GERIATRICS

WHO

SINGLE OR REPEATED ACT OR LACK OF ACTION IN REL’SHIP WHERE TRUST IS EXPECTED-CAUSE HARM OR DISTRESS TO OLDER PERSON

PHYSICAL ABUSE

NEGLECT

FINANCIAL ABUSE

PSYCHOLOGICAL ABUSE

SEXUAL ABUSE

NURSING HOME ABUSE

5 MILL/COMPARED TO 1.5 MILLION CHILD ABUSE

1 IN 5 FINANCIAL

300% INCREASED DEATH RISK

2/3 NUMBER OF ELDER ABUSE CASES WHERE FAMILY MEMBER IS THE ABUSER

PHYISCAL

THREAT

PHYSICAL/CHEMICAL RESTRAINING

FAILURE TO MEET MEDICAL SOCIAL PSYCHOLOGICAL NEEDS OF PERSON

WITHHOLDING ESSENTIAL NEEDS

FAILURE TO PROVIDE ASSISTANCE

MISSING CARETAKER

TAKES MONEY OR PROPERTY W/ THIER KNOWLEDGE UNDERSTANDING OR CONSENT

STEALING ASSETS

TAKING CONTROL OF ALL PROPERTY ASSETS AND SPENDING

COERCION AND UNDUE INFLUENCE

VULNERABILITY DRIVES FINANCIIAL ABUSE

MAY HAVE ALZHEIMERS DISEASE, DIFF VISION HEARING

VERBL ABUSE

THREATS

ISOLATION

QUESTIONS:

DO YOU FEEL PUT DOWN , RIDICULED OR MADE FUN OF BY YOUR CAREGIVER?

HAVE YOU BEEN THREATENED TO BE PUT IN A NURSING HOME?

HAVE YOU BEEN SHUT OFF FROM SEEING OR TALKING TO PEOPLE OUTSIDE THE HOME?

UNWANTED TOUCH

MASTURBTING INFRONT OF PERSON

PERSON CANNOT CONSENT OR DOESNT CONSENT

HAS ANYONE TOUCHED YOU WITHOUT YOUR CONSENT?

ANGER

MENTAL ILLNESS

GREED

STAFFING

CHARACTERISTICS

COG IMPAIRMENT, SOCIAL ISOLATION, FUNCTIONAL DEPENDENCE

HX OF FAMILY VIOLENCE ,POOR PHYSICAL HEALTH

SUSPICION:

INTERACTION- INTERRUPTS PT, INATTENTIVE

MEDICAL HISTORY -ACCIDENT PRONE, ER VISITS, UNEXPLAINED INJURY

INTERROGATION

DIRECT CONVERSATION W PATIENT EVEN IF COG IMPAIRED

INTERVIEW THE ABUSER SEPARATELY -CONFLICTING ACCOUNTS

FULL HEAD TO TOE

INCLUDE FINGER AND TOE NAILS, INTRA ORAL

SEX ABUSE-FORENSIC EXAM -WITH PT CONSENT

ASSESS INJURIES- CONSISTENT WITH REPORTED MECHANICAL INJURIES

SIGNS :

POOR EYE CONTACT

WITHDRAWN NATURE

MALNUTRITION

HYGIENE ISSUES

CUTS

BRUISES

INAPPROPRIATE CLOTHING

MED COMPLIANCE ISSUES

USPSTF NO RECOMMENDED SCREENING

THERE ARE ICD 10 CODES FOR THESE T76 NUMBERS

OR EMOTIONAL 995.82

CBC CMP

CK -

PRESENCE OF ANEMIA, DEHYDRATION, MALNUTRITION, RHABDOMYOLYSIS

UA-OPIOIDS , NEGLECTIN MED ADMIN, ALCOHOL ABUSE

PHARM

TREAT PRESENTING SX:

STI

BURNS

INJURIES

ULCERS

APS

OR SPECIALIZED ELDER CARE SERVICES

N/HOME

OMBUDSMANNJ LONG TERM CARE

IF COG IMPAIRED INVOLVEFAMILY FRIENDS HCPROVIDERS RELIGIOUS AND COMMUNITY SERVICES

HOME

DURABLE POA? TRUSTED

PROFESSIONAL HELP -MED PSYCH SUBSTANCE ABUSE

IMMEDIATE RISK CALL POLICE!!

SUSPICION :APS

APS

1 IN 44 CASES GET REPORTED

PERSON RELUCTANT TO REPORT-SHAME OR FEAR

MAINLY FAMILY MEMBERS

SENIOR SAFE ACT 2018:

FINANCIAL INNSTITUTIONS CAN REPORT SUSPECTED FINANCIAL EXPLOITATION AND RECEIVE IMMUNITY FROM THE REPORTING-INDUSTRY HAVE TO TRAIN STAFF TO RECOGNIZE SIGNS

