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



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Topics that need to be read in text—


-Rehabilitation

-Ethics

-Hospital Care

-Institutional Care

-Home Care

-Terminal Care

-Failure to Thrive?

-Falls and Falling

-Alcoholism

-Driving

6/27/00


DRIVING—


-see driving sheet

-3% of elders only use public transit

-mode of transportation

-social status

-independence

-Crashes involving elderly—

-absolute number of accidents is lower than the entire pop of drivers

-# of miles driven1/2 as many as average population (more crashes if look at mileage)


-Dementia

-some studies show that elders with mild dementia have more accidents than drivers without dementia, but as the disease progresses, the accidents tend to increase

-History—any medical conditions / medicines that affect driving ability

-Functional status

-Falls—recent or recurrenthigher risk of crashes

-Hx of accidents—can give good info that the pt might withhold

-are they the only one in the family with a license

-Driving Ability PE

-vision (Snellen)—near and far fields

-hearing test

-MMSE—thought content

-musculoskeletal exam

-ROM neck, shoulders, wrists, hips, trunk, knees, ankles, feet and grip strength

-Gait

-not an exact science



-weigh risks and benefits vs your family on the road with this elderly person driving

-What To Do—

-call dept of motor vehiclesmake person take written and driving test

*In the absence of medical conditions, age is not a factor for increased accidents but elderly have multiple conditions



PERIPHERAL VASCULAR DZ—


-Vision—

-most common sensory problem in elderly

-Big 3—glaucoma, cataracts, macular degeneration

-Aging changes in the eyes—

-decreased density and elasticity in the lense which leads to decreased accommodation

-decreased contrast sensitivity

-increased sensitivity to glarepain—big glasses

-progressive yellowing of the lens can interfere with blue-green vision

-decreased tear production and viscosity

-burning, eye pain, etc

-Glaucoma—

-increased intraocular pressure

-cupping on fundoscopic exam

-progressive abnormalities of the visual field

-types—

-simple or open angle glaucoma—develops slowly



-Hearing Loss—presbycusis

-65% over 85yo report it as a problem

-16% have some type of assistive device

-8% use the assistive device

-10 decibel reduction in hearing sensitivity per decade of life after 60yo

-decreased perception of high frequency loss



-Conductive Hearing Loss—

-cerumen impaction (outer ear)—very common

-otosclerosis—more common in elderly

-stiffening / hardening of bones around cochlea

-Tx—surgery / hearing aids

-Sensorineural—

-neoplasms of the brainstem or CNVIII

-long term exposure to high intensity noise

-medications



-PE—

-examine external ear

-whisper testing

-if they fail the whisper test to a formal audiogram before you refer them to the ENT

-Rinne--mastoid(conductive) and Weber (sensorineural)

-wax, TM perforations, scarring, etc

-DOCUMENT all findings
-Sexuality—

-they still have sex

-sexual satisfaction is still possible

-Problems with sexuality—

-Widow’s and Widower’s syndrome

-environmental

-fear of illness or death

-difficult to form relationships with new partners

-if in elderly homenot much privacy

-#1 have a handle on their illness

-#2 tell then if it is OK to have sex



-Genital Changes in the Average Elderly Male—

-reduced penile sensitivity

-slower, weaker erection

-reduced ejaculatory volume

-anejaculatory orgasm

-reduced forewarning of ejaculation

-speedier detumescence (penis going flacid faster)

-increased refractory period



-Genital Changes in the Average Elderly Woman—

-reduced vascularity and fat content in vaginal walls

-reduced size of vulva and vagina

-stickier, reduced secretions

-thinner, more lax vaginal walls

-less variability of vaginal size during intercourse

-shorter, less intense orgasms

-reduced sexual response in all four phases

-painful orgasms in some

-atrophic vaginitis—need to address thiseasily treated

-estrogen cream

-increases sexual satisfaction



-Physical Illnesses and Sex—

-dyspnea—cant exert yourself

-OA

-gynecologic surgery—bladder repair, etc



-prostatectomy—can lead to impotence

-mastectomy / colostomy—appearance

-urinary incontinence

-these can increase anxiety to the point that the patient doesn’t want to have sex at all



