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Physician Assistant 510
H&P of the Elderly
H&P of the Elderly
Physician Assistant 510
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What are some components of the H&P exam that are different in the elderly?
May require extra time
May require additional informant
Many patients have acquired health problems over time
How many medical problems do elderly patients have on average?
On an average of 6 medical problems
Pulmonary problems (smokers)
Smoked in their youth, even if they don't any more
Conditions can __________ – treating one condition may worsen another (for example treating osteoarthritis with NSAIDS may worsen CHF)
Can also affect PUD, GERD, can make GI lesions turn into bleeding lesions
Drugs that affect gastric pH can affect drugs that depend on that acidity to be absorbed
Example - patient with COPD (emphysema from smoking) with angina (CAD) so any lack of oxygen could tip her into an angina issue
Albuterol for COPD can cause tachycardia - would cause some ischemia if she couldn't keep up with myocardial oxygen demand
Above _____ meds, you can't really gauge interaction.
What are some general problems with the special senses found in older patients?
Problems with hearing and vision more common
Decrease the distraction so that the patient is more comfortable and focused
Make sure patient is using aids available to them (glasses, hearing aids, etc.)
Make sure the patient can
Remove distractions (muzak, TV when possible)
Speak clearly and in low tones
Lower pitched voices are easier heard than high pitched voices
What causes presbyopia in elderly patients?
Lens is unable to adjust because of stiffness, can become yellowed from UV, cloudy from cataracts, etc.
What is macular degeneration?
loss of light receptors of the macula
(which is the most sensitive part of the retina)
can cause vision loss over time
Usually the ______________ glasses are okay if they don't have a pre-existing problem
If pre-existing problem, may need bifocals or trifocals
What is presbycussis? Why is speech a hard sound to hear?
Loss of high frequency hearing receptors
Speech is a mix of high and low frequency
Difficulty distinguishing, especially in an environment with distracting noises
Older people seem more resistant to hearing aids than to glasses
How can you get a better medication history from the patient? What should you ask about? Who else can you talk to?
○ Sometimes hard to get a clear medication history
○ Ask patient to bring all medicines to visit
§ It will help you understand how well the patient is keeping up with meds/taking meds
○ Ask about OTCs
§ PPIs, H2 blockers, NSAIDs
§ A lot of people forget to tell you about over the counter medicines
○ Ask about vitamins and supplements
○ Ask about inhalers, patches
§ People forget that these are medicines too
Review third party info
Polypharmacy in the elderly
This is a huge problem, even before a patient is elderly
Relatively healthy people on 10-15 drugs
Unhealthy people on even more
Try to bring the pharmacy list down as rationally as possible
Often leads to iatrogenic illness
More than ___% of patients over 65 on at least 1 prescription drug
At least __% take 5 or more prescription drugs a day
No one understands the potential interactions when you get beyond 2-3 drugs
As the number of drugs rises, the potential for adverse reactions increases
An awful lot of problems can be attributed to drug issues - put this at the top of your list on considerations
What are some common issues in geriatric patients?
Why do elderly patients get acutely confused?
Less cognitive reserve in older folks
Even if clear, functional, and cognating normally - a small change in these circumstances
Changes in blood sugar, pressure, infection
Patient can be asymptomatic otherwise but present as having mental status changes
What are some factors when trying to diagnose causes of dizziness?
Common but difficult
Can be quite vague
Pin down what the patient means by dizziness
Can be vertigo - spinning room
More subtle vertigo - no spinning, but feel like they're falling to one side
Middle ear, CNS processing
Sensation of passing out/browning out
Like standing up suddenly on a hot day
Even more vague - get as specific description as you can
Factors influencing syncope in the elderly
A lot of possible pathologies
Changes in autnomic NS
When they stand up, the blood pressure falls
What types of arrhythmias can elderly patients develop?
Questions to ask regarding a fall
Did they fall from passing out or weakness?
_________ and __________ are common causes of mobility problems
What are some weight issues with elderly patients?
Very overweight - far more difficulties in the elderly than a younger person because of loss of muscle mass
A lot of elderly people lose their appetites
Difficulty maintaining appropriate nutrition
Which patients often develop urinary incontinence issues?
Particularly women who have had children (parous)
Men who have had prostate issues
Which is more damaging, systolic or diastolic hypertension?
Systolic is just as damaging as diastolic, contrary to what was belived previously.
What are some of the cardiovascular changes that happen to elderly patients?
Rise in systolic BP
vessels less distensible (loss of elasticity, more calcifications)
Loss of baroreceptor sensitivity coupled with stiff vessels results in postural hypotension
What is CHF?
• Stiffening, thickening of ventricular walls
• Problems from ischemia and muscle loss - not as much pumping
• May adjust activity so that they're not symptomatic
What are some issues associated with mobility for the elderly?
Just like with hearing aids, there's a stigma associated with mobility assistance devices
Canes can be very helpful for patients with balance and orthopedic problems
Quad canes for patients provide a lot of stability
Wheeled walkers to maintain independence
Remind patients that they can still go to the grocery store with a cane, but that it would become increasingly difficult with a broken hip
Does sex matter to older people?
Why, yes. Apparently it does.
What skin issues do elderly patients experience?
Loss of elasticity and collagen - wrinkles
Thinning – prone to damage with minor trauma
Basal cell carcinomas
Squamous cell carcinoma
Less of a geriatric issue
Areas that get sun
Decreased immune function – more prone to infection
Purpura from minimal trauma
What is the 5th/6th/7th vital sign in elderly patients?
tell them to keep up with exercise and activities - if mobile - walking, swimming, weight training
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