NR 601

Þ Scoring

0-1: Low risk; consider outpatient treatment 2: Brief hospitalization or closely monitored outpatient treatment ≥ 3: Severe, hospitalize and possible ICU

Interstitial Lung Disease (Dunphy) Types: "pulmonary fibrosis"

1. Allergic angiitis and granulomatosis (churg-strauss syndrome) Is characterized by necrotizing angiitis of the lungs, heart, skin, and CNS, with involved organs displaying infiltration with eosinophils. Pulmonary manifestations: present with an allergic history, often with asthma; chest x-ray abnormalities may range from patchy densities to large bilateral nodular infiltrated; lung cavitation is rare. Management: Corticosteroids (prednisone). Immunosuppressants (azathioprine, cyclophosphamide), and plasma exchange have been used. 2. Drug-induced pulmonary disease: iatrogenic and adverse complications of various drugs (cytotoxic agents, antibiotics, immunosuppressants) Can result in ILD. Pulmonary manifestations: hypersensitivity pulmonary disease with dyspnea, nonproductive cough, lung crackles, tachypnea. Diffuse linear streaks, and densities in lower lung zones on chest x-ray. Management: Discontinuing of the drug or reduction in drug dosage, in conjunction with corticosteroids therapy. 3. Sarcoidosis: A multisystem syndrome of unknown etiology, involving complex cellular immune pathways, that most frequently affects the lung. Pulmonary manifestations: lung most common organ affected; PFT's reveal a restrictive pattern and small lung volumes; tissue biology demonstration characteristic granulomas, with hilar lymphadenopathy (Plaquenil) and methotrexate (Rheumatrex). 4. Hypersensitivity pneumonitis (Allergic Alveolitis) Caused by inhalation of a variety of organic dusts. These dusts can be derived from animal dander and proteins, from fungi that contaminate vegetables, wood bark, or water-reservoir vaporizers, or from dirty and grains products. Colorful, descriptive names for this disease underscore the frequent occupational nature of exposure. Pulmonary manifestations: In the acute form of disease, respiratory and systemic symptoms develop explosively within 4 to 6 hours after dust is inhaled, consisting of dyspnea, cough, chills, fever, and malaise; symptoms typically abate within 12 hours but with each re-exposure, the acute episode occurs again. The acutely ill patient is dyspneic with inspiratory crackles in the lower lung zones; chest x-ray shows fine, diffuse alveolar filling and variable interstitial streaks, and PHT's are abnormal. Management: Avoidance of inhales substances; corticosteroids (prednisone) Þ Types: ILD comprises a heterogeneous group of diseases that cause inflammation and fibrosis of the lower respiratory tract. Four infections may be associated with the cause or onset of most of the various diseases: Þ disseminated fungus (coccidioidomycosis, blastomycosis, histoplasmosis), Þ disseminated mycobacteria Þ Pneumocystis pneumonia, Þ and certain viruses

Developmental changes Physiological

1. Reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. 2. There are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. 3. There are changes in the sympathetic response, which contribute to orthostasis and falls, as well as lack of hypoglycemic response. 4. There is impaired immunological function: infection risk is greater and autoimmune diseases are more prevalent. Laboratory: Reference ranges for older adults might be the intervals within which 9%% of persons over 70 fall. Causes: Physiologically: fasting or activity status. Pharmacologically: medication, tobacco, or alcohol use.

1) Transient insomnia

avoid caffeine 12 before bedtime, D/C ETOH and sleep-interrupting drugs, OTC melatonin, if ineffective, a short-acting sedative-hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata), at lowest dosage before desired bedtime for 1 week or less (space to avoid S/E), benzodiazepine - short-acting- temazepam (Restoril).

Radiographic findings:

chest x-ray is considered the gold standard for the diagnosis of pneumonia; C-reactive protein (CRP) and/or urine specific antigen when there is a question about when, or if, to start antibiotic therapy ; CT scan of the chest is often ordered and is more accurate than a chest x-ray; Pulmonary infiltrate, lobular consolidation, or opacities found on chest x-ray, CT scan, or ultrasound confirm the diagnosis of pneumonia.

Medical management :

corticosteroid treatment, analgesia, and NSAIDs for symptom management • non-biological disease-modifying antirheumatic drugs (DMARDs), which suppress the immune response: methotrexate hydroxychloroquine, leflunomide, and sulfasalazine, subcutaneously, intravenously, and by mouth • NSAID selection should be based on the shortest half-life and the lowest effective dose. Low-dose oral corticosteroids may provide relief and are recommended as a short-term therapy only for less than 3 months, until DMARD treatment is established • DMARD as a single therapy or a combination of two or more DMARDs. DMARDs suppress the immune response and prevent joint damage, although they may take up to 3 months to have an effect. • Traditional DMARDs include: ■ Methotrexate (oral, intramuscular, or rarely, subcutaneous given as a once-weekly dose; co-prescribed with folic acid, usually 5 mg once a week when the weekly dose of methotrexate is administrated to decrease nausea, diarrhea, and prevent MTX-associated macrocytic anemia) ■ Sulfasalazine ■ Leflunomide ■ Hydroxychloroquine • Tuberculosis and hepatitis testing is done before initiating the immune-suppressing medications • close monitoring for potential toxic effects such as renal and hepatic toxicity, NSAIDinduced gastritis, and central nervous system toxicity • anti-TNF agents could be administrated to elderly patients with RA • ROM exercises can help maintain function and muscle strength

Medication management Chronic insomnia

· temazepam (Restoril) for sleep onset insomnia · eszopiclone (Lunesta) for sleep onset and sleep maintenance · zolpidem CR and zolpidem (AmbienCR and Ambien) · zolpidem sublingual (Intermezzo) for sleep maintenance · zaleplon (Sonata) and ramelteon (Rozerem) for sleep onset insomnia. · All of these drugs are listed as potentially inappropriate medications (PIMs) on the Beers list (2015) to be avoided in older adults

Polypharmacy (Kennedy) Multiple definitions

· Polypharmacy can be simply defined as the use of multiple medicines (Mansoon, Shakin, Kalish-Ellet, & Caughey, 2017). This definition simply and briefly describes polypharmacy. The article also states that polypharmacy is common in older adult patients who have multiple chronic conditions due to one or more medications being used to treat each condition (Mansson, et al., 2017). · Polypharmacy can be defined as the use of five or more medications by an individual or the utilization of more medications then medically necessary. Another definition for polypharmacy is the duplication or overuse of medications (Doolan, 2018). · The first definition of polypharmacy appeared in medical literature centuries ago. When the term was first introduced, its definition was limited to excessive drug use and consuming multiple drugs. However, the definition of polypharmacy has since evolved to unnecessary drugs use and medication use without proper indications (Mortazavi, Shati, Keshtkar, Malakauti, Bazargan, & Assari, 2016). · Polypharmacy has been assigned several definitions throughout the course of medical history. In the past polypharmacy has been the overuse of a specified number of medications. Some resources say two drugs, while other say four to five. According to Kierner, Weixler, Masel, Gartner, and Watzke, the definition of polypharmacy is the overuse or underuse of over the counter medications, herbal agents, supplementary substances, or prescribed medications (2016). Multiple definitions (review discussion) o Prescribing many drugs, prescribing 5 or more drugs, or prescribing potentially inappropriate medications. o The use of multiple pharmacies (providers & self-prescribers) o Providers should routinely evaluate medication appropriateness to avoid the risk of polypharmacy

Possible consequences:

· Pulmonary hypertension · Systemic hypertension · Cardiac dysrhythmias · Right or left ventricle failure · Right ventricle hypertrophy · Myocardial infarction (increased risk of) · Stroke (increased risk of) · Nocturnal angina · COPD (exacerbation of) · Insulin resistance · Endothelial cell dysfunction

First-line treatment for late-life mania includes

· mood stabilizers lithium and valproic acid · antipsychotics, quetiapine and olanzapine Because older adults are frequently on multiple medications for other comorbid conditions, monotherapy has been recommended as a starting point with a backup plan for adding other drugs as indicated. Patients with coexisting dementia require individualized treatment, and co-management by a geriatric psychiatrist is advised. There is early evidence of a neuro-protective affect for developing dementia in those prescribed lithium Bipolar Mania U.S. Food and Drug Administration (FDA)-Approved Drugs ■ Anticonvulsant mood stabilizers: Lithium, valproic acid, divalproex, or carbamazepine (second line) ■ Antipsychotics: Olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, asenapine Bipolar Acute Depression FDA-Approved Drugs ■ Anticonvulsants: Lithium ■ Antipsychotics: Quetiapine, lurasidone, olanzapine-fluoxetine combination. Bipolar Maintenance FDA-Approved Drugs ■ Mood stabilizers: Lithium, lamotrigine, valproic acid ■ Antipsychotics: Olanzapine, aripiprazole, quetiapine, risperidone, ziprasidone Treatment may require a combination of the previously mentioned medications Electroconvulsive therapy (ECT) is highly effective in resistant cases of bipolar depression and should be considered if drug therapy is ineffective Dosing should begin at the lowest dose and be slowly increased, while monitoring comorbidities and adverse effects. Benzodiazepines are sometimes used for acute agitation in mania. SSRIs are generally not recommended for bipolar depression, as they are often ineffective and can induce mania; however, they are used in selective, resistant cases. A collaborative care model has been successful for patients with combined chronic medical and mental health problems Establishing a therapeutic alliance is key to management; psychotherapy and psycho-education are also an important part of treatment

Rheumatoid arthritis (Kenndy, Dunphy, Kahn) - incurable autoimmune condition that affects synovial joints in the body Signs and symptoms including musculoskeletal changes (symmetrical vs asymmetrical)

· morning stiffness > 1 hr · joint swelling & pain (small joints of hands, wrists, & feet) · symmetrical inflammatory polyarthritis · decreased physical function · In older adults, constitutional symptoms with RA may include low-grade fever, weight loss, malaise, and depression.

