NURS5461 Quiz 1 – Adult Gerontology Management Across the Continuum of Care (Latest 2026/ 2027 Update) 100% Verified Questions & Answers {Grade A} - UTA

NURS5461 Quiz 1 – Adult Gerontology Management Across the Continuum of Care (Latest 2026/ 2027 Update) 100% Verified Questions & Answers {Grade A} - UTA What are water requirements for the older adult - correct answer Recommended H2O intake per day—30 ml/kg/d What are 2 tests to determine vitamin B12 deficiency - correct answer Increased serum methylmalonic acid and serum homocysteine are ultrasensitive markers of B12 deficiency What should you always check when checking folate - correct answer Vitamin B12 levels Obesity - correct answer Body weight 13% of ideal or BMI 28 kg/m2 In seniors, defined as a BMI 30 kg/m2 Pharmacokinetics - correct answer The process by which drugs are absorbed, distributed within the body, metabolized, and excreted. What the body does to the drug Effects of aging on Volume Distribution - correct answer decrease body water=decrease Vd for hydrophilic drugs so more in blood decrease lean body mass=decrease Vd for drugs that bind to muscle so more in blood increase fat stores=increase Vd for lipophilic drugs so more in tissues decrease plasma protein (albumin)=increase percent unbound or free drug; increase plasma protein=decrease unbound or free drug Metabolic clearance of a drug by the liver may be reduced because: - correct answer Aging decreases liver blood flow, size, and mass, and Half-Life - correct answer time for serum concentration of drug to decline by 50% Which organ function is critical for drug elimination - correct answer KIDNEY Most drugs exit the body via kidneys The effects of Aging on the Kidneys - correct answer Gradual decrease in size Gradual decrease in blood flow Decrease in # of functional nephrons Renin secretion/vitamin D synthesis decreases Ability to secrete/absorb declines Results in Lower GFR Serum Creatinine does not reflect what? - correct answer Creatinine Clearance In older persons, serum creatinine stays in normal range, masking change in creatinine clearance (Cr Cl) Cockroft and Gault Equation for Creatinine Clearance - correct answer CrCl= (140-age) x Wt (kg)/ 72 x SCr **x 0.85 if female** Pharmacodynamics - correct answer what the drug does to the body What is the storage form of thyroid hormone - correct answer thyroglobulin Where is TSH synthesized - correct answer anterior pituitary gland What controls TSH production - correct answer TSH is controlled by TRH [thyrotropin releasing hormone] made in hypothalamus What are the two main thyroid hormones - correct answer T3 (triiodothyronine) and T4 (thyroxine) What is the major carrier protein of thyroid hormones - correct answer Thyroxine Binding Globulin In clinical practice what are the two main labs that we test for thyroid function? - correct answer Free T4 and TSH Action of thyroid hormones? - correct answer Growth and development Regulates basal metabolic rate Affects carbohydrate, protein, and fat metabolism Regulates central nervous system and skeletal development in utero Controls cellular metabolism and oxygen consumption Primary, secondary, and tertiary thyroid dysfunction? - correct answer Primary thyroid dysfunction occurs at the gland Secondary thyroid dysfunction occurs at the pituitary Tertiary thyroid dysfunction occurs at the hypothalamus What are Signs/Symptoms of Hypothyroidism - correct answer Depression, Hypersomnia, Fatigue, Forgetfulness, Inability to concentrate, Mental retardation, Cold intolerance, weight gain, Puffy eyes, Enlarged tongue, Hearing impairment, Deepening of voice Sore throat, Goiter What are Signs/Symptoms of Hyperthyroidism - correct answer -Heat intolerance, increased sweating -Weight loss -Agitation, nervousness, irritability, anxiety -Palpitations & tachycardia -Fatigue, muscle weakness -Frequent bowel movements, diarrhea -Insomnia -Tremor -Thinning hair -Goiter (possible) -Exophthalmos (protruding eyeballs), diplopia -Light or absent menstrual periods What population is more likely to be diagnosed with hypothyroidism - correct answer Women, 2-8x greater than men Subclinical Hypothyroidism is what? - correct answer a normal free T4 and an elevated TSH When should Diagnostic thyroid tests be taken? - correct answer Patients should have a baseline screen for thyroid disease between the ages of 35-40 years People at risk should be screened more frequently—pregnant, women 60 years, those with other autoimmune disease Women with infertility should be screened, as should the postpartum woman with vague symptoms Those with abnormal thyroid function or prior history of medically or surgically treated thyroid disease, should be screened yearly Those with autoimmune disease, depression, cognitive dysfunction, prior XRT to the head or neck, previous radioablation of the thyroid, cholesterol abnormalities, use of Amiodarone, Lithium, family history of thyroid disease should have a TSH What is the most valuable lab in a diagnosis of thyroid disease? - correct answer TSH What is the normal lab range for TSH - correct answer 0.5-5 mIU/L What is the normal lab range for free T4 - correct answer 0.7-1.7 ng/dL What is the laboratory presentation of Hypothyroidism - correct answer Elevated TSH Decreased Free T4 What meds might affect thyroid function tests? - correct answer Metoclopramide—increases TSH Dopamine, glucocorticoids, NSAIDs, Somatostatin— decreases TSH Dilantin, Amiodarone and Lithium are known to affect TFTs Nicotine can also affect TFTs Hypothyroidism might cause a lipid panel to what? - correct answer hypothyroidism reduces cholesterol catabolism, lipid panel will be increased What is the drug of choice for hypothyroidism - correct answer Levothyroxine (T4) How often should you reevaluate TSH levels after starting therapy - correct answer Reevaluation with a serum TSH need not be performed at intervals less than 6-8 weeks What does hypothyroid management look like in a pregnant patient? - correct answer Pregnancy causes an increased need of the dose—usually HCP will increase the Levothyroxine dose by 30% as soon as pregnancy is confirmed Then follow the free T4 during pregnancy Dose should be returned to pre-pregnancy level after delivery, then a TSH should be checked at 8 weeks postpartum What is myxedema coma? - correct answer severe hypothyroidism that was left not