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CMS II Final Comprehensive Review - GERIATRICS
Winter Semester 2011
151
Medical
Graduate
03/25/2011

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Cards

Term
What are the MC ADE that occur with cholinesterase inhibitors used in the treatment of dementia? What laboratory monitoring should be done when someone is prescribed cholinesterase inhibitors?
Definition
N/V/D NO monitoring needs to be done
Term
What is the benefit of cholinesterase inhibitors in treating dementia?
Definition
They have been shown to have minimal to modest improvement in cognition, and seem to slow the progression of the disease.
Term
How can delirium caused by anticholinergic drug overdose be reversed?
Definition
reversed by physostigmine
Term
Which Meds are the MC cause of reversible delirium? (ACDDDHLLM)
Definition
amitriptyline
codeine
digoxin
diphenhydramine
diazepam
haloperidol
lithium,
levodopa
meperidine
Term
Which med should be used as a pharmacological restraint, if one is found necessary? In which types of pts should you not use this drug?
Definition
Haloperidol; AVOID in pts with Parkinsonism
Term
If a pt is in sedative or alcohol withdrawl or has a hx of neuroleptic malignant syndrome what type of pharmacological treatment should be used?
Definition
Lorazepam
Term
Which drugs have STRONG anticholinergic properties and should have limited use in elderly?
Definition
Amitriptyline, codeine, oxybutynin, paroxetine
Term
What meds can cause ED?
Definition
Anticholinergics - Antidepressants, Antipsychotics, Antihistamines Antihypertensives - Beta-blockers, Clonidine, Thiazide Diuretics OTC Meds - Cimetidine, Ranitidine
Term
What category of drugs is used to treat erectile dysfunction in older men?
Definition
Phosphodiesterase-5 inhibition -Sildenafil (Viagra) -Vardenafil -Tadalafil
Term
What meds are phophodiesterase inhibitors contraindicated with?
Definition
Nitrates
alpha-blockers
Term
What are typical adverse events that are caused by Phosphodiesterase-5 Inhibitors?
Definition
Flushing, HA, loss of vision or hearing
Term
What is the best method for cleansing the wound bed of the pressure ulcer?
Definition
Normal saline irrigation is standard for wound cleansing
Term
What are the treatments for dizziness and syncope caused by meds?
Definition
Discontinue, substitute, or reduce the dosage of offending medication
Term
What are the treatments for orthostatic hypotension?
Definition
Treatment of specific cause (eg, proper hydration); slow rising from sitting or lying down position; graduated support stockings; PT and/or OT; midodrine (med to tx orthostatic hypotension)
Term
What are the treatments for Postprandial hypotension?
Definition
Frequent small meals; avoid exertion after meals; slow rising from sitting position; avoid antihypertensive drugs at or near meal time
Term
What are the treatments for Vertebrobasilar ischemia and/or cerebellar infarcts?
Definition
Low-dose aspirin, Clopidogrel (Plavix)
Dipyridamole - Blood Clot Reduction
Term
What is the treatment for acoustic neuroma?
Definition
Surgery
Term
What is the treatment for Vasovagal syncope?
Definition
Avoidance of triggers; medical therapy is somewhat controversial (β-blockers, clonidine, paroxetine, midodrine)
Term
What is the treatment for Carotid sinus hypersensitivity?
Definition
Avoid stimulating factors (tight collars or rapid neck movements); pacemaker
Term
When should pharmacologic therapy to treat orthostatic hypotension be used?
Definition
Pharmacologic therapy (eg, fludrocortisone and midodrine) should be used only if other measures fail.
Term
What treatment has the highest cure rate for stress incontinence?
Definition
Surgery;
Term
What is the pharmacological treatment for Urge incontinence?
Definition
Anti-muscarinic Meds- OXYBUTIN
Term
What behavioral treatment can be used to treat pts with UI who are cognitively impaired?
Definition
Prompted voiding
Term
What is the treatment for overflow incontinence caused by obstruction?
Definition
Foley catheter
Term
What is the MC used treatment for stress incontinence?