Medication management Transient insomnia

· zolpidem (Ambien) · zaleplon (Sonata) temazepam (Restoril

Seven major entities that are most frequently associated with diffuse ILD are

(1) IPF, (2) bronchiolitis obliterans organizing pneumonia, (3) connective tissue (collagen vascular) diseases (SLE, RA, progressive systemic sclerosis [scleroderma], and polymyositis-dermatomyositis), (4)systemic granulomatous vasculitis's (Wegener's granulomatosis, lymphomatoid granulomatosis, and allergic angitis and granulomatosis), (5) drug-induced pulmonary disease, (6) sarcoidosis, and (7) hypersensitivity pneumonitis.

Management of exacerbations

*Most often precipitated with respiratory tract infections. Mild: SABD (short acting bronchodilators) Moderate: SABD and/or corticosteroids Severe: ED and hospitalization

Medication Management:

1 st line: bisphoshonates are now the first line treatment alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis/Alendronate sodium (Fosamax), a third-generation bisphosphonate, has been approved by the FDA for the prevention and treatment of osteoporosis. • Calcium and Vitamin D • avoid malnutrition), calcium, and vitamin D • Post-menopausal women who are getting adequate calcium from dietary intake alone (approximately 1,200 mg daily) do not need supplementation • Women with inadequate dietary intake should take supplemental elemental calcium (generally 500-1,000 mg/day), in divided doses at mealtime, so that their total calcium intake (diet plus supplements) approximates 1,200 mg/day • Women should also ingest a total of 800 international units of vitamin D daily. Higher doses are required if they have malabsorption or rapid metabolism of vitamin D due to concomitant anticonvulsant drug therapy. Most postmenopausal women with osteoporosis require vitamin D supplementation because it is difficult to achieve goals with diet alone. TABLE 55.4 Recommended Daily Calcium Intake Women 50 years and younger 1,000 mg daily 51 years and older 1,200 mg daily Men 70 years and younger 1,000 mg daily 71 years and older 1,200 mg daily • ACP advises against estrogen replacement d/t higher risk of breast CA • Fluoride Oral sodium fluoride has been used extensively in Europe for the treatment of osteoporosis and has been found to significantly increase vertebral bone density by increasing the number of osteoblasts/ United States, sodium fluoride is currently not approved for the prevention or treatment of osteoporosis by the FDA. table 55.2 dunphy • Simple Calculated Osteoporosis Risk Estimation (SCORE) instrument, for example, is estimated to have 90% sensitivity and approximately 40% specificity for identifying individuals with low BMD at the hip. The Fracture Risk Assessment tool was developed to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as BMD at the femoral neck. It is a useful tool to aid clinical decision-making about the use of pharmacological therapies in patients with low bone mass. • The U.S. Prevention Task Force (USPTF) recommends osteoporosis screening in women 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors (Grade B). (DXA)—the "gold standard" for documenting osteoporosis of the proximal femur and lumbar spine

Management:

1 stop smoking! Inhaled short acting Beta2 agonist (SABA): 1st line therapy. "rescue" to alleviate acute episodes of bronchospasms. Albuterol Proventil Ventolin Pirbuterol Adverse reactions: Tremors Nervousness Dysrhythmias Short acting muscarinic antagonist: (ipratropium) rescue therapy, frequent use not recommended due to adverse effects. More frequent episode use LAMA (tiotropium (Spiriva) Corticosteroids Beclomethasone Budesonide (Pulmicort) Fluticasone (Flovent) *should be individualized* Potential risk: Immunosuppression Hypertension Hyperglycemia Adverse effects: Gastric ulcers Osteoporosis Masked infections Secondary infections *Management of acute COPD exacerbation do not use for more than 10-14 days. Combination therapy: LABA and ICS (in grade B or C patients) Advair (salmeterol plus fluticasone) Symbicort (formoterol plus budesonide LABA and LAMA (grade C &D) Tiotropium bromide plus olodaterol (Stiolto Respimat) Umeclidinium bromide plus vilanterol (Anoro Ellipta) PDE4 inhibitors Roflumilast (Daliresp) *COPD and bronchitis who have exacerbations. Xanthines Aminophylline Theophylline *4th line Antibiotics: Needed for acute exacerbation of chronic bronchitis when purulent sputum is present (S.pneumoniae, H.influenzae, M.Catarrhalis) Pseudomonas aeruginosa infection: Doxycycline 100 mg q12h. Trimethoprim-sulfamethoxazole 160/800mg q12h Cefpodoxime 200 mg q12h Azithromycin 500 mg (1st day), followed by 250 mg QD for 5 day Amoxicillin-clavulanate 875/125 mg Q12h Diuretics: may be necessary when there is evidence of cor pulmonale

Prevalence

20% of the U.S. population will experience a significant episode of depression at some time during their lives • The lifetime prevalence of an MDD is 16.5% with a 6.7% 12-month prevalence rate. • MDD in those 65 years and older is significantly less compared with younger age-groups • Those who are sick or in pain have a higher prevalence • Older adults have many risk factors for depression because of the frequent losses experienced within this age-group. • 10% to 44% prevalence of depressive symptoms in the elderly • 40% in nursing home patients • 30% in community-dwelling elders with chronic medical conditions. • Nursing home residents are three to four times more likely to suffer from depression compared to older adults living in the community • 85% of older adults with depression remain untreated, because it is often underdiagnosed, misdiagnosed, or obscured by comorbidities or somatic complaints that are physical problems • More common in women than men however men under report or do not report symptoms • 3% to 6% of women will develop PPD

Þ Incidence is community versus assisted living environments (Kennedy)

40% in nursing home patients 30% in community-dwelling elders with chronic medical conditions. • Nursing home residents are three to four times more likely to suffer from depression compared to older adults living in the community

Recommended exercises for sleep ad flexibility:

: Preferred amount is 30 minutes per day 5 days a week, if weight management is a part of this, 60 minutes per day is advised. To maintain the flexibility necessary for regular physical activity and daily life, older adults should perform activities that maintain or increase flexibility on at least 2 days each week for at least 10 minutes each day. Exercise recommendations for specific diagnosis P. 21 Osteoarthritis: waking, aquatic activities, tai chi, resistance exercises, cycling. *vary type and intensity to avoid overstressing joints, heated pool. Coronary artery disease: Walking, treadmill, cycle ergometry. *supervised program with BP and heart rate monitoring. Congestive heart failure: walking, treadmill, cycle ergometry. *Individualized to client, supervised program. Type 2 diabetes: Resistive, aerobic, aquatic, recreational activities. *Proper shoe fit; may need insulin reduction of insulin dependent. Anxiety Disorders: Walking, biking, weightlifting. * If able to do high-intensity exercise, this benefits anxiety. Depression: Walking, cycling, recreational activities. *Group participation helpful to keep patient engaged. Fibromyalgia: Aerobic, aquatic therapy, strengthening, tai chi, Pilates. *Heated pool, gentle stretches, counsel about possible increased pain initially. COPD: Cycle ergometer, treadmill, individualized. * Supervised program-consider pulmonary rehab. Chronic venous insufficiency: Walking, standing exercises. *Supervised program. Osteoporosis: Weight-bearing, weight training. *Assess balance and risk for falls before beginning. Parkinson's disease: walking, treadmill, stationary bike, dancing, tai chi, Pilates, boxing. *Assess balance and risk for falls before beginning. Age-related sleep disorders: tai chi, walking, aqua therapy, biking. *Assess balance and risk for falls before beginning. Dementia: Walking, recreational activities. *Provide safe environments, assess fall risk and ability to participate.

Medication management -first line;

: The goal is remission of symptoms. There are no specific guidelines specific to older adults, however, practice guidelines generally suggest similar pharmacological treatment for older adults as with younger adults Patients with bipolar disorder are often challenging to manage because of the fluctuating and chronic nature of bipolar disorder. Depending on the presentation and severity, inpatient treatment may be required to stabilize the patient.

