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2011-03-14 1 Geriatric Gems “Sex after ninety is like trying to shoot pool with a rope. Even putting my cigar in its holder is a thrill.” --George Burns A few notes on temperature patterns in the geriatric patient May not rise as rapidly with infections or as high A rise of greater than 1.5° C within 2 hours— consider sepsis Patients on neuroleptic drugs (dopamine blockers) Patients on neuroleptic drugs (dopamine blockers) tend to have lower basal temperatures (always complaining of “feeling cold”) Temperature patterns in the elderly Loss of subcutaneous fat (actually you don’t LOSE the fat, you just move it to the internal visceral organs) with age--difficulty maintaining internal temperatures with extremes of ambient temperature Hypothermia/hyperthermia Hypothermia/hyperthermia “You’re not dead until you’re warm and dead.” Always check the thyroid gland—myxedema coma + cold ambient temperature

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Page 1: 01H Barb Bancroft

2011-03-14

1

Geriatric Gems

“Sex after ninety is like trying to shoot pool with a rope. Even putting my cigar in

its holder is a thrill.” --George Burns

A few notes on temperature patterns in the geriatric patient

• May not rise as rapidly with infections or as high

• A rise of greater than 1.5° C within 2 hours—consider sepsis

• Patients on neuroleptic drugs (dopamine blockers)Patients on neuroleptic drugs (dopamine blockers) tend to have lower basal temperatures (always complaining of “feeling cold”)

Temperature patterns in the elderly

• Loss of subcutaneous fat (actually you don’t LOSE the fat, you just move it to the internal visceral organs) with age--difficulty maintaining internal temperatures with extremes of ambient temperature

• Hypothermia/hyperthermia• Hypothermia/hyperthermia• “You’re not dead until you’re warm and dead.”• Always check the thyroid gland—myxedema coma +

cold ambient temperature

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Pulse/heart rate

• Bradycardia—hypothyroidism, dig, beta blockers (even beta blocker eyedrops {Timoptic, Betoptic, etc.} can cause bradycardia), calcium channel blockers such as verapamil and diltiazem

• Palpitations with CHF, hyperthyroidism, AtrialFibrillation

• Unexplained tachycardia (60 to 80 is the normal resting heart rate)—consider hyperthyroidism, atrialfibrillation (which can also be caused by hyperthyroidism)

• Tachycardia (loss of vagus nerve due to autonomic neuropathy) and silent ischemia in diabetics

Respirations

• Fever and tachypnea in the older adult—consider an acute pulmonary syndrome—

• Pulmonary embolism (over 85? 700 PE/100,000)• Pneumonia—confusion, tachypnea, fever and shoulder pain—

referred pain due to a big “wet” lung*• Pneumococcus (strep pneumoniae) is the most prevalent• Pneumococcus (strep pneumoniae) is the most prevalent

pathogen; Strep pneumoniae and Legionella are the most serious; (pneumococcal vaccine @ 65)

• Let’s go back to referred pain for a momento…how much embryology did you get in nursing school?

Referred pain…Let’s go back about 80 years…to the embryo.

• Embryologic development and the diaphragm—C3, C4

• Shared sensory afferents with somatic structuresstructures—

• Diaphragm and the shoulder

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Blood pressure—Ideal? 120/80

• Depending on co-morbidities it may be kept slightly higher in the elderly to avoid hypotension, falls, and a broken hip

• But not TOO high as it is the MAJOR risk factor for strokes (besides AGE)—66% of all strokes due to hypertension

• Keeping the blood pressure BELOW 140/90 prevents strokes, ACS, CHF, dementia, and renal failure

• Blood pressure tends to increase with age—especially the systolic pressure—known as ISH or isolated systolic hypertension

Weight as a vital sign in the elderly

• Unexplained weight loss? Look for a cause…infection, inflammation, drugs, poverty, depression

• Weight loss defined as? (≥ 5% of usual body weight over 12 months or less)

• Drugs and weight loss (dig, metformin)

• Drugs and weight gain (insulin, sulfonylureas, SSRIs (paroxetine/Paxil; fluoxetine/Prozac), corticosteroids, atypical antipsychotics)

• Heart failure and weight gain

What is senescence??

• The process of senescence—the rate of deterioration of the structure and function of body parts

• The 1% rule

• Functional reserve of tissues is 4-10 x greater thanFunctional reserve of tissues is 4-10 x greater than baseline (the amount needed just to function)

• Peak functional capacity at 24

• 6 good years

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Senescence and normal aging...

