NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+, Exams of Nursing

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NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ UPADATE NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide Developmental Changes • Replicative senescence: theory states that cells can replicate or divide a specific number of times. o This ability decreases with age • Oxidative damage: Is the cumulative result of the aerobic metabolism, which generates chemicals called free radicals o Free radicals may interact with other chemicals in the body and cause damage to cells • Telomere shortening theory that links aging to a reduction in cell division • Weakening of the immune response: Leaves older adults more vulnerable to infection and debilitating diseases Dunphy physiological p.1285 Age-Related Change Appearance or Functional Change Implication Integumentary System Loss of dermal and epidermal thickness Loss of SQ tissue and thin epidermis Prone to skin breakdown and injury Decreased vascularity • Atrophy of sweat glands resulting in decreased sweat production • Decreased body odor • Decreased heat loss • Dryness • Alteration in thermoregulatory response • Fluid requirements may change seasonally • Loss of skin water • Increased risk of heat stroke Respiratory System Decreased lung tissue elasticity Decreased vital capacity Reduced overall efficiency of ventilatory exchange Cilia atrophy Change in mucociliary transport Increased susceptibility to infection Decreased respiratory muscle strength • Reduced ability to handle secretions and reduced effectiveness against noxious foreign particles • Partial inflation of lungs at rest Increased risk of atelectasis Cardiovascular System Heart valves thicken and become fibrotic Reduced stroke volume, cardiac output; may be altered Decreased responsiveness to stress Fibroelastic thickening of the SA node; decreased # of pacemaker cells Slower heart rate Increased prevalence of arrhythmias Decreased baroreceptor sensitivity (stretch receptors) Decreased sensitivity to changes in blood pressure Prone to loss of balance, which increases the risk for falls Gastrointestinal System Liver becomes smaller Decreased storage capacity NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Alternating hyperplasia and hypoplasia of Longitudinal ridges Nails prone to splitting nail matrix Thinner nails of the fingers Advise patient to wear gloves, keep nails short, and avoid nail polish remover (causes dryness); refer patient to podiatrist Thickened, curled toenails or claw-like nails known as onychogryphosis May cause discomfort Respiratory System Decreased lung tissue elasticity Decreased vital capacity Reduced overall efficiency of ventilatory exchange Increased residual volume NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Decreased maximum breath capacity Dental enamel thins Gums recede Staining of tooth surface occurs Teeth deprived of nutrients Tooth and gum decay; tooth loss Thoracic wall calcification Increased anteroposterior diameter of chest Obscuration of heart and lung sounds Displacement of apical impulse Cilia atrophy Change in mucociliary transport; mucus- producing cells increase Increased susceptibility to infection Decreased respiratory muscle strength Reduced ability to handle secretions and reduced effectiveness against noxious foreign particles Partial inflation of lungs at rest Prone to atelectasis Less sensitivity to hypoxia; impaired ability to recognize bronchoconstriction Increased respiratory distress Increased risk of mortality from acute respiratory conditions Cardiovascular System Heart valves fibrose and thicken Reduced stroke volume; cardiac output may be altered Decreased responsiveness to stress; heart rate and BP take longer to return to normal resting rate following exertion Slight left ventricular hypertrophy Increased incidence of murmurs, particularly aortic stenosis and mitral regurgitation Mucoid degeneration of mitral valve S4 sound commonly heard Valve less dense; mitral leaflet stretches with intrathoracic pressure Fibroelastic thickening of the SA node; decreased # of pacemaker cells Slower HR Increased prevalence of arrhythmias and extra heart beats become more common Irregular HR Increased sub pericardial fat Collagen accumulation around heart muscle Elongation of tortuosity and calcification of arteries Increased rigidity of arterial wall Aneurysms may form Elastin and collagen cause progressive thickening and loss of arterial wall resiliency Increased peripheral vascular resistance Decreased blood flow to body organs Altered distribution of blood flow Loss of elasticity of the aorta dilation Increased systolic BP, contributing to CAD Increased lipid content in artery wall Lipid deposits form Increased incidence of atherosclerotic events such as angina pectoris, stroke, gangrene Increased baroreceptor sensitivity (stretch receptors) Decreased sensitivity to change in BP Prone to loss of balance—potential for falls Decreased baroreceptor mediation to straining Valsalva maneuver may cause sudden drop in BP, orthostatic hypotension, and dizziness when the patient changes from a lying or sitting position to standing Gastrointestinal System Liver b omes smaller D creased storage capacity; decreased efficiency in metabolizing drugs that pass through the liver NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Less efficient cholesterol stabilization absorption Increased evidence of gallstones Atrophy of muscles and bones of the jaw Difficulty with mastication Ability to thoroughly chew food is impaired and can contribute to dysphagia with solid foods Fibrosis and atrophy of salivary glands Prone to dry mucous membranes Shift to mouth breathing is common; frequent complaints of dry mouth are expressed Decreased salivary ptyalin Membrane more susceptible to injury and infection NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Tendons shrink and sclerose Decrease tendon jerks Regional changes in fat distribution Increased relative adiposity Loss of neurons and nerve fibers Decreased conduction of nerve fibers Few neuritic plaques Altered pain response Possible postural hypotension Decreased deep tendon, Achilles tendon Safety hazard Decreased psychomotor performance Alteration in pain response Possible cognitive and memory changes Increased time to perform and learn Decreased processing speed and vibration sense Altered RNA function and resultant cell death Accumulation of lipofuscin Leg weakness may be correlated Loss of anterior horn cells in the lumbosacral area Thickened leptomeninges in spinal cord Decreased myosin adenosine triphosphate activity Prolonged contraction time, latency period, relaxation period Decreased motor function and overall strength Deterioration of joint cartilage Bone makes contact with bone Potential for pain, crepitation, and limitation of movement Loss of water from the cartilage Narrowing of joint spaces Loss of height Decreased bone mass Decreased bone formation and increased bone resorption, leading to osteoporosis More rapid and earlier changes in women Decreased osteoblastic activity Greater risk of fractures Osteoclasts resorb bone Hormonal changes Gait and posture accommodate to changes Increased proportion of body fat Centripetal distribution of fat and invasion of fat in large muscle groups Anthropometric measurements required NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Ciliary muscle atrophy Altered refractive powers Corrective lens often required Nuclear sclerosis (lens) Presbyopia