Community acquired pneumonia (Dunphy) Signs andsymptoms:

: Typical symptoms include fever, chills, cough, and rusty or thick sputum, with associated gastrointestinal upset or anorexia, malaise, and diaphoresis; pleuritic chest pain may also be present, crackles. Older patient - mental status changes, falls, inc. resp. rate, hypotension, anorexia, new onset of urinary

Þ Know criteria to determine severity (FEV1)

Stage 1 Mild: FEV1≥80% predicted Stage 2 Moderate: FEV1<50% to <80% predicted Stage 3 Severe: FEV1>30% to <50% predicted Stage 4 very severe: FEV1<30% predicted

Þ Xray findings in ILD

Abnormalities on chest x-ray may be the first clue to the presence of ILD; however, the patient with ILD may be asymptomatic or symptomatic with either normal or abnormal chest x-ray results. The initial abnormality on the chest x-ray film is usually described as a ground glass, A scattered reticulonodular pattern or hazy appearance of the lungs

Atypical disease presentation

Acute abdomen: absence of symptoms or vague symptoms. Acute confusion. Mild discomfort and constipation. Some tachypnea and possibly vague respiratory symptoms. Appendicitis pain may begin in RLQ and become diffuse. Depression: Anorexia, vague abdominal complaints, new onset of constipation, insomnia, hyperactivity, lack of sadness Hyperthyroidism: Hyperthyroidism presenting as "apathetic thyrotoxicosis," (fatigue and weakness; weight loss may result instead of weight gain; patients report palpations, tachycardia, new onset of atrial fibrillation, and heart failure may occur with undiagnosed hyperthyroidism). Hypothyroidism: Often presents with confusion and agitation; new onset of anorexia, weight loss, and arthralgias may occur. Malignancy: New or worsening back pain secondary to metastases from slow growing breast masses. Silent masses of the bowel. Myocardial infarction: Absence of chest pain. Vague symptoms of fatigue, nausea, and a decrease in functional and cognitive status; classic presentations: dyspnea, epigastric discomfort, weakness, vomiting; history of previous cardiac failure. Higher prevalence in females versus males. Non-Q-wave MI. Overall Infectious disease process: Absence of fever or low-grade fever. Malaise. Sepsis without usual leukocytosis and fever. Falls, anorexia, new onset of confusion, and/or alteration in change in mental status, decrease in usual functional status. Peptic ulcer disease: Absence of abdominal pain, dyspepsia, early satiety. Painless, bloodless. New onset of confusion, unexplained tachycardia, and/or hypotension. Pneumonia: Absence of fever; mild coughing without copious sputum, especially in dehydrated patients; tachycardia and tachypnea; anorexia and malaise are common; alterations in cognition. Pulmonary edema: : Lack of paroxysmal nocturnal dyspnea or coughing; insidious onset with changes in function, food, or fluid intake, or confusion. TB: Atypical signs of TB in older adults include hepatosplenomegaly. Abnormalities in liver function tests, and anemia. UTI: Absence of fever; worsening mental or functional status, dizziness, anorexia, fatigue, weakness.

Physiological aging

Age related Change Functional Change Implications Integumentary System Loss of dermal and epidermal thickness Loss of subcutaneous tissue and thin epidermis. Prone to skin breakdown and injury Decreased vascularity • Atrophy of sweat glands resulting in decreased sweat production • Decreased body odor • Decreased heat loss • Dryness • Alteration in thermoregulatory response • Fluid requirements may change seasonally • Loss of skin water • Increased risk of heat stroke Respiratory System Decreased lung tissue elasticity Decreased vital capacity Reduced overall efficiency of ventilatory exchange Cilia atrophy Change in mucociliary transport Increased susceptibility to infection Decreased respiratory muscle strength • Reduced ability to handle secretions and reduced effectiveness against noxious foreign particles • Partial inflation of lungs at rest Increased risk of atelectasis Cardiovascular System Heart valves thicken and become fibrotic Reduced stroke volume, cardiac output; may be altered Decreased responsiveness to stress Fibroelastic thickening of the sinoatrial node; decreased number of pacemaker cells Slower heart rate Increased prevalence of arrhythmias Decreased baroreceptor sensitivity (stretch receptors) Decreased sensitivity to changes in blood pressure Prone to loss of balance, which increases the risk for falls GI Liver becomes smaller Decreased storage capacity Decreased muscle tone Altered motility Increases risk of constipation, functional bowel syndrome, esophageal spasm, diverticular disease Decreased basal metabolic rate (rate at which fuel is converted into energy) May need fewer calories

Treatment standards (Dunphy p. 383

Antimicrobial therapy represents the mainstay of treatment for patients with suspected or confirmed pneumonia. Additional management is supportive and includes the use of analgesics for relief of chest pain and myalgia, antipyretics to control fever, increased fluid intake (typically at least 3 L over 24 hours), restricted activity or bedrest, a position of comfort (usually upright) to facilitate breathing, and humidified air to relieve irritated nares and pharynx. Expectorants may be indicated to decrease sputum viscosity and clear airways if a productive cough is present PATIENT PROFILE ANTIMICROBIAL AGENT Uncomplicated CAP Without recent antibiotic therapy (ATBX)* Azithromycin (Zithromax) or clarithromycin (Biaxin) or doxycycline (Vibramycin) With recent ATBX† Respiratory fluoroquinolone moxifloxacin (Avelox) or levofloxacin (Levaquin) OR Azithromycin or clarithromycin PLUS High-dose amoxicillin (Amoxil) OR Azithromycin or clarithromycin PLUS High-dose amoxicillin-clavulanate (Augmentin) Patient with CAP plus comorbidities: alcoholism; diabetes mellitus; lung/liver/renal diseases Respiratory fluoroquinolone OR Beta-lactam IV/intramuscular ceftriaxone (Rocephin) or Cefuroxime (Ceftin) PLUS Macrolide Patient with community-acquired methicillin-resistant S. aureus pneumonia Vancomycin (Vancocin) OR Linezolid (Zyvox)

Þ Prevalence in the elderly

Approximately 50% of people more than 65 years of age experience and regularly complain of poor sleep quality. Poor health confounds this problem, with older adults with respiratory problems reporting 40% greater difficulty with insomnia, and those with psychiatric problems being two and one-half times more likely to experience insomnia • Insomnia can occur at any age; however, older adults have greater difficulty falling asleep and staying asleep. • Gender: Women who are widowed, separated, or divorced have more insomnia up to age 85 years • men have more insomnia in the over-85-years age group

Medications for each severity class

Asthma Step 1 (intermittent) Controller: none Reliever: SABA (short acting beta 2 agonist) less than 2 times per week. Step2 (mild persistent) Controller: Daily: low dose ICS (inhales corticosteroids) Alternative daily meds: LTRA (leukotriene receptor agonist), cromolyn, nedocromil, or theophylline. Reliever: SABA, not to exceed 3 to 4 times per day. Step 3 (moderate persistent) Controller: daily: low dose ICS plus LABA (long acting beta 2 agonist) or Medium dose ICS, Alternative: low dose ICS plus either LTRA, theophylline or zileuton Reliver: SABA prn, not to exceed 3 to 4 times per day. Step 4 (Severe persistent) Controller: Medium dose ICS plus LABA. Alternative: Medium dose ICS plus either LTRA, theophylline, or zileuton. Reliever: SABA prn, not to exceed 3 to 4 times per day. Consider short course of oral systemic corticosteroids. Step 5 Controller: Daily; High-dose ICS plus LABA Alternative: consider omalizumab for patient who have allergies. Reliever: SABA, inhaled treatments at 20-minute intervals times 3 if needed. Consider short course of oral systemic corticosteroids. Step 6 Controller: Daily; high dose ICS plus LABA plus oral corticosteroids. Alternative: consider omalizumab for patients who have allergies. Long term therapy may include systemic corticosteroids. Reliever: SABA, inhaled treatment at 20-minute intervals times 3 if needed.

*Barriers, facilitators, and contraindications to exercise:

Barriers ■ Lack of time ■ Perceived need for equipment ■ Perceived barrier to beginning exercise/physical activity ■ Disability or functional limitation ■ Unsafe neighborhood or weather conditions ■ No parks or walking trails ■ Depression ■ High body mass index (BMI) ■ Lack of motivation ■ Interpersonal loss or significant life event ■ Ignorance of what to do Patient Facilitators ■ Social support ■ Positive self-efficacy ■ Motivation to engage in physical activity ■ Good health, no functional limitations ■ Frequent contact with prescriber ■ Regular schedule, planned program ■ Satisfaction with program ■ Insurance incentive ■ Improvement in mobility or health condition ■ Staff Contraindications ■ Unstable angina ■ Uncompensated heart failure ■ Severe anemia ■ Uncontrolled blood glucose ■ Unstable aortic aneurysm ■ Uncontrolled hypertension or tachycardia ■ Severe dehydration or heat stroke ■ Low oxygen saturation

