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213 Cards in this Set

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Purpose of Long Term Acute Care hospital…
Provides care for patients whose problems are too complex and acute for SNF (trach, TPN, tube feeds, complex wound care, PT/OT/ST, inhalation Rx, frequent IV tx)
Goal fo LTACH…
It is hospital where patients seen daily by physician. Stay there a few weeks with goal of transfer to SNF as needs decrease
Home hospice requirements and what services are covered by medicare…
<6 months, medicare covers meds, equipment, home visits, emotional/spiritual counseling, 24-hr crisis management, bereavement support for at least 1 year after patients death
Who bears most of responsibility for patient care in hospice… what percent of hospice patients have terminal cancer…
Families bear most responsibilty of care and nurses or CNAs give most of care rather then physician. Less then half have terminal cancer
Difference between hospice at SNF and home hospice…
Medicare will not pay for both hospice and SNF room and board
Inpatient hospice…
Comfort for patients who are expected to live approximately 7-8 days or less
Delirium can be diagnosed with up to… sensititivity and specificity using…
95% using Confusion Assessment Method
Confusion Assessment Method requires the presence of…
A and B and either C or D. A: acute fluctuating MS. B: Inattention. C: altered LOC. D: disorganized thinking
Incidence of delirium in hospitalized elderly patients…
>20%
Mortality of delirium in hospitalized elderly patients…
>20%, similar to MI or sepsis
Cost of delirium in medicare expenitures (annually)…
6.9 billion
Prevention and treatment of delirium requires… why…
Requires that all factors (predisposing and precipitating) be addressed because it is multifactorial
Most common causes of delirium..
Meds, infxn, metabolic problems
What percentage of cases of delirium can be prevented…
40%
Situations of delirium requiring specific treatment…
EtOH withdrawal, primary psych disorder, primary intracranial process and drug OD
When should D/C planning with delirium patient begin and when should it be a topic of discussion with patient…
Should begin immediately and be daily topic.
Predisposing factors for delirium (large list)…
Incr age (>65yo), h/o dementia or delirium, depression, immobility, falls, poor functional capacity, Sensory impairment (visual and hearing), malnutrition/dehydration, treatment with psychoactive drugs, tx with many drugs, alcohol abuse, severe coexisting med condition
Precipitating factors for delirium…
Meds, infxn, metabolic problems, primary neuro disease, surgery/anesthesia, uncomfortable or different environment, sleep deprivation, urinary retention or constipation
Management of meds in acute delirium…
Detailed review with d/c or decrease in possible offenders as well as tox screen and or drug levels
Possible offender drugs in delirium…
Anticholinergics, benzos, opiates, antihistamines, entiemetics, sleep meds, steroids, anticonvulsatns, clonidine, antiparkinsons, antipsychotics, muscle relaxants, lithium, polypharm, withdrawal
Workup for infxious cause of delirium..
CBC with diff, UA, CXR… further w/u: blood cultures, LP, Cdiff
Workup for metabo causes of delirium… metabolic causes of delirium…
w/u: CMP. Causes: hypovolemia (#1) or underperfusion, electrolyte and acid-base disturbances, hypoxia or hypercapnia, hypoglycemia, anemia, uremia, hepatic encephalopathy, thiamine or B12 def, thyroid/adrenal imbalance, HTN encephalopathy, acute cardiac problem
W/u for primary neuro cause of delirium…
Neuroimaging if new, inability to perform neuro exam or obtain hx, severly depressed LOC, h/o trauma, fever w/o other source of infxn, no identifiable cause EEG if seizure or nonconvulsive stat epipilepticus suspected
w/u for uncomfortable or different environment cause of delirium…
Tx pain aggressively, avoid restraints (Foley, IV, O2, continuous pulse ox), encourage hearing aids, eyeglasses, family, encourage mobility (ambulatioin, PT/OT), reorient patient regulary
w/u for sleep deprivation cause of delirium…
Encourage light and stimulating environment during day but dark and quite at night. Consider trazodone or quetiapine
Pharmacological tx of delirium and who for…
Only for patients with significant behavioral or emotional problems. Haloperidol 0.5mg-2mg PO/IV bid with extra doses prn, start low in elderly. QT prolongation concern. Atypical antipsychs equally effective, Lorazepam 0.5-1mg PO/IV q 4hrs prn as last resort, implicated as cause of delirium, start with .5mg in elderly. Other tx: sitter (family best) or if absoluelty necessary then restraints
In what percentage of time due adverse events (injury due to tx rather then underlying disease) occur within 3 wks of d/c… what percent of these are preventable or ameliorable… most are related to…
20% of cases and ¾ are preventable or ameliorable. Most are medication related
Medication mistakes in what percentage of discharges… associated with…