Near work and reading may become difficult Reduced accommodation Hyperopia Increased lens size Myopia Accumulation of lens fibers Lens yellows Color vision may be impaired Less able to differentiate low color tones: blue, greens, violets Diminished tear secretion Dullness and dryness of the eyes Irritation and discomfort may result Intactness of corneal surface jeopardized Neurofibrillary tangles in hippocampal neurons Heavy tangle formation and neuritic plaques in cortex of patients with Alzheimer’s disease Changes in sleep-wake cycle Decreased stage 4, stage 3, and rapid Increased or decreased time spent eye movement phases sleeping Deterioration of circadian organization Increased nighttime awakenings Changed hormonal activity Slower stimulus identification and Delayed reaction time Prone to falls registration Decreased brain weight and volume May be present in absence of mental impairments Sensory System Morphological changes in choroid, Decreased visual acuity Corrective lenses required epithelium, retina Visual field narrows Increased possibility of disorientation and social isolation Decreased rod and cone function Slower light and dark adaption Pigment accumulation Decreased speed of eye movements Difficulty in gazing upward and maintaining convergence Sclerosis of pupil sphincter Difficulty in adapting to lighting changes Glare may pose an environmental hazard Increased threshold for light perception Dark rooms may be hazardous Increased intraocular pressure Increased incidence of glaucoma Distorted depth perception Incorrect assessment of height of curbs and steps; potential for falls NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Loss of auditory neurons Decreased tone discrimination and voice localization Suspiciousness may be increased because of paranoid dimensions secondary to hearing loss High frequency sounds lost first Social isolation Angiosclerosis calcification of inner ear membrane Progressive hearing loss, especially at high frequency Presbycusis Difficulty hearing, particularly under certain conditions such as background nose, rapid speech, poor acoustics Decreased # of olfactory nerve fibers Decreased sensitivity to odors May not detect harmful odors Potential safety hazard Alteration in taste sensation Possible changes in food preferences and eating patterns Reduced tactile sensation Decreased ability to sense pressure, pain, temperature Misperceptions of environment and safety risk Endocrine system Decline in secretion of testosterone, growth hormone, insulin, adrenal androgens, aldosterone, thyroid hormone Decreased hormone clearance rates Increased mortality associated with certain stresses (burns, surgery); increased prevalence of hormonal disease Defects in thermoregulation Shivering less intense Susceptibility to temperature extremes (hypothermia/hyperthermia) Reduction of febrile responses Poor perceptions of changes in ambient temperature Reduced sweating; increased threshold for the onset of sweating Fever not always present with infectious process Unrecognized infectious process operative Alteration in tissue sensitivity to hormones Decreased insulin response, glucose tolerance, and sensitivity of renal tubules to antidiuretic hormone Enhanced sympathetic responsivity Increased nodularity and fibrosis of thyroid Increased frequency of thyroid disease Decreased basal metabolic rate Alteration in carbohydrate tolerance Increased incidence of obesity Hematological System Decreased percentage of marrow space occupied by hematopoietic tissue Ineffective erythropoiesis Risky for patients who lose blood Immune System Thymic involution and decreased serum thymic hormone activity Decreased # of T cells Production of anti-self-reactive T cells Less vigorous and/or delayed hypersensitivity reactions Decreased T-cell function Impairment in cell-mediated immune responses Increased risk of mortality NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o Mini Nutritional Assessment: obesity NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Atypical Disease Presentations • Erroneously associated aging with disease, disuse, and disability, older adults perceive this change as inevitable and either fail to present to their provider or, if they do, fail to challenge the assumption that this represents normal aging. At times an acute symptom such as pain or dyspnea is superimposed on a chronic symptom, and the older adult may not recognize that it represents a new or exacerbated pathology. Illness Atypical Presentations Acute abdomen • Absence of symptoms or vague symptoms • Acute confusion • Mild discomfort and constipation • Some tachypnea and possibly vague respiratory symptoms • Appendicitis pain may begin in RLQ and become diffuse Depression • Anorexia, vague abdominal complaints, new onset of constipation, insomnia, hyperactivity, lack of sadness Hyperthyroidism • Presenting as ―apathetic thyrotoxicosis‖ i.e., fatigue and weakness; weight loss may result instead of weight gain; patients report palpitations, tachycardia, new onset of a-fib, and HF may occur with undiagnosed hyperthyroidism Hypothyroidism • Confusion and agitation • New onset of anorexia, weight loss, and arthralgias may occur Malignancy • New or worsening back pain secondary to metastases from slow growing breast masses • Silent masses of the bowel Myocardial Infarction (MI) • Absence of chest pain • Vague symptoms o Fatigue, nausea, and a decrease in function and cognitive status o Classic presentations: dyspnea, epigastric discomfort, weakness, vomiting, history of previous cardiac failure • Higher prevalence in females vs males: Non-Q-wave MI Overall infectious diseases process • Sepsis w/o usual leukocytosis and fever • Falls • Anorexia • New onset of confusion and/or alteration in change in mental status • Decrease in usual functional status Peptic ulcer disease • Absence of abdominal pain, dyspepsia, early satiety • Painless, bloodless • New onset of confusion, unexplained • Tachycardia, and/or hypotension NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Pneumonia • Absence of fever • Mild coughing w/o copious sputum, especially in dehydrated patients • Tachycardia and tachypnea • Anorexia and malaise common • Alteration in cognition Pulmonary edema • Lack of paroxysmal nocturnal dyspnea or coughing • Insidious onset with changes in function, food or fluid intake • Confusion Tuberculosis • Hepatosplenomegaly, abnormalities in liver function tests, and anemia Urinary Tract • Absence of fever NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Exercise in Older Adults Recommended exercises for sleep and flexibility • To maintain the flexibility necessary for regular physical activity and daily life, older adults should perform activities that maintain or increase flexibility on at least 2 days each week for at least 10 minutes each day Exercise recommendations for specific diagnosis (Kennedy) Condition Exercise Osteoarthritis • Walking, aquatic activities, tai chi, resistance exercises, cycling • Vary type and intensity to avoid overstressing joints; heated pool Coronary Artery Disease • Walking, treadmill walking, cycle ergometry • Supervised program with BP and HR monitoring Congestive Heart Failure • Walking, treadmill walking, cycle ergometry • Individualized to client; supervised program Type 2 Diabetes Mellitus • Resistive, aerobic, aquatic, recreational activities • Proper shoe fit; may need insulin reduction if insulin dependent Anxiety Disorders • Walking, biking, weightlifting • If able to do high-intensity exercise, this