NR 601 Midterm Review Week 1, 2, 3, 4 Primary Care Of The Maturing & Aged Family Practicum (Chamberlain University)

NR 601 Midterm Review Week 1, 2, 3, 4 Primary Care Of The Maturing & Aged Family Practicum (Chamberlain University)1 NR 601 Midterm Review Weeks 1-4 Notes: CGA • Purpose: Physical health is r/t psychosocial functional ability and safe environment. o helps in dx conditions and improve outcomes o identify potential preventable conditions o patient-centered care • Most beneficial for the vulnerable, older adults but should be completed for all older adults. • Domains: Physical health, functional health, psychological health, socioenvironmental support & quality of life measures. o Physical health ▪ Medical history, PE (abnormals-differentials), ROS, diagnostics, ▪ Nutritional assessment- • Assessment tool: mini nutritional assessment instrument • Food diary • Phys assessment with measurements • Biochemical markers ▪ Medication review (Beers criteria) ▪ Functional health- goal is to improve function and prevent decline ▪ ADLs- Katz ADLs scale ▪ IADLs- Lawton & Brody Scale for IADLs ▪ Ask patients to demonstrate or explain how they complete adls ▪ Psychological health (cognition and mood) ▪ DSM-5 (delirium vs cognitive impairment) ▪ MMSE ▪ CDT, word recall ▪ Mini-Cog ▪ SLUMS ▪ Confusion Assessment Method (CAM) ▪ Geriatric Depression Scale- PHQ-9 ▪ HOPE, FICA, SPIRIT ▪ Socioenvironmental ▪ Social network/support ▪ Social isolation assessment (lubben social network scale) ▪ Living situation (housing, transportation ▪ Environmental ( utilities, heat, water) ▪ Economic (income, assets, afford meds and healthcare) ▪ Quality of life medical outcomes study ▪ Physical/social conditions ▪ Personal resources ▪ Preference of care (advance directive) Age related changes: Physiological ▪ Skin- ▪ decrease dermal thickness/elasticity = SBD risk2 ▪ Decrease vascularity= less sweat, odor, heat loss= altered temp regulation, risk of heat stroke, change in fluid needs ▪ Resp: decreased vital capacity = decreased gas exchange processes ▪ Cilia atrophy=increase infection risk ▪ Decreased resp muscle strength=risk for atelectasis o CVD: o GI: ▪ fibrosis to heart valves= reduced SV, CO= decreased stress responses ▪ Fibroclastic SA node thickens= slower HR=increased arrhythmias ▪ Decreased baroreceptors sensitivity=decreased sense to bp changes = more falls, injuries o liver smaller=decreased storage ▪ Decreased muscle tone=altered motility ▪ Decreased metabolism=need for less calories Lab results: normal levels vary with age, sex, race (don’t assume abn lab result is part of aging processes) o Decreased CrCl, GFR: nephrotoxic drugs ▪ Digoxin ▪ H2 blockers ▪ Lithium ▪ Water-soluble atb- ceftriaxone, piperacillin, gentamycin, vanco ▪ Review page 1285 table(Dunphy) Atypical Presentations Acute abd illness Vague sx, acute confusion, constipation, mild discomfort, tachypnea, Depression Anorexia, vague abd cramps, new constipation, agitation, insomnia, lack of sadness Hyperthyroidism Apathetic thyrotoxicosis- fatigue, weak, wt loss (not gain), palpitations, tachycardia, new afib onset, HF if undx Hypothyroidism Confusion, agitation, cardiac manifestations, new anorexia, wt loss, arthralgia Malignancy New/worse back pain 2nd to mets form slow growing breast masses or silent bowel masses Jaundice-GB disease MI No chest pain, fatigue, nausea, decreased function and cognition, classic: dyspnea, epigastric pain, weakness, nv, hx of cardiac failure Higher in females: non-Q-wave MI Infectious disease Low grade fever or none, malaise, sepsis: w/o leukocytosis or fever Falls, new confusion, or AMS3 Decreased function, anorexia Peptic ulcer Dyspepsia, early satiety Painless, bloodless stool New confusion Tachycardia, hypotension Pna Mild cough without copious sputum, no fever or mild, confusion Tachycardia, tachypnea, anorexia, malaise Pulmonary edema Lack of paroxysmal nocturnal dyspnea, Insidious onset of decreased function, appetite, fluids, confusion TB Hepatosplenamegaly, abn liver tests, anemia UTI No or mild fever, worse cognition, dizziness, anorexia, fatigue, weakness Geriatric Syndromes- multifactorial: sx seen in elderly that are r/t combo of diseases o SPICES (assessment tool) o Sleep disturbance o Problems eating or feeding o Incontinence o Confusion o Evidence of falls o SBD Categories of Aging o 65-74 = young old o 75-84 = old o 85-older = oldest Causes of delirium o Drugs o Electrolyte imbalance o Lack of drugs (w/d, uncontrolled