Nr 601 Midterm Review Primary Care Of The Maturing & Aged Family Practicum (Chamberlain University)

Nr601 Midterm Reveiw Primary Care Of The Maturing & Aged Family Practicum (Chamberlain University)1 NR 601 Midterm ● 75 questions- one at a time/1 minute per question ● Assess, diagnose, treat, who is at risk, what are the risk factors ● Define, prioritize, diagnose, treat, or plan ● Principles of Primary Care of Older Adults Rule of fourths- ¼-disease, ¼ disuse, ¼ Misuse, ¼ Physiological aging -knowing which one can help to decide how will treat. ● Developmental changes No developmental norms for later ages- protocols less valuable, and care must be individualized. ● Age-related changes - Decreased functional reserveEyesight decreases, average age needs reading glasses 50 Fertility peaks and declines. The amount of sway with the eye closed increases the older one gets. Reduced stamina and fatigue Categories of aging ● Incontinence- Common chronic conditions, underrecognized and underreported. ○ Symptoms- pain, bloating, and gas ○ Definition of constipation- infrequent passage of stool. May have straining to defecate or feelings of incomplete stool, ■ Rome IV criteria- 2 or more- straining, hard lumpy stool, the sensation of incomplete stool, using digital maneuvers to remove stool, the sensation of blockage with 25% BM, decrease in stool frequency. ■ Types of constipation- Slow transit, dyssynergia constipation, IBS-C ○ Definition of incontinence- involuntary loss of liquid or solid stool that is a social or hygienic problem. ■ Types of incontinence- ● Urgency FI- strong urgency followed by inability to hold stool in. ● Passive FI- Bowel blockage without sensation, cannot differential passing gas vs FI. May have seepage after BM ● Overflow FI- More common in older adults with impaired mobility and functional impairments. Associated with constipation, treating constipation can help improve this. ○ Treatment ■ Nonpharmacologic- diet modifications- including increasing fiber and fluids, exercise, Bowel habit training, probiotics ■ Pharmacologic- bulk-forming laxatives, stool softeners, osmotic2 laxatives, stimulant laxatives. ○ Treatment of fecal impaction- digital rectal exam is necessary. The large amount of stool in the rectum. KUB can help to quantify this. Disimpaction and colon evacuation are necessary to resolve this. A warm water enema can help. In rare cases colonoscopy is necessary. ● SKIN-Pressure wounds. ○ Intrinsic factors- those that alter skin integrity. They include limited mobility; medical comorbidities such as diabetes, COPD, congestive heart failure, or other medical conditions affecting perfusion and oxygenation, malignancy, and renal dysfunction; poor nutrition; and aging skin changes. ○ Extrinsic factors- those external factors that can damage the skin. They include pressure, friction, shear, and moisture. ● Health promotion for older adults ○ vaccines: Tetanus every ten years, Diphtheria once after age 65 Pneumococcal 1 Dose PPSV-23, high-risk 2nd shot PCB 13 Flu yearly shingles two doses 2-5 months apart Hep A/B only if high risk one time ● Screenings: USPSTF Bone health osteoarthritis- Bone density test- At least once in women over 65. ○ Colorectal 50-75 yearly fecal occult blood, every 5 yrs CT, every 10 years colonoscopy age 76-85 only selectively based on individual ○ Breast cancer: biennial 50-74 Breast exam inconclusive ○ Lung: 50-80 with 20+ pack history and quit within the last 15 years ○ Cervical cancer: every three years starting at 21, stop at age 65 ○ Prostate: 50 to 64 years - hard to determine if benefits outweigh the risks. This could lead to the potential harm of false positives and people receiving treatment who did not need it. Over the age of 70, PSA is not needed. ● Education: ○ Smoking cessation- Lower risk of cancer, heart attack, breathing, and lowers blood pressure. Regardless of age can have positive results. Use both behavioral approach and pharmacology. 