benefits anxiety Depression • Walking, cycling, recreational activities • Group participation helpful to keep patient engaged Fibromyalgia • Aerobic, aquatic therapy, strengthening, tai chi, Pilates • Heated pool, gentle stretches, counsel about possible increased pain initially NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Chronic Obstructive Pulmonary Disease • Cycle ergometer, treadmill walking: individualize • Supervised program- consider pulmonary rehab program Chronic venous insufficiency • Walking, standing exercises • Supervised programs Osteoporosis • Weight-bearing exercises, weight training • Assess balance and risk for falls before beginning Parkinson’s Disease • Walking, treadmill walking, stationary bike, dancing, tai chi, Pilates, boxing NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Assess balance and risk for falls before beginning; American Parkinson’s Disease Association resources Peripheral Artery Disease • Lower extremity exercises, treadmill walking, walking • Very short intervals initially, progress as tolerated Age-related sleep disorders • Tai chi, walking, aquatherapy, biking • Assess balance and risk for falls before beginning Dementia • Walking, recreational activities • Provide safe environment, assess fall risk and ability to participate • Testing prior to exercise initiation • Recommended testing prior to exercise initiation Recommended testing prior to exercise initiation • Assess balance and risk for falls Barriers, facilitators and contraindications to exercise • Barriers o Lack of time o Perceived need for equipment o Perceived barrier to beginning exercise/physical activity o Disability of functional limitation o Unsafe neighborhood or weather conditions o No parks or walking trails o Depression o High body mass index (BMI) o Lack of motivation o Interpersonal loss of significant life event o Ignorance of what to do • Patient facilitators o Social support o Positive self-efficacy o Motivation to engage in physical activity o Good health, no functional limitations NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Low-moderate dose statin for prevention of CVD w/o hx of CVD or ischemic stroke When all is met: *40-75 years old *One or more risk factors for CVD (dyslipidemia, diabetes, HTN, or smoking) *calculated 10-year risk of cardiovascular event of 10% of greater (requires universal lipids screening in adults aged 40-75) Abdominal aortic aneurysm AAA One time by ultrasound in men aged 65-75 years old who have ever smoked NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Obesity All adults, refer if BMI is > 30 or higher to intensive multicomponent behavioral interventions Mammography Biennial for women aged 50-74 years old Visual acuity Older adults Osteoporosis *Women aged 65 and older * younger women whose fracture risk is equal to or greater than that of a 65 year old white woman who has no additional risk factors Prostate cancer Older men Cognitive impairment Older adults Colorectal cancer Starting at age 50 and continuing until age 75 • Health Promotion o Vaccines: Tetanus, Diphtheria, Pneumococcal, & Influenza o Colorectal screening: ages 50-75 o Breast Cancer screening: biennial screening for women ages: 50-74 o Smoking cessation o Aerobic exercise & strength training o AAA screening: one time by ultrasound in men ages 65-75 years old who have ever smoked Travel (Kennedy) Risks Related to Travel • Patient with chronic disease that is well managed at home may decompensate in foreign environments because of heat, humidity, altitude, fatigue, changes in diet, and exposure to infectious diseases. • Fever is not always reliable indication of illness in the older adult. • Seroconversion rates decrease with age, rendering some vaccines less effective for older travelers • Immunizations for travel o All immunizations should be current: influenza, pneumococcal, Td/Tdap, zoster, and for some hepatitis B vaccination o Yellow fever and herpes zoster are the only live virus vaccine that people over age 50 receive o Immune response can be impaired if live virus vaccines are given within a 28 to 30-day interval of each other o If a patient is required to have a yellow fever vaccine for travel, they can’t enter a yellow fever country until 10 days after receiving the yellow fever vaccine o The most common vaccines used for protecting travelers are hepatitis A, hepatitis B, typhoid fever, yellow fever, adult booster polio, Japanese encephalitis, meningococcal, NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ and rabies Comprehensive Geriatric Assessment (Kennedy) Purpose of the CGA • Physical health is related to psychosocial, functional ability and safe environment • Most beneficial for the vulnerable, older adult NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Socioenvironmental health and Quality of Life Measures Beers Criteria (Article) Purpose • Guide to use for medical management of geriatric patient’s • List of potentially inappropriate medications for the elderly-listed by drug category and diagnosis • Lists alternative drugs that can be used safely in older adults • Drug to drug interactions listed, dosage for kidney impairment graded as high, medium, or low to assist with decision making • From the Geriatric Society • Purpose; Improve medication selection; avoid dangerous medications • Tailored for 65 years and older in all setting except hospice and palliative care • Stresses importance of deprescribing to avoid polypharmacy and adverse drug reactions Look at what medication not to give geriatric patients https://www.pharmacytoday.org/article/S1042-0991(19)31235-6/pdf Polypharmacy (Kennedy) Multiple definitions (review discussion) • Prescribing many drugs, prescribing 5 or more drugs, or prescribing potentially inappropriate medications • The use of multiple pharmacies (provides & self-prescribers) • Providers should routinely evaluate medication appropriateness to avoid the risk of polypharmacy Prevention Strategies • Have patients bring in all medications to their first visit • Review med list at every visit • Ask if other provider has changed or added any meds • Update med list at every visit Screening Tools NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Three available tools to evaluate patient’s prescriptions o STOPP (screening tool of older persons’ potentially inappropriate prescriptions) o MAI (Medication Appropriateness Index) o ARMOR (Assess, Review, Minimize, Optimize, Reassess) Week 2 NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ COPD (Dunphy & Kennedy) Signs and Symptoms - Cardinal symptoms of COPD include dyspnea, chronic cough, and/or sputum production - Other s/s: decreased activity tolerance, wheezing, recurrent lower respiratory infections, wheezing, chest tightness, fatigue, weight loss, anorexia. increased anteroposterior (AP) diameter of the thorax, use of accessory muscles for respiration, prolonged expiration, hyperresonance on percussion, dec heart/breath sounds, tachypnea, neck vein distention during expiration in absence of HF, ruddy or cyanotic skin color, and clubbing of nail beds Diagnostic Criteria - Spirometry is the gold standard for measuring airflow limitation. Airflow limitation that is not fully reversible is evident if post-bronchodilator FEV1/FVC is less than 0.70 and FEV1 is less than 80% predicted. o USPSTF recommends spirometry only in symptomatic patients- no direct evidence to support screening asymptomatic individuals. Sxs for considering a diagnosis and performing spirometry include dyspnea, cough, chronic