NOT JUST ON GROUND

SUDDEN SITTING CAN BE A FALL-HIGH RISK FOR FUTURE FALLS

1/3 OF PEOPLE OVER 65 WILL FALL EACH YEAR

10% FALLS LEAD TO HIP FRACTURE OR TBI

16% ER VISITS

10% HOSPITALZATIONS 2/2 FALLS

FALLS ARE MAJOR REASON FOR 40% OF NURSING HOME PLACEMENTS-?INCONTINENCE

95% HIP FRACTURES ARE FROM FALLS

65 UP: 60 % FATAL FALLS IN HOME, 30% PUBLIC PLACES, 10% HEALTHCARE INSTITUTIONS

NATIONAL TRAUMA DATA BANK:DEATH 3X > FOR GROUND LEVEL FALLS THAN YOUNGER PTS, LONG BONE AND PELVIC FRACTURES MOST COMMON

ELDER ADULTS IN COMMUNITYW HIP FX: 25-75% DO NOT RECOVER FULLY

PSOT FALL ANXIETY SYNDROME

ASSOC W INCREASED INSTITUTIONALIZATION AND DEATH

INTRINSIC

N

PERIPHERAL NEUROPATHY

VESTIBULAR DYSFUNCTION

DEMENTIA

GAIT AND BALANCE IMPAIRMENT

ORTHOSTATIC HYPOTENSION

M

MUSCLE WEAKNESS

VISION IMPAIRMENT

MEDICAL ILLNESS

FEAR OF FALLING

EXTRINSIC

ENVTL HAZARDS

POOR FOOTWEAR

RESTRAINTS

FACTORS ASSOC W FRACTURE DISLOCATION LACERATION:

DECREASED EXECUTIVE FUNCTION

PREVIOUS HX OF FALLS

FALL ASSOC W SYNCOPE

SHOES

THICK SOFT SOLED SHOES LIKE JOGGING SHOES

SANDALS

BOTH INCREASE FALL RISK

CDC WEAR FLAT WIDE HEEL BASED SHOE NON SLIP IF POSSIBLE

TUG >=12 SECS FAIL

30 SEC CHAIR BELOW AVG FOR AGE AND GENDER FAIL

FULL TANDEM STANCE <10 SECS FAIL

< SBP BY >=20 MMHG

<DBP BY >=10 MMHG

DDROPP

DISEASES

DRUGS + ALCOHOL

RECOVERY

ONSET

PRECIPITANTS

GOOD FOR HX TAKING POST FALL

MEDS: ANTIDEPRESSANTS, SEDATIVES, BPMEDS , PSYCHOTROPICS

DISEASE:PARKINSONS, O/A ESP KNEES, COG IMPAIRMENT, DEMENTIA, STROKE, DM

PRECIPITANTS: PRODROME-LIGHTHEADAED, IMBALANCE DIZY

LOC -? NEURO, CARDIAC ,ORHTO HYPO, ALCOHOL

CHECK ENVTL STUFF

TINETTI /POMA-HIGHLY RELIABLE

BALANCE AND GAIT

TAKES CHAIR TIME-15 MINUTES AND STOPWATCH

SPPB - TANDEM SEMI TANDEM CHAIR STAND, WALK 4 METERS

TUG OR GET UP AND GO <12 secs fail

RISE FROM ARMCHAIR WALK 10 FEET WALK BACK TO CHAIR SIT DOWN

30nsec stand test no arm use

compARE TO MEAN TIME OF ADULTS IN AGE GROUP

FUNCTIONAL REACH TEST

4 stage balance test

YARDSTICK ON WALL AT ACROMIUM HEIGHT

STAND

NO SOCKS OR SHOES

REACHES FORWARD W FIST AS FAR AS POSSIBLE W/O LSOING BALANCE OR TAKE STEP. MEASURE DISTANCE <6 INCHES =FAIL

SHORT PHYSICAL PERFORMANCE BATTERY ( SPPB)

WIDE RANGING TEST < 9 SCORE = DEP ADLS AND FALLS

GAIT BALANCE AND MOBILITY STRENGTH

LOWER EXTREMITY JOINT FUNCTION

LOWER EXTREMITY SENSATION

LIFGHT TOUCH SHARP TOUCH

PROPRIOCEPTION-TOE BEND

TUNING FORK DIP GREAT TOE

CHECK COGWHEEL RIDIGIY

HEART:

VISUAL ACUITY-<20/40 IS FALL RISK GLASSES ON

ORHTOSTATIC VS supine BP THEN TAKE 3 MINUTES AFTER STANDING TAKE HR ALSO

PERIPHERAL EDEMA

LOWER EXTREMITIES

EXAMINE LOWER EXTREMITIES-STRENGTH

NEUROPATHY. FEET FOR CALLUSES BUNIONS DEFORMITIES,

FOOT AND FOOTWEAR EXAM

CBC-ANEMIA INFECTION

CMP -R/O DEHYDRATION , ELECTROLYTE IMBALANCE

SERUM GLUCOSE

OCCULT BLOOD TEST

EKG

MRI BRAIN- * IF NEURO EXAM +VE

EG LOWER EXTREMITY SPASTICITY, HYPERRELFEXIA - R/O LUMBAR STENOSIS OR CERVICAL SPONDYLOSIS

STRENGTH BALANCE PROGRAM

VIT D ( + CALCIUM ?)