pain) o Infection o Reduced sensory input (vision/hearing) o Intracranial (CVA, SDH) o Urine retention, impaction o Myocardial/pulmonary conditions Exercise in Older Adults- recommended moderate- intensity aerobics 30min x5 days a week, or vigorous intensity aerobic 20 min x 3 days a week( can be intermittent throughout the day) o Barriers to exercise4 o Lack of time o Perceived need for equip o Disability or function limitation o Unsafe neighborhood/weather conditions o Depression/lack of motivation/sig life event o High BMI o Don’t know what to do Facilitators o Social networks o Positive self worth o Motivation to do it o Good health o Good contact with prescriber o Reg, scheduled programs] o Happy with program o Insurance incentive o Improved mobility/health Contraindications o Unstable angina o Uncompensated HF o Severe anemia o Uncontrolled BG o Unstable aortic aneurysm o Uncontrolled HTN/tachycardia o Severe dehydration or heat stroke o Low o2 sat Exercises for sleep o Tai-chi, walking, aquatherapy, biking ( assess balance and fall risk 1st) Exercise for flexibility: o To maintain flexabilty, perform exercises 10 min x 2 days a week Exercises for other dx: Review table on page 21 (Kennedy) Screenings before exercise: o Cardiac: stress test before beginning vigorous exercises o Parkinsons, osteoporosis, dementia: Assess balance and risk for falls o DM: proper shoe fit/insulin reduction o Fibromyalgia: may have increased pain initially Beers Criteria:5 • American Geriatric Society • Purpose: Improve medication selection; avoid dangerous medications. • Tailored fro 65 years & older in all settings except hospice & palliative care. • Stresses importance of deprescribing to avoid polypharmacy & ADRS • ***Look at these lists on the Beers criteria*** Ex: Don’t give Benadryl (antihistamines) Health Promotion: • Vaccines: Tetanus, Diphtheria, Pneumococcal & Influenza (***Know vaccine schedules***) • Colorectal Screening: 50-75 yr old • Breast Cancer Screening: Biennial screening for women ages 50-74 • Smoking Cessation • Aerobic Exercise & Strength Training (***Want to specialize to patient!! What kind of exercises for what disease processes should your patient do?***) • HIV testing- 15-65 yr old and high risk • AAA screening- men 65-75 who have ever smoked • Tobacco use- recommend cessation to all • Depression- all adults, pregnant, postpartum • Abnormal glucose screenings- 40-70 yr olds with obesity • Low dose statin use 40-75 yr olds with: o Risk factors- HLD, HTM, DM o 10 yr CVD risk factor 10% or higher • Low dose ASA use prevention of CVD 60-69 yrs- individual basis decision • One time screening for AAA- men 65-75 w/smoking hx • Obesity- all adults • Mammogram- every 2 yrs 50-74 yr olds • Osteoporosis screening- women 65 or older, and younger populations w/risk • Depression: all adults with routine screenings at each subsequent visit recommended Travel risks o Thromboembolic events: long flight, low humidity, low o2, cramped seats o Altitude illness: cardiac and cerebrovascular functions o High heat/humidity: increased risk for dehydration, heat stroke/exhaustion o CNS changes: increased anxiety, jet lag, longer delays6 o Immune system: increased risk for infections o Bladder dysfunction: long waits for bathroom stops o Vision/hearing impairments: increased fall and safety risks Polypharmacy Definitions: o Many RXs o 5 or more RXs o Prescribing potentially inappropriate meds (Beers criteria) Polypharmacy: primary predictor for ADRs o 10% ER visits, 17% admissions Causes o Multiple providers o Lack of communication b/w providers o Clinical inertia: failure to advance dose of drug to reach therapeutic dose level o Prescribing unnecessary drugs o Not evaluating true cause of CC (as possible ADR from other drug) before adding more RX leads to cascade of unavoidable events Screening tools for polypharmacy: o STOPP/START tool o BEERS criteria- list of potentially inappropriate meds (PIM) that should be avoided in elderly (except palliative or hospice care) o Medication Appropriateness index criteria (MAI)- used with Beers to determine benefit vs risk analysis Prevention strategies o medication review/reconciliations at visits o brown bag technique for elderly o parasimonious prescribing o quick HFU to assess and review medications o thorough patient education- expired drugs, side effects, adverse reactions, provide new med list at each visit and instruct pt to destroy old list o communicate with other providers