• Peak at 24, 6 good years, gradual decline to baseline; more rapid decline with chronic disease (DM, COPD)FC%

30

Baseline function

FC%

75 yrs1yr 30

Example of “livin’ on the edge…” (baseline)

• Acetylcholine in the CNS is the neurotransmitter of cognition; as we age the blood-brain barrier becomes more lipid-soluble and drugs can enter the brain with greater ease

• Drugs with “anti-cholinergic” effects can cause confusion and memory loss

RENAL FUNCTION…

• Glomerular filtration rate (GFR)—120-125 ml/min at age 25; decreases by ~1% per year;– 75-year-old = 1.2 mL/min x 45 years = 53

mL/min; 120-53=67 mL/min in a HEALTHY 75-year-old (not taking into account weight, ethnicity, or gender)

– BUT, a GFR of 60-89 mL/min=mild renal insufficiency

– a GFR of less than 60 mL/min/1.73 m2 represents a loss of more than half of normal kidney function

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Certain nephrotoxic drugs can “throw ya’ over the edge”

• Antibiotics (aminoglycosides)—vancomycin, tobramycin(the ears and the kidneys)

• Radiocontrast dyes (Metformin)• ACE inhibitors (“prils”) are especially dangerous if

renal blood flow is compromised—renal artery atherosclerosis (stenosis)

• NSAIDs combined with ACE inhibitors in the elderly may precipitate acute renal failure—HOW?

The healthy kidney

• Afferent arteriole(normally vasodilated(via prostaglandins)

• Blood enteringglomerulus

Prostaglandins –blocked by NSAIDs

glomerulus

• Glomerulus→filter

• Efferent arteriole(normally vasoconstricted(via angiotensin 2)

Angiotensin 2—blocked by ACE --

Toilet

filter

The combination of ACE inhibitors and NSAIDs can precipitate acute renal failure

• NSAIDs block prostaglandins and vasoconstrict the afferent arteriole decreasing blood flow to the glomerulus (prostaglandins are more important in the aging kidney than in younger kidneys—hence the high risk with NSAIDs in the elderly and not in a 20-

ld)year-old)• ACE inhibitors block ACE and the production of

angiotensin 2—blocking angiotensin 2 vasodilates the efferent arteriole of the kidney

• Decreased blood IN and increased blood OUT = decreased filtration and acute renal failure

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Water loss and aging

• Decrease in total body water stores

• Decreased volume of distribution

• Increased drug toxicity with water-soluble drugs—dig for examplefor example

• Encourage fluid intake

(loss of response to thirst receptors)

• Exception: patients w/ CKD or CHF (not more than 800 - 1500 mL per day for CHF patients)

Dehydration in the elderly

• Decreased collagen, elastic tissue, and water • What are the signs and symptoms of dehydration in

the elderly?

• Shrunken eyeballs?

• Pour skin turgor?

• Where do you check skin turgor in the elderly?

What else happens with a decrease in collagen and elastic tissue?

• What are some other consequences of the loss of collagen, elastic tissue and water?

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1% rule—but instead of a decrease, an INCREASE by 1% per year of clotting factors

• Increased risk of clotting in the elderly• Pulmonary embolism, acute coronary syndromes,

strokes, atrial fibrillation with mural thrombus formationformation

• Coumadin is a VERY popular drug in the over 70 group—more later

1% rule—an increase in body fat

• Retention of lipid-soluble drugs

• Half-life (T1/2) of diazepam (Valium) is the patient’s “age, in hours”

25-year old = 25 hours25 year old 25 hours

75-year old = 75 hours

Use shorter-acting benzodiazepines should be used in the elderly (Restoril, Serax, Ativan (lorazepam), Xanax, Halcion (triazolam)

Start low and go slow…(heard that before?)

