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112 Cards in this Set

  • Front
  • Back
Big 10 principles of geriatric medicine
1. Medical conditions in geriatric patients are commonly chronic and multiple, and multifactorial in origin
2. Aging is not a disease
3. Reversible and treatable conditions are often under-diagnosed and under-treated in geriatric patients (attributed to old age)
4. Functional ability and quality of life are critical outcomes in the geriatric population (self-care/maintenance)
5. Social history, social circumstances, and available social support are essential (problems with isolation, assistance)
6. Geriatric care is commonly multidisciplinary (teamwork and communication)
7. Cognitive and effective disorders are highly prevalent and commonly underdiagnosed at early stages (3 D's)
8. Iatrogenic illnesses are common and many are preventable
9. Geriatric care is provided in a variety of settings
10. Ethical issues and end-of-life care are critical aspects of practice
Define functional status
- the ability to preform self-care, self-maintenance, and physical activities
- assessed based on changes in ADL's and total capacity to do them
Define quality of life
- a subjective measure of both positive and negative aspects of life
- includes multiple domains: health, jobs, housing, school, community, family, culture, values, etc
- health related quality of life encompasses aspects of overall quality of life that can effect health (physical or mental). This includes health risks and conditions, functional status, social support, socioeconomic status, and resources/policies/practices that influence perception of health and functional status
Define an interdisciplinary team as it relates to geriatric care
- a group of healthcare professionals from different care specialties that work together to support the patient in different ways.
- requires: leadership, communication, mutual cooperation, situation monitoring
- may include: physicians, NPs, PAs, RNs, NA's, rehap therapists, social workers, house keepers, family members, etc
Hazards that may result from living at home alone
- Isolation: social interaction are beneficial to health
- Poor nutrition: due to lack of access to food or ability/motivation to cook well for oneself
- Environmental hazards and accidents: especially falls
- Behavioral hazards: depression and other cognitive problems may go unrecognized
Common Advance Directives
- Living will: a written, legal document that describes the kind of medical treatments or life-sustaining treatments and individual wants if they were seriously ill (does not allow someone else to make decisions for you)
- Durable power of attorney (DPA): states whom an individual chooses to make decisions for them in the event that they are unconscious or not cognitively functional.
--Both are legal in most states, and even if not they can still guide care for doctors and families
Define Geriatrics
the branch of medical science that focuses on health promotion and the treatment of disease and disability later in life
Define geriatrician
a physician who is specially trained to prevent and manage the unique and often multiple health problems of older adults
Define silver tsunami
the overall aging of the American population, especially the aging of the baby boomer generation
Define Assisted living facility
- living communities suitable for adults that need help with every day tasks (ADLs) but do not need trained medical care
- may be part of retirement communities or nursing homes so residents can changes support level as functional status changes
Define iatrogenic illness
"physician-origin"
an illness brought upon by medical or surgical treatment
Ex: drug interactions, delirium, falls and injuries, incontinence, immobility
Define polypharmacy
"many drugs"
refers to problems that can occur when a patient is taking more medication that they need, predisposing them to adverse interactions, overdose, unnecessary side-effects
Define advance directive
Advance directives are legal documents that allow an individual to convey their decisions about end-of-life care in the event of serious illness or injury
- Provide direction for physician and family about care objectives
- Two types: living will, durable power of attorney
Define aging
- progressive deterioration of every bodily function of time.
- CUPID criteria of changes (cumulative, universal, progressive, intrinsic, deleterious)
Define senescence
- aging, the process of becoming old, or the state of being old
- the last stage in post-embryonic development of multicellular organisms, during which loss of functions and degradation of biological components occur. A physiological aging process in which cells and tissues deteriorate and finally die
- occurs at a cellular level (controlled by genetics but influenced by environment)
- senescent span is stochastic (random), involving body breakdown and environmental input
Define lifespan
- the duration of life of an individual (average lifespan is the average duration of life for a given species)
- equal to the sum of the health span (genes) and the scenescent span (random breakdown of the body in the environment)
Define longevity
the absolute value of years lived by an organism
Define life expectancy
- The average number of years a person is expected to live (based on health and risk exposures)
- May also be the average number of years for a class of living beings
- Active life expectancy if the portion of lifespan without disability
CUPID criteria
"Scientific definition of Aging"
Cumulative: changes accumulate of time
Universal: changes are universal and happen to everyone (with some variation)
Progressive: changes compound and progress
Intrinsic: changes are not necessarily modifiable by the environment (arguable)
Deleterious: essential result in loss of function until death
Measurements of aging
- measure the probability of dying (insurance does this): high at birth, declines in puberty, then increases throughout life. The rate of increase is how fast we age
- measure "mortality doubling time": the time it takes for for the probability of dying to double (at 35 ~8yrs)
- chronological age is generally not a good indicator of performance capability
- there is no plateau period for most physiological functions
- may be biomarkers that are predictive of aging (though unclear how this data would be useful)
Clinical and social impact of aging studies
Clinical:
- identify biomarkers that could be used for drug development to increase lifespan
- demonstrate that people need to be treated individually and not just on chronological age
- provide physicians with information needed to provide advice on maximizing longevity
Social
- used to improve and develop care facilities
- predict number and type of facilities and services needed for growing elderly populations
- allow insurance companies to set premiums
Define homeostenosis
= the narrowing of the homeostatic reserve mechanisms and an apparent depletion of physiological reserves
- the process increases vulnerability to disease (harder to maintain homeostasis) and has great variability between individuals
Define frailty (relative to homeostenosis)
= the clinical manifestation of the later stages of homeostenosis
- marked by an intolerance of homeostatic challenges
Changes in cause of death since 1900
- causes of death around 1900 (and currently in 3rd world areas) are related to infection, injury, and other acute problems
- the greatest advancement since then has not been increasing longevity but reducing early death
- These changes have been accomplished by improvements in hygiene, disease control (antibiotics, vaccination), lower infant mortality
- Now most modern deaths are the result of chronic illnesses (though eliminating cancer would only give an person an extra 6 years)
- Maximum length of life is essentially fixed (for an individual)
- Best way to extend life now is by calorie restriction and gonad removal
Experimental systems used to understand the genetics of aging
- Yeast: virgin cells die after ~cycles, but can select for long lived mutations
- Mice: mutations in the insulin pathway (IGFR) allowed mice to live longer and resist oxidative stress. Increased GH also decreases insulin, increasing lifespan
- Drosophila: in 10 generations can select for long-lived animals by collecting eggs from older adults (then map genes)
- C. Elegans: (short lifespan ~20 days, 36% genes are homologous to humans). Have unique Dauer state that can extend life for months if calorie restricted
Advantages and disadvantage of studying aging in model systems
Advantages:
- many genes and pathways are conserved in yeast and C. elegans, while short lifespans, easily mutable genes (less duplication in pathways), and controlled environments makes experiments easier.
- can generate knock-out species to observe roles of specific genes on overall aging process
Disadvantages
- each system has disadvantages, overall none will fully replicate the human condition
- Humans have adaptive immune systems (missing in simpler organisms)
- Human models (Hutchinson-Gilford Progeria syndrome, Werner's syndrome, Down's Syndrome) do not have all the aspects of aging represented in the accelerated aging phenotypes
How stressors differ in the way the effect old vs. young people
- pleotropisms: whats good for you when you're young isn't necessarily good for you as you age (Ex: hormones)
- natural selection does not act after reproductive age, so only select pathways that are helpful at young age (regardless of whether they cause complications at old age)
Define genetic damage and its contribution to aging and age-related diseases
- chromosomal instabilities accumulate throughout lifetime and contribute to change in gene silencing and activation patterns in the body (disease-related genes may be activated later in life.
- 4 manifestations of genetic damage:
--somatic mutation (molecular damage) to genetic material
--codon restriction damage (effects accuracy of mRNA translation and inability to decode mRNA)
--Error catastrophe: decline in the accuracy of gene expression, leading to production of abnormal proteins
--dysdifferentiation: buildup of molecular damage that effects ability to regulate gene expression
Define oxidative stress and contribution to aging and associated diseases
- pathways involved redox reactions, generate ROS
- can be good: used to kill bacteria and breakdown waste products
- excess ROS (from mitochondria and PM oxidases) cause damage to proteins, DNA, and lead to inflammation and immune response
- Sensitivity to ROS changes with age, and damage accumulates
Define cellular senescence and contribution to aging and associated disease
- cells do not replicate indefinitely and have signal to trigger apoptosis (telomere deterioration, DNA damage, ROS stress)
- this is a mechanism to suppress tumor formation
- functional consquences lead to aging (including secretion of inflammatory cytokines and proteases)
- some cells are resistant to apoptosis, and exceptions to senescence are germ cells, stem cells, and tumor cells
Define stem cells and contribution to aging and associated disease
- stem cells normally divide to renew tissues
- cellular senescence cause failure of stem cells to renew due to telomere shortening or failure of checkpoints, leading to aging (failure to renew tissues)
Define teleomeres and contribution to aging and associated diseases
- telomeres are regions of repetitive DNA sequences at the end of chromosomes
- telomeres shorten with repeat replication (like in immune T cells and stem cells). Shortening prevents tissue renewal causing aging
Define apoptosis and contribution to aging and associated diseases
= programmed cell death, important for cells that have been aged (stem cells) or are damaged (does not provoke inflammatory response)
- controversial whether it is a strong driver of aging or not
Define checkpoint controls and how they contribute to aging and associated diseases
- control the steps in cellular replication
- cellular senescence leads to failures in checkpoint control allowing for increase replication error and increased susceptibility to diseases with age (especially cancer)
Define hormesis
- concept that low level stress can induce a protective state that allows an organism to stay alive until conditions improve and accelerated growth and/or reproduction can be reinitiated.
- low level stressors induced intracellular cell-autonomous signaling pathways which defend the cells and tissues against causes for aging (like ROS). These pathways regulate glucose, fat, and protein in a way that ensures the chance of survivial during times of stress and are under endocrine control to ensure a coordinated response across all tissues and organs
DAF-2 pathway in C. Elegans
- DAF-2 encodes insulin/IGFR1 (which is similar to the insulin receptor in humans).
