirium in comparison with blood flow patterns after recovery.  A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59) Agnosia  Loss of ability to identify objects ADA criteria for diagnosing DM-  FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*  2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*  A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*  In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L). • Urinary incontinence-  Involuntary loss of urine from the bladder ▪ So common in women many consider it normal ▪ Common in older men w/ enlarged prostate o Can affect quality of life o Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt & society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals o Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in placement ▪ URGENCY UI is greater in men ▪ STRESS UI is greater in women o Terminology ▪ UI- Unintentional voiding, loss or leakage of urine ▪ Continuous incontinence-Continuous loss or leak of urine ▪ Increased daytime frequency-More frequent during day than considered normal ▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50 ▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent ▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence o Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics o Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diuretics Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics o Physical changes w/ aging that contribute to UI ▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow ▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation ▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms NR 601 FINAL EXAM - Initial clinical workup for UI in Men o PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men - UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine ▪ Full bladder ▪ Standing position ▪ Asked to cough ▪ If urine leak is observed, stress incontinence is confirmed - Red flags in males o Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain, Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA o Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA tenderness,Nodular prostate,Any new neuro symptoms - Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden - 1st line management guidelines o AHRQ guidelines for management of UI in women ▪ Behavioral therapy ▪ Lifestyle modification ▪ Try for 3 months before pharm management o Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing o Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods o Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys - Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training - 2nd line management - Medication o Antimuscarinic medication: 1st line for women ▪ Block the parasympathetic muscarinic receptors ▪ Inhibit involuntary detrusor contractions ▪ Side effects due to the effects on other muscarinic receptors o Outcomes unpredictable and side effects common o Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache o AntimuscarinicsMechanism of action ● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic) ● CYP3A4 substrates ▪ Indications: UI and OAB ▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention ▪ Precautions:CNS depression,Caution in elderly ● Renal dosing o CrCl 30 o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq) ▪ Also approved for UI and OAB ▪ Clinical trials – significant reduction in incontinence and micturations ● No anticholinergic s/e ▪ Mech of action ● Selectively stimulates beta-3 adrenergic receptors ● Relaxes smooth muscle – bladder ▪ Contraindications/caution: HTN- Do not use if SBP 180, DBP 100 ▪ Avoid severe renal/liver disease ▪ Dose – 25-50mg PO QD ▪ CrCl 30 – max 25mg - 2nd line of UI in Males – Alpha 1 blockers o Men, not women! o Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptors o Used in men d/t high incidence of BPH in aging men o Alpha antagonists ▪ Alpha 1A – prostatic smooth muscle relaxation ▪ 1B – vascular smooth muscle contraction ▪ 1D – bladder muscle contraction and sacral spinal cord innervation o Meds ▪ Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence ▪ Terazosin SE: Asthenia, dizziness, postural hypotension ▪ Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough ▪ Alfuzosin- CrCl 30 use with caution, SE: Dizziness, URI ▪ Silodosin SE- Retrograde ejaculation Differentials as cause for erectile dysfunction-  Differential diagnosis: o Vascular, Endocrine, Neurological, Neurovascular, Substance abuse, End-organ disease, Psychogenic, Social causes (Kennedy-Malone 376) Elder abuse  Typeso Physical, Emotional, Sexual, Neglect, Exploitation, Abandonment, Self-Neglect  Risk Factorso Age, Gender, Cognitive Impairment, Living Arrangement, Social Isolation  Signs of abuseo bruises, slap marks, unexplained burns, increased accidents, lack of hygiene, failure to meet medical needs, weight loss, decubiti, changes in personality, decreased interaction, unexplained STD  Provider responsibility in reporting abuse o If you suspect elder abuse perform a physical exam and order any necessary tests. o Include a cognitive screen. o Document your findings. This includes what the patient says and your objective findings. o You may need to interview your patient and the caregiver separately to see if the stories are the same. o Be aware of your state laws regarding mandatory reporting of suspected abuse. Differentials as cause for hematuria- Differentials per class notes  Dietary substances o Caffeine, spices, Tomatoes, chocolate, alcohol, Citrus, soy sauce, & some herbal meds  Medication o Beta-lactam antibiotics, sulfonamide, NSAIDs, Cipro, allopurinol, Tagamet, & dilantin  Anticoagulation and papillary necrosis o Coumadin, Heparin, aspirin, & NSAIDs  Glomerular nephritis  Hydrocarbons (glue, paint) NSAIDs  Urolithiasis  menses Terazosin use(s)-  Alpha blocker for BPH . 