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NR 601 Final exam study guide (Comprehensive Guide & practice questions) How to conduct Mini-Cog-  The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE  The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function.  It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administer  The Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.  Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words.  A score of 0 to 2 is a positive screen for dementia Causes of delirium in elderly-  Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins.  Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of delirium in comparison with blood flow patterns after recovery.  A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59) Agnosia  Loss of ability to identify objects ADA criteria for diagnosing DM-  FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*  2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*  A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*  In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L). • Urinary incontinence-  Involuntary loss of urine from the bladder ▪ So common in women many consider it normal ▪ Common in older men w/ enlarged prostate o Can affect quality of life o Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt & society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals o Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in placement ▪ URGENCY UI is greater in men ▪ STRESS UI is greater in women o Terminology ▪ UI- Unintentional voiding, loss or leakage of urine ▪ Continuous incontinence-Continuous loss or leak of urine ▪ Increased daytime frequency-More frequent during day than considered normal ▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50 ▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent ▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence o Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics o Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diuretics Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics o Physical changes w/ aging that contribute to UI ▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow ▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation 1 ▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms - Initial clinical workup for UI in Men o PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men - UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vagin*l exam, perineal, Identify estrogen status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine ▪ Full bladder ▪ Standing position ▪ Asked to cough ▪ If urine leak is observed, stress incontinence is confirmed - Red flags in males o Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain, Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA o Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA tenderness,Nodular prostate,Any new neuro symptoms - Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden - 1st line management guidelines o AHRQ guidelines for management of UI in women ▪ Behavioral therapy ▪ Lifestyle modification ▪ Try for 3 months before pharm management o Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing o Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods o Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys - Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training - 2nd line management - Medication o Antimuscarinic medication: 1st line for women ▪ Block the parasympathetic muscarinic receptors ▪ Inhibit involuntary detrusor contractions ▪ Side effects due to the effects on other muscarinic receptors o Outcomes unpredictable and side effects common o Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache o AntimuscarinicsMechanism of action ● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic) ● CYP3A4 substrates ▪ Indications: UI and OAB ▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention ▪ Precautions:CNS depression,Caution in elderly ● Renal dosing o CrCl <30 o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq) ▪ Also approved for UI and OAB ▪ Clinical trials – significant reduction in incontinence and micturations ● No anticholinergic s/e ▪ Mech of action ● Selectively stimulates beta-3 adrenergic receptors ● Relaxes smooth muscle – bladder ▪ Contraindications/caution: HTN- Do not use if SBP >180, DBP >100 ▪ Avoid severe renal/liver disease ▪ Dose – 25-50mg PO QD ▪ CrCl <30 – max 25mg - 2nd line of UI in Males – Alpha 1 blockers 2 Delirium treatment- (Kennedy p. 560).  Identify causes, prevent delirium though complications of identified disorders. \  Focus on safety.  Frequent reassurance and re-orientation.  First generation --haloperidol.  Second generation (olanazapine, risperidone, ziprasidone and quitiapine) antipsychotics to control behavioral symptoms. Essential tremor vs. Parkinson’s Disease  Essential tremor is an action tremor 6 to 8 Hz, Parkinson’s tremor is a resting tremor which is 3 to 6 Hz. (Kennedy p. 425) Seizure causes  In older adults stroke is the most common underlying cause of seizures.  Other causes include neurodegenerative disorders, brain tumors and head injuries. (Kennedy p 438) Hospice & palliative care-  Hospice: o Last 6 mos of life. Uses palliative care principles to support pt and family. Includes bereavement services. Covered by Medicare/Medicaid, most private insurance. Interdisciplinary care, medical service, supplies, drugs  Palliative Care: o To relieve pain and improve QOL. Used early in dz process. Interdisciplinary Care. Provides care for the entire dz process, from diagnosis to death, including bereavement services. Pain-  Pain assessment tools: o Visual Analogue Scale o Numerical Analogue Scale o Wong Baker FACES o Pain Assessment in Advanced Dementia scale  Types of pain: o Somatic, o Visceral, o Neuropathic  Framework for pharmacological interventions for pain:  The WHO Step Ladder o 1st step: NSAIDs and Tylenol for mild pain o 2nd step: Opioids added, usually with APAP for moderate to severe pain with functional impairment and or decreased QOL o 3rd step: Opioid pain meds, sometimes around the clock for severe pain  Adjuvant meds: o Tricyclic antidepressants, Nortriptyline, Desipramine, Duloxetine, Gabapentin, Pregabalin, Lidocaine 5% patch, Capsaicin cream, Corticosteroids, Calcitonin, Baclofen Pain management in elderly Delirium vs. dementia-  Delirium- o rapid onset (hours to days). o Poor memory, disorientation, speech disturbance, perceptual disturbance. o Typically fluctuates over course of day. o History may reveal cause-medical condition, intoxication or withdrawal, use of med, toxin exposure or combination. (Kennedy 558).  Dementia- o Alz Disease most common. o An acquired persistent intellectual impairment with compromise in multiple spheres of mental activity. o Signal symptoms: confusion, impaired short-term memory, cog dysfunction. 5 o Progression is typically slow. o Could be reversible (secondary to treatable systemic disorder), or irreversible (primarily caused by progressive systemic or neuro disorder). o ***hallmark*** anosognosia- the patient is unaware of impairment and denies illness(kennedy, p.562) o Alz. ChEIs - cornerstone of pharm therapy as acetylcholine is important for brain cell function. Steps of the grieving process  Grief is the emotional response to loss, Mourning is the outward social expression of loss  Types of grief: o Anticipatory-experienced before death, can be experienced by everyone including the patient o Normal- encompasses the typical emotional, physical, cognitive, and spiritual reactions to a loss o Complicated-chronic, delayed, exaggerated, masked or disenfranchised  Stages of Grief: o Notification and shock o Experiencing the loss emotionally and cognitively o Reintegration  Tasks of grieving: o Acknowledging the reality of death o Sharing in the process of working through the pain of grief o Reorganizing the family system, restructuring the relationship with the deceased, and reinvesting in other relationships and life pursuits  Kennedy p. 631 Alzheimer’s treatment  Signs and symptoms- o Preclinical  can last 2-4+ years, impaired memory (excused or covered), poor judgement, decreased spontaneity, increased social anxiety, insidious instrumental ADL losses (bill paying, money handling), preserved basic ADLs o Mild/Moderate-  lasts 2-10 years, obvious memory impairment, overt instrumental ADL impairment, basic ADL failing, behavioral difficulties, shortened attention span, language difficulty, variable social skills, supervision required o Severe-  last 1-2+ years, memory fragments only, no recognition of familiar people, requires assistance with basic ADLs, reduced mobility, weight loss, fewer troublesome behaviors, infections, seizures, dysphagia, incontinence, groaning, moaning, grunting  First line pharmacological treatment- o Cholinesterase inhibitors donepezil (Aricept) o Memantine (Namenda) added at the moderate to severe stage  Kennedy p 567-568 Sexuality sundowning metformin side effects-  GI side effects take with supper. Most patients adjust to these SE. ADVERSE effect- Lactic acidosis. B12 deficiency  Biguanides (Metformin) has become a cornerstone of drug treatment for type 2 disease, based on its proven efficacy not only in controlling glucose intolerance but also in significantly reducing risk of important macro- and microvascular outcomes, especially in overweight and obese patients (as found in the UKPDS study referred to earlier and below). In glycemic treatment algorithms for type 2 disease, initiation of metformin is recommended at the time of diagnosis along with diet and exercise.  Mechanism of Action. Metformin differs from the traditional oral hypoglycemics (i.e., the sulfonylureas) in that it does not stimulate endogenous insulin secretion; rather, drugs of this class enhance tissue responsiveness to insulin. Consequently, biguanides are less likely to induce hypoglycemia and are particularly effective in the treatment of overweight patients with tissue resistance to insulin. Biguanides facilitate insulin uptake by 6 peripheral tissue, especially muscle and liver, and decrease hepatic gluconeogenesis and basal glucose output, thereby helping to lower fasting glucose levels. Glucose utilization also improves in adipose and intestinal tissues. The net result is an improvement in fasting and postprandial hyperglycemia. Insulin demand declines as glucose utilization improves. Serum lipid abnormalities also improve.  Preparations. Metformin is the only biguanide approved in the United States for the treatment of type 2 diabetes. The drug is rapidly and well-absorbed in the small intestine, with peak plasma concentrations in 2 hours. It is rapidly excreted unchanged by the kidneys. Impaired renal function (creatinine >1.5 mg/dL in men and >1.4 mg/dL in women) is a contraindication for use, especially at full doses. The drug is not metabolized by the liver. The original biguanide, phenformin, is no longer marketed because of its associated risk for lactic acidosis and an excess cardiovascular mortality (see later discussion).  Dosing. The starting dose of metformin is 500 mg once daily with dinner. After 1 week, the dose is increased to twice daily, given with the two largest meals of the day (usually breakfast and dinner) to minimize gastrointestinal upset. The dose can be increased by 500 mg every 1 to 2 weeks until treatment goals are met or the maximum dose of 2,000 to 2,500 mg/d is reached. An extended-release formulation is also available, which can help to improve compliance.  Efficacy. When used as monotherapy in an obese person with moderate glucose intolerance, metformin’s efficacy in terms of glycemic control (i.e., lowering fasting glucose and glycosylated hemoglobin levels) is about the same as that of a second-generation sulfonylurea. Incidence of monotherapy treatment failure is less for metformin than for glyburide (21% vs. 34% at 5 years). A synergistic effect is achieved when combined with sulfonylurea therapy in patients who do not respond well to metformin alone. Unlike the sulfonylureas, metformin is effective even in severe fasting hyperglycemia (>300 mg/dL), indicative of poor beta-cell responsiveness. Plasma triglycerides and LDL cholesterol levels are decreased. In the UKPDS trial noted earlier, obese patients (>120% of ideal weight) with type 2 diabetes treated with metformin and attaining target glycemic control achieved clinically important, statistically significant, sustained long-term reductions in risks of microvascular disease and macrovascular complications (i.e., myocardial infarction, stroke, and cardiovascular death); all-cause mortality was also significantly reduced. These findings make metformin one of the few antihyperglycemic drugs with demonstrated ability to reduce macrovascular risk, the holy grail of diabetes management.  Adverse Effects. The most common side effect of biguanide therapy is dose-related gastrointestinal upset (nausea, diarrhea, bloating, abdominal discomfort). The risk for serious prolonged hypoglycemia is minimal. Lactic acidosis represents the most potentially serious adverse effect. One of the original biguanides—phenformin —was taken off the market by the U.S. Food and Drug Administration (FDA) in 1977 because of its association with fatal episodes of lactic acidosis. The risk for lactic acidosis associated with metformin is greatest in the setting of hypoxemia, hypovolemia, and states with decreased tissue perfusion and in renal insufficiency (creatinine >1.5 mg/dL). Accumulation of the drug secondary to reduced excretion results in impaired hepatic metabolism of lactate. Other risk factors include binge drinking, use of intravenous radiologic contrast agents, hepatic failure (lactate is metabolized by the liver), and serious underlying illness, particularly heart failure.Long- term data on safety have yet to be accumulated. Because insulin secretion is not increased with metformin use, weight gain does not occur; some patients may even lose weight. Patients who are to undergo a radiologic procedure that requires intravenous iodinated contrast should have their metformin therapy held for a few days prior to the procedure and remain well hydrated.  