MED MGT-BEERS

EYEWEAR

CATARACT SX

ORTHOTICS

HOME MODIFICATION

POSTURAL HYPOTN

TAI CHI

foot wear -PROPET OLIVIA WOMENS-MCR APPROVED DIABETIC SHOE

HUSH PUPPIES GILS MENS

LOW RISK

< 4 OR NO TO ALL QUESTIONS, NO GAIT STRENGTH BALANCE

EDUCATE PT

VITAMIN D W OR W/O CALCIUM

REFERR FOR STRENGTH & BALANCE - TAI CHI CLASSES FALL PREV PROGRAM

GAIT/STRENGTH /BALANCE PROBLEM

NO OR 1 FALL W/O INJURY

EDUCATE PT

VIT D/CA

REFER TO PT PHYSICAL THERAPY

OR FALL PREVENTION PROGRAM

MOD FACTORS + 2 OR MORE FALLS OR 1 FALL W INJURY

MOD INTERVENTIONS+

HYPOTENSION MGT

MED MGT

FOOT PROBLEMS

HOME SAFETY

WITHIN 30 DAYS

REVIEW CARE PLAN

FALL RISK REDUCTION BEHAVIORS

EXPLORE BARRIERS TO ADHERENCE

TRANSITION TO MAINTENANCE EXERCISE PROGRAM WHEN PT READY

GROUP CLASSES + AT HOME

150 MINS MOD INTENSITY OR 75 MIN VIGOROUS INTENSITY WEEKLY

MUSCLE STRENGTHENING TWICE A WEEK

BALANCE TRAINING 3 R MORE DAYS A WEEK

TAI CHI CHEUN

STRENGTHENS BUTTOCKS AND THIGHS -GLUTS QUADS

NO HANDS!

10-15 TIMES

800 IU DAILY 65 AND OLDER W > RISK FOR FALLS -FOR 12 MONTHS USPSTF

800 IU DAILY IF AT RISK FOR FALLS -AGS

600-FOR ADULTS 51-70 , 800 FOR >70

NOTE TO SELF USPSTF DOES NOT RECOMMEND VITAMIN D ANYMORE

GERONOTLOGIST ( ME)

OPTHALMOLOGIST

PT

OT

CARDIOLOGIST IF APP

NEUROL

ORTHOTIST

PSYCHOLOGIST

>5 MEDICATIONS

MULTIPLE PRESCRIBERS

PRESCRIBE A SECOND MED TO COMBAT S/E OF FIRST MED

PRIMARY PREDICTOR OF ADVERSE DRUG REACTIONS

TREATED AGGRESSIVELY -FEAR OF AGEISM CULTURAL BIAS

ELDERLY BIGGEST MED CONSUMERS

1/3 ELDERLY >5 MEDS

10% >10

42 % OTC MEDS

49% SUPPLEMENTS

ADVERSE DRUG REACTION

>HOSPITALIZATION

COG AND FUNCTIONAL DECLINE

PRESCRIBING CASCADES

INCREASED HEALTHCARE COSTS

ABSORPTION

< GASTRIC ACIDITY=< ABSORP

BIOAVAILABILITY

< BODY MASS

< BODY FLUID

> FAT

<ALBUMIN

METABOLISM

<LIVER MASS + FUNCTION

ELIMINATION

<RENAL AND HEPATIC FUNCTION

• REDUCED ELIMINATION OF DRUGS AFTER AGE40 2/2 RENAL FUNCTION DECLINE IS *BIGGEST PHARMACOKINETIC CHANGE

stopp

SCREENING TOOL OF OLDER PERSONS PRESCRIPTIONS

START

SCREENING TOOL TO ALERT DOCTORS TO THE RIGHT TREATMENT

IS THERE INDICATION FOR THE DRUG?

IS THE DRUG EFFECTIVE FOR THE CONDITION?

IS THE DOSE CORRECT?

ARE THE DIRECTIONS CORRECT?

ARE THE DIRECTIONS PRACTICAL?

ARE THERE CLINICALLY SIGNIFICANT DRUG-DRUG OR DRUG DISEASE INTERACTIONS

ARE THERE UNECESSARY DUPLICATION OF MEDS

IS DURATION OF THERAPY ACCEPTABLE

IS DRUG LEAST EXPENSIVE COMPARED TO OTHERS OF EQUAL EFFICACY

STILL NEED DRUG, DOSE AND DIRECTIONS RIGHT ,DRUG-DRUG OR DRUG-DX, DUPLICATION, EXPENSE

DOXAOSIN

IST GEN ANTIHISTAMINES

ANTIPARKINSONS

NITROFURANTOIN’

