Health Issues for the Aging Adult - American … am 830 Wilson...7/30/2015 1 Health Issues for the...
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Health Issues for the Aging Adult Lynn M. Wilson, DO
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Transcript of Health Issues for the Aging Adult - American … am 830 Wilson...7/30/2015 1 Health Issues for the...
Health Issues for the Aging Adult
Lynn M. Wilson, DO
7/30/2015
1
Health Issues for the Aging Adult
Lynn M. Wilson, DO
Assistant Program Director
Family Medicine Residency
Morristown Medical Center, Morristown, NJ
Learning Objectives
O Manage common geriatric syndromes
O Diagnose and treat geriatric depression
O Define delirium
O Describe differential diagnosis and
evaluation of dementia
O Describe principles for prescribing for older
patients
Geriatric Syndromes
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Parkinson’s Disease
Common
Signs and Symptoms
Less Appreciated
Signs and Symptoms
O Resting tremor
O Rigidity
O Bradykinesia
O Akinesia
O Shuffling gait
O Masked facies
O Micrographia
O Drooling
O Decreased arm swing
O Truncal rigidity
O Hypophonia
O Orthostatic
hypotension
Other ParkinsonianSyndromes
Type Distinguishing Features
O Drug induced
O Progressve supernuclearpalsy (PSP)
O Cortical basal ganglion degeneration
O Multisystem atrophy
O Cerebellopontine degeneration
O Huntington’s disease
O History of neuroleptic use
O Impairment of vertical eye movements
O Cortical signs, apraxia
O Orthostatic hypotension
O Cerebellar dysfunction
O Chorea
Treatment of Parkinson’s Disease
O Dopamine Replacement:
O Levodopa
O Carbidopa
O Dopamine Receptor Antagonists
O Pergolide
O Pramipexole
O Ropinirole
O Bromocriptine
O Catechol-O-
methyltranferase
(COMT) inhibitors
O Entecapone
O Neuroprotection
O Selegiline
O Vitamin E
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Age-Related Macular Degeneration
O Leading cause of new blindness >55
O Risk Factors
O Age
O HTN
O Smoking
O Known cardiovascular disease
O Blue eye color
O Family history
O Loss of central vision
O Treatments:
O Exudative/“Wet”
O Laser
photocoagulation
O Non-exudative “Dry”
O Vitamin
Supplement:
vitamin C, vitamin
E, beta-carotine
and zinc
Glaucoma
O Most common cause of blindness in African
Americans
O Elevated intraocular pressure
O Changes in visual field
O Changes in appearance of optic nerve and disk
O Open vs Closed Angle
O Drops
O Surgery
O Systemic drugs
Falls
O 50% of adults over 80 years old have fallen
O Unintentional injury is the 6th leading cause of death in people >65
O Risks: O >4 medications
O Orthostatic hypotension
O Environment
O Lack of balance, unsteady giat
O Evaluation:O Screening
O History and Physical
O Labs, Imaging
O PT/OT/Exercise
O Gait testing: “up and go”
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Vitamin D
O Myopathy from Vitamin D deficiency
presents as muscle weakness and pain
O Supplementation improved strength,
function and balance
O Benefits translated in to a fall reduction
Pressure Ulcers
O Prevalence is 10.1%
O Most common locations: sacrum, heels
O Increased mortality fourfold; 1 in 3 events in LTC
O Age related skin changes:
O Decreased local blood supply
O Epithelial layers flatten
O Subcutaneous fat decreased
O Collagen fibers loose elasticity
O Cutaneous pain sensitivity decreases
Staging
http://www.npuap.org/
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Triple D:Depression, Delirium and Dementia
Depression
O Not a normal part of aging
O More common among elderly in medical settings (30% of CVA, cancer or MI)
O 80% of late life depression treated by PCP
O Depression can precede severe medical illness
O Increased health care costs
O Increased EtOH and drug use
O Increased mortality
DSM Criteria for Depression
O Depressed mood plus 4 or more of the symptoms for >2 weeks:
O Impaired sleep
O Lack of Interest
O Guilt
O Low Energy
O Difficulty Concentrating
O Poor Appetite
O Psychomotor Retardation
O Suicidal
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Treatment of Depression
O Psychotherapy
O Pharmacotherapy
O SSRIs: lexapro, celexa
O Venlafaxine
O Mirtazapine
O Trazadone
O Bupropion
O Benzodiazepines
O Psychostimulants
O Electroconvulsive Therapy
Delirium
O Disturbance of consciousness, INATTENTION
O Acute change in cognition
O Tactile or Visual Hallucinations COMMON
O Auditory Hallucinations RARE
O Onset is rapid: hours to days
O Tendency to fluctuate
Causes of Delirium
O Drugs
O Electrolyte Disturbance
O Lack of Drugs (withdrawal)/Liver disease
O Infection
O Reduced sensory input
O Intracranial
O Urinary/Fecal retention
O Myocardial/Metabolic/Pulmonary
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Treatment of Delirium
O Treat the underlying cause
O Most do not require medications themselves, simply redirections
O Medications are indicated when patients are harmful to themselves, others or interfering with treatment of their underlying condition.