sputum production, recurrent lower respiratory tract infections, hx of risk factors, fam hx of COPD, and/or childhood factors. o Although the GOLD guidelines are focused on spirometry results, FEV1 dec with age so the age-related change needs to be factored into interpretation of spirometry results. Spirometry has good sensitivity, although a peak expiratory flow measurement alone is unreliable when used as the only diagnostic tool because of weak specificity - In addition to results of spirometry, assessing the impact of COPD, the burden of disease, the risk of disease progression, and COPD exacerbation risk are integral components. o 13 disease-specific instruments have been identified as COPD assessment tools: assessment tools recommended for clinical practice include the COPD Assessment Test (CAT) and the COPD Control Questionnaire (The CCQ). Of the two, the CAT is widely utilized, applicable worldwide, and useful to predict clinical correlation of disease-related impact. - CXR: alone is not diagnostic of COPD but can provide value in excluding differential dxs, detecting the presence of concomitant pulmonary disease (bronchiectasis, pleural diseases, pulmonary fibrosis), pneumonia, or cardiac diseases (e.g., cardiomegaly). Chest radiography in early COPD appears normal. Abnormalities associated with COPD may be present on a chest x-ray, such as lung hyperinflation, hyperlucency of the lungs, or tapering of vascular markings. Structural lung disease may be seen on chest imaging (e.g., emphysema, gas trapping, or airway wall thickening) consistent with COPD. A chest x-ray in those having advanced COPD with emphysema may reveal hyperinflation, bullae or blebs, and a flat hemidiaphragm. A CXR is not recommended for screening of lung cancer. - Pulse oximetry: is a noninvasive intervention to assess a patient’s arterial oxygen saturation and need for supplementation oxygen therapy. If pulse oximetry is less than 92%, arterial or NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ - Pulmonary rehab in patients with high symptom burden to reduce symptomatology and risk of exacerbations. Pulmonary rehabilitation has been shown to be a highly effective therapeutic intervention to improve dyspnea, health status, and exercise intolerance - Long-term supplemental O2 therapy in patients with severe resting hypoxemic COPD has been shown to improve survival. Additional benefits include reductions in nocturnal hypoxemia and arrhythmias, reduction in polycythemia, dyspnea, inc exercise tolerance, and improved cognitive status. Criteria for oxygen therapy include PaO2 = 55 mm Hg or SaO2 = 88% with or without hypercapnia confirmed twice over a 3-week period; or PaO2 = 55 to 60 mm Hg or NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ SaO2 = 88% if there is evidence of pulmonary hypertension, polycythemia, or peripheral edema suggesting HF - Anxiety/depression are comorbidities associated w COPD, poor health outcomes. Assess for sxs and provide psych interventions. Pharmacological management is the cornerstone of COPD treatment and is directed at sx reduction, reducing the risk and severity of COPD exacerbations, and improving exercise tolerance and health status. - Surgical options: When dyspnea is unrelieved by medications and interferes w quality of life, consider eval for surgical options. Lung volume reduction therapy, lung resections, transplants, and laser bullectomy are available in selected circumstances. - Clinician–patient communication should include a discussion of disease progression and patient choices for care Pharmacological Treatment - Individualized. A step-wise approach to therapy is utilized in tx of COPD. No current drug therapy has been proved to influence the long-term, progressive decline in lung function. - Classes of medications o Inhaled Beta2-Agonist Bronchodilators: Bronchodilators to reverse bronchoconstriction by relaxing smooth muscles in the airways. Acute bronchospasms lead to permanent airway remodeling. There are two types of beta2-agonists: SABAs and LABAs. SABAs, AKA ―rescue‖ inhalers, for intermittent sxs on an as-needed basis. Meds: albuterol or levalbuterol. Onset is rapid, about 15 to 30 minutes, and duration of action is 4 to 6 hours. Beta-agonists are sympathomimetic agents with adverse effects that may include transient tachycardia, nervousness, palpitations, and/or arrhythmia. o LABAs: used for maintenance therapy to prevent acute bronchospasms and not for relief of acute symptoms. The duration is about 12 hours. Ex: Formoterol and salmeterol o Inhaled Anticholinergic/Antimuscarinic Bronchodilators: block the bronchoconstriction effects of acetylcholine on muscarinic cholinergic receptors in the smooth muscle of the airways. The short-acting antimuscarinic (SAMA) agent, ipratroprium, has a duration of 6-8 hrs, used in long-term and acute COPD management. Tiotropium, a long-acting anticholinergic/antimuscarinic, is used for maintenance of COPD. Duration of action is about 24 hrs. Tiotropium demonstrated more benefits, such as fewer COPD exacerbations, reduced hospital admissions, and improved quality of life, as compared to ipratropium. *Antimuscarinic agents have anticholinergic properties and should be used cautiously in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction, and are contraindicated in patients who are allergic to atropine o Combo Bronchodilator Therapy: When used in combo, bronchodilators w/ diff MOAs may improve degree of bronchodilation w/ a lower risk of increasing a monotherapy agent. - Stable COPD Pts w/ sxs: Combination inhaled therapy w/ LABAs, ICSs, or long-acting inhaled anticholinergics, may be more effective than the agents as individuals. - Stable, moderate to very severe COPD: a maintenance combo of an ICS/LABA or ICS and inhaled long-acting anticholinergic therapy are recommendations. NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ - Severe COPD & persistent symptoms: triple therapy is recommended with a combination ICS/LABA and inhaled long-acting anticholinergic. - Glucocorticoids: utilized in the management of COPD for the anti-inflammatory effects on COPD-associated inflammation. 2 types: ICSs and systemic corticosteroids. - ICSs are used in combination with LABAs for optimal sx management in persistent sxs. Ex: Fluticasone/salmeterol and budesonide/formoterol. ICSs are not recommended for use as monotherapy due to greater efficacy when combined with a LABA NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Pulmonary Function and Physical Findings in Obstructive and Restrictive Lung Diseases Parameters Asthma Chronic Bronchitis Emphysema Restrictive Disease Forced vital capacity (FVC) Normal Normal to increased Normal to increased Decreased Residual volume (RV) Normal: Increased during attacks Increased Increased Decreased or normal Total lung capacity (TLC) Normal to increased Normal Normal to increased decreased RV/TLC Normal to increased Increased Increased Normal Expiratory flow rates Normal to decreased Normal to decreased Normal to decreased Normal to increased FEV1/FVC Normal to decreased Decreased Decreased Normal to increased Bronchodilator response (% change) > 15% 0-15% None None Diffusing capacity Normal to increased Normal to decreased Decreased Normal or decreased (depends on type of disease) PaO2 Normal: decreased during attack Decreased Normal in mild- moderate disease Decreased in severe disease Normal or decreased PaCO2 First decreased, then increased during acute attack Increased Normal until advanced disease, then increased Normal or