Geriatrics Exam #1

What is fidelity?

-being faithful to the patients interests, even if they do not align with the interests of the clinician

What is discernment?

-bringing insight, judgement, and understanding to a clinical situation -"practical wisdom"

Late AMD clinical manifestations

-central vision loss -dry and wet AMD

Clinical interventions for dry AMD

high dose antioxidant and mineral supplements including: vitamin c, vitamin e, lutein, etc

What is the most frequent cause of sensorineural hearing loss?

presbycusis

Sensory changes as you age: Hearing

presbycusis may impair speech recognition

Sensory changes as you age: Vision

presbyopia (farsightedness caused by loss of elasticity in the lens) cataracts-lens become more opaque

Glaucoma is the ________ leading cause of blindness in the world

second

Complications of presbycusis

social withdrawal depression familial stress isolation

Risk factors for cataracts:

-cigarette smoking -alcohol consumption -age >65 -diabetes mellitus/metabolic syndrome -long term UV exposure -eye trauma -long-term ocular or systemic corticosteroid use -uveitis -HIV/AIDS -Malnutrition

What does "multimorbidity" mean in the 5 M's?

-consider the impact of therapeutics on the whole person making sure treatment of one problem doesn't worsen another

How do you treat presbycusis?

-patient education-no directed treatment to prevent or reverse the effect of presbycusis available -hearing aids -cochlear impant (if hearing aids dont work)

Non-age related causes of cataracts:

trauma, uveitis, scleritis, radiation of an intraocular tumor, metabolic impact of systemic disease, use of topical corticosteroids or certain phenothiazines, topical anticholinesterases

How do you diagnose cataracts?

visual acuity (reduced) red reflex (darkening) non-dilated fundus exam (lens opacity) Dilated fundus exam (normal optic nerve and fundus)

Patient must be _____________________ to make health care decisions

1. Capable of AND willing to make the decision 2. fully informed and understand their current medical situation 3. Made aware of options, risks, and benefits as well as be presented with realistic expectations (informed consent)

What are the 4 ethical principles?

Autonomy Beneficence Non-maleficence Justice

What is the most common cause of blindness worldwide?

Cataracts

What hormones are produced by the anterior pituitary?

FSH, LH, ACTH, TSH, prolactin, growth hormones FLATPiG

What is the leading cause of hospitalization in the older population?

Heart disease

Are suicide rates higher or lower in 65 years and older than 65 years and less? (males)

Higher

How do you treat open angle glaucoma?

LOWER IOP!!! pharmacologic options first line of tx before surgery include: -prostaglandins -beta blockers -alpha adrenergic agonists laser therapy (trabeculoplasty) to increase aqueous outflow -tx effect can last 3-5 years and can be repeated surgery to create filtration bleb to allow drainage of aqueous humor

What are the 5 M's?

Matters most Medication Mind Multimorbidity Mobility

Screening recommendations for open angle glaucoma:

all individuals greater than 40 years old by comprehensive exam (earlier for those with risk factors) once diagnosed: follow up depends on severity of disease, stability of IOP, but at least 2 times a year, severe disease may require q 1-3 month follow up

What is morbidity?

being ill/having disease

Is open angle typically unilateral or bilateral?

bilateral

Is macular degeneration unilateral/bilateral, painful/painless, peripheral/central vision loss?

bilateral, painless, central vision loss

What are the risk factors for open angle glaucoma

black ethnicity diabetes HTN family history elevated IOP occurs at earlier age than closed angle, but still primarily in patients >50 years old

Complications of cataracts:

blindness

What is secondary glaucoma?

elevated IOP resulting from uveitis, trauma, steroid use, vasoproliferativhe retinopathy, etc

What is glaucoma?

-a neurodegenerative condition -primarily due to dysfunction in outflow of the nutrient rich fluid (aqueous humor) that constantly flows through the eye

What is trustworthiness?

-acting in a manner that merits confidence in one's character and conduct

What is presbycusis?

-age related hearing loss -progressive -loss of high frequency hearing -symmetrical -occurs over many years

What is compassion?

-an active regard for another's welfare with sympathy, tenderness, and discomfort at suffering

How does skin change as you age?

-atrophy -dermoepidermal junction flattens -decreased production of collagen, elastin, and hyaluronic acid -subdermal fat layer thins

What does "Medication" mean in the 5 M's?

-be aware of any potential side effects, BEERS CRITERIA, etc -make sure medication doesn't cause more harm than benefit -make sure medication does not interfere with the other 4 M's

Who makes the healthcare decision (for elderly)?