Chronic

Chronic: • Lunesta (Eszopiclone)-good for initiation and maintenance • Ambien (zolpidem) CR-help with initiating sleep and controlled release to help maintain Short term: • Sonata (Zaleplon)- not for sleep maintenance • Ambien (zolpiem) -help with initiating sleep Orexin A and B blocking agent: schedule IV-Belsomra (suvorexant)- care in the elderly per Epocrates, not on BEERS list bc new receptor agonists: to promote sleep onset • Remelteon (Rozerem) FDA approved • Melatonin is on the BEERS 2015-PIM(avoid in elderly) Antihistamines: Benadryl OTC (may have a paradoxical effect in children and older adults) - BEERS-PIM avoid in elderly-cause cause "hangover" effect Benzodiazepines: not recommended in the elderly on the BEERS PIM list • Estazolam (pro-som)-short term-intermediate • Flurazepam (Dalmane)-short term-long acting-avoid in elderly • Temazepam (Restoril)-short term-intermediate-excellent option for elderly • Triazolam (Halcion)-short acting • Quazepam (Doral)-long acting Antidepressants: • TCA-Doxepin(silenor)-only one FDA approved for insomnia • Trazodone(commonly used off label)-mirtazapine Antipsychotics: • Quetiapine-olanzapine Follow up: 2 weeks

Medication management Who Diagnostic criteria (Dunphy p. 8650

Clinical tool developed to assist clinicians in the identification of patients at high risk for fractures: 1. FRAX: Fracture Risk Assessment Tool a. screen patients with low bone density who are not currently receiving treatment to help determine need for treatment b. integrates validated clinical risk factors and BMD of the femoral neck to calculate the 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip, or shoulder) c. not appropriate to use FRAX to monitor treatment response

Domains-identify all 4, screening tools associated with each domain:

DIMENSIONS OF COMPREHENSIVE GERIATRIC ASSESSMENT Physical health chief complaint, history of present illness, past history, family and social history, and a review of systems), History taking Physical examination Diagnostics Nutritional assessment Medication review Functional health the Katz Activities of Daily Living Scale Activities of daily living Instrumental activities of daily living Sensory assessment (hearing, vision) Gait and balance Psychological health MMSE: the Mini-Cog, Montreal Cognitive Assessment (MoCA), and Saint Louis University Mental Status Examination (SLUMS) Cognitive disorders (delirium, dementia, mild cognitive impairment) Affective disorders (depression, anxiety) Spiritual well-being Socioenvironmental The Medical Outcomes Study—Short-Form 36 Social network and support Supports Lubben Social Network Scale Living situation Environmental safety Economic resources Quality of life measures The Medical Outcomes Study—Short-Form 36 Physical conditions Social conditions Environmental conditions Personal resources (mental health, life perspective) Preferences for care

Diagnostic criteria

Diagnostics to assess for underlying or undiagnosed medical causes of depressive symptoms should be ordered. Standard blood work includes: · CBC with differential · CMP · lipid panel · thyroid function studies (TSH with reflex T4) · serum vitamin B12 · serum vitamin D levels. While the tricyclics (TCAs) and mono-amine oxidase inhibitors (MAOIs) are still available, these are no longer considered first-line recommendations. Þ 1st line treatment (mild, moderate, severe) Þ Medication management Monitor and evaluate therapeutic response to antidepressant therapy, and observe for side effects, tolerance, and unremitting symptoms of depression. Studies show that the majority of patients on a single agent (monotherapy) do not tolerate it, have limited or no response, stop the medication within the first 3 months, or never receive an adequate dose or trial of medication. Consequently, monotherapy is effective in approximately one-third of patients, and the great majority do not reach remission. · For those patients who do not respond adequately to monotherapy, other treatment strategies may be employed. · Switching agents within the same class or combining different types of antidepressants (e.g., a combination of sertraline and bupropion) may result in symptom remission. · With multiple failed trials of monotherapy or combination therapy, the patient may be considered to have treatment-resistant depression. · Several second-generation antipsychotic agents are FDA approved for augmentation to antidepressant therapy in treatment resistant depression: · aripiprizole (Abilify) · quetiapine extended release (Seroquel XR) · olanzapine (Zyprexa)

DEXA results: normal, osteopenia, osteoporosis BMD is measured:

Dual-energy x-ray absorptiometry (DEXA or DXA) The results are reported as T- and Z- scores · WHO T-score compares the bone mass of the patient to the mean of a young adult (20-year-old healthy woman) · Recommendations apply to postmenopausal women and men age 50 years and older · In premenopausal women, men less than age 50 years, and children, the International Society for Clinical Densitometry (ISCD) recommends the diagnosis of osteoporosis be made based on ethnic- or race-adjusted Z-score · A Z-score of -2 or less is defined as low BMD for chronological age and those above -2 are within the expected range for age T-score of -1.0 or above = normal bone density T-score between -1.0 and -2.5 = low bone density, or osteopenia T-score of -2.5 or lower = osteoporosis

COPD (Dunphy & Kennedy) Signs and Symptoms:

Dyspnea, chronic cough with or without sputum production, decreased activity tolerance, wheezing. Dyspnea, chronic cough with or without sputum production, recurrent lower respiratory infections, wheezing, chest tightness, fatigue, weight loss, and/or anorexia. increased anteroposterior diameter of the thorax, use of accessory muscles for respiration, prolonged expiration, hyperresonance on percussion, decreased heart and breath sounds, tachypnea, neck vein distention during expiration in absence of heart failure, ruddy or cyanotic skin color, and clubbing of nail beds

Know which airway diseases are reversible and irreversible

FEV 1 /FVC ratio before and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates reversible airway obstruction COPD: non reversible Emphysema: non reversible Asthma: reversible

Beers Criteria: Purpose:

Guide to use for medical management of geriatric patient's o List of potentially inappropriate medications for the elderly-listed by drug category and diagnosis o Lists alternative drugs that can be used safely in older adults o Drug to drug interactions listed, dosage for kidney impairment graded as high, medium, or low to assist with decision making.

Recommended health screenings-age ranges and frequency

Hearing loss: 50+ HIV: 15-65, and pt with increased risk. Alcohol misuse: 18+ Tobacco: all adults Depression: All adults including pregnant and PP women. Blood pressure: 18+ Blood Glucose: 40-70 as a part of cardiovascular risk assessment, overweight or obese. CVD: adults without a history of CVD (symptomatic CVD or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met; 1. They are aged 40-75 years. 2. They have one or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) 3. They have calculated 10-year risk of cardiovascular event risk requires universal lipids screening in adults aged 40-75 years. AAA: 1-time screening by ultrasonography in men age 65-75 years who have ever smoked. Obesity: all adults, offer to refer patients with a BMI of 30 or higher intensive multicomponent behavioral interventions. Mammography: Biennial age 50-74 Osteoporosis: women age 65+, younger whose fracture risk is equal or greater than that of a 65-year-old white woman. Prostate cancer: Cognitive impairment: Colorectal cancer: starting at age 50 to age 75.

Signs and symptoms & Hypersomnolence signs and symptoms:

Hypersomnolence is the single most important presenting symptom of sleep apnea. Daytime symptoms include a morning headache (from hypercapnia) and neuropsychological disturbances, including falling asleep while performing purposeful activities. The patient may complain of nocturnal restlessness, frequent urination, or enuresis, and choking. Patients also may report impaired intellectual performance, such as decreased concentration, ambition, and memory loss.

Þ Know criteria for diagnosis of reversible vs irreversible

If the patient has an obstructive defect, the physician should determine if it is reversible based on the increase in FEV1 or FVC after bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of age, or more than 12% and more than 200 mL in adults). Obstructive defects in persons with asthma are usually fully reversible, whereas defects in persons with COPD typically are not. If a patient's prior PFT results are available, they should be compared with the current results to determine the course of the disease or effects of treatment. According to Dunphy: • FVC=Forced vital capacity is the total volume exhaled during one spirometry maneuver (patient forcefully exhales into the spirometer) • FEV1 =volume exhaled in 1 sec (forced expiratory volume over 1 second) • FEV1/FVC ratio is expressed as a percentage of FVC TABLE 31.2 Pulmonary Function and Physical Findings in Obstructive and Restrictive Lung Diseases ParametersAsthmaChronic BronchitisEmphysemaRestrictive DiseaseForced vital capacity (FVC)NormalNormal to increasedNormal to increasedDecreasedResidual volume (RV)Normal; increased during attacksIncreasedIncreasedDecreased or normalTotal lung capacity (TLC)Normal to increasedNormalNormal to increasedDecreasedRV/TLCNormal to increasedIncreasedIncreasedNormalExpiratory flow ratesNormal to decreasedNormal to decreasedNormal to decreasedNormal to increasedFEV1/FVCNormal to decreasedDecreasedDecreasedNormal to increasedBronchodilator response (% change)>15%0%-15%NoneNoneDiffusing capacityNormal to increasedNormal to decreasedDecreasedNormal or decreased (depends on type of disease)PaO2Normal; decreased during attackDecreasedNormal in mild to moderate disease; decreased in severe diseaseNormal or decreasedPaCO2First decreased, then increased during acute attackIncreasedNormal until advanced disease, then increasedNormal or decreased; increased in very advanced diseaseBreath sounds Marked decrease during acute attacks If FEV1 = 0.5 L or less: absent If FEV1 = 1 L: barely audibleDecreasedNormal or decreased in pneumonia, atelectasisCrackles (rales)Coarse crackles during infectionsCoarse crackles during infectionsFine crackles may be presentVaries with type of restrictive diseaseWheezes (rhonchi)High-pitched; continuousForced expiratory wheezesNoNo

