Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
227 Cards in this Set
- Front
- Back
|
xerosis
|
medical term for Dry Skin
|
|
|
Symptoms & Signs of xerosis
|
Itchy and scaling
Especially lower legs Often worse in winter |
|
|
Asteatotic eczema
|
Asteototic eczema is also known as “winter itch” or “winter eczema”. This is characterized by red irritable skin that is caused from excessive dryness of the skin
|
|
|
Asteatotic eczema
|
eczema craquelé
fissures and slightly raised plaques anterior shins extensor surfaces arms |
|
|
Systemic causes of asteatotic eczema
|
-Thyroid (Myxedema and other thyroid diseases with diminished sweat and sebaceous gland activity3 )
-Nutrition (zinc and essential fatty acid deficiencies) |
|
|
Dry Skin Treatments
|
Lifestyle modification
Reduce use of soaps Rinse well Tepid water Avoid vigorous toweling Emollients hydrophilic petrolatum right after bathing Low potency steroid topical cream 1-2.5% hydrocortisone/inflammation |
|
|
Seborrheic Dermatitis
|
--Scaly, greasy eruption
-mainly face, scalp & presternal --Yeast overgrowth often implicated -Malassezia furfur --Scalp (dandruff) -all ages -brows & chest |
|
|
Seborrheic Dermatitis Treatment
|
Facial dermatitis
try hydrocortisone 1% cream* ketoconazole 2% cream BID may be useful Scalp sulfur, zinc, tar containing shampoos |
|
|
what kind of hypersensitivity is contact dermatitis
|
--Delayed-type hypersensitivity reaction
-antigen (allergen) contacts skin -severe pruritus |
|
|
what is the appearance of contact dermatitis?
|
localized or generalized
Clue: linear or artificial patterns follow external contact |
|
|
what is Contact Dermatitis
|
Delayed hypersensitivity reaction to an allergen, usually has a linear or artificial pattern.
|
|
|
Stasis Dermatitis
|
Chronic venous insufficiency
venous blood pooling in lower extremities most commonly associated with varicose veins Primary lesions red-brown hyperpigmented macules and patches Ulceration in up to 30% |
|
|
Psoriasis
|
T cell-mediated inflammatory dermatosis
Erythematous papules & plaques Arthritis of small and large joints may accompany psoriasis |
|
|
Herpes Zoster
|
Reactivation of varicella-zoster virus in dorsal root ganglion
Peak incidence ages 50-70 decreased cellular immunity Grouped vesicular lesions unilateral within 1-2 adjacent dermatomes Thoracic>*Trigeminal/Cervical>Lumbar |
|
|
Herpes Zoster is considered an emergency when...
|
*Cutaneous involvement V1 branch CN V
Dendritic ferning of cornea with fluroscein staining Immediate slit-lamp exam by ophthalmologist Topical anti-virals in conjunction with steroids Potential blindness |
|
|
Postherpetic neuralgia (PHN)
|
pain persists after resolution skin eruption
|
|
|
Antiviral drugs effective in acute phase of herpes zoster
|
Start within 48-72 hours of rash onset
Reduce pain, accelerate healing, decrease incidence of neuralgia Acyclovir (Zovirax) Famciclovir (Famvir) Valcylovir (Valtrex) |
|
|
Zoster Vaccine
|
FDA approved 2006
Zostavax Marked reduces morbidity & PHN herpes zoster (>50%) post herpetic neuralgia (>66%) |
|
|
Verrucae
|
medical term for warts
|
|
|
Plantar warts (verruca plantaris)
|
stubborn regardless of treatment
cryotherapy* cantharidin 0.7% salicylic acid 40% plasters caution in diabetics |
|
|
Lentigines is aka
|
(Liver Spots)
|
|
|
Lentigines
|
Benign lesions
increased number of pigment cells superficial skin sun-exposed areas backs of hands, face, shoulders Increase in number with age 0.2 to 2 cm. flat lesions discrete borders, dark color, irregular shape Usually benign-treatment unnecessary |
|
|
criter for biopsy of lentigines
|
highly irregular border
changes in pigmentation change in thickness |
|
|
what is the most common benign epithelial tumor of adulthood
|
Seborrheic Keratosis
|
|
|
Seborrheic Keratosis properties
|
Trunk affected more than extremities
Appear as waxy, stuck-on 5-20 mm papules and plaques, with varying shades of brown with a rough, warty surface If diagnosis uncertain, biopsy or excision Mostly hereditary: not caused by sun exposure No relationship to skin cancer: not threat to health |
|
|
what is the most common skin cancer
|
Basal Cell Carcinoma ~75%
|
|
|
Properties of basal cell carcinoma
|
Related to chronic UV light exposure
95% of cases in persons 40-79 years Head and neck most often involved Origin: stem cells in basal layer of epidermis Slow-growing-rarely metastasizes can invade deep tissues destroy bone and cartilage Primary lesions translucent or pearly papules or nodules Secondary changes include central ulceration or crusting |
|
|
Basal cell carcinoma treatments
|
Size, depth of invasion determine proper treatment
Electrodessication and curettage (ED&C) cure rates 90% for low risk small tumors Surgical: margins of 5 mm desirable Mohs’ surgery most effective for high risk Controlled, staged excision tissue margins examined as surgery proceeds |
|
|
what is the most common precursor lesion for squamous cell carcinoma
|
actinic keratosis
|
|
|
what is the distributino of AK (photodistribution of actinic keratosis)
|
face, lips, ears, dorsal hands, and forearms
|
|
|
properties of AK
|
Primary lesions 3-10 mm rough, scaly white papules and plaques
often on erythematous base Palpation reveals gritty, sandpaper-like texture |
|
|
what are the risk factors for AK
|
age, fair complexion, blue eyes, history of childhood freckling
1-20% risk of transformation to squamous cell carcinoma AKs > risk for basal cells & melanoma |
|
|
AK treatment
|
Cryotherapy with 2 freeze-thaw cycles
5-fluorouracil (5-FU) 5% cream applied BID for 3 weeks Annual full body exam |
|
|
what is the second most common skin cancer in the US
|
Squamous Cell Carcinoma
>200,000 cases per year in U.S |
|
|
how are squamous cell carcinomas develop?