- IGF negatively regulates genes for transcription factor DAF-16 which is a regulator of longevity genes.
- A mutation in DAF-2 allows for the extension of normal life span by reducing DAF-16 inhibition (mutation in DAF-16 negates this).
- this pathway is highly conserved across species, though has two components in mice and higher mammals (split insulin/IGF receptors). Blocking both in humans would result in diabetes.
- Essentially DAF-2 mutations lead to upregulation of DAF-16 which in turn regulates may genes including antioxidants, chaperones, antimicrobials, metabolic genes, and novel genes which extend life
SIR and sirtuins and effect on longevity
-SIR and sirtuins are histone deacetylases which stabilize (or silence) repetitive DNA (aging in yeast shown to be chromosomal breaks in repetitive DNA (ERC's) that excise and replicate to toxic levels)
- SIR gene also mediates the caloric restriction mechanism
SIR mechanism for caloric restriction effect on longevity
- during stressful events like caloric restriction, PNC1 is activated which depletes nicotinomide, resulting in a down-regulation of feedback inhibition of SIR2. Then the upregulated SIR2 stabilizes repetitive ribosomal DNA, leading to longevity (in yeast, mammalian PNC1 homolog is unknown)
- NAD is involved in the SIR2 pathway. If there is a large amount of glucose it will be used for glycolysis, but in CR it is shunted to the SIR2 pathway increasing longevity
Benefits of red wine
- contains resveratrol which is a sirtuin activating compound.
- in model organism resveratrol had a significant lengthening effect on lifespan if the organism had a functioning and responsive SIR2 pathway (seen in mice on high calorie diet, no benefit on normal or CR diet)
2 most important ways to improve active life expectancy
- smoking cessation, healthier eating, more exercise
- Leading causes of death are attributed to smoking (400K) and diet/exercise (300K)
4 Ways avoid falling in elderly
1. begin regular exercise program: loss of muscle tone can lead to poor balance and difficultly correcting misstep. Regular activity maximizes mobility.
2. Review of medications by healthcare provider: many medication alter balance, cause dizziness, have adverse interactions
3. Check vision: hazards are not seen as readily and vision loss is common
4. Make home safer: remove hazards
Normal aging vs disease
Normal aging:
- the process of homeostenosis
- represents loss of physical reserves, making the body more susceptible to disease
- variable between individuals
Disease:
- pathological change in the tissues involved
- not a direct consequence of aging
Changes in Body composition with aging and the impact on medication selection
Changes:
- loss of height, weight
- increased fat, decreased muscle (body water)
- loss of subcutaneous fat (causing wrinkles)
- thinning, graying hair
Medication changes:
- lipophilic medications will remain in the patient longer, have an extended effect
- hydrophilic medications may be concentrated
Structural and functional cardiac changes with aging and clinical implications
Heart muscle thickens an increases in weight
- increased dependence on active atrial filling (may hear 4th heart sound due to turbulence in the stiff ventricle), susceptible to atrial fibrilation
- Decreased atrial kick (atrial thickening)
- Decreased Max HR (and therefore Max Cardiac output) (resting is the same), Male:220-age, female 220- (0.6*age)
Hardening and thickening of the arteries
- increased blood pressure, especially systolic
Pulmonary changes with aging and impact on function
Stiffening of tissues: decreased alveolar surface area, weaker diaphragm, less effective cilliary action
- stiffness results in decreased airway flow
- decreased vital capacity (maximal expiratory capacity)
- increased residual volume
- Ventilation/Perfusion (V/Q) mismatch: areas ventlated aren't always perfused with blood
- PO2 (arterial) decreases: PaO2= 100-age/3
GI system changes with age
Decreased salivary production
- more oral ulcers
Gastric mucosa atrophy and impaired acid clearance
- predisposition for GERD
Decreased Ca2+ absorption
- predisposed osteoporosis
Slower transit time
- constipation (also induced by low fiber + poor mobility + medication effects)
Phase I drug metabolism in the liver
- redox reactions via the cytochrome P450 system (oxidases)
- Used to metabolize steroids and other drugs
- mechanism declines significantly with aging, so must be vary of drugs metabolized in this pathway (diazepam) because they will have delayed clearance
Phase II drug metabolism in the liver
- conjugation, usually detoxifying reactions, involve interactions of polar functional groups of phase I metabolites (ex: glucoronidation)
- facilitates renal excretion, less effected by aging
- used to metabolize lorazepam (alternate for diazepam)
Renal changes with aging and clinical implications
Decreased renal mass, especially in cortex (where filtration occurs)
- decreased creatinine clearance (indicative of overall decrease in function): CCr = (140-age)*(Kg)/(72*srm Cr) [*0.85 in women]
- 30% loss of glomeruli by age 75
Decrease in concentrating capacity
- tendency toward dehydration
Electrolyte changes
Dosing changes needed:
- Ex: heparin (blood thinner for DVT), reduce dosage by half if CCr <30 (1mg/kg/day)
Hormonal changes with aging
Changes in glucose tolerance
- fasting glucose increases (1%/decade)
-peripheral tissues show decreased response to insulin (predisposes diabetes if combined with sedentary lifestyle)
Decrease in growth hormones
Decrease in sex hormones (low estrogen due to ovarian failure)
Changes in the female reproductive system with age
Vagina becomes thicker, drier, less elastic
- difficult or painful intercourse
Sagging breasts
- less firm, elastic skin, ligaments
Menopause: permanent end to menstruation ~50yo
- fluctuating hormones can cause side effects like hot flashes and mood swings
Changes in the male reproductive system with age and relationship to disease process
Fewer sperm and decreased sex drive
- andropause, occurs slower/later in men
Blood flow to penis decreases
- causes problems with erections: less rigid, shorter lasting; Erectile Dysfunction is common (not normal aging)
Prostate enlarges
- cause problems with urination due to obstructed flow (less force, more time to initiate stream)
Changes in cognition with age
Intellect
- usually maintained until at least 80
- slowed central processing (takes longer to do a task)
Verbal Skills
- up to 70, vocabulary and general knowledge are increased.