-Meds that affect sex—

-etoh


-caffeine

-major and minor tranquilizers

-antihypertensives (except perhaps CCBs)

-antidepressants

-antihistamines

-analgesics

-digoxin, etc

-General Recommendations for Therapy—

-mornings are the best time for sexual activity

-proper lubrication

-may be a need for increased physical stimulation

-one partner may be more concerned about sexual activity than the other

-affirm the need for emotional as well as sexual needs

-elderly women may benefit from estrogens

-still normal to have sex after 65yo

7/6/00
FEET—
-Hallux Valgus—

-most common deformity of the first MTP

-also called a bunion

-presentation—

-painful swelling of the dorsomedial aspect of the 1st metatarsal head, associated with lateral deviation of the toe

-incompatability (foot-shoe)

-problems in the forefootmetatarsalgia and hammer toe

-RFs—


-flat feet

-inappropriate shoes (especially women)

-PE—

-tenderness



-deviation (lateral)

-Tx—


-properly fitting shoes (avoid toebox)

-orthotics

-surgery—last resort

*see pictures

-Hallux Limitus / Rigidus—

-limitation of motion (limitus)

-total absence of motion (rigidus)

-Etiology of HL / HR—

-biomechanical abnormalities—flat feet, etc

-trauma


-OA

-arthritides such as RA

-Presentation of Both—

-pain in first MTP

-sx usually gradual in onset

-worse with walking or prolonged weight-bearing

-sx worse over time

-PE—


-enlargement of first MTP on palpation

-may have nerve impingement

-decreased ROM on dorsiflexion

-no lateral deviation

-decreased ROM is the tell-tale sign

-TX—


-shoes with stiff soles and high toe box

-avoid excessive stair or hill climbing

-orthotics

-PT


-NSAIDS—true for all foot conditions

-joint infx

-surgery (rare in the elderly)

-Diabetic Foot—

-every DM should have foot exam Q3 months to include

-gross inspection

-neuro exam

-pulses


-every DM should be taught how to do daily pedal exams

-also—never wear open toed shoes

-keep clean but use gentle soap

-DM—2nd leading cause of below the knee amputations

-careful cutting toenails or go podiatrist)

-skin lubricant QD—Lubriderm

-should report any signs of infx, redness, swelling, etc immediately to the PA

-every DM should have a competent podiatrist that they see on a regular basis


-Bunionette—

-the 5th MTP equivalent of a bunion

-Presentation—

-painful deformity of 5th MTP

-foot-shoe incompatability

-PE—


-lateral aspect of 5th MTP is tender with swelling

-TX—


-wear wider or stretched shoes

-surgery
-Plantar Fascitis—

-old and young

-pain at insertion of the plantar fasciapain at base of heel

-inactivity

-first step out of bedPAIN (stretch the insertion of the plantar fascia)

-PE—

-tenderness



-aggravation of pain

-dorsiflexion of toesstretch fasciapain

-TX—

-orthotics



-rest, ice, NSAIDS

-local injections—pain, but steroids help

-surgery (rare)

7/11/00
Pressure Sores—

-AKA—decubitus ulcers / bed sores

-nasty stinky smelly d/c’s

-a failure of competent care (RN, PA, DR, etc)

