GERIATRICS FINAL

ASSIGNED READINGS:
VULNERABLE ELDERS:
1. Consequences of self-neglect: Unsafe environments, untreated chronic medical conditions, lack of basic
amenities. All pose problems for health care systems: increasing costs and burden.
2. Subtypes of self-neglect: self neglect w/ hoarding (Diogenes syndrome), lacking utilities/amenities, questionable
medication adherence, poor personal hygiene...
3. Continuum of self-neglect: mild with few consequences to severe, extreme health and safety consequences
(worst cases: "elders found lying in their own excrement laden with animal feces and roaches").
DIOGENES SYNDROME:
1. Etiologies & risk factors: paranoid/schizoid/OCD/mood disorders, single/widowed, live alone, can't relate to
others, Frontal lobe dementia.
2. Identification of Diogenes: extreme self neglect, reclusivity, compulsive hoarding with DENIAL of symptoms or
surroundings.
3. Intervention: Best approach=establish trusting relationship w/ caseworker at APS; regain control of env w/ living
space intervension. Provide day/community care. Prescribe SSRIs to manage paranoid symptoms.
ETHNOgeriatrics:
1. ETHNIC: Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, Spirituality/Seniors.
2. ETHNIC is a clinical tool for physicians to address cross-cultural interviewing. It is helpful for eliciting and
negotiating cultural issues during healthcare encounters.
2. Strengths of ETHNIC: elicits cultural issues and allows negotiating during healthcare encounters.
3. limitations: ETHNIC does NOT address other barriers such as senior disabilites, discrimination and bias (classism,
ageism, racism, sexism etc). Doesn't take into accound communication impairment such as hearing, language or
cognitive barriers.
DEMENTIA AND THE FAMILY:
The 5 challenges: (1) Pt refusal to accept need (2) Inability to distinguish sx of cognitive change ("just stubborn")
(3) family conflict arises from pt's decline (sibling rivalries) (4) over/underinvolvement in care (exhaustion/abuse)
(5) Guilt/discomfort/fear interfering w/ support systems
CVA ONLINE MODULE [2nd order Qs]
1. LOCATIONS: ACA=leg and bladder. PCA=eyes and sensory. Dominant MCA: aphasia/apraxia. NON-dominant
MCA: hemineglect. Lenticulostriate of MCA: dysarthria/hemiparesis. BASILAR=ataxia/cereballar CN palsies, etc.
2. Severity of strokes: NIHSS for severity of symptoms/damagaes, get CT SCAN do determine cause!
3. 2 types: Ischemic-blocked BVs to brain; Hemorrhagic-SAH/intracerebral. Mild strokes can undergo hemorrhagic
transformation of infarct.
4. Acute approach to stroke: rapid, focused H&P, stat LABS and non-contrast CT to determine if ischemic or
hemorrhagic.
5. tPA administration WITHIN 3 HOURS of an ISCHEMIC STROKE. (Absolute Contraindications=onset>3hrs ago, Hx
of ischemic stroke or trauma <3 months, major surgery within 2 weeks, BP>185/110 (use Labetolol), GI bleed,
heparin within 48 hrs, platelets<100,000. After tPA, avoid anticoag/antiplat or invasive procudures within 24 hrs,
monitor BP and neuro, give isotonic IV fluids (NPO to prevent brain edema)
6. How to avoid complications of CVA: prevent DVT (TEDs/Kendalls), prevent complications of tPA (see above), ASA
and Warfarin after 24 hrs.
7. Prevention of future strokes: warfarin (better for A-Fib, monitor INR), ACEi (BP control), statin, stop antiplatelets,
avoid hormone replacement therapy,
INCONTINENCE ONLINE MODULE [2nd order Qs]
1. Acute (sudden) vs chronic (gradual). Chronic Types: Stress, urge, overflow, functional, and MIXED (combo of
urge+stress=most common type in elderly females)
2. Causes: (note: NOT a nml part of aging) UTI, Caffeine/EtOH intake, diuretics, prostate, atrophic vagina, cognitive
dysfxn, polypharmacy, BPH, COPD, obesity etc.
