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Geriatric Gems

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. Let’s start with the 5 vital signs in the elderly—T, P, R, BP, and weight. Temperature patterns in the elderly. Loss of diurnal variation

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Geriatric Gems

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  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

  2. Let’s start with the 5 vital signs in the elderly—T, P, R, BP, and weight

  3. Temperature patterns in the elderly • Loss of diurnal variation • Contributes to sleep problems—diurnal variation and melatonin secretion • 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 (central dopamine blockers) such as haloperidal and/or the atypical antipsychotics*, tend to have lower basal temperatures (always complaining of “feeling cold”) • *higher mortality rates in elderly on antipsychotics

  4. 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 • “You’re not dead until you’re warm and dead.” • Always check the thyroid gland—myxedema coma + cold ambient temperature

  5. Pulse-temperature dissociation • Legionnaire’s (Legionella pneumoniae) disease—atypical pneumonia characterized by a pulse-temperature dissociation (pulse 80 with temp of 39.8°C [103.6°F]) + low serum phosphorus and elevated LFT (Legionnaire’s “triad”)—macrolides Rx of choice or doxycycline vs. PCN for Strep pneumonia

  6. Pulse/heart rate • Bradycardia—hypothyroidism, dig, beta blockers (even topical beta blocker eyedrops {Timoptic, Betoptic, etc.) can cause bradycardia), calcium channel blockers such as verapamil and diltiazem, and cholinergic drugs for AD--galantamine (Razadyne), rivastigmine (Exelon), donepezil (Aricept) • Palpitations with CHF, hyperthyroidism, AF • Unexplained tachycardia (60 to 80 is the normal resting heart rate)—consider hyperthyroidism, atrial fibrillation (which can also be caused by hyperthyroidism) • Tachycardia (loss of vagus nerve due to autonomic neuropathy) and silent ischemia in diabetics

  7. Anti-cholinergic drugs cause tachycardia and may precipitate chest pain in the elderly patient with angina—normal functions of acetylcholine • Mentation (CNS) • Pupillary constriction (PNS) • Decreases heart rate (PNS) • Increases salivation (PNS) • Increases peristalsis (PNS) • Loosens urinary sphincter (PNS)

  8. Anti-cholinergic drugs—side effects • Confusion • Pupillary dilation (blurred vision, glaucoma) • Tachycardia (angina, possible MI) • Decreased salivation (dry mouth) • Decreased peristalsis in GI tract (constipation) • Tighten urinary sphincter (urinary retention)

  9. Drugs for OAB (overactive bladder)—anticholinergic effects • oxybutynin (Ditropan)(Gelnique—topical gel)(Oxytrol patch) • Toterodine (Detrol LA); fesoterodine (Toviaz) • Darifenacin (Enablex); solifenacin (Vesicare) • Trospium (Sanctura) • (Prescriber’s Letter, June 2009;16(6):36

  10. Anti-cholinergic drugs—the usual suspects and some surprises… • Amitryptyline (Elavil)—the higher the dose, the higher the risk of anti-cholinergic effects; Rx for neuropathic pain vs. Rx for depression • Hyoscyamine (Anaspaz, Atropine) • Doxepin (Sinequan) • Meclizine (Antivert) • Captopril (Capoten), nifedipine (Procardia) • Prednisolone • dig, dipyridamole (Persantine) • warfarin • Furosemide (Lasix) • isosorbide dinitrate (Isordil)

  11. And then some… • Paroxetine (Paxil) • Codeine • Oxycodone • Diphenhydramine • Fexofenadine (Allegra) • Hydroxyzine (Atarax) • Loratadine (Claritin) • dicyclomine (Bentyl) • Cimetidine (Tagamet), ranitidine (Zantac) • Haloperidol (Haldol)

  12. Respirations • Tagamet (cimetidine) and morphine—increased bioavailability of morphine with a possible reduction in respiratory rate to 4-6 per minute • 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 pathogen; Strep pneumoniae and Legionella are the most serious; (pneumococcal vaccine @ 65) • Let’s go back to referred pain for a momento…

  13. Referred pain…Let’s go back about 80 years…to the embryo. • Embryologic development and the diaphragm—C3, C4 • Shared sensory afferents with somatic structures— • Diaphragm and the shoulder

  14. Blood pressure—Ideal? 120/80, BUT… • 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 are due to hypertension • Keeping the blood pressure BELOW 140/90 prevents strokes, ACS, CHF, dementia, and renal failure

  15. Hypertension • Systolic rises with age, diastolic tends to plateau or even decrease during 6th decade • Isolated systolic (ISH) is common (S > 140; D< 90) pulse pressure increases in the same manner; high S, normal or low D; elevated pulse pressure is increasingly recognized as an important predictor of CAD/CVD • Postural/orthostatic hypotension common—drop of > 20 mmHg S or 10 mm Hg D when rising from sitting position (one of early signs of Parkinson’s disease)