o slowly deprescribe include patient/family preferences when doing this. o Week 2 COPD o progressive Obstructive disease not fully reversible o due to airflow limitations=hyperreactivity of airways o involves both lung parenchyma (emphysema) and bronchioles (chronic bronchiolitis) o Exacerbations and comorbidities determines severity o Hyperinflation of lungs7 S/Sx o Cardinal sx= chronic/progressive dyspnea, chronic cough with or without sputum production o Other= wheezing, chest tightness, decreased activity tolerance , fatigue, wt loss, recurrent lower resp infections o Increased anterioposterior diameter of thorax, use of accessory muscles, prolonged expiration, hyperresonance on percussion, decreased heart/lung sounds, tachypnea, NVD with expiration, ruddy cyanotic color, clubbed nail beds Risk factors o SMOKING o Aging- high in 65-75 yr old (usually dx b/w 40-50 yr old) o Recurrent infections o Repeated chemicals/gases/irritants exposures o Long term asthma o Alpha 1 antitrypsin deficiency (less than 45 yrs old nonsmokers w/ clinical emphysema, family hx of COPD young age Diagnosis: o GOLD standard – spirometry Should be done in symptomatic patients only o DX criteria: Not fully reversible if: FEV1/FVC – less than 0.70 and FEV1- less than 80% o CXR: not used to dx COPD; can r/o other dx: CHF, pna, cardiomegaly, PF Management of COPD: o Smoking cessation o Flu vaccine annually o PNA (,PPSV 13, PPSV 23) age 65 and older (or high risk 19-64 yrs)- should be administered one year apart o Reduce risk factor exposures o Person-centered and shared decision- making management plan o Pulm rehab o O2 use- increases survival if used 15 hours/day (use caution to decrease risk of will to breathe) o O2 criteria: PaO2 =55 or higher, O2 sat =88% with/without hypercapnia 2 x in 3 weeks8 Medications goals: o reduce symptoms, o reduce exacerbations risk and severity, o improve exercise and overall QOL/health COPD exacerbations- acute worsening of resp sx that require added tx o Usually Occurs after URI o Mild: SABA only o Moderate: SABA and oral corticosteroids o Severe: ER/hospital (acute resp failure) o COPD action plans imperative to reduce risks of future exacerbations Pharmacological Tx- COPD DRUG CLASS MOA RX SABA- Bronchodilation: relaxes smooth Albuterol end in “terol” muscles in airway. Levoalbuterol rescue med**** Onset- rapid pirbuterol Q 4-6 hrs LABA End in “terol” Maintenance tx Bronchodilation: relaxes smooth resp muscles Onset: 10-20 min Salmeterol Formoterol Q 12 hrs DAILY LABAs: indacaterol (Arcapta) olodaterol (Striverdi Respirmat) Inhaled anticholinergics/ antimuscarinic “SAMA” Ends in “tropium” Used in acute and maintenance Caution in glaucoma pt, BPH, bladder neck obstruction, allergy to atropine Anticholinergic SE Cant see Cant pee Cant spit Cant shit Blocks bronchoconstriction of acetylcholine Ipratropium Q 6-8 hrs Inhaled anticholinergics Prevents bronchoconstriction, Tiotropium (Spiriva) LAMA causes some bronchodilation Umeclidinium (Incruse Ellipta) “tropium” Q 24 hours Maintenance tx9 Caution in glaucoma pt, BPH, bladder neck obstruction, allergy to atropine Anticholinergic SE Cant see Cant pee Cant spit Cant shit Combo LABA with ICS Suffix “one” or “ide” FEV1 <60% Best in combo with bronchodilators Improved bronchodilationreduces inflammation Budesonide/formoterol (Symbicort) Fluticasone/salmeterol (Advair) Vilanterol/fluticasone (Breo Ellipta) Systemic steroids Short term use for acute exacerbations Anti-inflammatory actions Prednisone Methylxanthines Risk for toxicity Drug interactions Toxic ADR Oral Bronchodilator theophylline Asthma: • Chronic, inflammatory, obstructive disease • Intrinsic (stress) or extrinsic (environmental) • Pathophysiology: REVERSIBLE hyperreactivity of bronchi & bronchioles to a variety of stimuli Sx: o Wheezing, sob, cough (worse at night ), chest tightness o Air hunger o May occur with URI, weather changes, environment allergens, stress or emotional reactions o May be exacerbated with NSAIDs, ASA, beta blockers Dx criteria: o Spirometry/PFT- FEV1 and FEV1/FVC ratio o Reversible airway dx if 12% or greater improvement post bronchodilator (differentiates asthma from COPD) o If spirometry normal- recommend methacholine challenge test SEVERITY AND TX: Intermittent Mild persistent Moderate persistent Severe persistent10 Sx < 2 days wk or Nighttime <2x/month >2 dys/wk, not daily Noc- 3-4 x month Daily sx Noc: 1x wk, not nightly Sx throughout day: Noc: 7x week PRN inhaler use