-Ideally the patient , either directly or through appointment of a surrogate decision-maker (healthcare power of attorney) -When and if a patient becomes incapable appoint a surrogate

What does "Mind" mean in the 5 M's?

-Prevent, ID, treat/manage, dementia, depression, and delirium (from UTI, etc --> it is reversible)

Clinical interventions wet AMD

-daily oral supplements (same as dry AMD) -VEGF inhibitor injected into the eye to reduce swelling and capillary growth -photodynamic therapy (photosensitizing dye injected, laser applied through eye, dye forms reactive free radicals that damage the vascular endothelium and result in thrombosis of the neovascular tissue)

Amsler grid: Scotomas

-dark areas, may represent atrophic areas of the macula

Pulmonary changes as you age:

-decrease in lung elastic tissue (increase in anatomic dead space, decreased surface area for gas exchange, decreased expiratory airflow) -cough is less vigorous and effective -increased work of breathing (diaphragm flattens, decreasing efficiency, increased chest wall stiffness) -decreased responsiveness to hypoxemia and hypercapnia

Renal changes as you age:

-decreased blood flow -decreased creatinine clearance -increased vulnerability to insults -impaired secretion and conservation of electrolytes

Gastrointestinal changes as you age: large intestine

-decreased colonic motility -decreased anal sphincter tone

Hematologic and immunologic changes as you age:

-decreased functional bone marrow reserves -procoagulation (increases blood stasis due to immobility, increased platelet reactivity, progressive endothelial dysfunction, elevated concentration of several coagulation factors) -immunosenescence (gradual decrease in function of the immune system with age)

Endocrine changes as you age:

-decreased in hormone secretion

Gastrointestinal changes as you age: Esophagus

-decreased peristalsis -decreased LES tone

What are the clinical manifestations of acute angle closure glaucoma?

-decreased vision -headache -halos around lights -severe eye pain -N/V -red eye -corneal cloudiness -poorly responsive pupil -hard eye on palpation

What is macular degeneration?

-degenerative disease of the central portion of the retina (the macula) that results primarily in loss of central vision -referred to as age-related macular degeneration (AMD)

Gastrointestinal changes as you age: Stomach

-delayed gastric emptying

What does beneficence mean?

-do good

What does non-maleficence mean?

-do no harm

Early and intermediate AMD clinical manifestations

-drusen deposits -macular pigmentary changes -normal or near normal vision

What does justice mean?

-fairness

What are the risk factors for closed angle glaucoma?

-family history of angle-closure glaucoma -advanced age (>60) -female -hyperopia (farsightedness-think about dilated pupil) -race-more common in people of Asian descent -closing of the angle is precipitated by pupillary dilation and can occur from: sitting in a darkened theater, during times of stress

What does "Matters most" mean in the 5 M's?

-gives us a place to start and stop each medical decision and encounter -aligning out care/actions to what matters most to the older patient (including end of life care)

Oral health changes as you age:

-gum recession can lead to increase in tooth decay and tooth loss (pain and tooth loss can result in difficulty in mastication) -decreased saliva production

Clinical manifestations of presbycusis:

-hearing deficits are exacerbated in the presence of competing background noise -often perform quite well in one-on-one communication in a quiet room -may have accompanying tinnitus, vertigo, disequilibrium

Cardiovascular changes as you age

-increased ectopic atrial and ventricular beats and dysrhythmias (calcification of mitral and aortic valves, cellular loss at the SA>AV nodes) -ventricular hypertrophy and LV stiffening -Decreased maximal HR

What are the factors of health aging?

-independence -ability to accomplish desired tasks -social support

Why do cataracts form?

-lens does not shed its nonviable cells -photo-oxidative insult plays a role

What does "Mobility" mean in the 5 M's?

-make sure your elderly patients move SAFELY in order to maintain function and do what matters

What are the clinical manifestations of chronic angle-closure glaucoma?

-may be asymptomatic -may not have increased IOP -more vision loss than acute*********

What is angle closure glaucoma?

-narrowing or closure of the anterior chamber angle -inadequate drainage leads to elevated intraocular pressure and damage to the optic nerve EMERGENCY

What is wet AMD?

-neovascular, 10-15% of AMD, more aggressive and can cause severe vision loss or blindness

What causes cataracts?

-normal aging process -trauma -metabolic disorders -medications -congenital problems (intrauterine infections, such as rubella and CMV)

What do cataracts result from?

-normal aging process -trauma -metabolic disorders (diabetes, etc) -medications (steroids) -congenital problems (intrauterine infections such as rubella and CMV)

Once a surrogate is appointed, do they make all healthcare decisions?