Definition
Kegel exercises Biofeedback training with Kegel exercises
Med: Pseudoephedrine (contraindicated in HTN) Surgery
Term
Which meds increase a pts risk of falls?
Definition
Benzodiazepines
Anti-depressants
Anti-psychotics
Cardiac Meds
Hypoglycemic agents
Term
How often are meds required to be reviewed by a physician for a nursing home resident?
Definition
Required at minimum 1 time per month, review should be done in concert with the pharmacist in regard to SE, lab monitoring and potential interactions
Term
What occurs with the VD of gentamycin (and other aminoglycosides) in the elderly? How must you address this change?
Definition
VD decreased so the LD of gentamycin should be reduced in the elderly
Term
What occurs with the VD of Diazepam in the elderly? How must you address this change?
Definition
Higher VD, which extends the half-life Lower dosage needed
Term
What condition affects the metabolism of Warfarin?
Definition
Hepatic congestion from heart failure reduces the metabolism of Warfarin
Term
What happens to serum creatinine concentrations and creatinine clearance in the elderly?
Definition
Serum creatinine remains relatively normal as individuals age, but the creatinine clearance declines 50% as a patient ages
Term
What are the two clinically relevant consequences of altered renal clearance in the elderly?
Definition
(1) the half-lives of renally excreted drugs are prolonged (2) the serum levels of these drugs are increased
Term
How is creatinine clearance in the elderly calculated?
Definition
Cockroft-Gault equation
Term
Which drug MC causes side effects in the elderly?
Definition
Digoxin
Term
How do the effect of Benzodiazepines change with aging?
Definition
May cause more sedation and poorer psychomotor performance in older adults
Term
How do the effects of morphine change with aging?
Definition
Older pts may experience longer pain relief with morphine.
Term
What are the most common meds involved in ADEs in the geriatric population?
Definition
Cardiovascular drugs, diuretics, NSAIDs, hypoglycemics and anticoagulants
Term
Which drugs have narrow theruputic ranges and should be monitored closely when used in the elderly population?
Definition
digoxin, coumadin, dilantin, quindine, theophylline
Term
What is the list of medications that have been identified as potentially problematic in older patients called?
Definition
“Beers’ List”
Term
What are some drugs that are commonly under-prescribed?
Definition
ACE inhibitors for patients with diabetes and proteinuria
β-blockers for patients after MI or with heart failure
Term
What are the risk factors for ADE?
Definition
6 or more concurrent chronic conditions
12 or more doses of drugs/day
9 or more medications
Prior adverse drug event
Low body weight or low BMI
Age 85 or older
Estimated CrCl < 50 mL/min
Term
Which drugs induce the CYP3A4 system? What does this cause
Definition
rifampin, phenytoin, and carbamazepine May cause some meds to decrease effectiveness
Term
Which drugs inhibit the CYP3A4 system? What does this cause?
Definition
Macrolides, Azoles, grapefruit juice Can enhance the effects of med, even causing toxicity
Term
What are the MC adverse effects caused by Drug-Drug Interactions?
Definition
Confusion/delirium Cognitive Impairment Hypotension Acute Renal Failure
Term
What are some common manifestations of acute drug reactions?
Definition
restlessness, falls, depression, confusion, loss of memory, constipation, incontinence
Term
Which drugs types are MC involved in drug/drug interactions?
Definition
psychotropic and cardiac
Term
What are some helpful tips for managing polypharmacy?
Definition
-M – Minimize the number of drugs
-A- Alternatives should be considered
-S- Start low and go slow with meds
-T- Titrate therapy to the desired goal
-E- Educate the patient, their family or caregiver
-R- Review drug plan at each visit
Term
What med can cause SE including Nausea, Palpitations and Yellow vision?
Definition
Digoxin
Term
What anti-arrhythmics should be avoided when pt is already on Digoxin? Why?
Definition
Verapamil, Quinidine and Amiodarone as they may increase serum digoxin levels by 50% - 70%.
Term
Which drug reduces the pain relieving effect of codeine?
Definition
Paroxetine
Term
What effect can ibuprofen have on the kidney?
Definition
may cause renal function to deteriorate.
Term
What can Propoxyphene, a pain reliever, increase the risk of in elderly adults?