treated. THESE PATIENTS WILL HAVE RESPIRATORY FAILURE, DEPRESSION, DECREASED CARDIAC OUTPUT AND FLUID AND ELECTROLYTE ABNORMALITIES [INCLUDING SEVERE HYPONATREMIA] What is hyperthyroidism - correct answer Excess thyroid hormone of one or both thyroid hormones—T4 [thyroxine] and T3 [triiodothyronine] What is Grave's Disease - correct answer autoimmune disorder where autoreactive, agonistic antibodies to TSH receptors occurs Peaks in those aged 20-40 years What is subacute thyroiditis - correct answer glandular inflammation and follicular destruction—thought to be viral Most common in those 40-50 years; mainly seen in women Diagnostics for Hyperthyroidism - correct answer Best screening test is a TSH A low TSH mandates that a free T4 and T3 levels be drawn TSH .35 mIU/L is usually consistent with an elevated free T4 In Grave's disease—the patient will have elevated thyroid autoantibodies and a TSH receptor antibody tested is also usually elevated Toxic nodular goiters and Grave's disease show increased uptake on thyroid scans Thyroiditis has low uptake Thyroid scans are also used to determine function of thyroid nodules in those with hyperthyroidism—as cold [nonfunctioning tissue] nodules are worrisome for cancer Subclinical Hyperthyroidism Diagnostics - correct answer •TSH 0.1; normal free T4; normal T3 •The patient may have no or only mild symptoms What are the three main types of management for hyperthyroidism - correct answer Surgery Drugs RAI ablation Grave's disease tachycardia management - correct answer For tachycardia, palpitations or tremors—Beta blocker can be used for symptom control Those with COPD, bronchospasm or uncompensated HF—avoid BB CCB can be used for those that cant do BB What are the two drugs of choice for hyperthyroidism in the pregnant patient? - correct answer In the pregnant women PTU [propylthiouracil] or Tapazole [methimazole] are the DOC Standard dose for Hyperthyroidism Drugs - correct answer PTU is 50-150 mg 2-3 times per day Tapazole is given 10-40 mg per day What should you check before starting anti-thyroid drugs? What does the follow-up schedule look like? - correct answer check a CBC and LFTs before therapy is started, then CBC every 2 weeks for 1st month, then every month thereafter; LFTs are checked every 3 months What is the treatment of choice for hyperthyroidism in older adults - correct answer Radioactiveiodine(RAI) is the treatment of choice for most older adults with Graves disease or toxic nodular thyroid disease Hypertension - correct answer high blood pressure 1-3 people have it What is the prevalence of hypertension between genders? - correct answer Higher in Men until 45 years Similar rate Men and Women 45-65 Higher in Women after 65 years renin-angiotensin-aldosterone system - correct answer -decreased blood pressure causes the juxtaglomerular cells of kidneys to secrete renin which converts angiotensinogen (inactive) to angiotensin I (active) which is then converted into angiotensin II by angiotensin-converting enzyme (ACE) -Angiotensin II stimulates the adrenal cortex to secrete aldosterone - leads to absorption of Na and increased blood pressure -once blood pressure is restored, there is a decreased drive to stimulate renin release What are some modifiable risk factors for hypertension? - correct answer Obesity Metabolic syndrome High dietary intake of fat Excessive sodium intake Physical inactivity Excessive alcohol intake Tobacco use What are some non-modifiable risk factors for hypertension? - correct answer African American Advancing age Family history Male gender Home blood pressure Monitoring - correct answer Initial screen HBPM (give standardized log to record) 2-3 measures in early AM and PM each day for 7 days Provider ignores all day 1 measures and 1st reading each set Circle and Average the remaining measures Criteria: Home readings greater than 135/85 mm Hg should be considered hypertensive When is ambulatory BP monitoring indicated? - correct answer To rule out white coat hypertension, resistant hypertension, hypotensive episodes, suspected autonomic dysfunction and masked HTN Ambulatory BP Monitoring Thresholds for HTN Diagnosis - correct answer A 24-hour average above 135/85 Daytime (awake) average above 140/90 mmHg Nighttime (asleep) average above 125/75 mmHg In hypertensive target organ damage, the organs commonly affected include: - correct answer Brain, eyes, heart, kidney, Erectile dysfunction When is diagnosis of hypertension made? - correct answer Based on BPs measured on 2 or more occasions after initial detection of HBP Diagnosis is made on 3rd elevated BP Exception: BP is 180/120 ICD-10 for Elevated BP without Dx of HTN R03.0 Presentation of Hypertension - correct answer • Normal - SBP 120. DBP 80 • Prehypertension- SBP 120-139 mm Hg - DBP 80-89 mm Hg • Stage I hypertension - SBP 140-159 mm Hg - DBP 90-99 mm Hg • Stage II hypertension - SBP /= 160 mm Hg - DBP /= 100 mm Hg Hypertensive Urgency SBP 180, DBP 120 NO TOD or SX • Hypertensive Emergency • SBP 180, DBP 120• TOD + or SX What is primary Hypertension - correct answer Essential or idiopathic, elevated BP without an identified cause, accounts for 90 - 95% of all cases of hypertension What is secondary Hypertension - correct answer Elevated BP with a specific cause, accounts for 5% to 10 % of hypertension in adults. Renal artery stenosis Pheochromocytoma Obstructive sleep apnea Hyperaldosteronism Renal parenchymal disease Coarctation of the Aorta Substances—ETOH, meds What are blood pressure goals (JNC 8) - correct answer SBP 140 mm Hg (unless 60 years, then 150) DBP 90 mm Hg Home SBP 135 mm Hg Home DBP 85 mm Hg For patients with diabetes, heart failure, or chronic renal failure BP 140/90 mm Hg If goal BP cannot be met, partial control yields some benefit Goals in Older Adults 140/90: 65-79 140-145 for 80 + if tolerated Interprofessional Education - correct answer Interprofessional education (IPE) is a teaching and learning approach that involves students from two or more professions learning together to improve health outcomes. Barriers to IPE - correct answer Communication, Time, Training, Roles, Resources 3 steps to Prevention Dx and Plan - correct answer Risk profile Prevention Needs and Deficits Prevention plan Transtheoretical Model of Change - correct answer 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance Precontemplation - correct