BACTRIM

MULTAQ-DRONEDARONE ANTIARRYTHMIC LIKE AMIOD

DIGOXIN

TCA ANTIPSYCHOTICS

BENZO

BRZA-BEN AND NON BEN

NSAIDS

PPI>8 WEEKS

SKELETAL MUSCLE RELAXANTS

PROMETHAZINE AND OR CODEINE

OPIOIDS

STOPP 2

ANY MED NOT EVIDENCE BASED CLINICAL INDICATION

ANY DRUG BEYOND RECOMMENDED DURATION

ANY DUPLICATE CLASS SCRIPT

RECS FOR MEDS TO STOP AND ALTERNATE TO PRESCRIBE

DRUG RISK/BENEFIT RATIO

DRUG DRUG INTERACTIONS WHEN STARTING NEW DRUG

EVALUATE RENAL FUNCTION AND ADAPT TREATMENT DOSING

DO NOT DO MED 2 TO COMBAT MED 1

DONT START 2 MEDS SAME TIME

SCREEN FOR OTC AND HERBALS

ELIMINATE PRN MEDS NOT USED FOR A MONTH

LEAST AMOUNT OF DOSING -OD BETTER

MED MGT-FAMILY PILLBOX ETC,pharmacist

PT TO RECITE BACK INSTRUCTIONS

NORMAL SERUM NA IS 135-145MEQ/L

NORMAL PLASMA OSMOLARITY IS 290 + OR - 50 MOSM

D5W OR 0.9% NS

1 KG WT GAIN/LOSS =1 LITER OF FLUID RETENTION

DEFINED AS FLUID INTAKE DEPRIVATION OR EXCESS FLUID LOSS

ISOTONIC:

BALANCE LOSS OF H2O AND NA -D+V

HYPERTONIC:

HYPERNATREMIA NA IS >148

NA >150 MeQ/L WILL DEVELOP NEURO SX- EXCESSIVE WATER LOSS- RENAL DX , OSMOTIC DIURESIS. MANNITOL IS AN OSMOTIC DIURETIC

HYPOTONIC:

<NA-EXCESS NA LOSS-DIURETICS

FUNCTION/ENVTL

CANNOT ACCESS WATER

INCREASE METABOLIC DEMANDS-INFECTION

PHARM-NARCOTICS SEDATIVES / DIURETICS/LITHIUM/ANTICHOLINERGICS

NORMAL AGING CHANGES, -DECREASED THIRST DRIVE

POOR APPETITE

FLUID LIMITATIONS-

CHF

PREVENT INCONTINENCE

ENVI

HOT WEATHER

INCREASED METABOLIC DEMANDS

INFECTION V+D

ENDOCRINE

DIABETES INSIPIDUS-HHNK > SERUM NA + HYPERGLYCEMIA-> HHNK

HIGH PG + LARGE WATER LOSS

PHARM

CONFUSION

LETHARGY

RAPID WT LOSS

FUNCTIONAL DECLINE

>NA >150 MEQ/L -NEURO

IRRITABILITY AGITATION CONFUSION PERSONALITY CHANGE

MUSCLE TWITCHING, SPASTICITY HYPERREFLEXIA

FLUID INTAKE

FUNCTIONAL STATUS

WT

COGNITION

BOWELS

MEDS

CV

ORHTOSTATIC HYPOENSION

HYPOTENSION AND TACHYCARDIA

TEMP ELEVATION-2/2 DEHYDRATION AND INFLAMMATORY RESPONSE

CONCENTRATED URINE

TONGUE-FURROWS AND SWELLING

SKINTURGOR NOT RELIABLE IN ELDERLY

CMP

NA>148 = HYPERTONIC

NA< 135MeQ/L

BUN/CREATININE RATIO -25>1 +DEHYDRATION

BCR LOOK IN MD CALC TELLS YOU PRE RENAL ETC

SERUM OSMOLALITY- NORMAL IS 285-295 MSOM ORDER BLOOD OR URINE OSMOLALITY TEST-DIAGNOSES DIABETES INSIPIDUS AND DEHYDRATION

H&H

GLUCOSE CONCENTRATION-?OGTT

ORTHOSTATIC HYPOTENSION

DELIRIUM

UTI

>1600ML/24HRS

HYPODERMOCLYSIS

HOSPITALIZATION

HEMODYNAMIC UNSTABLE

CANOT TOLERATE ORAL

AMS

6-8 8 OUNCE GLASSES DAILY WATER OR JUICE

>INTAKE HOT WEATHER

> INTAKE W FEVER

DENTIST-POOR DENTITION AFFECTS I NTAKE-

MONITORING-PEOPLE WITH MEMORY PROBLEMS NEED FLUID

SPECIALIZED MEDICAL CARE FOR PEOPLE WITH SERIOUS ILLNESS

CAN BE PROVIDED WITH CURATIVE TREATMENT, FOR SYMPTOM MGT

INTERDISCIPLINARY

ANY AGE ANY STAGE

FOCUS:

RELIEF OF SYMPTOMS-PHYSICAL PSYCHOLOGICAL SPIRITUAL

PATIENT CENTERED

GOAL: IMPROVE QUALITY OF LIFE

DESIGNED FOR LAST 6 MONTHS OF LIFE

PALLIATIVE CARE PRINCIPLES

COVERED BY INSURANCE

MOST DIE WITHIN 21 DAYS

USED FOR NON DISEASE SPECIFIC DECLINE THAT CORRELATES WITH A 6 MONTH PROGNOSIS

WT LOSS NOT DUE TO REVERSIBLE CAUSES

RECURRENT OR INTRACTABLE INFECTIONS

RECURRENT ASPIRATION/INADEQUATE ORAL INTAKE 2/2 INTRACTABLE DYSPHAGIA

DECLINE IN KARNOFSKY PERFORMANCE STATUS

PROGRESSING DEMENTIA BY OBJECTIVE MEASURES

PROGRESSIVE PRESSURE INJURIES STAGE 3 OR 4 DESPITE OPTIMAL CARE

0=DEAD 100=NORMAL

LEGAL DOCUMENT

5 WISHES

THE PERSON I WANT TO MAKE DECISIONS FOR ME WHEN I CANNOT

THE KIND OF MEDICAL TREATMENT I WANT OR DO NOT WANT

HOW COMFORTABLE I WANT TO BE

HOW I WANT PEOPLE TO TREAT ME

WHAT I WANT MY LOVED ONES TO KNOW

POLST

SERIOUS ILL

CURRENT CARE

MEDICAL ORDERS

HEALTH CARE PROXY CAN ENGAGE IN DISCUSSION IF PT LACKS CAPACITY

PORTABILITY IS PROVIDERS RESPONSIBILITY

PERIODIC REVIEW IS PROVIDER RESPONSIBILITY

ADVANCE DIRECTIVE

ALL ADULTS

FUTURE CARE

PATIENT COMPLETES

LEGAL NOT MEDICAL ORDERS

SURROGATE OR HEALTH CARE PROXY CANNOT ENGAGE IN DISCUSSION

PORTABILITY AND REVIEW ARE PT/FAMILY RESPONSIBILITY

PREVENTION FOCUSED HEALTHCARE ENCOUNTER FOR MCR RECIPIENTS

ONLY AVAILABLE IN 1ST 12 MONTHS OF COVERAGE

PROMOTES:

HEALTH

INJURY PREVENTION

OPTIMIZATION OF PHYSICAL AND MENTAL HEALTH

FACILITATION OF SOCIAL ENGAGEMENT

HEALTH HISTORY

FAMILY HISTORY

PHYSICAL ASSESSMENT

DETERMINATION OF FUNCTIONAL ABILITIES

IDENTIFICATION OF COGNITIVE IMPAIRMENTS

SCREENING FOR MENTAL HEALTH DISORDERS

COUNSELING ON ADVANCE DIRECTIVES

JOINT DEVELOPMENT OF A WRITTEN PLAN FOR PREVENTIVE AND SCREENING SERVICES

PMH

FALLS

PSH

CURRENT MEDS:

EVAL FOR POLYPHARMACY

EVAL USING BEERS CRITERIA

ALLERGIES

IMMUNIZATIONS: ?UP TO DATE

SOCIAL HX

TOBACCO

ALCOHOL-DO CAGE

DRUGS

RELIGIOUS /SPIRITUAL

FAM HX

DISEASES WITH FAMILIAL PATTERNS

SUDDEN CARDIAC DEATH <50

VS

BMI CONSIDER WAIST CIRCUM

VISUAL ACUITY

WHISPER TEST

THORAX

GU

MS

NEURO

HEMATOLOGIC/IMMUNE

GERIATRIC DEPRESSION SCALE

MINI COG SCALE https://www.alz.org/media/Documents/mini-cog.pdf

Geriatric Depression Scale (GDS, Short Form)

Choose the best answer for how you felt over the past week.

1. Are you basically satisfied with your life?

yes/no

2. Have you dropped many of your activities and interests?

yes/no

3. Do you feel that your life is empty?

yes/no

4. Do you often get bored?

yes/no

5. Are you in good spirits most of the time?

yes/no

6. Are you afraid that something bad is going to happen to you?

yes/no

7. Do you feel happy most of the time?

yes/no

8. Do you often feel helpless?

yes/no

9. Do you prefer to stay at home, rather than going out and doing new things?

yes/no

10. Do you feel you have more problems with memory than most?

yes/no

11. Do you think it is wonderful to be alive now?

yes/no

12. Do you feel pretty worthless the way you are now?

yes/no

13. Do you feel full of energy?

yes/no

14. Do you feel that your situation is hopeless?

yes/no

15. Do you think that most people are better off than you are?

yes/no

Score 1 point for each bolded answer. Cutoff: normal (0–5); above 5 suggests depression.

KATZ INDEX OF INDEPENDENCE

LAWTON-BRODY

GET UP AND GO OR TUG

MMSE

MINI NUTRITIONAL ASST

EG

LDCT

COLONOSCOPY/FIT/FOBT

MAMMO

PSA-55-69 USPTSTF

DEXASCAN

ENCOURAGE HEALTHY DIET

ENCOURAGE VITMAIN D-800IU>70 OR 65+ RISK FALLS,

AGED 51-70 600IU OR RISK FACTOR

ENDOURAGE VITS C,E BETA CAROTENE AND ZINC, AREDS

USE PRE PRINTED TOOLS

PROGRESSIVE LOSS OF :