Definition
it has narcotic-related adverse events, including an increased risk of hip fracture.
Term
A 60 y/o pt presents with an acute onset unilateral HA in her temporal region. Additionally she reports that she has double vision and cramping in her jaw with chewing. On PE you note scalp tenderness. What condition do you suspect?
Definition
Giant Cell Arteritis
Term
How is temporal arteritis diagnosed definitively?
Definition
Abnormal temporal artery biopsy with multi-nucleated giant cells & lymphocytic granulomas.
Term
What is the treatment for Giant Cell Arteritis?
Definition
Usually requires high dose steroids for at least one month
Term
What psychological factors can affect an older women's sexuality?
Definition
Married to older men Outlive their spouses, spend later years alone Lack of privacy due to living situation
Term
What is the treatment for postmenopausal atrophic vaginitis?
Definition
Longer Foreplay Regular Intercourse
Water-soluble lubricants
Topical Estrogen
Term
What common disease can cause sexual dysfunction due to its neurological effects?
Definition
DM
Term
How can psychological sexual dysfunction in a women be treated?
Definition
Cognitive-behavioral therapy
Masturbation
Kegel Exercises
Term
What are the normal age-related changes in the sexual function of men?
Excitement -
Plateau -
Orgasm -
Resolution -
Refractory -
Definition
Excitement - delayed erection
Plateau - Prolonged
Orgasm - diminished duration and intensity; decreased quantity and force of seminal emission Resolution - rapid detumescence
Refractory - Prolonged period between erections
Term
How does testosterone affect sexual health in the elderly?
Definition
low testosterone levels decreases libido more than it being the cause of ED
Term
What are the risk factors for the development of ED?
Definition
DM
HTN
Hyperlipidemia
Smoking
Term
What meds are phophodiesterase inhibitors contraindicated with?
Definition
Nitrates alpha-blockers
Term
What accounts for the difference in knowledge about sexual dysfunction in older men versus older women?
Definition
Difficulty in measuring female sexual response Exclusion of older adults from research
Term
What are the signs and symptoms of vaginal atrophy in elderly women?
Definition
Vaginal pH becomes higher than 4.5
Shift toward coliform organisms
Vaginal rugae smooth out Mucosa thins
Fissures may develop
Term
What can moderate weight changes in the elderly indicate?
Definition
sign of dietary issues
Term
What can artherosclerotic changes in the elderly cause?
Definition
May cause bouncing or decreased pulses and may cause elevated systolic HTN.
Term
Is the RR affected by aging?
Definition
Should not be affected
Term
What is arcus senillis?
Definition
graying of the limbus seen in aging
Term
What murmurs are common in the elderly?
Definition
Systolic ejection murmur
Term
Which of the following is the most accurate office screening tool for physiologic hearing loss in older adults?
Definition
Handheld audioscope
Term
What are the DEFINITIVE risks for dementia? (4) What are the POSSIBLE risks for dementia?
Definition
DEFINITIVE - Age, Down syndrome, family history, APOE4 allele
POSSIBLE - Head injury, fewer yrs of schooling, late onset of depression, cardiovascular dx, HTN, DM, hyprlipidemia.
Term
What factors have been determined to be PROTECTIVE and reduced the risk of Dementia?
Definition
NSAID,
Antioxidants,
statins,
exercise,
intellectual activity
Term
How can delirium be distinguished from dementia?
Definition
Delirium has an acute onset in which cognitive function declines over hours to days. LOC of a pt with delirium is impaired as well as their attention, a patient with dementia is usually alert even if they are not responsive. Delirium also presents with altered sleep cycles.
Term
Although depression and dementia often have overlapping symptoms, what separates depressed individuals from those with dementia?
Definition
1) Depressed pts demonstrate DECREASED MOTIVATION during cognitive testing
2) Depressed individuals express cognitive complaints that exceed measured deficit.
3) Depressed individuals maintain language and motor skills
Term
What are the key features of Lewy-Body Dementia that help distinguish it from the other types?