answer Precontemplation- stage w/ no intention to change behavior in foreseeable future. Denial, feel immune to threat, have given up etc. Have you tried change in the past? What would have to happen for you to know this is a problem? What warning signs would let you know it's a problem? Contemplation - correct answer Contemplation- Aware problem exists, thinking of overcoming, no commitment to action. Feel ambivalent, pros and cons, feel trapped. What reasons might make you want to change at this time? What are possible reasons for not changing? What would keep you from changing at this time? Preparation - correct answer Preparation- Intended action in next month, may have taken past action. Preparing to make specific change. Action - correct answer Action- Modify behavior, experiences, or environment to overcome problem. Praise any behavioral change. Maintenance/Relapse Prevention - correct answer -Working to prevent relapse and consolidate gains secured during action -Uses strategies to prevent the problem from re-occurring. -Actively engaged in continuing change efforts -"How do I keep going?" Three Main Types of Clinical Preventative Care - correct answer -screening -behavioral cousenling -preventative meds Screening - correct answer Think risk factors for most likely Diseases Identify- Age/Gender/Race/Ethnic/ FH/ Personal Risk United States Public Services Task Force (USPSTF) - correct answer Great tool for Prevention!! Utilize in clinical Levels of Evidence (USPSTF) - correct answer • Levels of Evidence: A: recommends the service. There is high certainty that the net benefit is substantial. B: recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C: recommends against routinely providing the service -Benefit small if present D: recommends against the service -harm benefit I: current evidence is insufficient What services are considered preventive care & required by ACA in 2015? - correct answer Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC Important A and B level Evidence - correct answer AAA screening ever-smoking men 65-75 ASA Men 45-79, Women 55-79 Behavioral dietary-counseling (increased risk) HTN & Lipid screening ( 18; M 35/20-45, W 45/20-45) Disc. Chemoprevention Breast Cancer (High risk) Pap, Mammo CRC screening Lung Cancer screening Depression screening• *Family HX risk & referral BRCA eval Obesity -intensive counseling & behavioral Tobacco HIV (pregnant, all 15-65)• ETOH misuse & counsel Hep C screen (1945-65) Changes in Selected Major Screening Guidelines - correct answer Cervical cancer screening (PAP & HPV) Q 3 yrs 21-29 PAP, 30-65 Q3yrs Pap or Q5 yrs Pap and HPV Prostate Cancer screening "D rating" Lung Cancer screening: LDCT 55-80 yrs w 30 pkyr & smoke or quit within 15 yrs (55/30/15) Colon cancer screening: 3 options Counseling topics - correct answer Behavioral Dietary counseling at risk B Intensive Dietary counseling risk for CVD B Discussion chemoprevention breast cancer B Prevention skin cancer 10-24 B Intensive counseling & intervention re Obesity B Tobacco counseling & intervention A Reduce alcohol misuse B Promote breastfeeding B Preventative Medications and Immunizations - correct answer Immunizations (see CDC immunization guidelines!!!) www.CDC.gov Influenza starting at 6 months TD q 10 years (Tdap at least once as adult) to protect pertussis 1X Tdap 65 if around infants (timing does not matter) Pneumovax (PPSV23)at 65 or 18 if smoker or any chronic pulmonary condition(repeat if given 65 & at least 5 years ago) 11 Prevnar (PCV3) at 65 then PPSV23 6-12 months later OR if PPSV23 first, Prevnar 6-12 months Hep B series as indicated (new: diabetes) HPV4 vaccinate females & males (9 to 26 years) best at 11-12 yo Zostavax for zoster prevention at 60 yo (FDA approved at 50) Meningococcal as indicated Pneumococcal Vaccines - correct answer Pneumococcal conjugate vaccine (PCV13) is recommended for all children younger than 5 years old, all adults 65 years or older, and people 6 years or older with certain RFs (immunocompromised) Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults 65 years or older. People 2 years through 64 years of age who are at high risk of pneumococcal disease should also receive PPSV23 (18 smokers, chronic diseases, etc). Preventative Meds - correct answer ASA as indicated 81 mg "A" Men 45-79 for MI; Women 55-79 (reduced CVA) Assess risk for GI bleed and decide 2010 Omega 3 fatty acids (fish oil)?? DHA, EPA 1-2 grams QD or fatty fish twice weekly (Vitamin C & E NOT indicated and may cause harm) Calcium with vit D for FX prevention "D" Many outstanding questions re MI risk Dietary sources show no risk so encourage Mediterranean Diet & DASH diet for everyone! Obesity BMI - correct answer Higher BMI risk for DM, CVD, HLD, HTN, OA Modest Weight loss of 5% can reduce? - correct answer Type II diabetes Cardiovascular disease Hypertension Dyslipidemia Osteoarthritis General Goals of Weight Loss - correct answer Initial goal: reduce body weight by ~10% from baseline in 6 months May attempt further weight loss if successful Weight loss should be 1-2 lb per week for period of 6 months with subsequent strategies Water Intake Guideline - correct answer Water intake (1/2 your body wt in ounces; e.g., 200 # person needs 100 ozs or 3000cc (3 L) Beginning Calorie Goal - correct answer For weight loss, a 1200 calorie meal plan for women and a 1500 calorie meal plan for men is recommended to start Physical Activity tips for Obesity - correct answer Accumulate up to 30 minutes per day (10 Step counters (pedometers) 2000 steps=1 mile Newer guidelines say 60 minutes daily Average = = maintain wt 10,000 = to lose wt (5 miles) Wt Training increases capacity to burn calories (more muscle mass & inc BMR) Pharmacotherapy for obesity - correct answer FDA approved meds may be part of comprehensive program including diet & activity Xenical Phentermine Newer: Qsymia (phentermine/topiramate) BMI /= 30 w/o concomitant obesity related RFs or diseases BMI /= 27 w/ RFs or diseases Requires continual monitoring Ozempic is not FDA approved for weight loss Tobacco Prevention - correct answer • Tobacco is the leading preventable cause of death • After 40 years of progress, the decrease in adult smoking rates has stalled in the past 6 yrs • But most people who have ever smoked have already quit, and most of today's smokers want to quit • Progress stalled