NR601 Midterm weeks 1-4 + midterm audible, Complete spring 2022 solution guide.
Week One Developmental Changes - NR601 Midterm Week 1
... [Show More] 2022.
Purpose of the CGA (comprehensive geriatric assessment): Physical health is r/t psychosocial functional ability and safe environment.
1. it helps in
2. identify potentially
3. perform - 1. dx conditions and improve outcomes
2. preventable conditions
3. patient-centered care
CGA
1. Most beneficial for the vulnerable, older adults but
2. Domains: include - 1. should be completed for all older adults.
2. Physical health, functional health, psychological health, socioenvironmental support & quality of life measures.
CGA Physical health
1. Medical history, PE including
2. Nutritional assessment; tools include
3. Medication review using - 1. (abnormals-differentials), ROS, diagnostics,
2. mini nutritional assessment instrument
Food diary
Physical assessment with measurements
Biochemical markers
3. (Beers criteria)
CGA Functional health
1. - goal is to improve
2. measure ADLs using
3. IADLs
4. Ask patients to demonstrate or explain how
5. Fall assessment tool
6. Mobility assessed with
7. Any change in their function is often the only sign of - 1. function and prevent decline
2. - Katz ADLs scale
3. - Lawton & Brody Scale for IADLs
4. they complete adls
5. Hendrich II Fall Risk Model
6. Time to get Up and Go Test
7. illness or could be the first sign of exacerbation of a chronic illness
CGA Psychological health (cognition and mood)
tools and acronyms include
*dementia, delirium and depression are what you're evaluating for in geriatric MH - 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-These are acronyms to assess spiritual beliefs
About the Cognitive Assessment tools
MMSE-ID scoring ranges
Minicog-explain type of tests and scoring - The MMSE Score of 24-30 is the normal range.
Scores of 20-23 represent mild cognitive impairment or possible early-stage Alzheimer disease.
The Minicog providers might prefer b/c its shorter
clock drawing and three-word recall.
The score range is 1-3.
Diagram of Cognitive Disorders and differences w/ each - Depression does not have an abrupt onset, but patients will usually be able to identify some time frame for when the mood disorder started. It is important that,as providers,we have identified a set of favorite screening tools
CGA Socioenvironmental
1. Social network/support
2. What tool assesses Social isolation
3. Living situation includes
4. Environmental includes
4. Economic includes - 1. blank
2. assessment (lubben social network scale)
3. (housing, transportation
4. ( utilities, heat, water)
5. (income, assets, afford meds and healthcare)
Quality of life
1. the medical outcomes study short form 36 looks at - Physical/mental/social domains
Personal resources
Preference of care (advance directive)
Age related changes: Physiological
1. Skin-
2. Resp: - 1. decrease dermal thickness/elasticity = SBD risk
Decrease vascularity= less sweat, odor, heat loss= altered temp regulation, risk of heat stroke, change in fluid needs
2 decreased vital capacity = decreased gas exchange processes
Cilia atrophy=increase infection risk
Decreased resp muscle strength=risk for atelectasis
Age related changes: Physiological
1. CVD:
2. GI: - 1. 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
2. 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)
* Clinicians may find that reference ranges, therefore, may be preferable - Decreased CrCl, GFR: nephrotoxic drugs
Digoxin
H2 blockers
Lithium
Water-soluble atb- ceftriaxone, piperacillin, gentamycin, vanco
Review page 1285 table(Dunphy)
Atypical Presentations of common diseases
1. Acute abd illness
2. Depression
3. Hyperthyroidism
4. Hypothyroidism
5. Malignancy
6. GB disease - 1. Vague sx, acute confusion, constipation, mild discomfort, tachypnea
2. Anorexia, vague abd cramps, new constipation, agitation, insomnia, lack of sadness
3. Apathetic thyrotoxicosis- fatigue, weak, wt loss (not gain), palpitations, tachycardia, new afib onset, HF if undx
