NR601 Physiological Changes in Aging

What are the 3 primary physiological changes of aging? (ANS)- 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? (ANS)- 30min/day 5 days/wk of moderate exercise. If trying to lose wt: 60min/day. What are PFTs? (ANS)- 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? (ANS)- Forced Expiratory Volume in 1 second (80-120%) What is FVC? (ANS)- Forced Vital Capacity (80-120%) What is normal FEV1/FVC ratio? (ANS)- <0.7 (70%) What is GOLD 1 criteria? (ANS)- Mild FEV1 >/= 80% predicted What is GOLD 2 criteria? (ANS)- Moderate FEV1 50-79% predicted What is GOLD 3 criteria? (ANS)- Severe FEV1 30-49% predicted What is GOLD 4 criteria? (ANS)- Very severeFEV1 <30% predicted What are the signal symptoms of COPD? (ANS)- Dyspnea Chronic cough w/sputum Decreased activity tolerance Wheezing What are characteristics of COPD? (ANS)- 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? (ANS)- 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? (ANS)- 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? (ANS)- Spirometry is gold standard (pre and post bronchodilator). Irreversible airflow limitation is hallmark. How is COPD treated? (ANS)- Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo.What is the MOA of beta agonists? (ANS)- Stimulates beta-2-adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways. What is the MOA of anticholinergics? (ANS)- Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation. Why are long-acting beta agonists prescribed for COPD? (ANS)- 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? (ANS)- CHF Hyperventilation syndrome Panic attacks Vocal cord dysfunction Obstructive sleep apnea Aspergillosis Chronic fatigue syndrome What are signal symptoms of asthma? (ANS)- Wheezing Shortness of breath Cough (esp at night) Chest tightness What is chronic bronchitis? (ANS)- 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? (ANS)- 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? (ANS)- Chest pain Chest tightness Chest discomfort What is ischemic heart dz? (ANS)- Imbalance between supply and demand for blood flow to myocardium What are signal symptoms of lung CA? (ANS)- Cough Dyspnea Wt loss Anorexia Hemoptysis What is lung CA? (ANS)- Malignant neoplasm originating in parenchyma of lung/airways What are signal symptoms of MI? (ANS)- Prolonged CP (>20min duration) SOB Confusion Weakness Worsening HF What is an MI? (ANS)- Necrosis of heart tissue caused by lack of blood and O2 supply to the heart What are signal symptoms of pneumonia? (ANS)- 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/confusionWhat is community acquired pneumonia? (ANS)- 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? (ANS)- Dyspnea CP on inspiration Anxiety Presentation is variable Symptoms nonspecific Some asymptomatic What is PE description? (ANS)- Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site. What are signal symptoms of tuberculosis? (ANS)- 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? (ANS)- Chronic, necrotizing infection caused by slowgrowing acid-fast bacillus (Mycobacterium tuberculosis). Most common cause of death related to infectious dz worldwide. What are signal symptoms of valvular heart dz? (ANS)- Asymptomatic in early stagesFatigue Exertional dyspnea What is valvular heart dz? (ANS)- 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? (ANS)- Abnormal narrowing of aortic valve orifice What is aortic regurgitation? (ANS)- Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole What is mitral stenosis? (ANS)- Abnormal narrowing of mitral valve orifice What is mitral regurgitation? (ANS)- Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve What is mitral valve prolapse? (ANS)- 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? (ANS)- Age-related degenerative calcifications Myxomatous degeneration Papillary muscle dysfunction Infective endocarditis Rheumatic dz What happens in valvular regurgitation? (ANS)- Portion of the ejected blood leaks back into the upstream cardiac chamber What happens in valvular stenosis? (ANS)- Usually results in elevated pressures in the chamber upstream from the stenosis What are signal symptoms of URI? (ANS)- Nasal congestion Rhinorrhea/mucopurulent discharge Sore throatCough HA Malaise What is a URI? (ANS)- 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? (ANS)- Rapid, shallow respirations Dyspnea Decreased activity tolerance Easily fatigued Nonproductive, irritating cough provoked by deep breathing/exertion What is restrictive lung dz? (ANS)- 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? (ANS)- Discovers the ability to care for themselves on a daily bases What can ongoing pain be linked to in the elderly? (ANS)- Depression Decreased socialization Sleep disturbance Impaired cognitive function Is chronic pain a normal sign of aging? (ANS)- No What is polypharmacy? (ANS)- 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? (ANS)- At