starting in 2004 SCREEN FOR RISK FACTORS Smoking Cessation Website - correct answer Clinical Practice Guideline for Treating Tobacco Use 2008 Update [] smoking cessation aids and drugs - correct answer (Zyban), Chantix, social support, & skills training Nicotine replacement therapy, bupropion 5 A's of tobacco cessation - correct answer 1. Ask 2. Advise 3. Assess 4. Assist 5. Arrange Pharmacotherapies for smoking cessation - correct answer Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:Bupropion SRNicotine gumNicotine inhalerNicotine lozengeNicotine nasal sprayNicotine patch, Varenicline (chantix) 5 R's to increase motivation to quit smoking: - correct answer Relevance Risks Rewards Roadblocks Repitition What is Health Literacy - correct answer "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" Malnutrition - correct answer lack of proper nutrition 30-50% of hospitalized patients have some sort of poor nutrition Marasmus malnutrition - correct answer Body fat and muscle wasting Kwashiorkor malnutrition - correct answer Loss of skin turgor, loss of hair color and softness, edema, enlarged liver and parotids Depletion of visceral protein mass Hamwi's method to calculate IBW - correct answer Men add 106 pounds + 6 pounds for each inch over 5 feet Women add 100 pounds + 5 pounds for each inch over 5 feet Some sources suggest adding 10% for large frame person and subtracting 10% for small frame person Skin Fold and Muscle Mass Measurements - correct answer Mid arm circumference can be used to estimate body's skeletal mass Triceps skin fold and subscapular skin fold thickness can be used to estimate SQ fat reserves Albumin - correct answer Accurately reflects visceral protein status in absence of acute changes in hydration or stress 3.5-5g/dl Transferrin - correct answer Beta globulin that supports iron transport into plasma 150-200 mg/mL mild protein depletion 100-149 mg/mL moderate protein depletion Less than 100 mg/mL severe protein depletion Subjective Global Assessment - correct answer • Class A • 5% weight loss or 5% weight loss but with recent evidence of weight gain and improved appetite Class B • 5-10%weight loss without recent weight gain, poor dietary intake and mild loss of SQ fat Class C • Weight loss of 10% with severe loss of SQ fat and muscle wasting, often with edema Caloric Needs - correct answer 25-30 kcal/kg per day to maintain weight 35 kcal/kg to gain weight 22-25 kcal/kg to lose weight Carbohydrates - correct answer Main source of energy and should be near 35% of total calorie intake Catabolized into glucose and stimulate insulin secretion 1 gram = 4 cal Protein - correct answer In healthy adults—daily need it 0.8 g/kg of body weight In the acutely ill adult— daily need is 1.5-2 g/kg of body weight 1 gram = 4 cal Lipids/Fats - correct answer 1 gram of lipids = 9 calories Those with an ileal resection are at risk for malabsorption Lipolysis is stimulated by steroids, catecholamines and glucagon, but is prevented by insulin Which 2 fatty acids are essential? - correct answer (have to eat) 1. Linolenic 2. Alpha-linolenic Changes in body composition with age - correct answer -increase body fat -decreased plasma volume, total body water, and extracellular fluid -less water, more fat. Caloric Requirements of the Older Adult - correct answer • Useful guide to calculate calorie needs: • No stress:• 25 cal/kg/d • Mild stress [URI; stage 1 or 2 pressure ulcer]: • 30 cal/kg/d • Moderate stress [UTI; stage 3 ulcer]: • 35 cal/kg/d • Severe stress [sepsis; stage 4 ulcer]: • 40 cal/kg/d What are lifestyles modifications for hypertension? - correct answer Weight loss Healthy diet (DASH) Decreased salt intake Limiting alcohol intake Tobacco cessation What affect does potassium have on BP? - correct answer Increasing potassium intake lowers BP Potassium can lower blood pressure through several mechanisms, including: Natriuresis: Potassium can cause sodium depletion. Plasma renin activity: Potassium can decrease plasma renin activity. Neurogenic components: Potassium can alter the neurogenic components of blood pressure regulation. Angiotensin II receptors: Potassium can decrease the number of angiotensin II receptors. Endothelium-dependent vasodilation: Potassium can hyperpolarize endothelial cells by stimulating the sodium pump and opening potassium channels What are the recommendations for sodium? - correct answer The new recommended sodium intake per day is 1500 mg Diuretics for hypertension - correct answer Most Common to treat HTN: -Thiazides/ Thiazide-like diuretics: These are to given to patients with Normal renal function, and are the *Best* initial choice for African Americans due to their low renin thresholds. -Loop Diuretics: these promote renal blood flow (so good to use in patients with renal problems), and good to use in African Americans due to their low renin thresholds -Combinations of Hydrochlorothiazide (a thiazide) with Potassium sparing diuretics and other antihypertensive drugs (like ACE inhibitors), will help normalize the potassium levels (most common will see a thiazide with an ACE inhibitors) Thiazides diuretics for hypertension - correct answer Increases excretion of Na+ and water follows Caution in gout or hyperlipidemia May increase lipids in high doses Most patients Hydrochlorothiazide 12.5-25 mg daily Reduces urinary calcium, may prevent stone recurrence Loop diuretics for hypertension - correct answer Used in patients with renal insufficiency May cause increase calcium loss, leading to osteoporosis Furosemide, bumetanide, torsemide K+ sparing diuretics for hypertension - correct answer Blocks aldosterone effects Cautious use in renal insufficiency Has anti-androgen effects Spironolactone & Eplerenone Pearl—Aldactone is often 3rd or 4th drug add-on to control BP, which it achieves very nicely Diuretic sites of action - correct answer ACE Inhibitors - correct answer Blocks conversion of angiotensin I to II Lower peripheral vascular resistance and BP No reflex stimulation of heart rate and contractility Has been preferred in diabetes, MI, HF Reduce morbidity and mortality in HF and MI Retard progression of diabetic renal disease and hypertensive nephrosclerosis Not in renovascular dz or pregnancy Pick a "pril" Angiotensin II Receptor Blockers - correct answer Blocks action of angiotensin II Used in HF, DM NOT in pregnancy or renovascular dz