SABA PRN < 2 dys/wk SABA PRN >2 dys/wk (not daily and not more than one time daily) SABA daily SABA: several times a day FEV1 >80% PFT variable: 20% FEV1 >80% PFT variable: 20-30% FEV1 >60-80% PFT variable: >30% FEV1 >60% PFT variable: >30% FEV1/FVCnormal FEV1/FVCnormal FEV1/FVCreduced 5% FEV1/FVCreduced 5% Treatment plan SABA PRN Low dose ICS+ SABA PRN Or LTRA (singulair or Xolair) Low dose ICS+LABA or Medium dose ICS SABA- no more than 3-4x day Medium dose ICS+LABA or Medium dose ICS +LTRA SABA- no more than 4x day Interstitial Lung disease:11 o affects cell surfaces of alveolar walls, satellite structures of lungs, and bronchioles o inflammation and “fibrosis of lower resp tract o diffuse parenchymal lung disease o honeycomb lung- worsened opacities on CXR as disease progresses o CXR: ground glass or hazy appearance in early disease o Pulmonary infiltrateso nodular (granulomatosis diseases and hypersensitive pna o , reticular (fibrosis diseases), or o reticulonodular Sx ▪ dyspnea on exertion due to no other dx ▪ nonproductive cough ▪ fatigue in the absence of dyspnea ▪ dry cough w/o resp sx ▪ fever, wt loss, ▪ abn cxr in absence of sx ▪ incidental abn PFTs IPF ▪ alveolitis to inflammation to fibrosis of the lungs ▪ SX: dyspnea, cough, fatigue, crackles (Velcro), clubbing, tachypnea, abn PFT ▪ Tx: no curative meds Bronchiolitis obliterans organizing pna (BOOP) ▪ Masses of granulation tissue in the small airway lumens ▪ SX: cough, flu-like sx, inspiratory crackles, exp squeaks, ▪ CXR: patchy alveolar infiltrates with ground-glass appearance ▪ TX: corticosteroids Systemic Lupus Erythematosus ▪ Chronic, multisystem inflammation of connective tissue of skin joints, pleura, pericardium, kidneys, heme system, CNS ▪ Pulm SX: pleuritis with or w/o effusion, pulm HTN, pulm thromboembolism ▪ TX: Benlysta, NSAIDs, corticosteroids, hydroxychloroquine, methotrexate, Cytotoxan RA ▪ Chronic systemic disease; recurrent inflammation of disarthrodial joints ▪ Pulm sx: abn PFTs with reduced diffusing capacity, pulm nodules, BOOP, pleuritis w or w/o effusion ▪ TX: NSAIDs, COX-2 inhibitors, methotrexate, TNF antagonists(Remicade, Enbrel, humira, Cimzia), Non TNF antagonists (Orencia, Rituxan) Progressive systemic sclerosis (Schleroderma) ▪ Connective tissue disorder of fibrotic, degenerative and inflammation in skin, vessels, skeletal muscle, and internal organs12 ▪ Pulm Sx: dyspnea, bibasilar crackles, reduced lung compliance, abn PFT, recurrent aspiration pna ▪ CXR: pulm fibrosis, plueral thickening ▪ TX: antifibrotic agents (Cuprimine),immunosuppressants (Imuran, methotrexate Lymphamatoid granulomatosis ▪ Systemic disease of angiocentric lymphoid granulomatous vasculitis in lungs, kidneys, skin ▪ Pulm sx: cough, dyspnea ▪ CXR: multiple bil ill defined or nodular densities ▪ TX: Cytotoxan, corticosteroids, chemotherapy Allergic Angiitis and granulomatosis (Churg-Stross Syndrome) ▪ Rare disorder; necrotizing angiitis of lungs, heart, skin, CNS ▪ Pulm sx: allergic hx, asthma ▪ CXR: patchy densities to large bilateral nodular infiltrates Sarcoidosis ▪ Multisystem syndrome of unknown etiology, affects lungs ▪ Pulm sx: PFT-restrictive pattern and small lung volumes ▪ CXR: hilar lymphadenopathy Hypersensitivity pneumonitis ▪ Caused by inhalation of organic dusts ▪ Pulm sx: resp/systemix sx dev 4-6 hr after exposure (dyspnea, cough, fever, chills, malaise) these sx abate in 12 hours but reappear with each re-exposure. Inspiratory crackles bases ▪ CXR; , diffuse alveolar filling anda variable interstitial streaks, abn PFT • Chronic Bronchitis Tx: Irritants lead to inflammation lead to mucus lead to decreased lung function. o Irritants: Removing lung irritants (smoking, pollution, coal, asbestos, allergens) is important for chronic bronchitis o Inflammation: Bronchodilator opens airway back up. B2 agonist (beta receptors in heart, eyes, and lungs). Anti-cholinergics are another bronchodilator, open lumen of airway so lung can be less inflamed. o Steroids/Leukotriene inhibitors target the cascade of inflammation. Stops the inflammation at the root. LT is the last step, steroids stop it earlier in the cascade. o Mucus: We do not treat with suppressants because we want pt to cough the mucus up. o Lung Function: Have to be careful with giving O2. CO2 controls breathing drive in people with healthy lungs. In chronic bronchitis, CO2 levels are high, but don’t signal patient to breath but instead O2 controls breathing drive. If we give extra O2, we