high risk for heart failure but w/out structural changes/symptoms What is Stage B HF? (ANS)- Structural heart dz but w/out s/s of HF (still "at risk" for HF) What is Stage C HF? (ANS)- Structural heart dz w/prior or current s/s of HF (actually have HF) What is Stage D HF? (ANS)- Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.) What are treatment goals for Stage A HF? (ANS)- Heart-healthy lifestyle Prevent vascular, coronary dz Prevent LV structural abnormalities What are drugs used in Stage A HF? (ANS)- ACEi or ARB in appropriate pt's for vascular dz or DM Statins as appropriate What are treatment goals for Stage B HF? (ANS)- Prevent HF symptoms Prevent further cardiac remodeling What are drugs used in Stage B HF? (ANS)- 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? (ANS)- Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality ID comorbidities What is treatment for Stage C HFpEF? (ANS)- Diuresis to relieve s/s congestionFollow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.) What are treatment goals for Stage C HFrEF? (ANS)- Control symptoms Pt education Prevent hospitalization Prevent mortality What are drugs used in Stage C HFrEF? (ANS)- 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? (ANS)- Control symptoms Improve HRQOL Reduce hospital readmissions Establish pt's end-of-life goals What are options for Stage D HF? (ANS)- 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? (ANS)- <100pg/mL (indicates HF is unlikely)What is normal BP? (ANS)- <120/80 What is "elevated" BP? (ANS)- 120-129/<80 What is Stage 1 HTN? (ANS)- 130-139 OR 80-89 What is Stage 2 HTN? (ANS)- >/= 140 or >/= 90 What is recommended BP for DM? (ANS)- <130/80 What is recommended BP for CKD? (ANS)- <130/80 How should HTN be managed? (ANS)- 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)? (ANS)- Thiazide, CCB, ACEi, or ARB, either alone or in combo What is the med guideline for ASCVD for those </= 75yo? (ANS)- High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for those >75yo? (ANS)- 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? (ANS)- High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for 40-75yo w/DM? (ANS)- 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? (ANS)- 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? (ANS)- Their 10yr risk is >7.5%, so moderate to high intensity statin What is the purpose for Beers criteria? (ANS)- 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? (ANS)- 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? (ANS)- 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? (ANS)- 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. (ANS)- True T/F The BC recommendations are graded as high, medium, low to assist w/decision making. (ANS)- True T/F The BC list includes dosage adjustments for kidney impairment. (ANS)- True T/F The BC list includes drug to drug interactions to avoid. (ANS)- True T/F Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts. (ANS)- True What vaccination is recommended for people traveling to countries where dz is common? (ANS)- Hep A How is Hep A vax given? (ANS)- Two doses: initial at least 4wks before departure, second dose 6-12mo later. When is Hep B vax recommended? (ANS)- High-risk people (IV drug users, persons w/multiple partners) How is Hep B vax given? (ANS)- Initial dose 1mo later: 2nd dose4-6mo after 2nd: 3rd dose When is Zostavax recommended? (ANS)- Anyone over 60yo, given as single dose Can people who have had prior episode of zoster be vaccinated? (ANS)- Yes When is flu vax recommended? (ANS)- Annually for all adults >50yo When should DTaP be given? (ANS)- Once in a lifetime for all adults, then Td booster every 10yrs. When is pneumococcal vax recommended? (ANS)- Once for 65yo and older Younger adults w/severe chronic health conditions What is primary prevention? (ANS)- Activities to prevent occurrence of dz or adverse health condition, including mental health. Health counseling and immunizations are examples. What is secondary prevention? (ANS)- 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? (ANS)- 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? (ANS)- Constipation Nausea HA Worrying about health, disability, finances What are phobic disorders? (ANS)- 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)? (ANS)- Often 20-30yrs of excessive worry about health, family, finances w/insomnia, muscle tension, restlessness, fatigue, irritability, memory problems. What is PTSD? (ANS)- Re-experiencing a traumatic event w/increased anxiety, avoiding thoughts of the trauma, feeling numb/uninterested, perceiving future as short. What is panic disorder? (ANS)- 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? (ANS)- Avoiding places where escape is difficult or embarrassing. Rare in older adults, usually does not occur w/panic attacks. What is OCD? (ANS)- Obsessions that cause anxiety or distress and/or