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



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Lightheadedness—a sense that the are going to faint


-cardiac / vascularinadequate cerebral perfusion

-PE

-bruits

-heart


-BP

-AAA


-renal bruits—renal stenosis / nephrosclerosis

-Cardiac Causes—

-AS—R 2nd ICS, grade II, III—ejection murmur

-loud murmur

-delay in carotid upstroke

-dyspnea

-Dysrhythmia

-any chest pain or palpitations?

-any relation to exertion?

-may need prolonged cardiac monitoring to detect

-holter—12h

-loop monitor—days at a time

-Carotid Sinus Syncope—

-turning the head worsens sx

-WAY down on the list

-Volume depletion and or severe anemia

-postural changes in BP and/or pulse

-lay to stand—systolic drop 1- or pulse up 10significant for ortho

-worsens with changes in position



-Autonomic Insufficiency—

-more common in DM or pts on meds such as antihypertensives—

-alpha 1 blockers—hytrin, cardura, aldomet (methyldopa)

-centrally acting alpha blockers



-Dysequilibrium—

-a sense of imbalance

-more of a body sensation than a head sensation (may be more in feet than in head)

-may come on with standing

-can be aggravated by walking or turning

-most common cause—



-multiple sensory deficits—

-DM with peripheral neuropathy

-cataracts and impaired vision

-not a dx of exclusion, but close



-Other—

-anxiety and depression

-ill defined dizziness

-constant

-may be previous psych hx

-other somatic sx (myalgia, fatigue, neck pain, etc)

*multiple complaints 3-5

-see flow sheets—
Treatment—

-benign positional vertigo—get up in a step-wise fashion

-acute labrynthitis / vestib—antivert / meguizine

-Meniere’s—ENT

-ototoxins—stop drug

-retrocochlear—if acoustic neuroma—C-T head

-TIAs/CVAs—ticlid/plavix

-lighthead—AS—watch it / fix valve

-dysequilibrium—DM—fix sugar

-fix underlying cause

6/15/00
Osteoporosis—

-1 in 3 postmenopausal women

-250,000 hip fx/y

-500,000 vertebral compression fx/y

-12-20% mortality of 1y with hip fx

-50% that live need long term care placement

-men make up 35% of hip fx maybe

-peak bone mass at late 20s, early 30s in women (but determinants like smoking, etoh, weight bearing exercise, and Ca2+ intake play a role

-at perimenopause/menopause there is a sharp increase in bone mass and after that it declines

-Osteoporosis is the loss of bone density which leads to increased vulnerability to fxs that may result from apparently insignificant movements or accidents

-an imbalance between bone formation and resorption

-Presentation—

-asymptomatic—if you wait until sx show up you’ve missed the boat

-Dowager’s hump—kyphosis of T-spine

-fxs

-Xray changes of osteopenia—wont see until large decreases in bone mass



-Types of Osteoporosis—

-Primary—

-most common

-idiopathic

-Secondary—

-a cause can be identified

-preventable cause

-screen all for a secondary cause

-RFs for Primary Osteoporosis—

-documented height loss of >2”

-tall, thin stature

-Caucasian

-inactivity

-etoh, cigarette, or caffeine use

-post-menopausal

-FH


-Cause of Secondary Osteoporosis—

-primary hyperparathyroidism—

-increased PTH in the presence of high serum Ca2+increased osteoclastic activity, etc

-more females—20-40yo

-asymptomatic usually

-chem 7 picks it up

-high Ca++ or low phosphorus

-fatigue, weakness, arthralgia, kidney stones—bones, stones, groans

-multiple myeloma—

-men over 50

-back pain

-lytic lesions on xray

-ESR increased, anemias

-chronic renal failure—increased BUN/Cr

-hyper/hypothyroidism

-osteomalacia—

-d/o of calcification of bone

-vitamin D deficiency

-medications—corticosteroids

-Labs that may need to be done—

-serum Ca++

-phosphate

-Alk Phos—e.g. MMincreased alk phos

-TSH


-24h primary calcium and Cr—increased in renal failure

-ESR/LS Spine films/CBC

-Imaging Studies—

-single or Dual photon absorptiometry(SPA,DPA)