can shut off their breathing drive and stop breathing. • Emphysema Tx: STOP SMOKING. o Chronic Treatment: Bronchodilators open up airway. B2 agonists (Albuterol) Anticholingergics (- opium) Leukotriene inhibitors help the disease from getting worse. o Acute Treatment: Antibiotics • Oxygen shown to decrease mortality. • Labs: CBC (evaluate eosinophil level) & Alpha 1 antitrypsin levels13 CAP • Patho: Acute inflammation of lung parenchyma; usually infectious • 70-80% of cases are people over age 60. • S. pneumonia- gram + (40%) MOST COMMON- DEADLY • H. influenza- gram neg (2nd most common) • Legionella- gram neg • Staph aureus: 2-9%, occurs in healthy individual s/p influenza, or elderly with DM, CRF, lung CA • Mycoplasma: atypical; walking pna; more prevalent in close proximity population groups • Chlamydia pna: gram neg-adult onset asthma prior to dx SX: o Lower lobes mostly affected o Sudden fever, cough, chest pain, fatigue o Pneumococcal: rust colored sputum o Myalgia in calf and thighs o Chest pain with splinting on one side o Crackles, dull percussion o Sx of consolidation: egophony, bronchophony Dx criteria: ▪ CXRo determines viral vs bacterial o rules out pleural effusion o cavities may be present indication of specific types of bacteria ▪ CBC o Indicate if hospitalization is needed (WBC >15000- bacterial ▪ Pneumococcal urinary antigen test o Detects S. pneumoniae protein within 15 minutes o Helps to determine atb tx Tx: ▪ CURB- 65 criteria-determines severity and need for hosp. o Confusion o BUN >7ml/L o Resp rate- alkalosis o BP (systolic)- <90 ▪ Antibiotics- uncomplicated CAP o Azithromycin, doxy o With comorbidities: resp quinolone(Levaquin) or IM/IV Rocephin or Ceftin +macrolide o MRSA; vanco or zyvox OSA: • Temporary pause in breathing for at least 10 secs in duration at least 5x/hr Sx: • Night and daytime sleepiness (hypersomnolence) • Morning h/a(hypercapnia) • Neuropsychological disturbance(falling asleep while doing purposeful activity)14 • Decreased concentration, ambition, increased memory loss • Irritable and moody • Decreased libido Risk factors: ▪ Obesity ▪ Increased neck size (collar size >17) ▪ Tonsillar hypertrophy ▪ Enlarged soft palate and tongue ▪ Retrognathia and micrognathnia • Anatomical RFs: Septal deviation, macrognathia (enlarged ), tonsil hypertrophy, obesity • Avoid alcohol, sedatives (alters REM sleep), and narcotics • Complications: Cardiac dysrhythmias (A. fib) • SE: Hypersomnolence resulting in HA • Alcohol DX: Stanford Sleepiness Score (SSS): records degree of sleepiness experienced by patient at a given time if below a 3 when alertness should be present- sleep deficit indicated Epworth Sleepiness Scale (ESS) measures patients tendency to fall asleep during 8 nonstimulating exercises 10 or higher: abnormal Definitive test for Dx: Overnight polysomnogram Week 3 Anxiety Excessive worrying that is difficult to control and interferes with daily life. Common in older adults Unrecognized and undertreated Females more than men Prevalence: unknown but higher than recognized (15-50%) 3-14% older adults with dx 50-90% have another mental illness along with GAD- most often depression DSM-5 criteria- sx for at least 6 months ▪ GAD o Dx: excessive anxiety, difficult controlling worrying with restlessness, palpitations, sweating, dyspnea, easily fatigued, difficult concentrating, irritability, muscle tension, difficult falling/staying asleep (must have at least 3 of associated sx) o Anxiety due to medical problem o Anxiety not otherwise specified15 o Substance induced anxiety o Acute stress reaction d/o o PTSD o Panic disorder- less common in elders S/SX ▪ Impending doom feeling ▪ Trembling ▪ Breathlessness, ▪ Tachycardia ▪ Impaired memory and attention ▪ Older: constipation, nausea, sleep disturbance, worry about health, finances Risk factors ▪ Poor physical health ▪ Financial stressors ▪ Loss of significant other ▪ Fear of disability ▪ Sleep disturbances ▪ Poor social support systems Tx: ▪ Mild: SSRI (lexapro, Zoloft, (caution w/ citalopram- prolonged QT interval) ▪ Moderate:Buspar or gabapentin if SSRI failed ▪ Severe: SSRI + short term Benzo ▪ Nonpharm: CBT, exercise, relaxation training, music Unipolar Depression o Pervasive feeling of sadness or a lack of interest or pleasure in previously Enjoyed activities o Single or recurrent episodes o Geriatric: MDD, vascular depression, dysthymia, depression r/t to dementia, bipolar, executive dysfunction o Not part of aging process, women