compulsions that reduce anxiety. Rare in older adults. Usually lifelong.What is treatment for anxiety? (ANS)- 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? (ANS)- Feeling sad Discouraged Lack of pleasure in usual activities Unmotivated Low energy Sleep/appetite disturbances The symptoms of depression may encompass what 4 domains? (ANS)- Affect/mood Cognition Physiological Behavior What is treatment goal for depression? (ANS)- Full remission and recovery What are first-line meds for depression? (ANS)- SSRIs: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) flovoxamine (Luvox) What is transient insomnia? (ANS)- 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? (ANS)- Similar to transient insomnia. Lasts <1mo Related to acute medical/psychological condition or to persistent situational stress. What is chronic insomnia? (ANS)- Lasts >1mo Results from age-related changes in sleep/chronic stressors. What is treatment for insomnia? (ANS)- 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, reeval dx and restructure treatment modalities. What are signal symptoms of polymyalgia rheumatica? (ANS)- 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? (ANS)- Elevated ESR and CRP Normochromic, normocytic anemia Thrombocytosis What is treatment for PMR? (ANS)- 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? (ANS)- Morning stiffness Joint deformitiesRheumatoid nodules Symmetrical inflammatory polyarthritis What are diagnostic tests for RA? (ANS)- Rheumatoid factor (RF) ESR CRP Erosive dz and raised RF indicate seropositive RA What is treatment for RA? (ANS)- 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? (ANS)- Morning stiffness <30min, improves with activity Bouchard's nodes (PIP joints) Heberden's nodes (DIP joints) Crepitus What are diagnostic tests for OA? (ANS)- 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? (ANS)- 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 affectedb. The gender that's affected c. Vessels that are affected d. The degree of pain (ANS)- 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 (ANS)- 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 (ANS)- D What is osteoporosis? (ANS)- 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? (ANS)- 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? (ANS)- 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? (ANS)- Osteoporosis What is a T-score of -1.0 to -2.5 indicative of? (ANS)- Osteopenia What is a T-score of -1.0 or higher indicative of? (ANS)- Normal bone density What is a Z-score of <-1.5 indicative of? (ANS)- Secondary cause of osteoporosis What are the risk factors for osteoporosis? (ANS)- Previous fracture Advanced age Low body wt/BMI Maternal h/o fracture Current smoking Physical inactivity Excessive exercise resulting in amenorrhea Poor lifetime intake of calcium Endocrine disorders GI dz Chronic systemic illnesses Nutritional deficiencies Meds (steroids, anticonvulsants, thyroid hormone, SSRI, aromatase inhibitors for breast CA) Alcoholism What is the treatment for osteoporosis? (ANS)- Aim to prevent those that are at risk Combine diet, exercise, meds Dietary Ca/vit D Wt-bearing/strength exercisesBisphosphonates Selective estrogen receptor modulators Calcitonin PTH Denosumab Fall prevention How does chronic pain differ from acute pain? (ANS)- Chronic pain tends to be more multifactorial, less amenable to cure, more influenced by psychological/social factors. Typically requires continuous long-term/multidisciplenary management. Can be triggered with seemingly minor biologic stimulus or persist long after injury is healed. What is the principle goal of chronic pain treatment? (ANS)- Improvement in QOL/function, rather than complete elimination of pain. What is nociceptive pain? (ANS)- Pain from nociceptive fibers in periphery triggered by actual or potential tissue damage. Typically attributed to specific anatomic location of tissue injury. Pain is well-localized, stabbing, throbbing, achy. What is neuropathic pain? (ANS)- Direct neuronal injury. Burning, tingling, lancinating. Often occurs in dermatomal pattern What are treatments for nociceptive pain? (ANS)- Nonopioid (APAP, ibuprofen) Weak opioids (Tramadol, tapentadol) Antidepressants (TCAs, SNRIs) OpioidsWhat are treatments for neuropathic pain? (ANS)- Characteristically more resistant to opioids and to pharm interventions in general than nociceptive pain. Antidepressants (TCAs, SNRIs) Anticonvulsants (gabapentin, pregabalin, carbamazepine, oxcarbazepine) Opioids Topical agents The percentage of the FVC expired in one second is: (ANS)- FEV1/FVC ratio The aging process causes what normal physiological changes in the heart? (ANS)- The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis. A 55yo Caucasian male follows up after referral to cardiologist. He thinks his med is causing a cough and sometimes he has difficulty breathing. Which med was most likely