Patient Selection. Based on the landmark results of the UKPDS, obese patients should be considered especially good candidates for metformin therapy. The drug helps to reverse their insulin resistance, peripheral responsiveness to insulin improves, and insulin needs decrease, so hyperinsulinism and its adverse effects, including weight gain, are minimized. The typical candidate is a moderately obese person with type 2 diabetes who has persistent moderate hyperglycemia (fasting glucose between 140 and 240 mg/dL, glycosylated hemoglobin >7.0%) despite a full program of diet and exercise. Early addition of metformin is suggested. Other candidates for metformin include obese patients who do not achieve tight control while taking a sulfonylurea at maximal doses. In this setting, metformin is added to the oral hypoglycemic program to improve control through its complementary mode of action. The sulfonylurea dose is reduced to lessen the risk for hypoglycemia. Combination therapy is most effective when initiated before the onset of symptomatic hyperglycemia (fasting glucose >250 mg/dL). Nonobese patients are also reasonable candidates for metformin. Typically, metformin lowers fasting blood glucose by approximately 20%.Patients who started drug therapy with a sulfonylurea and become unresponsive to maximal doses have likely exhausted their beta-cell reserve and can be switched to metformin or considered for exogenous insulin therapy (sometimes in conjunction with metformin). The same 7 Oxazepam (Serax)a Intermediate– slow Short– intermediate 10–15 $$ ($$$) Temazepam (Restoril)a Intermediate– slow Intermediate 15 $ ($$$) Melatonin Receptor Agonists No potential for abuse Ramelteon (Rozerem) Rapid Short 8 $$ Antidepressants Doxepin (Silenor) Rapid Long 3–6 $$$ Very-low-dose preparation may be helpful in elderly with chronic insomnia. GOLD criteria- Malone 207)  Gold standard = Spirometry for measuring airflow limitation. o GOLD Classification (post bronchodilator FEV1) o GOLD1 (mild): FEV1 > 80% predicted o GOLD2 (Moderate): 50-79% predicted o GOLD 3 (Severe): 30-49% predicted o GOLD 4 (Very Severe): FEV1 < 30% predicted  Treatment = individualize according to stages, cormorbidities, and patient goals. Treatment is targeted towards improvement of health status, And functional status, prevention of disease progression avoidance of exacerbations or complications prevention of treatment side effects and management of exacerbation. COPD management program  Risk factor reduction.  Assessment and monitoring.  Stable chronic management.  Management of exacerbation.  Smoking cessation is the most effective cost effective intervention and should be promoted every visit.  No current drug therapy has proven to influence the progressive decline of COPD.  Malone 208 - inhaled bronchodilators maybe useful and stable COPD patients. Arrhythmia evaluation SIG-E-CAPS-  S: sleep (insomnia or hypersomnia)  I: interests (diminished interest or pleasure);  G: guilt: (excessive or inappropriate guilt; feeling worthless);  E: energy (loss of or fatigue);  C: concentration (diminished concentration or indecisiveness);  A: appetite (decrease or increase; weight gain or weight loss);  P: psychom*otor retardation/agitation (move slow, agitated, restless);  S: suicide (recurrent thoughts of death, ideation, or attempt) DEXA scan results findings- (Pg 499) • BMD measurement is expressed as the number of standard deviations from the mean for normal young adults of the same sex (T-score) and as the number of standard deviations from the mean for persons of the same sex and age (Z score). • The World Health Organization diagnostic criterion for osteoporosis is a T-score of less than -2.5. Osteopenia is defined as a T-score between -1.0 and -2.5. A Z score of less than -1.5 suggests a secondary cause of osteoporosis • Osteoporosis: -2.5 or lower • Osteopenia: -1 to -2.5 (lower than normal bone density w/o full osteoporosis) Anxiety treatment- 10 • Treatment for anxiety should reduce symptoms and improve functioning. • Simply listening, being compassionate, and showing respect are important to improving outcomes. Treat comorbid depression and medical conditions that cause anxiety. • There are no large-scale studies of pharmacotherapy for late-life anxiety disorders to guide treatment decisions. • Start low and go slow with medication dosing to avoid risks from drug interactions, because older adults are more likely to take many medications and may have side effects from aging changes in absorption, metabolism, distribution, and excretion of medication. • Evaluate and manage side effects, because as many as 25% of patients stop taking medication in the first 6 months due to side effects. • First-line treatment is the selective serotonin reuptake inhibitors (SSRIs) o citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft). In older adults, they have the least risk of drug interactions, side effects, or worsening existing medical conditions. o Benzodiazepines, including lorazepam (Ativan), alprazolam (Xanax), and clonazepam (Klonopin), are effective according to research but are not the first choice due to the risk of falls and confusion. Research supports referral to psychotherapy for older adults, but this recommendation is limited to GAD and no other anxiety disorders (American Psychiatric Association, n.d.; Cassidy & Rector, 2008; Hollander & Simeon, 2008; Lenze et al., 2005; Lenze & Wetherell, 2009; Mohlman, 2005; National Institute of Mental Health, n.d.; Stanley et al., 2003; Wetherell, Lenze, & Stanley, 2005; Wetherell, Sorrell, Thorp, & Patterson, 2005). (Kennedy-Malone 553-554) ************************************************************************************************** FINAL EXAM NR 601 (Thanks Lisa Trevino!) The test covers weeks 1-8 content. 25% is weeks 1-4. 75% is weeks 5-8 Week 1 topics include: Aging (Chapter 1) Exercise (Chapter 3) Chest disorders: COPD, bronchitis Week 1 presentations In week 1 the required readings included: The physiologic changes of aging, Exercise, Polypharmacy Chest disorders were discussed in Kennedy-Malone et al Chapter 8 as well Gorroll Week 1 presentations WEEK 2 • Cardiac • Polypharmacy • Guidelines: – 2017 ACC/AHA guidelines for management of heart failure – 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults – 2017 blood pressure guidelines – Beers Criteria Week 2 topics included cardiac concerns Polypharmacy 2017 ACC/AHA guidelines for management of heart failure 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults 2017 ACC/AHA HTN guidelines Beers criteria- its purpose New York Heart Association functional classifications for heart failure (Gorroll) WEEK 3 Health Promotion 11 prevention education Mental health Insomnia Health promotion is discussed in Kennedy-Malone Chapter 2. Review vaccine recommendations, organisms responsible for outbreaks and patient education. Know the types of prevention: primary, secondary and tertiary. Mental health: review required readings and presentation Anxiety & Depression Somatic complaints, screening tools, mnemonics, contributing factors, appropriate labs: purpose and rationale and goals of treatment. Note symptoms and factors that are distinct to the elderly. Know first line treatments Insomnia: know the types of insomnia and recommended first line treatments. WEEK 4 Osteoporosis Polymyalgia rheumatica Rheumatoid arthritis Osteoarthritis Pain Review Chapter 12 of Kennedy –Malone et al Osteoporosis- review assigned readings and the recorded lecture. Know signs and symptoms, diagnostic tests and treatment Polymyalgia rheumatica and Rheumatoid arthritis, osteoarthritis - signs and symptoms, diagnostic tests and treatment Review the types of pain, common treatments WEEK 5 In week 5 the focus was diabetes. Review the presentation Know the risk factors – modifiable and nonmodifiable Physical exam findings Know the appropriate screening tests- this is based on the ADA guidelines which you reviewed when you completed the case study. Interpret screening test results and the appropriate next step. Appropriate diagnoses: prediabetes, diabetes type 2 Common medications, medication side effects. Education for side effects Review the complications and which are most common. Know recommended referrals for diabetic patients. Review the ACC 2017 Guidelines for assessment and treatment of BP in diabetic patients. This includes BP ranges and appropriate first line recommendations for diabetic patients. WEEK 6 Week 6 GU and GYN Disorders • Sexuality – Kennedy Chapter 11- Disorders: Erectile dysfunction, atrophic vaginitis, GSM, BPH Urinary UA dip interpretation Sexuality lecture Kennedy Chapter 11 covered urological and gynecological disorders Diagnose and initial treatment for a UTI, treatment for multiple UTIs 12 b. Long-term po steroids not recommended for stable COPD. Add inhaled steroids to inh bronchodilators with severe COPD or frequent exacerbation. c. Improve exacerbation frequency, QOL, hospitalization rates- doesn’t slow COPD progression d. Need to use with a LABA for COPD patients 4. Inhaled corticosteroids (ICS) a. ICS monotherapy is only FDA approved for treatment of asthma, not COPD b. Adverse reaction- candidiasis and dysphonia – RINSE after use c. Systemic absorption with high doses (1,000 mcg/d)- bruising, cataracts, reduced bone mineral density. d. Increased pneumonia risk & LABA+ICS no real improvement in exacerbation frequency e. Save ICS for severe COPD - FEV1 of less than 50% predicted 5. Improve spirometry use, Vaccinations (pneumaVAX <55 if smoker/ 65+ if non-smoker), Pulmonary rehabilitation, COPD registry, quit smoking, diet/exercise Agent (Trade name) Agent class Inhaler type (mcg/puff) Dose/frequency Nebulizer Solution Albuterol (ProAir, Ventolin, Proventil) SABA MDI (Metered dose) (90) 1-2 inh Q4-6 hrs PRN 0.63, 1.25 mg/3 mL; 2.5 mg/0.5 mL; 2.5 mg/3mL Levalbuterol (Xopenex) SABA MDI (45) 1-2 inh Q4-6 hrs PRN 0.31, 0.63, 1.25 mg/3mL Salmeterol (Serevent) LABA DPI (Dry powder) (50) 1 inh BID N/A Formoterol (Perforomist) LABA DPI (12) 1 inh BID 20 mcg/ 2 mL Arformoterol (Brovana) LABA N/A 15 mcg/2 mL Ipratropium (Atrovent) SAMA MDI (17) 2 puffs q6h 0.5 mg/2.5 mL Titotropium (Spiriva) LAMA DPI (18) 1 inh (DPI)/2 inhalations (SMI-soft mist) QD N/A Albuterol + Ipratropium (DuoNeb) SABA+SAMA MDI (90+18) 1 inh QID 2.5+0.5 mg/3mL Fluticasone/ salmeterol (Advair) ICS + LABA DPI (100/250/500+50) 1 inh BID Budesonide/ formoterol (Symbicort) ICS + LABA MDI (80/160 + 4.5) 2 inh BID Mometasone/ formoterol (Dulera) ICS + LABA MDI (100/200 + 5) NOT FDA ap for COPD (just asthma) Lesson Link to GOLD guidelines https://goldcopd.org/ and https://lms.courselearn.net/lms/CourseExport/files/bb47abfc-cc87-411a-8365-8471f7735d90/ Asthma_and_COPD.pdf differentiating asthma and COPD Great COPD link: https://www.healthquality.va.gov/guidelines/CD/copd/VADoDCOPDPocketCard.pdf 15 Spirometry measures: Flow loops indicate validity of results, but flow loops WILL NOT be on boards or tests – just included them because they help make sense of the changes in values Spirometry- tech enters age, weight, race, sex & height - when looking at results you don’t need this- it’s pre- calculated in the results Spirometry Results and GOLD classifications: Normal values GOLD classifications post bronchodilator 16 FEV1 (step 2 grade severity) FEV1 80% to 120% GOLD 1 mild FEV1 > = 80% predicted GOLD 2 moderate FEV1 50% to 79% predicted GOLD 3 severe FEV1 30% to 49% predicted GOLD 4 Very severe FEV1 < 30% predicted FVC 80% to 120% FEV1/FVC ratio (step 1 = determine if obstruction) > 70% (no obstruction) Step 3- Reversibility? A. Test spirometry pre and post bronchodilator (SABA or SAMA) B. Post testing is 10-15 minutes after SABA/SAMA C. ATS criteria: “significant response” is > = 12% FEV1 or FVC improvement and an absolute improvement of > = 0.2 L D. : “significant response” indicates asthma (due to reversibility) Interpreting PFT results Step 1: Check the ratio to see if obstruction exists. Is FEV1/FVC low? <70 = Obstructive defect or COPD Step 2: grade severity with FEV1 post bronchodilation to classify by GOLD criteria GOLD 1 mild FEV1 > = 80% predicted GOLD 2 moderate FEV1 50% to 79% predicted GOLD 3 severe FEV1 30% to 49% predicted GOLD 4 Very severe FEV1 < 30% predicted Step 3- Reversibility Is there a 12% FEV1 or FVC increase post bronchodilation? Yes = reversible TYPICAL PNEUMONIA SYNDROME- (see lesson;Hutt & Kramer, 2002; Furman, Rayner, & Tobin, 2004): Fast fever, cough = new/worse; purulent sputum (rusty, green), pleuritic CP; Lobar infiltrate on chest X-ray (day 2+ - may become infiltrates) indicating pulm consolidation; Consider Streptococcus pneumoniae & other bacterial pathogens ATYPICAL PNEUMONIA- (see lesson; Hutt & Kramer, 2002; Furman, Rayner, & Tobin, 2004): Gradual fever, dry cough, min secretions, HA, malaise, myalgias, pharyngitis, GI distress. crackles (rales); Abnormal or patchy chest X-ray pattern. Consider mycoplasma or chlamydia, pneumoniae, or oral anerobes. Viral pneumonia may be atypical in presentation. Helpful images below from this video (Thanks to Nicole Popovich-Johnson): youtube spirometry video link 17 NR 601: Week 2 Quiz Review by Alizabeth Anne Madison Week 1 Topics  Aging (Chapter 1) Chapter 1: Changes with Aging - Notes Fundamental Considerations - Recognize that presenting features of disease/illness may be different and having a greater awareness of the impact of chronic illness on the patient. - Perspective is different than with younger adults. Physiological Changes with Aging - The clinician must be aware that all the systems interact an, in doing so, can increase the older person’s vulnerability to illness/disease. - During the clinical decision-making process, the clinician knowledgeable about physiological changes with aging will be less likely to undertreat a treatable condition. -Example- Use the diagnostic process to differentiate the more benign seborrheic keratosis from actinic keratosis. - Be informed; do not attribute a finding to the aging process alone. The elder may conclude there is no point in changing behavior, because the process is inevitable. - Three primary points: 1) There is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. 