1-10 mg P.O. nightly.  Caution in those with cataracts and in elderly.  Side effects o hypotension, priapism, dizziness, dyspnea, tachycardia.  2nd Line Management of UI in males ***Alpha 1 Blockers  Pharmacologic agents for men with urinary incontinence differ from women;  Alpha 1 blockers antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha 1 blockers *Lifestyle changes and Behavioral Management are first-line but when not effective alpha 1 blockers are initiated; *This difference in choice of medication for men is due to the high incidence of BPH associated with aging men  Alpha 1 Adrenergic Receptor antagonists  Alpha 1A- Prosthetic smooth muscle relaxation  Alpha 1B- Vascular smooth muscle contraction  Alpha 1D -Bladder muscle contraction and sacral spinal cord innervation UTIs in men and women UTI treatment guidelines BPH-  Progressive, benign hyperplasia of prostate gland tissue  Etiology/incidenceo Cause is uncertain, About 50% of men have it by 60, By age 85, 90% have it o Most common cause of bladder outlet obstruction in men over 50  Symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate gland  Signs/Symptomso Gradual worsening of the following, Frequency, urgency, urge incontinence, Nocturia, dysuria, Weak urinary stream, dribbling, hesitancy, Sensation of full bladder even after voiding, Retention  Diff Dxo Urethral stricture, Prostate or bladder cancer, Neurogenic bladder, Bladder calculus, Acute or chronic prostatitis, Bladder neck contractor, Medications that affect micturition  Physical findingso Abdomen,May have distended bladder secondary to retention; Prostate,Nontender w/ asymmetric or symmetrical enlargement, gross enlargement atypical, Consistency is smooth, rubbery (eraser), Nodules may be present  Differentiation from BPH and CA needs biopsy  Tests/Findings o UA-No hematuria or UTI, Urinary flow rate, Voided volume and peak urinary flow rate (uroflowmetry) may detect obstruction flow, Abdominal US – rules out upper tract patho, PSA, Consider PVR urine volume, Cr to assess renal function, elevated levels suggest urinary retention or underlying renal disease – refer this patient  Treatment/Managemento Refer men who have the following,  Refractory urinary retention who have failed one attempt at cath removal,  Recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder, diverticula, or renal insufficiency related to BPH,  Consider referral if complications exist or if patients have severe symptoms  Managemento Men who have no indications for surgery,  Discuss risks/benefits of all options, Watchful waiting (observation), Behavioral techniques to reduce symptoms, Limit fluid after dinner,  Avoid medications such as Antidepressants, Antiparkinson drugs, Antipsychotics, Antispasmodics, Cold meds, Diuretics  Medication Treatments o Alpha adrenergic blocker – for smaller prostates o 5-alpha adrenergic blocker – larger prostates o Combo therapy is an alpha-adrenergic blocker and finasteride is used now for men w/ large prostates  Surgery has the best chance for relief of symptoms, but greater risks  Follow up: o Teach signs/symptoms of retention and obstruction, o If observing for now, recheck every 6-12 months, o In use of meds, recheck in 4-6 weeks, o If post surgery follow up is at the discretion of the urologist Acanthosis nigricans  A sign of insulin resistance that can be seen in African Americans  associated with colon cancer, obesity and DM Delirium treatment- Kennedy 560.  Identify causes, prevent delirium though complications of identified disorders.  Focus on safety.  Frequent reassurance and re-orientation.  First generation --haloperidol.  Second generation (olanazapine, risperidone, ziprasidone and quitiapine) antipsychotics to control behavioral symptoms. Essential tremor vs. Parkinson’s Disease  Essential tremor is an action tremor 6 to 8 Hz, Parkinson’s tremor is a resting tremor which is 3 to 6 Hz. Kennedy p. 425 Seizure causes  In older adults stroke is the most common underlying cause of seizures.  Other causes include neurodegenerative disorders, brain tumors and head injuries. Kennedy p 438 Hospice & palliative care-  Hospice: o Last 6 mos of life. Uses palliative care principles to support pt and family. Includes bereavement services. Covered by Medicare/Medicaid, most private insurance. Interdisciplinary care, medical service, supplies, drugs  Palliative Care: o To relieve pain and improve QOL. Used early in dz process. Interdisciplinary Care. Provides care for the entire dz process, from diagnosis to death, including bereavement services. Pain-  Pain assessment tools: o Visual Analogue Scale o Numerical Analogue Scale o Wong Baker FACES o Pain Assessment in Advanced Dementia scale  Types of pain: o Somatic, o Visceral, o Neuropathic  Framework for pharmacological interventions for pain:  The WHO Step Ladder o 1st step: NSAIDs and Tylenol for mild pain o 2nd step: Opioids added, usually with APAP for moderate to severe pain with functional impairment and or decreased QOL o 3rd step: Opioid pain meds, sometimes around the clock for severe pain  Adjuvant meds: o Tricyclic antidepressants, Nortriptyline,Desipramine,Duloxetine,Gabapentinm, Pregabalin, Lidocaine 5% patch, Capsaicin cream, Corticosteroids, Calcitonin, Baclofen Pain management in elderly Delirium vs. dementia-  Deliriumo rapid onset (hours to days). o Poor memory, disorientation, speech disturbance, perceptual disturbance. o Typically fluctuates over course of day. o History may reveal cause-medical condition, intoxication or withdrawal, use of med, toxin exposure or combination. (Kennedy 558).  