decreased Increased in very advanced disease Breath Sounds Marked decrease during acute attacks if FEV1 = 0.5L or less: absent If FEV1 = 1L: barely audible Decreased Normal or decreased in pneumonia, atelectasis Crackles (rales) Coarse crackles during infections Coarse crackles during infections Find crackles may be present Varies with type of restrictive disease NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Wheezes (rhonchi) High-pitched Continuous Forced expiratory wheezes No No COPD • Gold Standard: Spirometry • Levels o Mild: FEV1 > 80% predicted NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Alternate LTRA, cromolyn, nedocromil, or theophylline • Rescue: SABA PRN not to exceed 3-4x/day Persistent- Moderate • Symptoms daily; but not continual • Nighttime symptoms more than once a week but not nightly • Exacerbations affect sleep & activity • FEV1 60-80% predicted • PFT variability > 30% NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Daily: low dose ICS + LABA or Med dose ICS + LTRA • Rescue: SABA PRN not to exceed 3-4x/day Persistent- Severe Asthma • Symptoms continuous daily • Frequent nighttime symptoms • Frequent exacerbations • Physical activities limited by asthma • FEV1 < 60% • PFT variability > 30% • Daily med dose ICS + LABA or medium dose ICS + LTRA • Rescue SABA PRN, not to exceed 3-4x/day • Consider course of oral steroids Interstitial Lung Disease (Dunphy) Types - ILD comprises a heterogeneous group of diseases that cause inflammation and fibrosis of the lower respiratory tract. - Four infections may be associated with the cause or onset of most of the various diseases: o 1. disseminated fungus (coccidioidomycosis, blastomycosis, histoplasmosis), o 2. disseminated mycobacteria, o 3. Pneumocystis pneumonia, o 4. and certain viruses - Occupational and environmental inhalant diseases; include diseases resulting from inhalation of inorganic dusts, organic dusts, gases, fumes, vapors, and aerosols. - Other categories include ILDs caused by drugs, irradiation, poisons, neoplasia, and chronic cardiac failure. - Unknown causes are idiopathic pulmonary fibrosis (IPF) and connective tissue (collagen vascular) disorders with ILD, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), progressive systemic sclerosis, polymyositis-dermatomyositis, and Sjögren’s syndrome. - 7 major entities that are most frequently associated with diffuse ILD are o (1) IPF, o (2) bronchiolitis obliterans organizing pneumonia, o (3) connective tissue (collagen vascular) diseases (SLE, RA, progressive systemic sclerosis [scleroderma], and polymyositis-dermatomyositis), o (4) Systemic granulomatous vasculitis’s (Wegener’s granulomatosis, lymphomatoid granulomatosis, and allergic angiitis and granulomatosis), o (5) drug-induced pulmonary disease, o (6) sarcoidosis, and o (7) hypersensitivity pneumonitis. NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ X- ray findings in ILD - Abnormalities on CXR may be the first clue to the presence of ILD; however, pt with ILD may be asymptomatic or symptomatic with either normal or abnormal CXR results. - The initial abnormality on the chest x-ray film is usually described as a ground glass, A scattered reticulonodular pattern or hazy appearance of the lungs NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o Treatment Standards/Guidelines: Empiric Antimicrobial Choices for Community-Acquired Pneumonia (CAP) Patient profile Antimicrobial Agent Uncomplicated CAP Without recent Abx therapy Azithromycin (Zithromax) or clarithromycin (Biaxin) or doxycycline (Vibramycin) With recent Abx therapy Respiratory fluoroquinolone: moxifloxacin (Avelox) or levofloxacin (Levaquin) Or Azithromycin or clarithromycin + high dose amoxicillin (Amoxil) Or Azithromycin or clarithromycin + high-dose amoxicillin-clavulanate (Augmentin) Patient with CAP + comorbidities: alcoholism, diabetes mellitus, or lung/liver/renal diseases Respiratory fluroquinolone Or Beta-lactam IM ceftriaxone (Rocephin) Or Cefuroxime (Ceftin)+ macrolide Patient with community-acquired methicillin- resistant S. aureus pneumonia Vancomycin (Vancocin) Or Linezolid (Zyvox) Scoring o 0-1: Low risk; consider outpatient treatment o 2: Brief hospitalization or closely monitored outpatient treatment o ≥ 3: Severe, hospitalize and possible ICU CAP • Pathophysiology: acute inflammation of lung parenchyma; usually infectious • 70-80% of cases are people over age 60 • S. pneumoniae: gram + (40%) • H. influenzae • Legionella • Tx: uncomplicated: azithromycin, macrolides: clarithromycin or doxycycline • Tx with comorbidities: respiratory fluroquinolones Obstructive & Restrictive Airway Disease (kahn academy video and Dunphy) NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Understand the PFT interpretation for both (Kahn Academy) https://www.alphanetbfrg.org/pdfs/Understanding-PFT.pdf o PFT: Normal FEV 1 /FVC ratio o but decreased FVC and FEV 1 ; o decreased total lung capacity, residual volume, and functional residual capacity. o Residual volume–to–total lung capacity ratio is normal to low. NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Know which airway diseases are reversible and irreversible o FEV 1 /FVC ratio before and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates reversible airway obstruction Obstruction Pattern o An FEV1/FVC <70/80% suggests obstructive lung disease. • Decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC • Classically, these are the patients with asthma, chronic bronchitis, or emphysema • PFTs can help further distinguish between the above three: o Bronchodilator responsiveness - an increase in the FEV1 by 12% following bronchodilator use suggests asthma o Bronchial provocation - inducing asthmatic obstruction of reactive lower airways by administering methacholine, histamine, or adenosine monophosphate o DLCO will be decreased in patients with emphysema, and can be normal or increased in patients with asthma • Lower airway obstruction vs. upper airway obstruction ▪ Lower airway obstruction typically displays impaired expiratory capacity (see image below), while upper airway obstruction has impaired inspiratory capacity, which can be evident on the flow volume loop (seen as flattening of the inspiratory arm). Restrictive pattern o Restrictive lung disease typically has normal or increased FEV1/FVC o Decreased TLC, FEV1, and FVC with a normal FEV1/FVC, and a low DLCO o Typically, these are patients with interstitial lung disease, severe skeletal abnormalities, or diaphragmatic paralysis o The flow volume loop is generally normal in appearance, but has low lung volumes Spirometry (Kahn Academy video and readings) Know definitions for each spirometry criteria o Spirometry measures two key factors: o Expiratory forced vital capacity (FVC) o Forced expiratory volume in one second (FEV1). o Your doctor also looks at these as a combined number known as the FEV1/FVC ratio. o If you have obstructed airways, the amount of air you’re able to quickly blow out of your lungs will be reduced. This translates to a lower FEV1 and FEV1/FVC ratio. o Forced vital capacity (FVC). This is the largest amount of air that you can forcefully exhale after breathing in as deeply as you can. NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Know criteria for diagnosis of reversible vs irreversible Dunphy • Reversible airflow limitation and diurnal variation as measure by PEF constitute objective signs and symptoms of asthma. Variability between morning and evening PEF may reflect airway hyper-responsiveness and indicate instability and