ENERGY STRENGTH STAMINA

<FUNCTION

MENTAL + PHYSICAL DECLINE

NOT ASSOC W COMORBIDITY OR DISABILITY

LATE STAGE OF DECLINE

DISEASE

MEDS

ENVT-ISOLATION,NEGLECT, POVERTY

PSYCHIATRIC

GI CAUSES:TEETH, VIT DEFICIENCY, MALABSORPTION DYSPHAGIA

LOWER GROWTH HORMONE

ESTROGEN AND ANDROGEN HORMONE

DECREASED T CELL FUNCTION, < EFFECTIVENESS OF T MEMORY CELLS = SHORTER EFFECTIVENESS OF IMMUNIZATIONS

INCREASED VULNERABILITY TO INFECTION

WEIGTH LOSS GRADUAL

WEAK

DIZZY

INABILITY TO DO ADLS

MEMORY LOSS

DEPRESSION

SOCIAL HX,

CANCER HX- DISCUSS W PT AND PROXY DECISIONS ON TESTING-MAY NOT WANT.

CHECK FOR TOBACCO AND ALCOHOL USE

UNPLANNED WT LOSS OF 10% IN LESS THAN A YEAR

REMEMBER ANOREXIA NERVOSA OFTEN LIFELONG-AS OLDER ADULTS ALSO

SKIN-ULCERS, MUCUS MEMBRANES ,EYES-VIT DEFICIENCY,ANEMIA, DEHYDRATION

ORAL EXAM-CHECK DENTURE FIT

SWALLOWING ABILITY AND GAG REFLEX

VAGINAL AND BREAST EXAM-IF NOT F/U WITH GYN-

MAMMOGRAPYH REC BY ACS( AMERICAN CANCER SOCIETY) IF IN GOOD HEALTH AND REASONABLE FOR RX

PAP DC;D AFTER 65

MAY NEED BIMANUAL PELVIC EXAM

PROTEIN AND CALORIE INTAKE-SUPPLEMENTS

MOW, COMMUNITY SUPPORTS

800 IU VITMAIN D OR CALCIFEROL

DEPRESSION MGT

EXERCISE-WEIGHT TRAINING

ENCOURAGE FAMILY MEMBERS TO COME TO APPTS

VIT D UNDERGOES 2 HYDROXYLATIONS:

1 : LIVER CONVERTS IT TO CALCIDIOL -25-HYDROXYVITAMIN D -1,25(OH)2D25(OH)D

2: KIDNEY -FORMS PHYSIOLOGICALLY ACTIVE CALCITRIOL 1,25-DIHYDROXYVITAMIN D

VIT D PROMOTES CA ABSORPTION IN GUT, MAINTAINS ADEQUATE CA:: AND PHOSPHORUS-NORMAL BONE MINERALIZATION

HYPOCALCEMIC TETANY FROM <CA,PHOS -MUSCLE CRAMPS SPASMS INVOL CONTRACTION OF MUSCLES

ALZHEIMERS MOST COMMON TYPE

NO CURE

PRESENT IN 32-50% OF PEOPLE OVER AGE 85

5.8 MILL IN US

6TH LEADING CAUSE OF DEATH IN US-AD

50 % CAUSE OF NURSING HOME ADMISSIONS

DEFINED BY PROGRESSIVE MEMORY LOSS

PROGRESSIVE BEHAVIOURAL CHANGES

INTERFERENCE W ADLS

DSM5 DEFINES IT AS :

