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Do a syncope workup if the patient does not remember the fall or if the history is suggestive.
In established ulcers, keep pressure off the area; and if an eschar exists, remove it for proper staging. Then determine whether any arterial or venous insufficiency exists, treat infection if present, and maintain a "clean" ulcer. Immobility Patients adapt to bedrest; and the longer a patient is immobilized, the harder it is to ambulate again.
Give antibiotics, in addition to local wound care, if the patient is systemically ill. Use deep wound cultures to guide your choice. FSH and LH also decline but disproportionately compared to the more drastic decline in testosterone. For these patients. CD4 T cells increases with age. These [Know: The elderly are very sensitive to drugs for the following reasons: Avoid long half-life narcotics in treating geriatric pain.
With narcotic dependence. Many do not divulge this information unless you ask directly. Slowly taper following these general principles: General rules for medications in the elderly: This may cause poor sleep and insomnia.
Stage I and 2 ulcers heal quickly. TSH increases and go slow.
The average age of menopause is Many other hormones are normal in the amount produced but do not function as well. Growth hormone reduction appears to be compared to muscle. Sometimes this is feasible. These are the most common causes of falls in nursing homes. As discussed in the section on osteoporosis. Also avoid pioglitazone in the elderly. Patients with Paget disease have focal areas of marked Metformin should not be given to patients with increased uptake.
Testosterone promotes red cell proliferation and diabetes get the same micro. Rosiglitazone is no longer recommended by the ADA. The most likely causes of hypoglycemia are more often presents as cognitive vitamin D.
Diagnosis is strongly suggested by bone scan results. If the patient has any risk factors for vitamin D deficiency especially poor diet or lack of sun exposure. Decreased mentation Drugs used: Bisphosphonates etidronate. The bones are more brittle. Remember to adjust the insulin doses downward. Elderly patients with toms. Men receiving testosterone cations as younger patients. The collection of the above. The jury is still out on whether these drugs are associated with an increased risk of cardiac events and stroke.
Do not screen elderly men and do with a slight increase in fasting glucose. Glyburide has about twice the incidence versial for prevention of osteoporosis. Vitamin D deficiency is common because of decreased Hypoglycemia intake.
Assess the estimated glomerular filtrate rate eGFR prior to use of Osteoporosis The majority of women osteoporosis. It is a common problem in the elderly. Physical seizures. Any patient who and gallbladder disease. Calendars and orienting signs. Unopposed estrogen use is not delirious should be thoroughly evaluated for a serious associated with the heart disease or breast cancer risks. Common precipitating causes of delirium include drugs. But older women do. Prior to this study.
Know that physical restraints and bladder catheters can incite delirium as well. Acute discontinuation of alcohol.
H2 receptor blockers. Perimenopausal use of estrogen replacement is discussed later in Office Gynecology on page I Pharmacologic treatment of delirium in the elderly is tough because the meds themselves can worsen the confusion.
Sundowning fractures. Be aware especially of meperidine. It is not associated with a precipitating Treatment of delirium is supportive with focus on diagnosis and treatment of the underlying cause. John's wort and valerian root.. Main features are: It is also necessary to minimize daily stress.
In the post-op period. Work up the central nervous system imaging estrogen-progestin in women with a uterus is not The important concept: Do not give women becomes illness that may be associated with confusion e. Premature ovarian failure menopause before age 40 can be safely treated with combination HRT until the woman is 50 years old. The WHI data. Both groups have an increased incidence of gallbladder disease.
With sundowning. Combined opioids to manage postoperative pain is not associated with increased rates of delirium. Low-dose haloperidol is an option. Combination HRT is associated with an increase in Know that in the elderly.
What are some options for drug therapy. Treatment of LBD with neuroleptics may bring on a paradoxical psychosis and worsening of parkinsonism. Remember to avoid physical restraint of geriatric patients at all costs because it precipitates delirium and causes falls. Cis in patients with Parkinson's. Cis may be particularly useful in controlling behavioral problems make patients more confused and drowsy. Do not use BDZs in delirious patients because they do not help patients with Huntington disease.
Know that the benefit from treating Alzheimer's is greatest early in the disease. Book 5. CI side effects often involve the GI tract nausea. Dementia is a common development in patients with Parkinson disease as well. Best results When do patients derive the greatest benefit from Alzheimer treatment? The evidence-based review found little benefit for any of the current cholinesterase inhibitors or memantine. See Neurology. The same may occur with use of dopaminergic agents.