2) There are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. 3) There is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. Laboratory Values in Older Adults - Many factors can influence lab value interpretation in the elderly, including the physiological changes with aging, the prevalence of chronic disease, changes in nutritional and fluid intake, lifestyle (including activity), and the medications taken. - Reference ranges therefore may be preferable. Reference ranges or intervals, such as age, sex, or race can be defined demographically. For example, the reference range for older adults might be the intervals within which 95% of persons over age 70 fall. - Further defined physiologically (fasting or activity status) or pharmacologically (medication, tobacco or ETOH use). - Biochemical individuality is of particular importance in detecting asymptomatic abnormalities in older adults. Significant homeostatic disturbances in the same individual may be detected through serial laboratory tests, even though all individual test results may lie within normal limits of the reference interval for the entire group. - The clinician must determine whether a value obtained reflects a normal aging change, a disease, or the potential for disease. - Misinterpretation of an abnormal lab value as an aging change can lead to underdiagnosis and undertreatment in other (anemia or UTI) and overdiagnosis and overtreatment in others (hyperglycemia or asymptomatic bacteriuria). - At times, the result of a lab value may be within the appropriate reference range yet indicate pathology for the older adult. - Calculation of creatinine clearance is important in the estimation of renal function. - Reduced renal function, particularly GFR, affects clearance of many drugs, and creat clearance provides an index of renal function for use in choosing doses of renally eliminated or nephrotoxic drugs (such as dig, H2 blocker, lithium, and water soluble antibiotics) - The Modiciation of Diet in Renal Disease (MDRD) and co*ckcroft-Gault equations both provide useful estimates of the GFR. - Any risks involved in lab testing must be considered with respect to the patient’s clinical condition and weighed against the test’s expected benefits. Pharmaco*kinetic & Pharmacodynamic Changes - Polypharmacy and the potential for an adverse drug reaction (ADR) are major concerns in elders. - Polypharmacy primary predictor for an ADR (any unwanted response). - The therapeutic window narrows with age. The potential for benefiting the patient measured against risk of doing harm important. - Pharmaco*kinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) alter the dynamic processes that drugs undergo to produce therapeutic effect due to the effects of the aging process. Absorption - Less impact than distribution, metabolism, elimination. - Gastric acidity declines with age; offset by the longer contact time that occurs as transit time slows – which is more functional than physiological. - Presence of food and other drugs in the stomach at the same time affect drug absorption. - Antacids and Fe can inhibit absorption. - Anticholinergic meds cause a slowing of colonic motility and can result in greater absorption rates. - Metabolic diseases, such as thyroid disease/DM can increase or decrease transit time, can cause either increased/decreased drug absorption. - When the med passes through the esophagus without adequate water, can cause erosion. Distribution - Drug distribution is affected by aging, particularly in individuals of smaller body size, decreased body water, higher body fat. - Drugs distributed in water have a higher concentration in elders, and exert a more profound effect. 20 ______________________________________________________________________________________________ Week 3: SIG E CAPS”, for Sleep, Interest, Guilt, Energy, Concentration, and Appetite, Psychom*otor, and Suicidal ideation Asthma and COPD inhalers See 601 shared drive for a clearer chart below. Chronic bronchitis > 3 months x 2 years, s/s R heart failure Gold 1. 80% 2. 50-79% 3. 30-49% 4. < 30% = is WNL/ no change FVC TLC RV FEV1 FEV1 after bronchodilator FEV1/FVC Small airway obstruction COPD = or Chronic Bronchitis = or = = = or or = Asthma (obstr) = or = = Or = Emphysema or = Upper airway obstruction Variable intrathoracic = Variable extrathoracic = = = Fixed = Mild intermittent asthma < 1 per week & < 2 HS/week > 80% PFT >20 prn SABA Cromolyn Mild persistent asthma > 2x/w days; > 80% PFT 20-30 SABA QD ICS Cromolyn, leuk Mod persistent asthma QD but not QHS >1/week (HS); sleep affected; 60-80 >30% QD SABA, combo ICS/LABA Severe persistent asthma QD & freq HS < or = 60% > 30% SABA ICS cromolyn leukotriene Week 4 21 OsteoporosisMetabolic skeletal diseaseTenet ttc n neki res ic* Decrease in bone mass and microarchitecturalTee On 3 Ge at deterioration of bone tissue »consequent increase in boneCOUNSEL SOCIETY EF LABORATORIES fragility and susceptibility to fractureEu Occurrence+ Affects >10 million people in the United StatesSignal symptoms+ Kyphosis, decreased height, vertebral fractures, severeback painHematologic, neurologic, or psychiatricabnormalitiesGastric or ileal surgeryProlonged use of histamine H,-receptorblockers ar proten pump inhibitors‘Chronic gastrointestinal symptoms:Age >65 years "Measure serum vitamin 8,2 — Recheck vitamin B,, and Folic acid levelsand folic acid levels. ‘ , ~.Folic: acid normal Folic acid low ——» Treat with folic acid,’Serum vitamin By, level’ , v< 100 pg per mL 100 to 400 pg per mL >400 pg per mL(74 pmol per L) (74 ta 295 pmal per L)' ’ vVitamin B,z deficiency Check serum methylmalonic No vitamin 8, deficiencyacid and hom*ocysteine levels., ¥Either level is elevated. Both levels are normal,, ¥Vitamin B,2 deficiency* No vitamin B,, deficiency22Biofeedback -assisted relaxation- influence involuntary and voluntary physiological responses. frequently used in the management of pain conditions and has been found to be effective in headache management, temporomandibular disorders, and other pain conditions. Mindfulness Based Stress Reduction- a structured program; teaches self-acceptance, pain acceptance and present moment awareness. acceptance rather than the distraction of the pain and leads to improved coping with the pain. Imagery promotes relaxation. With practice, imagery reduces autonomic arousal and is an effective diversion strategy. And then diaphragmatic breathing teaches patients correct diaphragmatic breathing, which includes slow breathing. Autogenic training: attention of the patient towards desired somatic responses. sensations of warmth or heaviness in the extremities. increase blood flow to the extremities and cause a decrease in sympathetic nervous system arousal. And then progressive muscle relaxation. The patients are taught to distinguish between various forms of muscle tension. with practice, they can achieve a deep relaxation. Hypnosis involves perceptual alteration and muscle relaxation. Neuromodulation activities. TENS unit; systematic evals are inconclusive. Spinal cord stimulation- An implanted device that sends pulsed electrical signals to the spinal cord to control pain; used for chronic neuropathic pain. Deep brain stimulation- Neuromodulation of the brain to help control pain has been effective for central poststroke and facial pain. Large joint or trigger point Injections: Small-bore bore needles are inserted into the affected site, and a glucocorticoid or local anesthetic is injected. Spinal injections, intercostal nerve blockade, occipital and other peripheral nerve injections. These may provide short- term improvements but not long-term. neuropathic pain and topical treatments- topical capsaicin (causes warmth, used TID-QID) for diabetic neuropathy and postherpetic neuralgia. Topical lidocaine (cream or patch) for neuropathic pain. Neuropathic pain- gabapentin (Neurontin) and pregabalin (Lyrica)- reduce with renal insufficiency. Anticonvulsants for peripheral neuropathy, especially DMPN and fibromyalgia as well as partial onset seizures Carbamazepine (Tegratol) is also FDA approved for trigeminal neuralgia. 25 Off label neuropathic pain meds: Oxcarbazepine (Trileptal) potential benefits in trigeminal neuralgia and other neuropathic pain phenytoin, carbamazepine (not off label), and valproic acid- need CBC and baseline liver enzymes prior to initiation and checked for the first 3 weeks and periodically thereafter. Levetiracetam (Keppra) and zonisamide (Zonegran), sodium off label used in clinical trials and anecdotally for pain control. Keppra NOT effective in neuropathic pain. Tricyclic antidepressants have been used off label for neuropathic pain. TCAs used for pain are generally used at lower doses than they would use it for depression. Start at a dose of 10 milligrams and increase to an analgesic dose of 75 milligrams. An adequate trial of a TCA may take up to 6 to 8 weeks, with the highest dose tolerated given for at least 2 weeks. May experience side effects- decrease dose or another TCA with less anticholinergic effects can be considered. Tertiary TCAs, including amitriptyline (Elavi), are included in the Updated Beer's Criteria for potentially inappropriate medication use in the elderly. Adverse effects include the anticholinergic effects (constipation, orthostatic hypotension, dry mouth, urinary retention), antihistaminergic effects (sedation about 3h after taking), cardiac effects (prolonged QT interval, prolonged AV node conduction, and increased interventricular conduction), and alpha 1-adrenergic blockade. May have better results with secondary TCAs like desipramine or the nortriptyline. Doxepin is the least sedating TCA. Use with caution in pts with ischemic cardiac disease. Get a baseline EKG & keep dose < 100 mg/ day in elderly. Desipramine (Norpramine) and nortriptyline (Pamelor) can be used in older patients (start 10 mg po Qhs with typical dose 10-50 mg po qhs). SNRI: serotonin norepinephrine reuptake inhibitors. – Taper when dc to avoid withdrawal Venlafaxine is off label effective for diabetic neuropathy and polyneuropathy but not noted for postherpetic neuralgia. 2-4 weeks before desired dose. Caution with cardiac (r/t increased BP & cardiac conduction abnormalities). Starting 75 mg po (divided BID or TID) to typical dose 150-225 po (divided BID or TID). Duloxetine (Cymbalta)- chronic musculoskeletal pain including pain from arthritis and chronic low back pain, diabetic peripheral neuropathy, and fibromyalgia, as well as for depression and generalized anxiety disorder. Side effects include insomnia, constipation, dizziness, nausea, dry mouth, drowsiness. Start at 30 milligrams daily and then increased to 60 milligrams daily to reduce side effects. And then you want to avoid in patients with liver or severe renal insufficiency. Opioids are not known to work through mechanisms that decrease neuropathic pain, and so they're not the first-line treatment for neuropathic pain. Methadone (can cause QTc interval prolongation and dysrhythmias and hypotension) and tramadol may be more effective than opioids in neuropathic pain. Methadone ½ life 12 to 16 hours but may increase to 90 to 120 hours after 1 week of use. Methadone- need EKG at initiation, 1 month after & periodically. Tramadol (Ultram) weak opioid analgesic- GI upset, risk of seizure (decrease seizure threshold), serotonin reuptake inhibition (good for neuropathic or mixed pain); suicide risk. Reduced dose in older patients or liver impairment. Ultram 50-100 milligrams PO every 4 to 6 hours as needed, or Ultram extended release, 100 to 300 milligrams once a day are the options. Tapentadol (Nucynta, Nucynta ER) NO ETOH with! MOA: dual mode of action as an agonist at the mu-opioid receptor and as a norepinephrine reuptake inhibitor. For neuropathic pain. Contraindicated in those with convulsive disorders and with severe kidney or liver impairment. 50 mg po Q12h, increase dose q3days by 50 mg/12 hours. Max dose= 500 mg/24 hours. muscle pain: Use a biopsychosocial interdisciplinary approach with a cognitive behavioral component encouraging exercise and active participation of the patient in the plan of care. Cyclobenzaprine (Flexeril) FDA approved for muscle spasm Inflammatory pain: managing the inflammation. NSAIDs, corticosteroids, and, opioids are rarely helpful for inflammatory pain. Mechanical/compressive pain treat with splinting, strengthening, surgical decompression or stabilization, or the use of assistive devices nociceptive pain: cardiovascular risk or disease, utilize the lowest effective NSAID dose (use naproxen). 