MAJOR OR MILD NEUROCOGNITIVE DISORDERS

PROGRESSIVE DECLINE

ALZHEIMERS

FRONTOTEMPORAL

LEWY BODY

VASCULAR

TBI

SUBSTANCE OR MED INDUCED

ALZHEIMERS NEUROFIBRILLARY TANGLES AND AMYLOID PLAQUES-NOT DIAGNOSTIC

VASCULAR LACUNAR INFARCTS

80-90%

THEORY IT IS A PRODROME/TRANSITION TO DEMENTIA

MCI PROGRESSES TO DEMENTIA IN A YEAR 10-15% SO CONSIDERED A RISK FACTOR

CHANGE IN COGNITIVE ABILITIES

NEUROPSYCHOLOGICAL EXAM

MEMORY

ATTENTION

LANGUAGE

VISUOSPATIAL SKILLS

EXECUTIVE FUNCTIONING

REMEMBER MALVE ACRONYM

IMPAIRED IN ONE OR MORE + PRESERVED ABILITY TO MAINTAIN INDEPENDENCE IN ADLS =DIAGNOSIS

MILD INABILITY FOR IADLS CAN STILL QUALIFY AS MCI

AMNESTIC SINGLE DOMAIN -AMCI

AMN MUTLI DOMAIN-

NON AMN SINGLE- naMCI

NON AMD MULTI

amci = POOR PERFORMANCE MEMORY ALONE OR +

NAMCI = FINE ON MEMORY POOR ON OTHERS eg LANGUAGE EXECUTIVE FUNCTION

DEEPER TESTING NEUROPSYCH TO DIFF BETWEEN MCI AND DEMENTIA

AMYLOID PLAQUES

NEUROFIBRILLARY TANGLES

USU POST MORTEM EXAM

ATROPHY OF CEREBRAL CORTEX- DIFFUSE BUT IN FRONTAL TEMPORAL AND PARIETAL LOBES MOST

AMOUNT OF TANGLES DOESNT CORRELATE WITH DEGREE OF IMPAIRMENT

AMYLOID HYPOTHESIS = CENTRAL ROLE FOR ABNORMAL AMYLOID PROCESSING

BIOCHEMICAL

ACETYLCHOLINE-CHOLINERGIC

CATECHOLAMINERGIC

SEROTONERGIC

GENETIC LOTS OF CHROMOSOMES

AMYLOID THEORY CHROMOSOME 21

AMYLOID MRI OR TAU MRI DIAGNOSTIC BUT NOT COVERED BY INSURANCE

LOOKING AT INFLAMMATION AND AUTOIMMUNE AS CAUSATIVE

MUTIPLE AREAS OF INFARCT

SHOWN AS LACUNAR INFARCT

LACUNAE ARE HOLES OR GAPS IN TINY ARTERIES IN BRAIN

RISK FACTORS

HTN

DM

HLD

PAD

PTS CAN HAVE MIXED

LEWY BODIES IN BRAIN

LEWY BODIES ARE PROTEINS THAT ENTER NEURONS AND CAUSE CELL DEATH

MEMORY LOSS

LANGUAGE DISTURBANCE

IADLS PROBLEMS

OFTEN PT OBLIVIOUS TO THEIR CHANGE-NO INSIGHT

APRAXIA

AGNOSIA-LOSS OF ABILITY TO IDENTIFY OBJECTS OR PEOPLE

LEWY BODY: HALLUCINATIONS,POSTURAL INSTABILITY SLEEP IMPAIRMENT , GET WORSE WITH HALDOL- GOOD MARKER-INCREASED SENSITIVITY TO NEUROLEPTICS

3STAGES

1. EARLY STAGE

MEMORY LOSS-SHORT TERM

TIME AND SPATIAL DISORIENTATION

POOR JUDGEMENT

PERSONALITY CHANGE

WITHDRAWAL OR DEPRESSION

PERCEPTUAL DISTURBANCE

RECENT REMOTE AND SHORT TERM MEMORY WORSENS

INCREASED APHASIA-SLOWED SPEECH AND UNDERSTANDING

APRAXIA

HYPERORALITY

DISORIENTED TIME AND PLACE

RESTLESS OR PACING

PERSEVERATION

IRRITABILITY

LOSS OF IMPULSE CONTROL

INCONTINENCE B&B

LOSS OF MOTOR SKILLS

RIGIDITY

< APPETITE

DYSPHAGIA

SEVERELY IMPAIRED COMMUNICATION

POSSIBLE INABILITY TO RECOGNIZE FAMILY/SELF IN MIRROR

LOSS OF MOST/ALL SELF CARE ABILITIES

SEVERELY IMPAIRED COGNITION

DEPRESSED IMMUNE SYSTEM

CAREFUL + DETAILED HISTORY FROM FAMILY/CGVR

TIMING AND ONSET OF SYMPTOMS-UNDERSTAND LENGTH .REPORTED BEHAVIORS- WANDERING ANXIETY/AGGRESSION/DELUSION HALLUCINATIO

COMPLETE PHYSICAL- BP CAROTID BRUITS,

COMPLETE NEURO EXAM

SCREEN FOR COGNITION, MOOD FUNCTION, BEHAVIOR-

REVIEW MEDS- REMOVE ANTICHOLINERGICS

(STUDIES -CUMULATIVE ANTICHOLINERGICS AND DEMENTIA)

REVIEW OTC MEDS

TUG TEST-OR GET UP AND GO

KATZ INDEX OF IADL

MMSE

MOCA

MINI COG

GPCOG

GERIATRIC DEPRESSION SCALE SHORT FORM -VALID AND RELIABLE

SOME TESTS LACK DIAGNOSTIC PRECISION-FALSE + W POOR EDUCATION OR ESL OR SENSORY IMPAIRMENT

CEILING LIMITS - PERFORM WELL DESPITE COGNITIVE IMPAIRMENT-HIGH FALSE NEGATIVE

IMPROTANT TO MONITOR DECLINE

NO SINGLE STANDARD TEST, DX OF EXCLUSION

CHECK FOR UNDERLYING

CBC

CHEM 12

VIT B12 AND FOLATE

TSH

MED LEVELS DIG, TEGRETOL, THEOPHYLLINE, DEPAKOTE

IDENTIFY MASS LESION, VASCULAR LESIONS OR INFECTIONS

DO NOT CONFIRM A DIAGNOSIS OF DEMENTIA

CT , OR MRI -R/O SUBCORTICAL PATHOLOGY OR CVA

UPTODATE:

NATIONAL INSTITUTE ON AGING + ALZHEIMERS ASSOCIATION NIA-AA CRITERIA

MRI-EXCLUDE OTHERS - HIPPOCAMPAL DETERIORATION OR MEDIAL TEMPORAL LOBE ATROPHY CAN BE AD- BUT NOT SPECIFIC TO OVERRIDE CLINICAL DX.