-quantitative CT (QCT)

-quantitative Ultrasound (QUS)

*single (SXA) or Dual Energy/Emission Xray absorptiometry (DXA or DEXA)

-DEXA is gold standard

-medicare pay if reaason—osteopenia, fx, multiple RFs

-T-scale—bone mass density compared to WHO 30yo female average

-C-scale—pts bone mass density vs same age person average

-your bmd 1-2 SDs below averageosteopenia

-your bmd >2.5 SDs below averageosteoporosis

-Therapy Goals—

-Asymptomatic—

-measure bone density

-start therapy to limit bone loss

-Symptomatic—

-bone mass measurement

-treat pain

-try to restore functional abilities—PT, ROM ex, etc

-try to prevent future fxs

-minimize bone loss

-possibly increase bone formation

-Steroid Therapy—

-baseline and periodic follow-up bone mass measurements

-Treatment of Osteoporosis—

-Estrogen—

-should strongly be considered

-only perimenopausal/menopausal pt

-best to decrease bone loss in osteoporosis

-use in >70yo?

-hard question

-lose most bone by 55yo

-probably shouldn’t use

-HER—Hormone and Estrogen Replacement Study

-CVD in femalesestrogen did not decrease the incidence of CVD in females (its supposed to increase HDL and decrease LDL)

-Bisphosphonates—

-Fosamax—2nd generations

-decreases osteoclastic activityincrease in bone mass

-decrease in new vertebral fxs by 50% and other outstanding stats about fx reductions

-starting dose of 10mg qd

-contraindicated in PUD, esophageal stricture

-1st thing in morning—upright—8oz watert

-Calcitonin-salmon (Calcimar[IM], Miacalcin[spray]_

-inhibit bone resorption

-may increase bone formation

-one spray in one nostril qd

-analgesic effects for fxs secondary to osteoporosis—IM

-decrease osteoclastic activity

-increase osteoblastic activity

-well tolerated

-SERM—new—last 5y

-alternative to ERT

-produce estrogen-like effects

-mechanism of action is unclear

-raloxifene (Evista)

-60mg qd


-SE’shot flashes, blood clots

-decrease incidence of vertebral compression fxs but not hipfxs

-no breast ca risk

-Calcium/Vitamin D—

-calcium—

-men—


-25-65yo—1000mg/d

->651500mg/d

-women—

-35-50yo1000mg/day



-postmenopausal1500mg/day

-vitamin D—

-minimum of 400 IU/d

-increase absorption of Ca++

-calcium carbonate—Tums TID, Caltrate D, Oscal D

-most elemental calcium

-calcium citrate?

-Exercise—

-weight bearing—walking

-Sodium Fluoride—

-increase osteoblastic activity

-25-50mg/d

-only OTC but not high enough doses—

-has SE’s

-PTH—

-osteoblastic activity



6/20/00
Menopause—

-with age a decrease on ovarian follicles which is not noticed until menopause (approx age 50)

-ovaries and follicles can no longer produce enough estrogen which causes an increase in FSH

-decrease in estrogen correlates with decreases in HDL and increases in LDL (this was previously the argument of ERT)


Sx of Menopause—

-vasomotor episodes (hot flashes, nightsweats) cease within several YEARS of menopause

-urogenital atrophy (dysuria, dryness, dyspareunia) tend to persist beyond menopause

-various psych and somatic complaints

-very responsive to ERT

-all sx are responsive to ERT—even psych and somatic


Estrogen—

-works well to cut back on bony resorption

-as much as 50% reduction in cardiac events (very debatable—HER study)

-should be started in the perimenopausal period or later (but the sooner after menopause the better)—within 3-5y

-shown to decrease bone loss and decrease the risk of hip fxs

-increase HDL and decrease LDL?