-2-11% of hospital pts

-3-50% of long term care pts

-most common in the elderly but in young pts too

-sitesanywhere there is pressure

-ischial tuberosity

-greater trochanter

-heel


-sacrum

-medial/lateral malleolus

-ulcers can come from other things too

-In what settings

-long term care facilities

-community—home

-acute care hospital beds

-Cost—high cost of hospitalization

-prolongs stay, adds to nursing cost

-as much as $15,000 extra per stay

-increase stay by a couple of weeks

-Just remember BIG BUCKS

-Complications—

-local infx

-systemic infx

-death


-Cause—

-ischemic damage caused by intense pressure

-avg pressure32mmHg

-sitting300mmHgdecrease circulation

-increased source of litigation

-need ZERO TOLERANCE for pressure sores

Norton Risk Assessment Scale—

Physical Condition

Mental Condition

Activity

Mobility

Incontinent

TOTAL SCORE

Good 4

Alert 4

Ambulant 4

Full 4

Not 4




Fair 3

Apathetic 3

With help 3

Slightly limit 3

Occasional 3




Poor 2

Confused 2

Chair-bound 2

Very Limited 2

Usually/urine 2




Very bad 1

Stupor 1

Bed 1

Immobile 1

Doubly 1




*if 14 or lesshigh risk for pressure sores

Causes and RFs—

-pressure

-moisture—incontinent, sweaty

-shearing forces—friction—sliding ischial tuberosities

-immobility

-age—increased age = increased risk

-MALNUTRITION***

-albumin 3.3g/dLincrease risk of sores

-Hgb <11.1

-total lymphocyte countlast two not done as often in pressure sores

-without nutrition—more likely to get sores and less likely for sores to heel

Prevention of pressure sores—

-Maintain good nutrition

-Should be positioned so that they are not sitting or lying on reddened areas by

-put extremity on a pillow (b/t knees or ankles) [protect bony protuberances]

-frequent repositioning (15min to 2h)

-pts may be able to help if you installbed rails, trapeze

-Body positioning

-sitting (thighs should be horizontal to chair)

-lying (30 degree laterally inclined position)

-Support surfaces—air mattress, egg crates, etc


Prevention of Pressure Sores—

-maintain ROM

-protective filmsdecrease friction

-maintain clean and dry skin

-VIGILANCEcheck QD, move often, time consuming process
Skin Care—

-inspect on a routine basis

-massaging NOT recommended—increase damage and decrease wound healing

-moisturizing of the skin with

-lotions

-creams


-ointments (best)—KY is best
Protecting the Skin from Irritants—

-must protect from fecal (worst) and urinary incontinence

-better to use disposable absorbent diapers as opposed to cloth

-topical skin barriers such as

-petroleum jelly

-zinc oxide

-see pamphlet #3, p. 9
Staging—

-see pamphlet #3, p. 1

-stage 1—no skin breakage

-stage 2


-stage 3

-stage 4
Treatments—

-many—p 436—full column

-general instructionsif its wet, dry it, if its dry, moisten it

-see pamphlet 15

7/13/00
Prostate—

-1g at birth

-up to 20g

-pubertyenlarges until the end

-age 40starts to enlarge again

-physiology of the enlargement

-testosterone + 5-reductasedihydrotestosteronehypertrophy

-DiseasesBPH and prostatic ca
Benign Prostatic Hyperplasia / Hypertrophy

-Ubiquitous Dz

-Sxirritative and obstructive

-irritative—

-nocturia

-urgency


-frequency

-dysuria


-obstructive—

-decreased force of stream

-dribbling after urination

-hesitancy

-straining to urinate

*BPH is the most common cause of urinary complaints and common to get UTI

*50% of males >70 have BPH syndrome

-Dynamic and Static Components—

-static40yo—increased tissue—get nodular cells

-dynamic—smooth muscle within the gland hypertrophies

-smooth muscle receptors in bladder neck

-American Urological Ass. Sx Index for Eval of BPH—

-0-7 = mild

-8-19 = moderate

-20+ = severe

*do this evaluation on sx of prostatism

-TreatmentSEE HANDOUT

-Medical Therapy—

-finasteride (Proscar)—5-reductase inhibitor

-works on STATIC component

-peripheral 1-blockers—

-work on DYNAMIC component

-relax smooth muscle—Hytrin, Cardura

-SEortho hypo

-Flomax—more specific 1-blockerless SE’s

-Proscar—less dramatic effect

-6mo b/f see improvement if sx

-with the peripherals—hytrin/cardura—see difference within hours-weeks

-need to use 6weeks b/f give up

-can combine the two types

-Gold standard txTURP

-most people do this initially—

-medical tx—$2000

-prostatectomy is $13000


Prostate Cancer

-most commonly dxd cancer and the second leading cause of cancer death in US males