70% of discharges, associated with readmission
What percent of outpt workups are not completed… what makes this worse…
36%, occurs especially when f/u delayed or written documentation of recommendation not available to outpt MD
RFs for poor post-discharge outcome…
>80yo, inadequate support system, multiple active or chronic health problems; h/o depression; mod-severe functional impairment; multiple hospitalizations in prior 6mo,; hospitalization in past 30d; fair or poor health self-rating; h/o nonadherence to therapy
When should discharge planning be started… what should be included…
On day of admission including timing and location of discharge. Start paperwork that day so case managers can make a plan
When talk to case managers about plan of discharge and who should be updated…
Talk to them on admission and update family and patient daily about discharge plan
Ways that obstacles to d/c can be anticipated and proactively addressed…
PT/OT/ST, O2, Foley, PICC, f/u appt, transport home, med/wound VAC, prior authorization, 1:1 sitter, etc
When should d/c paperwork be completed and what should be written on it…
Evening prior and write “anticipate d/c tomorrow.” If you write anything other then this you are bad
When should final d/c orders be signed…
As early in the day as possible
When should d/c summary be completed… what parts are key..
On day of discharge. Med list and hospital course are key
7 components of every discharge…
Patient education, Safe post-discharge environment, All necessary treatments or tests can be received, appropriate f/u plan, careful med rec, direct communication between inpt and outpt providers, patient must know who they can call if questions or problems arise
Patient education on discharge should include…
What to expect, med side effects, potential complications, who to call, etc
Safe post discharge environment includes…
Based on patient’s cognition, functional capacity, and medical stability (vitals)
ADLs…
Bathing, Dressing, Toileting, Transferring, Continence, Feeding
Instrumental ADLs…
Using tele, Driving, Grocery shopping, Preparing meals, Housekeeping/laundry, Administering own meds, Handling own finances
Direct communication between inpt and outpt MDs includes…
Dispo location, diagnoses, test results, discharge meds and reasons for changes, details of f/u arrangements, results pending discharge, specific f/u needs, etc
Discharge options include…
Home health, Assisted living, SNF, Acute rehab, Long-term Acute Care Hospital, Home Hospice, Hospice at SNF, Inpt Hospice
Home health goal is to… what does it include…
Allow patient to stay at home. May include: PT/OT/ST, IV antibios, wound care, home safety eval, diabetes teaching and or med management
Advantages to assisted living… disadvantaes…
Ability to receive assistance (meals, housekeeping, meds) in home-like environment. Disadvantages: expensive and not covered by medicare.
Average length of stay in assisted living center… most common reason for d/c…
2 years. d/c to nursing home care is most common reason
SNFs do what…
Provides services (therapy, wound care, PO and IV meds) for patients who generally need help with ADLs…
Goal of SNFs… physician availability… when does medicare cover…
Goal: bridge patients between home and hospital. Physicians available 24hrs a day on emergency bases but only required to see patients within 72 hrs of admission and then monthly after that. After 3-mednight hospital stay, medicare covers 100% of first 20 days then lower percentage after that
Characteristics of patients going to acute rehab facilities…
Unable to go home but able to do 3 hrs of total therapy per day. Pts are seen daily by physician. A percentage of patients must have certain diagnosis such as spinal cord injury and stroke
Purpose of Long Term Acute Care hospital…
Provides care for patients whose problems are too complex and acute for SNF (trach, TPN, tube feeds, complex wound care, PT/OT/ST, inhalation Rx, frequent IV tx)
Goal fo LTACH…
It is hospital where patients seen daily by physician. Stay there a few weeks with goal of transfer to SNF as needs decrease
Home hospice requirements and what services are covered by medicare…
<6 months, medicare covers meds, equipment, home visits, emotional/spiritual counseling, 24-hr crisis management, bereavement support for at least 1 year after patients death
Who bears most of responsibility for patient care in hospice… what percent of hospice patients have terminal cancer…
Families bear most responsibilty of care and nurses or CNAs give most of care rather then physician. Less then half have terminal cancer
Difference between hospice at SNF and home hospice…
Medicare will not pay for both hospice and SNF room and board
Inpatient hospice…
Comfort for patients who are expected to live approximately 7-8 days or less
____% of patients over 80 fall every year?
50
How does the rate of falls in nursing homes and hospitals compare to the rate for community-dwelling persons?