Oral fluconazole interrupts conversion of losartan to active form If patient can not tolerate ACEI proceed to ARB "artans" Equally effective for CV and renal outcomes Do you ever give ACE inhibitors and ARB together - correct answer NO, never give together Central Acting Agents for Hypertension - correct answer Work at the CNS level to control BP Clonidine, Aldomet Excessive sleepiness, fatigue, BP rebound Start dosing at bedtime Beers List Med Calcium Channel Blockers - correct answer agents that inhibit the entry of calcium ions into heart muscle cells, causing a slowing of the heart rate, a lessening of the demand for oxygen and nutrients, and a relaxing of the smooth muscle cells of the blood vessels to cause dilation; used to prevent or treat angina pectoris, some arrhythmias, and hypertension Widely variable affects on heart Muscle, sinus node, AV conduction, peripheral arteries, and coronary circulation Dihydropyridines—dilate arteries Non-dihyro—less arterial dilation but reduce HR and contractility Inhibit calcium passage Relaxes vessel wall Causes constipation and pedal edema in some patients What are the two types of Calcium Channel Blockers - correct answer Dihydropyridines- nifedipine, nicardipine, amlodipine, felodipine, isradipine, nitrendipine Non-dihydropyridines - Phenylalkylamines—Verapamil, Benzothiazepines, Diltiazem Which calcium channel blockers do you not combine with a beta blocker - correct answer DO NOT combine non-dihydro with a beta blocker What is the only calcium channel blocker approved for HF - correct answer Amlodipine Beta Blockers - correct answer JNC 8 does not recommend BB as a first line drug anymore Unless there is a compelling indication - Beta blockers should not be used for 1st line therapy Used post MI, HF Bind epinephrine/norepinephrine Not use in PVD or severe lung disease Some of the long acting need to be given bid to increase effectiveness "olol's" Remember that they mask S/S of hypoglycemia EXCEPT for diaphoresis Alpha Adrenergic Antagonists - correct answer Blocks the alpha 1 adrenergic receptors—results in vasodilation Alpha blockers also can be used to relax smooth muscle in the bladder neck/prostate Increased incidence of heart failure Not a first line agent May be useful with BPH, use with caution -osin What signifies a orthostatic hypotension diagnosis? - correct answer Orthostatic hypotension is diagnosed when, within 2-5 minutes of quiet standing, one or more of the following is present: At least a 20 mmHg fall in systolic pressure At least a 10 mmHg fall in diastolic pressure Symptoms of cerebral hypoperfusion, such as dizziness Treatment strategies for Hypertension - correct answer If goal BP not met after 1 month of treatment: Increase dose of initial drug, or Add a second drug (Thiazide, CCB, ACEI, or ARB) If goal BP not met with 2 medications: Add and titrate a third medication (Thiazide, CCB, ACEI, or ARB) Do not use ACE and ARB together Other classes may be used in the following scenarios: Goal BP not met with 3 medications Contraindication to thiazide, ACEI/ARB, or CCB 75% of MIs occur with plaque rupture in vessels that are __ occluded? - correct answer 50% occluded! Unstable plaques What is a main cause of plaque instability? - correct answer Inflammation What is dyslipidemia - correct answer An excessive accumulation of one or more of the major lipids transported in plasma, or a decrease in HDL What is a lipoprotein? - correct answer When a lipid combines with a apoprotein the transport form of fat and cholesterol in the circulation Arise from exogenous dietary sources and endogenous hepatic sources Think of "trucks" that carry cholesterol Measurement of Cholesterol - correct answer Standard cholesterol tests [lipoprotein] measures "cholesterol content" or "amount" in a particular lipoprotein Apolipoprotein measures the number of "particles" of lipoprotein Normal Total cholesterol level - correct answer 200 mg/dL Normal HDL level - correct answer 40-60mg/dL Normal LDL level - correct answer 100 mg/dL Normal Triglyceride levels - correct answer 150 mg/dL What are two advanced lipid tests? - correct answer Apolipoprotein B (apoB) LDL particle number (LDL-P) What are the types of lipoproteins? - correct answer Chylomicrons: largest type; elevated after fatty meals; high levels associated with pancreatitis VLDL: Measure of remnant particles [indirect measurement of IDL] IDL: Very atherogenic when present LDL: Primary target of lipid-lowering therapy; small dense particles are atherogenic HDL: Responsible for transport of cholesterol from tissues to liver for removal; low levels associated with atherogenesis [HDL2 most protective] What is the goal range for HDL in men and women? - correct answer 40 in males and 50 in females What is non-HDL cholesterol? - correct answer Total cholesterol minus HDL What are the steps to managing lipids and CV risk? - correct answer Risk Assessment, Lifestyle therapy, Pharmacologic therapy What are modifiable risk factors for CAD - correct answer Elevated serum lipids, elevated BP, tobacco use, physical inactivity, obesity, DM, metabolic syndrome, psychologic states, and homocysteine level. What is the relationship between HDL and Triglycerides? - correct answer HDL-C tends to be low when triglycerides are high Inverse Relationship Metabolic Syndrome - correct answer Abdominal obesity Men: waist circumference 102 cm / 40 in. Women: waist circumference 88 cm / 35 in. Atherogenic dyslipidemia (triad) High triglycerides ( 150 mg/dL), Small LDL particles so LDL-C is low or mildly elevated, Low HDL ( 40 men; 50 women) Elevated blood pressure (/= 130/85) Insulin resistance (impaired fasting glucose /= 100) Prothrombotic and pro-inflammatory states (not usually measured but implied with + metabolic syndrome) If a patient has Type 2 DM what should you add in addition to lifestyle changes to lower cholesterol? - correct answer Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients a-lipoprotein levels - correct answer Levels 30 = independent risk factor for CHD More atherogenic than LDL Increased in renal disease, post-menopausal women & Family Hx of CVD May interfere with fibrinolysis (structurally similar to plasminogen) Lowering LDL may decrease associated risk Levels reduced with Niacin / estrogen C-reactive protein - correct answer Marker of inflammation Independent risk factor for CHD