Dementiao Alz Disease most common. o An acquired persistent intellectual impairment with compromise in multiple spheres of mental activity. o Signal symptoms: confusion, impaired short term memory, cog dysfunction. o Progression is typically slow. o Could be reversible (secondary to treatable systemic disorder), or irreversible (primarily caused by progressive systemic or neuro disorder). o ***hallmark*** anosognosia- the patient is unaware of impairment and denies illness(kennedy, p.562) o Alz. ChEIs - cornerstone of pharm therapy as acetylcholine is important for brain cell function. Steps of the grieving process  Grief is the emotional response to loss, Mourning is the outward social expression of loss  Types of grief: o Anticipatory-experienced before death, can be experienced by everyone including the patient o Normal- encompasses the typical emotional, physical, cognitive, and spiritual reactions to a loss o Complicated-chronic, delayed, exaggerated, masked or disenfranchised  Stages of Grief: o Notification and shock o Experiencing the loss emotionally and cognitively o Reintegration  Tasks of grieving: o Acknowledging the reality of death o Sharing in the process of working through the pain of grief o Reorganizing the family system, restructuring the relationship with the deceased, and reinvesting in other relationships and life pursuits  Kennedy p. 631 Alzheimer’s treatment  Signs and symptomso Preclinical  can last 2-4+ years, impaired memory (excused or covered), poor judgement, decreased spontaneity, increased social anxiety, insidious instrumental ADL losses (bill paying, money handling), preserved basic ADLs o Mild/Moderate-  lasts 2-10 years, obvious memory impairment, overt instrumental ADL impairment, basic ADL failing, behavioral difficulties, shortened attention span, language difficulty, variable social skills, supervision required o Severe-  last 1-2+ years, memory fragments only, no recognition of familiar people, requires assistance with basic ADLs, reduced mobility, weight loss, fewer troublesome behaviors, infections, seizures, dysphagia, incontinence, groaning, moaning, grunting  First line pharmacological treatmento Cholinesterase inhibitors donepezil (Aricept) o Memantine (Namenda) added at the moderate to severe stage  Kennedy p 567-568 Sexuality sundowning metformin side effects-  GI side effects take with supper. Most patients adjust to these SE. ADVERSE effect- Lactic acidosis. B12 deficiency  Biguanides (Metformin) has become a cornerstone of drug treatment for type 2 disease, based on its proven efficacy not only in controlling glucose intolerance but also in significantly reducing risk of important macro- and microvascular outcomes, especially in overweight and obese patients (as found in the UKPDS study referred to earlier and below). In glycemic treatment algorithms for type 2 disease, initiation of metformin is recommended at the time of diagnosis along with diet and exercise.  Mechanism of Action. Metformin differs from the traditional oral hypoglycemics (i.e., the sulfonylureas) in that it does not stimulate endogenous insulin secretion; rather, drugs of this class enhance tissue responsiveness to insulin. Consequently, biguanides are less likely to induce hypoglycemia and are particularly effective in the treatment of overweight patients with tissue resistance to insulin. Biguanides facilitate insulin uptake by peripheral tissue, especially muscle and liver, and decrease hepatic gluconeogenesis and basal glucose output, thereby helping to lower fasting glucose levels. Glucose utilization also improves in adipose and intestinal tissues. The net result is an improvement in fasting and postprandial hyperglycemia. Insulin demand declines as glucose utilization improves. Serum lipid abnormalities also improve.  Preparations. Metformin is the only biguanide approved in the United States for the treatment of type 2 diabetes. The drug is rapidly and well-absorbed in the small intestine, with peak plasma concentrations in 2 hours. It is rapidly excreted unchanged by the kidneys. Impaired renal function (creatinine 1.5 mg/dL in men and 1.4 mg/dL in women) is a contraindication for use, especially at full doses. The drug is not metabolized by the liver. The original biguanide, phenformin, is no longer marketed because of its associated risk for lactic acidosis and an excess cardiovascular mortality (see later discussion).  Dosing. The starting dose of metformin is 500 mg once daily with dinner. After 1 week, the dose is increased to twice daily, given with the two largest meals of the day (usually breakfast and dinner) to minimize gastrointestinal upset. The dose can be increased by 500 mg every 1 to 2 weeks until treatment goals are met or the maximum dose of 2,000 to 2,500 mg/d is reached. An extended-release formulation is also available, which can help to improve compliance.  