5 A’s assess, advise, agree, assist, and arrange ○ Aerobic exercise and strength training, essential for healthy aging, 150 minutes a week recommended. Tailor the amount of exercise to patient ○ Write exercise prescription- 150 minutes/week goal for older adults ● BEERS criteria and polypharmacy Geriatrics metabolize drugs differently than younger patients - ⅔ have3 a decline in creatinine clearance. Dose according to this. ○ American Geriatric Society ○ Improve medication selection and avoid dangerous medications ○ For 65 years and older not in hospice/palliative care ○ De-prescribing to avoid polypharmacy and drug reactions ○ Polypharmacy definition: Persons taking many medications that could interact with each other or cause other diseases. Careful consideration needs to be taken when managing multiple disease processes. ■ No clonidine, benzos, cimetidine, or alpha-blockers. Geriatric assessments- 4 main domains of patient care - mental, physical, functional, social/economic. Should be done on stable patients on initial appointments and then yearly. Use tools in the EMR. Know the pts health literacy Should screen for: Sensory, nutrition, sleep, continence, mobility, mood, cognition, social support and functional screening. Functional screening- reflects pts overall health status and quality of life. Predictor of mortality and reflection of overall independence Functional loss can lead to multiple chronic conditions. Screening ADLS’ Screening IADLs more in-depth and using complex mental processes.- can be helpful to show if there is dementia developing. Can utilize self-report- less reliable than family or caregiver report. ○ Functional assessment ■ Lawton IADL ■ Timed up and go test- assesses gait and lower leg function. Its timed how long it takes to get up and walk 10 feet and back- This can indicate fall risk. an older adult who takes more than 12 seconds to complete the TUG test is at risk for falling. ■ Consider DD: causing the above ○ Herpes Zoster vaccine ■ Prevent shingles ■ Double series 2-6 months apart ● Cardiac disorders: ○ HTN- common in older adults and associated with increased cardiovascular morbidity and mortality. BP treatment can lower these risks. ■ Guidelines for diagnosis and treatment- 2 or more BP readings. Use the right size cuff to get accurate readings ● ACC/AHA <130 if older than 654 ○ TREAT IF >130/80 ○ OK 140/80 unless CKD= use ACEi ● JNC8 goal: less than 60= < 140/90, older than 60=<150/90 ○ Treat if >150/90 ■ Pharm treatment for older adults ● Thiazide + ACE and BB have the most risk reduction Thiazide and CCB are most effective in older people ● ACEs, ARBS, CCBs ○ Avoid ace/arbs in AA ● Chlorthalidone OKAY- thiazides can result in gout ● Avoid: clonidine and alpha blockers Do not prescribe ACE and ARBs together will impact renal function If the first med does not work, add a second and then a third. Can maximize med dose before adding another class. ■ Patient Education ● diet/exercise- BP reduced with physical exercise. ● Heart-healthy diet and lots of fiber. Limit salt intake to 2 G/day. ● 150 mins/week (30 mins 5x/week) ● Weight loss significantly impacts BP; being overweight causes BP to rise. DASH diet also has a significant impact on blood pressure. ● Avoid NSAIDS, steroids, and decongestants as they increase BP. ● Smoking Cessation ● Moderation of alcohol consumption ● Risk Factors- Thyroid disease, Diabetes, and prior MI, can cause hypertension. ■ HYVET trial recommendations for older adults: ● HTN in the elderly treatment ● Recommend thiazide + ACE or CCB ● older age group, treatment was associated with a 39% reduction in the rate of death by stroke, 23% reduction in rate of death from cardiovascular diseases, 64% reduction in the rate of heart failure, and 21% reduction in the rate of death by any cause. ● ACEs proved to be effective in reducing stroke risk ■ Evaluate both systolic and diastolic (Together and separate) ■ Systolic elevation 140-190 is isolated systolic HTN ○ CAD - affects 17 million people in US- the largest cause of MI, leading to Coronary death. Leading cause of death. ■ Atheroscletoritc plaques in the vascular system are caused by inflammation built5 to the point of narrowing the blood vessel. Can develop erosion fissure and or rupture leading to ACS. Manifest as unstable angina or MI, or STEMI. ● Risk Factors- elevated