NR601 Midterm Exam Study Guide 2024

What are the 3 primary physiological changes of aging? – 1. Reduced physiological reserve of most body systems, esp. cardiac, resp, renal. 2. Reduced homeostatic mechanisms that fail to adjust regulatory systems (i.e. temp control, fluid/lyte balance, etc.). 3. Impaired immunological function (infection risk is greater, autoimmune dz's more prevalent) What is the preferred amount of exercise for elderly? - 30min/day 5 days/wk of moderate exercise. If trying to lose wt: 60min/day. What are PFTs? - Group of tests that provide quantifiable measurement of lung function, used to dx resp abnormalities or assess progression/resolution of lung dz. What is FEV1? - Forced Expiratory Volume in 1 second (80-120%) What is FVC? - Forced Vital Capacity (80-120%) What is normal FEV1/FVC ratio? - 0.7 (70%) What is GOLD 1 criteria? - Mild FEV1 /= 80% predicted What is GOLD 2 criteria? - Moderate FEV1 50-79% predicted What is GOLD 3 criteria? - Severe FEV1 30-49% predicted What is GOLD 4 criteria? - Very severe FEV1 30% predicted What are the signal symptoms of COPD? - Dyspnea Chronic cough w/sputum Decreased activity tolerance Wheezing What are characteristics of COPD? - Common, preventable, treatable. Characterized by persistent airflow limitation. Usually progressive, associated with enhanced chronic inflammatory response in airways and lungs to noxious particles/gases Airway fibrosis, luminal plugs, airway inflammation, increased airway resistance, small airway dz. Decreased elastic recoil of alveoli. What are risk factors for COPD? - Smoking (increasing w/number of pack years) Second hand smoke Environmental pollution (endotoxins, coal dust, mineral dust) What is seen on phys exam in COPD? - May be normal in early states As severity progresses: lung hyperinflation, decreased breath sounds, wheezes at bases, distant heart tones (b/c of hyperinflation, so S1/S2 sounds off in distance), accessory muscle use, pursed lip breathing, increased expiratory phase, neck vein distention. How is COPD diagnosed? - Spirometry is gold standard (pre and post bronchodilator). Irreversible airflow limitation is hallmark. How is COPD treated? - Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo. What is the MOA of beta agonists? - Stimulates beta-2-adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways. What is the MOA of anticholinergics? - Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation. Why are long-acting beta agonists prescribed for COPD? - They are for moderate airflow limitation. They relieve symptoms, increase exercise tolerance, reduce number of exacerbations, improve QOL. What are some non pulmonary diagnoses that result in COPD-type symptoms? - CHF Hyperventilation syndrome Panic attacks Vocal cord dysfunction Obstructive sleep apnea Aspergillosis Chronic fatigue syndrome What are signal symptoms of asthma? - Wheezing Shortness of breath Cough (esp at night) Chest tightness What is chronic bronchitis? - Daily chronic cough w/increased sputum for at least 3 consecutive months in at least 2 consecutive years. Usually worse on wakening. May or may not be associated with COPD. What is emphysema? - Characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Chronic inflammation/remodeling, trapping air, hindering effective O2/CO2 exchange (all due to inflammatory mediators infiltrating airways). What are signal symptoms of ischemic heart dz? - Chest pain Chest tightness Chest discomfort What is ischemic heart dz? - Imbalance between supply and demand for blood flow to myocardium What are signal symptoms of lung CA? - Cough Dyspnea Wt loss Anorexia Hemoptysis What is lung CA? - Malignant neoplasm originating in parenchyma of lung/airways What are signal symptoms of MI? - Prolonged CP (20min duration) SOB Confusion Weakness Worsening HF What is an MI? - Necrosis of heart tissue caused by lack of blood and O2 supply to the heart What are signal symptoms of pneumonia? - Fever Chills Hypothermia New cough w/or w/out sputum Chest discomfort or dyspnea Fatigue HA Some older adults will be asymptomatic but may experience falls/confusion What is community acquired pneumonia? - Acute lower resp tract infection of lung parenchyma. Can be bacterial or viral. Bacterial is most common in older adults. What are signal symptoms of a PE? - Dyspnea CP on inspiration Anxiety Presentation is variable Symptoms nonspecific Some asymptomatic What is PE description? - Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site. What are signal symptoms of tuberculosis? - Initially asymptomatic Later: productive, prolonged cough Fatigue Low-grade fever Night sweats Poor appetite Hemoptysis Wt loss Fever/sweats are less common in elderly Symptoms in elderly are often attributed to other comorbidities What is tuberculosis? - Chronic, necrotizing infection caused by slow-growing acid-fast bacillus (Mycobacterium tuberculosis). Most common cause of death related to infectious dz worldwide. What are signal symptoms of valvular heart dz? - Asymptomatic in early stages Fatigue