week 1
Normal aging (list 3)
-an increase in fat and decrease in total body water
-atrophy of the brain with a decrease in weight by 7%
-altered sleep patterns with decrease in stage 3 and stage 4 sleep and more frequent awakenings
-decreased visual acuity up to 70%, reduced intensity of colour
-decline in hearing acuity, which starts as early as age 12, with a decline in the highest frequency hearing range first
-altered/reduced taste up to 70%
-reduced cardiac maximum heartbeat reduced from 195 to 155 bpm
-reduced renal perfusion each decade up to 50%
-reduced bone mineralization by up to 10-30%
-increase in the size of prostate gland up to 100%
-loss of libido (male and female) and erectile dysfunction (male) and atrophic vaginitis (female)
fever, nausea, change in bowel regimen (constipation, diarrhea, or tenesmus), and left lower quadrant (LLQ) pain, tender LLQ mass and leukocytosis as well
Diverticulitis Classic presentation
Recent guidelines have now focused on WHAT as key factor in determining target A1c in older adults NOT age
functional status
independent- less than 7.0, dependent < 8.0, frail < 8.5, end of life do not measure
what are the causes of peripheral vertigo and how do we differentiate them
BPPV
Menieres
labryntitis
Rule of fourths
The rule clarifies that changes/decline in function are often attributed to normal aging by the general public (and sometimes by medical professionals caused by:
disease,
disuse,
misuse and
physiology- about one-fourth of the time for each.
What is the pharm and non-pharm treatment of constipation?
-fluid, exercise, bowel routine,
-fibre first (titrated gradually.. increased 5. g per week) up to 20-30 g /day
-recommended that therapy begin with
-a bulk-forming agent, (like psyllium) but the patient must be able to drink it with a full glass of water (contraindicated in bedridden, are cognitively impaired, or have other contraindications)
-then an osmotic laxative (like PEG)
DM II over 70 otherwise well + at least a decade of life expectancy should be treated to normal targets
true or false?
TRUE
What is the purpose of the hints exam
Central vs peripheral vertigo
Head impulse (none in central) (peripheral corrective saccade)
Nystagmus (central bidirectional) (peripheral- unidirectional)
Test of skew (central vertical saccade) (no skew peripheral)
Patho (neurotransmitters) for delirium
Stressors lead to metabolic changes that modify cerebral neurotransmission, ultimately causing cholinergic deficiency and dopaminergic excess
What is an example of social, physical, and environmental influences impacting nutrition and feeding problems in older adults
Social: widow, isolation, poverty
environmental: housing, transportation, local resources
physical access: mobility limitations, no driving, no ramp
meds: changes to taste/smell, xerostomia, anorexia
biological: age-related changes, vision, dental, dysphagia
what are the ABCDESSS of DM?
A1C less than 7 (most adults), less than 6.5 reduce risk of CKD, frail 7.1-8.5
BP <130/80
LDL < 2 or 50%
Drugs Ace/ARB (if CVD, age ≥55 with risk factors, OR diabetes complications), Statin (if CVD, age ≥40 for Type 2, OR diabetes complications), ASA (if CVD), SLGT2i/GLP1ra with demonstrated CV benefit (if have type 2 DM with CVD and A1C not at target)
Exercise: 150 mins of moderate to vigorous activity + 2-3 X resistance training (health diet like Mediterranean)'
S: Screening: ECG Q3-5 years if >40 or DM complications, Foot Monofilament yearly, Kideny eGFR+ACR yearly, yearly dilated retinal exam
S Smoking cessation
Self-management: get goals
Open-angle vs closed glaucoma patho/presentation
-open problem with the balance of aqueous fluid production and draining, increases pressure leading to peripheral loss
Insidious, painless, can be bilateral (usually asymmetrical)
-closed: either chronic or acute- drain angle is closed and becomes blocked resulting in an increase in ocular pressure damage to nerve
Severe eye pain, headache, N/V, decreased vision, halos around light, headache,
Unilateral (but both eyes at risk)
*** chronic may not be as obvious
What symptoms of depression are older adults more likely to display
igher tendency for somatic complaints (gastrointestinal primarily), hypochondriasis, and agitation; higher rates of psychotic and severe (melancholic) depression with more weight loss and decreased appetite
How do older adults present differently with appendicitis
One-fifth of all elderly patients with appendicitis present after 3 days of symptoms and another 5% to 10% of patients present after 1 week of symptoms
Scoring systems to risk stratify patients don’t have good discriminatory or predictive ability in the elderly.
Less than one-third of patients have fever, anorexia, right lower quadrant pain, or leukocytosis. One-quarter of patients have no right lower quadrant pain at all
Keep a high suspicious, liberal use of CT for elderly pts.
A1C >1.5 above target? or if symptomatic
-start metformin + second agent
start insulin +/- metformin
COPD when to start ICS
HX of hospitalization of COPDE
> 2 moderate exacerbations in one year
Blod eosinophils > 300
HX of asthma
Differentiate between the two types of dysphagia
Oropharyngeal/transfer dysphagia: characterized by difficulty initiating a swallow. Swallowing may be with nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in pharynx
-difficulty transferring food from mouth to pharynx and report obstruction in neck, and may point to cervical region as site of S/S
-common complaints: coughing, drooling, and regurgitation when swallowing liquids or solid food
Esophageal Dysphagia: characterized by difficulty swallowing several seconds after swallowing and a sensation of food getting stuck
-may point to suprasternal notch or area behind sternum as site of obstruction
Patients may have a history of long-standing post-prandial abdominal pain or ‘intestinal angina"
SMA (superior mesenteric artery) thrombosis
Mesenteric artery thrombosis (MAT) is a condition involving occlusion of the arterial vascular supply of the intestinal system
Which diabetic medication has shown a great safety profile in terms of hypoglycemia and should be selected first
DPP-4 "gliptins"
Dipeptidyl peptidase (DPP)-4 inhibition is a glucose-lowering treatment for type 2 diabetes. The classical mechanism for DPP-4 inhibitors is that they inhibit DPP-4 activity in peripheral plasma, which prevents the inactivation of the incretin hormone Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed
New blood vessels formed under the macula that leak fluid and blood under the macula
Wet MD