glucose, smoking, hypertension, hyperlipidemia, Chronic renal disease, Family history of CV, Peripheral artery disease. Older adults gain the most by utilizing risk factor reduction. ■ Presentation= can have angina= need long-acting nitrate, BB, and CCB; if pt remains symptomatic on medication, Cath lab or CABG are indicated. ■ Class 1 recommendations ● Lifestyle recommendations- reducing CV risk through treatment of modifiable risk. ● Reduce saturated fats and trans fats, and whole-fat dairy products ● More fruits and vegetables - The Mediterranean diet is recommended. ● Exercise- Moderate intensity- primarily walking most days of the week. ● Cardiac rehab shows great success and is underutilized in the older population. Geriatric considerations- Many patients in hospital settings have CAD and have frailty, nutritional deficits, inability to move, cognitive impairment, fracture history, and loss of independence. Frailty alone is associated with worse outcomes in pts that are revascularized. CAD pts should be evaluated for polypharmacy and removal of medicines where harm outweighs benefits. ■ Spirometry diagnostics ● Can help assess patients with CAD ■ Management: ● Smoking cessation ● Diet recommendations ● Physical activity = 150 mins/week ○ AFIB - Most common cardiac arrhythmia. Chaotic atrial electrical activity. Increase in morbidity and mortality. 2x likely to be hospitalized yearly. ● Risk Factors- Age, male, European ancestry, HTN, DM2, history of MI, valvular heart disease, OSA, Obesity, HF, diastolic dysfunction, CAD, Parenchymal lung disease, ETOH, smoking, long-term endurance exercise. Post-op, cardiothoracic surg, PE, hyperthyroidism ● Presentation and assessment ● S/S Fatigue, SOB, palpitation, lightheadedness, or no symptoms. Geriatric ps can present with falls, delirium or syncope ● Irregularly irregular- need ECG to confirm. ● Common in hyperthyroid ■ Impact on older adults ● Common in hyperthyroidism ● CAD, DM, HTN, ■ Diagnostic criteria6 ● CBC, LFTs, electrolytes, chest-x-ray, ECG, stress test, OSA sleep study ■ Anti-coags: Xarelto, warfarin, Pradaxa, Eliquis ● DOACs ● DOACs over warfarin in non-compliant patients ● Consider renal function with DOACs can give lower dose. ■ Long-term management ● The goal is to minimize signs/symptoms- the use of medication for rate control helps to reduce morbidity but not mortality. Use of BB, CCB. Less often, amiodarone or digoxin. ● Electric cardioversion can reset the rate in someone who is highly symptomatic ● Evaluate the bleeding risk of CHADSVASC RVR treatment- diltiazem pg 372 ■ Ischemic stroke: tools/assessment CHADS2-VASc ● Clotting risk/ AC needs ● DOACs over warfarin ■ CHADS2-VASc score (Annual risk of stroke in AFIB patients) Initiate OAC in score >2 for male >3 female ● CHF-1 ● HT-1 ● Age > 75-1 ● Diabetes -1 ● Stroke/TIAS (2pts) ● Vascular disease-1 ● Age >65-74-1 ● Sex female-1 Rates it from 0-9. A 0 has 0.2% of having a stroke and a 9 has 12.2% chance of having a stroke. ○ CHF- growing worldwide with 6.2 million Americans impacted. Mortality remains high. 20% are readmitted to the hospital within 30 days. ● Risk Factors- ischemic heart disease, HTN, infection, genetic mutations, ETOH/illegal drugs, cardiotoxic medications, valvular disease, normal aging predisposing pt to HF. ■ Typical presentation and assessment- need careful history and physical examination. ● SOB, dyspnea with exertion or at rest, BLE swelling, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, abdominal distension. ● JVD is the most helpful way to evaluate intravascular overload7 ● Consider medications when swelling: CCB and CKD ○ CCB can cause BLE swelling and should be ruled out. ○ Increase loop diuretics- furosemide ● confusion/GI issues - present with worsening fatigue, decreased functional capacity, altered sensorium(confusion/delirium), or GI disturbances( anorexia, nausea, abdominal bloating). ■ Impact for older adults- S4 gallop can be present due to the stiffness of vessels. May have pulm edema, which could have different causes like COPD and atelectasis. ■ Diagnostic ● BNP, NT-PROBNP ● ECHO- transthoracic (look at sys/dia