26 Chronic kidney disease and advanced age, you want to avoid NSAIDs and COX-2 inhibitors. Liver disease, avoid APAP, NSAIDs, and COX-2 inhibitors. Use TCAs or duloxetine as first line. Peptic ulcer disease or patients on glucocorticoids, avoid NSAIDs. Mild-to-moderate pain: Approach in the following order. topical agents, APAP, NSAIDs plus PPI, or COX-2 inhibitor (Celebrex and Bextra, Meloxicam) with or without APAP to manage some of the GI irritation. Or TCA or duloxetine. You can do an opioid. Consider adding baclofen (Lioresal) or tizanidine (Zanaflex) if they is a spasmodic component. moderately severe to severe pain: noninflammatory or patient with risk factors for NSAIDs, APAP or NSAIDs plus a PPI or COX-2 inhibitor with or without APAP, if there's no NSAID risk, TCA or duloxetine, opioids. Consider adding baclofen or tizanidine if there is a spasmodic component. If on APAP and heavy ETOH max 2 grams/day dose. More than 4 days of APAP intake at therapeutic doses can lead to increase in serum aminotransferases (AST, GOT, ALT) NSAIDs: for mild-to-moderate somatic pain or non-neuropathic pain; for periodic flare ups rather than long-term. Some newer drugs are for severe pain. headaches, arthritis, strains, sprains, and other soft tissue injury. But you want to use caution when considering NSAIDs in those gastropathy, low creatinine clearance, cardiovascular disease and heart failure. Relative contraindications: high risk for peptic ulcer disease, they're in advanced age, they have a history of peptic ulcer disease or prior NSAID gastroduodenopathy, concurrent glucocorticoid use, advanced illness, and risk of bleeding. interaction with antihypertensive medications, warfarin, and low-dose aspirin. Side effects: platelet inhibition, GI (dyspepsia, abd discomfort/pain, mucosal lesions, NV, hemorrhage, peptic, and esophageal ulcerations), decreased GFR/ renal failure, edema, increased BUN and creatinine, reversible renal insufficiency, inability to concentrate, confusion, hepatic toxicity (reversible with med cessation), increased MI/CVA risk. NSAIDs can interfere with the cardioprotective effects of aspirin. NSAIDs can exacerbate heart failure, may raise blood pressure. It can have prothrombotic effects, relative contraindication is history of DVT. Absolute contraindications: active peptic ulcer disease, chronic kidney disease, and heart failure. Relative contraindications, hypertension, H. pylori, history of peptic ulcer disease, they haven't had active, just history, concurrent use of SSRIs or corticosteroids. Exceptions to adverse effects are a choline magnesium trisalicylate (Trilisate) and COX-2 inhibitors. fewer side effects than NSAIDs but doses > 200 mg/day = increased CV risk. Celecoxib 200 milligrams po qd or 100 milligrams bid per AGS guidelines, older adults should take a PPI or misoprostol for GI protection when taking nonselective NSAIDs or an NSAID and COX-2 inhibitor together. Opioids- ALL patients need pain contract if on narcs. “PEG" pain, energy, general activity: pain intensity over the past week, how it has affected their energy level, and how the pain has affected their general activity. If patients don't improve or PEG scores remain high, the opioids may be ineffective. Consider other pharmacological and nonpharmacological treatments and reconsider diagnosis. Available data does not support the use of doses above morphine 200 milligrams in the treatment of noncancer pain. A slow taper of 10% per week is recommended to decrease withdrawal symptoms. The taper rate for those on very high doses may be as high as 25% to 50% and slowed when the dose reaches morphine 60 to 80 milligrams or equivalent. Week 5: 27 Risk Factors for Ul+ Aging: is the number 1 factor * Wemen— Aging+ Obesity — Obesity— Smoking+ Smoking and caffeine intake — Caffeine intakeDiabetes+ Uncontrolled diabetes — Pregnancy— Multiparity~ Constipation — Estrogen deficiencyHistory of pelvic surgery— DiureticsPhysical Changes with Aging that Contribute toUlin Men and Women* Primary changes occur to the lower urinary tact:— Detrusor muscle overactivity— Decrease in detrusor contractility= Increase in postvoid residual— Decrease in urethral blood flow+ Use of diuretics+ Women can experience a decrease urethral closure pressure+ Low estrogen following menopause may lead to atrophy of urethralmucosal epithelium and an increase in urethral sensation+ Men can experience a construction of the urethra due to BPH whichmay result In bladder autlet obstructing symptomsi]Types of IncontinenceTyp DefiniFunctional (environmental)Incontinence results whenRisk Factors for Ul by GenderMen— AgingObesitySmoking— Caffeine intakeDiabetes— Prostate diseaseHistory of prostate surgery— History of UTIs— Diureticsloion Cause/Pathophysiology Impaired mobi '; dementia unable to get to the toilet or usethe bedpanUrgeStressMixedto void30Involuntary leakage precededby sudden need to voidInvoluntary leakage of urineduring increased abdominalpressure in the absence of adetrusor contractionInvoluntary leakage of urinewith activity or exertion andpreceded by sudden needDetrusor overactivity; exactmechanism unknownUrethral hypermobility causedby weakness in pelvic floormuscle, pelvic fascia &pubourethral ligaments andintrinsic sphincter deficiencycaused by pudendal nervedamage and damage to intrinsicand extrinsic urethral sphincterCombination of detrusoroveractivity, urethralhypermobility due toweakness in pelvic floor ornerve damage BPH- mild-to-moderate symptoms, alpha-adrener-gic blockers such as terazosin (Hytrin) and tamsulosin (Flomax) relax smooth muscle of the bladder neck and prostate and can increase peak urinary flow rate; all alpha-adrenergic blockers are equally effective (Kennedy-Malone, et al., 2019) 1ST line mgt- helps with stress, mixed, and urge UI, but not NOT functional UI 31 Men Alpha 1 adrenergic antagonists’ better choice with BPH. Not used for women 32 Urinalysis-continued+ Dipstick results UTILeukocyte esterase dipstick test-positive; means there are WBCs in theurine + Other tests may be required for very ill patient or any male with a tue UTI— Nitrite positive test = gram negative Infections CBC with diff, BC, ESR STD screen for all males and for females whenindicated- Urine dipstick positive for protein, blood, nitrites suggestive of UTI — Male with UTI-VOUG or IVP. renal ultrasoundManagement/Treatment/Uncomplicatedifemale— Single dose regimens-Septra DS-2 tabs, Amoxicilin 500 mg-6 tabs— Three day regimens-Septra DS 1 tab bid for 3 days is standard of care forwomen + Treatment complicated female— Fluorequinolones-UTI Treatments= Based on culture results+ Used in area with high rasistant rates to sulfa drugs — Gram negative organism+ Used when a sulfa has been used in the last 6 months + Septra DS-10-14 days+ Used for women who were recently in the hospital + Fluoroquinolone-14 days— Nitrofurantoin and Monural — Gram positive organism:+ Useful if resistance to others increases: — [s best to culture urine before and after treatmentsTreatment Recurrent UTI Female Acute Bacterial Prostatitis+ Culture before and after treatment Definition- inflammation/intection of the prostate gland: + Etlology'incidence* Consider treating longer-up to 8 weeks — Eooll or other gram-negative becteris-oommon«Test BUNCreatnine, IMP or VCUG, LYTES — Occasionally acute urinary retention develops-requires suprapubicdrainage, NO CATHS— Absence of zinc in prostatic fluid can predispose* Explore eauses-dlephragm, voiding timely — Young men mere prone to nonbacterial+ Advise to incraase H2O and decrease carbonated drinks + WBC are present in expressed prostatic secretions, but no organismsculture out+ Refer to specialist + Causative agents include mycoplasma, gonorrhea, and chlamydiaAcute Bacterial Prostatitis Chronic Bacterial ProstatitisUncommon tyre+ Physical findings— Fever— Bladder distention may be present— Prostate-edemataus, firm or boggy. warm and tender— Avoid vigorous massage, it may lead to bacteremiaMen 50-80Symptoms are slow in onset-varying degrees of bladder obstruction dribbling,hesitancy, loss of stream forceHematuria, hamatospermia, or painful ejacul*tionHallmark feature is recurrent UTI, asymptomatic between episodesChronic Nonbacterial Prostatitis/Chronic PelvicPain Syndrome (CPPS) Asymptomatic Inflammatory Prostatitis+ Most common type + Diagnosed incidentally with evaluation of other disorders+ Men 30-50 + Limited research on natural history, clinical presentation+ Symptoms are indistinguishable from bacterial Type Il + FYLail types can have dangerous sequelae and lead to urinary retention,renal parenchymal infection, or bacteremia, chronic infection and may+ lev men with type IIIB pelvic pain is the predominant complaint produce prostatic stones35Prostatitis+ ChlassificationsType 1-acute infection‘Type Il- chronic or recurrentType II chronic genitourinary pain in absence of infection anduropathogenc bacteria in glandType IIA- inflammatory-WBCs in any secretions‘Type IWv- asymptomatic inflammatory-No subjactiva symptoms- diagnosisby blopsy, or WBCs in secretionsProstatitisProstatitis+ Differential DiagnosisAcutaichronic bacterial cystitisChronic prostatitisNenbacterial prostatitisProstatic seminal vesicle abscessesBPHProstatic cancerEpididyritisAcute diverticulitisNengonecoecal urethritis:Prostatitis= Maniagementirestment— Acute bacterialWith severe symptoms-hospitalization with Iv antibiotics, aggressivewith abscessChronic bacterial3-4 month Bactrim DS bidConsider prophylacticsEvaluate pm for stones with xrayCultures every 46 weeksProstatic massage once or twice a week for 4 weeks may be helpfulProstatitis+ Chronic nonbacterialNo affective treatments available+ Can try meds such as doxycycline, erythromycin or Bactrim+ Reassure+ CounselingNonsteroidalsDitropanAlphe-adrenergic blocking drugs:36Prostatitis‘Signs and symptoms:Man 40-60 yearsMay have painful intercourseFever/chills, malaise, myalgiasLow back pain— Dysurla, urgeney, nocturla, frequencyPerineal pain increased with defecation« Abscess is complication, consider if not responding to treatment= Diagnostic Tests‘findingsUrine culture is positiveProstatic secretions-expressed prostatic secretions-VVYBC greater than 20cells/HPF is abnormalDiagnosis is best made by performing simultaneous quantitative culturesOf urethral urine, bladder urine, and expressed secretions-the glass testPatient often treated based only on physical exam and urine cultureProstatitis+ Asymptomatic inflammatory prostatitis— Limited research to guide treatmants— May try antibiotics— Education+ Avoid aleohol, coffee, ar tea+ Discontinue and avold over-the-counter drugs with anticholinergicproperties such as cold meds+ Recheck is four to six weeks.Epididymitis+ Diagnostic Tests/Findings= Men+ STD testing+ Urinalysis+ Culture of urine+ Sorotal ultrasonography— Older men+ Search for obstruction at the bladder outlet, [VPBenign Prostatic HyperplasiaBenign Prostatic HyperplasiaDefinition: progressive, benign hyperplasia of prostate gland tissueEtiology/Ineidenoe + Signs and symptoms— Cause is uncertain Gradual worsening of the following— About 50% of men have BPH by age 60 + Frequency, urgency, urge incontinence— Bage 85 is 90% + Noctunia, dysuriaMost common cause of bladder outlet obstruction in men over 50 » Weak urinary strema, dribbling, hesitancy— Symptoms are attributad to mechanical obstruction of the urethra by the+ Sensation of full bladder even after voidingenlarged prostate gland -el i + RetentionBenign Prostatic Hyperplasia Benign Prostatic Hyperplasia+ Differential DiagnosesPhysical findingsUrethral stricture— Prostate or bladder cancer— Neuragenic bladder .Abdomen-mey have distended bladder secondary to retentionProstate-nontender with asymmetrical or symmetrical enlargement, gross— Bladder calculus enlargement atypical— Acute or chronic prostatitis— Bladder neck contractor— Medications that affect micturitionConsistency is smooth and rubbery (eraser)Nodules may be present-differentiation from BPH and CA needs biopsyBenign Prostatic Hyperplasia Benign Prostatic Hyperplasia- Tests'Findinos + Treatment/Management~ UA-NO hematuria or UTI ~ Refar men who have the following- Urinary flow rate-vaided volume and peak urinary flow rate (uroflawmelry) + Refractory urinary retention wha have failed one attampt at cathBenign Prostatic Hyperplasiamay detect obstruction flow— Abdominal US-rules out upper tract pathologyPSA levels should be normalConsider past void residual urine volume(Creatinine to assess renal function, elevated levels suggest urinary Gitininsretention or underlying renal disease-refer this patient suremoval+ Recurrent infection, recurrent retention, refractory hematuria, bladder‘stone, large bladder, diverticula’s, or renal insufficiency related to BPH+ Consider referral if complications exist or if patients have severeBenign Prostatic Hyperplasia= Management + Medication Trestments— For men who have no indications for surgery+ Discuss risks and benefits of all options~ Alpha adrenergic biocker-for smaller prostates+ Watchful waiting (observation) - Salpha adrenergic blocker for larger prostates,+ Behavioral techniques to reduce symptoms - Combo therapy is an alpha-adrenergic blacker and finasteride is used now— Limit fluid after dinner for men with large prostates- Avoid medications such as, Antidepressant. antiparkinson agents, g .antipsychotic, antispasmodics, cold meds, and diuretics Surgery has the bast chance for relief of symptoms, but has greater risks37 * urate elevation above is per lecture & book. BUT “men, but not women, with higher urate concentrations had a lower future risk of developing PD doi:10.1212/WNL.0000000000002351  Conversely, Gout may increase PD risk https://doi.org/10.1186/s12883-018-1234-x  Inverse PD risk: outdoor activity and total vitamin D intake esp. outdoor activity for less PD risk doi: 10.1631/jzus.B1400005  nicotine is an inverse risk factor for PD. Likely due to striatal activity via dopaminergic system (balance dopamine transmission, decrease levodopa-induced dyskinesias). A small amount of nicotine can saturate a substantial portion of nicotine receptors in the brain. doi:10.1186/s40035-017-0090-8 Pathophysiology of PD:  Neuron and glial cells in the substantia nigra (basal ganglia) stop Dopamine (neurotransmitter) production  Once cell loss is > 60% the dopamine deficiency is critical and subsequent motor systems develop.  