3 times the rate greater in nursing homes.
What is the rank of unintentional injuries as a cause of death in older adults?
5th
What is responsible in 2/3 of the of the cases of death caused by unintentional injuries?
falls
What % of falls result in a serious injury?
10%
How does fall-related mortality for adults aged >65 compare to younger age groups?
10 to 150 times greater.
what % of fall deaths in the US occur in the 65+ population?
72%
Are most falls multifactorial or unifactorial?
Multi, involving an interaction between long-term factors and short-term precipitating events.
What are four intrinsic factors contributing to falls?
Lower extremity weakness, balance disorders, functional and cognitive impairment, and visual defects.
What are four extrinsic factors contributing to falls?
Polypharmacy, lack of bathroom safety equipment, loose carpets, and poor lighting.
What is the definition of polypharmacy?
Greater than OR equal to 4 medications.
11 risk factors for falls in order from greatest to least?
Muscle weakness (4.4), History of falls (3.0), Gait deficit (2.9), Balance deficit (2.6), Use of assistive device (2.6), Visual deficit (2.5), arthritis (2.4), Impaired ADL (2.3), Depression (2.2), Cognitive impairment (1.8), Age > 80 (1.7).
What is the annual fall risk for 0-1 of the 11 risk factors?
10-27%.
What is the annual fall risk for greater than or equal to 4 risk factors?
69-78%
What are four types of high-risk medications (and 3 types of the first type)?
Psychotropic medications (Benzos, sedative-hypnotics, antipsychotics/antidepressants) (1.7), Class 1a antiarrythmic medications (1.6), Digoxin (1.2), Diuretics (1.1).
What should we ask about in our hospitalized elderly patients, even if they have not presented with a fall complication?
Falls
Who should undergo a fall evaluation?
presented to a medical facility because of a fall or complication. Have a history of recurrent falls. Have a history of a single fall and who demonstrate persistent gait/balance problems on examination or with PT. Have a fear of falling.
Do restraints prevent falls? What do they do?
No. In fact, they likely contribute to falls, injuries, and death from strangulation.
8 assessments/risk factors for falls in elderly?
Circumstances of previous falls. Medication use (high-risk medications or >/= 4 meds). Vision (acuity <20/60, decreased depth perception, decreased contrast sensitivity, cataracts). Postural blood pressure. ballance and gait. Targeted neurologic examination. Targeted musculoskeletal exam. Targeted cardiovascular eval. Home safety evaluation.
What is the risk factor for medication use? The Management?
High-risk medication or >/= 4 mediations. Review and reduction of medications.
What is the management for circumstances of previous falls?
Changes in environment and activity to reduce the lklelihood of recurrence.
What is the risk factor for vision? The management?
(acuity <20/60, decreased depth perception, decreased contrast sensitivity, cataracts). Ample lighting without glare, avoid multi-focal glasses when walking. Referral to an ophthalmologist.
What is the risk factor for postural blood pressure?
After >/= 5 min in supine position, immediately after standing, 2 minutes after standing. Review and reduction of medications, modify salt restriction, adequate hydration, compensatory teaching (rising slowly, HOB elevated), pressure stockings, ???pharmacologic therapy.
What is the risk factor for balance and gait?
Patient's report of observation of unsteadiness. Impairment on timed get-up and go test (TUG).
What is the management for balance and gait?
Reduction of medications that may impair balance. refer to PT for gait and balance training, assisteive devices.
What is the risk factor for neurologic examination? The management?
Impaired proprioception. Impaired cognition. Decreased muscle strenght. (Assistive devices or foot wear for increased proprioception, reduction of medications that impede cognition)
What is the risk factor for musculolskeletal exam? (The management?)
Exam of legs (joints, range of motion), exam of feet. (Referral for PT for strenght, range of motion, gait and and balance training. Use of appropriate footwear and referral to a odiatrist if needed. Referral for PT for gait, balance, and stregth training).