Efficacy. When used as monotherapy in an obese person with moderate glucose intolerance, metformin’s efficacy in terms of glycemic control (i.e., lowering fasting glucose and glycosylated hemoglobin levels) is about the same as that of a second-generation sulfonylurea. Incidence of monotherapy treatment failure is less for metformin than for glyburide (21% vs. 34% at 5 years). A synergistic effect is achieved when combined with sulfonylurea therapy in patients who do not respond well to metformin alone. Unlike the sulfonylureas, metformin is effective even in severe fasting hyperglycemia (300 mg/dL), indicative of poor beta-cell responsiveness. Plasma triglycerides and LDL cholesterol levels are decreased. In the UKPDS trial noted earlier, obese patients (120% of ideal weight) with type 2 diabetes treated with metformin and attaining target glycemic control achieved clinically important, statistically significant, sustained long-term reductions in risks of microvascular disease and macrovascular complications (i.e., myocardial infarction, stroke, and cardiovascular death); all-cause mortality was also significantly reduced. These findings make metformin one of the few antihyperglycemic drugs with demonstrated ability to reduce macrovascular risk, the holy grail of diabetes management.  Adverse Effects. The most common side effect of biguanide therapy is dose-related gastrointestinal upset (nausea, diarrhea, bloating, abdominal discomfort). The risk for serious prolonged hypoglycemia is minimal. Lactic acidosis represents the most potentially serious adverse effect. One of the original biguanides—phenformin —was taken off the market by the U.S. Food and Drug Administration (FDA) in 1977 because of its association with fatal episodes of lactic acidosis. The risk for lactic acidosis associated with metformin is greatest in the setting of hypoxemia, hypovolemia, and states with decreased tissue perfusion and in renal insufficiency (creatinine 1.5 mg/dL). Accumulation of the drug secondary to reduced excretion results in impaired hepatic metabolism of lactate. Other risk factors include binge drinking, use of intravenous radiologic contrast agents, hepatic failure (lactate is metabolized by the liver), and serious underlying illness, particularly heart failure.Longterm data on safety have yet to be accumulated. Because insulin secretion is not increased with metformin use, weight gain does not occur; some patients may even lose weight. Patients who are to undergo a radiologic procedure that requires intravenous iodinated contrast should have their metformin therapy held for a few days prior to the procedure and remain well hydrated.  Patient Selection. Based on the landmark results of the UKPDS, obese patients should be considered especially good candidates for metformin therapy. The drug helps to reverse their insulin resistance, peripheral responsiveness to insulin improves, and insulin needs decrease, so hyperinsulinism and its adverse effects, including weight gain, are minimized. The typical candidate is a moderately obese person with type 2 diabetes who has persistent moderate hyperglycemia (fasting glucose between 140 and 240 mg/dL, glycosylated hemoglobin 7.0%) despite a full program of diet and exercise. Early addition of metformin is suggested. Other candidates for metformin include obese patients who do not achieve tight control while taking a sulfonylurea at maximal doses. In this setting, metformin is added to the oral hypoglycemic program to improve control through its complementary mode of action. The sulfonylurea dose is reduced to lessen the risk for hypoglycemia. Combination therapy is most effective when initiated before the onset of symptomatic hyperglycemia (fasting glucose 250 mg/dL). Nonobese patients are also reasonable candidates for metformin. Typically, metformin lowers fasting blood glucose by approximately 20%.Patients who started drug therapy with a sulfonylurea and become unresponsive to maximal doses have likely exhausted their beta-cell reserve and can be switched to metformin or considered for exogenous insulin therapy (sometimes in conjunction with metformin). The same pertains to the severely hyperglycemic obese patient (fasting glucose 300 mg/dL). Some diabetologists use metformin to supplement an insulin program in obese type 2 diabetics who require large insulin doses and have difficulty losing weight. The combined program helps to reduce insulin requirements and the appetite stimulation and weight gain that accompany hyperinsulinism. Caution and careful patient monitoring are required when a patient taking exogenous insulin is started on metformin; the insulin requirement may drop considerably, putting the patient at risk for hypoglycemia. Use in pregnancy is not associated with major congenital malformations. ACC 2017 Guideline for High Blood Pressure in Adults2017 HTN guidelines  Normal BP is defined as 120/80 mm Hg  Elevated BP 120-129/80 mm Hg  Hypertension stage 1 is 130-139 or 80-89 mm Hg  Hypertension stage 2 is ≥140 or ≥90 mm Hg. Acute prostatitis kennedy 380.  lower urinary tract symptomso frequency, pain on urination or pain increasing with uriuiation.  Acute bacterial prostatitiso presence of more than 10 WBC per high power field on mid stream urine collection.  If acutely ill, hospitalization. o Treat with Cipro 500mg BID x 10 days or Levaquin 500mg daily