4. Confusion, agitation, cardiac manifestations, new anorexia, wt loss, arthralgia
5. Jaundice; New/worse back pain 2nd to mets form slow-growing breast masses or silent bowel masses
6. Jaundice
Atypical Presentations of common diseases
1. MI
2. Infectious disease
3. Peptic ulcer - 1. 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
2. Low grade fever or none, malaise, sepsis: w/o leukocytosis or fever
Falls, new confusion, or AMS
Decreased function, anorexia
3. Dyspepsia, early satiety
Painless, bloodless stool
New confusion
Tachycardia, hypotension
Atypical Presentations of common diseases
1. Pna
2. TB
3. UTI - 1. 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
2. Hepatosplenamegaly, abn liver tests, anemia
3. No or mild fever, worse cognition, dizziness, anorexia, fatigue, weakness
Geriatric Syndromes- multifactorial: sx seen in elderly that are r/t combo of diseases
1. SPICES (assessment tool) - 1. Sleep disturbance
Problems eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
Categories of Aging
65-74 =
75-84 = old
85-older = oldest - 65-74 = young old
75-84 = old
85-older = oldest
Causes of delirium - Drugs
Electrolyte imbalance
Lack of drugs (w/d, uncontrolled pain)
Infection
Reduced sensory input (vision/hearing)
Intracranial (CVA, SDH)
Urine retention, impaction
Myocardial/pulmonary conditions
1. Exercise in Older Adults- experts recommend
1. Barriers to exercise - 1. 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)
2. Lack of time
Perceived need for equip
Disability or function limitation
Unsafe neighborhood/weather conditions
Depression/lack of motivation/sig life event
High BMI
Don't know what to do
Exercise in Older Adults
Facilitators - Social networks
Positive self worth
Motivation to do it
Good health
Good contact with prescriber
Reg, scheduled programs]
Happy with program
Insurance incentive
Improved mobility/health
Exercise in Older Adults Contraindications - Unstable angina
Uncompensated HF
Severe anemia
Uncontrolled BG
Unstable aortic aneurysm
Uncontrolled HTN/tachycardia
Severe dehydration or heat stroke
Low o2 sat
Exercises for sleep - Tai-chi, walking, aquatherapy, biking ( assess balance and fall risk 1st)
Exercise for flexibility:
To maintain flexabilty, perform exercises 10 min x 2 days a week
Screenings before exercise: - Cardiac: stress test before beginning vigorous exercises
Parkinsons, osteoporosis, dementia: Assess balance and risk for falls
DM: proper shoe fit/insulin reduction
Fibromyalgia: may have increased pain initially
Vaccine schedules for geriatrics
Pneumococcal
Tdap/Td
Influenza
Hep B
Herpes Zoster - shingrix is the new booster for HZV
Beers Criteria:
American Geriatric Society
1. Purpose:
2. Tailored for
3. Stresses importance of - 1. Improve medication selection; avoid dangerous medications.
2. 65 years & older in all settings except hospice & palliative care.
3. deprescribing to avoid polypharmacy & ADRS
*drugs freq causing ADRs: antibiotics and antihistamines and well as anticonvulsants, antipsychotics, diuretics, digoxin, hypoglycemic agents, antineoplastic medications, and NSAIDS
Beers Criteria:
1. Why do the elderly need special criteria
2. What is the risk to the elderly
3. Important facts about Beers - 1. Pharmacodynamics and Pharmacokinetics of aging
2. ADRs are a real problem
3. Meds listed are not absolutely contraindicated
list includes dosage adjustments for kidney impairment
list includes drug-drug interactions to avoid
Healthy People 2020 indicates three overarching goals for health promotion and disease prevention
1. Attain high quality, longer
2. Promote quality of life,
3. Achieve health equity, - 1. lives free of preventable disease, disability, injury, and premature death.
2. healthy development, and healthy behaviors across all life stages.
3. eliminate disparities, and improve the health of all groups.
Three specific objectives of Healthy People 2020
1. Increased use of the Welcome
2. Increase the number of adults who
3. Decrease the number of - 1. to Medicare visit.
2. are up to date with preventative services.
