Elderly:History and Physical

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  1. Geriatric Syndromes
  2. 16/2010
    •  Falls
    •  Incontinence
    •  Delirium/dementia/depression
    •  Polypharmacy
    •  Vision and hearing impairments
    •  Malnutrition
    •  Dizziness and syncope
    •  Sleep problems
  3. Screening for PRIMARY PREVENTION
    Bone Density
    BP screening
    DM screening
    Lipid screening
    Obesity screening
    Smoking cessation
    • Bone Mineral Density At least once after age 65
    • BP screening yearly
    • DM screening every 3 when BP135/80
    • Lipid screening yearly
    • Obesity screening yearly
    • Smoking cessation every visit
  4. Screening for SECONDARY prevention
    Alcohol abuse
    Hearing impairment
    Mammography, clinical breast exam
    visual impairment
    • AAA Once in men 65-75 who have ever smoked
    • Alcohol abuse Periodically
    • Depression yearly
    • sigmoidoscopy/colonoscopy yrly/q5yr/q10yr 50-75
    • Hearing impairment yearly
    • Mammography,breast exam q 1-2 yrs
    • PAP q 3 yrs until age 70
    • Visual impairment yearly
  5. Immunizations Frequency (elderly)

    Herpes Zoster
    • Herpes Zoster
    • Once in immunocompetent elderly
    • Flu
    • Yearly
    • Pneumonia
    • Once after 65, or repeat if taken before age 65
    • DT
    • Every 10 yr, (but T-dap 18-64)
  6. Timed Get up and Go
    • Assesses Risk for Falls- do practice 1st time then time them the second time
    • Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with arm rest. On the word, "Go", the patient is asked to do the following:
    • 1. Stand up from the arm chair
    • 2. Walk 3 meters (in a line)
    • 3. Turn
    • 4. Walk back to chair
    • 5. Sit down
  7. Timed Get up and Go
    • Time the second effort.
    • Observe patient for postural stability, steppage, stride length and sway.
    • Scoring:
    • Normal: completes task in < 10 seconds.
    • Abnormal: completes task in >20 seconds
    • Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls.
  8. Functional Reach Test
    • Measures balance
    • Measure of balance
    • Difference, in inches, between arm's length and maximal forward reach, using a fixed base of support.
    • 48-inch measuring device or "yardstick" used to measure reach from sitting or standing position
    • A reach of less than or equal to 6 inches predicted fall
  9. ADLs
    • IADLs
    • Mobility
    • Incontinence
    • Affect/Mood
    • Cognition (Memory)
  10. ROS tailored to:
  11. CC and syndromes
    • Knownage related changes
    • Function
    • Cohort and career 80s lived during polio epidemic, rheumatic fever, agent orange (babyboomers)
    • E.g., childhood illnesses or exposures, wars
    • Establishingbaseline or change from it
  12. Social History (elderly)
  13. Support network and living situation
    • Health beliefs and preferences
    • DNR, advanced directives, durable POA
    • Stressors and coping patterns
    • Family! (Abuse screen)
    • Recent losses, moves
    • Finances
    • Habits
    • Drug use, sexually active
  14. Physical Assessment