severity of asthma • The diagnosis is made by demonstrating the reversibility of obstruction from the pre- and postbronchodilator PFRs NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o A greater increase in the FEV1 after two puffs of a short-acting beta-agonist (SABA) have been inhaled • Asthma reversible • Chronic bronchitis and emphysema (COPD) are irreversible Sleep Apnea (Dunphy) Diagnostic criteria (includes risk factors) o Diagnostic criteria (includes risk factors) Sleep apnea o is defined as a temporary pause in breathing during sleep that lasts at least 10 seconds. o For a confirmed diagnosis, this should occur a minimum of five times an hour. o The predominant physical examination findings of OSA reflect the risk factors: ▪ obesity (particularly of the upper body), ▪ increased neck size ▪ crowded oropharynx (tonsillar hypertrophy and enlargement of soft palate [uvula] and tongue). Signs and symptoms & Hypersomnolence signs and symptoms o Hypersomnolence is the single most important presenting symptom of sleep apnea. o Daytime symptoms include o a morning headache (from hypercapnia) o neuropsychological disturbances o including falling asleep while performing purposeful activities. o The patient may complain of nocturnal restlessness, o frequent urination or enuresis and choking. o Patients also may report impaired intellectual performance, such as decreased concentration, ambition, and memory loss. Possible consequences • Possible complications of sleep apnea o Pulmonary hypertension o Systemic hypertension o Cardiac dysrhythmias- especially a-fib o Right or left ventricular failure o Right ventricular hypertrophy o Myocardial infarction (increased risk of) o Stroke (increased risk of) NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o Nocturnal angina o Chronic obstructive pulmonary disorder (exacerbation of) o Insulin resistance o Endothelial cell dysfunction Obstructive Sleep Apnea (OSA) • Temporary pause of breathing for at least 10 seconds in duration at least 5 x an hour • Anatomical risk factors: o Septal deviation NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o Avoidance, distractibility, and restlessness o Apathy, compulsions, rigidity, overreactions, preoccupation, and repetitive actions • Somatic o Loss of appetite, dry mouth, fatigue, diarrhea, sweating, chest pain, hyperventilation, vomiting, and paresthesia • Dunphy Signs and symptoms o Sense of impending doom, trembling, breathlessness, and tachycardia o Impair working memory, attention, and problem-solving skills o Somatic complaints: constipation, nausea, and sleep disturbances • Types of anxiety o Panic disorder: the specific worry is focused on the symptoms of panic o Social anxiety disorder: the worry is about social situations o Obsessive-compulsive disorder: the worry becomes focused on a specific object or activity o Separation disorder: the worry is about being away from parents and caregivers o Somatic symptoms disorder: the worry is focused on physiologic symptoms o Body dysmorphic disorder: the worry is focused on a perceived defect in physical appearance o Post-traumatic stress and acute stress disorder: the worry is focused on reminders of traumatic event o Anxiety disorder due to another medical condition (e.g. hyperthyroidism) o Psychotic anxiety disorders: the worries are not reality tested (delusions) o Substance-induced anxiety disorders: the anxiety is caused by substance intoxication (stimulants, caffeine) or substance withdrawal (alcohol, alprazolam, fluoxetine) Prevalence • 40 million adults, it is the most common psychiatric disorder in the U.S. • In elderly, the Incidence is unknown, but higher than previously reported o The elderly report more somatic complaints Risk factors • Ages 20-45 y/o • Women 1.5-2x > Men • From the U.S. Diagnostic criteria • DSM-5 Criteria o Requires ▪ Excessive anxiety ▪ Difficulty controlling worry ▪ At least three associated symptoms: • Restlessness • Easy fatigability NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Difficulty concentrating • Irritability • Muscle tension • Difficulty falling or staying asleep • Diagnostic Test: o Complete H&P o Lab test to rule out medical conditions with anxiety symptoms: CBC, CMP, and TSH o Screening test NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ 1st line treatment (mild, moderate, severe) • Tx should reduce symptoms and improve functioning • Selective serotonin reuptake inhibitors (SSRIs): least risk of drug interactions, side effects, or worsening existing medical conditions o Escitalopram, sertraline, and citalopram are commonly used in older adults ▪ Citalopram should not be used routinely in doses above 20 mg due to prolonged QT interval precautions ▪ Gi disturbances, sexual dysfunction, and altered mental status due to hyponatremia may occur o Start dose low and go slow • Serotonin norepinephrine reuptake inhibitors (SNRIs) (venlafaxine and duloxetine): have been shown effective in older adults with anxiety o Blood pressure should be monitored in high doses • CBT or relaxation training • Exercise, mindfulness, and relaxation training Medication management • 2nd line o Benzodiazepines (lorazepam, alprazolam, and clonazepam) are effective and may be used as a bridge until the SSRI takes effect, but are not first choice due to the risk of falls and confusion o Buspirone and gabapentin when first-line agents fail • Maintenance SSRI use has been shown to reduce relapse of anxiety in older adults. • SSRIs can increase anxiety if started at higher doses. • It may take several weeks for full effect to occur Unipolar Depression (Kennedy and Dunphy) Dunphy: • Chapter 64: overview, stress & anxiety and depressed mood (p.1055-1058) • Chapter 67: major depressive disorder (p.1100-1110) Kennedy-Malone • Depression p.451-456 Depression • Major depressive episode: 5 or more symptoms for at least 4 weeks • Prevalence depression is 3-4x in nursing home residences • May present with complaints of pain due to concerns of social stigma NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ waking earlier than necessary, inability to fall back asleep), hypersomnia, frequent napping • Psychomotor agitation or retardation (including as observed by others) • Fatigue or loss of energy • Feelings of hopelessness • Feelings of worthlessness, excessive guilt • Diminished concentration, indecisiveness • Recurrent thoughts of death, suicidal ideation or gestures, suicide attempt, suicide plan NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ ▪ Distinct clinical manifestations in older adults include: • ■ Report of lack of emotions (versus depressed mood) • ■ Excessive concern with bodily functions • ■ Seeking reassurance and support • ■ Isolative, withdrawn behavior • ■ Change in previous level of function, decline in ADLs • ■ Feeling overwhelmed, easily frustrated, excessive crying • ■ Irritability, fearfulness, agitation, anxiety • ■ Transient, recurring symptoms, diurnal fluctuations or pattern • ■ Minimizing expressed death wishes or passive suicidal behavior ▪ Diagnostic criteria o DSM-5 for MDD ▪ Sustained, disruptive, and pervasive depressed mood or loss of interest or pleasure. With the exception of suicidal ideation and weight change, five or more of the following symptoms must be present for most of the day, on most days, over a 2- week period: • Depressed mood as reported in subjective report or as observed by others • Obsessive rumination or worry • Change in appetite and significant change in weight • Change in sleep pattern: insomnia (difficulty