Brock’s theory: PD initial prodromal symptoms occur (outside the brain) in the olfactory bulb or in the enteric (gut) systems then move upward into the hypothalamus, then the midbrain, and up into the cortex. PD Diagnosis: diagnosis of exclusion  Symptom presentation and progression  There are no specific lab tests  Brans scans (PET and SPECT scans) help monitor disease progression  Diffusion MRI aids in neurosurgery procedures  DaT scan identifies the dopamine loss in Parkinson’s by targeting a specific dopamine transporter protein on the nerve cell; FDA approved for PD dx confirmation & monitoring progression  No one test identifies the disease  Initially tough to discern Parkinson’s from other neurological disorders  Cardinal signs due to dopamine deficiency:  Unilateral arm/hand tremor initially  Postural instability-unstable gait; Parkinsonian gait (AKA festinating gait) NOT a circumducted or Wernicke-Mann gait  Muscle rigidity-cogwheel rigidity in joints, stiffness  Bradykinesia (slow movement)-often handwriting first Early or prodromal symptoms can include:  Prodromal-decrease in sense of smell (i.e. coffee)  Bradykinesias (handwriting, decreased speed of motion)  Muscle fatigue in a limb, requires more strength to move a limb  Decrease of loss of arm swing with walking  Unilateral resting tremor of hand or arm-slow velocity  Cog wheel rigidity passively felt in a limb by examiner  A positive clinical response with levodopa administration i.e. symptom abatement = diagnosis  Myerson sign may be present-forehead tapping elicits an uncontrollable blinking. This is the glabellar reflex and may also be present in dementia or other neurological disorders.  Cognitive changes occur later and over time in the disease PD Differential Diagnoses to rule out: Some/ all of PD cardinal signs present with these as well  Common neuro s/s in neuro disorders AND PD  Stuttering  Hypophonia- low volume voice  Monotonic speech  Drooling, impaired swallowing 40  Masked facies, decreased blinking  Progressive Supranuclear Palsy-additional cardinal sign is loss of upward gaze  Overlapping disease- Alzheimer’s, Fronto-temporal dementia, Huntington’s chorea  Secondary parkinsonism-toxins, neuroleptic drugs  Brain Tumor or trauma  Hydrocephalus-additional cardinal sign of incontinence  Cerebral arteriosclerosis, Infectious encephalopathy, Creutzfeldt-Jakob disease, Wilson disease, HIV/AIDS PD Staging: International Parkinson & Movement Disorder Society recommends 1 of 3 scales for staging PD: 1. Unified Parkinson’s Disease Rating Scale (UPDRS) - (2001) = most recognized tool 2. MDS-UPDRS (updated 2008) – specialists use because time consuming & complex + need licensure to use 3. Hoehn and Yahr 5 stages Scale: shorter & most commonly used no licensure to utilize and easily available i. Stage One  Usually presents with tremor of one limb  Mild Unilateral s/s  Symptoms inconvenient but not disabling  Friends have noticed changes in posture, locomotion and facial expression ii. Stage Two (still mild but progressive)  Medications generally administered towards end of this stage  Bilateral signs and symptoms  Minimal disability  Posture and gait affected iii. Stage Three  Significant slowing of body movements  Early disequilibrium on walking or standing  Generalized dysfunction that is moderately severe iv. Stage Four  Severe symptoms  Can still walk to a limited extent  Marked rigidity and bradykinesia  No longer able to live alone  Tremor may be less than earlier stages v. Stage Five – severe symptoms  Decisions must be made re: swallowing ability and tube feedings. Cachectic stage  Aspiration pneumonia likely and often the cause of death.  Complete invalidism. Cannot stand or walk and requires constant nursing care PD Management: (incurable and progressive)  Treatment is focused on the disabling symptoms  Individualized management; no algorithm  Levodopa/ dopaminergic meds start after 65 R/T long term use association with disabling complications  Dopaminergic replacement provided when: ADL difficulty including walking & compromised employment PD Med management:  Early stages of PD initial meds: 1. Rasagiline (Azilect) Monoamine B Inhibitors (MAO-B) a. MOA: inhibits MAO-B, the major metabolizing enzyme of dopamine for less dopamine breakdown 41 b. Provide symptomatic relief in patients with early PD or adjunctive therapy for moderate PD c. Delays motor disability progression in the first 2 years of the disease d. Can be used adjunctively with carbidopa/levodopa in moderate to advanced disease as well e. Side effects include sleep disturbance, hyper or hypotension f. Contraindicated with meperidine (Demerol), opioids, SSRIs, and MAO inhibitors g. MUST STOP Rasagiline 2 weeks prior to any general anesthesia (see package insert) 2. Selegiline (Eldepryl) (MAO-B) inhibitor a. MOA: inhibits MAO-B, the major metabolizing enzyme of dopamine for less dopamine breakdown b. Some symptomatic benefits in early PD and may elevate mood and decrease fatigue c. Has been shown to delay levodopa use by one year d. Poorly tolerated in confused patients e. Contraindicated with meperidine or SSRIs 3. Amantadine (Symmetrel) Viral m2 channel inhibitor and Dopamine agonist a. MOA: Dopamine promoter, glutamate receptor, and antiviral drug (Anti Flu-A); prevents release of viral nucleic acid by interfering with the function of the transmembrane domain of the viral M2 protein b. Improves tremor in early PD patients c. May used in more advanced PD patients to help reduce dyskinesias d. Side effects- hallucinations and livedo reticularis (mottled and purplish discoloration to the skin) e. Caution in older adults with renal dysfunction  To a lesser degree: Anticholinergic drugs or Neuroprotection options 1. Anticholinergic drugs  Rarely used due to high side effects  Useful for younger patients who present with significant tremor  Side effects-urinary retention, constipation, and can aggravate confusion in older patients 2. Neuroprotection options  Coenzyme Q (CoQ) at 1200 mg/d had some effect on progression of ADL scores. not FDA approved  Dopamine Replacement Therapy  Carbidopa/levodopa combination permits greater entry of levodopa into the central nervous system.  Carbidopa/Levodopa is orally administered and absorbed in the small intestine  Carbidopa/levodopa absorption is inhibited if taken with large protein meals  It is better absorbed on an empty stomach or with reduced dietary protein Dopamine Replacement Drugs: initial monotherapy or adjunctive therapy of PD (with carbidopa/levodopa)  D2 & D3 dopamine agonists are newer drugs approved for treatment of PD  Directly act on dopamine receptors and mimic the endogenous neurotransmitter  Dopamine Agonists: Apokyn (apomorphine hydrochloride); Parlodel (bromocriptine); Neupro (rotigotine transdermal system); Mirapex (pramipexole dihydrochloride) or Mirapex ER; Requip (ropinirole) or Requip XL o Start low and go slow! o Beware! case reports of patients falling asleep while driving- no driving with somnolence o Reports of impulse control problems (compulsive gambling) or hypersexuality 1. Pramipexole (Mirapex) 2. Ropinirole (Requip) 3. Rotigotine (Neupro)  Ergot-derived dopamine agonists: initial therapy and adjunctive therapy of PD 42 Miscellaneous neuro: GREAT video on gaits- https://youtu.be/FFki8FtaByw _______________________________________________________________________________________ Week 8 video notes: Degenerative diseases have replaced communicable diseases as the leading cause of death in the United States and most economically advanced countries. 80% of all US deaths (2000) are caused by (in order): heart disease, malignant neoplasms, cerebrovascular disease, chronic lower respiratory disease. Accidents with unintentional injuries, diabetes, Alzheimer's disease, influenza and pneumonia, nephritis, nephrotic syndrome, septicemia. Increased life expectancy related to demographics and social trends, reduction in infant and child mortality. Hospice is one type of palliative program, it's outlined by Medicare, and it's restricted to individuals with a disease trajectory or life expectancy of six months or less of life. Hospice is outlined with the requirements and rules from Medicare. With normal disease progression a life expectancy of six months or less of life would qualify someone for hospice services. Hospice is regulated and covered by Medicare, BUT most private insurances also have hospice allowances. Hospice- generally a bundle payment reimbursem*nt system. The hospice agency determines which services, equipment, and medications are covered. Specific hospice guidelines indicate what must be provided. Including a case manager that's a registered nurse, a social worker, a nurse aide, assistant, chaplain, grief counsellor, volunteer services. Admission to hospice: 1. Provider certifies that the patient is terminally ill (< 6 mos. life expectancy if the disease runs its normal course). 2. Patient elects to receive hospice care rather than curative treatments. T 3. Patient then enrolls in the Medicare approved hospice organization. Palliative care (relief): Specific types of palliative care programs. Palliative care may be provided to anyone, regardless of their life expectancy or disease progression. Some facilities offer community based palliative care and some offer inpatient palliative care consults. Primary palliative care should be included by any healthcare provider in any patient encounter . PPC is managing physical symptoms, psychological, social, and existential distress. Secondary, or specialty palliative care, that's the extra layer of support that's initiated in specific patient situations. Palliative care is billed fee-for-service. Consultations take an extended time period and are often more expensive than they are reimbursed. Most palliative care programs are subsidized by another agency or philanthropy. Palliative care services are typically considered cost avoidance entities rather than revenue streams. Palliative programs are nurse practitioner or physician led, some may include a RN, a social worker, or a chaplain. Routine weekly visits or hours are not often provided. 45 2010 NEJM seminal study found that routine treatment plus palliative care actually exhibited higher quality of life and lived longer than those not receiving palliative care in metastatic non-small-cell lung cancer. PCP role in palliative care? Provide risk factors and health promotion information. Be involved in screening and diagnosis, be involved in discussion of treatment options, especially if the therapeutic window is small. And make that referral to specialty care, especially emotional and spiritual support. Advanced Care Planning (ACP) Living will: specify what a person’s health wishes if unable to participate in healthcare decision-making. California developed a state law which they called the Natural Death Act Patients have Determination to Act (1990) law: all facilities that receive federal funds (e.g. CMS – Medicare and Medicaid) must educate their patients on right for self-determination of care and ask about advanced directives. ACP conversations reimbursed by Medicare (2016) in illness OR wellness visits DPOA- (durable power of attorney for health care) This person acts for patient when they cannot self-determined care and can legally receive HIPAA protected info and make healthcare decisions on behalf of the patient. They need a DPOA document, becomes part of the patient’s record. POLST = physician orders for life-sustaining treatment (Dr’s orders NOT a living will or an advanced directive). Developed for patients with less than a year life expectancy. Order set must be followed by emergency workers. Emergency workers are not bound to follow a living well or DPOA, but they are bound to follow orders outlined a POLST. Review your state’s POLST laws to see if an APRN can develop or sign POLST. Find documents and instructions through an organization called Respecting Choices. Look at the Conversation Project. It's a free online resource to help you start your conversation with your patients. SPIKES approach for difficult conversations. S is for setting (private location for the discussion, but also setting your role in the process.) P is for perception. You want to assess the patient's and family's perception of the situation. I is for invitation to share knowledge. Ask your patient & family for permission to talk about the subject. K is for knowledge or information sharing, listen for themes and hot topics. E: emotions and empathy. S is for summarize and strategize. Summarize what you have heard, and what is the next step, or steps, based on the prognosis and wishes of the patient and family. (in real life meetings= who’s gonna do what, and by when? 46 PRACTICE QUESTIONS: 1.6mo ago an elderly pt was dx'd with subclinical hypothyroidism. Today the pt returns and has a TSH of 11 and c/o fatigue. He has taken Synthroid 25mcg daily as prescribed. What is the best course of action for you?:Double the dose of Synthroid 2.48yo female presents for annual exam. A1C is 6.2%. You interpret this result as: a. Prediabetes b. T2DM c. T1DM d. Normal: ANS: A 3.52yo Caucasian woman comes in for annual exam. She has mitral valve prolapse, no symptoms. PE reveals clear/equal breath sounds, midsystolic click. You know her stage of HF is: a. A b. B c. D d. C: ANS:B (Stage B) 4.55yo Caucasian man follows up w/you after referral to cardio. He reports that he thinks the med is causing a cough and sometimes he has dyspnea. Which of the following meds was most likely prescribed? a. Metolazone b. Enalapril c. Amlodipine d. Irbesartan: ANS:B 5.55yo Caucasian man w/T2DM presents as new pt. Take metformin 500mg BID. Labs reveal albuminuria and A1C was 7%. He's current on eye/foot exams. BP today is 136/84. According to 2017 ACC Guidelines, the most appropriate med for his current status is: a. Furosemide b. Amlodipine c. Lisinopril d. Clonidine: ANS:C 6.55yo post-menopausal woman with h/o HTN c/o jaw pain on heavy exertion. There were no c/o CP. Her EKG indicates NSR w/out ST segment abnormalities. Your plan may include::Exercise stress test 7.55yo