What is the targeted cardiovascular eval looking for? (What is the management?)
Looking for syncope. Carotid sinus massage, arrythmia w/u, referral to cardiologist.
What is the management in a home safety evaluation?
Removal of loose rugs, use of nightlights, non-slip bathmats, stair raiils, etc.
What are four health-care based strategies shown in randomized controlled trials to be effective in reducing the occurrence of falls? (and what is their rates of risk rduction)
Balance/gait training and strengthening exercises (14-27%). Reduction in home hazards after hospitalization (19%). Discontinuation of psychotropic medications (39%). Multifactorial risk assessment with targeted management (25-39%).
What is one community-based strategy shown in randomized controlled trials to be effective in reducing the occurrence of falls?
Specific balance or strenght exercise programs (29-49%)
What are treatments that patients have the right to refuse…
Mechanical ventilation, artificial nutrition/hydration, dialysis, recurrent hospitilizations and more
What is default position if patients cannot express their wishes..
Aggressive curative care
What are advance directives…
Specific instructions to direct medical care if person unable to
What percentage of patients have a written AD… do most who do have them discuss them with their physician…
25%... no
What are the two general categores of advance directives…
Instructional directives (living will, POLST, DNR) and Designation of proxy decision maker (POA, undersigned surrogates)
What are problems with living wills…
Legally valid documents but often fail to capture important patient preferences and documented preferences may not be authentic representations of patients wishes
What does a POLST do…
Specifies which treatment options (resustictation, intub, etc) the patient would want and is transferable between hospitals and home
What are indications for POLST…
Multiple medical problems, life-limiting illness, recurrent admissions and discharge to facility
What percent of patients who arrest survive discharge…
15% and half of those who do have significant decline in functional status
What are predictors of worse outcomes in people who arrest and survive…
Metastatic cancer, sepsis, renal failure, hypotension preceding arrest, >70 yo with comorbidities
What do studies show about surrogates ability to accurately state preferences of patient…
Frequently unable to do so
When are a POAs decisions not accepted…
When not acting in good faith or decisions contradict directives from the patient that are so specific and direct as to be clear and convincing
In absence of designated surrogate, Utah recognizes proxy decision makes in what order…
1. Spouse (if not legally separated). 2. Parent of patient. 3. Adult child of patient or majority of children available upon good faith efforts. 4. other relative
What are hospitals required to do with regards to advance directives…
Advise patient that they have right to AD, inquire whether patients
With regards to an AD, hospitals are required to:
advise patients that they have right to AD, inquire whether patients have AD, follow AD to extent of law,. Ad is under communications under documents tab in powerchart
When should AD be asked about…
On admission
Written directives should be clarified about what…
Whether binding, weighty but not binding, or informative
Decision making capacity is…
Decision-specific, changes with time, assessed by knowledgable clinicians
A patient with decision making capacity should be able to…
Understand and process info related to treatment options and consequences and should be able to communicate choice. Document this
How do surrogates work in decision making process in case of written directives…
Complementary help, clarify and fill in gaps not specified
Hierarchy of decision making with regard to medical treatment of incapacitated…
1. patients known wishes  2. substituted judgment based on values, beliefs, and past statements/decisions of patient  3. best interest of patient
Do Advance directives guide decisions even if not complying with all legal formalities…
Yes
How should life-sustaining treatments be presented to families or patients…
Not as menu options but framed within realistic goals specific to patient
Who should be consulted in situations where physician feels uncomfortable…
Palliative care or ethics committee
What happens to baseline functionof organ systems with age?
Progressively declines, resulting in a decreased physiologic ability to handle stress.
What has more impact on morbidity and mortality in the geriatric population, coexisting disease, or age alone?
Coexisting disease.
Five things that play a role in the physiology of perioperative cardiovascular complications?
Stiff ventricle, impaired diastolic filling, increased PVR, fibrosis/fatty myocardial infiltration, conduction problems.
Why is estimation of cardiac reserve difficult?
Most elderly patients with cardiac dysfunction will only show signs when stressed.
Six risk factors in revised cardiac risk index?
High-risk surgery (intraperitoneal, intrathoracic, aortic). Ischemic heart disease. History of heart failure. History of cerebrovascular disease. Insulin therapy for diabetes. Creatinine greater than 2.0 mg/dl.
