Geriatrics


Meperidine (Demerol) should not be used in elderly b/c it's metabolite can cx sz. REF

Medicare now pays for some preventive measures that were not covered previously: pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou smear every 3 years. REF

Quetiapine is an atypical antipsychotic that has no clinically significant effect on the dopamine D2 receptor, which is responsible for the parkinsonian side effects of antipsychotic medications. REF

Akathisia (motor restlessness and an inability to sit still) can be treated with either anticholinergic drugs or beta-blockers. REF

The Mini-Mental State Examination, developed by Folstein in 1975, has become a standard tool for rapid clinical assessment of cognitive impairment. REF

Thalamotomy and pallidotomy contralateral to the most affect effective body side, are most effective for tx of disabling unilateral tremor and dyskinesia from Parkinson’s disease. REF


MC presenting symptom in elderly patients with open-angle glaucoma ? REF

Recent genetic work indicates high risk of Alz ds in pts w/ apolipoprotein E4 genotype. REF 

Essential tremor is the most likely cause of a disabling action tremor in a 75 yo. Tx ? REF
- Can't remember ? Then what problem do both propranolol and primidone solve ?

Cholinesterase inhibitors donepezil, rivastigmine, and galantamine delay nursing home placement by a yr or longer in ALZ ds. REF

Resting tremor is the most common presentation of Parkinson’s disease. REF
It is rare in progressive supranuclear palsy and multiple system atrophy, and less common in drug-induced parkinsonism. 

Depression - SSRIs preferred initially ex. sertraline 25 mg QD. SNRIs like duloxetine (Cymbalta), venlafaxine more expensive but not more effective. Also bupropion, mirtazapine (Remeron), Trazodone. p. 271 2013 ST Louis 

Hallmarks of Alzheimer's ds: memory loss, aphasia, apraxia, agnosia, executive dysfunction. 2013 St Louis.

Nursing Home Phone Call (Pages) Pearls (Handout from Dr. Stafford - 7/3/12)
1. Always ask nurse for VS and drug allergies.
2. Altered Mental Status - Ok to ask nurse to call you back in X hours.
3. UTI - Ok to order Cx and wait on results to treat (IF not sick).
            Must ask nurse to change Foley and culture fresh urine.
            Probiotics recommended if you have to use a quinolone (acidophilis or florastore)
            Use amoxicillin or Bactrim emperically, not ciprofloxacin.
            Order the UA with reflex to culture sensitivity.
            If ABX used treat for 10 days, not the usual 3.
4. Cough / Congestion - Ask if pt has COPD ? Change in sputum ?  If <= 2 days it's likely viral.
            Key is to maintain oral hydration, but you can order a PICC.
            Rocephine and Maximpine can be given IM !
            Options for congestion: Robitussin DM, Tessalon, Albuterol, Opiods, Mucinex (expensive), don't             use phenylephrine.
5. Diarrhea - Emperic tx with metronidazole usually resolved diarrhea in < 24 hrs.
            Lomotil is bad - potent anticholinergic, decreases motility increasing chance of perf & sepsis.
            Immodium is better - also anticholinergic.  Limit to 1 week of use.
6. Warfarin - If INR is high give 1/2 dose the next day instead of none.
            Try to avoid vitamin K - use only if  INR > 8-9.
            Think of Warfarin as a total weekly dose.
            Xarelto and Renexa - intent was that these would replace Warfarin, but they can't be reversed.
            - A bleed with these is a nightmare.
7. Falls - ask if they are on WARFARIN. If yes and head was hit send for CT scan.
            The NH will have a policy on "cranichecks".
8. Respiratory Distress / "congestion". 
            Mobile CXRs are available, BetaNP also, but not quickly.
9. Pain - topicals - diclofenac or Valtaren gel are good but hard to get. 
                              Capscacin works long term but is painful at first.
            - Tramadol - give 25 mg (1/2 50 mg tab)
            - Opiods - it's fine to give Morphine if needed.
10. Fever - an uncommon call (altered mental status is more common)
            - Even stat blood cx will take quite a while.
            - If patient has a foley, there is a 60% chance that the source is urine.
            - Note - 60% of females have asymptomatic bacteruria or pyuria with WBCs.
11. Behavior - if you order Ativan, give it just 1X.
                        Use haldol or geodon 0.5mg x1 IM or PO - may repeat q 10 minutes up to 2gm.

Comments