|
derived from keratinocytes above the basal layer of epidermis
often AK precursor lesions |
|
|
properties of SCC
|
Primary lesions
firm, indurated papules, plaques or nodules secondary scaling, erosion or ulceration with crust Lesion does not heal, breaks down, bleeds Photodistribution Overall risk of metastasis 2-5% SCC on lips or ears has 10-15% risk of spread to cervical nodes |
|
|
Risky lesions of SCC
|
High risk lesions
recurrent tumor, tumor on trunk and extremities > 2 cm; tumor on head and neck > 1 cm; tumor occurring on genitals, lips, ears, site of prior radiation |
|
|
treatment of SCC
|
Treatment
surgical excision Mohs’ surgery (98-100% cure rate) |
|
|
Melanoma highest risk for metatstasis
|
lymph nodes, liver, lungs and brain
|
|
|
melanoma incidence increases with
|
age; Prevalence increasing faster than any other cancer
|
|
|
Melanoma risk factors
|
light complexion, blistering sunburns during childhood, positive family hx
|
|
|
Melanoma distribution on body
|
Trunk and legs affected more than face and neck, but face and neck more likely to be affected in the elderly
|
|
|
ABCDE of Melanoma
|
Asymmetry
Border irregularity Color variegation Diameter > 6mm Elevation (?growing in height) |
|
|
Melanoma identification
|
Primary lesion often brown/black macule, papule, plaque or nodule
Asymmetry, border irregularity, color variegation, diameter > 6 mm |
|
|
Melanoma treatment
|
Treated by wide surgical excision
margins determined by histological tumor thickness Check sentinel node Lesion deeper than 1.0 mm If histological ulceration present Advanced melanoma with metastases is usually incurable and treated palliatively |
|
|
Pressure Ulcers definition
|
Localized areas of tissue necrosis
tend to occur with soft tissue compression bony prominence against external surface prolonged period Unable to reposition Bedridden or chair bound, Less fat and muscle to dissipate pressure “bedsores, decubitus ulcers, pressure sores” |
|
|
Pressure Sores: Common Sites
|
sacrum, greater trochanters (femur), ischial tuberosities (pelvis), medial and lateral condyles
less often-elbows, scapulae, vertebrae, ribs, ears, back of head |
|
|
Pressure areas for decubitus ulcers
|
Varies with patient position
Ischial: most common with paraplegia Sacral: prolonged bed rest |
|
|
Pressure Sores: Mechanisms
|
Pressure
reduces blood supply and lymphatic drainage Friction skin rubs against another surface patient slides down in bed or pulled up without pull sheet Shearing forces two layers of skin slide on each other in opposite directions when skin sticks to a surface and traction stretches it Advise patient to take small steps when walking to reduce shearing forces Maceration moisture- perspiration, urinary or fecal incontinence |
|
|
Extrinsic factors for decubitus
|
Pressure, friction, shearing, maceration
|
|
|
Intrinsic factors for decubitus
|
Immobility, inactivity, fecal & urinary incontinence, malnutrition, decreased LOC
|
|
|
Medical conditions for decubitus
|
Anemia, infection, PVD, edema, DM, stroke, fractures, dementia, alcoholism, cancer
|
|
|
Most important factor in management of pressure ulcers reduction
|
Pressure reduction
Schedule for repositioning patients: at least every 2 hours Avoid placement in 90o lateral position (puts pressure on greater trochanter and lateral malleolus) Avoid elevating head of bed >30o (except when eating) to decrease shearing forces Avoid leaving patient seated in chair > 2h Foam, plastic, silicone gel pads to decrease pressure on bony prominences |
|
|
prophylactic antipressure devices for decubs
|
water mattress, alternating air pressure mattress or wheel chair cushions
thought to decrease incidence not well studied static air/foam mattresses $50-400 good wheelchair cushion is $100-300 Do not use “donuts” |
|
|
prophylaxis moisture reduction for decubs
|
skin clean and dry
thin layer of moisturizing lotion massaged gently around rather than over reddened area |
|
|
Nutritional support-screen at risk patients for decubs
|
30-35 cal/kg/day
1.25-1.5 g/kg/day protein vitamin C and zinc supplements or daily multi-vitamin albumin < 3.5 g/dL total lymphocyte count <1800/μL body weight ↓ more than 15% |
|
|
Treatment for Decubitus ulcers
|
Early treatment
Inspect skin at least daily Adequate skin care; mild cleansing agents; moisturizers for dry skin Late treatment: Debridement: surgical, mechanical, enzymatic Surgical repair: musculocutaneous skin flaps Monitoring and treatment of infection |
|
|
Treatment of Stage 1 decub
|
Intensive implementation of preventive measures as usual
Polyurethane dressings (transparent) applied every 1 to 10 days (Tegaderm) semipermeable films, permeable to water vapor, oxygen and other gases and impermeable to water and bacteria Most lesions expected to heal by 2 weeks |
|
|
Treatment-Stage 2 decub
|
As Stage I plus:
wound inspected for infection polyurethane dressings Tegaderm or thin Duoderm more effective and less costly than wet-to-dry dressings W-T-D rarely indicated at this stage |
|
|
Treatment-Stage 3 decub
|
Remove necrotic material
Small eschar: Debridement by experienced PCP Topical application of enzymatic debriding agents Eschar should be scored Enzymes must not touch surrounding areas Surgical consultation for large eschar consider specialized beds: air fluidized beds low-air-loss beds used for at least 60 days before D/C large defects: surgery consult large sacral defects with urinary incontinence may require catheterization |
|
|
In dry wounds with decub use...