HIPPOCAMPAL ATROPHY HAS TO BE COMPARED TO AGE NORMS-ALZH DX NEUROIMAGING INITIATIVE-HELPS W RATE OF PROGRESSION

AMYLOID PET IMAGING W FLORBETAPIR- MEASURE AMYLOID LESION BURDEN -NOT DIAGNOSTIC

TAU PET IMAGINGW FLOURTAUCIPIR F18 -NEUROFIBRILLARY TANGLES -ADDS TODX

EXPENSIVE NOT COVERED BY INS,NIA-AA DOES NOT RECOMMEND EXCEPT IN RESEARCH

BIOMARKERS- OF ABETA PROTEIN DEPOSIT-

INDICATED FOR PTS USING ADUCANUMAB

GENETIC TESTING NOT RECOMMENDED APOE- DUE TO FALSE POS AND NEG

APP,PSEN Q AND PSEN 2 COMMERCIALLY AVAILABLE-SHOULD BE RESERVED FOR YOUNG PTS WITH AUTOSOMAL DOMINANT DISTRIBUTION OF EARLY ONSET.NEED GENETIC COUNSELLING

DELIRIUM

PARKINSONS

LEWY OBDY

ALCOHOLIC DEMENTIA

MEDS

MEDICAL ILLNESS: CUSHINGS, LIVER DX, HYPOTHYROID, ADRENAL INSUFFICIENCY, CHRONIC LOW PG

VITAMIN DEFICIENCY

VIT B12, FOLIC ACID, THIAMINE

MAL NEO

TBI, SUBDURAL HEMATOMA

HYDROCEPAHLUS

INFECTIONS

HIV DEMENTIA

SYPHILLIS,LYME

VIRAL ENCEPHALOPATHY- HSV

HIV

TOXOPLASMOSIS,CMV , CRYPTOCOCCOSIS

DELIIRUM CAN BE ONLY CLUE THAT THERE IS MEDICAL UNDERLYING ILLNESS: INFECTION, MI, DRUG TOXICITY

UNDERLYING DEMENTIA= GREATER RISK OF ACUTE ILLNESS-DELIRIUM IN SETTING OF DEMENTIA(DSD)

DELIRIUM IS ACUTE ONSET OF MENTAL STATUS

HALLMARK IS CLOUDING OF CONSCIOUSNESS=

MENTAL IMPAIRMENT WITH REDUCED AWARENESS OF THE ENVIRONMENT

MANIFESTS LIKE DEMENTIA , BUT DELIRIUM W:

FLUCTUATIONS IN SEVERITY

RAPID ONSET

DISORIENTED TO TIME DATE OR PLLACE

OFTEN FRAGMENTED SLEEP CYCLE

WORSE SYMPTOMS LATE AFTERNOON EARLY EVENING

PRESENT IN DELIRIUM BUT USU ASSOC W DEMENTIA

NO SCREENING TOOL

OVERLAPS W DEMENTIA

PSYCH, MOOD DISORDERS

CHECK

TWO CLASSES APPROVED BY FDA

INCREASES CHOLINERGIC TRANSMISSION -INHIBIT CHOLINESTERASE AT SYNAPTIC CLEFT

EARLY DEMENTIA

DONEPEZIL/ARICEPT 5MG INITIAL DOSE

10 MG DAY AFTER 4-6 WEEKS

PILL OR DISINTEGRATING TAB GIVE IN AM

S/E GI N+V,D

GALANTAMINE/RAZADYNE- BID TAB OR ELIXIR

4MG BID -8MG TOTAL

4WEEKS > TO 8MG BID, THEN MAINT 24 MG DAILY

RIVASTIGMINE/EXELON-ORAL OR 24 HOUR PATCH-DONT CUT

INIT 4.6 MG/24

4 WEEKS 9.5MG/24

13.3 MG /24 HOURS TOP DOSE

NMETHYL DASPARTATE RA-NMDA RANTAGONIST

NEUROPROTECTIVE-GLUTAMATE EXCITATORY ACTIVATES NMDA-ASSOC W MEMORY AND LEARNING-ISCHEMIA >NMDA -> EXCITOTOXICITY + DAMAGE. BLOCK PATHOLOGICAL STIMULATION OF NMDA

MEMENTAMINE/NAMENDA 5MG OD

1 WEEK > 5MG BID, THEN 5A-10 P , TOTAL 10A-10P

TITRATE AT 7 DAY INTERVALS

NO S/E

RENAL IMPAIRMENT 5MG BID

SUPPORT

CGR- ALZ ASSOC

RESPITE CARE, MULTIDISC TEAM APPROACH

CLOCKS CALENDARS

AVANCE DIRECTIVES

DOOR ALARMS

REMINISENCE THERAPY -OLD PHOTOS

TEACH FAMILY ABOUT PT SELF ESTEEM, DO NOT CUT THEM OFF EVERYTHING

NEUROLOGIST FOR NEW ONSET DEMENTIA

PT

OT

HOMECARE

ST

MCR PROVIDES HOSPICE FOR CRITERIA STAGE LATE-BEDBOUND, ADVANCED STAGE

MVA-TAKE KEYS AWAY

HOME SAFETY -STOVE

UTI

CONTRACTURE

PI

WT LOSS -APRAXIA FORGET HOW TO CHEW AND SWALLOW