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Common Medication Side Effects

Cholinesterase Inhibitors: Slowed heart rate, incontinence, diarrhea.

Memantine:

Antidepressants: Orthostatic Hypotension.

Opioids: Slowed breathing, constipation.

Ca++: Constipation.

Ca++ Blockers: Constipation.

Fe++: Constipation.

Oxybutinin (AntiCh): Worsening mental status, worsening glaucoma, constipation.

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Nursing Home Admission

Causes:

1. Loss of Autonomy / Mobility / Care Giver Burnout.

2. Dementia.

3. Incontinence.

4. Palliative Care.

History (CHAMPS):

ID, HPI, Allergies, Medications, PMH, Family, Social, ROS.

- ROS (DDDDDD, SSS, Vision / Hearing / Balance, Heart, Incontinence, Joints Pain and Mobility, ADLs and iADLs).

Physical Exam:

Impression:

Plan:

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Elderly Assessment

Nutrition and Weight, Exercise, Mood, Sleep.

- Vitals and Orthostatic Hypotension.

- Cognition (Delirium, Depression, Dementia).

- Sensory Loss (Vision, Hearing, Proprioceprion).

--- Balance and Gait.

- Heart.

- Incontinence.

- Joints (Mobility and Pain).

- Feet.

- ADLs / iADLs.

2. Osteoporosis (With Calcium and Vitamin D).

3. Cancer Screening.

4. Vaccines.

[D]DD (Dementia, Delirium, Depression).

[D]DD (Deprivation, Dizziness, Drugs).

[H]O (Heart and Orthostatic Hypotension).

[I]ncontinence.

[J]oints and Mobility.

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Falls

Causes (Intrinsic v. Extrinsic):

Vitals: Fever / Orthostatic Hypotension / Arrhythmia / Low Saturation

Psych: Dementia, Delerium, Depression, Drugs (Antihypertensives, Psychoactives)

CNS: Syncope / Seizure / TIA or Stroke (Main arteries or Vertibrobasilar) / Subdural Hematoma / Gait and Balance.

Optho: Vision problems

HEENT: Hearing problems

Cardiac: TIA (Carotid or A-Fib) / Arrhythmia / Valve / ACS or MI

Resp: Pneumonia

GI: Bleed or Dehydration (Diarrhea).

GU: Infection or Dehydration (Abnormal fluids and electrolytes), Urge Incontinence, Overactive Bladder, Nocturia

Heme: Anemia

MSK: Dégénérative Joints / Trips especially at night / Foot problems (Diabetes, Bunyons, Callouses, Hammertoes, Badly fitting shoes)

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Immobility

Complications:

1. Orthostatic Hypotension.

2. Decreased respiratory Vital Capacity, Atelectasis and Pneumonia (if unable to swallow).

3. Hypercalcemia, Disuse Osteoporosis and Fractures.

4. Renal Stones from Hypercalcemia.

5. Urinary stasis, urinary retention, urinary incontinence, urinary tract infections.

6. Constipation, impaction and difficult to evacuate feces.

7. Negative nitrogen balance and Catabolic Protein Breakdown.

8. Contractures, muscular weakness, muscular atrophy.

9. Venous Stasis and DVT.

10. Pressure Ulcers.

11. Apathy and Depression.

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Frailty Scales

Frailty (Four I’s).

— inability to carry out important practiced social ADLs.

1. Instability (Poor Balance).

2. Immobility (Weakness and Poor Gait).

3. Intellectual (Cognitive) Impairment.

4. Incontinence (2nd leading cause of nursing home admissions).

So the most important tests in the elderly are:

A] Gait, Balance and Strength.

B] Cognitive Assessment and assessing for Depression / Demoralization.

C] Diagnosing incontinence.

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Diabetes

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Adrenal

Sugar.

Salt.

Sex.

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Dementia - BAT

[B]12 / Folate

[A]lcohol.

[T]hyroid.

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Clinical skills

A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and a treatment plan.

The components of the medical history are:

Chief complaint (CC): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'

History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.

Current activity: occupation, hobbies, what the patient actually does.

Medications: what drugs the patient takes including over-the-counter, and home remedies, as well as herbal medicines/herbal remedies such as St. John's Wort. Allergies are recorded.

Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.

Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).

Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.

Review of systems (ROS) or systems enquiry: an set of additional questions to ask which may be missed on HPI, generally following the body's main organ systems ( heart, lungs, digestive tract, urinary tract, etc).

The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:

Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation

General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)

Skin

Head, eye, ear, nose, and throat (HEENT)

Cardiovascular ( heart and blood vessels)

Respiratory (large airways and lungs)

Abdomen and rectum

Genitalia (and pregnancy if the patient is or could be pregnant)

Musculoskeletal (spine and extremities)

Neurological (consciousness, awareness, brain, cranial nerves, spinal cord and peripheral nerves)

Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

Laboratory and imaging studies results may be obtained, if necessary.

The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.

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Immobility:

Causes (Intrinsic v. Extrinsic):

1. Cognitive (Dementia, Delirium, Depression, Drugs, Fear of Falling).

2. Physical (CNS Disease like Parkinson or Paralysis, Stroke, Cardiac, Pulmonary, Degenerative Joint Disease and Hip Fractures, Bed Sores, Foot Problems, Gout).

3. Social and Environmental.

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Falls

Causes (Intrinsic v. Extrinsic):

Vitals: Fever / Orthostatic Hypotension / Arrhythmia / Low Saturation

Psych: Dementia, Delerium, Depression, Drugs (Antihypertensives, Psychoactives)

CNS: Syncope / Seizure / TIA or Stroke (Main arteries or Vertibrobasilar) / Subdural Hematoma / Gait and Balance.

Optho: Vision problems

HEENT: Hearing problems

Cardiac: TIA (Carotid or A-Fib) / Arrhythmia / Valve / ACS or MI

Resp: Pneumonia

GI: Bleed or Dehydration (Diarrhea).

GU: Infection or Dehydration (Abnormal fluids and electrolytes), Urge Incontinence, Overactive Bladder, Nocturia

Heme: Anemia

MSK: Dégénérative Joints / Trips especially at night / Foot problems (Diabetes, Bunyons, Callouses, Hammertoes, Badly fitting shoes)

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Hypertension in Older Adults

Reversible causes of Hypertension:

Steroids.

Hyperparathyroidism.

Renovascular Hypertension

Aldosteronoma.

Pheochromocytoma.

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Palliative Care

Pain.

Anxiety / Depression / Hallucinations.

Decreased Appetite and Weight Loss.

Fatigue (Ritalin).

Shortness of Breath (Oxygen, Morphine and BDZ, Steroids).

Secretions (Dextromethorphan, Diuretics, Antibiotics).

Cough (Codiene, Dextromethorphan).

Nausea / Vomiting (Haldol, Metoclopramide).

Constipation.

Diarrhea (Loperamide, Questran).

Bowel Obstruction (Disimpact, Octreotide).