How is dementia different from delirium? Preventive Services Task Force on screening for dementia is that there is insufficient evidence to recommend for or against it. Patients with dementia have a progressive deterioration In March of cognition that is insidious and chronic-but without altered consciousness. Vitamin E is no longer recommended as a supplement because it may increase the risk of heart disease and death.
Most patients in the U. Lewy body dementia LBD is marked by progressive cognitive decline with concomitant hallucinations. The combination of cholinesterase inhibitor plus tions are always the best choices.
The cognitive impairment presents as: Cis provide a small benefit and help some patients carry out their activities of daily living ADLs. Dementia acetylcholine has been reported. Ginkgo biloba extract and vitamins A and D have not been shown in clinical trials to improve cognition in elderly patients. Alternative drugs include the 24 points on the risperidone. A couple of ways to tell the difference: Depressed patients often present complaining of memory loss.
These drugs have fewer short-term side effects but have been associated with increased mortality with long-term use.
Notes Drug of Choice Caution! May cause anxiety. Pure SSRls are not likely to increase blood pressure.. Note 1: Most anticholinergic of receptor increases Sexual dysfunction.. Note 2: Elderly patients are especially susceptible to bad patient's depression can help their comorbidities improve outcomes from sleep drugs.
Depression is the most common mental problem in the elderly. A host of substances and drugs can potentiate depression. These patients simply have short-duration sleep. See Table I Treatment is usually psychotherapy combined stopped or started meds.
Untreated thyroid disease. It is particularly likely to occur in those who live Insomnia. Get in the bed only when you're sleepy. Pay special attention to the elderly man with depressed mood. But they have the frequency of awakenings.
What is the role of benzodiazepines in treatment of insomnia? Depression-associated delusions are more common in the elderly than in the general population. Medications specifically associated with insomnia include corticosteroids. What are common side effects of fatigue. No bright lights or TV. Eat dinner or an evening snack to prevent bedtime hunger. Exercise helps. Watch for the side effects potential restless sleep hygiene: Know that treating a Set a schedule for sleep and stick to it.
When you're rested. Selective increase slowly with the goal of eventually reaching the diagnose managed comorbidities. Always check that there is a recent assessment of thyroid function. Exercise during the day. Dopamine agonists generally are the drugs of warming. The following expert panel treatment recommendations are based on whether the RLS is intermittent. Low-potency opioids generally avoided.
Always check a ferritin level to rule out iron deficiency even if the patient does not have anemia. Try non-pharmacologic therapy first: Diagnosis is made based on clinical history. Because of this. Multisensory deficits: Think about multisensory deficits as a cause for disequilibrium in the patient with a mix of visual. Symptoms are worse in the evening and at night. The FDA required reduced recommended doses for zolpidem products in because of persistent impairment the next morning.
Be careful -may cause augmentation worsened symptoms or rebound. Make sure that the patient's complaints aren't actually akathisia from medications phenothiazines and SSRJs. Dizziness that sounds like presyncope or "faintness" should be taken seriously and evaluated with a cardiovascular workup. The melatonin agonist. RLS can be primary or caused by other conditions: Multisensory deficits vestibular than in other patient groups.
Treat this by maximizing support for each sensory impairment and providing assistance devices e. It is a then eventually resolves good choice for the elderly.
Try non-pharmacologic first. Their cost can be prohibitive. When any patient complains of "dizziness. Try gabapentin. In geriatric patients. In these cases. It increases the risk of myocardial non-benzodiazepine sleep agents? In the elderly. No drugs are used to treat BPV. BPV can be diagnosed by the 80 years. Digoxin is indicated only for more severe Treatment of BPV can be accomplished through one of heart failure and reduces hospitalizations.
This maneuver involves turning the charged from hospital. Around these patients. Epley and Semont. Hearing aids can help they may have developed it as an aging adult. Low What cause of dizziness is associated with diastolic pressures have been associated with increased improvement when the patient holds onto a cardiovascular events. The incidence of congestive heart failure CHF in the elderly is increasing dramatically and is now the number I cause of hospitalizations in this group.
Be sure Elderly patients with asthma may have long-standing to check for cerumen impaction. A positive test is visible nystagmus in either the recumbent or the upright position.