more than men o Prevalence: 3-4x more in nursing homes o Community living: 2-4% o ALF: 13-24% o LTC: 12-20% Unipolar Depression Sx: ▪ Affect/Mood o Sadness o Anhedonia o Apathy o Helplessness o Hopelessness o Worthlessness and loneliness16 ▪ Cognition o Ambivalence o Uncertainty o Cant concentrate o Confusion o Poor memory o Slow speech o Self criticism o Poor self esteem o Psychosis: hallucinations, delusion, illusions ▪ Physiological o Sleep, appetite, energy disturbance o Wt change o Constipation o Pain, h/a o Decreased libido o Sexual nonresponsiveness o Exaggerated concerns over body function ▪ Behavior o Psychomotor retardation o Agitation o Poor personal hygiene o Tearful o Social w/d Risk Factors o Family or other losses, autonomy, privacy, social network, move to NH o Illness: DM, cancer, parkinsons, AD, CVA, OSA, COPD, anemia, CVD o Alcohol/substance abuse, family hx, genetics o Prevalence of depression is 3-4x more in nursing home residents o May present with c/o pain due to concerns of social stigma o CBT o Medications: anxiolytics, sedatives, antipsychotics, beta blockers, H2 blockers, narcotic pain meds, steroids Unipolar Diagnostic criteria DSM-5 Sustained disruptive and pervasive depressed mood or loss of interest with 5 or more for at least 4 weeks o Depressed mood reported o Obsessive worry o Appetite and sig wt change o Sleep pattern change- insomnia, waking earlier, inability to fall back to sleep) o Psychomotor agitation o Fatigue or no energy o Hopelessness17 o Feeling of worthlessness/excessive guilt o Diminished concentration, indecisiveness o SI Older adults include: o Lack of emotions o Excessive concern over body functions o Seeking reassurance and support o Isolation or w/d o Decline in ADLs o Irritable, fearless, agitation, anxiety Labs: CBC, TSH, B-12 Assessments o PHQ-9 o BDI o GDS Medication: Review medications and eliminate possible contributing to depression 1st line med tx: SSRI (start low, go slow) Bipolar Depression BP 1: at least one manic episode BP II: at least one previous episode of major depression and at least one hypomanic episode Cyclothymic: milder mood alteration over a period of time Unspecified: sx cause clinical impairment but don’t meet dx criteria for any of the above 3 Sx: o Elevated mood of euphoria or irritability o Dysphoria (depression and/or irritability) o Rapid mood cycling Bipolar Depression DSM-5- must have increased energy with these sx: DIGFAST o Distractibility o Insomnia o Grandiosity o Flight of ideas o Activities (hyperactive) o Speech (rapid) o Thoughtlessness (impulsive) Diagnostic criteria: o MDQ (useful but not specific for elders) o GDS o CBC, CMP, TSH, RPR, HIV, EKG, tox screen, UDS o MMSE18 Medication: 1st line (lowest dose) • Lithium and valproic acid (mood stabilizers) • Quetiapine and olanzapine (antipsychotics) Metabolic side effects Lithium: baseline renal,cardiac, thyroid function before beginning. o Levels affected by NSAIDs, thiazide or loop diuretics, ACEi o Monitor lithium levels: ▪ Adverse effects: hypothyroidism, wt gain, cognitive, renal impairment, Valproic acid: o Monitor drug levels, LFT, CBC o Adverse effects: wt gain, hepatoxicity, pancreatitis, thrombocytopenia Antipsychotics o Monitor wt, glucose, and QT interval prolongation o Increased mortality in older adults Sleep Wake Disorders Diagnostic overlay of conditions that affect normal sleep • Insomnia- most common • OSA • Substance/medication induced • RLS Underlying medical causes: • Pain • Fibromyalgia • Dementia, delirium • GERD • Pulm conditions causing sob • Thyroid • Obesity • Pregnancy • Med side effect Underlying psychological causes: o MDD o GAD o Manic o Psychosis o Traumatic events precipitate acute insomnia o PTSD o Poor sleep hygiene o OSA, RLS Insomnia Complex common sleep disorder19 Difficulty falling asleep or staying asleep 25% geriatrics Prevalence in elderly: 50% age 65 or older , respiratory conditions increase risk • Staying asleep is most common complaint • Melatonin (Start out on low dose) • Avoid antihistamines • Educate on proper sleep hygiene • Can be early sign of mental illness Insomnia Sx: • Report of not sleeping • Daytime sleepiness excessive • Loud snoring (OSA) • Restless legs • Difficulty falling asleep and staying asleep • Irritability • Impaired concentration • Nonrefreshing sleep Diagnostic criteria: Medical: o History and Physical exam o Falls, o MMSE o Sleep hx Psychiatric: o MMSE o GAD o Depression o Alcohol abuse Chronic insomnia: 