|
less absorptive Hydrogels or moist soaks with normal saline
Packings are changed daily |
|
|
For exudative wounds in decubs...
|
use absorptive dressings
hydrophilic foam alginates (Kaltostat ) saline impregnated gauze hydrocolloid dressings are not appropriate Packings are changed daily |
|
|
Stage 4 treatment of decub
|
surgical consultation for initial debridement
wet-to-dry dressings may help whirlpool baths may facilitate debridement clean deep ulcers require packing consider grafting procedures |
|
|
Effect of aging on GI function
|
Large functional reserve capacity
Aging has relatively little effect on GI function associated with increased prevalence of GI disorders Often drug related effects Clinically significant changes should be evaluated not written off as aging E.g.reduction in food intake |
|
|
Oral region effect of aging and nutrition
|
Taste sensation decreases with age
Drugs can affect taste Poor dentition is major contributor to impaired chewing and reduced caloric intake |
|
|
Effect of aging on the esophagus
|
Only minor effects on esophageal motor and sensory function
GE reflux is common in elderly 40% of elderly on monthly basis 7-10% on daily basis |
|
|
possible reason for reflux in older populations
|
Possibly due to reduction in intra-abdominal length of lower esophageal sphincter and increased incidence of hiatal hernia
|
|
|
Pyrosis
|
substernal burning with radiation to mouth and throat
|
|
|
Water brash
|
increased salivary secretions stimulated by acid reflux
|
|
|
GERD
|
Pyrosis: substernal burning with radiation to mouth and throat
Differentiate from angina: chest pain most often after meals or on reclining Sour regurgitation Water brash: increased salivary secretions stimulated by acid reflux Atypical symptoms: chronic cough, difficult-to-control asthma, laryngitis, recurrent chest pain |
|
|
Untreated or undertreated GERD can lead to
|
Esophagitis
Peptic strictures Barrett’s esophagus |
|
|
Tests for GERD
|
Barium swallow most frequent test
Upper endoscopy (assess mucosal injury) Earlier in elderly than younger patients With persistent symptoms despite medical therapy |
|
|
Treatment for GERD
|
Lifestyle modifications
Small meals; minimize fats, alcohol, caffeine & nicotine especially at night Do not eat 3-4 h before bed Head of bed elevated 6 in. OTC Mylanta, Maalox, Gaviscon H2 RAs (Pepcid AC, Axid AR, Zantac-75) H2 Receptor Antagonists Famotidine (Pepcid) Nizatidine (Axid) Ranitidine (Zantac) Proton Pump Inhibitors (any of the meds ending in -zole) |
|
|
Surgical treatment for GERD
|
Nissen fundoplication
|
|
|
Aging & the GI Tract: stomach
|
No significant effect on acid and pepsin secretion
Diminished capacity of gastric mucosa to resist damage may increase risk of peptic ulcer disease associated with NSAID use Elderly appear to feel fuller with food |
|
|
Aging & GI Tract: large intestine
|
No major changes in colonic or anorectal motility
Perception of anorectal distention is reduced in elderly may play role in pathogenesis of constipation Fecal incontinence occurs in up to 50% of nursing home residents Constipation with fecal impaction Laxative use Neurologic disorders Increased incidence of diverticulosis & colon cancer Mesenteric ischemia (intestinal angina) Ischemic colitis occurs almost exclusively in elderly |
|
|
Mesenteric ischemia
|
(aka intestinal angina)
presents with postprandial pain and weight loss emboli or thrombosis superior mesenteric artery high mortality rate (71%) with bowel infarction |
|
|
Ischemic colitis
|
occurs almost exclusively in elderly
increased prevalence of atherosclerosis LLQ pain and loose bloody stools diagnoses by colonoscopy |
|
|
Aging & GI Tract: pancreas
|
Structural changes: decrease in weight, lobular fibrosis
Pancreatic enzyme levels decrease minimally Type II diabetes more common in elderly decreased insulin secretion decreased responsiveness of cell to glucose |
|
|
what color does liver become with age and why
|
brown; increased lipofuscin pigment in hepatocytes
|
|
|
T or F: Aging alters LFT (liver function tests)
|
False
|
|
|
hepatic blood flow is decreased by what percentage and why?
|
35%
decrease in splanchnic blood flow |
|
|
what is decreased in aging of the gall bladder
|
bile acid synthesis; LDL cholesterol
|
|
|
what is the prevalence of gallstones in the elderly
|
often asymptomatic
30% of women, 20% of men have stones by age 70 40% of women have gallstones by age 80 |
|
|
What is charcot's triad
|
recurrent attacks of
1) RUQ pain 2) fever 3) jaundice due to Choledocholithiasis (Common bile duct stones) |
|
|
<1000 kcal/day
|
16% of elderly in community consume
|
|
|
Undernutrition affects
|
17-65% in acute care hospitals
|
|
|
Failure to thrive
|
applied to elderly to indicate deterioration in functional status disproportional to disease status
Multifactorial: loss of muscle mass, declining cognition, depression |
|
|
What are the trends for body weight seen in aging
|
Body weight in men tends to increase from age 30-60, plateau for 10-15 years, then slowly declines
Women same pattern except changes occur about 10 years later |
|
|
Other trends in the aging with body composition and nutrition
|
Fat mass increases
Muscle mass declines Daily energy requirements decline with age |
|
|
Caloric requirements decline
|
22% between 30-80 years
1/3 due to reduction of muscle mass and parenchymal tissues 2/3 attributed to reduction in physical activity |
|
|
Caloric requirements in the elderly
|
No Stress (minimal activity) 25 Kcal/Kg/day
Minimal Stress (cold) 30 Kcal/Kg/day Moderate Stress (Pneumonia) 35 Kcal/Kg/day Severe Stress (sepsis) 40 Kcal/Kg/day |
|
|
What level of Na is considered Hypernatremia?