Neurology of aging…

• 5% loss of cerebral weight in females by 70

• 10% loss in men (men start out with a bigger brain, however)

80 20% l• By 80, 17-20% loss

• Selected areas are the frontal lobes and the medial temporal lobes

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Loss of hippocampal cell function

• Loss of recent memory

• This is the first neurologic function to go with h ithe aging process

• Benign forgetfulness

• Mild cognitive impairment

What is mild cognitive impairment? (MCI)

• Borderline state—individuals are not demented, but they perform worse than their peers

• They sense that they are forgetful, and somebody close to them has probably noticed it, too; (repetition of questions and comments; misplacing things—relying more on notes and calendars, forgetting meds, familiar persons; word finding difficulties;

• Demanding task – new technology may prove challenging

• 10-15% per year evolve to clinical Alzheimer’s disease vs. normal elderly who do so at a rate of 1-2% per year

Reduction in prefrontal lobe function with the aging brain…

• Personality changes

• Decreased ability to concentrate on the task at hand

i i l i b h i ( h l f• Anti-social, regressive behavior (the loss of tact)

• Hostile behavior

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“MOTHER” is responsible for your behavior…your prefrontal lobe is your “mom”

• What’s the only word a mother needs to know?

• NO, Stop, Don’t, Negative…she is inhibitory

S i li i j d i i h• Socialization, judgment, insight

• You learn through inhibitory influences

With a dementing process…

• Mom is no longer responsible for “sociable behavior” (bilateral frontal lobes)

• Sexual indiscretions

h ld b h b h• The world becomes the bathroom

• Clothing is optional

• The number one cause of dementia in the elderly is Alzheimer’s disease

Alzheimer (s) disease or DAT

• The Alzheimer’s brain

• Cortical atrophy

• Sulcal widening

• Atrophy of gyri

• “feathering”

• Brain weight

• 90% decline in Ach

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Pathology

• Beta-amyloid plaques (BAP)—sticky globs outside the cells; abnormal processing and cleaving of amyloidprecursor protein—earliest indication of the development of dementia (may occur 5 to 20 years before the signs and symptoms of dementia)

It takes “tau” to tangle…

• Neurofibrillary tangles—tangled microtubules inside the cells; tau protein helps to stabilize the microtubules and thus, maintain the integrity of the neuronneuron

• Neuronal degeneration• Tau and FTD

• BAPtists vs TAUists

Diagnostic features…

• Hallmark is memory impairment• Apraxia—inability to carry out a motor function in

the absence of paralysis• Auditory and/or visual agnosias• Impaired executive functioning—planning,

organizing, abstracting (judgment/problem solving)• Abstraction• Significant impairment in occupational functioning

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Work-up of a patient with dementia

• CBC, Glucose, Electrolytes, calcium, renal function, liver function, vitamin B12, TSH, RPR (for neurosyphilis), ESR (sed rate)

• Toxicology screen HIV LP EEG Brain imaging• Toxicology screen, HIV, LP, EEG, Brain imaging (CT scan)

Treatment for acetylcholine deficiency…

• Acetylcholinesterase inhibitors such as donepezil (Aricept)—inhibit the breakdown of ACH in the brain; helps about 50-70 percent of the patients, but effects are modest; think back to what the patient was doing 7-8 months ago; reprieve only lasts a fewwas doing 7 8 months ago; reprieve only lasts a few months

• Others—galantamine (Razadyne, Razadyne ER), rivastigmine (Exelon)

• Reminyl was renamed Razadyne to avoid errors with the diabetes drug, Amaryl (glimepiride)…mistakes led to hospitalizations and deaths

Benefits of cholinesterase inhibitors?

• Many clinicians doubt the practical significance of response to ChEIs; however, other reports show that ChEIs have significant efficacy in the treatment of neuropsychiatric symptoms in AD patients. A meta-analysis involving 7954 patients demonstrated thatanalysis involving 7954 patients demonstrated that the numbers needed to treat (NNT) for 1 additional patient to experience benefit in the area of cognition were 7 for stabilization or better, 12 for minimal improvement or better, and 42 for marked improvement.

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Benefits of cholinesterase inhibitors?

• Other tangible clinical outcomes: delayed nursing home admission by as much as 21 months with donepezil (Aricept); Donepezil (Aricept) also slows the progression of atrophy of the hippocampus in the brains of patients with AD—suggesting athe brains of patients with AD suggesting a neuroprotective effect of this particular ChEI. Galantamine (Razadyne) and donepezil (Aricept) have also been shown to be neuroprotective by preventing neuronal apoptosis (programmed cell suicide).