prescribed? (ANS)- Lisinopril JM is a 68yo man who presents for a physical. He has T2DM x5yrs, smokes 1/2 PPD, BMI is 30. No other previous medical dx, no current complaints. According to the AHA/ACC guidelines, JM is stage A HF. Treatment goals for him include: (ANS)- Heart healthy lifestyle MJ presents with h/o structural damage with current s/s of HF. Treatment will be based on his stage of HF, which is: (ANS)- Stage C 65yo Caucasian female presents with mitral valve stenosis, physical exam unremarkable. You know her stage of HF is: (ANS)- B DG, 65yo man, presents for eval of CP and L-sided shoulder pain, beginning after strenuous activity, including walking. Pain is dull, aching, 8/10 during activity, otherwise 0/10. Began few mo ago, intermittent, aggravated by exercise, relieved by rest. Occasional nausea. Pain is retrosternal, radiating to L shoulder, affects QOL by limiting activity. Pain is worse today, did not go away after stopped walking. BP 120/80, HR 72 and regular. Normal heart sounds, no murmur, S1, S2. Which differential dx would be most likely? (ANS)- Coronary artery dz w/angina pectorisThe best way to dx structural heart dz/dysfunction non-invasively is: (ANS)- Echocardiogram Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: (ANS)- Depression, sleep disturbance, decreased socialization The Beers criteria are appropriate for use in evaluating use of certain meds in pts: (ANS)- >65yo Pt presents with c/o increasing SOB, cough w/occasional white sputum, fatigue. As part of the plan you order labs. You know the likelihood of HF is low if the BNP is: (ANS)- <100 All of the following statements are true about lab values in older adults except: a. Normal ranges may not be applicable to older adults b. Abnormal findings are often due to physiological aging c. Reference ranges are preferable d. References values are not necessarily acceptable values (ANS)- B According to the 2017 ACC HTN guidelines, the recommended BP goal for a 65yo African American woman w/a h/o HTN and DM and no h/o CKD is: (ANS)- <140/80 The pathophysiology of HF is due to: (ANS)- Inadequate cardiac output to meet the metabolic and O2 demands of the body A 60yo woman w/30 pack yr hx, presents for eval of persistent, daily cough w/increased sputum, worse in the AM, occurring over past 3 months. She tells you, "I have the same thing year after year." Which of the following choices would you consider strongly in your critical thinking process? (ANS)- Chronic bronchitis JM is a 68yo man who presents for a physical. He has T2DM x5yrs, diet controlled. His BMI is 32. He has HTN, smoker (10 cigs/day x20yrs). He denies other medical problems. Fam hx includes CAD, CABG x4 for dad, now deceased; CHF, T2DM, HTN for mom. He is asymptomatic today, exam is normal, EKGNSR. According to AHA/ACC guidelines, JM is at risk for what stage of HF? (ANS)- Stage A The volume of air a pt is able to exhale for total duration of the test during maximal effort is: (ANS)- FVC According to the 2017 ACC HTN guidelines, normal BP is: (ANS)- <120/80 Functional abilities are best assessed by: (ANS)- Observed assessment of function LB is a 77yo pt w/chronic poorly controlled HTN. You know that goals include prevention of target organ damage. During your eval you will assess for evidence of: (ANS)- L ventricular hypertrophy Aortic regurgitation requires medical treatment for early signs of HF with: (ANS)- ACEi The volume of air in the lungs at max inflation is: (ANS)- TLC (total lung capacity) Preferred amount of exercise for older adults is: (ANS)- 30min/day of aerobic activity 5 days/wk The total volume of air a pt is able to exhale in the first second during max effort is: (ANS)- FEV1 You know the following statements regarding the pain of acute coronary syndrome are true except: a. Present atypically more often in men than women b. May be retrosternal or poorly localized c. May last longer than 20min d. May radiate to arms, back, neck, jaw (ANS)- A Elderly pt presents w/new onset of feeling heart race, fatigue. EKG reveals afib w/rate >100. Pt also has a new tremor in both hands. Which of the following would you suspect? (ANS)- Hyperthyroidism62yo female c/o fatigue, lack of energy. Constipation increased, pt gained 10lbs in past 3mo. Depression is denied although pt reports lack of interest in usual hobbies. VS are WNL, skin is dry/cool. Which of the following must be included in the DD? (ANS)- Hypothyroidism Mrs. Black, 87yo, has been taking 100mcg Synthroid x10yrs. She comes for routine follow-up, feeling well. HR is 90. Your first response is to: (ANS)- Order TSH Which pt is most likely to have osteoporosis? (ANS)- 80yo underweight male who smokes and has been on steroids for psoriasis When evaluating the expected outcome for hypothyroid elderly pt on levothyroxine, you will: (ANS)- Assess TSH in 4-6wks Postmenopausal woman w/osteoporosis is taking bisphosphonate daily PO. What action info statement