- After 70, may show gradual decrease in vocab and increase in semantic errors
- difficulty learning new languages
Mentation
- difficultly learning (esp. languages)
- forgetfulness in non-critical areas (should not effect function in normal aging, have good important memory recall)
CNS changes with age
Stable intelligence until 67 then modest changes until 80
- decreased brain weight and blood flow
- fewer dendritic connections (variable)
- decreased selective attention
- neurotransmitter changes: less NT released, less activity in hippocampus and cortex (where NTs produced)
- problems with corpus colossum (hemispheres less effective in communicating with eachother)
- Non-uniform changes: >50% loss occurs in superior temoral gyrus (memory connections), minimal losses in parietal (sensory processing/integration) and occipital (visual processing) lobes
- Changes are variable between individuals and present differently in clinic. In successful aging there will be some changes, difficult to differentiate from early disease
PNS changes with age
- decreased number of spinal motor neurons
- slower nerve conduction (decreased large myelinated fibers)
- decreased vibratory sensation (especially in feed)
- decreased thermal sensitivity
Difference between dementia and normal aging
Dementia:
- "sweater in the microwave"
- difficulty naming common words, forgetting names of known places, people
Normal aging:
- "forgetting keys"
- occasional word difficulty
- difficulty learning new languages
Changes in bone metabolism with age and clinical implications
Loss of bone/decreased bone formation
- decreased bone density (decreased calcium uptake)
- increased bone loss (more osteoclast vs osteoblast activity)
- decreased vitamin D absorption
Implications:
- loss of height
- susceptibility to fracture
- Osteoporosis is not normal aging
Changes in muscle with age and functional implications
Decreased muscles mass by 30-40% (rate of loss increases linearly with age)
- fewer motor units (leads to decreased muscle power and less heat production
Implications:
- decrease in stair climbing activity, decrease in gait speed (can be minimized by regular exercise and weight bearing activity), susceptibility to hypothermia
Visual changes with age and clinical implications
Decreased cornea sensitivity
- decreased contrast sensitivity
- increased iris rigidity
- hardening of the lens (presbyopia): causes difficulty in accommodation, requires glasses (normal aging)
- Yellowing and drying lens: causes problems with glare, decreased lacrimal/tear production, can lead to cataract formation (NOT normal)
Auditory changes with age and clinical implications
- decrease in activity of cerumen glands: cerumen accumulation/dry wax impaction
- presbycusis: normal degeneration of the choclea
- tympanic membrane thickening: results in loss of high frequency hearing
Implications:
- speak at lower frequency
- rule out cerumen impaction before referring to ENT
Skin changes with age and clinical implications
- Wrinkles (loss of subcutaneous fat deposits)
- Skin thickening: impairs protective barrier function of skin, more susceptible to infection
- Photoaging: includes brown spots, can be reduced by sunscreen use
- Loss of subcutaneous fat deposits: less padding (especially over bony prominences), can lead to pressure ulcers if immobile
- Atrophy of sweat glands: increased susceptibility to hyperthermia
- Impaired vasoconstriction/dilation response in skin arterioles: impairs temperature regulation
- decreased temperature discrimination: increased risk for hypo/hyperthermia (less shivering)
- inaffective DNA repair (from UV and other damage): risk for tumor formation
Taste and smell changes with aging
- number taste buds and responses are unchanged
- Olfaction decreases significantly: can cause loss of taste and predispose malnutrition
-- Detection thresholds increases by 50% by 80, smell recognition decreases by 15%
Dehydration risk in elderly
- response to too much water remains intact (hypervolumia)
- response to too little water (hypovolumia) is impaired: stretch receptors lose sensitivity, decreased thirst sensation, decreased renal concentration capacity
Components of Frailty
= sarcopenia, weight loss, reduced strength, slowed perfomance, reduced balance, low physical activity, cognitive disability
Clinical diagnosis: 3 of 5:
- low physical activity, muscle weakness, slowed performance, fatigue or poor endurance, unintentional weight loss.