falling asleep or staying asleep, waking earlier than necessary, inability to fall back asleep), hypersomnia, frequent napping • Psychomotor agitation or retardation (including as observed by others) • Fatigue or loss of energy • Feelings of hopelessness • Feelings of worthlessness, excessive guilt • Diminished concentration, indecisiveness • Recurrent thoughts of death, suicidal ideation or gestures, suicide attempt, DEPRESSION IS NOT A NORMAL PART OF THE AGING PROCESS o Diagnostics to assess for underlying or undiagnosed medical causes of depressive symptoms should be ordered. Standard blood work includes: · CBC with differential · CMP · lipid panel · thyroid function studies (TSH with reflex T4) · serum vitamin B12 NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ · serum vitamin D levels. Medication management- first line Type of Antidepressant Medication-Generic: Trade Names SSRI • Citalopram (Celexa) • Escitalopram (Lexapro) • Fluoxetine (Prozac, Sarafem) • Paroxetine (Paxil, Pexeva, Brisdelle) NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Signs and symptoms • Variable presentation ranging from depression to mania or hypomania, feelings of grandiosity, rapid speech, or irritability • Cognitive deficits affecting verbal fluency and memory are common in older adults • The depressive symptoms often include trouble with eating and sleeping • Types o Bipolar 1: an individual to have experienced at least one manic episode. A manic episode involves a change in mood that may be expansive, euphoric, or irritable, and accompanied by an increase in energy level o Bipolar 2: one prior episode of major depression and at least one hypomanic episode (a milder form of mania) o Cyclothymic disorder: milder mood alterations that occur over a longer period of time o Unspecified bipolar disorder: consist of symptoms that cause clinical impairment but do not meet criteria for the previously mentioned listings Diagnostic criteria • DSM-5 : an individual must also experience increased energy while having these symptoms o DIGFAST (distractibility, insomnia, grandiosity, flight of ideas, activities (hyperactive, does not require rest), speech (rapid, can be garbled), thoughtlessness (impulsivity) • Symptoms during the depressive phase (SIGECAPS) o Sleep disturbances, interest/pleasure reduction, guilt feelings/thoughts of worthlessness, energy changes/fatigue, concentration/attention impairment, appetite/weight changes, psychomotor disturbances, suicidal thoughts • The Mood Disorder questionnaire (MDQ) screening tool • Rule out other conditions with labs o CBC, CMP, toxicology screen, UA, thyroid function test, rapid plasma regain (RPR), HIV, EKG. • New onset of psychosis: EEG, MRI, CT to rule out certain pathologies • Screening for cognitive disorders: Mini-mental state exam Medication management- first line • Tx for late-life mania includes o mood stabilizers lithium and valproic acid o Or the antipsychotics, quetiapine and olanzapine • The goal is remission of symptoms. • There is no specific guidelines specific for older adults, however, practice guidelines generally suggest similar pharmacological treatment for older adults as with younger adults • Often a challenge to manage because of the fluctuating and chronic nature of bipolar disorder. Depending on the presentation and severity, inpatient treatment may be required to stabilize the patient NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Because older adults are frequently on multiple medications for other comorbid conditions, monotherapy has been recommended as a starting point with a backup plan for adding other drugs as indicated. • Patients with coexisting dementia require individualized treatment, and co-management by a geriatric psychiatrist is advised. There is early evidence of a neuro-protective affect for developing dementia in those prescribed lithium NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Bipolar mania FDA Approved Drugs o Anticonvulsant mood stabilizers: Lithium, valproic acid, divalproex, or carbamazepine (2nd line) o Antipsychotics: olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, asenapine • Bipolar Acute Depression FDA Approved Drugs o Anticonvulsants: lithium o Antipsychotics: quetiapine, lurasidone, olanzapine-fluoxetine combination • Bipolar Maintenance FDA Approved Drugs o Mood stabilizers: lithium, lamotrigine, valproic acid o Antipsychotics: olanzapine, aripiprazole, quetiapine, risperidone, ziprasidone • Treatment may require a combination of the previously mentioned medications • Electroconvulsive therapy (ECT) is highly effective in resistant cases of bipolar depression and should be considered if drug therapy is ineffective • Dosing should begin at the lowest dose and be slowly increased, while monitoring comorbidities and adverse effects. Benzodiazepines are sometimes used for acute agitation in mania. SSRIs are generally not recommended for bipolar depression, as they are often ineffective and can induce mania; however, they are used in selective, resistant cases. • A collaborative care model has been successful for patients with combined chronic medical and mental health problems • Establishing a therapeutic alliance is key to management; psychotherapy and psycho- education are also an important part of treatment Medication metabolic side effects • Lithium o Initial evaluation of renal, cardiac, and thyroid function before initiating therapy, and then periodically during therapy o Levels need close monitoring during the initial period and period monitoring once stabilized o Concurrent use of NSAIDs, thiazide or loop diuretics, and ACE inhibitors may adversely affect lithium levels o Adverse effects include ▪ Tremor ▪ Hypothyroidism NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • 25% of geriatrics suffer from this • Staying asleep is most common • Melatonin • Avoid antihistamines • Educate on proper sleep hygiene o Establish regular bedtime and wakeup time o Set aside a time each evening for relaxation and thinking o Avoid caffeine, alcohol, and nicotine because they all interrupt sleep o Minimize awake time in bed, reserving bed for sleep and sexual activity NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ o Create an optimal sleep environment o Establish regular eating habits because hunger can interrupt sleep o Avoid napping o Exercise daily to the extent possible, but avoid exercise just before bedtime o Maximize daytime exposure to bright light • Can be early sign of mental illness Signs and symptoms • Reports not sleeping • Excessive daytime sleepiness • Loud snoring (sleep apnea) • Restless legs • Difficulty falling asleep and staying asleep • Irritability • Difficulty concentrating • Sleep that is not refreshing and restful • Daytime fatigue • Older adult may spend 10-12 hours in bed at night trying to sleep • Falling may be a sign Prevalence in the elderly • Approximately 50% of people more than 65 years old experience and regularly complain of poor sleep quality • Women who are widowed, separated, or divorced have more insomnia up to age 85 then after than men have more insomnia Diagnostic criteria (medical and psychiatric causes) • Insomnia is a clinical diagnosis, verified by a sleep history or sleep log o Assessment of daytime sleepiness, fatigue, or sleep disturbances, the sleep environment, and the duration of symptoms, information on frequency and duration of awakenings, sleep times, nap times, and lengths is important 1st line treatment for chronic insomnia • Transient insomnia o Avoid caffeine for 12 