3. Dx and Eval: Post-void residual urine > 50cc, Urinalysis for UTI/hematuria/malignancy.
4. Tx and plan: kegals, bladder training, vaginal estrogen cream. Alpha-adrenergics for stress incont. Alpha-blocker
for overflow incont (BPH). Anticholinergic drugs (haloperidol)=urinary retention for urge incont. Surgical tx,
pessaries, pudendal N stimulation, urethral bulking injection, biofeedback, vag cones, penile compressors, inserts.
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INTRO TO GERIATRICS:
1. INDEPENDENT vs ASSISTED LIVING-doesn't require constant care; vs SKILLED NURSING FACILITY (SNF)RNs/healthcare team/24hr care

2. Demographic Trends: 50K seniors by 2020; 60K seniors by 2030 (1 in 5 Americans will be >65 yrs old)
3. MEDICARE PART A=Inpatient, SNFs; PART B=Outpatient, imaging, labs, monthly premium; PART D=outpatient
Rx, only thru private insurance, additional cost.
4. Basic ADLs (Katz Scale) =bath/dress/toilet/feeding. vs Instrumental ADLS=cooking, cleaning, shopping, taking
own meds.
5. Mental status exam: MMSE <24 is cognitive impairment. Do a depression screen. High Yeild Labs: CBC, BMP,
ESR, B12, TSH.
6. PNEUMOCOCCAL: "13" and two-part "23". wait 6-12 months between "13" and "23". Wait 5 yrs between both
"23"s.

FALLS IN THE ELDERLY [1 hr]

1. Causes: obstacles, instability, weakness, forget limitations, co-morbidities, etc.
2. MORSE FALL RISK ASSESSMENT (MFS): Low risk 25-50; High Risk >51. (fall hx, secondary dx, ambulatory aids,
IV/heparin, impaired gait/transferring, forgetful mental status)
OSTEOPOROSIS [1 hr]
1. Measuring bone mass density: DEXA (gold standard), Peripheral DXA (pDXA), Quantitative U/S (QUS),
Quantitative CT (QCT)
2. Strongest Predictors of Fx risk= AGE, BMD, PRIOR FXs. Risk assessment FRAX tool: (femoral neck T-score or Zscore & obtainable clinical risk factors for fracture). BMD and clinical risk factors combined provide a better
estimate of fracture risk than either assessed alone.
3. Screening Guidelines for osteoporosis: USPSTF recommends screening for osteoporosis in women aged 65 years
or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman
who has no additional risk factors. BMD testing advised for: Women>age 65; Men>70; Younger postmenopausal
women; or Men 50 or older w/ prev fx.
4. MOST COMMON FRACTURE = VERTEBRAL. MOST DEVASTATING FX = HIP.
PALLIATIVE/HOSPICE CARE: [2 hrs]
1. Eligibility for hospice: prognosis < 6 months from 2 different Drs. Do not need to be a DNR to qualify. Hospice
team is an interdiscliplinary team. It has to have all licensed members. Part A Medicare benefit. Hospice Pts
allowed full medical treatment is a sense of what is rational with their diagnosis (includes antibiotics).
2. Palliative care requires 3 yr res plus fellowship, addresses symptom management
3. Partial bowel obstruction: Metoclopromide, Dexamethasone. Complete bowel obstruction: Haloperidol,
Olanzapine, Octreotide, Stent placement, Percutaneous endoscopic gastrostomy
4. Anytime you give someone an opioid, you need a bowel protocol that accompanies opioid. MUST GIVE A
LAXITIVE. Someone on opioid with new onset abd distension/pain, need to ask whether they are having BMs and
presume gastric dysmotility. Gastric dysmotility = #1 adverse effect of opioids. Also: High Risk of benzodiazepines
in the elderly leading to delusional behavior. Know that it can be secondary to med. Consider Secondary causes
before primary
5. POLST = Physicial Orders for Life Sustaining Treatment. Order set. What you want done if you cannot speak for
yourself, dont need a witness, you and doctor sign it. You have choices, POLST doesnt make you DNR.