would indicate she understood your instructions regarding this med? (ANS)- Take med w/full glass of water when up in the AM 30min before other food and meds Primary reason levothyroxine sodium is initiated at low dose in elderly pt w/hypothyroidism is to prevent which of the following untoward effects? (ANS)- Angina and arrhythmia 6mo ago an elderly pt was dx'd w/subclinical hypothyroidism. Today the pt returns and has TSH of 11 and c/o fatigue. He has taken Synthroid 25mcg daily as prescribed. What is the best course of action? (ANS)- Double the dose A fluoroquinolone (Cipro) is prescribed for a male pt w/a UTI. What should you teach him regarding this med? (ANS)- Its effectiveness is decreased by antacids, iron, or caffeine Pt has been rx'd metformin (Glucophage). One wk later, he returns w/lowered BGL but c/o loose stools during the week. How should you respond? (ANS)- Reassure him that this is an anticipated SEWhich of the following s/s of hyperthyroidism commonly manifest in younger populations, but is notably lacking in elderly? (ANS)- Exopthalmos 60yo obese male has T2DM and lipid panel of TC = 250, HDL = 32, LDL = 165. You teach him about his modifiable cardiac risk factors, which include: (ANS)- DM, obesity, hyperlipidemia Diabetic pt presents w/R foot pain but denies any recent known injury. He states it has gotten progressively worse over past few months. On exam, vibratory sense, as well as sensation tested w/monofilament, was abnormal. Pt's foot is warm, edematous, misshapen. You suspect Charcot foot. What intervention is indicated? (ANS)- Referral to orthopedist What is a s/s of insulin resistance that can present in African Americans? (ANS)- Acanthosis Nigricans During routine exam of 62yo female, you ID xanthelasma around both eyes. What is the significance of this? (ANS)- Abnormal lipid metabolism requiring medical management Mr. White is 62yo, had CKD that has been relatively stable. He also has h/o hyperlipidemia, OA, HTN. He is compliant w/meds, BP has been well controlled on CCB. Last lipids showed: TC = 201, HDL = 40, TG = 180, LDL = 98. He currently takes Crestor 20mg daily. Today his BP is 188/90 and urine dip shows significant proteinuria. He denies changes in dietary habits or med regimen. What would be the best med change at this point? (ANS)- Change CCB to ACEi You are working as NP in Fast Track of ER. 76yo male presents w/LUQ pain. There can be many conditions that present as LUQ pain, but which of the following is least likely to cause pain here? (ANS)- Acute pancreatitis Which is cardinal feature of failure to thrive? (ANS)- Poor nutritional status Feeding gastrostomy tubes at end-of-life Alzheimer's pt's have been associated with: (ANS)- Aspiration pnaWhich of the following nutritional indicators is not an indication of poor nutritional status in elderly? (ANS)- BMI 25 OA of cervical and lumbar spine causes pain related to all of the following except: (ANS)- Crystal deposition In differentiating OA from chronic gout, pseudogout, or septic arthritis, the most valuable diagnostic study would be: (ANS)- Synovial fluid analysis Pt's w/OA of hip and knee often have distinguishable gait described as: (ANS)- Antalgic Which of the following best describes pain associated w/OA? (ANS)- Begins upon arising and after prolonged wt bearing and/or use of the joint Joint effusions typically occur later in the course of OA, especially in the: (ANS)- Knee You ordered CBC for your pt you suspect has polymyalgia rheumatica (PMR). Which 2 clinical findings are common in pt's w/PMR? (ANS)- Normochromic, normocytic anemia and thrombocytosis You suspect your pt has PMR and now are concerned that they may have Giant Cell Arteritis (GCA) too. Which of the following 2 symptoms are most indicative of GCA and PMR? (ANS)- Scalp tenderness and aching in shoulder and pelvic girdle 63yo Caucasian pt w/PMR will begin Tx w/corticosteroids until the condition has resolved. You look over her records and it has been 2yrs since her last physical exam and any labs or diagnostic tests as she relocated and had not yet ID'd a provider. In prioritizing your management plan, your first orders should include: (ANS)- Duel-energy x-ray (DEXA) scan and updating immunizations Which of the following DD for pt's presenting w/PMR can be ruled out w/a muscle biopsy? (ANS)- PolymyositisIn reviewing lab results for pt's w/suspected PMR, you realize there is no definitive test to dx PMR, rather clinical response to Tx. Results you would expect to see include: (ANS)- Elevated erythrocyte sed rate (ESR) >50 Which of the following is the most appropriate lab test for monitoring gout therapy over the long-term? (ANS)- Serum urate level In providing health teaching related to dietary restrictions, you should advise a pt w/gout to avoid which of the following dietary items: (ANS)- Beer, sausage, fried seafood The best method of verifying gout dx in a joint is which of