Namenda (memantine)

• Namenda, Ebixa (memantine)—decreases excessive activation of NMDA receptor by glutamate; offers modest benefits to patients with Alzheimer’s disease

• Who is glutamate? Excitatory transmitter that plays a major role in memory and learning; continuousmajor role in memory and learning; continuous stimulation of the NMDA receptor leads to increased calcium influx and ultimate damage to the neuron; Memantine allows normal glutamate fx; blocks excessive excitation

Suspect delirium if…

• The patient is unable to focus attention on the conversation you initiate

• The patient gives bizarre answers to questions

• The patient cannot spell the word “WORLD” forwardThe patient cannot spell the word WORLD forward and backwards (inattention)

• Forget the “serial 7s”—try for 3s OR

• Ask the patient to add a quarter, dime, nickel, and penny

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“Assume that the onset of delirium in the old person is due to infection.”—Clifton Meador, M.D.

• Pneumonia—decreased oxygenation to brain

• Listen to the base of the lungs

• A few basilar crackles can be normal in the ld ivery old patient

Also consider a urinary tract infection as the cause of acute delirium…

• Check the urinary tract• Urinalysis• WBCs in urine, WBC casts in the urine• Estrogen and the urinary tract; pH of urine• Estrogen and the urinary tract; pH of urine

and pH of vagina• Topical estrogen and a reduction in urinary

tract infections

Polypharmacy and delirium…

• The blood brain barrier in the elderly is more permeable to drugs

• Narcotics • Benzodiazepines (a note on Valium and Librium in

h ld l )the elderly)• Anticholinergics• And more, more more…• Sudden withdrawal of drugs

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Other causes of delirium…check lab tests for…

• Low sodium (think drugs—diuretics, SSRIs)• High or low potassium• High calcium (cause in elderly?)• Hypoglycemia (insulin, sulfonylureas—not metformin

alone)alone)• TSH —hyper/hypo• LFTs• BUN, Creatinine• Hypoxia, hypercarbia• MI, Stroke with aphasia

Other considerations for delirium…

• ETOH withdrawal—3rd to 5th day after last drink—due to dopamine rebound (11th-14th day increased risk of thromboembolism)

• Fecal impaction

• Urinary retention

• Transfer to unfamiliar surroundings—ICU, hospital, nursing home

Depression…

• More common than dementia• Often co-exists with dementia• May appear withdrawn, uncooperative or

intermittently agitatedy g• Functionally or cognitively impaired• May prolong recovery from illness due to lack of

cooperation• Geriatric depression scale…• If within 10 minutes…

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The usual neurovegetative signs of depression are unreliable in the elderly…(The SALSA signs)

• Sleep disturbances, appetite changes, low, self esteem, and anhedonia (lack of interest in day-to-day activities)

• There is NO significant illness or medical condition in late life that does NOT impinge upon sleep appetitelate life that does NOT impinge upon sleep, appetite or energy or sense of vitality

• Usual aging also brings changes in sleep patterns and energy expenditure…

Movement disorders…

• The basal ganglia—

• Paired nuclei at the base of the brain

• 50:50 balance betweenCaudate nucleus

50:50 balance between acetylcholine and dopamine

• Gamma-amino butyric acid (GABA) keeps dopamine in check

Substantia nigra

Subthalamic nucleus

Globus pallidus

The BASAL GANGLIA…

• Control of movement, initiation and cessation of movement

• Postural reflexes—the righting reflex• Dopamine levels decrease with aging gradually—we

ll l dall slow down• Dopamine loss of greater than 80% results in signs

and symptoms of Parkinson’s disease

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Clinical symptoms

• Anosmia (loss of smell)• Resting tremor (70%)—unilateral or bilateral• Rigidity (vs. spasticity of stroke patients)• Loss of voluntary movements (spontaneous)

B d ki i ( h k it)• Bradykinesia (check gait)• Postural instability (sternal push)• Progression to dementia is common (40-60%)

Peripheral neuropathy--stocking glove distribution—dermatone distribution

• 3 major causes in the elderly?

• DM, B12 deficiency, B1 (thiamine deficiency)

• Get up out of a chair? Use arms? Check gait.

Herpes zoster—Shingles—Hell’s fire

• Treat acute pain? One of the “cyclovirs” + prednisone

• Treat chronic pain? Post-herpetic neuralgia; try single therapy first with either

Gabapentin (Neurontin) or (nortriptyline)(Pamelor/Gabapentin (Neurontin) or (nortriptyline)(Pamelor/ Norpramin)

• If they don’t work as single therapy, combine the two drugs for better response

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Zostavax at age 60; why?

• 10—0.5%• 20—1.3%• 30—2.7%• 40—4.8%• 50—7.5%• 60—11.9%• 70—19.7%• 80—31.8%• 90—46.1%• Donahue JG, et al. Archives of Internal Medicine, 1995.