More of predictor with women Not correlated with LDL levels; so separate RF Consider if Risk level at least 5-7.5% to inform your tx approach May be increased years before an event Aspirin may decrease a bit Smoking cessation lowers Statins decrease 17-30% Weight loss decreases What are the drugs of choice for Dyslipidemia? - correct answer Statins are the DOC for LDL Niacin - correct answer lowers TGS / LDL; raises HDL; lowers Lp(a); does not reduce morbidity or mortality; NO longer approved by FDA to be given to those on statins— contraindicated Fibrates - correct answer LDL effect variable, lower TGS, raise HDL, lower fibrinogen levels; NO longer FDA approved to be given to a patient on statins—contraindicated Bile acid resins - correct answer lower LDL, may increase TGS, HDL effect variable Omega 3 - correct answer fatty acids—lowers TGS and LDL, raises HDL What two statins are 1st line treatment for diabetics - correct answer atorvastatin and rosuvastatin Muscle related terminology - correct answer Myopathy-General term describing any diseases of muscle Myalgia-Muscle ache or weakness without elevated CK Myositis-Muscle SX with elevated CK Rhabdomyolysis-Muscle SX with CK 10x normal limit Usually brown urine & urinary myoglobin Statins can cause these symptoms What is Diabetes - correct answer Person does not produce enough insulin Inability to use insulin appropriately Liver overproduces glucose [from stored glycogen] Combination of the above Function of inuslin - correct answer Insulin is a carrier protein that gets glucose out of the bloodstream and into the cells where it is used for fuel It also stores sugar in the form of trigs, which can be turned into fat It prevents the breakdown of fat Diabetes Diagnostic criteria - correct answer Diagnostic Criteria for Diabetes [ADA, 2018] Fasting glucose 126 mg/dl confirmed by a repeat test Casual glucose 200 mg/dl plus classic signs/symptoms 2 hr. postprandial glucose 200mg/dl after 75 g glucose load A1C /= 6.5% [do not use with hemoglobinopathies] Type 1 Diabetes - correct answer 5-10% of all diabetics Insulin dependent Insulin level or C-peptide is low Antibody markers usually seen—insulin autoantibodies, islet cell antibodies, glutamic acid decarboxylase antibodies [GAD] Rapid onset of symptoms Weight loss Ketones + in urine & blood Kussmaul respirations Type 2 Diabetes - correct answer 90-95% of all patients Primarily insulin resistant and with time eventual decline in insulin production Insulin and C-peptide levels vary— could be very high, normal or low Strong family hx No autoantibodies Associated with HTN, obesity & dyslipidemia obesity insulin resistance patho - correct answer Tissue sensitivity to insulin is decreased by 30-40% when a person is 35% over Ideal Body Weight Acanthosis nigricans - correct answer thickening and darkening of skin near axillary/ back of the neck region, A/w Diabetes Type II and gastric carcinoma General complication strategies for prevention in Diabetes - correct answer A—A1C target 7% B—BP target 130/80 C—Lipid Targets TC less than 200 mg/dL HDL above 45 mg/dL LDL less than 100 mg/dL [70 mg/dL or less if patient already has CAD] Trigs less than 150 mg/dL [90 mg/dL ensures large dense LDL, per Framingham data] D—Do Not Smoke Patho of type 1 diabetes - correct answer beta cell destruction leading to absolute insulin deficiency Patho of type 2 diabetes - correct answer Increased hepatic glucose production, impaired insulin secretion and action in the peripheral tissues, resulting in elevated glucoses In response to elevated glucoses, insulin pathways become resistant to hormonal impulses, resulting in hyperinsulinemia IR is decreased sensitivity of tissue to glucose uptake What is hemoglobin A1C? - correct answer compound formed when glucose attaches or glycosylates to the protein in hemoglobin Evaluates glucose control for previous 3 months What is the starting dose range for insulin in type 1 diabetes - correct answer Range: 0.4-0.5 units/kg per day Action of GLP-1 agonists - correct answer *promotes insulin secretion *decreases glucagon *decreases gastric emptying "Glutide" Action of SGLT2 inhibitors - correct answer Increase urinary excretion of glucose "glifozin" Action of Biguanides (Metformin) - correct answer decreases gluconeogenesis & reduces insulin resistance, Increase glucose uptake in muscle Action of Sulfonylureas - correct answer stimulates release of insulin from pancreatic islets "Three G's" - Glimepiride, Glipizide, Glyburide Action of Thiazolidinediones - correct answer decreases insulin resistance Increase glucose uptake in muscle and fat Decrease HGP "glitazone" Renal glucose absorption in type 2 diabetes - correct answer Sodium-glucose cotransporters 1 and 2 (SGLT1 and SGLT2) reabsorb glucose in the proximal tubule of kidney Ensures glucose availability during fasting periods Renal glucose reabsorption is increased in type 2 diabetes Contributes to fasting and postprandial hyperglycemia Hyperglycemia leads to increased SGLT2 levels, which raises the blood glucose threshold for urinary glucose excretion Hypoglycemia - correct answer low blood sugar 70 Diabetic Ketoacidosis (DKA) - correct answer A form of hyperglycemia in uncontrolled diabetes in which certain acids accumulate when insulin is not available. Hyperglycemic Hyperosmolar State (HHS) - correct answer *Usually Type 2 DM *Profound dehydration *Glucose may be 600 *Small ketonuria and absent-to-low ketonemia *pH greater than 7.30 *Bicarbonate concentration greater than 15 mEq/L Anemia - correct answer A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume. Blood Composition - correct answer RBC-erythrocytes Platelets-thrombocytes WBC- Nongranulocytes (lymphocytes, monocytes), Granulocytes (Neutrophils, eosinophils, basophils) Red blood cells live for how long? - correct answer 120 days What hormone stimulates the bone marrow to produce red blood cells? - correct answer Erythropoietin (produced by kidney) What is hematocrit? - correct answer Percentage of RBCs in the whole blood • Males• Females• Newborns 40-54% 37-47% 50-62% What is hemoglobin? - correct answer Vehicle for transport of O2 & CO2; the oxygen combing capacity of the blood is proportional to the HBG. Hemoglobin is MORE important then Hct. & RBCs in anemia • Males• Females• Newborns 13.5-17.5 grams 12-16 grams 14-20 grams What is mean corpuscular