-not necessarily (until patient is unable to) -if no family, practitioner makes decisions

What is healthy aging?

-not necessarily the absence of disease -adapting the age-associated changes to optimize function in a manner acceptable to the patient

How do you treat macular degeneration?

-ophthalmology referral -patient education (stop smoking, lower cholesterol, lower saturated fat intake) -vitamin/mineral supplements

How do you diagnose acute angle closure glaucoma?

-optic disc cupping on fundoscopy -increased IOP usually >50 -Gonioscopy (definitive test for diagnosing angle-closure glaucoma

How to treat cataracts:

-patient education: multivitamin/mineral supplements-lutein, B vitamins and smoking cessation -if they do not have functional vision impairment you can observe progression and do annual eye exams -if they do have functional vision impairment surgical excision of opacified lens replaced by a synthetic intraocular lens

complications of AMD

-progression to advanced ARMD in one eye -development of advanced ARMD in second eye -severe loss of central vision -photosensitivity reaction after photodynamic therapy

What does autonomy mean?

-respect for persons -patients have the right for their practitioner to do what's in line with the patients values, not necessarily the practitioners

Musculoskeletal changes as you age:

-significant loss of muscle mass (30-50% decrease in body weight, lower body strength decreases faster than upper body strength) -Bone loss (decline in osteoblast number and activity, 0.5% loss per year in healthy older adults

How does circadian rhythm change as you age:

-temperature, cortisol, and sleep

What is homeostenosis?

-the diminished capacity to respond to various homeostatic challenges (AKA decreased physiologic reserve) -risk for more rapid decline with acute or chronic illnesses -vulnerable to bedrest/immobility, external temperature changes, and complications of diseases

How to treat acute angle-closure glaucoma?

-urgent ophthalmology referral/consult -reduction of IOP -topical carbonic anhydrase inhibitors and/or topical beta blocker and/or topical alpha 2 agonist -systemic meds (PO/IV acetazolamide, IV mannitol, PO isosorbide) -laser peripheral iridotomy -recheck pressure 30-60 minutes post topical/systemic tx, 30-120 minutes post iridotomy

Gastrointestinal changes as you age: small intestine

-villus atrophy -decreased Fe B12 Cu Ca absorption

What are the complications of acute angle closure glaucoma?

-vision loss

How do you diagnose AMD?

-visual acuity -amsler grid (determines subjective changes in the central visual field) -fundoscopic exam -slit lamp exam

How do you diagnose presbycusis?

-weber/rinner -otoscope-cerumen impaction? -whisper hearing test -audiogram

What is elderly (age)?

65 y/o

What are the risk factors for AMD?

>50 years old high saturated fat diet overweight smoking family history (CFH gene) hypertension

What is mortality?

death

Sensory changes as you age: Smell

decreased sensitivity

Sensory changes as you age: Taste

decreased sensitivity

Amsler grid: metamorphopsia

distortion, may represent active areas of macular exudation

What happens to physiologic reserve?

loss of it --> decreased variability in HR, BP, temperature control

Are homicide rates higher or lower in 65 years and older than 65 years and less?

lower

What hormones are produced by the pineal gland?

melatonin

What are the tx targets for open angle glaucoma?

no standard target IOP Goal is > or equal to 25-30% below initial IOP lower target if patient continues to have progression of disease

What is dry AMD?

nonexudative, more common 85-90% of AMD, causes gradual vision loss (drusen spots)

Clinical manifestations of open angle glaucoma:

often asymptomatic often identified incidentally on routine exam

Risk factors for presbycusis

older age (affects >50% of adults by age 75) noise trauma drug exposure (ototoxins) genetic predisposition white race low SES hypertension diabetes vascular disease infections

How is open angle glaucoma diagnosed?

on routine eye exam (must have two of three parameters) 1. optic disc cupping 2. Increased IOP (normal 10-21) on tonometry 3. Visual field abnormalities

What are cataracts?

opacity of the lens of the eye that causes partial or total blindness

What types of glaucoma are there?

open angle angle closure

What is open angle glaucoma?

open angle but with an obstructed and slowed drainage system outflow (reduced drainage of aqueous fluid through the trabecular meshwork)

Which form of glaucoma is most common?

open angle-accounts for 2/3 of those affected

What are the clinical manifestations of cataracts?

painless, gradual decrease in vision blurred or cloudy vision reduced visual acuity disruption of ADL's usually bilateral difficulty with night driving difficulty reading road signs or fine print

What type of vision loss in early disease?

peripheral ---> central in late disease