|
PNa >150 mmol/L
(Common in elderly in nursing homes who have decreased thirst reflex or are unable to feed themselves) |
|
|
Mortality rate of elderly with Hypernatremia (esp with rapid onset or Na > 160)
|
40 %
|
|
|
S & S of Hypernatremia
|
Weakness and lethargy
Focal neurologic deficits: hemiparesis Severe obtundation, stupor, coma, seizures Because hypernatremia represents a pure water loss, typical signs of volume depletion may be absent |
|
|
Causes of Hypernatremia
|
Decreased water intake
-Mental or physical impairment -Obtundation Increased Na intake (rare) -IV administration of Na bicarbonate Increased water losses -Fever -Tachypnea -Sweating -Diarrhea -Loop diuretics |
|
|
Tx of Hypernatremia
|
Electrolyte-free water: by mouth, NG tube, or IV (D5W)
|
|
|
Urinary Incontinece affects how many people?
|
10-13 million
|
|
|
What are the 4 Types of incontinence
|
Transient
Urge incontinence/detrusor overactivity Stress incontinence Overflow incontinence |
|
|
What are some Male Health Issues specific to geriatrics
|
Hypogonadism and hormonal changes
Erectile dysfunction Benign Prostatic Hypertrophy (BPH) Prostate Carcinoma |
|
|
What are Tx for testosterone deficiency?
|
Intramuscular Injection
Transdermal Testosterone patches or gel Oral tstosterone (should be avoided) all are contraindicated in men with known or suspected prostate cancer) |
|
|
Medications that cause Erectile Dysfunction
|
B-blocker, methyldopa (antihypertensives)
Diuretics Antidepressants tranquilizers, H2 receptor blockers (cimetidine/Tagamet®) NSAIDs |
|
|
Causes of ED
|
Tobacco, alcohol or opiates
Endocrine -DM -thyroid disease -Cushings Neurologic: spinal cord injury, multiple sclerosis, CVA Systemic: renal failure; COPD; cirrhosis Psychological: depression |
|
|
Treatments of ED
|
Testosterone only if hypogonadal (low serum)
Phosphodiesterase type 5 (PDE5) inhibitors -Sildenafil (Viagra) -Vardenafil (Levitra) -Tadalafil (Cialis) Vasodilators -intracorporeal injections or urethral suppositories such as Prostaglandin E1 (Alprostadil) or papavarine Mechanical devices: vacuum pump |
|
|
S&S of Benign Prostatic Hypertrophy
|
more frequent urination (day & night)
not emptying the bladder completely weak stream inability to delay urination difficulty stopping and starting incontinence (no control) painful or bloody urination |
|
|
TX for BPH
|
Watchful waiting
Decrease fluid intake in evening Limit caffeine & alcohol Medications Transurethral Prostate Resection Laser prostatectomy Interstitial Laser Coagulation (ILC) Transurethral needle ablation TUNA Microwave Thermotherapy |
|
|
What is the 2nd leading cause of cancer death in men
|
Prostate Cancer
(after Lung Cancer) |
|
|
What test identifies Prostate Cancer
|
PSA leads to early ID
Doesn’t distinguish aggressive tumors from the indolent ones |
|
|
High risk for dehydration
|
thirst sensation with aging
intake of fluids loss of fluids Especially elderly in nursing homes, demented, polypharmacy, chronic and debilitating diseases |
|
|
recommendation for water intake
|
30 mL/kg of weight to day
|
|
|
is the lymphocyte count accurate for nutrition?
|
Due to its poor sensitivity and specificity, the total lymphocyte count is of no value as a measure of the nutritional state.
|
|
|
what are efficient lab clues for nutrition?
|
Cholesterol level < 160 mg/dL
Albumin level <3.5 g/dL |
|
|
what are the half-lives of albumin and pre-albumin
|
Albumin has half-life of 3 weeks
Pre-albumin has half-life of 2-3 days |
|
|
what are anorexia causes of weight loss?
|
Depression
Drugs Diseases Nutritional deficiencies |
|
|
what are malabsorption causes of weight loss?
|
Intestinal ischemia
Celiac disease |
|
|
what are swallowing causes of weight loss?
|
Neurological
Esophageal diseases |
|
|
Can dental diseases cause weight loss?
|
Yes
|
|
|
what are metabolic causes of weight loss?
|
Hypo and Hyperthyroidism
Diabetes mellitus Liver disease |
|
|
what are physical causes of weight loss?
|
Unable to cook or buy food
Reduced activity |
|
|
what are social problems that lead to weight loss?