- frailty is the aggregate burden of illness that confers risk for loss of independence or a distinct clinical syndrome (single condition, not collection of comorbidities)
Frailty vs. Aging
Aging: the natural physiological process an organism undergoes as it accumulates changes over time
Frailty: a physiologically-based condition with clinical manifestations marked by an intolerance to homeostatic changes
- Aging: not disease, but predisposes it
- Frailty: not disease, but increases the effect disease has on a person--frailty leads to further frailty, predisposes loss of independence
Causes/mechanism of frailty
- molecular changes or disease (various stresses/aging processes, genes, disease) lead to impaired physiological functioning resulting in clinical presentations of frailty
- SNPs have found some genes that may predispose frailty, mostly involved in apoptosis and transcription regulation (rather than inflammation)
- Frailty is multifactorial with variable causes, pathways, and presentations
Relationship between homeostasis and homeostenosis
- homeostenosis affects the body's ability to maintain homeostasis
- different people and different systems within them become homeostenotic at different rates (unclear whether reserves are totally gone or just more occupied)
- decreased homeostasis leads to increased frailty which in turn leads to an increased mortality
Define DEALE and how it applies to clinical senarios
DEALE = Declining Exponential Approximation of Life Expectancy
- defines the patient specific mortality as the some of age and disease mortalities.
- As a patient ages the effect of individual comorbidities declines as the overall age mortality is just not that high
Physical and sensory changes that lead to functional impairment and injury risk in the home
Vision: lens of eye hardens, night vision declines, contrast differentiation declines.
Joints: stiffening and pain makes fine movement (opening things) difficult
Muscle/gait/balance: gait and stability decline increasing risk of falls
Strength: difficulty moving, getting up
Common design factors contributing to functional impairment and injury risk
- non-contrasting colors, dark colors make differentiating objects difficult
- throw rugs are slip risk
- Rocking chairs, couches, soft chairs, non-attached padding, no armrests: challenge to get out of
- revolving doors and other visually complicated features: difficult to identify and use
- Carpeting/flooring transitions: difficult to transition, patterning can disguise features
- Lighting, should be easily accessible from be and door
- Space: need width for walking appliances
Senior-friendly built environment
- living space with wide, clear pathways and well lit entrances
- chairs are sturdy, good height, have arms
- floors are conducive to easy walking with easy, marked transitions between surfaces
- kitchens should have items easily accessible storage, reduced fire hazards
- bright, contrasting colors for visual cues
- wheelchair and mobility-impaired entrances
5 Design features that reduce disability of seniors in a community
- safe, wide, even walking paths
- door handles that are large and have D-handles
- building entrances that are simple (not rotating) and are wide enough for walkers/wheel chairs
- stairs are well marked, lit, and have contrasting colors and rails
- housing is available that meets their specialized needs and care level
- accessible, affordable transportation to places of common interest
5 reversible and treatable conditions that are often under-diagnosed in older patients
- gait instability and falls
- sleep disorders
- incontinence
- depression
- delerium
- abuse
Where do older American's live and what are the differences between sides of care for men and women?
- 80% live in their own home, and the majority want to stay that way (despite needs)
- NORC: Naturally occuring retirement community, 25% is over 65
- More women live by themselves (since they outlive men), but they also are higher represented in communities
What are the ADLs and IADLS
DEATH SHAFT

ADLs: Dressing, Eating, Ambulating, Toileting, Hygiene

IADLs: Shopping, Housekeeping, Accounting, Food preparation, Transportation (also includes taking medication and using the phone)
Define Senior Housing Communities and the patients that live there
- neighborhoods in metropolitan areas where seniors tend to accumulate (NORCs)
- for relatively self-sufficient patients, that might have slight deficiencies in IADLs
- may have home care service providers (skilled and non-skilled) to provide basic medical care or living support. Usually only a few times a week though
Define Assisted Living and patients living there
- can be called personal care home or a group home
- 3-5,000/month
- not licensed to provide medical care, but may supervise to make sure medication taken.
- Provides help with some ADLs and many IADLs, 24 hour supervision
- for those that need assistance with daily living but do not need intensive or skilled medical care. Must be able to get around by themselves (not bedridden). May have some cognitive decline
Define skilled nursing facility and the patients that live there
- a medical community (may be associated with assisted living facility). Also called rehab facility
- for patients who are either immobilized, need lots of care to move from bed to toilet, or have severe dementia that cannot be otherwise managed. Generally need help with 2+ ADLs and have need for skilled care.
- must be ordered by a physician along with medication and therapy orders (states have specific requirements).
- Paid for by medicare/medicaid
- Also used for short-term, skilled rehabilitation (stay is <20 days paid by medicare). Must be undergoing therapy
Alternate forms of Senior care:
Adult foster care
Adult day care
Continuing Care retirement community
Adult foster care: hiring another family to take care of seniors (paid stipend); for seniors who are not bedridden but need daily assistance
Adult Day care: good for patients that need a lot of supervision (dementia), but may be physically mobile. Get care that adds to their life (socialization, meal, exercise)
Continuing care retirement community: for wealthy patients (monthly fee), buy in community with varying levels of services
Financing long term care
- most is out of pocket.