function) ● S3 gallop- LV volume overload ● S4- increased stiffness ventricle ● Ace/arbs, BB, Aldactone, loop diuretic as needed- start with low dose first. BB is good if the liver function is reduced. ● Afib is common in clinical practice, and advanced age increases the risk of stroke TTE is recommended. Referral to cardiology ■ A- the risk of structural heart disease ex: HTN ■ B- structural heart disease without symptoms ex: valve issue ■ C- structural heart disease with symptoms ● 1- no effect on daily function ● 2- minimal effect ● 3- moderate effect and exacerbation ● 4- severe effect on daily function ■ D- end stage, consider hospice ○ Cancer in older adults- leading cause of death age 65 and older. PCP typically finds cancer first. Solid Tumors Lung, Breast, colon, prostate, and ovarian. Increases with age. ■ Lung cancer: small cell leading cause of death ● SCLC is more aggressive; SCLC occurs in 10%-15% of people and metastasizes faster than NSCLC.In most people with SCLC, cancer has spread before diagnosis. This type of cancer responds well to chemotherapy and radiation therapy but tends to recur. Treatment- pegfilgrastim S/E neutropenia and toxicity ● NSCLC is more common. About 80-85% of all lung cancers are NSCLC, though. NSCLC is further broken down into subcategories of adenocarcinoma, large cell carcinoma, and squamous cell carcinoma. These all have similar treatments and prognoses. Lung resection is very effective. ● Presentation= new cough, SOB, nodules= refer to pulmonology8 ● Screening-The U.S. Preventive Task Force (USPTF, 2021) recommends annual screening by low-dose computed tomography (LDCT) for individuals who: ● have a 20-pack-year smoking history AND ● currently smoke or who quit smoking within the last 15 years, AND ● are aged 50-80 years ● Screening is discontinued after an individual has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability/ willingness to have curative lung surgery. ● Chemo- monitor kidney function, change dose based on gfr. Older adults will have severe bone marrow suppression. Support with hematopoietic growth factors. Either cancer or treatment can cause anemia. Cardiotoxicity can occur even years after stopping treatment. CHF. Mucocitosis can happen to lead to malnutrition. ● Surgical management ● Management= pulmonology and chemo/radiation ● Survival disparities ○ Problems with accessing care ● Medication options to reduce risks in smokers ○ Retinoids to reduce risks - prevent cancer of upper airways in pts that smoke. The current recommendation is to avoid using them due to adverse side effects. ■ Breast, prostate, colorectal ● Prevalence in older adults- high ● Prostate tumors- most common in men, 2nd leading death >50 ○ Tumor biology prognosis (poor prognosis if PSA is >30) If over 70yrs old and gleeson score <7 Active observation is warranted. ○ Diagnostic criteria/lab markers ■ PSA not decreasing after finasteride- will look for cancer ○ Treatment Local treatment- External Beam radiation therapy ( younger men have increased risk of secondary radiation-induced cancer. Chemo dosages-hormone treatment is the first choice. Testosterone-blocking medications. ■ Side effects- shrinking of testicles. ○ Management- spot radiation will help with pain in bones if metastasis occurs.9 ○ Review guidelines and age-related issues- Pulmonary diseases - ● Pulmonary function tests- ■ Spirometry ● FVC/FEV1 ratio ● FEV1 post-bronchodilator severe ■ FEV1: the volume of air exhaled in the first second after deep inspiration and forced expiration ● GOLD rating: (FEV1/FVC) mild, moderate, severe, very ■ Evaluate post-bronchodilator values for FEV1 severity rating ● GOLD 1 mild >80 SABA ● GOLD 2 moderate 50-79 *** SABA, LAMA ● GOLD 3 severe 30-49 SABA, LABA/ICS ● GOLD 4 very severe <29 SABA, LAMA, LABA/ICS, PDE-4 inhibitor ■ FVC: the total volume of air the patient can exhale in one breath ■ FEV1/FVC ratio: ratio expressed as a percentage ● Xray- used to identify acute changes- PNA, COPD- hyperinflation, ILDinterstitial linings ● CT- Can show all the above and lung nodules in Cancer, PE, lung abnormalities, pleural effusions. ● Less than 70 is obstructive ● Greater than 70 is restrictive ○ ILD= restrictive lung disease ■ Definition: progressive and fibrotic, interstitial pneumonia and cause ■ Presentation: non-productive cough, inspiratory rails, clubbing Dypsnea, crackles on lung examination, opacities and honeycombing on CT ■ Diagnosis: CT scan and clinical symptoms ■ Supportive treatment, need pulmonology if caught early can get lung transplant ○ Pulmonary diseases ■ Definitions for spirometry criteria ● FEV1/FVC ratio above 70, FVC below 80 ■ Criteria to determine the severity of FEV1 ■ Criteria for diagnosis of obstruction (FEV1/FVC ratio)10 ● Criteria for diagnosis of reversible vs. irreversible: 12% BD value or decrease by 15% methacholine challenge ■ Obstructive disease: COPD, asthma, bronchiectasis ■ Restrictive: Obesity, ILD, pulm fibrosis etc. ○ Asthma- reversible airflow obstruction, airway inflammation disorder Challenging in older person- highest rates of asthma deaths. May be more severe. Can have coexistence of COPD. ● Common comorbidities- GERD, Rhinosinusitis, CHF, DM, obesity ● Consider their inhaler technique with uncontrolled symptoms. ■ Chronic, inflammatory ■ OBSTRUCTIVE ■ Intrinsic: stress ■ Extrinsic: environment, virus, pathogens ■ REVERSIBLE hyperreactivity of bronchi and bronchioles to variety of stimuli- look for >12% post-bronchodilator response in FEV1 or greater than 15% decrease in methacholine challenge ■ Treatments: ● LABA ● LAMA ● ICS: low and medium dose ● SABA: rescue inhaler/ short-acting/ albuterol ■ Intermittent asthma ● Less than 2 days/week, Less 2x month nighttime awakening ● FEV1 above 80%, variability 20% ● Not daily symptoms- using SABA <2 x weeks, no daily meds ● Step up if symptoms not controlled ● Step down if asthma controlled for 3 months ■ Mild persistent asthma ● Symptoms more than 2 days a week, NOT daily ● 3-4x at night per month ● FEV1> 80, PFT variable 20-30% ● Daily low-dose ICS ● Alternate: LTRA, cromolyn, nedocromil, theophylline ● Rescue SABA due not exceed 3-4/day ■ Moderate persistent asthma ● Symptoms daily but not continual ● Nighttime symptoms more than once a week, NOT NIGHTLY ● Exacerbations affect sleep and activity ● FEV1 60-80% (moderate) PFT variability> 30%11 ● Daily: low dose ICS + LABA or ICS+ LTRA ○ Rescue SABA ■ Severe persistent asthma ● Continuous daily symptoms ● <60% FEV1 PFT variability >30% ● Frequent exacerbations ● PA limited by asthma ● ICS+ LABA and rescue inhaler ● Consider a course or oral steroids ■ COPD ● Gold standard: spirometry and FEV1 assessment ● OBSTRUCTIVE: ○ FEV1/FVC <70 ● FEV1 GOLD rating- look at PBD value ○ Mild: >80 ○ Moderate: 50-79 LAMA ○ Severe: 30-49 LAMA ○ Very severe: <30 LAMA, ICS ● Treatment: LABA/ICS, LAMA, ICS, steroids oral or IV, antibiotics ○ SABA for all ○ Step up or step down based off of symptoms ● Non-medicine treatment ○ Smoking cessation ○ Pulmonary rehab ○ Oxygen therapy decrease mortality ● CBS for eosinophils and AAT level ● LABA must have ICS with it ● LABA CANNOT BE USED ALONE IN ASTHMA AND COPD PTS ● Diagnosis criteria- Dyspnea, chronic cough with sputum production, tobacco history or exposure. Confirmed by the spirometer. ○ GI and nutritional disorders ■ International incontinent society ■ Lower GI disorders ● constipation/fecal incontinence ● Define fecal incontinence: watery and loose stools ● Most common types of fecal incontinence: ■ Managing constipation for older adults12 ● Laxatives, diet. fluids ■ Upper GI disorders ● dysphagia: the sensation of difficulty swallowing. Can be caused by any disruption in the swallowing process. Always considered an alarming symptom. ○ Oropharyngeal: cannot initiate swallow, decreased salivary production. ● Causes - Stroke, brain tumor, dementia ○ Esophageal: decreased peristalsis, strictures of esophagus, food gets stuck whole swallowing ● Causes: Malignancy, strictures, rings, webs, diverticula, Inflammatory, reflux esophagitis, infectious esophagitis, Eosinophilic esophagitis. Differential Dx: Malignancy?Benign Strictures? Diverticula vs Spams? ● Lab testing: Check for anemia, weight loss, and nutritional testing. ● All patients w/dysphagia should undergo upper endoscopy ○ Management: ■ Swallowing rehab, dietary management (thickening liquids) ■ Malignant- needs sx, chemo/radiation ■ Benign strictures- txt w/endoscopic dilation ■ Infectious- antiviral or antifungal therapy ● Risk factors for malnutrition in older adults ■ Malnutrition: Protein-calorie malnutrition occurs when there is a reduced ability to effectively utilize nutrients that leads to changes in body composition and function. Acute and chronic disorders may reduce the older adult's ability to consume protein, leading to a delay in recovery, increased complications, and prolonged hospitalization. Increased falls and physical disability, and increased mortality. ● Causes of malnutrition- ○ Depression and dementia - decreased appetite, social cues, forgetting to eat ○ Dentition- missing or loose teeth, poor oral hygiene ○ Dysgeusia- reduced taste sensation, decreased appetite ○ Drugs- Adverse effects, reduced nutrient absorption ○ Dysphasia- Swallowing issues, increased anxiety ○ Poverty and food insecurity- 1 in 11 adults struggle with food insecurity. ● Def: inadequate intake of protein and low intake of energy ○ Evaluate albumin ● Side effects: nutritional screening-malnourish risk >7, 0-7 malnourished ● Interventions: ○ Mini Nutritional Assessment- first step to identify an adult who has malnutrition.13 ○ Dietitian consult-weight monitoring ○ Alleviate dry mouth ○ Maintain adequate nutritional intake ○ Improve oral intake ○ Promote texture-modified diets ○ Provide oral supplements ○ Monitor for refeeding syndrome ○ Create NPO orders ○ Consider meal time and environmental aspects in Dementia ○ Check for pocketing of food in Dementia *** ○ Reduce distractions ○ 1:1 feeding ● Family Education ○ Ensure adequate hydration and protein ○ Endocrine ■ Diabetes Mellitus - ¼ of adults over 65 have DM2. Males have a higher prevalence rate. Obesity levels increasing will increase this number as time goes on. They Suffer from high rates of functional disability and geriatric syndromes. ● Risk factors: obesity, age, race, family history ● Diagnostic criteria ○ A1C < 5.7 normal ○ 5.7-6.4 pre-diabetes ○ >6.5 diabetic ○ Older adults with decreased lifespan goal of <8.0 ● Signs & Symptoms older people may not experience these symptoms. 30% do not have them. If not they will present with dehydration with altered thirst perception. Many older people present with weight loss and show more signs of Type 1 diabetes because the pancreas is no longer putting out insulin. ○ Polyuria ○ Polydipsia ○ Polyphagia ○ Dry mouth, confusion, incontinence, fatigue ● Initial treatment recommendations ● Lifestyle interventions ○ Diet carbohydrates intake kept to 45-65% a day of food intake. Fiber is encouraged. ○ exercise ● Insulin- is prescribed if A1C is >11% or failure of two or more oral antidiabetic agents14 ● Sulfonylureas should be discontinued when insulin is prescribed ● Metformin - minimally hypoglycemia, no weight gain. SE: GI issues (abd discomfort & diarrhea, contraindicated in renal insufficiency (GFR<30), liver, or cardiac failure, lactic acidosis can be caused. ○ >11 SGLT-2 and GLP-1 ○ If unsuccessful, do insulin with metformin ○ Metformin: best for hypoglycemia prevention ● Common medication side effects ○ Hyper and hypoglycemia ○ Sulfonylureas-( Glyburide, glipizide, Glimepride)- Hypoglycemia, weight gain, skin rash ● Meglitinides- (Repaglinide, Nateglinide)- weight gain, hypoglycemia, frequent dosing schedule ● TZD- (pioglitazone, Rasiglitazone)- weight gain, edema/HF, bone fractures, increases LDL, possible MI ● DPP4 inhibitors(sitagliptin, saxagliptin)- urticaria/angioedema, increase risk pancreatitis, increases HF, expensive ● SGLT-2 inhibitors (canagliflozin, empagliflozin)- yeast infections, polyuria, hyperkalemia, ortho hypotension, pancreatitis. ○ glioglitrione ○ Glargine: long-acting insulin ○ 70/30 insulin and different varieties- if low in evening split and have pt mix themselves. ● Treatment goals for older adults ○ A1C <7 majority of the population ○ <8 for advanced age and limited life span ○ A1C goals based on complications ● Weight loss recommendations to decrease risks obese pts ○ Physical activity ○ Weight-bearing exercise ○ fiber ● Long term management- Evaluations for follow-up visits ○ hypertension management ○ Smoking cessation ○ Yearly eye care ○ Nephropathy ○ Neuropathies and foot care ○ Fall and fractures ○ cognition15 ● Treatment for complications ● BP ranges, creatinine, lipids, triglycerids ○ <140/80, monitor kidney function, watch lipid panel=statins ● Thyroid- significantly related to lipid dysfunction. Undiagnosed in ages >65. ○ Clinical presentation ■ Hyper: prevalence 3%. Look for radiation in history ● Tachycardia, fatigue, weight loss, tremor, afib/HF, nervousness, anorexia, ● Low TSH, high T4 ● Graves: similar symptoms: + frequent BM, enlarged thyroid, goiter, insomnia- look for antibody ○ Lab results LOW TSH and HIGH T4 ● The long-term effects of inadequately treated hyperthyroidism include heart disease, osteoporosis, mental illness, and infertility. ● Treatment- PTU, methimazole, radioactive iodine, ectomy, ● ○ BB: palpitations ○ NSAIDS: pains for thyroiditis ■ Hypothyroidism: High TSH and Low T4. Prevalence 24% in Adults >65. ● At Risks: autoimmune disorder/relative, Hx neck radiation, abnormal thyroid examination ● Subclinical Hypothyroid- Increase of T4 and normal TSH ○ Signs and Symptoms- ■ general slowing of mental and physical function. ■ Cold intolerance, ■ weight gain, ■ Constipation ■ effects on blood pressure ■ anemia. ■ Dry skin, brittle nails ● Treatments: synthroid -consider cardiac population ● Should be increased by 25 every 6 weeks ● Do stress test before treatment ■ Start low and go slow ● Lab tests:16 ○ TSH ○ Free T4 ● Thyroid crisis: ○ Rapid heart rate, fever, agitated, diarrhea, LOC ● Thyroid cancer is often asymptomatic ○ Mass or nodules ○ Change in voice/problem swallow/throat ○ Need radioactive iodine scan ○ Normal TSH ○ Fine needle aspiration ○ Consider thyroidectomy ● Geriatric assessment- encompass 4 domains of patient care: mental physical, functional, social economical. ● Purpose: check the functional status and can help early identification of geriatric ● Screening tools ○ IADL- finances, driving, shopping, preparing meals, med management, technology use ○ ADL - bathing, dressing, toileting, transferring, feeding, grooming ○ GDS - ○ MMSE-mini mental state exam- cog testing. ○ MNA ○ time get up/go: greater than 12 seconds indicates a fall risk ○ CAGE- ETOH tool. ● Assess health issues and comorbidities- ● Weight: concerned with 5% weight loss ● Effective communication ○ Normal unless ask for help ○ Functional assessment ■ Lawton IADL ■ Timed up and go test ○ Skin problems ■ National pressure ulcer advisory committee ■ Pressure injuries ● Lack of sensory perception, hydration ● Nutrition has a big impact ■ Consider DD: causing the above ○ Osteoporosis - systemic skeletal disease characterized by decreases in bone quality and bone mineral density leading to decreased strength in bones. Increased risk of bone fractures. Significant morbidity and mortality due to fractures. Peak bone mass is from ages 18-25. ■ Risk factors: ETOH and smoking, obesity, sedentary lifestyle,17 genetics, general health, medications ■ Screening: DEXA for 65 and older (densitometry is GS) ■ Most common presentation is a bone fracture ■ T-score < -2.5 standard deviation below the mean, indicates osteoporosis ■ -1 to -2.5 is considered osteopenia ● Management- If pt has fractured, have T score low with 10-year prob of fracture, FRAX evaluation shows need. ○ Non-pharm treatment- Calcium and vit D supplements. Diet of calcium and vit D-rich foods. Exercise, specifically strength training exercise, 150 minutes of moderate-intensity aerobic activity. ○ Pharm- ■ Consider bisphosphonates( inhibit osteoclastic activity amd slow remodeling process)- Aledronate- can only give for 5 years. Contraindicated in Renal failure. donelumab if cannot tolerate bisphosphonates ● Common side effects- take med on an empty stomach and have to stay upright or it will burn a hole in the esophagus. , gastritis, abdominal pain, myalgia, arthralgias, and hypocalcemia. Rare is osteonecrosis of the jaw. ■ Cannot tolerate zoleandroic acid given once a year intravenous Limit of 3 years. ○ RA vs