volume (MCV)? - correct answer • Mean Corpuscular Volume—individual cell size; MCV BEST index to classify anemia • MCV 87 mm • Microcytic • MCV 87-103 mm • Normocytic • MCV 100-103 mm • Macrocytic What is mean corpuscular hemoglobin concentration (MCHC)? - correct answer • Mean Corpuscular Hemoglobin Concentration—measure of the average concentration of Hbg in RBCs • Valuable to evaluate therapy for anemia • 31-37 grams What are spherocytes - correct answer RBCs that are sphere-shaped rather than biconcave disc • Cells are smaller and round, instead of bioconcave discs • Seen after transfusions What are schistocytes? - correct answer Fragmented RBCs • Fragmented RBCs with bizarre shapes • DIC• Burns• Vasculitis• Artificial heart valves • Glomerulonephritis What are the two main labs to look at for anemia workup? - correct answer Hgb, MCV Microcytic anemia causes (MCV 87) - correct answer • Iron Deficiency Anemia• Anemia of Chronic Disease [late stage disease]• Sideroblastic Anemias [drugs/toxins—ETOH, INH, Lead] • Thalassemias• Hemoglobinopathies Normocytic anemia causes? (MCV 87-103) - correct answer • Acute Post-hemorrhagic Anemia • Hemolytic Anemia • Anemia from Impaired Bone Marrow [chronic disease anemia] • Aplastic anemia; myelofibrosis; renal disease; liver disease; malnutrition; anemia of chronic disease Macrocytic anemia causes? (MCV 103) - correct answer • B12 Deficiency • Vegetarianism; intrinsic factor deficiency [PA; achlorhydria; PPI use; bariatric procedures]; sprue; parasites; chronic pancreatic disease; pregnancy; cancer; hypothyroid ism; enzyme deficiency leading to a lack of transcobalamin II • Folate Deficiency • Lack of vegetables; ETOH; steatorrhea; anticonvulsants; OCP; pregnancy; cancer; hemodialysis; drugs—Methotrexate, Triamterene, Sulfa What lab would you check to see if bone marrow is producing new RBC? - correct answer • Check the reticulocyte count • Reticulocytes are young immature non-nucleated RBCs What are two labs that are precursors to B12? - correct answer can check homocysteine and/or methylmalonic acid [MMA] levels [precursors of B12], which will be elevated If MCV what are some tests to do? - correct answer • Check stools for occult blood • if they are negative—send them home with 3 stools cards • Check ferritin• Primary storage form of iron; correlates well with total body iron stores • Check transferrin saturation • Transferrin regulates iron absorption and transport in the body • TIBC reflects transferrin• When body is deficient in iron—TIBC is elevated • When body has excess iron—TIBC is low Serum Iron levels - correct answer • Females: 65-165 ng • Males: 75-175 ng What are normal TIBC values? - correct answer • 240-450 mcg/dL • In IDA, TIBC will be 400 micrograms/dL Etiology of several different forms or types of dementia - correct answer Alzheimer disease • Amyloid plaques/oligomers • Tau neurofibrillary tangles Lewy body and Parkinson dementia • Cytoplasmic α-synuclein inclusion bodies Frontotemporal dementia • Tau or ubiquitin proteins What are some common quantitative screens for cognitive function - correct answer For example, Mini-Cog, SLUMS, MoCA, Folstein's MMSE When do you consider neuroimaging such as CT or MRI? - correct answer Onset occurs at age 65 years Symptoms begin suddenly or progress rapidly There is evidence of asymmetric or focal neurologic deficits Clinical picture suggests normal-pressure hydrocephalus Patient has had recent fall or other head trauma Mild Cognitive Impairment (MCI) - correct answer represents a transitional state between the cognitive changes of normal aging and very early disease Alzheimer's disease (AD) - correct answer A progressive disease that destroys the brain's neurons, gradually impairing memory, thinking, language, and other cognitive functions, resulting in the complete inability to care for oneself; the most common cause of dementia. Onset—gradual Cognitive symptoms—memory impairment core feature with difficulty learning new information, language, visuospatial Motor symptoms—rare early, apraxia later Progression—gradual, over 8-10 yr on average Lab tests—normal Imaging—possible global atrophy, small hippocampal volumes Vascular Dementia - correct answer Onset—may be sudden/stepwise Cognitive symptoms—depend on anatomy of ischemia, but dysexecutive deficits and slowing common Motor symptoms—correlates with ischemia Progression—gradual or stepwise with further ischemia Lab tests—normal Imaging—cortical or subcortical changes on MRI Lewy body dementia - correct answer A form of dementia characterized by an increase in Lewy body cells in the brain. Symptoms include visual hallucinations, momentary loss of attention, falling, and fainting. Onset—gradual Cognitive symptoms—memory, visuospatial, hallucinations, fluctuating symptoms Motor symptoms—parkinsonism Progression—gradual, but faster than AD Lab tests—normal Imaging—possible global atrophy Frontotemporal Dementia - correct answer Frontal and temporal regions degenerate, resulting in badly impaired emotional stability, decision-making and language use Onset—gradual, usually age 60 Cognitive symptoms—executive, disinhibition, apathy, language, +/- memory Motor symptoms—none [rare genetic forms associated with ALS] Progression—gradual but faster than AD Lab tests—normal Imaging—atrophy in frontal and temporal lobes Cholinesterase Inhibitors - correct answer A class of drugs to treat people with dementia that help increase levels of acetylcholine in the brain. Widespread use in vascular dementia not recommended Attention and behavioral disturbances in Lewy body dementia can benefit from treatment Rivastigmine is FDA-approved for mild to moderate dementia in Parkinson dementia Treatment in frontotemporal dementia may worsen agitation Memantine (namenda) - correct answer Neuroprotective effect is to reduce glutamate-mediated excitotoxicity Modest benefit on cognition, ADLs, and behavior in ADLimited effect on cognition and no evidence to support widespread use in vascular dementiaFDA-approved for moderate to severe AD Common adverse events—constipation, dizziness, headache What are two main drug classes to be avoided in dementia patients? - correct answer Benzodiazepines and anticholinergic Behavioral symptoms by dementia type - correct answer Frontotemporal dementia [Pick's disease]—often associated with prominent disinhibition, compulsive