- People in nursing homes can pay out of pocket or apply for Medicaid (must spend down assets first). Medicare will cover short rehab stays
- Some health insurance may cover some long-term care
- VA benefits may help
Types of Home Health Care
Skilled:
- home health agencies, licensed professionals (RN, PT, OT, ST, SW) can provide wound care, blood draws
- services ordered and supervised by a physician, paid for by Medicare
- only for patients who are homebound, and services are only intermittent
Non-skilled:
- home health aide (NOT RN), works for licensed health agency
- helps with ADLS
- covered by medicare only if you also need skilled home heath care
Define Medicare
- US publicly funded federal health insurance plan for the elderly and disabled that covers 45 million Americans
- people contribute payroll taxes during years of employment
- covers most >65 who contributed, <65 on disability, people on dialysis for ESRD
- includes hospital insurance, medical insurance, prescription drug coverage
Define Medicaid
- US Welfare program for low-income adults and their children and people with certain disabilities
- jointly funded by state and federal gov'ts
- will cover nursing home care for those who have medical illness and have exhausted all their own financial resources
4 illness trajectories
1. Sudden death (trauma, sudden cardiac death): death resulting from acute illness, immediate decline from high functioning status
2. Terminal illness (cancer, degenerative neural disease): sustained high function with relatively rapid and steep decline (decline is fairly predictable)
- Organ failure (heart, renal, liver, lung): gradual decline in function with intermittent severe symptom crises and recoveries (incomplete return of function); sinusoidal decline; difficult to tell which crisis will be fatal
4. Frailty (associated with dementia, CVA complications, Parkinson's): illness trajectory begins with low physical function and have progressive, slow decline of function until death. Most common trajectory
5. Combined trajectory: EX: someone with renal disease dies of something else (though disease contributed to decline)
Physical changes and symptoms that occur at the end of life
(most changes are more alarming to the family than the patient)
- Weakness: at EOL effects whole body and increases toward death causing immobility, fatigue, skin breakdown. Do not treat unless iatrogenic, patient uncomfortable
- Nutrition: intake deceases or stops mostly due to non-hunger and weight-loss; avoid forced nutrition (uncomfortable), educate
- Dehydration: decreased or no intake, usually not uncomfortable, IV fluid may prolong dying and cause discomfort, only treat if thirsty or let family aid in care (mucosal relief)
- Decreased blood flow: sign of active dying, leads to tachycardia, hypotension, peripheral cooling, cyanosis, mottled skin, decreased/absent urine, skin breakdown. IV fluids do not treat
- Neurologic changes: 80-90% experience delerium (mostly hypoactive, but can be mixed); assume patient is hearing at all times
- Gastrointestinal changes: dysphagia (noisy breathing), loss of sphincter control, nausea/vomiting (requires treatment), constipation (requires treatment, esp if w/ opiates), diarrhea
- Skin: pressure ulcers, require treatment, ideally prevention w/ rotation
- Pain: requires prompt treatment (somatic, visceral, or neuropathic), rare for new-onset (evaluate with care)
-Respiratory: dyspnea (breathlessness) requires prompt treatment, O2 may prolong dying, not usually related to hypoxemia; changes in breathing pattern: active dying, last reflex breaths, indicative of neurological compromise, not treated or uncomfortable
Define caregiver burden
= the physical, emotional, and financial toll for providing care
Challenge of caring for dementia patients vs. physically impaired
Dementia:
- often mobile, may wander
- at risk for injury/safety when operating normally in the home
- may not take medication
- often have behavioral disorders and personality changes
Physically Disabled:
- mobility in the home
- difficulty accomplishing ADLs without assistance
- require physical assistance
- modifying the home to accommodate wheelchair, etc
Relationship between functional impairment, financial burden, and behavioral problems with respect to caregiver burden
- Functional impairment does not correlate with caregiver burden but behavioral problems (in dementia patients) do
- high caregiver burden increases the risk of needing to place a senior in a long term care facility or increase use of in-home services, all increasing the financial burden
Health consequences of caregiving
- Depression: incidence 18-47%
- Anxiety: 17.5% of caregivers (10.9 in controls)
- Lower perception of health than individuals not in a care giving role
- decreased immune function (viral illnesses last longer)
- overall higher level of burden may correlate to increased morbidity and mortality
5 Sources of caregiver stress
- feeling lonely, only one caring for the person
- frustration, with behavioral issues, inability/weakness of the patient to do things
- Physical stress: have to do a lot of the individual in addition to their own work
- Financial stress: use many resources for the patient
- Guilt, feel they should be doing more
- others...
Programs that can reduce caregiver burden
Respite care: adult day care or church programs so that the caregiver has time to themself
Support groups: share stresses and worries, feel community
Core Competency 1
- The competency: Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and Central Nervous System sensitivity.
- Importance: The body changes with aging, which include decreased hepatic function, decreased renal blood flow, increased fat to water ratio and loss of neural dendrites. These all lead to the need to closely monitor the types and dosages of medications given to the elderly.