the following: (ANS)- Joint aspiration and polarized-light microscopy The most appropriate first-line Tx for acute gout flare is (assuming no kidney dz or elevated bleeding risk): (ANS)- Indomethacin 50mg TID x2 days, then 25mg TID x3 days You order bilat wrist XR on 69yo man c/o pain both wrists x6 wks no related to any known trauma. You suspect early onset RA. The initial XR finding in a pt w/elderly onset RA would be: (ANS)- Soft tissue swelling You examine the hands of a 55yo woman w/RA and note bilat spindle shaped deformities on middle interphalangeal joints. These are known as: (ANS)- Haygarth's nodes A 72yo female has been dx'd w/gout. She also has h/o chronic HF. The most likely contributing factor to development of gout in this older female is: (ANS)- Thiazide diuretics Which of the following statements about OA is true? (ANS)- It affects primarily wt-bearing joints In considering the specificity of lab data, the most reliable diagnostic test listed below would be: (ANS)- Synovial fluid analysis to differentiate between infectious versus inflammatory infusionWhen examining the spine of an older adult you notice a curvature w/a sharp angle. This is referred to as a: (ANS)- Gibbus The prevalence of depression in nursing home residents is ___________ greater than adults living in the community. (ANS)- 3-4 times The majority of depressed older adults remain untreated because of: (ANS)- Misdiagnosis, social stigma, environmental barriers Symptoms of depression distinct to the elderly include: (ANS)- Lack of emotions The justification for ordering CBC, TSH, serum B12 for a pt you may suspect have clinical depression is: (ANS)- Because of overlapping symptoms w/anemia, thyroid dysfunction, and nutritional deficiencies One major difference that is useful in the DD of dementia versus delirium is that: (ANS)- Dementia develops slowly and delirium develops quickly Which of the following is the most appropriate screening tool for delirium? (ANS)- Confusion Assessment Method The proposed mechanism by which diphenhydramine causes delirium is: (ANS)- Anticholinergic effects The elderly are at high risk for delirium because of: (ANS)- Multisensory declines, polypharmacy, multiple medical problems A consistent finding in delirium, regardless of cause, is: (ANS)- Reduction in regional cerebral perfusion Older adults w/dementia sometimes suffer from agnosia, which is defined as the inability to: (ANS)- Recognize objects In late stages of dementia, a phenomenon called sun downing occurs, in which cognitive disturbances tend to: (ANS)- Become worse in the eveningOf the following, which one is the most useful clinical eval tool to assist in the dx of dementia? (ANS)- St. Louis University Mental Status Exam (SLUMS) The cornerstone of pharmacotherapy in treating Alzheimer's is: (ANS)- Cholinesterase inhibitors The comorbid psych problem w/the highest frequency in dementia is: (ANS)- Anxiety When treating depression associated w/dementia, which of the following would be a poor choice and should not be prescribed? (ANS)- Amitriptyline The leading COD in elderly travelers worldwide is: (ANS)- Accidents Which of the following should be avoided in countries where food and water precautions are to be observed? (ANS)- Salad buffet What insect precautions are not necessary to prevent insect-borne dz's in the tropics? (ANS)- Using 100% DEET on skin to prevent bites An example of secondary prevention you could recommend/order for older adults would be to: (ANS)- Check for fecal occult blood Ali is a 72yo man who recently came to US from Nigeria. He reports having BCG (bacille Calmette-Guerin) vax as a child. Which of the following is correct regarding a TB skin test? (ANS)- Vax hx is irrelevant; read as usual Ivan is 65yo man who is new to your practice. He has h/o COPD, CAD, HTN, T2DM. He has had no immunizations since his d/c from military at 25yo. Childhood dz's include chickenpox, measles, mumps, and German measles. He presents for a dz management visit. Which of the following immunizations would you recommend for Ivan? (ANS)- Tdap, pneumococcal, influenza, Zostavax Leo is a 62yo African American male who comes in for an initial visit. Personal health hx includes smoking 1 PPD since 11yo, consuming a case of beer (24 bottles) every weekend, and working as an assembler (sedentary job) for the past 10yrs. Fam Hx in first-degree relatives includes HTN, high cholesterol, MI,T2DM. Leo's BMI is 32. BP is 130/86. You order fasting glucose, lipid profile, and return visit for BP check. This is an example of: (ANS)- Secondary prevention A local chapter of NP organization has begun planning a community-based screening for HTN at a local congregate living facility. This population was selected on the basis of: (ANS)- A recognized element of high risk within this group. Performing ROM exercises on a pt who has had a CVA is an example of which level of prevention? (ANS)- Tertiary