Most common sleep disorder

Insomnia

Þ Severity classifications

Intermittent: < 2 days/w ; nighttime awakenings: ≤2x/month Persistent: § Mild: 2 days/week but not daily; nighttime awakenings: 3-4x/month § Moderate: daily; nighttime awakenings: 1x/week but not nightly § Severe: Throughout the day; nighttime awakenings: often 7x/week

Immunizations:

Kennedy p.12: PCV13: over 65: single dose; for those with chronic health conditions may administer a dose before age 65 and boost with a second dose after age 65. PPSV23: Over 65: Given 1 year after PCV13. Diphtheria-tetanus-pertussis (Tdap): Any adult-one-time substitute for Td; Single dose. Tetanus diphtheria (Td): Every 10 years after single dose of DTaP; Single dose after 10 years. Influenza: All adults: annual Hepatitis B: All with risk factors due to lifestyle, history of diabetes; 3 doses. Herpes zoster (HZV): adults aged 50 years or older regardless of whether they had a prior episode of herpes zoster, immunize those who have had Zostavax with shingles; 2 doses age 50 or older. Dunphy: Influenza: annually adults over 50, unless contraindicated. Tdap: once in a lifetime booster, following this, a Td booster every 10 years. pneumococcal: administered as a 1-time dose to PVC13 naïve adults age 65, followed by a dose of PPSV23 12 months later. Hepatitis b: high risk, pt over age 60 with DM. additional dose, then 2nd dose 1 month later, 3rd dose 4-6 months. Zostavax: all over 60.

Diagnostic criteria:

Kennedy: Spirometry is the GOLD standard for measuring airflow limitations. FEV1 >/= 80% predicted Mild 50% FEV1</= 80% predicted Moderate 30% FEV1 </= 50% predicted severe FEV1 <30% predicted very severe Chest X-ray: will appear normal in early copd. CT: to rule out bronchiectasis. Labs: CBC with differential, HGB, HCT, RBC should be evaluated to rule out anemia or polycythemia. Serum alpha1-antitrypsin levels should be checked in patients who develop COPD at an early age (younger than 45), those with clinical emphysema of early onset COPD. A blood chemistry profile is done to assess electrolyte balance (K, Na, Cl) and nutritional status (total protein, albumin), as well as rule out renal or liver problems. GRAM stain is the best clinical method for diagnosis an acute exacerbation because the bacteria can be seen and quantified. (if a gram stain shows neutrophils but no bacteria in a patient with chronic bronchitis, the acute exacerbation is probably viral or chlamydial, even when the sputum culture yields haemophilus or pneumovovvid. A negative gram stain indicates that a positive culture results likely represent bacterial colonization, rather than a true infection).

Þ Medication metabolic side effects.

Lithium: initial evaluation of renal, cardiac, and thyroid function before initiating therapy, and then periodically during therapy. Lithium levels need close monitoring during the initial period and periodic monitoring once stabilized. Concurrent use of NSAIDs, thiazide or loop diuretics, and angiotensin-converting enzyme (ACE) inhibitors may adversely affect lithium levels · Adverse effects include o tremor o hypothyroidism o weight gain o cognitive and renal impairment Valproic acid: · drug levels, liver function tests (LFTs), and CBC. Adverse effects include weight gain, hepatotoxicity, pancreatitis, and thrombocytopenia. · Atypical antipsychotics · have weight gain, glucose, and lipids monitored. · QT interval prolongation can also occur. § prescribed for older adults with dementia=increases mortality.

Þ Underlying psychological causes

MDD, GAD, manic episode, psychotic illness-schizophrenia, traumatic eventsPTSD, poor sleep hygiene

Þ Medication management

Maintenance SSRI use has been shown to reduce relapse of anxiety in older adults. SSRIs can increase anxiety if started at higher doses. It may take several weeks for full effect to occur.

*Recommended testing prior to exercise initiation:

None for all adults who do not have symptoms and have not been diagnosed with chronic disease such as OA, diabetes, heart disease • Patients with chronic conditions: need to consult with health care professional • Men over 45 and women over 55 who are considering a vigorous program need to screening and routine stress testing • Sedentary older adults and adults with cardiac disease/or strong risk factors need screening and stress test before undertaking vigorous exercise program

PFT:

Normal FEV 1 /FVC ratio but decreased FVC and FEV 1; decreased total lung capacity, residual volume, and functional residual capacity. Residual volume-to-total lung capacity ratio is normal to low.

Þ Sleep/ Wake Disorders (Dunphy) Þ Underlying medical causes

OSAH (obstructive sleep apnea hypopnea) • RLS (Restless leg syndrome)-dysfunction of dopaminergic system/low iron: leading to neurological/sensorimotor condition-burning-tingling-itching-crawling sensation and desire to move the lower ext-tx dopaminergic agents (ropinirole/requippramipexol/mirapex) • GERD • Arthritis/muscle cramps • Fibromyalgia • Delirium/dementia • Conditions causing SOB • Thyroid disease • Obesity • Substance use/intoxication/withdrawal • Pregnancy/postpartum • Nocturia • Medication side effects • Periodic limb movement disorder

o Signs and symptoms including musculoskeletal changes (symmetrical vs asymmetrical)

Osteoarthritis morning stiffness lasting <30 mins but improves with activity. Also known as degenerative joint disease. It most commonly affects hips, knees and cervical and lumbar spine. While the joint deformity with minimal pain is usually found in the DIP and PIP joints of the hand and the first metacarpal joint and metatarsophalangeal (MTP) joint OA may present as monoarticular or polyarticular. • Morning joint stiffness lasting less than 30 minutes; joint stiffness that improves with mild activity. gel phenomenon. • Bouchard's nodes (PIP joints), Heberden's nodes (DIP joints), and joint crepitus. • Weight-bearing joints such as the knees and hips are most affected by OA. • Persistent pain and limitation of motion in the affected joint. • Bouchard's nodes (nontender nodules of the PIP joints), • Heberden's nodes (nontender nodules of DIP joints of the hands and feet), or both may be found • The carpometacarpal joint located at the thumb base is often involved, and crepitus may be elicited. • metacarpophalangeal joints are rarely involved in OA • In women, erosive OA often occurs in the PIP joints and DIP joints, manifesting red, tender joints that eventually result in joint erosion, joint deformity, and subsequent ankylosis. • autoimmune disorder to consider is also psoriatic arthritis, as these symptoms can mimic inflammatory OA. • MTP joints may be involved in OA. • OA of the knee- crepitus (a grinding sensation of the joint) of the affected joint. In addition to pain and morning stiffness, enlargement of the knee joint; knee locking and unsteadiness • OA of the hip and knee may present with a counteractive gait; patients are limping to avoid pain of the affected hip and/or knee. • Examine bilateral quadriceps muscles for signs of weakness and an internal and/or external hip rotation that may be reduced • Patients with OA of the cervical spine often complain of paresthesia in the arms waking them from their sleep • cervical spine may show some restricted joint movement and muscle tenderness • OA of the lumbosacral spine: pain across the lower back with radiation to the buttocks and the posterior thigh. If nerve root compression has occurred, patients may complain of pain in the lower leg known as pseudoclaudication. • antalgic gait; patients are limping to avoid pain on the affected hip and/or knee. Examine bilateral quadriceps muscles for signs of weakness; internal and external hip rotation may be reduced. • Internal derangement in weight-bearing joints may cause them to "lock" or "buckle," increasing the risk for falls

Risk related to Travel

Patients with chronic disease that is well managed at home may decompensate in foreign environments because of heat, humidity, altitude, fatigue, changes in diet, and exposure to infectious diseases. Fever is not always a reliable indicator of illness in the older adult. Seroconversion rates decrease with age, rendering some vaccines less effective for older travelers. all immunizations should be current. influenza, pneumococcal, Td/Tdap (tetanus, diphtheria, and acellular pertussis), zoster, and for some, hepatitis B vaccination. Yellow fever and herpes zoster vaccine are the only live virus vaccines that people over age 50 receive. Immune response can be impaired if live virus vaccines are given within a 28- to 30-day interval of each other. Yellow fever vaccine is not effective until 10 days after administration. If the NP gives a patient a herpes zoster vaccine, that patient cannot receive a yellow fever vaccine for 30 days. If the patient is required to have a yellow fever vaccine for travel, he or she cannot enter a yellow fever country until 10 days after receiving the yellow fever vaccine. If a patient receives a yellow fever vaccine, he or she cannot receive a herpes zoster vaccine for 28 days. The patient may receive both vaccines on the same day with no decrease in immune response The most common vaccines used for protecting travelers are hepatitis A, hepatitis B, typhoid fever, yellow fever, adult booster polio, Japanese encephalitis, meningococcal, and rabies.