- Strategy: To achieve this competency, the physician should ensure the patient’s ability to manage his or her own medications. The physician should also maintain a knowledge about relevant drugs and their side effects and know how to access reliable resources.
Core Competency 3
- The competency: Document a patient’s complete medication list, including prescribed, herbal and over-the-counter medications, and for each medication provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.
- Importance: A complete medicine list is important to prevent medicine errors from unwanted side effects, adverse interactions and medication duplications. Also, this helps the patient with self-management of medications. When going through transitions of care, a medication list aids providers, in administering the correct medications.
-Strategy: Before seeing a patient, instruct them to bring in all medications, vitamins and OTC supplements that are being taken. Have the patient demonstrate the frequency and dosage that they take the medications and also verify with relatives and other caregivers the correct medications.
Core Competency 4
- Competency: Compare and contrast among the clinical presentations of delirium, dementia, and depression.
- Importance: Symptoms of delirium, dementia and depression are very similar and often overlap. It is important to be careful when diagnosing these conditions because delirium and depression are treatable while dementia is not.
- Strategy: To correctly identify these conditions, one must give a through history and physical exam and establish a timeline of cognitive changes through the years. Also by considering the social environment of the patient the physician should be able to make a better diagnosis of these conditions.
Core Competency 5
- Competency: Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits delirium, dementia, or depression.
- Importance: Since all of these conditions present very similarly, a differential diagnosis is key to finding the proper diagnosis. Often times it is the physician and not a psychiatrist who is charged with making a mental health diagnosis.
Strategy: Always be aware of polypharmacy when making a diagnosis. Also time with patient is critical to make an accurate recognition and assessment. Tools like the DSM-IV and the MMSE and Confusion Assessment Method are good diagnostic tools.
Core Competency 8
- Competency: Develop an evaluation and non-pharmacologic management plan for agitated demented or delirious patients.
- Importance: There is great similarity between the symptoms of dementia and delirium and both of which increase the patient mortality rate. Non-pharmacologic management can prevent the common drug interactions and exacerbations of symptoms that is associated with polypharmacy and iatrogenic illnesses.
- Strategy: Reorientation and behavioral intervention through personal contact, familiar objects and aids to orientation can be used for delirium and dementia treatment. Sleeping and calming aids are other useful treatments. Along with treating the patient, family members also require treatment and intervention.
Core Competency 1
- The competency: Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and Central Nervous System sensitivity.
- Importance: The body changes with aging, which include decreased hepatic function, decreased renal blood flow, increased fat to water ratio and loss of neural dendrites. These all lead to the need to closely monitor the types and dosages of medications given to the elderly.
- Strategy: To achieve this competency, the physician should ensure the patient’s ability to manage his or her own medications. The physician should also maintain a knowledge about relevant drugs and their side effects and know how to access reliable resources.
Core Competency 3
- The competency: Document a patient’s complete medication list, including prescribed, herbal and over-the-counter medications, and for each medication provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.
- Importance: A complete medicine list is important to prevent medicine errors from unwanted side effects, adverse interactions and medication duplications. Also, this helps the patient with self-management of medications. When going through transitions of care, a medication list aids providers, in administering the correct medications.
-Strategy: Before seeing a patient, instruct them to bring in all medications, vitamins and OTC supplements that are being taken. Have the patient demonstrate the frequency and dosage that they take the medications and also verify with relatives and other caregivers the correct medications.
Core Competency 4
- Competency: Compare and contrast among the clinical presentations of delirium, dementia, and depression.
- Importance: Symptoms of delirium, dementia and depression are very similar and often overlap. It is important to be careful when diagnosing these conditions because delirium and depression are treatable while dementia is not.
- Strategy: To correctly identify these conditions, one must give a through history and physical exam and establish a timeline of cognitive changes through the years. Also by considering the social environment of the patient the physician should be able to make a better diagnosis of these conditions.
Core Competency 5
- Competency: Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits delirium, dementia, or depression.
- Importance: Since all of these conditions present very similarly, a differential diagnosis is key to finding the proper diagnosis. Often times it is the physician and not a psychiatrist who is charged with making a mental health diagnosis.
Strategy: Always be aware of polypharmacy when making a diagnosis. Also time with patient is critical to make an accurate recognition and assessment. Tools like the DSM-IV and the MMSE and Confusion Assessment Method are good diagnostic tools.
Core Competency 8
- Competency: Develop an evaluation and non-pharmacologic management plan for agitated demented or delirious patients.
- Importance: There is great similarity between the symptoms of dementia and delirium and both of which increase the patient mortality rate. Non-pharmacologic management can prevent the common drug interactions and exacerbations of symptoms that is associated with polypharmacy and iatrogenic illnesses.
- Strategy: Reorientation and behavioral intervention through personal contact, familiar objects and aids to orientation can be used for delirium and dementia treatment. Sleeping and calming aids are other useful treatments. Along with treating the patient, family members also require treatment and intervention.
Core competency 9
- Competency: Assess and describe baseline and current functional abilities in an older patient by collecting historical data from multiple sources, making sure to include instrumental activities of daily living and activities of daily living, and performing a confirmatory hearing and vision examination.