You demonstrate an understanding of primary prevention of falling among the elderly through which management plan? (ANS)- Provide info about meds, SE, interactions An example of an active strategy of health promotion for an individual to accomplish would be: (ANS)- Beginning stress management program You are working w/an older adult male w/a long h/o ETOH abuse and a 30yr h/o smoking. In recommending an intervention, your responsibility is to: (ANS)- Promote positive change in lifestyle choices The 4 main domains of clinical preventive services that you will provide are: (ANS)- Counseling interventions, screening tests, immunizations, chemoprophylaxis Which organism that can be prevented by immunization is most often responsible for an infectious "outbreak" in the nursing home setting? (ANS)- Influenza A What is the appropriate method for TB screening of an older adult entering a nursing home? (ANS)- 5 TBU intradermal PPD injection and if negative, repeat w/same dose one week later Meds known to contribute to constipation include all of the following except: (ANS)- Broad-spectrum abxAll of the following are considered contributors to dysphagia except: (ANS)- Smooth muscle relaxants The term "geriatric syndrome" is best described as: (ANS)- Condition that has multiple underlying factors and involves multiple systems The anal wink reflex is used to test: (ANS)- Sensation and pudental nerve function Atypical presentation of acute coronary syndrome is: (ANS)- More common in females What dz can mimic and often co-exists w/MI in elderly w/CAD? (ANS)- Esophageal dz Thoracic aortic dissection presents typically as: (ANS)- Severe retrosternal CP that radiates to the back and both arms Bordetella pertussis is best characterized by: (ANS)- Sub-acute cough lasting >2wks Routine testing of TB should occur in all of the following vulnerable populations except: (ANS)- Hospitalized elderly Which of the following statements about fluid balance in elderly is false? (ANS)- Assessment of skin turgor at the sternum is a reliable indicator of dehydration in elderly. Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the DD is: (ANS)- Rapid change and fluctuating course of cognitive function Presbystasis is best described as: (ANS)- Age-related disequilibrium of unknown pathology characterized by gradual onset of difficulty walking If dizziness has a predictable pattern associated w/it, you should first consider: (ANS)- HypoglycemiaEvidence shows that the most important predictor of a fall is: (ANS)- Prior h/o a fall The most cost-effective interventions used to prevent falls are: (ANS)- Home modifications and vit D supplements Chronic fatigue syndrome is best described as: (ANS)- Fatigue lasting longer than 6mo and not relieved by rest Which form of HA is bilat? (ANS)- Tension Microscopic hematuria is defined as: (ANS)- 3 or more RBCs on 3 or mor samples of urine Risk factors associated with the finding of a malignancy in a pt w/hemoptysis include all of the following except: (ANS)- Childhood asthma Recent wt loss is defined as: (ANS)- Loss of >10lbs over the past 3-6mo The most common cause of disability in elderly is due to: (ANS)- Arthritis Lipedema is best described as: (ANS)- Bilat distribution of fat in lower extremities Drug-induced pruritis is distinguished because it: (ANS)- May occur right after drug is taken or months later A form of syncope that is more common in elderly than in younger adults is: (ANS)- Orthostatic hypotension All of the following statements about tremor are true except: (ANS)- The most common tremor is the Parkinson tremor Overflow incontinence is usually associated with: (ANS)- Bladder outlet obstruction Wandering is best described as: (ANS)- Purposeful excessive ambulatory behaviorA key symptom of ischemic heart dz is CP. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: (ANS)- Women w/ischemic heart dz many times don't present w/CP. Some pt's may have no symptoms or atypical symptoms so dx may only be made at the time of the actual MI. Which test is clinical standard for assessment of aortic stenosis? (ANS)- Echocardiogram Ischemic heart dz is: (ANS)- Defined as an imbalance between O2 supply and demand. Frequently manifested as angina. Leading COD in elderly. Preceding a stress test, the following lab work might include: (ANS)- CBC w/diff to differentiate ischemic heart dz from anemia. Thyroid studies to rule out hyperthyroidism. On exam, what type of murmur can be auscultated w/aortic regurg? (ANS)- Austin flint Which of the following statements is true regarding anti-arrhythmic drugs? (ANS)- Most anti-arrhythmics have low toxic/therapeutic ratio and some are exceedingly toxic. In mitral stenosis, p waves may suggest: (ANS)- L atrial enlargement Aortic regurg requires medical tx for early signs of CHF with: (ANS)- ACEi The best evidence rating drugs in a post-MI pt include: (ANS)- ASA, ACEi/ARB, BB, aldosterone blockade 55yo