St. Joseph Mercy – IM/TY Residency Blog – Our Residents ...
MalnutritionEpidemiologyHospitalized elderly patients – About ? malnourished, and ? at riskDiagnosisAny:>10lb loss / 6 monthsBMI < 22Alb < 3.8Cholesterol < 160Vitamin deficienciesDB12 - 15 percent of people >60Calcium//////////////////////SLIDE/////////////////////////EvaluationAccess to nutritious foodsDentures/teeth problemsUnderlying medical illnessesiADLs (e.g. grocery shopping)DepressionMalignancy//////////////////////SLIDE/////////////////////////TreatmentNatural course: some carbs replaced with fatsSelect healthy fats (e.g. olive oil, nuts, avacados, fish) to increase omega 3 and monounsaturated fat intakeSupplement VitaminsLimit EtOH to 2-3 drinks per day or 7/week//////////////////////SLIDE/////////////////////////FallsEpidemiology50% annual rate of Falls (age > 80)5% = FracturesPathophysiologyDecreased position reflexes, and agilityProprioceptionBaroreceptorsSwayingOrthostasisEspecially postprandial falls (? hypotension related to carbohydrate meals)//////////////////////SLIDE////////////////////EvaluationRisk Factors –---????????AgeHx of fallsFemale genderPoor visionPoor gaitCognitive impairmentetc. Enviornment: dim lighting, rugs, untidinessDrugs: Benzos, Antidepressants, Neuroleptics, HTN meds//////////////////////SLIDE////////////////////Exam Website: 3 metersSee TableCheck gait speed, calf circumferenceVision examTandem (heel to toe) walkIf no memory of fall: consider syncope evaluationTreatmentAddress enviormental factorsSupplement Vitamin D (400-1000 u per day)Exercise (balance and resistance training)reduces fallsprolongs survivalSupports in the home (eg shower hand-rails)//////////////////////SLIDE////////////////////////Decub UlcersEpidemiologyRisk factors –---????????Friction and pressureMoisture (urine)MalnutritionArterial or venous insufficiencyDiagnosisStages Image//////////////////////SLIDE////////////////////////TreatmentRotating bed bound patients q2h (? helpful)Treat infection if present Chemical debridementSurgical debridementWet to dry dressings?St Joes now has a wound clinic (with other treatment modalities including hyperbaric oxygen and ? Maggot therapy). “Cochrane reviews do not support a role for electromagnetic therapy, ultrasound therapy, or hyperbaric oxygen therapy in pressure ulcer treatment.”Address malnutrition and if possible arterial/venous insufficiency//////////////////////SLIDE////////////////////////Osteoporosis & FracturesEpidemiologyestimated 9,000,000 osteoporotic fractures around the world? of all post menopausal women will have an osteoprotic fracture mortality –---????????20% 1 year mortlity rate for hip fractures//////////////////////SLIDE////////////////////////Risk factors includeAge, GenederHx of fragility fracturesBMI < 21Alcohol consumptionMenopause < 40 year of agesmoking and steroidsChronic conditions (IBD, RA, endocrine problems, etc.)DiagnosisDexa screen –---????????women > 65, men > 70Pts > 50 with risk factorsEvaluationt-score for diagnosisz-score (aZe-matched) – to determine co-existing illnesses contributing to low bone densityTreatmentAnabolic – Teriperatideonly for 2 years – risk of osteosarcomabisphosphonatesHRT – not a 1st line choice!Raloxifene – for both prevention as well as treatment of osteoporosis//////////////////////SLIDE////////////////////////HRTIndicationVasomotor symptomsOsteoporosis prevention if other Tx contraindicatedTreatmentEstrogen vs combination therapyFact or fictionCVDBreast cancerEndometrial cancerVTEColon cancerYounger vs Older patientsFinal recommendations//////////////////////SLIDE////////////////////IncontinenceCommon, but do not consider it a normal consequence of agingTypes –---????????Urge Possible a/w certain triggershearing running waterentering cold enviormentunlocking home doorDue to detrussor instability/hyperreflexia or cystitisTx: behavioral therapyAttempt relaxation techniques when urge is presentGoal void only q4h hours, with no leakage in between2nd line: anticholinergics (avoid if on meds for dementia/glaucoma), Kegel exercisesStress = leakage with intrabdominal pressureRisks FactorsMultiple vaginal deliveriesPostmenopausal vaginal atrophy or BPH surgeryPelvic surgeryTx: Kegel Exercises –---????????//////////////////////SLIDE////////////////////Target muscle – not Abdomen. “[S]top urination in midstream. If you succeed, you've got the right muscles.”Empty the bladder and lie on back and contract muscle. Hold x 10 secs, repeat x 10. Complete 3/+ sets. Mixed – behavioral therapy including Kegel exercisesIncomplete bladder emptyingCausesOveractive bladderObestruction – BPHAnticholinergic medsMuscle/Nerves – DM, Parkinsons, MS, EtOH useTx underlying cause and use 5-alpha blockers for BPH//////////////////////SLIDE////////////////////EDCausesPsychogenic – Stress, DepressionMedications – SSRI, clonidine, spironolactone, beta blockers, thiazidesNeurogenic – DM, prostate surgery, MS, ALS, Parkinsons, Cyclists who sit for more than 3 hrs weeklyVascular – indicated by a penile brahcial indexTreatmentSildenafil, Vardenafil, Tadalafil (can use daily for BPH, AE: back pain), Avanafil (Stendra, newest), yohimbine (alpha-2 blocker), vacuum devices, alprostadil, penile implants. //////////////////////SLIDE////////////////////////Geriatric PharmacologyChange in metabolism/execretion → increased serum concentrationsProportion of body fat increases → volume of distribution may increaseAnd increased effect from opioids, benzodiazepinesGeneral RulesStart lower dose (? dose) – e.g. coumadin 2.5 mg instead of 5 mgPolypharmacy - Assume adverse effects to be d/t drug until proven otherwiseErrors in self administration – with 3/+ Rx medsUpto 75% Pts may be on herbal supplements – need to specifically ask ................
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