Cardiac event rates for 1, 2, and 3 risk factors?
1=0.9%, 2=7%, 3=11%
Three prevention strategies for perioperative cardiovascular complications?
revascularization, beta blockers, statins.
When should revascularization be considered in prevention of perioperative cardiovascular complications?
Controversial. Consider only if surgery can be delayed for several months or another indication exists.
Describe use of beta blockers in prevention of perioperative cardiovascular complication?
Controversial. May increase mortality. Do not start in hospital unless treating an unstable coronary syndrome.
Whould statins be held perioperatively?
No, acute discontinuation can worsen outcomes.
What is one problem with postop use of statins?
Caution in patients at risk for delirium, as data suggests increased risk of postop delirium in statin users (OR 1.3).
Four factors in physiology of perioperative pulmonary complications?
Loss of elastic recoil. Impaired chest wall movement (decreased VC, FEV1). Loss of alveoli (decreased gas exchange). Decreased cough/ciliary function.
What lowers an elderly patient's complication rate from 42-9%, mortality from 13-1%?
Exercise capacity of 2 min. with HR of 99 BPM.
Five effects of splinting from poor pain control post--op?
Restircts lung expansion. Limits cough secretions. Increases risk for atelectasis, pneumonia, hypoxia.
Six risk factors for aspiration pneumonia?
Acute/chronic cognitive dysfunction, dysphagia, GERD, CVA/Parkinson's disease, dementia, low albumin.
Six things that can be done to prevent aspiration pneumonia?
Appropriate diet, HOB elevation, upright eating, oral hygiene (rinses), dentures, lung expansion maneuvers.
What are four factors in physiology of perioperative renal considerations?
Decreased: renal plasma flow, GFR, creatinine clearance, renal mass.
Three renal things that elderly patients are more susceptible to?
Volume overload. Prolonged sedative effects. Drug-induced acute renal failure with NSAIDs, diuretics, antibiotics.
What is the most sensitive marker of renal function in the elderly? What should you not rely in?
Calculated creatinine clearance is the most sensitive marker of renal function in the elderly (DO NOT RELY ON CREATININE ALONE).
Seven risk factors associated with poor nutritional status?
Low weight, poverty, alcohol abuse, declining physical/cognitive function, recent hospitalization or surgery, change in the number or type of medications, micturation dysfunction.
How is low preop albumin correlated with mortality?
<1% with albumin >4.6 g/dL to 29% mortality with albumin < 2.1 g/dL
how do pain medication requirements in the elderly compar to younger patients?
Pain medications requirements in the elderly are initially similar to younger patients, but decrease more rapidly 1-2 days later.
Five things to prevent delirium post-operatively?
Orientation to surroundings. Sleep protocol. Early mobility. Visual/hearing protocol. Monitor for dehydration.
Three things to emphasize in careful consideration of risks and benefits of surgery in the elderly:
Age alone is not a contraindication to surgery. patient/family education of the specific risks involved based on age and comorbidities, and the expected needs for recovery and rehabilitation in the post-operative period (rehab, SNF, home health, etc.). Consider palliative care evaluation if there are any uncertainties regarding the patient's goals of care.
11 risk factors on Arozullah respiratory failure index?
AAA repair. Thoracic surgery. Neurosurgery/upper abdominal/peripheral vascular. Neck surgery. Emergency surgery. Albumin <3.0 g/dl. BUN>30 mg/dl. Paritally or fully dependent functional status. History of COPD. Age >/= 70. Age60-69. READ THE NUMBERS ON THE CHART.
What % of community-dwelling older people suffer from imporant pain problems?
25-50%
What % of nursing home residents have substantial pain that is under treated?
45-80%
Three things that make assessment and management of pain inthe elderly more difficult?
High prevalence of dementia, sensory impairments, and disability.
Six consequences of persistent under-treated pain in the elderly?
Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, increased health-care utilization and costs.
What is paramount in assessing pain in patients who can communicate? Why?
A thorough discussion about pain because pain is highly subjective.
7 factors important in history of pain?
Onset, localization, radiation, intensity, quality, pattern, exacerbatin/releiveing factors.
Three types of pain scales?
numeric index scale (1-10), faces scale, thermometer scale.
Should pain scales or patient's own pain terminology be used when assessing pain?