Special senses…

• Vision—accelerated loss between 50-69

• Loss of retrobulbar fat and reduction of eye mass

Sh k b ll l f d d• Shrunken eyeballs—loss of upward gaze and peripheral vision

• Decreased lens elasticity with presbyopia

Hearing…

• Greater than 25% of all patients over 65 have a significant hearing loss

• Accelerated loss after 40

G l f hi h f• Greater loss of high frequency tones

• Sound localization problems

• Selective hearing loss

• Wearing a hearing aid; public perception

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Taste and smell…

• Questionable loss of taste; • Decreased number of taste buds• Decreased saliva• Atrophy of the olfactory bulbs (90 percent of• Atrophy of the olfactory bulbs (90 percent of

what we perceive as taste is actually smell)• Smell and memory

The aging heart…

• 1% rule--maximal O2 consumption and cardiac output decrease by 1% per year;

• Heart rate does not decrease with age

d h d i• Decreased heart rate reserve and maximum attainable heart rate; decreased contractile reserve—increased risk of CHF

The aging heart and vascular system

• Decline in sinus node function—increased risk for sick sinus syndrome; increased risk for atrial fibrillation and atrial flutter; impairedatrial fibrillation and atrial flutter; impaired chronotropic responsiveness—increased need for pacemaker

• Endothelial dysfunction—increased risk for atherosclerosis; increased risk of CHD

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The aging heart and vascular system…

• Increased vascular stiffness—increased systolic BP with widened pulse pressure; increased afterload

• Increased myocardial stiffness—impaired LV y pfilling; increased risk for diastolic heart failure with preserved LV systolic function

• Increased risk for heart failure—systolic and diastolic

Pitting edema—consider CHF

• Pitting at the ankles

• 4.5 kg of excess fluid (10 pounds)

Fluid overload—jugular vein distention

• Check the RIGHT jugular vein in the older patient—WHY?

• The left inominate vein dumps into the left jugular; this vein may be compressed between an elongated and unfolded aortic arch and the back of the sternum; increased mechanical pressure of the inominate vein may lead to increased left jugular vein distention continuously—i.e. falsely distended

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“Funny things happen in the middle of the night…”

• Nocturia

• Paroxysmal nocturnal dyspnea

• Orthopnea

Listening to the heart…

• S3 heard immediately after S2

• In other words, it is a diastolic sound

• Indicates an elevated left ventricular diastolic pressure

• Nothin’ that a little Lasix won’t cure

A quick primer on listening to the heart…the easy way (5th ICS, MCL for S2)

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Respiratory system

• Increased risk of pneumonia due to decreased immune function

• Dyspnea…is it lungs or is it CHF?

h diff i d f• The BNP test to differentiate dyspnea from CHF vs. COPD

• 15 minute blood test correctly diagnoses CHF in 95% of the cases without ordering CXR or ECG

A major reproductive difference…

• Women get all the eggs they are ever going to have prior to birth*

HOW MANY EGGS/FOLLICLES DO WE GET?

• At 6 months gestation ________________• At birth _____________• At age 30 ___________• At age 50 __

Th f i YOUR !• The age of an egg is YOUR age! • Could you possibly get pregnant at 50?• How do eggs meet their demise? as the follicles drop

out, the FSH rises—trying to stimulate the ovary to produce more eggs…rising FSH levels signal impending doom of the ovary

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A major reproductive difference…

• However, our ovaries die at 51.3 +-2.7 years

• Estrogen, progesterone, and androgens drop

• Menopausal symptoms

• Androgen deprivation—low energy, low libido

• To ERT or Not to ERT?

Do guys get all the sperm they’re going to get at birth?

• Nooooooooooo…• Men produce sperm PRN until the day they

die• Sperm is only 75-90 days old when freshlySperm is only 75 90 days old when freshly

ejaculated• However, there are some interesting

differences…

• The sperm of a 20-year-old vs. the sperm of an 80-year-old

• Swimming prowess

h ll h k h d• The germ cells that make the sperm and DNA mutations

• Older fathers and mental illness in their offspring

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The Endocrine system

• Type 2 diabetes—aging and pancreatic islet cell dysfunction; insulin resistance and beta cell dysfunction—

• 50% are over 60; 18% are 65-75; 40% over 80 have diabetes

• DM type 2 is also considered a Cardiovasculardisease—signs and symptoms of atherosclerosis

• 4 out of 5 diabetics die from CV complications—heart failure, MI, stroke, peripheral arterial disease

The Geriatric Patient and blood glucose control

• Blood sugars? (may want to keep the HbA1C in the 7-8 range)—hypoglycemia can break a hip

• Consider co-morbidities before aggressively treating—8 years needed benefit of glycemic control in reducing microvascular complications

• 2-3 years for benefit from BP and lipid control for reducing macrovascular complications

• Life expectancy?