OA - Osteoarthritis most common joint disease among older adults. ● RA is bimodal. ○ Risk Factors- genetic, smoking, periodontal disease ■ RA goal: decrease inflammation ■ RA symptoms: More acute onset with more proximal joints. ● Pain >60 mins ● Ulnar deviation ● Swan-neck deformity ● Symmetrical LOF ● Joint subluxation ● Metacarpophalangeal joints MCP *** ● Affects unilaterally and more joints ● Test ACPA, RF ● RA therapy: DMARDS ○ Manage pain: Ultram, endocet, APA, fentanyl patch, steroid injections ○ Labs: RF, anti-CCP ● OA- most common, insidious onset, affects DIP joints and PIP joints ○ Risk Factors- obesity, female gender, trauma or joint injury, quads muscle weakness, genetics. ○ symptoms: asymmetrical, Bouchard and herbeden nodes, morning18 stiffness< 30 mins, hips, knees, back, Joint function: limited ROM ■ Due to repetitive microtrauma ○ Labs reveal negative ANA, RFCRP may be mildly elev ○ Tx: Tylenol, OA labs, topical NSAIDs ○ NO STEROIDS ○ Gout ■ Presentation ● redness/tenderness/swelling in joint (big toe on fire) ● Severe pain ● Acute flares: colchicine or indomethacin ● Treatment: allopurinol ■ Diagnostic criteria ● Joint fluid: mononitrate sodium crystals- evaluate joint fluid ● Blood: uric acid ● High ESR/CRP levels ● crystals!! ■ Management ● Diet: avoid ETOH, shellfish, organ meat = AVOID PURINE ● NSAIDs and ice packs ● Allopurinol ● Flare: indomethacin or colchicine ○ Anemia- Common condition in adults. Prevalence is 10-11% > 65 20% >80 ■ Define: low H/H general identification of anemia < 12.7 Black men < 13.2 white men < 11.5 black women <12.2 white woman Anemia assoc - cardiovascular disease, CHF, dementia, cog impairment, insomnia, depression. QOL and functional status. Causes increased falls and hospitalizations ■ Look at MCV for micro vs. macro/megaloblastic Normal is 80-100 Below normal microcytic anemia - low iron, lead poisoning, thalassemia) Normal- Blood loss, long-term diseases, Kidney failure, aplastic anemia Above normal, macrocytic- low folate, low B12 or chemotherapy. MCH normal 27-31 if low iron deficiency If high B12 or folate MCHC 32-3619 RDW- 12-15% if high assoc with anemia. ● Iron Deficiency Anemia (IDA): microcytic hypochromic -Gi tract bleed, being on anticoag, primary GI disease - poor diet and iron intake - Gi absorption issues ● B12- increase due to PPI use. H Pylori, gastric surg, ○ Symptoms- mouth ulcers and pale skin, fatigue and weakness, muscle cramps and chronic pain, headache, depression, memory loss, numbness and tingling in extremities, thinning and hair loss, constipation or diarrhea ○ May appear as ischemic heart disease ○ Treatment mcg B12 oral or subq ○ For mild vitamin B12 deficiency caused by malabsorption, metformin use, or chronic acid-reducing medication, treatment is 500 to 1,000 mcg orally once daily. ● Classic pernicious anemia- loss of intrinsic factor and ability to uptake b12. Rare reason ● Folate- etoh malnutrition., or drugs such as metotrexate, gastric surgeries ○ Look at ferritin, iron, TIBC, transferritin ○ Most common in older adults- first in dif diagnosis ○ Do endoscopy for further evaluation ● Anemia of inflammation/chronic disease- most common cause of anemia. chronic inflammatory process suppresses EPO in kidneys, increases hepcidin reducing iron gut absorption. Spleen and hepatic macrophages destroy erythrocytes at higher levels. ● Who is at risk?- Advanced cancer, infection, autoimmune diseases, DM, CHF, obesity ○ Critically ill or hospitalized older adults ● CBC, reticulocyte count, ferritin, iron, TIBC, iron studies, B12, ferritin, CRP ● Chronic inflammation= decreased EPO= anemia ● Treatment: iron PO or IV, diet, or Sub q B12, folate ○ GI issues can't tolerate? IV therapy required ○ Or try to decrease PO dose to QD or QEOD first ● Peripheral blood smear test and bone marrow test ● Anemia caused CKD- strongest if gfr is <30 ● Unexplained anemia- ⅓ in adults. Not micronutrients, chronic20 inflammation or kidney related. ○ Mild, normocytic, low reticulocyte count ■ Declining testosterone levels decline renal function, myelodysplasia, chronic inflammation ■ Multifactoral ● Can have multiple anemias at once