Definition
Visual hallucinations, delusions, as well as Parkinsonism motor dysfunction
Term
What are the triad of symptoms that are key to the presentation of Normal-Pressure Hydrocephalus?
Definition
Progressive Dementia
Urinary Incontinence
Apraxic Gait
Term
What are the key feature of fronto-temporal lobe dementia that distinguish it from the others?
Definition
Preservation of memory and visual-spatial skills Excessive eating and drinking and personality changes
Term
What is the pharmacologic treatment for Alzheimer's disease and Lewy Body Dementia?
Definition
Donepezil (aricept) - for mild to moderate
Term
T/F - Dementia is common in older adults but is not an inherent part of aging
Definition
T - Dementia is not a normal finding and should be investigated
Term
Which type of dementia is MC?
Definition
Alzheimer's Disease
Term
If a patient has progressive symptoms, including "not being able to find a word", but his memory and ADLs are unaffected, what condition should you suspect?
Definition
MCI - Mild Cognitive Impairment
Term
If a pt presents with slight memory dysfunction, spontaneous parkinsonism as well as visual hallucinations, what condition should you suspect?
Definition
Lewy-Bodied Dementia
Term
What findings on a PET is supportive of Lewy-Bodied Dementia?
Definition
Occipital lobe hypometabolism on PET is a supportive feature for the diagnosis
Term
With what type of dementia should anti-psychotic meds NEVER be used?
Definition
Lewy-Body Dementia
Term
What is the basis of the diagnosis of delirium based on? (what deficits are shown) What tests are used to determine these deficits?
Definition
changes in cognitive function and attention deficit Tests: Digit-span memory, Montreal Cognitive Assessment, Confusion Assessment Method, Delirium Rating Scale - Revised 98
Term
What is the strongest risk factor for developing delirium?
Definition
Dementia
Term
What are the predisposing risk factors for delirium?
Definition
Dementia
Advanced age
Functional Impairment
Medical Comorbidity
Hx of alcohol abuse
Male Sex Sensory Impairment
Term
What are the precipitating factors for delirium?
Definition
Catheter Use
Dehydration
Environmental Change
>3 new meds
>6 total meds
Iatrogenic Event
ICU admission,
infection,
psychotropic meds,
malnutrition,
restraint use
Term
What can delirium be diagnosed with, with a high sensitivity and high specificity?
Definition
CAM - Cognitive Assessment Model
Term
What is the best treatment for delirium?
Definition
PREVENTION
Term
If a pt presents with acute delirium, what is MANDATORY to review in order to look for possible causes?
Definition
MED REVIEW, Hx, physical and focused labs
Term
Which disease causes a pt to have a greater propensity for developing delirium, due to their impaired cholinergic systems?
Definition
Alzheimer's Dz
Term
What are the MC causes of acute confusion? What tests should be done if a pt presents with acute delirium and new onset symptoms ie falls, confusion and new onset incontinence?
Definition
medical illness, metabolic disturbance, and medications
Lab tests - Basic metabolic panel, CBC, and pulse oximetry
Term
What is the MC type of UI in the elderly?
Definition
Urge Incontinence
Term
Which type of UI is described as an abrupt or compelling need to urinate, frequent urination and nocturia?
Definition
Urge Incontinence
Term
Which type of UI is described as episodic leakage with increased inter-abdominal pressure or continual leakage may occur with sitting or standing?
Definition
Stress Incontinence
Term
Which type of UI is described as small but continual leakage, weak urinary system, intermittency, hesitancy, frequency, and nocturia?
Definition
Mixed Incontinence
Term
What are some causes of nocturia?
Definition
Fluids late in the day
Pedal Edema
Heart Failure
Obstructive Sleep Apnea
Meds
Detrusor overactivity
BPV
Impaired Bladder Emptying
Term
What are some tests that can be performed to aid in the diagnosis of UI?
Definition
bladder diary, stress test, urinalysis, 24-hr urine, renal function
Term
What is an antalgic gait?
Definition
Pain-induced limp with shortened phase of gait on affected side.
Term
What is circumduction?
Definition
Outward swing of leg in semi-circle from the hip
Term
What is Equinovarus?
Definition
Excessive plantar flexion and inversion of the ankle
Term
What is Festination?