|
Social isolation
Poverty Caregiver fatigue Elder neglect Elder abuse Lack of attention to food preferences |
|
|
Malnutrition Risk Factors
|
Oldest Old
Depression Social isolation Functional decline Cognitive impairment Low socioeconomic level |
|
|
Management of Malnutrition
|
Identify causes of weight loss
Treat underlying cause aggressively Elders who lose weight do not consume sufficient calories to cover their needs Nutritional objective increase the number of calories Promote socialization Supportive environment Reduce isolation Provide personal assistance |
|
|
nutritional supplement use
|
Use nutritional supplements
rich in calories high in proteins Administer between meals or before bedtime Avoid simultaneous use of supplements and meals No net caloric intake |
|
|
Anorexigenic
|
causing loss of appetite; there are a lot of drugs out there that will cause loss of appetite
|
|
|
Malnutrition in the Hospital: Enteral Nutrition
|
Preferred for long periods of time
Thin nasogastric tubes Cooperative patient Percutaneous Gastrostomies Uncooperative and confused patients Long periods of time Less irritation Do not interfere with ability to swallow |
|
|
Most common GI complaint in elderly
|
Constipation; 60% report using laxatives
|
|
|
constipation
|
decrease in stool frequency
difficult passage of feces hardness of stool feeling of incomplete evacuation |
|
|
age-related issues with defecation
|
Impaired rectal sensation
larger rectal volume needed to elicit desire to defecate Factors in fecal incontinence reduced resting anal sphincter pressure decreased maximal sphincter pressure |
|
|
Conditions that can cause or worsen constipation
|
Intestinal
Diverticular disease Irritable bowel syndrome Post-surgical Neoplasm Metabolic Dehydration Diabetes Thyroid disease Myopathic Amyloidosis Neurologic Dementia Parkinson’s disease Stroke Miscellaneous Decreased intake fiber and fluid Fever Immobility Poor access to toilet Weakness |
|
|
Medications that can cause constipation
|
Analgesics
NSAIDs Opioids Anesthetics Antacids Anticholinergics Antidepressants Antihistamines Antipsychotics Antispasmodics Anticonvulsants Antihypertenives Ca-channel blockers Clonidine Antiparkinson drugs Calcium Diuretics Iron MAO inhibitors Phenothiazines |
|
|
major complication of constipation?
|
fecal imCan result in intestinal obstruction
Overflow incontinence leakage of stool around obstructing feces Urinary retention & UTI frequently co-exist with fecal impaction Excessive straining can result in syncope, cardiac ischemia, TIA’s paction |
|
|
diagnosis of constipation
|
Laboratory
exclude underlying metabolic conditions most commonly hypothyroidism Colonoscopy or barium enema for recent change in bowel habit rule out structural lesion malignancy, stricture |
|
|
treatment of constipation
|
Laxatives
For most chronic constipation osmotic laxatives effective present lowest risk lactulose & sorbitol 7.5 to 30 mL/day Magnesium containing products only for short-term use avoid with renal disease Miralax-Polyethylene Glycol 3350 Safe for occasional use Gentle, typically produces stool in 1-3 days Stimulants short term use senna, cascara, bisacodyl (Dulcolax) Stool softeners docusate sodium/Colace® little relief for constipation/impact Enemas may help with fecal impaction plain tap water (HHH) sodium phosphate and biphosphate |
|
|
major 3A4 inhibitor
|
grapefruit juice
|
|
|
BMI formulas
|
BMI=weight in kg divided by the square of the height in meters
BMI=weight in lb times 704 with that product divided by the height in inches |
|
|
What are the common S &S of Prostate Carcinoma
|
Most early disease is asymptomatic
Locally advanced disease causes obstructive or irritative voiding symptoms Most frequently spreads to bone, leading to bone pain. Spinal cord impingement from epidural spread can result in loss of bowel and bladder function. Metastases to lymph nodes can cause lymphedema and/or renal failure due to obstruction |
|
|
What is the upper limit for a PSA test
|
4 ng/mL
|
|
|
What are the screening recommendations for Prostate Carcinoma
|
PSA testing and rectal exam
-age 40 for African American men or family history of prostate cancer -age 50 for all other men |
|
|
What are the signs of major depression
|
Depressed mood/loss of interest > 2 weeks accompanied by 3-4 symptoms/signs
-Insomnia or hypersomnia -Feelings of worthlessness or guild -Fatigue or loss of energy -Diminished ability to think or concentrate -Change in appetite or weight -Psychomotor agitation or retardation -Recurrent thoughts of death or suicide |
|
|
What are the Risk Factors for Suicide
|
Age >55 years
Male gender Painful or disabling physical illness Solitary living Debt, reduced income, poverty Bereavement History of drug or alcohol abuse |
|
|
Differentiate between Bipolar I and Bipolar II Disorder
|
Bipolar I Disorder
Manic episodes with or without depression Bipolar II Disorder Episodes of major depression. Between episodes, maybe elated. |
|
|
Treatment of Depression includes
|
Patient & family education/supportive care
Psychotherapy + drugs Pharmacotherapy -Start at half of manufacturer-recommended dose -Full effects may not be seen for 8-12 weeks |
|
|
What are the 5 Parts of cognition
|
Attention
Orientation Memory Language Function Praxis – the ability to perform learned tasks |
|
|
What is Delirium
|
Acute change in baseline mental status
|
|
|
What are the causes of Delirium
|
Develops over hours to days
Course fluctuates -inattention -perceptual hallucinations, delusion Organic cause -illness -drug related -metabolic |
|
|
What are the 4 levels of psychomotor activity
|
Hyperactive
Hypoactive Mixed Normal |
|
|
Risk Factors for Delirium
|
DELIRIUM