Mortality benefit has been shown for ACE inhibitors. The most common cause is presbycusis.
Spironolactone can be a useful adjunct that can also lower mortality for systolic heart failure. Several studies show these patients benefit from treatment. It is bilateral. Avoid Rheumatology. Number 2 is pneumonia.
See polymyalgia rheumatica are also present e. The systolic heart failure. Decreased hearing is an age-related condition. Group Dix-Hallpike test. Treat CHF itself primarily with diet. Repeat the maneuver with the head turned in the opposite direction. If you use spironolactone. Bronchoprovocation is used to diagnose asthma in patients with normal spirometry. Urinary incontinence.
Know that reversible obstruction is consistent with asthma. Normal micturition is dependent on an intact neurologic air pollution. Urge incontinence UI is a common cause of geriatric incontinence. UI is related to overactive bladder.
Risks for development of adult-onset asthma are the same as for younger patients: Book 2. This is due to the fact that this criterion contractility or "outflow" problem outlet obstruction is not as specific in this age group and overdiagnoses or incompetence. Know that apnea that results in poor sleep and excessive daytime somnolence carries a higher rate of morbidity in patients who are frail and already prone to falls.
A response to bronchodilators incontinence: Always consider the possibility that the patient has a serious underlying condition responsible for the leakage. With urge incontinence. It is a urologic condition defined by Management of geriatric asthma is the same as for the urgent need to void frequently and during the younger patients.
Diagnosis and management is the same as in younger patients. Definitive diagnosis is made with spirometry. With SUI. Bladder training and Kegel only! Stress urinary incontinence SUI is second in frequency in geriatric women. Remember that anticholinergics can precipitate acute angle glaucoma! Review Also. Surgery has Is urinary incontinence considered a normal consequence of aging? Bladder training and Kegel exercises: Treat underlying cause if when there is an increase in intra-abdominal pressure possible..
SUI is associated with multiple garments. The true etiology is unknown. The goal is to eventually delay voiding to every 4 hours with no interval leakage. As the bladder loses the modulating influence from the brain.
Once the urge is controlled. They have other anticholinergic side effects e. Incomplete Emptying Incomplete bladder emptying is sometimes still called Treatment is best accomplished with behavioral therapy. What is the best initial treatment for stress urinary incontinence? Pelvic muscle exercises Kegel's are also helpful for UI.
Periurethral collagen injections are an option for those What are the 4 types of incontinence? Bladder training and Kegel's help these patients.
What are the GOLD recommendations for diagnosis of asthma in the elderly? Note that some women with urinary incontinence have a mixture of SUI and urge incontinence. Psychogenic retention can also be a cause. Anticholinergic drugs are the most Bladder training is more effective than the more commonly common causes of drug-induced incomplete emptying. What is the role of bladder catheterization in the treatment of geriatric incontinence?
Mixed Incontinence V d ti e n U Mixed incontinence. Stress incontinence is initially best treated with behavioral therapy. The outlet obstruction causes a distended bladder and high-volume. We still do not understand what causes BPH and have yet to identify any specific risk factors-except age.. A 5-alpha-reductase inhibitor finasteride. The organic causes are neurogenic. This cGMP causes the relaxation of the smooth muscle in the penis.
Treatment The smooth muscle in the flaccid penis is in a o Neurogenic: Usual cause is diabetes. Other causes are surgical procedures especially prostate. Of the alpha-blockers.
Certainly ficient for satisfactory sexual intercourse. Treatment is disimpaction and subsequent bulking agents. The swelling of this tissue causes with intake of caffeine and alcohol diuretics. Know that these drugs decrease serum PSA. BPH does not increase the chance of prostate cancer. Be careful with combining sildenafil or vardenafil with these drugs because the combination worsens hypotension.
Other causes are surgical procedures.
Make sure patients know to reduce t increases the inflow through the helicine artery into the erectile tissue. Generally start with alpha-blockers terazosin. These can be grouped as follows: Usually slow onset. Most common side effects of these meds are orthostasis and dizziness. ED that occurs other diseases can cause these symptoms e. In elderly men. Typical presentation is an elderly person with complaints of diarrhea and abdominal discomfort and who has hard stool in the rectal vault on physical exam.
Most causes of ED are at least partially organic. These drugs work better for large prostates and have a more durable effect. I a digital rectal exam to palpate the prostate and assess for irregularities and increased size.