woman presents with somatic complaints. You suspect anxiety. You know that somatic symptoms of anxiety include: a. All answers are appropriate b. Palpitations, CP, tachycardia c. Fatigue, insomnia, diaphoresis d. Diarrhea, nausea, vomiting: ANS:A 8.55yo woman w/BMI of 28, has 20yr h/o primary HTN, has been on HCTZ 25mg for years w/excellent response. During this follow up visit, she reports that for the last 6mo she has felt thirsty all of the time even though she drinks at least 10 glasses of water/day. Previous fasting BGL was 136. No further testing was done at that time. You check random BGL now, is 210. What is the next appropriate step? a. Order 3hr OGTT b. Order another random BGL in 2wks c. Order A1C d. Prescribe metformin XR 500mg PO: ANS:D 9.59yo female c/o pain when she urinates. She has been seen three times for this in the last 3mo. Each time, dx'd with UTI, given abx. She carefully followed instructions, but has no relief of symptoms. Last UA: WBC: 2-3 RBC: 0-2 Epithelial cells: few Nitrite: neg Leuk: neg Which should be done next? a. Perform pelvic exam b. Reassure the pt that she has asymptomatic bacteriuria and does not need abx 47 c. All answers are appropriate d. Depression ANS: A 32.Acanthosis Nigricans is associated with all of the following except: a. Colon cancer b. Tinea versicolor c. Obesity d. DM: ANS:B 33.ACC 2017 guidelines for high BP in adults, adults w/stage 1 HTN and high ASCVD risk should be managed w/both nonpharm and antihypertensive drug therapy. You know the pt should return for a follow up appointment which includes BP check in: a. 3wks b. 1wk c. 1mo d. 2wks: ANS:C 34.ACC 2017 Guidelines for High BP in adults discusses screening/management of other CVD risk factors for hypertensive pts. According to the guideline, basic testing for primary HTN includes fasting BGL, CBC, lipids, BMP, TSH, UA, EKG w/optional echo, uric acid, and urinary albumin-to-creatinine ratio. a. True b. False: ANS:A 35.According to 2017 ACC HTN guidelines, normal BP is: a. <130/90 b. <120/80 c. <140/80 d. <140/90: ANS: B 36.According to 2017 ACC HTN guidelines, the recommended BP goal for 65yo African American woman w/a h/o HTN and DM and no h/o chronic kidney dz is: a. <130/80 b. <120/80 c. <140/80 d. <140/90: ANS: A 37.According to 2017 Guidelines for HTN in adults, recommended BP goal for 68yo Asian American woman w/no h/o DM and a h/o CKD is: a. <150/90 b. <120/80 c. <140/80 d. <130/80: ANS: D 38.According to ADA guidelines, which of the following are appropriate screening tests for T2DM? a. Fasting plasma glucose b. 2-hour OGTT c. HgbA1C d. All of the above: ANS:D 39.According to the GU presentation, #1 risk factor for urinary incontinence is: a. Uncontrolled DM b. Obesity c. Aging d. Smoking and caffeine intake: ANS: C 40.A drug that can be used to treat two very common symptoms in a dying pt (pain and dyspnea) is::Morphine 41.A fluoroquinolone (Cipro) is prescribed for a male pt w/a UTI. What should you teach the pt regarding taking this med?:Its effectiveness is decreased by antacids, iron, or caffeine 42.A form of syncope that is more common in elderly than younger adults is::Orthostatic hypotension 50 43.Age-related changes in the bladder, urethra, and ureters include all of the following in older women except::Increased estrogen production's influence on the bladder and ureter 44.Aging process causes what normal physiological changes in the heart? a. Dilation of R ventricle occurs w/sclerosis of pulmonic and tricuspid valves b. Hypertrophy of R ventricle c. Heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis d. Cardiology occurs along w/prolapse of mitral valve and regurgitation: ANS:C 45.A key symptoms of ischemic heart dz is CP. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because::A & B only (women w/ischemic heart dz many times do not present w/CP, Some pt's may have no symptoms or atypical symptoms so dx may only be made at the time of the actual MI) 46.Ali is 72yo man who recently came to US from Nigeria. He reports having BCG (bacille Calmette-Guerin) vaccinations as a child. Which of the following is correct regarding TB skin test?:Vax hx is irrelevant; read as usual 47.All of the following antimicrobials may be indicated in chronic bacterial prostatitis except::Azithromycin 48.All of the following are considered as contributors to dysphagia except::Smooth muscle relaxants 49.All of the following are true about lab values in older adults except: a. Normal ranges may not be applicable for older adults. b. Abnormal findings are often due to physiological aging c. Reference ranges are preferable d. Reference values are not necessarily acceptable values: ANS: B 50.All of the following may be reasons associated w/an elevated PSA besides prostate ca except::UTI 51.All of the following pts have a risk of adverse reaction from Metformin except: a. Pts w/alcoholic disorder b. Pts w/BMI >30 c. Pts w/hypoxia d. Pts w/renal dz: ANS: B 52.All of the following statements about tremor are true except::The most common tremor is the Parkinson tremor 53.All of the following statements are false about drug absorption except: a. Antacids increase bioavailability of digitalis b. Gastric acidity decreases w/age c. Anticholinergics increase colonic motility d. Underlying chronic dz has little impact on drug absorption: ANS: D 54.All of the following statements are true about drug absorption in the elderly except: a. Drugs distributed in water have lower concentration b. Drugs distributed in fat have less intense, more prolonged effect c. Drugs highly protein bound have greater potential to cause an adverse drug reaction d. The fastest way to deliver a drug to the action site is by inhalation: ANS: A 55.All of the following statements are true about interventions in working w/the bereaved except::There is strong evidence behind recommended interventions 56.All of the following statements are true regarding anxiety except: a. Common in older adults b. Often co-occurs w/depression c. Is a normal part of aging d. More common in females: ANS: C 57.Anal wink reflex is used to test::Sensation and pudental nerve function 58.An effective exercise therapy for RA is: a. Yoga and/or Pilates b. Walking 20min daily c. Bicycle riding d. Water exercise programs: ANS:D 59.An elderly nursing home pt is maintained on phenytoin tx for h/o sz. In addition to periodic serum drug concentrations, which of the following are needed for annual eval?:CBC, LFT, platelet count 51 60.An elderly pt has had a CVA in the anterior cerebral circulatory system (frontal lobe). What symptoms are most likely expressed?:Disorders of behavior and cognition 61.An elderly pt presents w/a new onset of feeling heart race and fatigue. EKG reveals afib w/rate >100. Pt also has a newfound tremor in both hands. Which of the following would you suspect?:Hyperthyroidism 62.An example of secondary prevention you could recommend/order for elderly would be to: a. Provide foot care for DM pt b. Check for fecal occult blood c. Administer tetanus shot d. Wear seat belts: ANS: B 64.An older adult female pt had a stroke. What symptoms are not usually expressed by pt's who have had a vertebrobasilar stroke?:Monocular blindness 65.An older adult w/a h/o sz disorder comes into the clinic for routine checkup. Although sz-free, the pt continues on long-term phenytoin tx. You would assess for which of the following long-term effects?:Gingival hyperplasia and nystagmus 66.An older male pt is experiencing acute onset of R-sided weakness, slurred speech, and confusion. What should you do promptly?:Eval for stroke and arrange for transport to the hospital right away 67.Aortic regurgitation requires medical tx for early s/s of HF with: a. Surgery b. BB c. ACEI d. Hospitalization: ANS: C 68.A pelvic mass in a post-menopausal woman::Is highly suspicious for ovarian ca 69.Atypical presentation of acute coronary syndrome is::More common in females 70.Atypical presentation of dz in elderly is reflected by all of the following except: a. Infection w/out fever b. Depression w/out dysphoric mood c. MI w/CP and diaphoresis d. Cardiac manifestations of thyroid dz: ANS:C 71.Beers criteria are appropriate for use in evaluating use of certain meds in pts: a. >70yo b. >50yo c. >65yo d. >60yo: ANS: C 72.Best method of verifying a dx of gout in a joint is::Joint aspiration and polarized-light microscopy 73.Best recommendation for pt who state they have no equipment to exercise would be::Improvise w/recommended objects at home that can be used. 74.Best way to diagnose structural heart dz non-invasively is: a. CXR b. Heart cath c. Echo d. EKG: ANS: C 75.Biochemical individuality is best described as::Each individual's variation is often much smaller than that of a larger group. 76.Bordetella pertussis is best characterized by::Sub-acute cough lasting >2wks 77.CC, 62yo male, new to your practice. Previously dx'd w/Stage B HF. According to week 2 HF lecture, you'll look for the following med classes to ensure appropriate tx of HF: a. ACE/ARB, statin, BB b. ACE/ARB c. BB: ANS: A 78.Chronic fatigue syndrome is best described as::Fatigue lasting longer than 6mo not relieved by rest 79.Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: 52 132.JM, 68yo males, presents for physical. He has T2DM x5yrs, smokes 1/2PPD, BMI 30. No other hx, no current complaints. According to AHA/ACC guidelines, JM is Stage A. Tx goals include: a. Control symptoms b. Heart healthy lifestyle c. Diuresis to relieve symptoms of congestion d. Prevent further cardiac remodeling: ANS: B 133.Joint effusions typically occur later in the course of OA, especially in the::Knee 134.Justification for ordering CBC, TSH, serum B12 for a pt you suspect may have clinical depression is: a. Overlapping symptoms w/anemia, thyroid dysfunction, nutritional deficiencies b. Rule out vascular dz c. Differentiate between depression and anxiety d. Determine the cause of sadness: ANS: A 135.KK, 53yo man, presents w/concerns about low energy, lack of joy. You assess him using SIG-E-CAPS. You know the C stands for: a. Catatonia b. Concentration c. Cognition d. Control: ANS:B 136.LB presents w/following hx and presentation: h/o MI 5yrs ago, currently has SOB, cough, 2+ pitting edema. Tx will be based on LB's stage of HF, which is: a. D b. C c. A d. B: ANS: B (Stage C) 137.Leo is 62yo African American male who comes in for initial visit to your practice. Personal health hx includes smoking 1ppd since age 11, consuming a case of beer (24 bottles) every weekend, and working as assembler (sedentary job) for the past 10yrs. Fam hx in first-degree relatives includes HTN, high cholest, MI, T2DM. Leo's BMI is 32. BP today is 130/86. You order fasting glucose, lipids, and return visit for BP check. This is an example of::Secondary prevention 138.Lifestyle approaches to postmenopausal symptom management include: a. Avoiding sugar, caffeine, chocolate, ETOH b. Sleeping more than 8hrs per night c. Decreasing levels of physical activity d. More than 1000 iu/day of Vit E: ANS:A 139.Lifestyle modifications for managing HTN include all of the following except: a. DASH diet b. Wt reduction c. HCTZ d. Physical activity: ANS:C 140.Lipedema is best described as::Bilat distribution of fat in lower extremities 141.Local chapter of NP organization has begun planning a community-based screening for HTN at a local congregate living facility. This population was selected on the basis of::A recognized element of high risk w/in this group 142.Majority of depressed older adults remain untreated because of::All of the above (misdx, social stigma, environmental barriers) 143.Male pt with BMI of 30 presents with c/o fatigue, increased hunger, wt gain despite exercise. You suspect prediabetes. Initial testing to confirm can include: a. Fasting plasma BGL b. A1C c. OGTT d. All of the above: ANS: D 144.Meds known to contribute to constipation include all of the following except::Broad-spectrum abx 55 145.Meds that contribute to hematuria.:Beta-lactam abx Sulfonamides NSAIDs Cipro Allopurinol Tagamet Dilantin Anticoagulants ASA 146.Men have faster and more efficient biotransformation of drugs and this is thought to be due to::Testosterone 147.Men w/an initial PSA <2.5 can reduce their screening frequency to what intervals?:Every 2yrs 148.Microscopic hematuria is defined as::3 or more RBCs on 3 or more samples of urine 149.Middle-aged pt has been dx'd w/PD. What influences your decision to begin pharm tx for the pt?:Symptoms interfering w/functional ability 150.MJ presents with h/o structural damage w/current s/s of HF. Tx will be based on MJ's stage of HF, which is: a. C b. A c. D d. B: ANS: A (stage C) 151.Most appropriate first-line tx for acute gout flare is (assuming no kidney dz or elevated bleeding risk)::Indomethacin 50mg TID x2 days; then 25mg TID x3 days 152.Mr. Andrews experienced a brief onset of R-sided weakness, slurred speech, and confusion yesterday. The symptoms have resolved. What should you do?:ID modifiable CV risk factors 153.Mrs. F is a 65yo Caucasian who presents for her annual exam. Chart review reveals she smokes 1PPD, drinks 2 beers/day since retirement. She doesn't exercise but likes to sit and knit. You know the nonmodifiable risk factor for OA is: a. ETOH consumption b. Tobacco use c. Age d. Sedentary lifestyle: ANS:C 154.Mrs. G, 65yo Caucasian, presents for her annual physical. Chart review reveals she smokes 1PPD, drinks 2 beers every evening since she retired. She does not exercise, likes to sit and knit. As part of health maintenance, DEXA was ordered. You have received results, T-score of -2.0, which is consistent with: a. Normal result b. Osteopenia c. At risk for fragility fracture d. Osteoporosis: ANS: B 155.Mr. X returns to office for follow-up of first line tx of UI. He reports continued UI despite compliance w/first line measures. PE and lab findings today are normal. You initiate 2nd line tx and prescribe: a. Morabegron