Definition
Acceleration of gait
Term
What is foot drop?
Definition
Loss of ankle dorsiflexion secondary to weakness of ankle dorsiflexors
Term
What is foot slap?
Definition
Early, frequent audible foot-floor contact with steppage gait compensation
Term
What is propulsion?
Definition
Tendency to fall forward
Term
What is Retropulsion?
Definition
Tendency to fall backward
Term
What is scissoring?
Definition
Hip adduction such that the knees cross in front of each other with each step
Term
What is steppage gait?
Definition
Exaggerated hip flexion, knee extension, and foot lifting, usually accompanied by foot drop
Term
What is trendelenburg gait?
Definition
Shift of the trunk over the affected hip, which drops because of hip abductor weakness
Term
What is turn en bloc?
Definition
Moving the whole body while turning
Term
If a pt has a proprioceptive peripheral sensory dysfunction, what type of gait will they have?
Definition
unsteady, uncoordinated
Term
If a pt has a vestibular peripheral sensory dysfunction, what type of gait will they have?
Definition
unsteady, weaving
Term
If a pt has a visual peripheral sensory dysfunction, what type of gait will they have?
Definition
tentative, uncertain
Term
What type of gait is suggestive of a proprioceptive or sensory deficit?
Definition
Wide-based steppage gait with loss of position sense
Term
If a pt presents with a gait that has leg circumduction and loss of arm swing unilaterally, what condition do you suspect?
Definition
Hemiplegia or Hemiparesis
Term
If a pt presents with a gait that has bilateral circumduction and possible scissoring, what condition do you suspect?
Definition
Paraplegia or Paraparesis
Term
If a pt presents with a gait that has small, shuffling steps, hesitation, propulsion, turning en block and absent arm swing, what condition do you suspect?
Definition
Parkinsonism
Term
If a pt presents with a gait that has a wide-based gait with increased trunk sway and irregular stepping, what condition do you suspect?
Definition
Cerebellar Ataxia
Term
What type of gait is associated with dementia?
Definition
cautious gait, fear of falling
Term
Describe the classic gait associated with NPH?
Definition
hesitation, gait ignition failure, small steps, straighter legs (not much bend)
Term
What are some critical parts of a gait screening?
Definition
Dix-Hallpike = test vestibular integrity
BP Sitting and Standing = Orthostatic Hypotension Visual Acuity MM test (ROM, strength)
Neurologic assesment
Rhomberg = postural control
CAM = Cognitive Function
Term
With the Timed-get-up-&-go test, what time is normal, what time is indicative of an increased risk of falls and what time is indicative of a high need for further evaluation?
Definition
<10 sec = Normal
>14 sec- high fall risk
>20 sec - high need for further evaluation
Term
Which bacteria cause the highest risk of worsening pressure ulcers?
Definition
Pseudomonas, P. Aeruginosa and anerobic bacteria
Term
What tools are used to asses a geriatric patient’s risk for pressure ulcers?
Definition
Norton Scale
Braden Scale
Term
What device is contraindicated in a pt who is at high risk for developing pressure ulcers?
Definition
Doughnut
Term
Which stage is an pressure ulcer that is described as Purple or maroon localized area of discolored intact skin or blood-filled blister?
Definition
Suspected deep tissue injury
Term
Which stage pressure ulcer is described as Intact skin with nonblanchable redness of a localized area that may be painful, firm, soft, and warmer or cooler than adjacent tissue?
Definition
Stage 1
Term
What stage of pressure ulcer is described as Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed?
Definition
Stage II
Term
What is the treatment for a Stage I pressure ulcer?
Definition
Dressing: Transparent Film
Term
What is the treatment for a Stage II pressure ulcer?
Definition
Dressing: Foam Island, Hydrocolloid, petroleum-based non-adherent, hydrogel, amorphous
Term
What is the treatment for a Stage III pressure ulcer?
Definition
Dressing: Foam Island, hydrocolloid, petroleum-based non-adherent, Alignate, hydrogel, amorphous, gauze packing Surgical Repair: (skin grafting, skin flaps, musculocutaneous flaps, free flaps)
Term
What is the treatment for a Stage IV pressure ulcer?