    General observations and vital signs
  15. Signs of ADL deficits
    • Odor, clothing disheveled,poor fit
    • Signs of neglect, abuse or falls
    • General posture and gait
    • Orthostatic BPs with each visit
    • Weight change
  16. Common Skin condition of the elderly
    • Sehorrheic keratosis sun exposed areas scabby raised
    • Actinic keratosis shinnier with irregular border precancerous
    • Senile lentigines liver spots
    • Squanous cell CA
  17. HEENT elderly
  18. Look for head trauma
    • Palpate temporal artery
    • Internal eye exam may not be tolerated
    • But look for blepharitis (inflammation of eyelid margins), entropion (rolling inwards of eyelid), ectropion (outward rotation of eyelid)
    • Check for cerumen (ear wax)
    • Inspectmouth and dentures
  19. Dix-Hallpike test
    • Determines whether vertigo is triggered by certain head movements.
    • observe any involuntary eye movements (nystagmus) that may occur during this test to determine if the cause of your vertigo is central or peripheral. Central vertigo=inside the brain
    • peripheral vertigo=problem with the inner ear or the nerve leaving the inner ear.
  20. Chest assessment (elderly)
  21. CV
    • Kyphosiscan cause displacement of PMI
    • Systolic murmur may be benign
    • Diastolic murmur always abnormal
    • Signs of arterial or venous insufficiency
    • Pulmonary
    • Impact of kyphosisand/or scoliosis
    • Breast exam
  22. Extremities (elderly)
    • Pulses often diminished
    • arteral and venous insufficiency
  23. Neurological exam (elderly)
    • MS screen to establish baseline:
    • MiniCog
    • GeriatricDepression Scale–Short Form
    • CAM and CAM-ICU (CAM-ICU pt doesnt need to be able to speak or write to score)
    • DTR and vibratory diminished
  24. Differential Diagnosis of 3 D's
  25. ANY change in mentationor behavior, label as delirium until proven otherwise
    • All three present with similar symptoms and signs
    • All three can occur simultaneously
    • BUT consequences for each are much different, txdiffers
  26. Delirium
  27. Delirium -Transient mental disorder reflecting acute brain failure
  28. Dementia
    A syndrome of progression cognitive decline
  29. Depression
    Affective disorder of overwhelming sadness
  30. DSM -IV Necessary Criteria for Delirium
    • must have
    • Disturbance of consciousness
    • Impaired attention
    • Change in cognition
  31. Supportive features for Delirium
    • need at least 2 of these
    • * develops acutely and fluctuates most common
    • *sleep disturbances most common
    • *evidence of underlying physiological cause
    • *disturbed psychomotor behavior (ie hyper or hypoactive form..HYPO has worse outcome)
    • *emotional disturbance
    • *EEG abnormalities
  32. DSM-IV Necessary Criteria for Dementia
    • Multiple cognitive deficits with both
    • Memory impairment
    • One of the following:
    • Aphasia –loss of ability to use language
    • Apraxia–loss of ability to initiate mechanics of speach
    • Agnosia–loss of ability to connect words to objects
    • Disturbance in executive functioning –control of cognitive functions including planning, executing, anticipating, imagining
    • Deficits cause significant impairment in daily life
    • Gradual onset and progression
    • Able to exclude delirium, depression and psychosis
    • A diagnosis of exclusion
  33. DSM-IV Criteria for Depression
  34. Depressed mood on report or observed by others
    Loss of contact with reality (absent in dysthymic disorder)
  35. At least two of the following for dysthymic disorder, all for major depressive episode
    • Loss of interest in previously enjoyed activities
    • Weight loss, loss of appetite
    • Fatigue, low energy
    • Indecisiveness, poor concentration
    • Hypersomniaor insomnia
    • Psychomotor retardation or agitation
    • Feelings of worthlessness, self reproach, excessive guilt
    • Suicidal thoughts
    • 10/16/2010Vermeersch
    • 40
  36. dysthymic disorder
    Dysthymia is a depressive mood disorder characterized by a chronic course and an insidious onset. Many people with dysthymia describe life-long depression.By definition, dysthymia is a chronic mood disorder with a duration of at least 2 years
  37. Causes of Delirium
    • Virtually anything and usually a combination
    • medication SE or toxicity
    • hypoxia
    • infection or other metabolic abnormality
    • change in environment
    • pain
  38. Risk Factors for Delirium
    • Age
    • Pre-existing cognitive impairment
    • Visual impairment
    • Severe illness
    • BUN/ Creatinineratio >18
    • Immobility
    • Hearing impairment
    • Sleep disturbance
  39. Delirium Precipitating Factors
    • Physical restraints
    • Malnutrition
    • >3 medications added
    • Use of a bladder catheter
    • Any iatrogenic event
  40. ALZ Disease Risk Factors
    • Age
    • Female
    • Family hx
    • head injury
    • education
    • Down?s syndrome
    • Genetic
    • Early Onset
    • PS (presenilin) 1 and 2 (14, 1)
    • APP (21)
    • Late Onset
    • ApolipoproteinE4 (19)
    • HTN (stroke)
    • Atherosclerosis (stroke
  41. Depression and Risk Factors (elderly)
    • Normal life events + daily hassle > coping
    • Suicide is more lethal in older adults
    • Prior hx
    • Medical illness
    • Medications
    • Social factors
    • female
    • poor social supports
    • low income
    • early traumatic experiences
    • baby boomers
  42. Differential Diagnosis
    • Delirium
    • 1.Rapid Onset
    • 2.Attention Deficit
    • 3.Fluctuation course
    • 4.Unable to participate in cognitive screen
    • 5.There is a likely source for delirium
    • Dementia
    • 1.slow onset
    • 2. memory deficit
    • 3.usually steady decline in function
    • 4.makes up answers to cognitive screen
    • 5.Unable to find source for MS changes-diagnosis of elimination
    • Depression
    • 1.uncertain onset
    • 2.memory deficit
    • 3.some decline but tends to hold steady
    • 4."Idont know" replies to cognitive screen
    • 5.Likely source is symptoms r/t losses,comorbidity

Card Set Information

Elderly:History and Physical
2010-10-27 05:07:01
Elderly Hx Physical

History and physical of the elderly
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