behaviors, and social impairment, often with a younger age of onset • In severe cases, a syndrome of hyperphagia, hyperactivity, and hypersexuality may occur Dementia with Lewy bodies—prominent psychosis characterized by visual hallucinations Behavioral problems can occur in all dementia types Selective Serotonin Reuptake Inhibitors (SSRIs) - correct answer a group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters Escitalopram, Citalopram, Fluoxetine, Sertraline Selective Norepinephrine Reuptake Inhibitors (SNRIs) - correct answer Desvenlafaxine, duloxetine, mirtazipine, venlafaxine Tryciclic Antidepressants (TCA) - correct answer proper name Heterocyclics blocks the reuptake of NE and serotonin anticholinergic (potent muscarinic antagonist) weak alpha1 receptor antagonist weak histamine antagonist - amitriptyline (elaviil), depression and nerve pain - doxepine SE: anticholinergic effects- dry mouth, constipation, urinary retention, blurred vision, slowed gastric emptying lowers seizure threshold contraindications acute recovery from MI arrhythmias Labs messes up blood count increase blood glucose increases catecholamines What is delirium? - correct answer disorder of attention and awareness that develops acutely and tends to fluctuate What is a useful tool at bedside to determine delirium - correct answer Confusion Assessment Method [CAM] Most useful bedside assessment tool for delirium per several systematic reviews What is a useful test to screen for depression? - correct answer 9-Item Patient Health Questionnaire [PHQ-9] 9 items cover diagnostic criteria for major depressive disorder Divaloprex (Depakote) pharmacotherapy for mania - correct answer Considered first-choice for treatment and prevention of mania Therapeutic level of 50-100 mcg/mL is considered safe and efficacious If little to no response after 2 weeks at or above the upper limit of therapeutic level, drug trial has failed Inhibits hepatic enzymes that metabolize medications used by many older adults CBC with PLT, AST, ALT, amylase should be performed at initiation of treatment, dose increase, and at least every 6 months Response requires at least 3 weeks One of the main mood stabilizers for bipolar depression is? - correct answer Lamotrigine Lamotrigine is preferable to lithium, divalproex, and carbamazepine due to its adverse-event profile and the likelihood of drug interactions Electroconvulsive therapy - correct answer • Effective for treatment of major depression and mania • First-line treatment for patients at serious risk for suicide, life-threatening poor intake • First-line treatment for delusional depression; response rates ~80% Movement Disorders - correct answer Result from dysfunction of the extrapyramidal motor system, not weakness or sensory deficits What is hypokinesia? - correct answer Hypokinesia—paucity of movement o Parkinson Disease [PD] o Parkinsonism or Parkinson-plus Syndromes—have some features of PD but also have other features; less or not responsive to dopaminergic drugs What is hyperkinesia? - correct answer Hyperkinesia—too much movement o Conditions that produce chorea—Huntington Disease; dyskinesias, dystonia, and tremor Tardive dyskinesia (TD) - correct answer a late-onset, irreversible neurologic side effect of antipsychotic medications; characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet Essential tremor - correct answer a nerve disorder causing tremors to occur in a person who is moving or trying to move. Not usually associated with Parkinson's disease Present when the limbs are in active use [purposeful or intention tremor] Most common in the arms, but can affect—head, voice, legs Treatments for essential tremor - correct answer Initial therapy—nonselective β-blocker [propranolol, nadolol] or primidone [SOE=A] Other options—BaclofenOL, GabapentinOL, MirtazapineOL, PregabalinOL, and TopiramateOL have been described as effective in some patients, but results have not been consistent [SOE=B/C] OT can add additional benefit Botulinum toxin may provide benefit is some cases Severe, medically refractory tremor may be treated with deep brain stimulation Patho of Parkinson's Disease - correct answer Destruction of neurons in the substantia nigra thus decreasing dopamine production. This causes an imbalance between dopamine and acetylcholine in the basal ganglia resulting in dysfunction of the extrapyramidal motor system. Therefore posture, balance, eye blinking, facial expression, gait and cognition (neurons from SN go to frontal lobe) are problematic a result of loss of function in the substantia nigra—but recent data show that non- dopamine neurons in other areas contribute The non-dopamine pathways are thought to cause the nonmotor signs and symptoms. These non-dopamine pathways are thought to degenerate long before the substantia nigra degenerates Evidence based guidelines for parkinson's treatment - correct answer Individualize treatment based on patient's clinical presentation, lifestyle, preferences and goals—weigh risk and benefits of the different drug options Levodopa in early stage disease in those whose motor s/sx impact their QOL Consider dopamine agonists, Levodopa or MAO-B inhibitors in the early stages in those whose motor s/sx do not impact their QOL Do not offer ergot derived dopamine agonists as first line drugs Levodopa - correct answer Dopamine precursor: used in parkinsonism, usually combined with carbidopa (a peripheral inhibitor of dopamine metabolism). Tox: dyskinesias, hypotension, on−off phenomena, behavioral changes Dopamine Agonists - correct answer Stimulate Dopamine receptors Ergot—Bromocriptine Non-ergot (preferred)—pramipexole, ropinirole Used primarily in early treatment before starting Levodopa AND in those with motor fluctuations in order to prolong the effect of the Levodopa MAO-B inhibitor drugs - correct answer All agents provide mild to moderate symptomatic benefit—can be used as monotherapy in those with mild disease and no motor symptoms Selegiline Rasagiline Safinamide COMT inhibitors - correct answer Catechol-O-methyl transferase [COMT] is the second major enzyme involved in the breakdown of Levodopa in the periphery These drugs slow the breakdown of Levodopa and so there is prolonged effect, smoother blood levels and less response fluctuations Used in those on 3 or more daily doses of Levodopa Entacapone, Tolcapone