Demographics-young old-65-74 middle old-75-84



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Pharmacotherapeutics—


-be aware of the cost of meds—may be MOST IMPORTANT

-keep a good med list—very important

-bring all meds q visit

-start slow, go slow

-give correct dosage forms


ALTERED PRESENTATION OF DZ—always need to know baseline functionality (do ADLs and IADLs at least yearly—use family members too)


--classic—depression without sadness

-may present as clumsy / wt loss



-silent infectious dz (pneumonia)

-no changes on CBC / may be minor

-no fever

-no tachy

-no changes on Xray

-PE—


-auscultate—rales

-consolidation in lungsINCREASED tactile fremitus

-look sick

-keep high index of suspicion



-other atypical presentation of illnesses—

-silent surgical abd—confusion, fall, decreased appetite

-silent MI—no chest pain. Maybe syncope/SOB

-nondyspneic CHF

-apathetic hyperthyroidism—presents like depression, lethargic, etc

-reason for the altered presentations—

-altered central processing—brain/connections/etc

-negativity—they ignore their sx—don’t like dr

-ignorance—think its nl—BPH e.g.

-peripheral sensitivity—decreased sensation—etoh, DM, etc

-depression—silent, etc



-comprehensive geriatric assessment—

-functional, physical, and mental assessment of pt and caregivers and assessment of environment in order to plan care and prevent problems



-home visits—

-should be included in the assessment

-should go yourself

-helps to clarify issues—

-environment

-family relationships

-compliance

-planning

-they don’t want to admit shortcomings

-cant appreciate it fully unless you see their home



-info obtained from a home visit—

-suitability and safety of home for pts functional level

-attitudes and presence of other persons at home

-proximity of help (relatives, friends, neighbors)

-emergency assistance arrangements

-nutritional and etoh habits

-daily living skills

-hygiene habits

-safety and convenience modifications needed

-problems in getting to local stores and services



-mental status exam—

-Folstein MMSE

-short portable mental status questionnaire

-date, day, place, phone #, age, DOB, president, serial seven’s, etc

-function—ADLs and IADLs

-approach of the pt—

-prepare for hearing impairment—

-assume face to face eye contact position

-sit at same level as the pt

-good lighting

-wear hearing aid

-ask the pt first

-ask supportive hx from caregiver later



-instructions before they come in—

-bring all meds

-list of previous providers

-medical records / sign release

-preappointment questionnaire

-ROS most important—sometimes they are embarrassed to tell you face to face—sex, continence, etc



-assess the caregiver—

-they are part of the picture too

-can give you good info

-can also have problems

-don’t forget that!

-Hx—

-obtain from pt and others

-preappointment quest very helpful

-direct questions to the pt first

-CC / HPI is not as specific

-injuries

-illnesses

-immunizations—Td, flu, pneumoVax

-allergies

-meds


-habits—sleep, etoh, nicotine

-watch out for abuse

-occupation—exposures

-FH—not as important

-marital hx—social situation

-PH / SH—determines how you treat them



-ROS—

-MORE IMPORTANT

-underreporting of illness, etc

-PE—

-have exam table fixed so they can get up on it

-privacy for changing

-provide physical assistance when necessary

-sequence of exam—

-in walking shoesgait, balance, rising from chair

-sitting with legs downvitals, HEENT, CNs, upper extremity, neuro and ROM

-lay on back—45 degree angle—legs extendedJVP, abd (if orthopneic)

-lay flat on pillowabd, male genitals, lower ext ROM, neuro, feet

-L side—rectal, LS mobility and tenderness / pressure areas

-etc

CONFUSION—


-a distance of consciousness with reduced ability to focus sustained or shift attention

-change in cognition

-perceptual disturbance

-may be disoriented when they come in

-impaired memory / hallucinations

-Three main causes of confusion—

-delerium

-dementia

-depression



-Initial Approach—

-Is it delerium or dementia??

-presume that it is delerium until proven otherwise

-30% mortality rate with delerium—it’s a medical emergency

-30-40% of admissions are delerious

-DELERIUM—

-a transient global d/o of cognition and consciousness

-it is the acute effect of physical illness on brain function

-can usually be reversed completely or at least to a degree if the cause can be identified and treated promptly

-NOTEif the supportive care person says this is a change from their usual or there is no accurate source of hx you should presume this is new and work them up appropriately
-Diagnostic Criteria for Delerium—

-disturbance of consciousness with change in cognition that is not better accounted for by a dementia

-develops over hours to days—ACUTE

-fluctuates during the course of the day

-impaired ability to focus, sustain, or shift attn

-cognition impaired (memory, orientation, language), or perceptual disturbance (misinterpretations, illusions, hallucinations)

-p. 219

-associated with sleep-wake cycle disturbance, disturbed psychomotor behavior (restlessness, hyperactivity, or decreased psychomotor activity; may be stuporous), emotional disturbance including fear, EEG abnormalities (generalized slowing or fast activity)



-evidence that disturbance is caused by a general medical condition, substance intox or w/drawal, or multiple etiologies
-Common Causes of Delerium—

-metabolic d/o’s—

-lytes

-acid-base



-hypoxia

-hypercapnia

-hypo or hyperglycemia

-azotemia

-Infxs

-decreased cardiac output—



-dehydration

-acute blood loss

-acute MI

-CHF


-medications

-intoxication (etoh, etc)

-hypo-hyperthermia

-acute psychoses

-transfer to unfamiliar surroundings

-miscellaneous

-fecal impaction

-urinary retention



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