  16. Weight as a vital sign in the elderly • Weight is a vital sign in the elderly • Weight loss defined as? (≥ 5% of usual body weight over 12 months or less) • Drugs and weight loss (dig, metformin, chemo) • Drugs and weight gain-- insulin, sulfonylureas, SSRIs (paroxetine/Paxil; fluoxetine/Prozac), corticosteroids, atypical antipsychotics—clozapine/Clozaril and olanzepine/Zyprexa, mirtazepine/Remeron • Heart failure and weight gain

  17. “The leading cause of hospitalization due to deteriorating heart failure is excessive sodium intake.” (Arch Int Med 2001;161(19):2337-42) • Weight gain and CHF—greater than 1 kg (2 lbs) per day—adjust diuretics; ?sign of worsening heart failure or too much salt in the diet? • Diuretics should be adjusted to maintain euvolemia as reflected by daily-recorded weights that are within 1 kg (2.2 lbs) of the patients predetermined dry weight

  18. What is 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 than baseline (the amount needed just to function) • Peak functional capacity at 24 • 6 good years

  19. Senescence and normal aging... • Peak at 24, 6 good years, gradual decline to baseline; more rapid decline with chronic disease (DM, COPD) FC% Baseline function 1yr 30 75 yrs

  20. Senescence and normal aging... • More rapid decline with chronic disease (DM, COPD) FC% Baseline function 1yr 30 75 yrs

  21. Senescence and normal aging... • Gender differences—the ovary (51.3 +/- 2.7) FC% Baseline function 1yr 30 75 yrs

  22. Example of livin’ “on the edge/baseline…” • One of the compensatory mechanisms in heart failure is an adrenal surge of epinephrine to boost the strength of contraction and increase the heart rate • However, epinephrine also “remodels” the heart…remodel = enlarge…resulting in cardiomegaly and an increased risk of sudden cardiac death due to ventricular dysrhythmias)

  23. Beta blocker use in CHF • Traditionally beta blocker use was a big “no, no” for patients with heart failure…why would you want to decrease the strength of contraction and decrease the heart rate in a failing heart… • In the “old” days, beta blockers were known to precipitate heart failure in patients with hypertension…one of the reasons that beta blockers are no longer first line therapy for hypertension • BUT…

  24. Beta blockers to the rescue • Beta blockers (“olols, alols, ilols”) may initially worsen heart failure symptoms when they are used to prevent “remodeling” of the heart post-MI or in the patient with CHF • However, beta blockers actually improve survival rates and quality of life when used in CHF patients • Carvedilol (Coreg), metoprolol succinate (Lopressor)

  25. Example of “livin’ on the edge…” • 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

  26. 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

  27. Nephrotoxic drugs and the elderly • Antibiotics (aminoglycosides) (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?

  28. The healthy kidney • Afferent arteriole (normally vasodilated (via prostaglandins) • Blood entering glomerulus • Glomerulus→filter • Efferent arteriole (normally vasoconstricted (via angiotensin 2) Prostaglandins – blocked by NSAIDs filter Angiotensin 2—blocked by ACE -- Toilet

  29. 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-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

  30. More on NSAIDs in the elderly… • NSAIDs and fluid retention (due to vasoconstriction of the afferent arteriole)—especially the long-acting nonselective NSAIDs (piroxicam/Feldane) • NSAIDs can counteract the positive effects of thiazide diuretics for blood pressure control • Why? Opposing actions • NSAIDs can exacerbate HF symptoms due to sodium and water retention (+peripheral edema); can also increase K+ levels

  31. More on NSAIDS in the elderly… • In addition to all of the above, one must worry about the GI effects of the NSAIDs…the older the patient, the higher the risk, especially with the non-selective NSAIDS • GI complications are 3-10x more common in users of nonselective NSAIDs than in nonusers • Use celecoxib (selective COX-2) if possible (also decreases risk of lower GI bleeding as well as perforations, obstructions and bleeds in upper 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.

  32. (In addition to NSAIDs), certain calcium channel blockers can also cause/exacerbate peripheral edema • Peripheral calcium channel blockers cause peripheral edema due to their strong peripheral vasodilating effects (the “dipines”) • Felodipine (Plendil) is the worst of the bunch; amlodipine (Norvasc) is the best of the bunch

  33. Water loss and aging • Decrease in total body water stores • Decreased volume of distribution • Increased drug toxicity with water-soluble drugs—dig for 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)

  34. Herbal products… • Have your patients taken any herbal products that can interfere with diuretics or dig? Most of the herbal diuretics can cause low sodium (seizures), low potassium (muscle cramping, arrhythmias), and low magnesium (arrhythmias) • Dandelion (Pissenhüt), licorice, St. John’s wort • Herbal laxatives also decrease total body K+ stores and can cause dig toxicity • (K+ and dig compete for receptors on myocardium—dig toxicity with hypokalemia)

  35. Dehydration in the elderly • Decreased collagen, elastic tissue, and water • FYI, estrogen maintains collagen health • (Wolff EF, et al. Long-term effects of hormone therapy on skin rigidity and wrinkles. Fertility Sterility 2005 Aug; 84:285-8.) • What are the signs and symptoms of dehydration in the elderly?