Drug use Electrolyte Lack of drugs (withdrawal) Infection (UTI, pneumonia, meningitis) Reduced sensory input (blindness, deafness, darkness) Intracranial problems (stroke, bleeding) Urinary retention and fecal impaction Myocardial (infarction, arrhythmia, heart failure) |
|
|
What are the Clinical Findings in Delirium
|
Cognitive Changes
Inattention Disorganized Thinking Altered level of Consciousness |
|
|
values for BMI
|
Below 18.5 per meter squared is underweight
18.5-24.9 is normal 25.0-29.9 is overweight 30.0 or more is obesity |
|
|
DM Type I
|
autoimmune disease with absolute decrease in insulin production; early onset, insulin-dependent
|
|
|
Diabetes in the Elderly is associated with
|
declining pancreatic cell function, relative insulinopenia, and insulin resistance
|
|
|
DM Type II
|
relative insulin deficiency secondary to insulin resistance (decreased insulin effectiveness in stimulating glucose uptake by skeletal muscle and restraining hepatic glucose production)
Most common form of DM in elderly |
|
|
signs and symptoms of DM
|
(polyuria, polydipsia, unexplained weight loss) plus casual glucose level ≥ 200 mg/dL
|
|
|
criteria for diabetes diagnosis
|
Fasting plasma glucose ≥ 126 mg/dL
2-hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test (OGTT) with glucose load equivalent of 75 grams of anhydrous glucose Fasting = no caloric intake for at least 8 h OGTT not routinely needed but may help dx Type II DM in patients whose FBS is 110-126 mg/dL |
|
|
Glycosylated hemoglobin
|
HbA1c: used primarily to identify the average plasma glucose concentration over prolonged periods of time. It is formed in a non-enzymatic pathway by hemoglobin's normal exposure to high plasma levels of glucose. Glycosylation of hemoglobin has been implicated in nephropathy and retinopathy in diabetes mellitus
|
|
|
HbA1c should be determined every 1-3 months
|
to determine blood glucose control
Poorly controlled: level 9-12% Goal: level ≤ 7% associated with significant risk reduction for neuropathy, retinopathy, renal disease and CVD |
|
|
micro vascular and macrovascular complications of diabetes
|
Microvascular
Retinopathy Nephropathy: albuminuria may develop after about years of DM Peripheral & autonomic neuropathy Macrovascular CVA/stroke Coronary artery disease Peripheral vascular disease |
|
|
sulfonylureas
|
stimulate insulin secretion, and also improve peripheral and hepatic insulin sensitivity
First-generation Tolbutamide (Orinase) Chlorpropamide (Diabinese) Tolazamide (Tolinase) Acetohexamide (Dymelor) Second-generation Glyburide (Micronase) Glipizide (Glucotrol) Glimepiride (Amaryl) |
|
|
What are some causes of Dementia
|
DEMENTIA
Drugs Emotional disorders Metabolic or endocrine disorders Eye and ear dysfunctions Nutritional deficiencies Tumor and trauma Infection Arteriosclerosis: MI, CHF; Alcohol |
|
|
What is the major difference bt Delirium and Dementia
|
Delerium can be reversible
Dementia is permanent damage |
|
|
What is Benign Senescent Forgetfulness
|
age-related memory loss
new information learned more slowly intellectual performance unchanged from baseline -patient just needs more time ADLs unaffected |
|
|
What are the signs of Alzheimer's Disease
|
Classic Triad
-Memory impairment (esp. new info) -Visuospatial problems -Language impairment |
|
|
What is Lewy Body Dementia
|
Rounded eosinophilic intracytoplasmic neuronal inclusion bodies
May be 2nd most common cause of dementia in some settings Visual hallucinations common (30-60%) |
|
|
What is Frontotemporal Dementia
|
Early on changes in personality & behavior
Selective atrophy of the frontal and temporal lobes Pick’s Disease variant |
|
|
What is Normal Pressure Hydrocephalus
|
Defect in CSF resorption in the arachnoid granulations
Treated by ventriculoperitoneal shunt |
|
|
What are the classic S & S of Normal Pressure Hydrocephalus
|
Classic triad:
- Gait disturbance - Urinary incontinence - Dementia |
|
|
What are S & S of chronic Subdural Hematoma
|
Chronic subdural hematomas rarely cause dementia
-may produce behavioral disturbances -Often no clear history of head trauma or bleeding diathesis Symptoms occur >2 weeks after insult |
|
|
What are some classic changes in the aging Nervous System
|
Decreased number of neurons
Ventricles enlarged Decreased cerebral blood flow Decrease in amount of some neurotransmitters Lengthening and production of dendrites |
|
|
biguanides
|
Metformin (Glucophage): decreases hepatic glucose production, increases muscle insulin sensitivity
Used with caution because elderly are at risk for other conditions that predispose to lactic acidosis (pneumonia, heart failure) |
|
|
Meglitinides
|
increase pancreatic response to meal-related glucose loads
Repaglinide (Prandin) Nateglinide (Starlix) |
|
|
Thiazolidinediones
|
act as insulin sensitizers. Bind to specific nuclear receptors that enhance transcription of genes involved in glucose metabolism
Rosiglitazone (Avandia) Pioglitazone (Actos) |
|
|
Α-Glucosidase inhibitors
|
interfere with brush-border gut enzymes that digest disaccharides/polysaccharides to monosaccharides with decrease in postprandial glucose; flatulence & diarrhea main side effects
Acarbose (Precose) Miglitol (Glycet) |
|
|
hypothyroidism is most often due to
|
autoimmune thyroiditis
|
|
|
Diagnosis: typical symptoms of hypothyroidism
|
Dry skin
Weakness & fatigue Paresthesias Depression Constipation Cold intolerance PE: prolonged relaxation time DTRs may not be detectable in elderly because of decreased or absent reflexes |
|
|
why is hypothyroidism called a masquerader?
|
elderly have fewer symptoms than younger patients
hyperthyroidism is a bigger masquerader |
|
|
hypothyroidism is more prevalent in males or females?