Trick question. Both should be used.
What two groups often have multiple sources of pain?
The elderly and cancer pain patients.
What is essential in patients with significant cognitive impairment?
Discussion about pain with family and caregivers and a through exam.
Six behavioral or non-verbal pain indicators?
Facial expressions. Verbalizations/vocalizations. Body movements. Changes in interpersonal intneractions. Changes in activity patterns/routines. Mental status changes.
Three types of pain?
Nociceptive. Neuropathic. Psychological.
What is nociceptive pain? What does it respond well to?
Visceral or somatic stimulationo f pain receptors (e.g. tissue inflammatin, mechanical deformation, ongoing injury). Usually responds well to analgesic medications and non-pharmacologic strategies.
What is neuropathic pain?
Pathophysiologic process of inappropriate activation of central, peripheral, or even sympathetic neurons.
Five examples of neuropathic pain?
diabetic neuropath, trigeminal neuralgia, post-herpetic neuralgia, phantom limb pain, post-stroke thalamic pain.
What does neuropathic pain respond to?
Conventional analgesic therapy. Often respond to unconventional analgesics (TCA, antivconvulsants, antiarrhythimc drugs).
What psych disorders may exacerbate or be responsible for pain symptoms?
Conversion disorder, depression.
What two things should be the focus of treating pain?
identify types of pain and treat any causative pathology.
Where waht WHO ladder developed?
In cancer patients, but now also suggested for non-cancer pain.
What is mild pain on scale of 1-10?
1/3/2010
Three types of therapy fo mild pain?
Nonpharmacologic (repositioning, heating pads, ice packs). Non-systemic therapies (joint injections, topical lidocaine, capsaicin). Parmacologic therapies (NSAIDs, acetaminophen, +/- adjuvants).
What is moderate pain on scale of 1-10?
4 to 6
What medications are used for moderate pain?
Opioid combination pils, tramadol, +/- adjuvants
What limits the max dose of opiate in treatment of moderate pain?
Ceiling effect of the APAP or NSAIDs in combo pills.
What is severe pain on 10 point scale?
8 to infinity
What three types of pain meds are used in severe pain?
Immediate acting, short-acting, long acting.
Three examples of immediate acting meds for severe pain?
IV formulations of: morphine, dilaudid, fentanyl.
Three examples of shor-acting meds for sever pain?
Oral-IR (MSIR, OxyIR, dilaudid)
Four examples of long-acting meds for severe pain?
Oral-LA, SR (Oramorph SR, OxyContin, methadone), Trandermal - Fentanyl patch.
Which route should be used for opiates?
Least invasive route.
What should you start with for moderate to severe pain?
Short-acting strong opiates (morphine, hodromorphone, oxycodone).
When should long-active strong opiates be started?
Once pain is controlled on short-active preparations if using more than 3-4 prn doses/day.
Who should never be started on long-active medications (before short-acting)?
Opioid -naive patients.
What should be the up titration % for mild-moderate inadequately controlled pain? for moderate-severe pain?
25-50% dose increase for mild-moderate pain, 50-100% increase if moderate-severe pain.
Which two opioids should be avoided?
Meperidine or codeine.
Which two opioids should only be used with supervision?
Fentanyl or methadone.
Should opiate side effects be treated aggressively or passively?
Constantly monitor, TREAT AGGRESSIVELY!!!
What are three GI side effects from opioids?
Constipation (use a prophylactic bowel regimen), nausea, vomiting.
Which opiate side effects clears more slowely?
Most opiate side effects will clear in a few days, but constipation clears more slowly.
What are three CNS side effects from opioids?
Hallucinations, confusion, loss of cognition (especially onge term, high doses in dehydrated patients with renal impairment).
What makes respiratory depression from opiates more likely?
Combination with other CNS depressants. Elderly, debilitated patients and those with underlying pulmonary conditions (SOPD, MS, etc.)
What is the effect of functional impairment of excretory organs in elderly (esp. kidneys) on opiates?
Increased 1/2 life of the active drug AND metabolites.
Remember:
Consult palliative care or acute pain if uncomfortable; cancer pain often needs a multidisciplinary approach.
Three characteristics of osteoporosis?
Loss of bone mass, deterioration of bone tissue, and disruption of bone architecture.
What % of female caucasians will experience an osteoporosis-related fracture in their lifetime? Males?