  36. Decreased collagen and elastic tissue with aging • Shrunken eyeballs? • Poor skin turgor? • Where do you check skin turgor in the elderly? • What are some other consequences of the loss of collagen, elastic tissue and water?

  37. Intervertebral discs are made from collagen, elastic tissue and water • Loss of collagen, water, and elastic tissue resulting in disc shrinkage • Loss of height (change in size and shape of chest cavity) • How many inches can you lose with disc shrinkage?

  38. Combine the disc shrinkage with compression fractures of osteoporosis—loss of trabecular bone

  39. Compression fracture of vertebrae • Vertebral bodies with the loss of height with compression fractures • How many inches can you lose with vertebral compression fractures? • Vertebral compression fractures + disc shrinkage =

  40. Other fractures due to osteoporosis • Neck of the femur—broken hip • What is the prognosis after a broken hip? • Radius of the wrist (Colles fracture of the wrist) • Do men have osteoporosis? YES, and they have a worse prognosis after a hip fracture • One in 2 women and one in four men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime

  41. Osteoporosis • Skin, aging and vitamin D conversion • Check Vitamin D levels! Low vitamin D = increased risk for balance problems and falls (and joint and muscle pain) • Vitamin D deficiency—levels of 25-hydroxyvitamin D below 25 ng per milliliter are associated with an increased risk of hip fracture in men and women older than 65 • Muscle aches, bone aches, joint aches and pains may be due to low vitamin D

  42. Digression--prevention and treatment of osteoporosis • Weight-bearing exercise 5 x per week • Stimulates bone remodeling with osteoblasts and osteoclasts

  43. Prevention/treatment of osteoporosis • Calcium—1200-1500 mg/day; best way to get calcium is to eat calcium-fortified foods • Vitamin D—1000-2000 IU per day • Foods—broccoli florets, sardines, milk, yogurt • Calcium supplements are only beneficial if taken consistently** • Calcium supplements interfere with synthroid

  44. Drugs to prevent and treat osteoporosis • Alendronate (Fosamax) (most potent bisphosphonate) • Risedronate (Actonel) • Ibandronate (Boniva) • Can your patient follow directions for the bisphosphonates?

  45. EXPERIENCE-BASED MEDICINE—give a 1-year holiday to relatively low risk women (no fx, young and healthy, active, with BMD that is not horribly low 2) Do NOT tend to stop risedronate as it has a shorter half-life and there are NO DATA on cessation except after 3 years of use and BMD goes down rapidly after stopping 3) 5 years on ALN then stop for up to 5 years without losing too much BMD; after stopping measure urinary NTX or serum CTX in 6 months; if elevated above ideal, restart ALN. If ok, she starts ALN after a one year holiday. ALN is retained longer in bone than other BS Carolyn Becker, MD, Master Clinician, Harvard University, Cambridge MA Bisphosphonate therapy

  46. Other drugs for osteoporosis • Evista (raloxifene)—antagonist in breast and uterus; agonist in bone; increased risk of DVT • What about tamoxifen? Antagonist in breast and brain; agonist in uterus and bone: not approved for osteoporosis • Calcitonin (Miacalcin)—has some opiod-like properties and is useful for the pain of vertebral fractures

  47. Other drugs for osteoporosis • Forteo (teriparatide)—for treatment of osteoporosis and for use in preventing steroid-induced osteoporosis (boosts osteoblasts and blocks steroids effects on the bone)(better results compared to Fosamax) • Reclast (zoledronic acid)—15’ infusion x 1 per year decreases vertebral fractures by 70%; hip by 41% • Denosumab (Prolia) – new monoclonal antibody to boost bone building • And don’t forget the best bone builder of all

  48. 1% rule and the INCREASE in size of the prostate gland • Benign prostatic hypertrophy—alpha one receptors on the smooth muscle of the prostate • Treatment of BPH—alpha one blockers—tamsulosin (Flomax)** generic; silodosin (Rapaflo), doxazosin ER (Cardura XL) • Prostate cancer—risk increases with age • Protect that prostate! • Vitamin D and prostate protection

  49. PSA testing for prostate cancer • The controversy continues • What are the cut-off levels? • A PSA of greater than 4 ng/mL is generally accepted as the cutoff level for biopsy in the general population • Age-adjusted PSA cutoff values are as follows:

  50. PSA testing • 2.5 to 3.5 ng/mL and over for 41- 50-year old patients • 3.5 to 4.5 ng/mL and over for patients who are 50-60-years old • 4.5 to 5.5 ng/mL and over for those who are 60 to 70 years old • 5.5-6.5 ng/mL for men in their 70s • For African-American men, the diagnostic range is shifted downward • PSA velocity

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