-by age 80 nearly 2/3 of men have histological evidence of prostate cancer

-the course is often benign

-most cancers occur in older men and remain asymptomatic for years

-the average life expectancy of men with prostatic cancer differs little from men without ca

Prostate Cancer FlowchartSEE HANDOUT

-DRE start at 50yo unless +FH / African American—start at 40yo


High risk for prostate CA—

-age


-FH

-black race—by1.3x

-vasectomy—leaning away but maybe

-diet high in saturated fat—leaning away but maybe

Screening—

-DRE


-PSA

0-4—nl


4-10—equivocal—follow them

>10—abnl


Treatment—

-very controversial but includes three general types

-watchful waiting

-surgery—radical prostatectomy

-radiation therapy

-Watchful Waiting

-do if life expectancy <10y

-esp if not aggressive ca

-follow with DRE and PSA q3mo fro 1st year

-not appropriate if life expectancy >10y

-Radical Prostatectomy—GOLD STANDARD

-#1 SEimpotence

-may lose a lot of blood

<70 and life expectancy >10ydo this

-Radiation

-Xray beams

-bracytherapy—implant radioactive seeds

-use if cant tolerate surgery

-high variability

-Hormonal therapy

-palliative tx—not mainstay

-advanced dz / metastaticcant curedo hormonal—treat some sx

90% of cancer is well localized

Follow-up Tx—

-follow with PSA—if removed—should go to 0

-make sure proper things are being done
7/18/00
CONSTIPATION—

-1/2 elderly people at home

-one definition is <3 bowel movements / week

-males have more >5/week


Pathophysiology and Causes of Constipation—

1. Decreased activity levels—decrease colonic transit timeconstipation

-exercise increases colonic transit timecure

2. Metabolic and Endocrine Disturbances

-the following processes can slow colonic transport

-hypokalemia which can produce an ileus (most often seen in pts taking diuretics, and from chronic laxative abuse)

-hypothyroidism

-DM


-hypercalcemia

3. Mechanical Obstruction—

-tumor, stricture (stenosis), volvulus (mechanical obstruction—round ball of foreign obstruction)

-cramping, abd pain, and distention

-marked change in bowel habits

-hyperactive bowel sounds, mass on palpation, dull on percussion

4. Drugs—

-opiates (codeine)

-agents with anticholinergic activity such as antidepressants

-CCBs (decrease bowel mobility)—verapamil but not the dihydropyridines

-cholestyramine (Questran) may cause by binding up bile salts

-aluminum hydroxide / calcium carbonate antacids (negate eachother)

5. Psychiatric disease and Psychological distress—

-depression—don’t eat well, decreased activity, etc

-irritable colon (irritable bowel) syndrome

6. Neurologic impairment—

-spinal cord injury

-multiple sclerosis

7. Environmental—

-immotility

-poor hydration

-dietary fiber


Hx of Constipation—

-What is the change from normal?

-Define bowel movements in terms of:

-size


-character

-frequency

-Chronicity of constipation

-GI Hx


-Anxiety / Depression Hx

-Medication Hx (must ask about OTC drugs like antacids and laxatives and herbs)

-Exercise Hx

-Dietary Fiber Hx

PE of Constipation—

-General Appearance

-Weight—loss, etc

-check for signs of hypothyroidism

-abdominal exam

-rectal exam—important

-stool for consistency

-stool for occult blood

-Neuro—

-sensory (perianal light touch)



-DTRs (for hypothyroidism)
Labs / Xray—

-K+ level if on diuretics

-Ca2+ level

-TSH?