Exertional dyspnea What is valvular heart dz? - Damage to valve(s) of the heart, causing cardiac dysfunction. Most prevalent types in elderly: calcific and degenerative aortic valve dz What is aortic stenosis? - Abnormal narrowing of aortic valve orifice What is aortic regurgitation? - Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole What is mitral stenosis? - Abnormal narrowing of mitral valve orifice What is mitral regurgitation? - Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve What is mitral valve prolapse? - Mitral regurgitation associated with bulging of one or both mitral valve leaflets into L atrium during ventricular systole What are most common causes of VHD in elderly? - Age-related degenerative calcifications Myxomatous degeneration Papillary muscle dysfunction Infective endocarditis Rheumatic dz What happens in valvular regurgitation? - Portion of the ejected blood leaks back into the upstream cardiac chamber What happens in valvular stenosis? - Usually results in elevated pressures in the chamber upstream from the stenosis What are signal symptoms of URI? - Nasal congestion Rhinorrhea/mucopurulent discharge Sore throat Cough HA Malaise What is a URI? - Most frequently called the common cold Usually caused by virus Results in nasal passage inflammation Most are self-limiting, accompanied by minor complaints Included in URI dx: acute laryngitis, acute rhinosinusitis, acute pharyngitis What are signal symptoms of restrictive lung dz? - Rapid, shallow respirations Dyspnea Decreased activity tolerance Easily fatigued Nonproductive, irritating cough provoked by deep breathing/exertion What is restrictive lung dz? - Heterogenous group of disorders that share common abnormal ventilatory function. Characterized by small tidal volume, rapid rate. Hallmark restrictive pattern is decreased lung volm, esp. total lung capacity and vital capacity. What is the purpose of functional assessment of the elderly? - Discovers the ability to care for themselves on a daily bases What can ongoing pain be linked to in the elderly? - Depression Decreased socialization Sleep disturbance Impaired cognitive function Is chronic pain a normal sign of aging? - No What is polypharmacy? - Broad definition, but basically too many medications for what is going on with the patient, the use of multiple pharmacies/providers. What is Stage A of HF? - At high risk for heart failure but w/out structural changes/symptoms What is Stage B HF? - Structural heart dz but w/out s/s of HF (still "at risk" for HF) What is Stage C HF? - Structural heart dz w/prior or current s/s of HF (actually have HF) What is Stage D HF? - Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.) What are treatment goals for Stage A HF? - Heart-healthy lifestyle Prevent vascular, coronary dz Prevent LV structural abnormalities What are drugs used in Stage A HF? - ACEi or ARB in appropriate pt's for vascular dz or DM Statins as appropriate What are treatment goals for Stage B HF? - Prevent HF symptoms Prevent further cardiac remodeling What are drugs used in Stage B HF? - ACEi or ARB as appropriate Beta blockers as appropriate In selected pt's: ICD Revascularization/valvular surgery as appropriate What are goals of Stage C HFpEF? - Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality ID comorbidities What is treatment for Stage C HFpEF? - Diuresis to relieve s/s congestion Follow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.) What are treatment goals for Stage C HFrEF? - Control symptoms Pt education Prevent hospitalization Prevent mortality What are drugs used in Stage C HFrEF? - Diuretics for fluid retention ACEi or ARB BB Aldosterone antagonists Drugs in selected pts: Hydralazine/isosorbide dinitrate ACEi and ARB Digitalis Procedures in selected pts: CRT ICD Revascularization/valvular surgery as appropriate What are treatment goals in Stage D HF? - Control symptoms Improve HRQOL Reduce hospital readmissions Establish pt's end-of-life goals What are options for Stage D HF? - Advanced care measures Heart transplant Chronic inotropes Temporary or permanent MCS Experimental surgery/drugs Palliative care, hospice ICD deactivation What is the normal BNP level? - 100pg/mL (indicates HF is unlikely) What is normal BP? - 120/80 What is "elevated" BP? - 120-129/80 What is Stage 1 HTN? - 130-139 OR 80-89 What is Stage 2 HTN? - /= 140 or /= 90 What is recommended BP for DM? - 130/80 What is recommended BP for CKD? - 130/80 How should HTN be managed? - Stage 2 and up should be given consideration for pharm treatment. Others can wait for lifestyle modification. What is first-line meds for non-black HTN population (including those w/DM)? - Thiazide, CCB, ACEi, or ARB, either alone or in combo What is the med guideline for ASCVD for those /= 75yo? - High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for those 75yo? - Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mg BID) What is the guideline for meds for LDL /= 190? - High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for 40-75yo w/DM? - Their 