Acute Intestinal Ischemia
-Presents w/ significant pain in absence of physical findings
-Hx of cv disease - think widespread vascular
... [Show More] involvement
-Elderly with low flow states due to cardiac events can have abd pain due to nonocclusive bowel ischemia
-Can be caused by vasoconstrictors - triptans, ergots, vasopressin, NE, cocaine
-Tx underlying condition first, if no improvement - Dx with Arteriography
sepsis
SIRS due to confirmed infection
-mortality increases with age
prevalance of adrenal insufficiency in septic shock
50%
corticosteroids in septic shock
low-to-moderate quality evidence that corticosteroids reduce mortality from septic shock if given in low dosages equivalent to < 400 mg /day of hydrocortisone.
-evidence best for 28 day course
Causes of volume depletion in sepsis
Venodilation and capillary leak
-pts require large amounts of fluids in 1st 24 hours of mgmt
Bicarb therapy in sepsis
Not rec for improving hemodynamics or reducing vasopressor requirements
Dopamine
increases MAP and CO by increasing stroke volume and heart rate
Norepinephrine
increases MAP by vasoconstriction; little effect on HR and less effect than dopamine on SV
Best test of pancreatitis
CT w/ contrast - distinguishes interstitial from necrotizing pancratitis, 2-3 days of illness
Initial management of Pancreatitis
aggressive fluid resuscitation and improved delivery of O2
-prevent necrosis and improve survival
Gut feeding
better than TPN cause it stabilizes gut barrier function - thereby preventing infection
Medicare Part D
for married couple to qualify
-both must have Part A
-both must be enrolled in part D
-Income must be < 150% of federal poverty level for a couple
-If on Medicaid, then automatically eligible - not required to file an application
Peri-operative/post-operative complications
-Smoking - increases risk of post-operative pneumonia
-Poor exercise tolerance increases risk of CV complications, neuro complicaitons, and unexpected transfer to ICU
-COPD - risk of post op pneumonia
-DM - increased risk of peri op cv probs, risk for wound infection
-Controlled HTN NOT RISK FACTOR
Elderly Abuse
-Neglect > physical abuse
-increasing in recent years
-< 25% reported from physicians
-1/5 cases are reported
-financial exploitation cases are even lower
Urinary Catheters in Elderly
-insert only when necessary, and kept in as long as necessary
-Don't use soley for convenience
-alternatives to foleys - condom cath drainage, suprapubic cath, intermittent urethral cath
-as of 2008, medicaid and medicare won't pay for cath associated UTI infections not present at admission
Indwelling catheter
-should not be changed at fixed intervals
-avoid irrigation unless obstrucion
-intermittent irrigation if clot, mucus, or other causes of obstruction
-BID cleaning of urethral meatus with iodine solution and soap and water NOT shown to reduce CAUTI - so don't do it
Omnibus Budget Reconciliation Act (OBRA)
-established training guidelines and minimum staff requirements
-strengthened resident's rights - restraints usage and psychoactive meds
-periodic comprehensive assessment of all nursing home residents
-decreased over all use of restraints and prevalance of pressure ulcers
-However no significant improvement in QUALITY of care
Exercise in elderly
-can moderate increase Life expectancy even after age 75
-should include aerobic, resistance, balance/flexibility
Stress Exercise testing
-rec by American college of sports medicine for all minimally active older adults who plan to start vigorous intensity
-however most can start mild to mod with resistance training w/o stress testing
Exercise recs
-3o minutes of mod/day
-ex: brisk walk, leisure cycle, power mower mowing
-can be broken down to 10 minute windows
Muscle strength in elderly
-declines by 15% per decade after 50
-by 30% per decade after age 70
-resistance training can prevent this 20-100%
-need 10-15 reps
balance programs
-improve stability
-decrease risk of falls
pharyngeal dysphasia
-sxs - weight loss, food sticking, coughing, choking
-risk of aspiration
-food dribbling frm mouth
-can refer to upper chest but RARELY LOWER
-nasal quality of voice due to nasal regurg or soft palate insufficiency
Activities of Daily Living (ADLS)
eating, drinking, ambulating, taking meds, personal hygiene, position changing (bed or chair)
Instrumental activities of daily living (IADLS)
meal prep, telephone, shopping, laundry, making/keeping appointments, writing letters, taking part in social activities, driving, arranging transport
Weight Loss in elderly
-assess for anorexia or increased metabolic requirements (fever, infection, chronic skin wounds)
-anorexia may be due dysphagia, chewing probs, n/v/d, pain or fecal impaction
-Assess hydration status
-obtain geriatric depression scale
-If all else fails, then feeding tube; but non-invasive first
Delirum
-can be cause of involuntary weight loss
-reversal can reverse appetite
How to increase dietary intake in elderly
-calorie dense food
-exercise
-supplementation - do b/w meals rather than with meals
Techniques to improve communication with patients with hearing loss
-use handheld amplifier
-reduce background noise
-longer phrases easier for those with hearing impairment - provide more clues than shorter phrases
-seeing speaker provides cues, face the patient, ensure vision is corrected
Relieve pain and improve function in osteoarthritis
-supervised exercise improves pain and exercise
-NSAIDS more effective than acetaminophen for initial treatment, safety concerns may limit use
-Celecoxib may not offer much GI protection even in the younger gen
-studies shown benefits from assistive devices
-joint replacement can provide pain relief and functional status, may be appropriate nonsurgical measures to reduce pain or improve function
Risks for falls
-alcohol consumption
-orthostatic hypotension
-detect and treat gait/balance disorders, reduce risk of falls
-visual impairment increases risk
-CV disease is not major risk factor unless syncope is involved - stress testing not helpful
Best treatment of pain with malignancy
-morphine is gold standard; however remember opioid induced constipation and debilitation
-give with bowel regimen
Managing pain 2/2 bony mets
-NSAIDs, opioids, bisphosphonates and radiotherapy/radiopharmaceuticals = best
-Bisphosphonates should specifically be used for bone pain
-insufficient evidence for acupuncture or exercise to reduce pain at end of life
Feeding tube placement decreases what
-reduce human contact
-reduces prognosis
-no evidence it reduces pressure ulcer
Feeding tube placement increase what?