-in acute onsetplain supine and upright films of the abd

-sugar if suspect DM

-Heme X 3

-Flex sig / BE or Colonoscopy? (Especially if high risk for colorectal CAA—do later


Treatment of Constipation—

-5 Categories of drugs to use

1. Bulk Forming Agents—1st line for simple constipation

-bran (fibermed)

-psyllium (fiberall, metamucil, perdiem, etc)

-methylcellulose (Citrucel)

-polycarbophil (FiberCon)

-polyethylene glycol (Miralax)—newest—colorless, odorless, tasteless

*overview of bulk forming agents info overview

-indicated for simple constipation

-non-absorbable

-some natural and some semi-synthetic and some are cellulose derivatives which:

-absorb water

-increase stool mass

-stimulate intestinal motility

-these most closely approximate normal bowel function

-should be taken with full 8oz water

-many contain 50% dextrose so DM can get sugar free


2. Emmolient Laxatives

-Two types—

-Lubricants—mineral oil, no more than 15mL / d

-Surfactants—add lubrication and H2O

-docusate sodium (Colace)

-docusate calcium (Surfak)

-docusate potassium (Dialose)
3. Saline Laxatives—

-magnesium hydroxide (Milk of Magnesia)

-magnesium sulfate (Epsom Salt)

-magnesium citrate (Citroma)

-sodium phosphate (Fleet [oral or rectal])

*Saline Laxatives Info—

-poorly absorbable

-osmotically attract water

-increase stool bulk

-increase intestinal motility

-short onset of action (30min to 3h)

-sodium phosphate (Fleets) rectally is rapid—within 2-15min

-watch sodium content in HTN pts

-avoid magnesium preps in elderly because of reduced renal function

-intermittent use only
4. Stimulant Laxatives—

-Senna (Senokot)

-Bisacodyl (Dulcolax)

-Phenophthalein (Correctol, Ex-Lax, Feen-A-Mint)

*senna—active ingredient in all

*Stimulant actions—

-direct stimulation of intestinal motility and influx of water and electrolytes into bowel lumen
5. Hyperosmotic—

-glycerin suppositories

-lactulose (Cephulac, Chronluac)

*Action—


-increase water content of the stool

-stimulate intestinal motility

Parkinson’s Disease—

-1% >55yo in US

-150 in every 100,000 in US
-Pathophys—

-a neurodegenerative disorder

-a loss of DA containing neurons from within the substantia nigra (this hooks into the basal gangliacoordination of movements)

-Sx are thought to be due to the imbalance between dopaminergic and cholinergic influences

-decreased DA and relative increase in AcH

-Epidemiology—

-Parkinsonism—sx of parkinsons secondary to an indentifiable cause

-toxins—CO, cyanide

-Syphilis

-Drugs (Haldol, Reglan)

-CVA

-Parkinsons—



-idiopathic

-RFs


-residence in industrialized nations

-living in rural areaas with exposure to:

-well water

-herbicides

-pesticides

-genetic?

-increasing age

-cigarette smokingreduces the risk

-Clinical Presentation—

-age—60-65, 5% are under 40yo

-male

-tremor at rest



-rigidity

-bradykinesia

-masked face

-stooped posture

-shuffling gait

-postural instability—falls, fxs


-Clinical Course—

-2 general ways—

-pts that present primarily with a tremor

-pts who present with significant postural and gait instability


-Dx—

-Presence for 1year or more of two of the three following signs

-resting or postural tremor

-bradykinesia

-rigidity

-Responsiveness to levodopa therapy with moderate to marked improvement and duration of improvement for 1 year or more

7/20/00
-95% of pts with Parkinson’s respond to Levodopa

-AcHmusclular contraction

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