O Atypical antipsychotics
O Oral then IV
O Start LOW, go SLOW
Risk Factors for Dementia
O Age
O Family history of Dementia or Parkinson’s disease
O Head trauma
O Depression
O Low educational attainment
O Hyperlipidemia
O Diabetes
O HTN
O ?Gender
O Down’s syndrome
DSM Criteria for Dementia
O Memory impairment
O At least one of the following:
O Aphasia
O Apraxia
O Agnosia
O Disturbance in executive functioning
O Disturbance in the above interferes with daily function
O Does not occur exclusively during delirium
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Suicide in Elderly
O Accounts for 13% of total population and
24% of completed suicides
O Elderly men at highest risk
O Often seen in first episode of depression
O Most had seen a physician within 1 month
of suicide
Depression vs Dementia
O Patient comes in alone complaining about
loss of memory = depression
O Patient brought in by family complaining of
loss of memory = dementia
Dementia Types
O Alzheimers
O Vascular
O Lewy Body Dementia
O Frontotemporal Dementia
O Normal Pressure Hydrocephalus
O Creutzfeldt-Jacob Disease
O HIV/AIDS Dementia
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Dementia Work Up
O History and Physical
O Labs
O ImagingO CT
O MRI
O EEG
O Cognitive TestingO MMSE (mini mental status exam)
O SLUMS (St. Louis University mental status exam)
O FAB (frontal assessment battery)
O GDS (geriatric depression scale)
O Cornell Depression Scale
O Clock Draw
Treatment of Dementia
Prescribing
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Pharmacokinetics
O Absorption: oral absorption is the same in older
and younger patients
O Distribution: decreased water and lean muscle
mass with increased fat changes the distribution
of hydrophilic and lipophilic medications
O Metabolism: Liver is most common site; normal
aging reduces liver mass and blood flow
O Excretion: Renal is most common, serum Cr
does not accurately indicate CrCl
Cockcroft-Gault Formula
Estimated CrCl = [(140-age)*(body wt in kg)]__________________________________________________________________________________________________
serum Cr x2
Adverse Drug Events
O Responsible for 5-28% of all acute Medicare hospital admissions
O Warfarin
O Hypoglycemic medications
O Digoxin
O Psychoactive drugs
O NSAIDs
O In nursing homes $1.33 is spent on ADEs for every $1.00 spent on medications
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STOPP Criteria
Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially Inappropriate Medications Defined
by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern
Med. 2011;171(11):1013-1019. doi:10.1001/archinternmed.2011.215.
ReferencesO Bordelon P, Ghetu MV, Langan RC. Recognition and management of vitamin D
deficiency. Am Fam Physician. 2009 Oct 15;80(8):841-6.
O Distelhorst JS, Hughes GM. Open-angle glaucoma. Am Fam Physician. 2003 May 1;67(9):1937-44.
O Fong DS. Age-related macular degeneration: update for primary care. Am FamPhysician. 2000 May 15;61(10):3035-42.
O Fuller, GF. Falls in the elderly. Am Fam Physician. 2000 Apr 1;61(7):2159-68, 2173-4.
O Gazewood JD, Richards DR, Clebak K. Parkinson disease: an update. Am FamPhysician. 2013 Feb 15;87(4):267-73.
O Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med. 2011;171(11):1013-1019. doi:10.1001/archinternmed.2011.215.
O U.S. Preventive Services Task Force. Screening for glaucoma: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(7):484–489.
O The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/
O Geriatric Review Syllabus, 8th Edition. 2013. American Geriatrics Society.
Questions? Thank You!