Osteoporosis ·

Personal history of fractures? Family hx? Questions about libido and potency in men are important to determine secondary gonadal issues. ·Most common fractures are those of the spine, hip, wrist, and distal forearm. ·Exceptions are fractures of the fingers, toes, face, and skull, which tend to be more related to trauma than low bone mass

Unipolar Depression (Kennedy and Dunphy) Þ Signs and symptoms, risk factors, prevalence

Pervasive and sustained mood of sadness, discouragement, lack of pleasure in usual activities, guilt, loss of motivation, low energy, and sleep and/or appetite disturbances. Depression is described as a pervasive feeling of sadness or a lack of interest or pleasure in previously enjoyed or usual activities. Feelings of guilt, low self-esteem, sleep and appetite disturbances, low energy, and poor concentration are common. Late-life depression is defined as a new onset of depression occurring in one's sixties. Depression may be categorized as · a single episode or recurrent · further qualified as mild, moderate, or severe · with or without features such as melancholy, mood-congruent, catatonia, peripartum · onset, or with seasonal pattern. Types of geriatric depression include · MDD · Vascular depression § The comorbidity of depression, vascular disease, vascular risk factors, and the association of ischemic cerebral lesions with distinctive behavioral symptoms supports the "vascular depression" hypothesis. This hypothesis proposes that cerebrovascular disease may predispose, precipitate, perpetuate, or exacerbate some geriatric depressive syndromes o Dysthymia o Depression that manifests as a comorbid condition in dementia, bipolar § disorder, and executive dysfunction Depression is not a normal part of the aging process

o 1st line treatment:

Treatment: multifaceted approach · Walking · Water therapy · Acetaminophen · NSAIDs- cyclooxygenase type 2(COX-2) such as celecoxib (Celebrex) 50-100mg BID. In patients who cannot afford COX-2 may try, nonacetylated salicylates such as Magnesium trisalycylate 500-750mg BID-TID. · Tramadol can be given at 50mg Q 4 -6 hours · Opiates such as codeine and oxycodone can be used for severe OA · Glucosamine and chondroitin · Topical diclofenac sodium

Geriatric syndrome

SPICES Sleep Disturbances Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown They are starting to experience bladder control problems, sleep problems, delirium, dementia, falls, gait and balance, depression, visual acuity, and weight loss. Early implementation of preventive therapies and safety measurement are important. Prevention is best provided using an interdisciplinary team approach. Early detection and correction of problems such as sensory deficits, confusion, and gait and balance issues can increase independence and longevity among this group. The focus of all healthcare should be on maintaining function, dignity, and individual control to promote health and quality of life. Associated with substantial morbidity and poor outcomes. They are multifactorial and although each is distinct, they share several risk factors. For example, older age, cognitive impairment, functional impairment, and mobility impairments are risk factors for falls, functional decline, delirium, and pressure ulcers.

Categories of aging-know age ranges for old, young old, old-old, ect.

TABLE 1-2 Select Bimodal Presentations of Illness in Younger Adults versus Older Adults TYPE OF CONDITION YOUNGER ADULTS OLDER ADULTS Dermatological Psoriasis Late teens to 20sIrregular course which tends to generalize Hereditary factors 50s—males60s—femalesSporadic onset GastrointestinalInflammatory bowel disease Ulcerative colitis (UC) Crohn's disease (CD) 20-40 years oldRight lower UCInsidious onset >60-75 years old a second peak occursMore often older womenProctitisLeft-sided UCHigher rates of anemiaMay present as chronic diarrheaFistula developmentIncreased cases of associated malnutritionExtraintestinal manifestations including: arthritis spondylitis,uveitis, and erythema nodosumMore comorbid conditionsMay be confused with other forms of colitis MalignanciesHodgkin's lymphoma 20-30 years oldPossible infectious etiology >50 years oldIncreased mortality NeurodegenerativeMyasthenia gravis (MG) Women 20-40 years oldMore thymus abnormalities Men—50-70 years oldWomen—70 years oldDysphoniaMore frequent ocular form MGIncreased rate of AChR seropositivity implementation of preventive therapies and safety measurement are important. Prevention is best provided using an interdisciplinary team approach. Early detection and correction of problems such as sensory deficits, confusion, and gait and balance issues can increase independence and longevity among this group. The focus of all healthcare should be on maintaining function, dignity, and individual control to promote health and quality of life. Associated with substantial morbidity and poor outcomes. They are multifactorial and although each is distinct, they share several risk factors. For example, older age, cognitive impairment, functional impairment, and mobility impairments are risk factors for falls, functional decline, delirium, and pressure ulcers.

Purpose of the CGA

The comprehensive approach to the geriatric assessment recommended because the physical health of the older adult is inextricably related to function ability, psychosocial health, and a safe and enabling environment. CGA helps not only to diagnose treatable conditions and improve patient outcomes, but also to identify potentially preventable conditions.

1. Chronic insomnia

Thorough family hx (inc. sleep problems), A validated self-administered instrument, such as the Epworth Sleepiness Scale or Stanford Sleepiness Scale, sleep diary, interrogate sleep partner (if any), If sleep apnea is suspected, refer for polysomnography, review sleep hygiene tips (Combined, sleep hygiene instruction and cognitive behavioral therapy are more effective than either modality alone or usual treatment), music therapy, aerobic exercise

o Medication management

Tramadol can be given at 50mg Q 4 -6 hours Opiates such as codeine and oxycodone can be used for severe OA Glucosamine and chondroitin Topical diclofenac sodium

Medication management

Treatment of osteoporosis should be considered for patients with low BMD, as well as a 10-year risk of hip fracture of 3% or more or a 10-year risk of a major osteoporosis-related fracture of 20% or more. GOAL: to prevent fractures Basic level of prevention and treatment includes diet, exercise, and fall prevention strategies. Adequate intake of calcium and vitamin D is essential to decrease bone loss and bone turnover. Vitamin D replacement is available in two forms, ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3). optimal and safe range. Vitamin D levels should be at least 77 µmol/L or 30 ng/mL because lower levels can result in secondary hyperparathyroidism and have been linked to an increase in other chronic diseases. When interpreting serum calcium level in older adults, it is important to correct for albumin level because 30% to 55% of calcium is bound to albumin. A falsely low measurement results when albumin is low. Every 1 g/dL of albumin binds 0.8 mg/dL of calcium. The correction adds 0.8 mg/dL for every 1 g/dL decrease in albumin. Ionized calcium measures free calcium, but it is an expensive test that is difficult to interpret; consultation before requesting may be helpful

o Radiographic findings:

Two views of the affected joint are recommended with the exception of the sacroiliac joint and the pelvis. Other types of imaging tests such as ultrasound and MRI may be used to detect damage to cartilage, ligaments and tendons, which cannot be seen on Xray joint space narrowing due to loss of cartilage, later finding Asymmetrical joint space narrowing • subchondral cyst formation can be seen on xray beneath the surface of the joints, • subchondral bony sclerosis, and osteophytosis, resulting in proliferative bone spurs known as osteophytes develop at the margin of the joint as a protective measure for the damaged joint structure • Two views of the affected joint are recommended, with the exception of the sacroiliac joint and pelvis • ultrasound and MRI may be used to detect damage to cartilage, ligaments, and tendons, which cannot be seen on x-ray. • Arthrocentesis should be considered for joint effusions to rule out crystalline disease or infection. • The synovial fluid in OA is usually clear, viscous, and has less than or equal to 2,000 white blood cells per µL. • Baseline laboratory studies (CBC, liver function tests [LFTs], BUN, and creatinine) should be obtained before initiating long-term drug therapy for monitoring purposes • Magnetic resonance imaging (MRI) and computed tomography (CT) scans may be ordered for patients with suspected spinal stenosis

Lab results Dunphy table 77.2

UA Normal Changes with age Comments Protein 0-5 rises slightly Due to kidney changes, UTI, renal SG 1.005-1.020 Lower 1.016-1.022 Decline in nephrons impairs ability to Concentrate urine Hematology ESR M: 0-20 W: 0-30 Sign increase Neither sensitive nor specific Iron binding 50-160 230-410 Slight decrease HGB M: 13-18 W:12-16 M: 10-17 W: none Anemia is common in elderly HCT M: 45-52 W: 37-48 Slight decrease Decline in hematopoiesis Leukocytes 4,300-10,800 Drop to 3,100-9,000 Decrease may be due to drugs or sepsis Lymphocytes 500-2,400 Tcells Fall infection risk higher 50-200 Bcells Immunizations encouraged Platelets 150,000-350,000 no change Blood chemistry Albumin 3.5-5.0 Decline R/T decreased liver size and enzymes. Protein-energy malnutrition common. Globulin 2.3-3.5 Slight increase Total serum Protein 6.0-8.4 no change Decrease may indicate malnutrition Infection, liver disease BUN M: 10-25 Increases significantly Decline in GFR W: 8-20 up to 69 Decreased cardiac output Creatinine 0.6-1.5 increases to 1.9 RT lean body mass Creatinine Decreases 10% Used for prescribing meds Clearance 104-124 after 40 yrs old for drugs excreted by kidney GT 62-110 (after fasting) Slight increase 10 Diabetes increase in prevalent <120 (2h PP) after 30 yrs drugs may cause intolerance Alk Phos 13-39 increase by 8-10 Elevation >20% usually due to disease Elevations may be found with bone Abnormalities, drugs (narcotics), and Eating fatty meals.