DEMENTIA [1 hr]
1. Causes/Risks of dementia: older age, lower education, FmHx, head injury, genetic (APOE*4 on chromosome 19
for late onset)
2. Dementia eval: MMSE or MINI-COG ASSESSMENT (3 words + clock draw) FAIL=clock drawing is incorrect unless
pt repeats all 3 words. or only 1 word and correct clock.
3. Behavioral management: routines, redirection, community support, appropriate level of stimuli
4. Pharm management: cholinesterase inhibitors, cognitive enhancers, antidepressants, last resort is
antipsychotics. (avoid BZDs or antihistamines)
DELIRIUM [1 hr]
1. Risk factors: POST-OP, age, dementia, medical comorbitiy, EtOH abuse, male, sensory impaired etc.
2. Interventions: BEST=non-pharm management, prevention, warm milk, limit psychoactive or high-risk meds.
Mobilize pt asap, orienting-stimuli, family. Avoid daytime naps or restraints.
3. Recognizing/diagnosing delirium: waxing/waning LOC, reversible. High sens/spec diagnosis using the CAM.
(Confusion Assessment Method-Acute AMS, inattention, disorganized thinking of altered LOC)
4. Treating agitated delirium (medical emergency): low dose haloperidol (must monitor for Torsades)
PRESSURE ULCERS [1 hr]
1. Pressure &/or shear of tissues-->vascular impaired & local ischemia/tissue dmg. most common at Sacrum, then
heels
2. Stage 1-intact skin. Stage 2-partial dermis loss. Stage 3-full thickness tissue loss. Stage 4-exposure of
bone/tendon/muscle w/ undermining/tunneling. INCREASED risk of osteomyelitis in this stage. Unstagable-full

thickness loss w/ slough at base. If in the process of healing, add description next to original stage (eg Stage 3,
granulating).
3. Prevention: repositioning, mobility, adequate nutrition (not TPN), pillows etc.
4. Tx: PRESSURE REDUCTION. then for clean ulcers: moist/protective dressings; for Cellulitis ulcers: add topical
abx; for Necrosis: debridement (note: don't apply antiseptic bc may destroy healing granulation tissue, prolong
recovery)
ELDER ABUSE [1 hr]
1. Types of elder abuse: Neglect (active/passive), physical, financial, psychological, sexual, self-neglect.
2. indicators of abuse: acts differently around caregiver, trauma/bruises, malnourished, overmedicated,
exacerbated health problems, psychological symptoms
3. Causes: isolation (self-neglect), or caregiver burnout (external stress, drug abuse, lack of control)
4. How to appropriately intervene in self-neglect cases: establish trusting relationship with pt, get pt to accept
intervention.
5. Prevention: social support/checks, set up legal stuff now, arrange simplified finances, assess resources/situation
of care.
GERIATRIC EMERGENCIES [3 hrs]
1. HYPOGLYCEMIA = Pt w/ altered LOC (never want to miss this. r/o with fingerstick)
2. DELIRIUM = Pt w/ acute WAXING and WANING LOC
3. DELIRIUM TREMENS = EtOH w/d. Treat pt w/ BZD (lorazepam/valium) and IVF
4. AAA = Pt w/ abd pain, back pain radiating to front, tossing and turning in older pt. (risk factors for AAA: smoking,
HTN, FmHx, HTN, High cholesterol)
5. Drugs to AVOID in elderly w/ kidney probs: TMP-SMX (Bactrim), Nitrofurantoin, Ibuprofen/NSAIDs,
Aminoglycosides, ACEi, Contrast media
6. Suicide Risk assessment: SADPERSONS: Sex (male), Age (teen/elder), Depression, Prev attempt, Ethanl/drg use,
Rational thinking loss, Sickness, Organized plan, No spouse, Social support lacking.