|
females; Prevalence rises with age
|
|
|
Laboratory diagnosis of hypothyroidism
|
Elevated serum TSH
Low serum T4, free T4, T3, free T3 Radioactive iodine uptake usually low Hyponatremia |
|
|
Hypothyroidism: therapy
|
“Start low and go slow”
L-thyroxine (Synthroid) Elderly may have underlying CVD Start with 25 μg/day (0.025 mg) with gradually increasing increments every 4-6 weeks Patients generally will require replacement therapy for life |
|
|
Classic triad in elderly with hyperthyroidism
|
tachycardia, weight loss, and fatigue
|
|
|
Most common cause of goiter
|
most common cause is toxic multinodular goiter and uninodular toxic goiter
Graves disease is not the most common but still prevalent |
|
|
common symptoms and PE findings of hyperthyroidism
|
Decreased appetite common
Thyroid gland normal in size in 40% Sweating less common Symptoms of heart failure & angina may dominate clinical picture Lab evaluation: suppressed TSH; increased T4, free T4, T3, free T3 |
|
|
osteoporosis definition
|
low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and increased risk of fracture
|
|
|
Primary osteoporosis
|
results from hormonal changes that occur with age (sex hormones estrogen & testosterone)
|
|
|
Secondary osteoporosis
|
more common in premenopausal women and men
Hyperparathyroidism Hyperthyroidism Malignancy Immobilization GI disease & Vitamin D deficiency |
|
|
Signs and symptoms of osteoporosis
|
Silent disease because until a fracture occurs, symptoms are silent
Loss of height→vertebral compression fracture Dorsal kyphosis (Dowager’s hump) may result from multiple compression fractures Chronic back pain can occur, but more likely to be due to joint or disk disease Associated with hip fractures; also wrist (distal radius), pelvis, proximal humerus, shaft-distal femur |
|
|
vertebral fracture facts
|
Only ~25% of vertebral fracture are clinically apparent
~1 % of back pain episodes are caused by vertebral fracture May be asymptomatic or unrecognized |
|
|
Female osteoporosis demographics
|
32 million women older than 50 have either osteoporosis or low bone mass
Fracture is considered to be osteoporotic (fragility fracture) if it is due to relatively low trauma Positive family history increases fracture risk More common in white and Asian than among blacks, reasons unclear |
|
|
Hip fracture risk facts
|
-a 50-year old white woman has an 18% lifetime risk of suffering a hip fracture
-a prior hip fracture increases their chance of having another one |
|
|
What are some risks of NSAIDS
|
GI bleeding
Renal impairment Sodium retention Platelet dysfunction |
|
|
What is the Leading cause of Disability in the US
|
Cerebrovascular Disease
|
|
|
What is the S & S of Cerebrovascular Disease
|
Stroke presents as a neurologic deficit or headache of abrupt onset
|
|
|
What are the Types of Stroke
|
Ischemic
Hemmorhagic |
|
|
What is the difference between a Stroke and a Transient Ischemic Attack
|
Stroke lasts more than 24 hours
Most don't recover |
|
|
What are common S & S of Stroke
|
Sudden weakness or numbness
Sudden decrease in vision Dizzyness Dudden Severe headache Aphasia |
|
|
What is the common Tx for stroke
|
Non contrast CT
TPA if no hemorrhage Give ASA if atherosclerotic Give heparin if an embolus |
|
|
What are ways to prevent Stroke
|
Stop smoking
Treat HTN, Diabetes, Hyperlipidemia treat bleeding lesions surgically |
|
|
Risk Factors for Ischemic Stroke
|
Diabetes
Hypertension Smoking Family hx premature vascular disease Hyperlipidemia Atrial fibrillation (emboli) History of TIA CHF with LV ejection fraction <25% Drugs (ex. oral contraceptives) |
|
|
Name 3 Types of Tremor
|
Essential
Cerebellar Neuropathic |
|
|
vertebral fracture: key facts about risk
|
2 of every five 50-year old women will sustain an osteoporotic fx. during their remaining lifetime
a 50 year old whit woman has a 32% risk of sustaining a vertebral fx A prior vertebral fx (VFx) is associated with a 5-fold increased risk of future VFx and nearly a 2-fold increased risk of future hip fx. |
|
|
Osteoporosis in men
|
Growing awareness: 33% of all hip fractures occur in men
Risk factors: low femoral neck bone density, quadriceps weakness, low body weight, cigarette smoking Age-related decline in testosterone levels |
|
|
bone density measurements
|
Bone density measurement will be compared to the average peak bone density of young adults of the same sex and race.