1st line tx: complete med and psych hx ESS or SSS sleep scale to identify aspect of problem Sleep diary CBT and instructed sleep hygiene together Medication: All on the Beers List Sleep onset: temazepam (Restoril), zaleplon (Sonata), ramelteon (Rozarem) Sleep onset and maintenance: eszopiclone (Lunesta) Sleep maintenance: zolpidem (ambien), Belsomra Silenor (not more than 6mg) Melatonin Trazadone (off label use) Benzo (not recommended)20 WEEK 4 Sx and structural remodeling of articular cartilage with inflammation of synovitis and ligament Unknow etiology Age related changes in cartilage leads to remodeling response of matrix Common over 45, women more than men Factors: ▪ Age ▪ Obesity ▪ Previous joint injury ▪ Prior surgeries ▪ Occupation ▪ Prolonged sports that involve wt bearing joints ▪ Low bone density ▪ Family hx ▪ Uric acid acromegaly- gout, pseudogout Sx: • Morning stiffness (less than 30 minutes) “gel phenomenon” • Stiffness that improves with activity or muscle spasms • Persistent joint pain • Bourchards nodes (nontender nodules PIP joints) • Heberdens nodes (nontender at DIP joints of hands and feet) • CMC joint of thumb • Women: erosive OA- red tender joints PIP and DIP that lead to joint erosion, deformity and ankylosis • Knee: Crepitus grinding sensation. “lock and buckling”, Baker’s cysts posterior popliteal • Cervical: Parathesia in arms that improves with movement • Lumboscacral/Hip: Low back and buttocks pain • Shoulders: crepitus, decreased ROM, tender with palpation • Foot: hallux valgus deformity (bunion) DX: o Physical exam and H&P o Xrays useful for: o Hip dx o Disease severity o Baseline status to compare to future xrays o Screen for other bones and joint diseases if severe pain and affecting sleep o Bilateral standing 2 view xrays: o Asymmetrical joint space narrowing r/t loss of cartilage o subchondral cyst formation o subchondral bony sclerosis OA: Asymmetrical joints of hands, knees, hips, spine are common21 o osteophytosis (bone spurs) MRI o Detect cartilage, ligament, tendon damage (spinal stenosis) Arthrocentesis o Completed with joint effusions o r/o infection and crystalline disease (gout and calcium pyrophosphate crystals) o normal result- clear viscous fluid with <2000 wbc Tx: aimed at controlling pain, maximizing function, minimize disability 1st line: nonpharmacological: exercise/ therapy Pharmacological: Acetaminophen Medication management Hand: o Topical capsaicin o Topical NSAIDs o Oral NSAIDs (not in 75 or over) o Tramadol Knee: o Tylenol o Oral NSAIDs o Topical NSAIDs o Tramadol o Corticosteroid injections Hip: o Obesity management o Oral NSAIDs o PT o Intra-articular steroid injections o Assess/tx for depression, anxiety, etc Other meds: o Gabapentin o SSRI o TCA Ortho or pain specialist referral RA vs OA: • RA goal to decrease inflammation • RA sxs pain >60 mins; ulnar deviation, swan-neck deformity, symmetrical loss of function; joint subluxations (autoimmune) • RA tx: NSAIDs & DMARDs; RA labs: RF & anti-CCP • OA sxs: asymmetrical, Bouchard’s & Herbeden’s Nodes; morning stiffness <30 mins • OA d/t repetitive microtrauma (d/t overuse) • OA tx: Acetaminophen; OA labs CBC • OA RF: Obesity Osteoporosis – DEXA Scan 65 years old22 Generalized skeletal disorder caused by bone mineralization and low bone mass density, increasing risk for fx (usually at hip or vertebra) Risk Factors: • Smoking, etoh Sx of osteoporosis: o No clinical sx until fx o May have gradual upper/midthoracic back pain with activity or prolonged sitting/standing that is relieved when laying down Objective: • Vertebral compression fx: sudden severe pain with focal point tenderness where fx is • Microfractures of vertebral spine: Dorsal kyphosis (dowager’s hump) causing ht loss • As kyphosis worsens- decreased lung volumes result in more resp complaints • Most common presentation: BONE FX DEXA results DX RESULTs Normal BMD within 1 SD of young adult reference mean Osteopenia- less than normal BMD but less severe BMD >1 SD below young adult reference mean (21) Osteoporosis- BMD > 2.5 SD below young adult reference mean (22.5) Osteoporosis (severe) BMD >2.5 SD below young adult ref AND presence of osteoporotic fx Medication Management GOAL- pain management ▪ First line: Bisphonates x 5 years ( No DEXA during tx o Alendronate (Fosamax)- weekly o Risedronate (Actonel)-weekly23 o Ibanodronate (Bonvia)- monthly o Zoledronic acid (Reclast)- IV annually o Forteo- injection annually o Denosumab (Prolia) injection