10yr risk is 7.5%, so high intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for LDL 70-189? - Their 10yr risk is 7.5%, so moderate intensity statin (atorvastatin/Lipitor 10mg, rosuvastatin/Crestor 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mgBID) What is the ASCVD med guideline for 40-75yo w/out ASCVD or DM? - Their 10yr risk is 7.5%, so moderate to high intensity statin What is the purpose for Beers criteria? - The American Geriatrics Society developed Beers Criteria for use of providers as a guide for medical management of geriatric pts. Goal: to improve quality and safety. Not a sub for individualized care, but should be incorporated into prescribing practices for elderly. As an NP, be familiar w/the lists to avoid prescribing potentially inappropriate meds. Why do elderly need special prescribing criteria? - Age-related changes also change metabolism. Pharmacodynamics change. Pharmacokinetic changes: absorption, distribution, metabolism, elimination. Half-lives altered, which affects steady state and dosing intervals. What are potential risk factors for ADRs in elderly? - 6 or more chronic dz's. 9 or more Rx or OTC meds. 12 doses per day 85yo BMI 22 Creatinine clearance 50 H/o previous ADR What are some 2015 changes in med awareness for elderly? - Nitrofurantoin can be used w/creatinine clearance of 30, but should be avoided long term due to possible irreversible pulmonary fibrosis, liver tox, peripheral neuropathy. Non-benzos, benzo receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) should be avoided for insomnia regardless of duration due to associated harm. PPI should be avoided 8wks w/out justification due to possible c-diff infection, bone loss, fractures. Opioids should be avoided in those with h/o falls/fractures. T/F The meds listed in Beers Criteria are not absolutely contraindicated in elderly. - True T/F The BC recommendations are graded as high, medium, low to assist w/decision making. - True T/F The BC list includes dosage adjustments for kidney impairment. - True T/F The BC list includes drug to drug interactions to avoid. - True T/F Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts. - True What vaccination is recommended for people traveling to countries where dz is common? - Hep A How is Hep A vax given? - Two doses: initial at least 4wks before departure, second dose 6-12mo later. When is Hep B vax recommended? - High-risk people (IV drug users, persons w/multiple partners) How is Hep B vax given? - Initial dose 1mo later: 2nd dose 4-6mo after 2nd: 3rd dose When is Zostavax recommended? - Anyone over 60yo, given as single dose Can people who have had prior episode of zoster be vaccinated? - Yes When is flu vax recommended? - Annually for all adults 50yo When should DTaP be given? - Once in a lifetime for all adults, then Td booster every 10yrs. When is pneumococcal vax recommended? - Once for 65yo and older Younger adults w/severe chronic health conditions What is primary prevention? - Activities to prevent occurrence of dz or adverse health condition, including mental health. Health counseling and immunizations are examples. What is secondary prevention? - Activities aimed at detection of dz or adverse health condition in asymptomatic pt who has risk factors but no detectable dz. Screening tests are examples, like mammography. What is tertiary prevention? - Management of existing conditions to prevent disability and minimize complications, striving for optimal function and QOL. Pulmonary rehab for COPD is an example. What are common s/s of anxiety in elderly? - Constipation Nausea HA Worrying about health, disability, finances What are phobic disorders? - Anxiety from a specific feared object or situation. Person feels anxiety is excessive or unreasonable. Often leads to distress or avoiding the fear. Often lifelong, common in older adults. What is generalized anxiety disorder (GAD)? - Often 20-30yrs of excessive worry about health, family, finances w/insomnia, muscle tension, restlessness, fatigue, irritability, memory problems. What is PTSD? - Re-experiencing a traumatic event w/increased anxiety, avoiding thoughts of the trauma, feeling numb/uninterested, perceiving future as short. What is panic disorder? - Involves recurrent, often unexpected attacks of severe anxiety w/one month of worry about future attacks and consequences. May include changes in behavior. Rare in older adults, less severe/frequent than in younger adults. Usually keeps them from leaving home. What is agoraphobia? - Avoiding places where escape is difficult or embarrassing. Rare in older adults, usually does not occur w/panic attacks. What is OCD? - Obsessions that cause anxiety or distress and/or compulsions that reduce anxiety. Rare in older adults. Usually lifelong. What is treatment for anxiety? - Should reduce symptoms and improve function. First-line: SSRI (citalopram/Celexa, escitalopram/Lexapro, sertraline/Zoloft). For elderly, these have lowest risk of drug interactions, SE, or worsening existing conditions. Effective but not recommended