The GI system

• The acute abdomen—abdominal pain is the second most common medical complaint in ER in patients over 65

• If they still have an appendix, always consider it as a problemas a problem

• Appendicitis—rate of perforation is 50%; may NOT have “board-like” rigidity; the rectus abdominis muscle “disappears” as we age. Peritonitis causes spasm of this muscle in younger patients resulting in “board-like” rigidity? No muscle? No board-like rigidity

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NSAIDS and the GI tract…

• the older the patient, the higher the risk, especially with the non-selective NSAIDS

• Use celecoxib (selective COX-2) if possible (also decreases risk of lower GI bleeding as well as perforations, obstructions and bleeds (POBs) in upper GIupper GI

• Use PPI with nonselective NSAIDS and coxib if over 75

• Celecoxib does NOT affect platelets so can be used up to and following surgical procedures

• (Stillman MJ, Stillman MT. Choosing nonselective NSAIDs and selective COX-2 inhibitors in the elderly: A clinical use pathway. Geriatrics 2007;62(2):26-34.

The GI tract--constipation

• Definition? Normal bowel movements from 3 per day to 3 per week

• Constipation—causes?Drugs—anticholinergic, opiods, certain calcium channel blockerschannel blockersfluid and fiber intake? Decreased activitylaxative abuse—prune abuse dementia-- “the neglect of the call to stool”…cancer of the colon

Thank you… stay healthy, age well, and have a nice day.

• Barb Bancroft, RN, MSN

www.barbbancroft.com

[email protected]

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Bibliography• Interstate Postgraduate Medical Association and MEV Healthcom, Inc.

Managing the Symptomatic Menopausal Patient in Primary Care: A Case-Based Approach. January 31, 2008.

• Landefeld CS, Palmer RM, et al. Current Geriatric Diagnosis and Treatment. McGraw-Hill Companies, 2004.

• Mendelsohn ME and Karas RH. HRT and the young at heart. N Engl J Med2007 June 21;356:2639-41;

• Manson JE et al. Estrogen therapy and coronary-artery calcification. N Engl J Med 2007 Jun 21; 356:2591-602.

• Pineiro MA. Abdominal pain in the elderly patient. Clinician Reviews 2009 May;19(5):14-19.

• Rossouw JE et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007 Apr 4; 297:1465-77

Bibliography

• Seppa Y et al: Severity assessment of lower respiratory tract infections in elderly patients in primary care. Arch Intern Med 2001;161:2709.

• Standridge JB, Talbert MG. Dementia workup and treatment: Do the drugs really work? Patient Care 2007 (November):10-1515.

• The Women’s Health Initiative Steering Committee. JAMA 2004;291:1701-1712.

• Writing Group for the WHI Investigators. JAMA 2002;288:321-333.

• Xiong G, Doraiswamy PM. Combination drug therapy for Alzheimer’s disease. Geriatrics 2005;60(6):22-26.

CoQ 10 in older patients with systolic heart failure

• Coenzyme Q10 is important in mitrochondrial electron transport and energy generation, and depletion of coenzyme Q10 has been correlated with an increased clinical severity of heart failure.

• CoQ10 intervention trials have shown significant i i j i f i ( i f 3 7%) dimprovements in ejection fraction (an increase of 3.7%) and cardiac output 0.28 liter per minute) in patients with systolic heart failure

• Sander S, Coleman CI, Patel AA, Kluger J, White CM. The impact of coenzyme Q10 on systolic function in patients with chronic heart failure. J Card Fail 2006;12:464-72.

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Mnemonic for investigation of altered mental status—AEIOU TIPS

• Alcohol use• Electrolyte disturbances• Infection, Ischemia• Overdose• Uremia

• Trauma• Insulin use• Psychomotor disturbance• Space-occupying lesion (mass, bleed)• Source: Myers et al. Principles of Pathophysiology and

Emergency Medical Care. 2001)