every 6 months ▪ Calcium 500-1200mg daily ▪ Vit D 800-1000 units daily RA Chronic progressive systemic inflammatory disease affecting synovial joints Women more than men Symmetrical polyarthritis Sx: Subjective: o Malaise o General diffuse arthritis o Wt loss, anorexia o Low grade fever o Morning joint stiffness and swelling that improves as day progresses(>60MIN) o Progressive disease: recurrent pain, swelling in small and large peripheral joints lead to low activity, worsening pain and immobility Objective: o Symmetrical peripheral polyarthritis and morning stiffness o PIP, MCP joints of hands and wrists painful to palpation, edematous, limited ROM o ULNAR DEVIATION o Advanced disease: Boutinneire deformity of fingers (PIP nonreducible flexion hyperextension of DIP) o Advanced: swan neck deformity(PIP hyperextended and DIP constant flexion) o Severe: arthritis mutilans- complete loss of joint space,shortening and malpositioning of fingers, almost complete SYMMETRICAL loss of function Diagnostics Anti-CCP- higher sensitivity and specificity RF ESR CRP Xrays: necessary to check for early sx of erosions indicating a need for aggressive tx o Soft tissue swelling o Symmetrical joint space narrowing o Joint subluxations CBC: o normochromic, normocytic anemia, o mild leukocytosis o thrombocytosis Tx GOAL: DECREASE INFLAMMATION24 1st line tx: Nonpharmacological o Therapies PT/OT o Heat/cold compresses o Exercise (isometric) (low resistant aerobics) o Rest o Assistive devices, canes, walker, splint o Meditation o Wt loss Drugs: o Tylenol or capsaicin gel o NSAIDS- ASA (if liver, platelet, renal, and hgb ok), take with 8oz milk or water o 6Corticosteroids- prednisone (short term less than 6 months) o DMARDS- start within 3 months of disease onset ▪ Hydroxychloroquine (Plaquenil ▪ Cyclosporine- only used if methotrexate failed ▪ Methotrexate (Rheumatrex)- ▪ Adalimumab (Humira)- mod to severe RA ( can be given with methotrexate) ▪ Etanercept (Enbrel) ▪ Infliximab (Remicade)- must be given with methotrexate o Review page 1007 in Dunphy25 ASTHMA Intermittent Mild persistent Moderate persistent Severe persistent Sx < 2 days a week or Nighttime - <2x/month >2 days/week, not daily Noc- 3-4 x month Daily sx, but not continual Noc: > 1x week, not nightly Affects sleep & activity Sx throughout day, Continuous. Noc: 7x week frequently Affects Activity PRN inhaler use SABA PRN < 2 days/week SABA PRN >2 days/week (not daily and not more than 3-4 times daily) SABA daily (no more than 3-4 times a day) SABA: several times a day (no more than 3-4 times a day) FEV1 >80% PFT variable: 20% Normal Peak Expiratory flow between exacerbations FEV1 >80% PFT variable: 20-30% FEV1 >60-80% PFT variable: >30% FEV1 >60% PFT variable: >30% FEV1/FVC-normal FEV1/FVCnormal FEV1/FVC- reduced 5% FEV1/FVC- reduced 5% Treatment plan SABA PRN No daily meds Step up if not controlled. Step down if controlled for 3 months Low dose ICS+ SABA PRN Or LTRA (singulair or Xolair) Low dose ICS+LABA OR Medium dose ICS SABA- no more than 3- 4x day Medium dose ICS+LABA OR Medium dose ICS +LTRA SABA- no more than 4x day • Consider steroids26 DRUG CLASS MOA RX SABAend in “terol” rescue med**** Bronchodilation: relaxes smooth muscles in airway. Onset- rapid Albuterol Levoalbuterol pirbuterol Q 4-6 hrs LABA End in “terol” Maintenance tx Bronchodilation: relaxes smooth resp muscles Onset: 10-20 min Salmeterol Formoterol Q 12 hrs DAILY LABAs: indacaterol (Arcapta) olodaterol (Striverdi Respirmat) Inhaled anticholinergics/ antimuscarinic “SAMA” Ends in “tropium” Used in acute and maintenance Caution in glaucoma pt, BPH, bladder neck obstruction, allergy to atropine Anticholinergic SE – think dry Cant see Cant pee Cant spit Cant shit Blocks bronchoconstriction of acetylcholine Ipratropium Q 6-8 hrs Inhaled anticholinergics LAMA “tropium” Maintenance tx Caution in glaucoma pt, BPH, bladder neck obstruction, allergy to atropine Anticholinergic SE Prevents bronchoconstriction, causes some bronchodilation Tiotropium (Spiriva) Umeclidinium (Incruse Ellipta) Q 24 hours Combo LABA with ICS Suffix “one” or “ide” FEV1 <60% Best in combo with bronchodilators Improved bronchodilation-reduces inflammation Budesonide/formoterol (Symbicort) Fluticasone/salmeterol (Advair) Vilanterol/fluticasone (Breo Ellipta) Systemic steroids Short term use for acute exacerbations Anti-inflammatory actions Prednisone Methylxanthines Risk for toxicity and ADR Oral Bronchodilator theophylline27 Drug interactions