- Importance: Different patients have different goals for their treatment that are not always obvious to the physician. Treatments affecting the quality of life is not always in the patients best interest.
- Strategy: It is important to understand that patients are not created equal and they share different values from you. Treat and educate both the caregivers and the patients to create an effective treatment plan.
Core competency 10
- Competency: Develop a preliminary management plan for patients presenting with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy.
- Importance: Elderly care is a multidisciplinary endeavor that involves the collaboration with many different types of caregivers. A management plan is essential to stop duplications of care.
- Strategy: Frequent communication between the health management group is necessary provide for quality and comprehensive care. Through using the tools of Community-Based Long-term Care, there can be a good support base created fro a patient and family members. Make sure that there is a consensus between all members of the team and that there is frequent documentation of ALL of the team’s activities. Pay particular attention to the patient’s support system.
Core competency 13
- Competency: In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.
- Importance: Falls are a very common problem win the elderly population where 1/3 of fall patients >65 fall each year. Impacting society as a whole, falls account for 19 billion dollars of healthcare spending. Falls are the leading cause of death in people over 65.
- Strategy: Always perform a full physical on the patient to identify and assess all risk factors for falls. Be sure to ask about previous falls and the home environment that can support the risk for falls. Simplifying medications can prevent against iatrogenic illness induced falls.
Core competency 14
- Competency: Being able to differentiate between types of code status, health care proxies, and advance directives in the state where one is training.
- Importance: Gives patients autonomy for their own care and reduces the stress of decision making from doctors and families.
- Strategy: Discuss a living will, power of attorney with patients to allow for better end of life management. Also discuss DNRs and know the code statuses. In Georgia these are called advance directives
core competency 15
- Competency: Accurately identify clinical situations where life expectancy, functional status, patient preference or goals of care should override standard recommendations for screening tests in older adults.
- Importance: Most screenings are based towards the general population and the needs of the elderly population are not generally reflected. Most people will not outlive the benefits of the screenings.
- Strategy: Standardized recommendations should be used to form a loose basis to decide on a screening procedure. Know the patient and the patient’s priorities to give the patient the best advise possible. Remember, respect the patient’s autonomy
Core competency 17
- Competency: Identify at least 3 physiologic changes of aging for each organ system and their impact on the patient, including their contribution to homeostenosis (the age-related narrowing of homeostatic reserve mechanisms).
- Importance: Homeostenotic changes of the body are very different between individuals and thus must be treated accordingly. Changes in the ability to maintain homeostasis are normal but can be influence chronic disease
- Strategy: Advise patients to remain active and live a healthy lifestyle. Seek information of social and mental status. Make sure to ask about key symptoms like dizziness or forgetfulness or falls
Core Competency 18
- Competency: Generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults, including acute coronary syndrome, dehydration, urinary tract infection, acute abdomen, and pneumonia.
- Importance: In older adults symptoms of diseases present differently than in a middle age adult. Not all symptoms lead to one disease; multiple symptoms can lead to many different diseases.
- Strategy: Know how the symptoms present in older patients and know that confusion is not always a symptom of dementia
Core Competency 22
- Competency: Identify potential hazards of hospitalization for all older adult patients (including immobility, delirium, medication side effects, malnutrition, pressure ulcers, procedures, per and post operative periods, transient urinary incontinence, and hospital acquired infections) and identify potential prevention strategies.
- Importance: Hospitalizations of elderly represent 1/3 of all hospital admissions and once an elderly individual is admitted, the length of stay is longer than the average patient.
- Strategy: To achieve the strategy a physician needs to understand the altered physiology, the breakdowns in care that happen with an elderly population and the increased systemic risks. Another way to achieve this strategy is to adopt a “Safety-Oriented” culture, which includes checklists, medication lists, and system reviews.
Core Competency 23
- Competency: Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient.
- Importance: Over 25% of older patients have a Foley catheter while hospitalized. Infections from these catheters is frequent but preventable.
- Strategy: Know the risks, indications of complications of a Foley, and the alternatives of having a Foley catheter. Using a Foley catheter as a last resort ensures unnecessary use of the catheter. If a catheter is used be sure to monitor the complications associated with the catheter.
Core Competency 24
- Competency: Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use.
- Importance: Restraint use in long-term care facilities is widespread around the US and restraint use is associated many negative outcomes like muscle atrophy, increased risk of falls and pressure sores.
- Strategy: Follow the ethical guidelines put out by the AMA to make sure that restraints are not used improperly. Education of healthcare workers of when to not use restraints is important, and most importantly educate on the alternatives to not using restraints. Education of family members is also important to reduce the usage of restraints. Reducing the use of psychotropic drugs can reduce agitation and the need for restraints.
Core competency 26
- Competency: Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers and describe existing ulcers.
- Importance: Bedsores are important in many nursing homes and care facilities and can be dangerous and lead to infections and sepsis.
- Strategy: To decrease the incidence of bedsores, patients who are at risk need to be identified. The highest risk patients are those who are frail and have mobility issues. Prevention may be achieved by changing bed positions frequently and maintaining skin hygiene.