b. Solifenacin c. Oxybutynin d. Doxazosin: ANS: D 156.Name some differentials for proteinuria.:Exercises Environmental conditions Fever Illness CHF Injury Nephrotic syndrome Multiple myeloma (indicated by finding of Bence Jones protein) 157.Normal FEV1:80-120% 158.Normal FEV1/FVC ratio:>70% 159.Normal FVC:80-120% 56 161.OA of the cervical and lumbar spine causes pain that is related to all of the following except: a. Bone spur formation b. Pressure of the ligaments c. Crystal deposition d. Reactive muscle spasm: ANS: C 162.Of the following, which one is most useful clinical eval tool to assist in dx of dementia?:St. Louis University Mental Status Exams (SLUMS) 163.Older adult male presents w/incontinence, has a wide-based and irregular gait, and progressive dementia. Which of the following presents w/these cardinal signs?:Normal pressure hydrocephalus 164.Older adult may present w/atypical clinical s/s of Pna. You need to be aware that clustering of all the following s/s may be indicative of Pna in older person except::Bradycardia 165.Older adult pt is being eval'd after a stroke, which affected the anterior cerebral circulatory system. Which of the following s/s would be positive in the assessment of the pt?:Disorders in behavior and cognition 166.Older adults w/dementia sometimes suffer from agnosia, which is defined as the inability to::Recognize objects 167.One major difference that is useful in the DD of dementia vs delirium is that::Dementia develops slowly and delirium develops quickly 168.On exam, what type of murmur can be ascultated w/aortic regurg?:Austin flint 169.Organism most commonly responsible for CAP in older adults is::Strep pneumoniae 170.Overflow incontinence is usually associated with::Bladder outlet obstruction 171.Pain at the end of life is most often due to all of the following except::HA 172.Pathophysiology of HF is due to: a. Incomplete closure of tricuspid valve b. Impaired atrial filling c. Normal ventricular function d. Inadequate cardiac output to meet metabolic and O2 demands of the body: ANS: D 173.Performing ROM exercises on a pt who has had a CVA is an example of which level of prevention?:Tertiary 174.PG is a 58yo Caucasian man w/stable mental health dx of schizophrenia who presents for yearly physical. He takes aripiprazole for it. You know the labs and assessments should be ordered to assess for cardiometabolic changes related to his meds except for: a. Waist circumference b. Glucose c. Cholesterol d. AST/ALT: ANS: D 175.Pharmaco*kinetic changes w/aging is reflective of::What the body does to the drug 176.Pharm interventions for dyspnea include all of the following except::Sedatives 177.Polypharmacy is best described as taking::Even a single med if there is not a clear indication for its use. 178.Postmenopausal woman w/osteoporosis is taking a bisphosphonate daily by mouth. What action info statement would indicate the pt understood your instructions? a. Take med when up in AM w/glass of OJ to increase absorption b. Take med w/full glass of water when up in AM 30min before other food and meds c. Take med at bedtime w/full glass of water d. Take med sitting up with a meal to avoid GI distress: ANS: B 180.Preceding a stress test, the following labs might include::A & C only (CBC w/diff to differentiate ischemic heart dz from anemia, thyroid studies to rule out hyperthyroidism) 181.Preferred amount of exercise for older adults is: a. 10min of physical activity each AM b. 30min/day of aerobic activity 5 times/week c. 60min/day that includes 30min of aerobic activity and 30min of wt training 5 times/week d. Any increase in physical activity over a sedentary lifestyle: ANS:B 182.Presbystasis is best described as::Age-related disequilibrium of unknown pathology characterized by gradual onset of difficulty walking 183.Pt education for COPD is essential. You know that COPD education includes all of the following except: a. Increased risk for DM 57 c. 2-3 times d. 1-2 times: ANS: B 221.The primary reason levothyroxine is initiated at a low dose in an elderly pt w/hypothyroidism is to prevent which of the following untoward effects?:Angina and arrhythmia 222.The proposed mechanism by which diphenhydramine causes delirium is::Anticholinergic effects 223.The purpose of Beers Criteria is to: a. Define Type A reactions b. All answers are appropriate c. Define changes in drug metabolism in elderly d. Improve quality and safety when prescribing meds: ANS: D 224.The strongest evidence regarding normal physiological aging is available through::Longitudinal studies 225.The tasks of grieving include all of the following except::Begin to disengage 226.Thoracic aortic dissection presents typically as::Severe retrosternal CP that radiates to the back and both arms 227.TLC:Total lung capacity: volume of air in lungs at the end of max inspiration (max inflation); equals VC plus RV; 80- 120% 228.Total volume of air a pt can exhale in first second during max effort: a. FVC b. TLC c. FEV1/FVC ratio d. FEV1: ANS: D 229.Urinary incontinence is defined as: a. Sudden, compelling desire to pass urine that is difficult to prevent. b. Urination occurs more frequently during the day than what would be considered normal c. Continuous loss of urine or leakage of urine d. Unintentional voiding, loss, or leakage of urine: ANS: D 230.VC:Vital capacity: max volume of air exhaled on complete exhalation after full inspiration 231.Volume of air a pt is able to exhale for total duration of the test during maximal effort is: a. FVC b. TLC c. FEV1/FVC ration d. FEV1: ANS:A 232.Volume of air in the lungs at maximal inflation is: a. TLC b. FEV1 c. FEV1/FVC ratio d. FVC: ANS: A 233.Vt:Tidal volume: amount of air inhaled and exhaled during normal ventilation 234.Wandering is best described as::Purposeful excessive ambulatory behavior 235.What amount of protein in a 24hr urine is indicative of nephrotic dz?:>3.5g 236.What are abx alternatives for UTI in pregnancy?:Sulfisoxazole Cephalosporins 237.What are common SE of alpha-1 blockers?:Dizziness (doxazosin, terazosin, tamsulosin, alfuzosin) Dyspnea (doxazosin) Edema (doxazosin) Fatigue (doxazosin) Somnolence (doxazosin) Postural hypotension (terazosin) Asthenia (terazosin, tamsulosin) Abnormal ejacul*tion (tamsulosin) Back pain (tamsulosin) Increased cough (tamsulosin) 60 URI (alfuzosin) Retrograde ejacul*tion (silodosin) 238.What are common s/s of chronic bacterial prostatitis?:Bladder obstruction Dribbling Hesitancy Loss of stream form Hematuria Hematospermia Painful ejacul*tion Recurrent UTI (HALLMARK SIGN) 239.What are complications of uncontrolled DM?:-Leading cause of CV mortality/morbidity -Vision loss -Renal complications -Amputation 240.What are contributing factors of UTI in men?:Residual urine due to prostatic enlargement Naturopathic bladder Calculi Prostatitis Cath Instrumentation Meatal stenosis 241.What are different types of sexual dysfunction?:Desire Arousal org*sm Pain 242.What are first-line management guidelines for UI?:Behavioral therapy (bladder training, prompted/timed voiding, Kegels, pelvic floor training) Lifestyle modification Wt loss Eliminate bladder irritants: Smoking, ETOH, sodas, coffee, acidic/spicy foods Maintain adequate fluid balance 243.What are meds for BPH?:Smaller prostates: -Alpha adrenergic blockers Larger prostates: -5-Alpha adrenergic blockers 244.What are meds for interstitial cystitis?:Tricyclics Antihistamines NSAIDs Pyridium Ditropan Procardia Long-standing opioids 245.What are some barriers that affect quality of care at the end of life?:Failure to acknowledge limits of medicine Lack of healthcare provider training Poor understanding of hospice/palliative care services Denial of death Rules and regulations 246.What are some behavioral responses to grief?:Crying Withdrawal Impaired work performance Overreactivity 247.What are some cardinal signs of PD?:Unilat arm/hand tremor Postural instability Unstable gait Muscle rigidity Cogwheel rigidity Bradykinesia (usually in handwriting first) Decreased sense of smell Myerson sign (tap forehead, uncontrollable blinking) 61 Progressive supranuclear palsy (loss of upward gaze) Incontinence 248.What are some cognitive responses to grief?:Confusion Poor concentration Sense that deceased is present Search for meaning in the loss 249.What are some common dipstick results in UTI?:Leukocyte esterase: positive (WBCs present) Nitrates: positive Protein: pos Blood: pos 250.What are some common physical findings in acute bacterial prostatitis?:Fever Bladder distention Edematous/warm/tender prostate (can be firm or boggy) 251.What are some common SE in opioid administration?:Constipation Nausea Sedation Respiratory depression 252.What are some contributing factors for UTI in women?:Intercourse Pregnancy DM Cath Instrumentation Retention Constipation Diaphragm use Meatal stenosis Bowel incontinence 253.What are some definitions of polypharmacy?:Use of multiple meds (usually 5 or more) More meds than are clinically indicated leading to unnecessary/unwanted drug use Taking meds that are inappropriate for the pt Taking meds for longer than what is needed The use of multiple prescribers and pharmacies 254.What are some diagnostic tests for interstitial cystitis?:UA Urine cx Potassium sensitivity test Cystoscopy 255.What are some diagnostic tests used in evaluating proteinuria?:24hr urine (measure protein & creatinine) Chemistry panel Lipids Urine Cx w/sensitivity CBC w/diff Bence Jones test 256.What are some diagnostic tests used to rule out hematuria causes?:UA: positive blood Urine Cx & ID/sensitivities Micro UA: RBCs (if <3, hemoglobinuria? If >3, test for cause: ANA, immunoglobulins, CMP, CBC) 257.What are some dietary substances that can cause hematuria?:Caffeine Spices Tomatoes Chocolate ETOH Citrus Soy sauce 258.What are some diff dx's for interstitial cystitis?:UTI Prostatitis Cystitis 62 -Reg exercise -Healthy wt -Don't smoke/stop smoking -Statins if: Already have ASCVD, LDL >190, 40-75yo w/T2DM, or 40-75yo with 7.5% or higher risk of having MI/CVA in 10yrs; or fam h/o premature MI/CVA, any other area that puts higher risk of ASCVD 283.What are the most common abx for UTI?:Bactrim Fluoroquinolone (no pregnant women!) 284.What are the most common SE for antimuscarinics?:Dry mouth Blurred vision Constipation Nausea Dizziness HA 285.What are the signal symptoms of COPD?:Dyspnea Chronic cough w/sputum Decreased activity tolerance Wheezing 286.What are the stages of grief?:Notification and shock Experiencing loss emotionally and cognitively Reintegration 287.What are the stages of HF?:A, B, C, D 288.What are the tasks of grieving?:Acknowledging the reality of death Sharing in process of working through pain of grief Reorganizing family system Restructuring relationship w/the deceased Reinvesting in other relationships and life pursuits 289.What are the two types of hematuria and what do they mean?:-Transient: occurs on one occasion -Persistent: occurs on 2 or more occasions 290.What are the values for BP?:Normal: <120/80 Elevated: 120-129/<80 Stage 1: 130-139 or 80-89 Stage 2: 140 or higher OR DBP 90 or higher Hypertensive crisis: SBP >180 and/or DBP >120 For CKD and DM: Goal is <130/80 291.What are treatment goals for UI?:Individualized Similar for men and women Reduce urgency symptoms Reduce frequency Reduce nocturia Reduce UI episodes Improve QOL Increase social activities Reduce leakage volume Increase dryness Use less protection Avoid leakage during certain activities Increase independence in UI management Decrease caregiver burden 292.What are two lifestyle changes for interstitial cystitis?:Drink plenty of water Bladder training 293.What can be added to any step of the WHO Step Ladder for pain?:Adjuvant meds such as: -Tricyclic antidepressants -Nortriptyline -Desipramine -Duloxetine -Gabapentin -Pregabalin 65 -Lidocaine 5% patch -Capsaicin cream -Corticosteroids -Calcitonin -Baclofen 294.What dz can mimic and often co-exists w/MI in elderly w/CAD?:Esophageal dz 295.What else should be tested for if a man has urethritis?:Gonorrhea 296.What increases the risk of ED?:CVD DM Obesity Submissive personality 297.What insect precautions are not necessary to prevent insect-borne dz's in the tropics?:Using 100% DEET on skin to prevent bites 298.What is 2nd line management for UI in males?:Alpha-1 blockers (doxazosin, terazosin, tamsulosin, alfuzosin, silodosin) 299.What is an abnormal amount of protein in a 24hr urine?:>160mg 300.What is a normal A1C?:<5.7 301.What is anticipatory grief?:Experienced before death. Can be experienced by everyone involved, including the pt. 302.What is a sign of insulin resistance that can present in African American pts? a. Seborrheic Nigricans b. Psoriasis Nigricans c. Bullemic Nigricans d. Acanthosis Nigricans: ANS: D 303.What is atrophic vaginitis?:Thinning and increased fragility of both the genital and urologic tissues 304.What is bereavement?:State of experiencing the death of a loved one; includes grief/mourning. Process that involves adjusting to a world w/out the deceased. 305.What is complicated grief?:Chronic, delayed, exaggerated, masked, disenfranchised. 306.What is grief?:Emotional response to a loss. Normal reaction to loss. Affected by circ*mstances at the time of death. 307.What is gross hematuria usually associated with?:Malignancy 308.What is MOA for beta-3 adrenergic agonists?:Stimulates beta-3 adrenergic receptors, which relaxes bladder smooth muscle 309.What is most common valvular heart dz in older adults?:Aortic stenosis 310.What is mourning?:Outward, social expression of loss 311.What is normal BNP?:0.5-30 (100-400 warrants investigation) 312.What is normal grief?:Encompasses typical emotional, physical, cognitive, spiritual reactions to loss. 313.What is one of the ways PD can be ID'd?:Improvement with levadopa administration 314.What is proteinuria usually associated with?:Renal pathology, usually glomerular. Can be functional. Can be intermittent (stress, UTI, exercise). Can be from overproduction of filterable plasma protein, which can be associated with multiple myeloma. 