7. tPA window: within 2-4 hrs of stroke. MAX is 4.5 hrs.
8. AMYROSIS FUGAS= light shade coming down over one eye that lasts 30 mins then goes away (Pt had a TIA)
9. Narrow Angle Glaucoma - sudden onset severe eye pain, steamy cloudy cornea, HA, fixed-mid-position pupil.
10. Trigeminal Neuralgia- electric shock-like intolerable pain at times.
GERIATRIC PHARMACOLOGY [2 hrs]
1. ARMOR method to avoid polypharmacy: Assess dz, Review current meds, Minimize meds, Optimize regimen,
Reassess recommendations.
2. PHARMACOKINETIC CHANGES: changes in absorption: decreased first pass effect (eg morphine or propranolol)
-->increased bioavailability & higher plasma concentrations. Transdermal absorption decreases (due to less skin
hydration, surface lipid, peripheral circulation and increased keratinization). GI absorption is slowed, but no
significant change in quantity delivered. Decreased IM absorption (due to less mm mass, peripheral circulation and
increased CT). Volume of hydrophilic drugs decreases bc of less total body water. Volume of distribultion of
lipophilic drugs increases due to higher body fat. Free fraction of highly-protein bound drugs due to less serum
albumin and protein binding affinity. HEPATIC MASS DECREASES: Decreased Phase I Oxidation (less clearance and
greater half life of drugs such as Diazepam, theophylline, quinidine, alprzaolam, flurazepam). Renal
excretion/clearance decreases by 50% by age 85 (decreased GFR, RBF and tubular secretion): increased half life &
concentrations of renally-excreted drugs (esp Aminoglycosides, Digoxin. Want to prevent toxicity!)
3. PHARMACODYNAMIC CHANGES: Increased receptor sensitivity to BZDs, Warfarin, Opioids, decreased sensitivity
to b-blocker, ACEi. Orthostatic HoTN w VDs, TCAs, antiHTN drugs.
4. Major drug interactions: Warfarin+sulfa+macrolides+quinolones, ACEi+spirinolactone, Digoxin+amiodarone,
ALCOHOL, etc
5. Psychoactive Meds Risks: orthostatic HoTN, confusion, sedation, extrapyramidal effects, weakness, arrhythmias,
falls, GU upsets,
6. Beer's list: what drugs to avoid in nursing home and decrease med-related problems; list or always inappropriate
drugs and a list of inappropriate drugs with certain conditions
7. Anticholinergics in elderly: BPH, urinary retention, xerostomia, increased IOP, constipation, Alzheimers Disease,
Confusion.
8. serious herbal/drug interactions: INCREASED BLEEDING RISK: Ginkgo bilobo+ASA or Coumadin. INCREASED
SIDE EFFECTS of Antidepressants w/ ginkgo biloba. St. John's Wort+ Demerol.
9. Uses, MOA & side effects of herbal products:
-Black cohosh for menopause.
-Cranberry for UTIs (ADR=diarrhea, GI/urinary stones)
-Garlic for CV, DM, HTN, hyperlipidemia. contains Allicin, reduces CoA & HMG CoA activity. Adverse: N/V,
bleeding, heartburn
-Ginkgo Biloba-flavinoids+terpenoids for memory/dementia/asthma/stress/vertigo. Adverse: can be allergicN/V, dizziness, SZ, HA, palpitations, Bleeding.

-Echinacea-cross sensitivity allergies to daisies and sunflower seeds (not for pt's w/ autoimmune disease)
-Ginseng adverse: HA, HTN, tachycardia, anorexia, N/V, bleeding.
-St. John's Wort for depression. Inhibits 5HT, dopamine, NE reuptake. Adverse: paresthesia, HA, SZs.
WITHDRAWAL irritability/agitation.
REVIEW:
-High Risk Meds in Elderly: Benzodiazepines, SSRIs, Tricyclic Antidepressants, Antihypertensives, Narcotics, Antiepileptics, sleep aids.