Osteoporosis is defined as having a bone density of more than 25% below this average Bone density between 10 to 25% below average levels is termed osteopenia and reflects a milder degree of bone loss than osteoporosis. 60-80% of bone strength is related to BMD |
|
|
BMD measurements
|
bone mineral density
BMD values are expressed as absolute values in g/cm2 or as standard deviations related to the young adult (T score) or age-matched mean values (Z score). BMD recommended for all white women >65 and for postmenopausal women <65 with risk factors Family history Low trauma fracture age >45 Current smoking T-scale often used to characterize bone mineral density measurement (BMD) |
|
|
WHO categories of osteoporosis
|
Normal: BMD not > 1 SD below young adult
Osteopenia: BMD 1-2.5 below young adult (life style modification, HRT for women 50-60, Calcium and Vitamin D) Osteoporosis: BMD > 2.5 SD below young adult mean (life style advice, Calcium and Vitamin D) T< -2.5 Severe Osteoporosis: BMD > 2.5 SD below young adult mean plus 1 or more fragility fracture (life style advice, pain control, Calcium and Vitamin D, pharmacologic treatment) Each SD change in BMD increases fracture risk by 2-2.5 times |
|
|
Describe Essential Tremor
|
Positive family history
4-12 Hz (high frequency, low amplitude) Beneficial response to alcohol |
|
|
Describe Cerebellar Tremor
|
A form of ataxia rather than a true regular tremor or oscillation
-3-5 Hz Irregular tremor present during finger-to-nose maneuver -Often exhibited as forward and backward movement -overshoot/undershoot |
|
|
What are the Features of Parkinsons Disease
|
Tremor
Rigidity Bradykinesia Anteroflexed posture Postural instability Freezing/festinating gait Poor balance, falls |
|
|
What are the Tx for Parkinsons Disease
|
l-DOPA or related drugs
Carbidopa-levodopa Amantadine, bromocriptine, pergolide, ropinirole, tolcapone and other Transplant fetal nigral cells in corpus striatum Stereostactic pallidotomy, thalamotomy Implanted thalamic stimulator |
|
|
What are some complications of Levadopa treatment of PD
|
Levodopa
-After 5-10 years many patients experience motor complications -response to L-dopa doses becomes progressively shorter |
|
|
Bone densitometry
|
Only method for diagnosing or confirming osteoporosis in absence of fracture
Dual energy x-ray absorptiometry (DEXA) most common because it gives precise measurements with minimal radiation Routine DEXA should include scans of hip and spine, that give more reproducible results |
|
|
DEXA
|
A computerized image is generated, which the operator uses to identify regions of interest and analyze the scan. Amount of radiation is low, less than one-tenth of a standard chest x-ray
DXA instruments use narrow, tightly collimated X-ray beams. The X-rays are generated below the supine patient, travel upward through the patient, and are detected above by banks of electronic detectors. |
|
|
Osteoporosis treatment
|
Calcium Remains the Foundation of Osteoporosis Treatment
Recommended Ca intake ≥ 1200 mg/day Recommended Vitamin D ≥ 400 IU/day Vitamin D intoxication can occur with intake > 50,000 Units/week Hormone replacement therapy for women (HRT): beneficial effect documented for conjugated estrogens. Timing and duration topic of much debate. Women who have not undergone hysterectomy should have progestins added to estrogen regimen to prevent endometrial hyperplasia. HT increases risk of venous thromboembolism & cholelithiasis Low dose can reduce amount of dysfunctional uterine bleeding Concerns about CV risk (stroke, MI) will limit use to older women |
|
|
what vitamin deficiency is extremely common in older adults
|
Vit D
Due to: -Low dietary intake -Low sun exposure -Less effective skin production |
|
|
bisphophonates for osteoporosis
|
Bind to hydroxyapatite crystals on bone surfaces and are potent inhibitors of bone resorption
Bisphosphonates significantly reduce vertebral fracture rates after only 1 years of treatment Alendronate (Fosamax): GI side effects (heartburn, pain while swallowing); important that patients take medication in AM with full glass of water and remain upright for at least 30 min after the dose Risedronate (Actonel): it is not known if GI side effects are different from alendronate Ibandronate (Boniva) new nitrogen-containing bisphosphonate approved by FDA 2003 |
|
|
Parathyroid Hormone
|
Teriparatide (Forteo)
Recombinant 1-34 Parathyroid Hormone Teriparatide stimulates bone growth and slows the rate of bone loss SQ injection into thigh or abdominal wall Supplied as a pen with 28-day prefilled cartridge of 20 mcg dosage |
|
|
Other osteoporosis agents
|
Salmon calcitonin nasal spray (Miacalcin) can reduce the risk of new vertebral fractures
200 IU daily administered into alternating nostrils Selective estrogen receptor modulators (SERM) bind to and activate estrogen receptors: raloxifene (Evista) |
|
|
Name two Male genital disorders that comes with aging
|
BPH
Prostate Cancer |
|
|
What changes occur to the kidney with aging?
|
Renal and function declines
Renal blood flow per unit mass declines Decreased creatinine clearance; hence caution Creatinine clearance reflects GFR Renal mass decreases Glomerular hyalinization and scelerosis Less ability to concentrate urine and to dilute urine and to excrete acid Less renin and so less aldosterone |
|
|
What is the creatinine level range in a normal adult?
|
.8-1.2 mg/dL
|
|
|
What is the Creatinine Clearance GFR equation?
|
= [(140-Age) x (weight in kg)] / [serum creatinine x 72]
for females- multiply result by .85 |
|
|
How much do aldosterone levels decrease by in elderly?
|
30-50%
|
|
|
What drugs should be given to elderly with caution to avoid hyperkalemia?
|
spironolactone, triamterene, NSAIDs, B-blockers, ACE inhibitors
|
|
|
The most common renal disorders in elderly are?
|
Acute or chronic renal failure
Nephrotic syndrome Renal artery stenosis |
|
|
The most common electrolyte disorder
|
Hyponatremia
(common in sick institutionalized or hospitalized elderly) |
|
|
Renal Atherosclerosis S & S
|
Sudden onset of new hypertension
Worsening of previous well-controlled hypertension Refractory hypertension Other signs of peripheral vascular disease (bruits, decreased peripheral pulses) |
|
|
What test are best in Dx of Renal Vascular Disease
|
Doppler ultrasonography to estimate RBF
Angiogram is definitive test but most risky MRI angiography also used |
|
|
Signs of UV exposure
|
-Fine & coarse wrinkling
-Irregular mottled pigmentation -Lentigines -Telangiectases |
|
|
Lentigines
|
also known as sun spots, age spots or liver spots, are harmless, flat, brown discolorations of the skin which usually occur on the back of the hands, neck and face of people older than 40 years of age
|