due to falls/confusion: benzos (lorazepam/Ativan, alprazolam/Xanax, clonazepam/Klonopin) What are signal symptoms of depression? - Feeling sad Discouraged Lack of pleasure in usual activities Unmotivated Low energy Sleep/appetite disturbances The symptoms of depression may encompass what 4 domains? - Affect/mood Cognition Physiological Behavior What is treatment goal for depression? - Full remission and recovery What are first-line meds for depression? - SSRIs: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) flovoxamine (Luvox) What is transient insomnia? - Lasts a few nights. Related to emotional stress. Usually resolves w/out meds when elderly adapts to or removes change. What is short-term insomnia? - Similar to transient insomnia. Lasts 1mo Related to acute medical/psychological condition or to persistent situational stress. What is chronic insomnia? - Lasts 1mo Results from age-related changes in sleep/chronic stressors. What is treatment for insomnia? - Avoid caffeine for 12hrs before bedtime. D/C ETOH/unnecessary sleep-interrupting drugs. OTC melatonin or Rx ramelteon can be tried; if ineffective, initiate short-acting sedative-hypnotic like zolpidem (Ambien) or zaleplon (Sonata) at lowest dose before desired bedtime for 1wk or less. Suggest spacing dose to every other day to avoid SE. If benzos used, temazepam (Restoril) is relatively short-acting; if ineffective, re- eval dx and restructure treatment modalities. What are signal symptoms of polymyalgia rheumatica? - New onset stiffness/aching in neck, shoulders, pelvic girdle. Unable to get out of bed in the morning w/out extreme difficulty. Difficulty lifting arms over head. What are common lab findings in polymyalgia rheumatica? - Elevated ESR and CRP Normochromic, normocytic anemia Thrombocytosis What is treatment for PMR? - If s/s are only of PMR and not of GCA as well, start low dose prednisone 10-20mg/day and taper dose. What are signal symptoms of rheumatoid arthritis? - Morning stiffness Joint deformities Rheumatoid nodules Symmetrical inflammatory polyarthritis What are diagnostic tests for RA? - Rheumatoid factor (RF) ESR CRP Erosive dz and raised RF indicate seropositive RA What is treatment for RA? - Drug management is for symptom/dz control. For symptoms: Corticosteroids Analgesia NSAIDs For dz control: Corticosteroids, which can be used in combo w/traditional dz-modifying therapies What are signal symptoms of osteoarthritis? - Morning stiffness 30min, improves with activity Bouchard's nodes (PIP joints) Heberden's nodes (DIP joints) Crepitus What are diagnostic tests for OA? - Often dx is made w/out XR Bilat XR reveal joint space narrowing, subchondral cysts, subchondral bony sclerosis, osteophytosis resulting in proliferative bone spurs. What is treatment for OA? - Multifaceted approach is maintstay. Walking. Water therapy in pts w/no evidence of inflammation. In non-inflammatory: APAP is med of choice (2.6-4g/day) What is the major difference between varicose veins and atherosclerosis? a. The limbs that are affected b. The gender that's affected c. Vessels that are affected d. The degree of pain - C Pt has had poorly controlled HTN 10yrs. Indicate the most likely position of his PMI. a. 5th ICS MCL b. 8th ICS MCL c. 5th ICS left of MCL d. 6th ICS R of MCL - C 43yo hispanic male has audible diastolic murmur best heard at the mitral point. No audible click. He has been monitored for 2yrs. What is the most likely murmur? a. Mitral valve prolapse b. Acute mitral regurgitation c. Chronic mitral regurgitation d. Mitral stenosis - D What is osteoporosis? - Skeletal disorder characterized by impaired bone strength that predisposes to increased risk of fracture. Can occur from not only bone loss but also from failure earlier in life to make sufficient bone. Primary: due to aging (increased bone resorption/reduced new bone formation) Secondary: consequence of underlying medical condition/drug What are s/s of osteoporosis? - Sometimes not seen until fracture sustained spontaneously or after minimal trauma, usually in thoracic/lumbar vertebrae, hip, wrist, humerus, pelvis. With each fracture, risk of another increases exponentially. Loss of height, kyphosis development. XR: bones appear osteopenic (at least 30% loss in bone mass); spine shows loss of horizontal vertebral trabeculae, accentuating end plates, producing biconcave "codfish" vertebrae; maybe compression fracture. What are diagnostic tests for osteoporosis? - XR DEXA (screen all women 65yo, hip/spine; test earlier if major risk factors present; repeat every 3-5yrs depending on degree) What is T-score of -2.5 or lower indicative of? - Osteoporosis What is a T-score of -1.0 to -2.5 indicative of? - Osteopenia What is a T-score of -1.0 or higher indicative of? - Normal bone density What is a Z-score of -1.5 indicative of? - Secondary cause of osteoporosis What are the risk factors for osteoporosis? - Previous fracture Advanced age Low body wt/BMI Maternal h/o fracture Current smoking Physical inactivity Excessive exercise resulting in amenorrhea