post-menopausal woman with h/o HTN c/o jaw pain on heavy exertion. No c/o CP. EKG is NSR w/out ST segment abnormalities. Your plan may include: (ANS)- Exercise stress test What is the most common valvular heart dz in elderly? (ANS)- Aortic stenosisElderly may present with atypical clinical signs of pna. You need to be aware that clustering of all of the following s/s may indicate pna in the elderly except for: (ANS)- Bradycardia A common auscultatory finding in CHF is: (ANS)- S3 The most common organism responsible for CAP in the elderly is: (ANS)- Strep pneumoniae 72yo woman and her husband are driving cross-country. After a long day of driving, they stop to eat. Midway through the meal, the woman becomes very SOB w/CP and a sense of panic. Which problem is most likely? (ANS)- Pulmonary embolism Exercise recommended for elderly should include activities that: (ANS)- Strengthen muscles Preferred amount of exercise for elderly is: (ANS)- 30min of aerobic activity a day 5 days a week Which of the following medical conditions is not considered restrictive for engaging in physical activity? (ANS)- Depression The best recommendation for a pt who says they have no equipment to exercise is: (ANS)- Improvise w/recommended objects at home that can be used When you recommend exercise for elderly, which of the following pieces of advice should be considered for all types of exercise? (ANS)- Start low and go slow All of the following statements are true about lab values in the elderly except: (ANS)- Abnormal findings are often due to physiological aging Biochemical individuality is best described as: (ANS)- Each individual's variation is often much smaller than that of a larger groupAll the following statements about drug absorption are false except: (ANS)- Underlying chronic dz has little impact on drug absorption The cytochrome p system involves enzymes that are generally: (ANS)- Inhibited or induced by drugs A statement not shown to be true about pharmacodynamic changes with aging is: (ANS)- Decreased sensitivity to oral anticoagulants The major impact of the physiological changes that occur w/aging is: (ANS)- Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunolgoical response The strongest evidence regarding normal physiological aging is available through: (ANS)- Longitudinal studies Pharmacokinetic changes w/aging is reflective of: (ANS)- What the body does to the drug All of the following statements are true about drug distribution in the elderly except: (ANS)- Drugs distributed in water have lower concentration Men have faster and more efficient biotransformation of drugs and this is thought to be due to: (ANS)- Testosterone Atypical presentation of dz in elderly is reflected by all the following except: (ANS)- MI w/CP and diaphoresis Polypharmacy is best described as taking: (ANS)- Even a single med if there is not a clear indication for its use CXR findings Active TB (ANS)- -Active TB: darkening of parenchyma CXR findings in PE (ANS)- -atelectasis -infiltrates -pleural effusion-westermark's sign -hampton's hump -fleischner sign CXR findings in Microwave popcorn workers lung disease (ANS)- Bronchiolitis obliterans CXR findings of asbestosis (ANS)- Hallmark of exposure: calcified hemidiaphragmatic plaque small irregular opacities in the lower lung zones, pleural plaques and blunting of the costophrenic angle CXR findings of Hypersensitivity Pneumonitis (ANS)- miliary or larger discrete opacities in the middle and lower lung zones CXR findings in COPD (ANS)- depression and flattening of the diaphragm w/ blunting of the costophrenic angles on PA; irregular lucency of the lung fields, abnormally enlarged restrosternal space and diaphragmatic flattening of concavity on the lateral film CXR findings of pleural effusion (ANS)- blunting or shadowing of costophrenic angle, base of lungs CXR findings of abscess (ANS)- presence of a subdiaphragmatic air fluid level and elevation of the hemidiaphragm "CXR findings in CHF" (ANS)- "Cardiomegaly, right or bilateral pleural effusions, Kerley's B lines, increased pulmonary vascular markings and pulmonary cephalization, interstitial edema, butterfly pattern of pulmonary edema" CXR findings in lung cancer (ANS)- Lesion CXR findings in asthma (ANS)- During acute episode: flattened diaphragms, hyperinflation and some infiltrates (may develop pneumothroax) CXR findings in sarcoidosis (ANS)- bilateral hilar adenopathyCXR findings of interstitial lung disease (ANS)- REticular, reticulondoular, nodular and ground glass CXR findings in pneumonia (ANS)- Lobar consolidation infiltrates can be patchy Signs and symptoms of heart failure (ANS)- A NEW LEAF A - acute agitation/anxiety N - nighttime shortness of breath or increased nighttime urination E - edema in lower extremities W - weight gain 2-4lb/week L - lightheadedness E- extreme sob lying down A - abdominal s/s nausea, pain, decreased appetite distension F - fatigue