-risk of aspiration pneumonia
-risk of malnutrition
-risk of morbidity/mortality
Hospice Services
-medicare hospice does not pay for room and board if pts in nursing home; only for hospice services; ONLY HOSPICE MEDS
-unlimited 60 day extensions available if disease does not run it's course
-medicare hospice benefit covers bereavement for 13 months
-federal eval requirement for medicare reimbursement
-state eval mandatory for state licensure
When to eval for Decision making Capacity
1.) change in mental status
2.) when patient's refuse rec treatment
3.) pts consent too hastily to risky or invasive treatment
4.) when pt has known risk factor for impaired decision-making
RFs include chronic neuro / psych condition, significant cultural or language barrier, low education level
eval for depression, this can affect DMC
Decision making capacity eval patient should be able to
1.) understand recommended treatment and alternatives
2.) appreciate how the information applies to their own situation
3.) reason with that information, supported by facts and patient's own values
4.) Communicate and express a choice clearly
Prevalences of Parkinsons Disease
0.3% in US
Signs and symptoms of parkinsons disease
-bradykinesia (may describe as weakness)
-resting tremor
-rigidity
-postural instability
essential tremor
bilateral action tremor
-no extrapyramidal signs
-may involve head
Treatment of Parkinson's Disease
-Levodopa
-dopamine agonists
-Catechol-O-methyltransferase inhibitors (COMT inhibitors)
-MAO inhibitors
-NMDA-receptor inhibitors - amantadine
-surgery
-Memantine been shown to have some effect in early PD
Carbidopa/Levodopa
-primary tx w/ motor sxs
-controls bradykinesia / rigidity
-when combined carbidopa increases bioavailability of levo in cerebrum, decreases peripheral side effects - so less nausea/hypotension
Dopamine agonists
-direct stim of dopamine receptors
-bromocriptine, pramipexole, ropinirole
-levodopa seen as more effective; also combo less expensive
Primidone / propranolol
tx for essential tremor; NOT PD
Post-depression stroke
-commonly develops
-may require concurrent tx for optimal recovery
-insufficient evidence to start ppx SSRI; however have been shown to be effective if depression present
Reduction of Stroke Risk
-increased physical actvity - 30 min mod exercise rule - however AHA rec 40 min vigorous phys activity 3-4 days per week
-Aspirin 81 mg daily or if high risk then 325 mg
-reduction in OH consumption - no more than 2 drinks per day per men/ 1 drink per woman (non-pregnant); further reduction after age 65
-no evidence of CRP being helpful
Treatment of disequilibrium
-multifactorial approach is most beneift
-correct visual impairment
-improve muscle strength
-review and adjust meds
-instruct on balance and vestibular exercises (PT)
BPPV
-caused by small otoliths that migrate into semicircular canal, causing intense sensations of movement when head is turned a certain way
-epley maneuver can help with this, but will not work for other causes of vertigo / dizziness
meclizine (antivert)
will help with acute labyrtinthitis or vestibular neuronitis or cerebellar stroke
-not rec for chronic symptoms
-elderly at risk of side effects - increased sedation, risk of falls, urinary retention
Meniere's Disease
-hearing loss, ear pressure, tinnitus
-caused by increased endolymphatic fluid pressure - affects both vestibular and cochlear function
-symptoms can last minutes to hours
-tx with endolympatic shunt when unresponsive to therapies [Show Less]