Loss of nocturnal and morning erections. It is not ED. ED is directly correlated with depression. There is a risk of hearing loss with all of the ED? PDES inhibitors.
It has is on no medications. This drug is approved for daily use. Side effects are due to its vasodilatory The properties-headaches. Tissue erosion may occur. Uroselective alpha-blockers medications are commonly used for treatment? Usually used only for those who have failed all other therapy. Symptoms may include gradual onset of frontal headaches or visual disturbances space-occupying Alprostadil prostaglandin EI injected into the corpora tumor.
Which medications most commonly cause ED? Scarring may cause erections to curve. Relative contraindications are CHF. Complications are associated with the surgery. They and flexible rods. Erectile function may be improved for up to 36 hours. Contraindications are any concurrent nitrates. I Beneficence: One specific side effect is back pain. If an exam presents a young male with ED who Yohimbine is a naturally occurring alpha-blocker.
This is the usual cause for ED in younger patients. They continue to have nocturnal and morning erections. Better than placebo but much less effective than sildenafil. Penile implants: Various types-hydraulic. If there are no complications.
ED due to vascular compromise indicates increased risk of present and or the patient prefers them to oral therapy. Many others also cause ED. Reports of hearing loss have also been documented. It is especially useful 3rd line treatment for ED: Normal aging: Sexual potency does decrease with age.
SSRis used for depression treatment are also associated with a very high incidence of h ta sexual dysfunction generally delayed ejaculation.
What is the initial treatment for BPH? What doxazosin. Examples are anxiety. The advanced The physician's own recommendations based on best clinical judgment but the information in the chart belongs to the patient.
Patients should be an active part of the decision-making process. If he comes into the emergency department and requires intubation to survive-and states that he Know that physicians are responsible for providing honest information on disability claim forms and should not attempt to assist a patient in obtaining disability benefits erroneously.
It is absolutely unethical for physicians to have any sexual relationship with a current patient. Most decisions on patient care are carried out without need for competency hearings. Know that physicians are responsible for caring for 9 9 If requested. A lawyer is not needed to make a living will.
Decision-making capacity is determined by the physician and at times may be difficult to determine. The physician must give the patient written notice of intent and must request approval from the patient for transfer of medical records to the accepting physician.
V d ti e n U Patients require informed consent. If this process is not followed. Even former patients can cause ethical problems. There are many transitory or reversible conditions that can interfere with this capacity.
Constraint of a person's free choices is permissible only when these choices infringe on another person's rights and welfare. Use of social media has added a new dimension to interactions with patients. It is assumed that the physician takes appropriate infection control precautions. The ethics document from the Federation of State Medical Boards says that physicians cannot even have sexual relationships with the relatives of existing patients.
Competency refers to the legal determination of one's decision-making capacity. Know that fluids and nutrition are ethically regarded as the same as other forms of treatment. Good end-of-life care entails treatment based on many issues.
Organ donation decisions should be broached at the appropriate time with decision makers by organ procurement specialists who are separate from prospective donors' health care providers in order to avoid conflicts of interest or a perception of conflicts of interest. The "contract for health physician supplies the means of death to a patient. Welfare considerations include suffering. If the surrogate has no knowledge of the patient's wishes. What should you do?
The downside of pain medications is that they can cause V d ti e n U confusion and a decreased ability to communicate. His family does not want anything patients in pain are in a special situation. Terminal G R intubation. For instance. Health care providers of prospective recipients should not be providing care to prospective donors for similar reasons.
The surrogate's authority ends when the patient dies i. Another option is for the subject to give someone 9 9 durable power of attorney. The waxing and waning associated with certain conditions.
The assistance of hospice workers in this situation can be very helpful. Know that respecting a patient's choice to refuse life-sustaining treatment is different from either of these. In some states. Euthanasia is illegal in all 50 states. This is known as substituted judgment. If the patient has expressed certain Euthanasia is when the physician directly administers wishes on a topic regarding medical intervention in a lethal dose of a medication with the intention of the past.
The surrogate's decisions must promote the patient's suicide PAS is when the with instructions on its use for terminating one's own life. You depression.
Organs can then be donated without patient's prior consent if the next of kin or surrogate gives permission. I wish you were around then, as the lectures were better than any in my school.
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