NR-601 Primary Care of the Maturing & Aged

Family Practicum

Midterm Review Weeks 1 – 4 Notes

CGA

• Purpose: Physical health is r/t psychosocial functional ability and safe environment.

o helps in dx conditions and improve outcomes

o identify potential preventable conditions

o patient-centered care

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• Most beneficial for the vulnerable, older adults but should be completed for all older adults.

• Domains: Physical health, functional health, psychological health, socioenvironmental support &

quality of life measures.

o Physical health

▪ Medical history, PE (abnormals-differentials), ROS, diagnostics,

▪ Nutritional assessment-

• Assessment tool: mini nutritional assessment instrument

• Food diary

• Phys assessment with measurements

• Biochemical markers

▪ Medication review (Beers criteria)

▪ Functional health- goal is to improve function and prevent decline

▪ ADLs- Katz ADLs scale

▪ IADLs- Lawton & Brody Scale for IADLs

▪ Ask patients to demonstrate or explain how they complete adls

▪ Psychological health (cognition and mood)

▪ DSM-5 (delirium vs cognitive impairment)

▪ MMSE

▪ CDT, word recall

▪ Mini-Cog

▪ SLUMS

▪ Confusion Assessment Method (CAM)

▪ Geriatric Depression Scale- PHQ-9

▪ HOPE, FICA, SPIRIT

▪ Socioenvironmental

▪ Social network/support

▪ Social isolation assessment (lubben social network scale)

▪ Living situation (housing, transportation

2

▪ Environmental ( utilities, heat, water)

▪ Economic (income, assets, afford meds and healthcare)

▪ Quality of life

medical outcomes study

▪ Physical/social conditions

▪ Personal resources

▪ Preference of care (advance directive)

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Age related changes: Physiological

▪ Skin-

▪ decrease dermal thickness/elasticity = SBD risk

▪ Decrease vascularity= less sweat, odor, heat loss= altered temp regulation, risk of heat

stroke, change in fluid needs

▪ Resp:

decreased vital capacity = decreased gas exchange processes

▪ Cilia atrophy=increase infection risk

▪ Decreased resp muscle strength=risk for atelectasis

o CVD:

▪ fibrosis to heart valves= reduced SV, CO= decreased stress responses

▪ Fibroclastic SA node thickens= slower HR=increased arrhythmias

▪ Decreased baroreceptors sensitivity=decreased sense to bp changes = more falls, injuries

o GI:

o liver smaller=decreased storage

▪ Decreased muscle tone=altered motility

▪ Decreased metabolism=need for less calories

Lab results: normal levels vary with age, sex, race (don’t assume abn lab result is part of aging processes)

o Decreased CrCl, GFR: nephrotoxic drugs

▪ Digoxin

▪ H2 blockers

▪ Lithium

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▪ Water-soluble atb- ceftriaxone, piperacillin, gentamycin, vanco

▪ Review page 1285 table(Dunphy)

Atypical Presentations

Acute abd illness Vague sx, acute confusion, constipation,

mild discomfort, tachypnea,

Depression Anorexia, vague abd cramps, new

constipation, agitation, insomnia, lack of

sadness

Hyperthyroidism Apathetic thyrotoxicosis- fatigue, weak,

wt loss (not gain), palpitations,

tachycardia, new afib onset, HF if undx

Hypothyroidism Confusion, agitation, cardiac

manifestations, new anorexia, wt loss,

arthralgia

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Malignancy New/worse back pain 2nd to mets form

slow growing breast masses or silent

bowel masses

3

Jaundice-GB disease

MI No chest pain, fatigue, nausea,

decreased function and cognition,

classic: dyspnea, epigastric pain,

weakness, nv, hx of cardiac failure

Higher in females: non-Q-wave MI

Infectious disease Low grade fever or none, malaise, sepsis:

w/o leukocytosis or fever

Falls, new confusion, or AMS

Decreased function, anorexia

Peptic ulcer Dyspepsia, early satiety

Painless, bloodless stool

New confusion

Tachycardia, hypotension

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Pna Mild cough without copious sputum, no

fever or mild, confusion

Tachycardia, tachypnea, anorexia,

malaise

Pulmonary edema Lack of paroxysmal nocturnal dyspnea,

Insidious onset of decreased function,

appetite, fluids, confusion

TB Hepatosplenamegaly, abn liver tests,

anemia

UTI No or mild fever, worse cognition,

dizziness, anorexia, fatigue, weakness

Geriatric Syndromes- multifactorial: sx seen in elderly that are r/t combo of diseases

o SPICES (assessment tool)

o Sleep disturbance

o Problems eating or feeding

o Incontinence

o Confusion

o Evidence of falls

o SBD

Categories of Aging

o 65-74 = young old

o 75-84 = old

o 85-older = oldest

Causes of delirium

o Drugs

o Electrolyte imbalance

o Lack of drugs (w/d, uncontrolled pain)

o Infection

o Reduced sensory input (vision/hearing)

4

o Intracranial (CVA, SDH)

o Urine retention, impaction

o Myocardial/pulmonary conditions

Exercise in Older Adults- recommended moderate- intensity aerobics 30min x5 days a week, or vigorous

intensity aerobic 20 min x 3 days a week( can be intermittent throughout the day)

o Barriers to exercise

o Lack of time

o Perceived need for equip

o Disability or function limitation

o Unsafe neighborhood/weather conditions

o Depression/lack of motivation/sig life event

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o High BMI

o Don’t know what to do

➢ Facilitators

o Social networks

o Positive self worth

o Motivation to do it

o Good health

o Good contact with prescriber

o Reg, scheduled programs]

o Happy with program

o Insurance incentive

o Improved mobility/health

➢ Contraindications

o Unstable angina

o Uncompensated HF

o Severe anemia

o Uncontrolled BG

o Unstable aortic aneurysm

o Uncontrolled HTN/tachycardia

o Severe dehydration or heat stroke

o Low o2 sat

Exercises for sleep

o Tai-chi, walking, aquatherapy, biking ( assess balance and fall risk 1st)

Exercise for flexibility:

o To maintain flexabilty, perform exercises 10 min x 2 days a week

Exercises for other dx:

Review table on page 21 (Kennedy)

Screenings before exercise:

o Cardiac: stress test before beginning vigorous exercises

o Parkinsons, osteoporosis, dementia: Assess balance and risk for falls

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