50% of females, 20% of males.
What are three common fracture sights?
Vertebrae (2/3 of which are asymptomatic, proximal femur (hip), and distal forearm.
What are ten common medications that contribute to osteoporosis?
Glucocorticoids, phenytion, cyclosporine, tacrolimus, chemotherpaeutic drugs, GnRH agonists, depo-medroxyprogesterone, lithium, heparin, and aromatase inhibitors.
Eight common osteoporosis risk factors to consider?
Advanced age, female gender, low BMI, family history of fractures, heavy smoking, excessive alcohol intake, inflammatory arthritis, medications.
Five common risk factors for falling?
Previous history of falls. muscle weakness. Balance and visual deficits. Environmental factors in home. Fear of falling.
What does a dual-energy x-ray absorptiometry measure?
Bone mineral density.
Who should be screened for osteoporosis?
women > 65 yo, men>70 yo, women and men aged 50-69 with significant risk factors for osteoporosis, any adult with a fracture after the age of 50 yo.
What is required for the diagnosis of osteoporosis?
T-score of </= -2.5 (BMD at least 2.5 SD below that of a young normal adult of same sex).
What is required for the diagnosis of osteopenia (low bone mass)?
T score of -1.0 to -2.5
What are the three components of preventing and treatin osteoporosis?
Lifestyle, dietary, and medications.
What are the lifestyle changes that can help in treatment/prevention of osteoporosis?
Regular weight-bearing and muscle-strengthening exercise. Avoidance of tobacco and excessive alcohol
What are the dietary changes that can help in treatment/prevention of osteoporosis?
Calcium intake (1200-1500 mg per day). Vitamin D (800-1200 IU per day)
What is the recommended dose of Ca for treatment/prevention of osteoporosis? Vitamin D?
1200-1500 mg per day. 800-1200 IU per day.
Three reasons to give medications for osteoporosis?
1) a history of hip or vertebral fracture 2) Osteoporosis on DXA 3) Osteopenia on DXA plus a 10-yr hip fx probability >/= 3% or or 10 yr osteoporosis-related fx probability >/= 20%
Alendronate: Daily dose (cost)? Weekly? Monthly? Yearly?
10 mg ($87.80). 70 mg ($81.95). NA. NA.
Ibandronate: Daily dose (cost)? Weekly? Monthly? Yearly?
2.5 mg ($100.12). NA. 150 mg ($100.11). NA.
Risedronate: Daily dose (cost)? Weekly? Monthly? Yearly?
5 mg ($99.02). 35 mg ($92.44). 150 mg ($100.15). NA
Zoledronic acid: Daily dose (cost)? Weekly? Monthly? Yearly?
NA. NA. NA. 5 mg ($1250 /infusion).
Whatis the one year mortality for hip fracture?
20-30%
What is required for optimal outcomes after hip fracture?
Surgical intervention.
What should patients with hip fractures be evaluated for?
Medical causes (including syncope)
Four examples of decompensated medical conditions that keep patients with hip fractures from getting early surgery?
Decompensated heart failure. Acute coronary syndrome. Uncontrolled rhythm disturbance. Severe valvular disease.
What is early surgery of hip fractures associated with? (three things)
Lower mortality, shorter length of stay, and fewer complications.
What 8 key componenets are important in medical management of patients with hip fractures?
Bone health and recurrent fracture prevention. Venous thromboemblism prevention. Pain management. Delirium. UTI prevention. Strength and mobility. Pressure sore prevention. Fall prevention.
What is one of the most common causes of death after hip fracture?
Fatal PE.
Four prophylactic agents for VTE?
LMWH. Warfarin. Heparin. Fondaparinux.
What prophylactic agents should be used preoperatively if surgery will be delayed?
LMWH or heparin.
What is teh duration of prophylaxis after hip fracture surgery?
beyond 10 days and up to 35
What is inadequate pain control associated with in hip fractures? (three things)
poor recover, longer stay, delirium.
What % of hip fracture patients get delirium?
10-40%
When can indwelling catheters be removed after hip surgery?
within 24 hours
Can patients be allowed to bear weight after hip fracture surgery?
Most can.
Is physical and occupational therapy recommended after hip fracture surgery?
Yes
How can pressure sores be prevented?
Minimized with attention to mobility and good nursing care.