315.What is pyuria?:10 WBCs per high power 316.What is second-line management strategies for UI and overactive bladder in women?:Antimuscarinics (first-line meds for women; response unpredictable; SE common): oxybutynin, tolterodine (Detrol), fesoterodine (Toviaz), trospium. Beta-3 adrenergic agonists (less SE than antimuscarinics): mirabegron (Myrbatriq) 317.What is step 2 on the WHO Step Ladder for pain?:Opioids added, usually w/APAP, for moderate-to-severe pain w/functional impairment and/or decreased QOL. 318.What is step 3 on the WHO Step Ladder for pain?:Opioid pain meds, sometimes around the clock, for severe pain. 319.What is the A1C level indicative of prediabetes?:5.7-6.4 320.What is the A1C level indicative of T2DM?:>/= 6.5 321.What is the ADA recommendations for screening for T2DM?:-Screen all adults at 45yo -Test all adults who are overwt/obese w/1 risk factor (BMI >25, >23 for Asians) 66 -Screen at risk adults every 3yrs -Screen yearly: prediabetes, increasing hyperglycemia, multiple risk factors 322.What is the age of onset for interstitial cystitis?:30-70 323.What is the appropriate method for TB screening of an older adult entering a nursing home?:5 tbu intradermal ppd injection and if negative repeat w/same dose 1wk later 324.What is the best test for continuous proteinuria?:24hr urine 325.What is the definition of acute bacterial prostatitis?:Inflammation, infection of prostate, usually by E. coli or other gram-neg 326.What is the definition of a UTI?:Inflammation and infection of the urinary bladder w/possible involvement of the urethra 327.What is the definition of interstitial cystitis?:Chronic bladder inflammation syndrome Characterized by pelvic pain and irritative voiding symptoms Pathology unknown Related to autoimmune, allergic, or infection etiology Dx of exclusion Mostly women 328.What is the fasting plasma glucose level indicative of prediabetes?:100-125 329.What is the fasting plasma glucose level indicative of T2DM?:>/= 126 330.What is the first step on the WHO Step Ladder for pain?:NSAIDs and acetaminophen for mild pain 331.What is the goal of palliative care?:To prevent and relieve suffering and support the best QOL, regardless of dz stage or need for other therapies and can be concurrent with other life-prolonging therapies. 332.What is the initial workup for UI in men?:Complete PMH PE (DRE, prostate eval) UA PSA if new onset UI 333.What is the initial workup for UI in women?:Complete PMH PE (Pelvic: perineal/vag exam to eval estrogen status, pelvic prolapse, fistula) UA Cough test 334.What is the main MOA of alpha-1 blockers?:Prostatic smooth muscle relaxation 335.What is the MOA for antimuscarinics?:Block acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detruser muscle contraction. 336.What is the most common organism causing UTI in men?:Proteus species 337.What is the most common organism causing UTI in women?:E. coli 338.What is the OGTT level indicative of prediabetes?:140-199 339.What is the OGTT level indicative of T2DM?:>/= 200 340.What is the provider's responsibility in elder abuse?:Physical exam Diagnostic tests Reporting 341.What is the treatment goal for interstitial cystitis?:Symptom management 342.What meds are commonly used in later stages of PD?:Carbidopa/levadopa (absorption inhibited w/large protein meals) D2/D3 dopamine agonists (newer): mirapex, requip, neupro 343.What meds are commonly used in the early stages of PD?:Rasagiline (MOA-b inhibitor): do not give w/demerol; be off for at least 2wks before general anesthesia Amantadine: use caution w/renal pts Selegiline (MOA-b inhibitor): don't give w/demerol or SSRIs; not well tolerated by confused pts 344.What provides a framework for pharmacological interventions for pain?:The WHO Step Ladder 345.What qualifies Stage A HF?:-Fam h/o HTN, DM, heart problems -Personal h/o HTN, DM, heart problems OR -High-fat diet, ETOH/drug abuse, smoke 346.What qualifies Stage B HF?:Dx'd w/HF but never had s/s 347.What qualifies Stage C HF?:-Cardiac dysfunction present -Symptoms present -Tiredness while performing simple activities, SOB, overall fatigue, etc. 348.What qualifies Stage D HF?:-Have undergone tx but still have s/s present -Many times associated w/surgical options 349.What should be avoided in interstitial cystitis?:Acidic food Caffeine 67 ANS: D 386.Which of the following statements is true concerning anti-arrhythmic drugs?:Most anti-arrhythmics have low toxic/therapeutic ratio and some are exceedingly toxic 387.Which organism that can be prevented by vax is most often responsible for infectious "outbreak" in nursing homes? a. Influenza A b. Haemophilus influenza c. Mycobacterium tuberculosis d. Streptococcus: ANS: A 388.Which pt is most likely to have osteoporosis?:80yo underweight male who smokes and has been on steroid for psoriasis 389.Which pt should be screened for DM? a. 47yo Caucasian male w/HTN b. 45yo female on disability from back injury, unable to exercise c. Hispanic man, BMI 26 d. Overweight middle-aged African American woman w/fam h/o T2DM e. All of the above: ANS: E 390.Which race has the highest incidence of PD?:Hispanic 391.Which race has the lowest incidence of PD?:African Americans 392.Which test is clinical standard for assessment of aortic stenosis?:Echo 393.Which would be an appropriate tx for pt with minimal symptoms of BPH? a. Watchful waiting b. Refer to urology for surgery c. Prescribe trial of tamsulosin d. Recommend cranberry supplements: ANS: A 394.Who might be referred to hospice for consult?:Pt's who you wouldn't be surprised would die in within 12mo. Frequent admissions w/in several mos. Difficult to control symptoms. Complex care requirements. Decline in function, feeding intolerance, unintentional wt loss. Admission from LTC. Elderly, cognitively impaired w/hip fracture Metastatic or local advanced incurable cancer. Chronic home O2 use. Out of hospital cardiac arrest. Limited social support. 395.Who should receive 7-10 day abx for UTI?:Men Children Elderly DM Women w/pyelo Pregnancy 396.You are evaluating an elderly pt's c/o new onset of hand shaking when he drinks from a cup. The pt is euthyroid and does not drink ETOH. Which of the following signs indicate that this tremor is most likely an essential tremor rather than a PD tremor?: ANS:It is a moderate amplitude tremor that occurs only w/movement or activity. 397.You examine the hands of a 55yo woman w/RA and note bilat spindle shaped deformities on the middle interphalangeal joints. These are known as:: ANS:Haygarth's nodes 398.You have completed the first follow up visit for a new COPD pt who is in stable condition. The pt asks how often he needs to follow up for COPD. You state that stable COPD pts should return for follow up eval: a. Yearly b. Monthly c. Every 3-6mo d. Every 2mo: ANS:C 70 399.You know that the gold standard for COPD dx is: a. Spirometry b. Dyspnea, chronic cough w/sputum production c. Irreversible airflow limitation d. Decreased breath sounds, wheezes at lung bases: ANS: A 400.You know the following statements regarding pain of acute coronary syndrome are true except: a. Present atypically more often in men than women b. May be retrosternal or poorly localized c. May last longer than 20min d. May radiate to arms, back, neck, jaw: ANS: A 402.You order bilat wrist XR on a 69yo man c/o pain in both wrists for 6wks not related to known trauma. You suspect elderly onset rheumatoid arthritis. To guide tx, you look for which radiographic finding? a. Symmetric joint space narrowing b. Soft tissue swelling c. Subluxation of joints d. Joint erosions: ANS:D 403.You ordered a CBC for pt you suspect has PMR. Which 2 findings are common in pt's with PMR? a. Normochromic, normocytic anemia and thrombocytosis b. Macrocytic, hyperchromic anemia and leukocytopenia c. Neutropenia and hypochromic, normocytic anemia d. Microcytic, hypochromic anemia and reticulocytopenia: ANS: A 404.You're evaluating a pt's pelvic muscle strength by digital exam. This is performed when:: ANS: You need to confirm a cystocele or stress incontinence 405.You're reviewing CXR report on 56yo male who presented w/increasing SOB. You suspect COPD. You know the dx can be made with a high degree of accuracy if 2 of the following criteria are met: 1. Flattening of diaphragm w/blunting of costophrenic angle on PA film 2. Upper zone redistribution of pulmonary blood flow (cephalization) 3. Abnormally enlarged retrosternal space 4. Signs of interstitial edema: ANS:1 and 3 407.You're working in the Fast Track of ER. 76yo male presents w/LUQ pain. There can be many conditions that present as LUQ pain, but which of the following is least likely to cause pain in LUQ?: ANS: Acute pancreatitis 408.You're working w/an older male w/a long h/o ETOH abuse and 30yr h/o smoking. In recommending intervention for this pt, your responsibility is to:: ANS: Promote positive change in lifestyle choices 409.You're working with an older male w/a long h/o ETOH abuse and 30yr h/o smoking. In recommending an intervention for him, your responsibility is to: a. Make him abandon his own health practices and follow your recommendations b. ID the barriers he will encounter c. Register him for local intervention program and secure payments d. Promote positive change in lifestyle changes: ANS: D 410.You see a new pt for acute care visit. She is 68yo Caucasian who is dx'd w/PMR. You prescribe corticosteroids and will continue tx until the condition has resolved. You look over her records and note it has been 2yrs since her last exam and labs/diagnostic tests. In prioritizing your health maintenance management plan, your orders today should include: a. DEXA and updating vax b. Recommending increased dietary intake of Calcium and vit D c. Ordering once a year bisphosphonate and PPI d. Participate in a fall prevention program: ANS:A 411.You suspect that your pt has PMR and now are concerned that the pt may also have Giant Cell Arteritis (GCA). Which of the following two symptoms are most indicative of GCA and PMR?: ANS: Scalp tenderness and aching in shoulder and pelvic girdle 412.You understand primary prevention of falling among elderly through which management plan?: 71 ANS:Provide info about meds, SE, interactions 1. A 77-year-old Hispanic Catholic Nun (retired) who immigrated to the United States 15 years ago lives alone but in an apartment complex where her sister lives as well. She is being discharged home after a hospitalization for congestive heart failure with prescriptions for eight different medications. She is considered at risk for noncompliance due to the following contributing factors except: (Select all that apply) a) Language barrier b) Living alone c) Large number of medications d) Ethnic background e) Religious background ANS: A,B, C 2. A 78-year-old patient who is dying of colon cancer with metastases to the liver is refusing to eat or drink. He is alert and oriented, and states that he has no desire to eat, which is causing the family great distress. In order to best address the client and family, you should: a) Comply with the patients wishes b) Force fluids c) Contact the physician for an order for enteral feeding d) Contact the dietitian for feeding supplements ANS: A 3. A 79-year-old female client resides independently in the community. The client’s daughter is concerned because her mother insists on wearing a sweater and keeps all of the windows closed even though it is 90 degrees Fahrenheit outside. The nurse practitioner initially recognizes that this behavior may be related to: ANS: age-related neurosensory changes that diminish awareness of temperature changes 4. An 88-year-old, being admitted to rule out lung cancer, is assessed using the short form of the Geriatric Depression Scale tool. When it is determines that the earned score is 9, the nurse practitioner initially: ANS: Asks if they have any thought of committing suicide 5. The area in which nurse practitioners have the greatest effect on the safe, effective medication therapy of an older client is: ANS: educating the client to all aspects of the medication 6. The Beers list is an effective tool for healthcare professionals prescribing and/or managing the medication therapy of older adults since it identifies medications that for this population: ANS: have a higher than usual risk for injury 7. A client who reported, “a problem sleeping” shows an understanding of good sleep hygiene when: ANS: limiting the afternoon nap to just 30 minutes 8. Common causes of dyspnea in the older adult may include which of the following? a) Heart failure b) Asthma c) Chronic obstructive lung disease d) Pneumonia e) All of the above ANS: E all of the above 9. Common ethical issues in the nursing home may include which of the following? a) Quality of life b) Decision-making capacity c) Preservation of autonomy d) Surrogate decision making e) All of the above ANS: E all of the above 10. The cost of nursing home care is significant. The primary payer for nursing home care is: ANS: Medicaid and private pay 11. Each of the following assessment finding is a contributor to an older client’s risk for falls except: 12. Each of the following data supports the diagnosis of sleep apnea in the older adult except: 13. Factors that affect the pharmaco*kinetics of lipophilic medications in older include: 14. The following precautions are beneficial in minimizing an older adult’s risk of being a victim of fraud except: Rely on the advice of people who only friends have recommended. 15. In order to focus on the older population with the greatest risk for suicide the nurse practitioner would conduct a depression screening that targets: 16. In planning teaching for a client with diabetes, which precaution related to fall prevention is particularly important for the nurse practitioner to include? 72