Þ Bipolar Depression Signal Symptoms

Variable presentation ranging from depression to mania or hypomania, feelings of grandiosity, rapid speech, or irritability. Up to 22% of older adults with bipolar disorders experience anxiety symptoms Cognitive deficits affecting verbal fluency and memory are common in older adults the depressive symptoms often include trouble with eating and sleeping Bipolar disorders are classified as 1. Bipolar I disorder requires an individual to have experienced at least one manic episode. A manic episode involves a change in mood that may be expansive, euphoric, or irritable, and accompanied by an increase in energy level. Most patients also have depressive episodes, but this is not a required component. 2. Bipolar II disorder requires at least one prior episode of major depression and at least one hypomanic episode, a milder form of mania. 3. Cyclothymic disorder is characterized by milder mood alterations that occur over a longer period of time, while unspecified bipolar disorder consists of symptoms that cause clinical impairment but do not meet criteria for the previously mentioned listings 4. Other specified bipolar and related disorders Each depends on the presentation and intensity of symptoms. It is important to distinguish bipolar disorder from major depression, as treatment differs. Elevated mood, presenting as euphoria or irritability. Dysphoria, manifesting with depression alone or with irritability. Rapid cycling includes back-and-forth shifts from mania to depression. Inquiring about suicide ideation or intent should be addressed at every visit. Psychotic symptoms can present in either manic or depressed states, and cognitive impairment is common. The acronym DIGFAST has been used to describe signs and symptoms during a manic or hypomanic phase. According to the DSM-5, the individual must also experience increased energy while having these symptoms ■ Distractibility ■ Insomnia ■ Grandiosity ■ Flight of ideas ■ Activities (hyperactive, does not require rest) ■ Speech (rapid, can be garbled) ■ Thoughtlessness (impulsivity) Symptoms during the depressive phase are similar to those of major depression. Use the acronym SIGECAPS: ■ Sleep disturbance ■ Interest/pleasure reduction ■ Guilt feelings, thoughts of worthlessness ■ Energy changes/fatigue ■ Concentration/attention impairment ■ Appetite/weight changes ■ Psychomotor disturbances

Diagnostic criteria (medical and psychiatric causes:

insomnia is a clinical diagnosis, sleep history should include an assessment of daytime sleepiness, fatigue, or sleep disturbance; the sleep environment; and the duration of symptoms. Additionally, information on frequency and duration of awakenings, sleep times, nap times, and lengths is important

Þ Sleep apnea (Dunphy) Diagnostic criteria (includes riskfactors)Sleep apnea

is defined as a temporary pause in breathing during sleep that lasts at least 10 seconds. For a confirmed diagnosis, this should occur a minimum of five times an hour. The predominant physical examination findings of OSA reflect the risk factors: obesity (particularly of the upper body), increased neck size, crowded oropharynx (tonsillar hypertrophy and enlargement of soft palate [uvula] and tongue).

1st line treatment

methotrexate - disease-modifying antirheumatic drugs (DMARDs) o Medication management corticosteroids, analgesia, NSAIDs DMARDS - suppress immune system, may take up to 3 mos for full effect methotrexate - 5mg once/w, co prescribed with folic acid ■ Sulfasalazine ■ Leflunomide ■ Hydroxychloroquine TB and hep testing prior to tx. TNF inhibitor biological agents etanercept, adalimumab, infliximab, certolizumab, golimumab, rituximab, abatacept

Prevention strategies

o Have new patients bring in all medications to their first visit o Review med list at every visit o Ask if any other provider has changed or added any meds o Update med list at every visit

Screening tools

o Three available tools to evaluate patient's prescriptions § STOPP (screening tool of older persons' potentially inappropriate prescriptions § MAI (Medication Appropriateness Index) § ARMOR (Assess, Review, Minimize, Optimize, Reassess)

systemic evaluation

o eye examination - keratoconjuctivitis, scleritis, corneal ulcers o lungs - pleuritis, pneumonitis o cardiac examination -pericarditis o nerve- nerve entrapment, sensory neuropathy

Clinical joint findings

o hyperflexion of the PIP joints o flexion of the DIP joints (swan neck deformities) o flexion of the PIP joints and extension of the DIP joints (boutonniere deformity) o ulnar deviation of the metacarpophalangeal joint o knee and ankle effusions o skin should be checked for subcutaneous nodules, which are generally <1 to 3 cm in diameter - firm and fixed on palpation

Asthma (Dunphy): Þ Signs and symptoms

recurrent wheezing, cough (especially at night), recurrent chest tightness, shortness of breath

Insomnia Signs and symptoms

reports not sleeping, excessive daytime sleepiness, loud snoring (sleep apnea), restless legs, difficulty falling asleep and staying asleep, irritability, difficulty concentrating, sleep that is not refreshing and restful, daytime fatigue, an older adult may spend 10 to 12 hours in bed at night trying to sleep

Blood tests

rheumatoid factor (RF), CRP, ESR, anti-citrullinated peptide antibodies ( when accompanied by high RF titer), anti-CCP antibodies, CBC may show normochromic, normocytic anemia, mild leukocytosis, and thrombocytosis

The largest group:

Ø occupational and environmental inhalant diseases; these include diseases resulting from inhalation of inorganic dusts, organic dusts, gases, fumes, vapors, and aerosols. Ø Other categories include ILDs caused by drugs, irradiation, poisons, neoplasia, and chronic cardiac failure. Ø unknown causes are idiopathic pulmonary fibrosis (IPF) and connective tissue (collagen vascular) disorders with ILD, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), progressive systemic sclerosis, polymyositis-dermatomyositis, and Sjögren's syndrome.

Obstructive pattern

Þ An FEV1/FVC <70/80% suggests obstructive lung disease. o Decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC o Classically, these are the patients with asthma, chronic bronchitis, or emphysema § PFTs can help further distinguish between the above three: § Bronchodilator responsiveness - an increase in the FEV1 by 12% following bronchodilator use suggests asthma § Bronchial provocation - inducing asthmatic obstruction of reactive lower airways by administering methacholine, histamine, or adenosine monophosphate § DLCO will be decreased in patients with emphysema, and can be normal or increased in patients with asthma o Lower airway obstruction vs. upper airway obstruction § Lower airway obstruction typically displays impaired expiratory capacity (see image below), while upper airway obstruction has impaired inspiratory capacity, which can be evident on the flow volume loop (seen as flattening of the inspiratory arm).

Diagnostic criteria:

Þ CURB -65 (each criteria worth 1 pt) C - Confusion U - BUN >19 ng/dL R - Respiratory rate ≥ 30 breaths/min B - BP: Systolic <90 mm Hg OR Diastolic <60 mm Hg

Diagnostic criteria:

Þ FEV 1 /FVC ratio before and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates reversible airway obstruction; If spirometry is near normal, bronchoprovocation such as a methacholine challenge test may help to differentiate other conditions with a similar presentation

Spirometry (Kahn Academy video and readings) Know definitions for each spirometry criteria:

Þ Spirometry measures two key factors: expiratory forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Your doctor also looks at these as a combined number known as the FEV1/FVC ratio. If you have obstructed airways, the amount of air you're able to quickly blow out of your lungs will be reduced. This translates to a lower FEV1 and FEV1/FVC ratio. Forced vital capacity (FVC). This is the largest amount of air that you can forcefully exhale after breathing in as deeply as you can. A lower than normal FVC reading indicates restricted breathing. Forced expiratory volume (FEV). This is how much air you can force from your lungs in one second. This reading helps your doctor assess the severity of your breathing problems. Lower FEV-1 readings indicate more significant obstruction. Spirometry Þ PFTs can be used in a variety of settings, and they are generally ordered to: o Look for evidence of respiratory disease when patients present with respiratory symptoms (e.g. dyspnea, cough, cyanosis, wheezing, etc.). o Assess for any progression of lung disease. o Monitor the efficacy of a given treatment. o Evaluate patients pre-operatively; and o Monitor for potentially toxic side effects of certain drugs (e.g. amiodarone) Þ The components of PFTs include: o Lung volumes o Spirometry and flow volume loops o Diffusing capacity

Þ Know criteria for diagnosis of obstruction (FEV1/FVC ratio FEV1/FVC ratio (<70%)

Þ Stage 1: Very mild COPD with a FEV1 about 80 percent or more of normal. Þ Stage 2: Moderate COPD with a FEV1 between 50 and 80 percent of normal. Þ Stage 3: Severe emphysema with FEV1 between 30 and 50 percent of normal. Þ Stage 4: Very severe COPD with a lower FEV1 than Stage 3, or those with Stage 3 FEV1 and low blood oxygen levels

Diagnostic Criteria:

Þ The Mood Disorder Questionnaire (MDQ) is a validated (Hirschfeld et al., 2003, 2000) screening tool to assess for bipolar spectrum disorder, however, is not specific to older adults. The tool can be accessed at www.integration.samhsa.gov/images/res/MDQ.pdf For patients with depressive features, the Geriatric Depression Scale, regular (www.stanford.edu/~yesavage/GDS.english.long.html) or short form (www.stanford.edu/~yesavage/GDS.english.short.score.html), is recommended as a screening tool. • Mood Disorder Questionnaire (MDQ) is a validated screening tool for BD-MDQ can identify 70% of persons with BD while eliminating the diagnosis for 90% of persons without it • Bipolar Spectrum Diagnostic Scale: better for ruling out the diagnosis of BD • Assessment for suicide risk is essential • Most suicide attempts are associated with depressive episodes or during depressive features of mixed episodes • Obtain a consultation with a psychiatrist if you suspect BD once you have excluded medical etiologies • GDS for elderly with depressive symptoms • CBC and comprehensive metabolic panel (CMP), toxicology screen, urinalysis, thyroid function tests, rapid plasma reagin(RPR), HIV, electrocardiogram (EKG), and other individualized testing as indicated by the individual patient presentation and anticipation of treatment modalities • EEG/MRI/CT for new onset psychosis • MMSE/SLUMS to detect other cognitive impairments

Obstructive & Restrictive Airway Disease (Kahn Academy video and Dunphy Understand the PFT interpretation for both (Kahn Academyvideo):

Þ https://www.alphanetbfrg.org/pdfs/Understanding-PFT.pdf FEV1=forced expiratory volume in the 1st second of expiration Obstructive disease: TLC increases, TV remains the same, IRV decreases, ERV increases and the RV increases, FVC is the same or decreases, FRC increases because of the reduction of airflow to the lungs due to obstruction and air trapping. To diagnose: FVC1/FVC is less than 0.7 (less than 70%) Restrictive lund disease: TV remains the same, IRV is reduced bc of fibrosis, ERV is reduced, RV is reduced, FVC is reduced, FRC is reduced , TLC is reduced, FVC is reduced however FVC1 is not as affected as in those with obstructive lung disease, in restrictive lung disease the FVC1 can be normal The FEV1/FVC ratio is not as affected neither >0.7 (around 75% in the you tube scenario) thus its restrictive • Fibrosis causes stiffness and restrictions causing reduction in lung volumes and lung capacities

Restrictive pattern

Þ restrictive lung disease typically has normal or increased FEV1/FVC o Decreased TLC, FEV1, and FVC with a normal FEV1/FVC, and a low DLCO o Typically, these are patients with interstitial lung disease, severe skeletal abnormalities, or diaphragmatic paralysis o The flow volume loop is generally normal in appearance, but has low lung volumes

Management: Non-Pharmacologic:

• CBT-1 st line tx for chronic insomnia • Reassurance and supportive counseling/lifestyle changes and situational support • Combined, sleep hygiene instruction and cognitive behavioral therapy are more effective than either modality alone or usual treatment. • Music therapy with patient-selected music is also effective. • Medications should be evaluated in light of ability to interfere with sleep. • sedentary to moderate aerobic exercise • Sleep hygiene strategies and barriers to implementation/symptoms should be reviewed in subsequent visits prior to resorting to pharmacological implementations • avoid caffeine for 12 hours before bedtime and discontinue alcohol and unnecessary sleep-interrupting drugs.

Chronic

• Chronic (lasts more than 1 month): fatigue, mood changes (irritability/depression), difficulty in concentration and daytime sleepiness • Older adult may spend 10 to 12 hours in bed at night trying to sleep • Falling may be a sign of insomnia

Diagnostic test-highest sensitivity & specificity (Kennedy) Radiographic findings:

• Erosions at the joints may take several years to occur • Radiographs of the hands and feet are needed to look for early signs of erosions • Additional radiographic findings in RA include soft tissue swelling, symmetrical joint space narrowing, and joint subluxations

1 st line tx OA:

• In noninflammatory OA, acetaminophen is the medication of choice in doses of 2 to 3 g per day • nonpharmacological therapies, such as walking • Water therapy has been shown to improve the function of patients with OA with no evidence of inflammation • For patients who are not getting relief from acetaminophen and exercise, the cyclooxygenase type 2 (COX-2) selective agents: celecoxib 50 to 100 mg PO twice daily • Selection of a nonselective NSAID should be based on dosing frequency, toxicity potential, and cost to the patient • NSAIDS should be avoided in older adults with a calculated creatinine clearance less than 35 ml/min. • codeine and oxycodone can be used for patients with severe OA pain or those who cannot tolerate NSAIDS • glucosamine and chondroitin sulfate (1,500 mg/1,200 mg per day) may relieve the pain of OA • Capsaicin cream 25% applied twice daily to the affected joint has also been shown to reduce pain • Viscosupplementation is another nonpharmacological option for patients with OA; an intraarticular injection of the highly viscous joint lubrication has been shown to be effective for 6 months. • topical diclofenac sodium gel (DSG) 1% for OA of the hand was found to relieve the local arthritic pain. • Mediterranean diet was found to have a lower prevalence of OA of the knee. • physical therapy for muscle strengthening, particularly quadriceps strengthening for patients with knee OA • Heat, ice, or ultrasound may be applied locally to decrease pain. • For hand osteoarthritis, the ACR conditionally recommends using one or more of the following: • Topical capsaicin • Topical NSAIDs • Oral NSAIDs • Tramadol The ACR conditionally recommends against using intra-articular therapies or opioid analgesics for hand OA. For patients 75 years and older, the ACR conditionally recommends the use of topical, rather than oral, NSAIDs. • For knee osteoarthritis, the ACR conditionally recommends using one of the following: • Acetaminophen • Oral NSAIDs • Topical NSAIDs • Tramadol • Intra-articular corticosteroid injections for hip osteoarthritis conservative therapy, the AAOS conditionally recommends using one or more of the following for initial management: • Obesity management (moderate evidence) • Nonnarcotic management (strong evidence): oral NSAIDs improve short-term pain function • Physical therapy (strong evidence) • Intraarticular corticosteroid injections (strong evidence) • Mental health disorder (moderate evidence): management of depression, anxiety, and psychosis impact pain relief, function, and ADL

Osteoporosis: S/S

• No symptoms until a fracture occurs usually • gradual development of upper or midthoracic back pain associated with activity or long periods of sitting or standing, which is relieved with rest in the recumbent position • a strong predictor for future osteoporosis-related fractures is a history of previous fractures, notably those occurring from minimal trauma. • Acute vertebral compression fractures generally occur in the thoracic or high lumbar region, with the patient experiencing a more sudden, severe onset of pain • With acute compression fractures, point tenderness in the specific area of the fracture can be elicited during the physical exam. • As bone density decreases, microfractures of the anterior vertebral bodies in the thoracic spine are likely to accumulate over time, leading to the characteristic dorsal kyphosis (or "dowager's hump"). • exaggerated kyphosis produces a loss of height • As kyphosis worsens over time, impairment of rib mobility, a decrease in lung volumes, and an increase in respiratory complaints may occur. WHO diagnostic criteria: Normal: BMD within 1 SD of young adult reference mean Osteopenia BMD >1 SD below young adult reference mean (21) Osteoporosis BMD >2.5 SD below young adult reference mean (22.5) Osteoporosis (severe) BMD >2.5 SD below young adult reference mean (22.5) AND presence of osteoporotic fractures

Pharmacologic-last choice tx-avoid long term use potential for abuse

• OTC melatonin or prescription ramelteon can be tried. If ineffective, initiate a short-acting sedative-hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata), at lowest dosage before desired bedtime for 1 week or less. Suggest spacing dosing to every other day to avoid side effects. • If a benzodiazepine is used, temazepam (Restoril) is relatively short-acting. If this is ineffective, reevaluate the diagnosis and restructure the treatment modalities. Benzodiazepine receptor agonists (Z-drugs) Note that for the elderly: All of these drugs including intermezzo (sublingual ambien) are listed as potentially inappropriate medications (PIMs) on the Beers list (2015) to be avoided in older adults.

Diagnosis:

• Polysomonography only for those suspected to have sleep apnea, periodic limb movements, REM disorders and usual tx fails • men at greater risk for sleep apnea than men however women tend to develop sleep apnea in the peri/post-menopausal periods (altered upper airway tone) • verified by a sleep history or sleep log • sleep history should include an assessment of daytime sleepiness, fatigue, or sleep disturbance; the sleep environment; and the duration of symptoms. • Additionally, information on frequency and duration of awakenings, sleep times, nap times, and lengths is important • Insomnia is a clinical diagnosis, verified by a sleep history or sleep log. history should include an assessment of daytime sleepiness, fatigue, or sleep disturbance; the sleep environment; and the duration of symptoms. Additionally, information on frequency and duration of awakenings, sleep times, nap times, and lengths • Epworth Sleepiness Scale/ Stanford Sleepiness Scale for chronic insomnia eval • Treat hot flashes w/ hormones-indirectly tx the sleep problem (primary therapy) • Depression, anxiety pre-occupation, sleep apnea-not a primary therapy

Signs and symptoms

• Sleepiness, negative mood, impaired performance, • Sleep quality is poor accompanied by early morning awakening

Diagnostic test highest sensitivity and specificity: kennedy

• anti-CCP antibodies is newer than the RF testing and is associated with higher sensitivity and specificity for RA • Anti-CCP antibodies may be detected before the RF develops, and are found in up to 40% of RF-negative patients • RF is positive in 70% to 80% of patients with RA, with an 86% specificity. • anti-citrullinated peptide antibodies( anti-CCP) have been shown to be an important indicator for destructive disease when accompanied by a high RF titer