Geriatrics

• Medicaid asset transfer rule

  • your assets need to be given away 5 years prior to Medicaid to be able to use
• 5 factors in order of importance in deciding to enter a nursing home

  1. Function
  2. Cognitive impairment
  3. Martial status
  4. Prior living arrangements
  5. Race
• What are the two strongest predictors of mortality in the elderly?

  Age and sex (male)
• Most common causes of death in the elderly are coronary heart disease, cancer, and stroke
• Hip fracture in the elderly has a one year mortality of >25%
• Poor prognosis associated with hip fracture

  1. Old age
  2. dementia
  3. lack of functional independence pre-morbidity
  4. longer than expected hospital stay
  5. Post surgical confusion
  6. Depression
  7. number of comorbidities
• Hearing loss due to age is called presbycusis due to OA of the bones in the ear
• Hearing changes with age

  • loss of higher frequency sounds
  • Localization (90 degrees of being able to localize sounds)
  • Speech discrimination
  • Loss of s, sh, f, g, t, z
  • May exhibit not paying attention, repeating "what"
• Hearing loss could be due to sensory neural, conductive issues, or mixed
• Rinne test is tuning fork placed at the mastoid process
• Weber test is the tuning fork on top of the head
• Will have loss of visual acuity as we age

  • senile miosis (pupillary constriction)
  • normal is 2.9-4 mm
  • Permanent pupillary constriction <2.9 mm
  • Glare
  • Decreased ability to see contrast
  • Decreased ability to discriminate color
• Will have visual field loss

  • senile ptosis and loss of retrobulbar fat pad
  • eye will retract into head by 1 inch
  • loss of upper field
  • Will miss overhead cues such as traffic signals, street signs, exit signs
• Visual acuity is the measured by the ability to discriminate two spatially separated objects at a distance
• Loss of elasticity of the lens and thickening of the lens with aging

  • impacts near>distance vision
• Decreased pupillary reflex which results in loss of night vision
• Illumination

  • senile miosis is age related decrease in pupillary size
  • better to see in moderate background lighting and extra lighting on the work area
• Glare is diffuse light scattering on the retina
• Indirect glare is light reflecting off another surface such as hardwood floor, a lake, or snow
• Direct glare is when light enters the lens directly from the source, such as an opened window, sunlight, or exposed light bulb
• Reds, oranges, and yellows are easier to differentiate than blues and greens.
• loss of color vision without disease

  • women 1/200
  • maen 1/15
• Pathologies that lead to color blindness

  • Alzheimer's
  • PD
  • Diabetes
  • MS
  • Alcoholism
  • Glaucoma
  • Macular degeneration
  • Use of viagra
• Loss of color differentiation and contrast results in loss of depth perception and inability to judge distances such as height of curbs and steps
• Loss of serum albumin due to lack of eating
• Decreased respiratory efficiency and laryngeal function with aging results in

  • lower pitched voice
  • lower volume
  • Shorter expiration period
• • Increased number of hours of sleep is required as we age
  • increased number of awakenings
  • Increased time to fall asleep
  • Loss of REM
  • Greater difficulty with concentration and problem solving with loss of sleep
• Heart rate: regularly irregular

  • dropped beats such as in 2nd degree heart block
• Heart rate: irregularly irregular

  • arrhythmia such as atrial fibrillation or atrial flutter
• When to not take BP

  • history of breast cancer
  • Dialysis arteriovenous fistula, arteriovenous graft or venous access
  • Central or PICC line
  • Recent fracture or infection
  • Fragile skin
• Arteriovenous fistula is a surgical procedure that connects an artery to a vein

  • used for dialysis

  
• Arteriovenous graft is a tube placed in the arm to connect the artery to the vein

  • used for dialysis

  
• Mycotic nails (onychyomycosis)

  • same fungus as athletes foot or ring worm
  • Thick nails

  
• Chemotherapeutic Nail Changes

  
• Mees lines

  • due to chemotherapy, heavy metal poisoning, chronic kidney injury

  
• Seborrheic keratosis

  • pigmented lesions with waxy or greasy appearance

  
• Solar Lentigo

  • brown, flat, lesion due to chronic sun exposure

  
• Actinic Keratoses

  • found on sun-exposed skin
  • Scaly and may develop into squamous cancers

  
• Basal Cell Cancer

  • resembles an ulcer or nodule
  • May constantly bleed
  • Do not metastasize
• Nummular Eczema

  • seen in the winter and may resemble ringworm
  • Due to lack of ambient humidity