hours before bedtime and D/C alcohol and unnecessary sleep- interrupting drugs o OTC melatonin or Rx ramelteon if ineffective, try a short-active sedative-hypnotic such as zolpidem (ambien) or zaleplon (sonata) at the lowest dose before bedtimes for 1 week or less • Chronic insomnia o Complete medical and psychiatric history is indicated, including any family hx of sleep NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ problems o Self-administered instrument: Epworth Sleepiness Scale or the Stanford Sleepiness Scale o Keep sleep diary o If sleep apnea is suspected, refer to polysomnography o Combined sleep hygiene and CBT are more effective than either alone or usual treatment), music therapy, aerobic exercise • Pharmacological Therapy NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ 1st line treatment Kennedy-Malone • Noninflammatory OA o Walking, water therapy o Acetaminophen is the medication of choice in doses of 2-3g/day • Not responding to acetaminophen and exercise o Cyclooxygenase type 2 (COX-2) ▪ Celecoxib 50-100mg PO BID o Tramadol can be given at 50mg q4-6 hours o Opiates such as codeine and oxycodone can be used for severe OA o Glucosamine and chondroitin o Topical diclofenac sodium Dunphy • Hand OA o Topical capsaicin o Topical NSAIDs o Oral NSAIDs o Tramadol • Knee OA o Acetaminophen o Oral NSAIDs o Topical NSAIDs o Tramadol o Intra-articular corticosteroid injections • Hip OA o Obesity management o Non-narcotic management: oral NSAIDs improve short-term pain function o Physical therapy o Intra-articular corticosteroid injections o Mental health disorder: management of depression, anxiety, and psychosis impact pain relief, function and ADL Medication Management Osteoporosis (Dunphy) Dunphy: p. 851-870 Osteoporosis NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Risk Factors o ETOH o Smoking • Screening: 65 years old: DEXA scan (Densitometry is gold standard) • Know your levels o Osteopenia: -1 o Osteoporosis: -2.5 o Osteoporosis: -2.5 and presence of osteoporotic fractures NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Most common presentation is bone fracture • Tx Goal: pain control Signs and symptoms, findings on presentation • Gradual development of upper or midthoracic back pain associated with activity or long periods of sitting or standing, which is relieved with rest in the recumbent position • Acute vertebral compression fx generally occur in the thoracic or high lumbar region, with the patient experiencing a more sudden, severe onset on pain • Acute compression fx: o Point tenderness in the specific area of the fx can be elicited during the physical exam o Dorsal kyphosis (―dowager’s hump)- loss of height ▪ As it progresses, impairment of rib mobility, a decrease in lung volumes, and an increase in respiratory complaints may occur WHO diagnostic criteria (Dunphy p.865) BMD = Bone mineral density Diagnosis Diagnostic Finding Normal BMD within 1 SD of young adult reference mean Osteopenia BMD > 1 SD below young adult reference mean (21) Osteoporosis BMD > 2.5 SD below young adult reference mean (22.5) Osteoporosis (severe) BMD > 2.5 SD below young adult reference mean (22.5) AND presence of osteoporotic fractures DEXA results: normal, osteopenia, osteoporosis DEXA- dual energy absorptiometry = the gold standard for documenting osteoporosis of the proximal femur and lumbar spine Diagnostic Tests: Osteoporosis is defined based on the BMD measurement BMD is measured: Dual-energy x-ray absorptiometry (DEXA or DXA) The results are reported as T- and Z- scores • WHO T-score compares the bone mass of the patient to the mean of a young adult (20-year- old healthy woman) NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Osteoporoti c Rule out secondary cause Preventive measures • Adequate calcium and vitamin d intake throughout life • Smoking cessation • Avoid excess alcohol • Regular moderate weight-bearing exercise • Fall prevention Postmenopausal women: • Pharmacological Tx with Alendronate, Risedronate, Zoledronic acid, or denosumab to reduce the risk for hip and vertebral fx in women with known osteoporosis for 5 years NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ Men • Pharmacological tx with bisphosphonate s to reduce the risk for vertebral fractures in men with clinically recognized osteoporosis Drugs commonly prescribed for osteoporosis • Bisphosphonates (therapy for five years) o Risedronate (Actonel), available in daily, weekly, twice monthly, and once-monthly dosage forms ▪ Considerations • Swallow whole; take in the morning with a full glass of water before other food and drink; remain in upright position for at least 30 minutes • Caution with other GI irritants such as aspirin • May cause abdominal pain, atrial fibrillation, and esophageal ulceration • Hypocalcemia is an absolute CI o Alendronate (Fosamax) ▪ Considerations • Take on an empty stomach at least 30 minutes before a meal; drink full glass of water and remain upright for at least 30 minutes • Can increase toxic effects of aspirin; can decrease absorption of calcium supplements and vitamin D • See adverse effects above o Ibandronate (Boniva) ▪ See above adverse effects ▪ The IV form may cause bone pain, arthralgia, and a-fib o Zoledronic acid (Reclast) ▪ Yearly injection ▪ Obtain baseline renal function within 10 days before initial dose ▪ Avoid in renal disease ▪ Adequate hydration is important ▪ Concomitant administration of calcium and vitamin d before, during, and after drug administration ▪ Osteonecrosis of the jaw has been seen; also arthralgia, a-fib, and bone pain can occur ▪ Consider IV zoledronic acid holiday after 3 annual doses in moderate-risk patients or after 6 annual doses in higher-risk patients NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Parathyroid Hormone o Teriparatide (Forteo) ▪ indication • Tx of osteoporosis in postmenopausal women at high risk for fracture (prior fx and T-score less than -3 ▪ Adverse effects • Daily DQ injections for up to 24 months • Stimulates bone formation more than bone resorption • Contraindicated in NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ • Radiographs of the hands and feet are needed to look for early signs of erosions, which are important factor indicating the need to start an aggressive treatment approach aimed at halting further joint damage progression. • Radiographic findings in RA include soft tissue swelling, symmetrical joint narrowing, and joint subluxations 1st line treatment • NSAIDs & DMARDS (methotrexate, sulfasalazine, leflunomide, hydroxychloroquine) Medication Management • Corticosteroids, analgesia, NSAIDs • DMARDS suppress immune system, may take up to 3 months for full effect o Methotrexate -5mg once/week, co prescribed with folic acid o Sulfasalazine o Leflunomide o Hydroxychloroquine ▪ TB and hep testing prior to Tx • TNF inhibitor biological agents o Etanercept, adalimumab, infliximab, certolizumab, golimumab, rituximab, abatacept RA Vs OA • RA • Goal: to decrease inflammation • Symptoms o pain > 60 minutes o ulnar deviation o swan-neck deformity o symmetrical loss of function o joint subluxations • Treatment o NSAIDs & DMARDS • Labs o Rheumatoid factor o Anti-CCP (most sensitive- this is the diagnostic lab) • OA o Symptoms ▪ Asymmetrical ▪ Bouchard’s and Heberden’s nodes ▪ Morning stiffness < 30 minutes o Cause: NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ NR 601 Midterm Exam Study Guide latest LATEST UPDATE GRADED/RATED A+ ▪ Due to repetitive microtrauma o Treatment ▪ Acetaminophen o Labs ▪ CBC o Risk Factor ▪ Obesity