3. emergency department visits for older adults, especially for falls
health promotion
1. Colorectal Screening:
2. Breast Cancer Screening:
3. Smoking Cessation
4. Aerobic Exercise & Strength Training
5. HIV testing-
6. AAA screening-
7. Depression-
8. Abnormal glucose screenings-
9. Low dose statin use 40-75 yr olds with:
10. Low dose ASA use prevention of CVD
11. Obesity-
12. Mammogram-
13. Osteoporosis screening- - 1. 50-75 yr old
2. Biennial screening for women ages 50-74
3. recommend cessation to all
4. ***Want to specialize to patient!! What kind of exercises for what disease processes should your patient do?***
5. 15-65 yr old and high risk
6. men 65-75 who have ever smoked
7. all adults routine screenings at each subsequent visit, pregnant, postpartum
8. 40-70 yr olds with obesity
9. Risk factors- HLD, HTM, DM; 10 yr CVD risk factor 10% or higher
10. 60-69 yrs- individual basis decision
11. all adults
12. every 2 yrs 50-74 yr olds
13. women 65 or older, and younger populations w/risk
Travel risks
1. Thromboembolic events:
2. Altitude illness:
3. High heat/humidity:
4. CNS changes:
5. Immune system:
6. Bladder dysfunction:
7. Vision/hearing impairments: - 1. long flight, low humidity, low o2, cramped seats
2. cardiac and cerebrovascular functions
3. increased risk for dehydration, heat stroke/exhaustion
4. increased anxiety, jet lag, longer delays
5. increased risk for infections
6. long waits for bathroom stops
7. increased fall and safety risks
Preparing the Elder in a Primary Care Setting for Travel
1■Current health status—stability of preexisting conditions
2■Past medical history
3■Medications and allergies
4■Diet
5■Mental status
6■Immunization status
* Medicare does not cover the cost of health care outside the US - 1. blank
2. blank
3. blank
4. Does the patient have any special dietary restrictions? Airlines offer diabetic and vegetarian options but may not offer gluten-free
5. Travel may disrupt routines-Misplacing passports, room keys, or wallets or not remembering hotel names or addresses can be distressing, advise them to keep hotel business car
6. All routine immunizations should be current. This includes influenza, pneumococcal, Td/Tdap (tetanus, diphtheria, and acellular pertussis), zoster, and for some, hepatitis B vaccination
Polypharmacy
1. Definitions:
2. Polypharmacy: primary predictor - 1. Many RXs, or >5 RXs, or Prescribing potentially inappropriate meds (Beers criteria
2. for ADRs
10% ER visits, 17% admissions
Causes of polypharmacy
1. Multiple
2. Lack of
3. Clinical inertia:
4. Prescribing
5. Not evaluating true cause of CC (as possible ADR) before adding - 1. providers
2. communication b/w providers
3. failure to advance dose of drug to reach therapeutic dose level
4. unnecessary drugs
5. more RX leads to cascade of unavoidable events
Screening tools for polypharmacy:
1. STOPP/START tool
2. BEERS criteria- list of
3. Medication Appropriateness index criteria (MAI)- used with Beers to
4. ARMOR - 1. blank
2. potentially inappropriate meds (PIM) that should be avoided in elderly (except palliative or hospice care)
3. determine benefit vs risk analysis
*and monitor for adverse SE
4. (Assess, Review, Minimize, Optimize, Reassess)
Prevention strategies for polypharmacy
1. medication
2. brown bag technique for elderly
3. parasimonious prescribing
4. quick HFU to assess and review medications
5. thorough patient education-
6. communicate with
7. slowly deprescribe include - 1. review/reconciliations at visits
2. where the patient brings in all current medications are helpful, but time consuming.
3. stingy or frugal prescribing
4. expired drugs, SE, ADR, provide new med list at each visit and instruct pt to destroy old list
5. other providers
6. patient/family preferences when doing this.
Ongoing polypharmacy surveillance: Medication Reconciliation
1. Review your patient's medication list at every visit with your patient.
Specifically ask if
2. Update the office medication list with the patient's medications
3. Consider deprescribing. Is every prescribed or OTC - 1. if any other provider has changed or added any medications since the last visit.
2. every visit.
3. medication currently necessary?
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