-stops vasomotor sx

-may decrease the risk of Alzheimer’s dz—some decent evidence


Negatives about Estrogen—

-risks—


-increased risk of breast cancer—big in the press

-increased risk of endometrial cancer (main reason for progestins)

-thrombosus

-SE’s—


-breast tenderness

-bloating

-menstrual bleeding

-increase in triglycerides

-2x increase in gallbladder dz

CHART—


Progesterone—

-positive effects—

-decrease risk of endometrial cancer

-will allow women to have menses—some want that—feels natural

-negative effects—

-may decrease HDL

-may cause women to have menses—some women don’t want that

-increase risk of breast cancer


Drug Regimens for ERT—

-minimum dose required is 0.625mg of conjugated estrogen (Premarin), 0.05mg of transdermal estrogen (less favorable effect on lipid profile)

-probably need to take for life

-cyclic vs. continuous


Continuous—

-Premarin (PO)(estrogen) 0.625mg and Provera (progestin) 2.5—take together QD

Cyclic—

-Premarin 0.625mg days 1-25 of cycle



-Prevera—5-10mg days 16-25 of cycle
*ERT is recommended for the primary prevention of everything (MI, etc)

*ERT is NOT recommended for secondary prevention of anything (post MI, etc)

-alternative is Avista—if get hot flashes with ituse clonidine
Incontinence—

-involuntary loss of urine sufficient to be a problem

-very common

-15-30% of non-institutionalized people

-much more females—85%

-need to ask about on routine care


-Social and Psychological Impacts—

-changes in social activities outside the home

-depression

-social isolation

-anxiety about friends finding out

-embarrassment about accidents in public

-changes in sexual activity
-Normal Mechanism to Pee

1. bladder filling and storage phase—

-impulse from s.c. to contract balanced with signal to relax

-in tact internal and external sphincters

2. emptying—

-150-250mL is storedthen urge to peeexternal sphincter relaxesinternal sphincter relaxesbladder contracts

-intravesicle pressure exceeds urethral pressure/resistencepee
-Intrinsic factors that increase the risk of urinary incontinence—

-postvoid residual volume (>100mL)

-diminished bladder capacity

-decreased bladder sensitivity

-detrusor instability (from cerebral cortex changes)

-BPH—increases residual volume

-excessive nocturnal urine excretion

-childbirth—trauma to the area

-obesity—push on it

-smoking—chemicals to bladderurgency

-estrogen withdrawal and menopauseatrophy, etc

-brain failure

-dysmobility
-Extrinsic Factors—

-relocation and environment

-UTI

-acute illness



-intravesicle lesions

-meds—sedatives, sleeping pills, hypnotics

-urinary obstructions

-neurological lesions


Types of Urinary Incontinence—

1. Stress UI

-characterized by—

-leakage of urine with physical activity such asbending/jumping

-leakage of urine with conditions that increase intrabdominal pressure such ascoughing/sneezing

-loss of SMALL amounts of urine at a time

-very seldom lose urine at night

-etiology—

-Tx of stress UI—

-behavioral tx—

-bladder training—hold it longer

-kegels—100s per day

-consider surgical referral

-keep diary

-meds—

-HRT


-alpha adrenergics—

-ephedrine—10-25tid/qid

-imipramine (TCA)—10tid up to 25 tid

-surgery is last resort

2. Urge Incontinence—

-characterized by—

-leakage of urine associated with sudden strong uncontrollable urge to void—gotta go gotta go

-inability to delay voiding

-urgency

-frequency

-nocturia

-loss of urine in LARGE amounts

-Detrol—anticholinergic

-Etiology—

-main cause in detrusor instability/hyperreflexia

-Central—

-dementia, CVA, parkinsons

-increased afferent stimulation if the UT from—

-UTI, BPH, neoplasm, fecal impaction, post-prostatectomy, deconditioning secodary to chronic cath

-Tx—


-treat the cause—UTI, BPH, etc

-same as stress incontinence

-if no improvement refer

-anticholinergics—

-detrol

-propanthenone—15-20mgqd in 3-4 doses



-oxybutinin—2.5-20mgqd in 2-4 doses

-antispasmodics—

-urispas—300-500mg/day in 3-4 doses

-CCBs


-imipramine—10mgtid and work up to 25 tid

3. Overflow Urinary Incontinence—

-presents with urinary:

-dribbling

-incomplete emptying

-frequency with loss of small volumes of urine

-nocturia without urgency*

-large postvoid residual

-Causes—

-outlet obstruction—

-BPH

-fecal impaction



-cystocele

-BNO


-drug SE’s

-impaired nerve function—DM and etoh neuropathies

-uneractive detrusor*

-more men

-Tx—

-treat the cause—



-meds or surgery for BPH

-Rx—alpha blockershytrin, cardura

-no anticholinergics

-underactive detrusorsurgery


4. Functional Incontinence—

-caused by—

-patients mood—e.g. depression

-inaccessability to rest rooms—cant walk that far, too dark

-treatment—correct the cause

-D—delerium

-I—nfection

-A—trophic

-P—harmacologic

-P—sychiatric

-E—xcessive (fluids/meds)

-R—estricted (activity—cant get around)

-S—tool—fecal impaction

-Approach to Urinary Incontinence—

-history—8 dimensions

-list all meds

-attempt to classify the type

-PE—


-palpate bladder for distention

-check postvoid residual—pee then cath (100-150mL =significant postvoid residual)

-pelvic

-rectal—fecal impation/prostate



-neuro exam—MMSE, etc

-UA with culture—always do UA

6/27/00
Material for Exam II
Perioperative Care—

-risk not much higher than younger

-emergency surgery is a much higher risk

-more risk up higher (head vs toe)

-length of surgery is increased risk—esp past 3h threshold
RFs For Morbidity and Mortality—

-Heart Dz—#1 cause of perioperative mortality and a leading cause of morbidity

-Lung dz—#1 cause of morbidity and a leading cause of mortality

-Poor nutrition

-Dementia
Preoperative Evaluation—

-Thorough H&P

-MMSE

-Functional Assessment (ADLs, IADLs)



-Med review—interactions with anesthetics, blood thinners, etc

-Should have advanced directive done (POA, living will)

-Labs—

-CBC


-Chem 7

-Serum Albumin

-Liver functions

-UA


-Preop EKG if >65
Cardiac Risks—

-EKG


-Moderate Risk—

-older men with chest pain

-older men with several risk factors

-High Risk—

-Hx of angina

-Hx of previous MI

-Hx of LV dysfunction (CHF, etc)

-Very High Risk—

-Current CHF

-Recent MI

-Angina
Who needs Further Evaluation of their CARIAC Status b/f Surgery—

-Discuss with MD

-Do they need a stress test?
Pulmonary Risk—

-preoperative Xray NOT helpful except maybe for baseline comparison

-spirometry?

-ABG for baseline comparison (except for hypercapnia which indicates higher risk)

-Smoking—should stop
ELDER ABUSE—

-1 million elders neglected, emotionally debilitated, or physically abused by a care giver

-only 1 in 14 get reported

-on the riseliving longer—more problems

-LAW—must report abuse
Five Different Types of Abuse—

-Physical Abuse

-Physical Neglect—living conditions, feeding

-Psychological Abuse—ignored, call names, etc

-Material or Financial Abuse

-Violation of Rights—church, activities, etc


Assessment—

-Ask direct questions, separate from caregivers—

-Do you feel safe at home?

-Do you have disagreements with your caregiver?

-Do you feel you are treated rough or intimidated?

-Also ask questions of caregiver later…

-Detailed PE—

-General appearance—

-hygiene

-emaciated

-dress

-Cognition—



-Skin—

-bruising—bruises in different stages of resolution / on inner surfaces of extremities

-poor turgor

-pressure ulcers

-Head—

-trauma—lacs, hematomas



-GU—

-rectal / vaginal bleeding

-DOCUMENT EVERYTHING

-TAKE PICTURES

Labs for signs of malnutrition—

-Anemia


-Low albumin

-Lymphocytopenia—maybe

Xrays—

-signs of old fractures



What to Do as A PA—

-LEGALLY obligated to report this to Adult Protective Services

-Be sure the caregiver understands the extent of the pts illness AND the extent of the necessity of care

-Explore respite care programs, insurance benefits, free Rx programs—CONSULT A SOCIAL WORKER—anything we can do to ease stress on the family will make a difference



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