Definition
Dressing: Alignate, hydrogel, amorphous, gauze packing
Surgical Repair: (skin grafting, skin flaps, musculocutaneous flaps, free flaps)
Term
What is the treatment for a pressure ulcer classified as unstageable?
Definition
Debridement of Eschar then appropriate staging and treatment determined
Term
Which stage of pressure ulcer is described as full-thickness tissue loss with sub-q fat visible, but no bone, muscle or tendon destruction, slough may be present as well as undermining?
Definition
Stage III
Term
Which stage of pressure ulcer is described as Full-thickness tissue loss with exposed bone, tendon, or muscle with slough or eschar as well as undermining?
Definition
Stage IV
Term
Which stage of pressure ulcer is described as Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed?
Definition
Unstageable
Term
When are Hydrocolloid dressings contraindicated?
Definition
contraindicated in infected ulcers
Term
What is disequilibrium?
Definition
Sensation of being unsteady when standing or in particular walking
Term
What is the treatment for BPPV?
Definition
Epley’s maneuver is treatment of choice
Term
What is the tx for Meniere's Disease?
Definition
Salt restriction, diuretics; vestibular suppressants may be helpful during acute attacks; in severe cases, may need surgery, including endolymphatic decompression, vestibular nerve resection, and labyrinthectomy
Term
Which meds are ototoxic?
Definition
aminoglycosides, diuretics, NSAIDs
Term
What are some common causes of syncope in the geriatric population?
Definition
Aortic Stenosis
Dehydration
Hypoglycemia
Orthostatic Hypotension
Postprandial Hypotension
Vasovagal faint
Term
What is the screening questions for alcoholism?
Definition
Use screening questionnaire, eg, CAGE:
Cut down
Annoy
Guilt
Eye-opener
Term
What are the guidelines for breast CA screening?
Definition
Mammography every 1‒2 years for robust (≥5 year life expectancy)
Perform clinical breast exam (CBE) periodically
Term
What is the screening guidelines for colorectal CA?
FOBT Guidelines -
Colonoscopy -
Definition
FOBT annually or sigmoidoscopy every 5 years starting at age 50
Colonoscopy at age 50 and every 10 years to age 75
USPSTF recommends against routine screening in adults ≥ 75 years old and against ever screening adults ≥85 years old as risks outweigh benefits
Term
What is the cut-off age for PAP smears, and what are the associated guidelines?
Definition
Cut-off age 65 with 3 normal Pap smears on previous screening and not high risk of cervical cancer
Term
An 86-year-old man comes to the office for a routine visit. He is in good health and has never been screened for colon cancer. Which of the following should you recommend?

A. Colonoscopy
B. Fecal DNA test
C. Flexible sigmoidoscopy
D. Air-contrast barium enema
E. No testing
Definition
No testing
Term
A 75-year-old man comes to the office for his annual visit.
He has a family history of heart disease and wonders whether he would benefit from taking aspirin.
He exercises frequently.
His history includes borderline dyslipidemia.
On examination, his blood pressure is 130/70 mmHg.

Which of the following is true about the role of aspirin in primary prevention?
A. Enteric coating decreases the risk of aspirin-related GI bleeding.
B. The recommended dose for primary prevention is 325 mg/d.
C. Aspirin reduces the number of cardiovascular events in men.
D. Aspirin reduces the risk of ischemic stroke in men.
Definition
C. Aspirin reduces the number of cardiovascular events in men.
Term
An 85-year-old woman comes to the office for an evaluation because she recently fell.
She lives independently in a rural community.
She has no significant medical history and takes no medications.
She has not had her vision assessed in several years.
Which of the following is true regarding visual acuity in older adults?
A. Visual acuity should be screened every 1–2 years.
B. Routine eye examinations have not been shown to improve functional status.
C. Age-related macular degeneration, glaucoma, diabetic retinopathy, and cataracts usually produce early symptoms.
D. Visual loss has not been shown to impair postural stability or cause falls in older adults.
Definition
A. Visual acuity should be screened every 1–2 years.
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