Factors to consider when prescribing psychotropic medications to the elderly

● Psychotropic meds have serious side effects that affect older population more severely
● >70 y/o = 3.5x more likely to be hospitalized d/t adverse drug reactions associated w/ psychotropic meds than
younger population
● Primary goal: Enhance the quality of life, Maximize function… cognition, mood, and behavior, Least restrictive
environment, Multidisciplinary team approach
● Pharmacologic and nonpharmacologic treatments available
○ STRESS nonpharmacologic therapies first.
○ RECOGNIZE underlying , undiagnosed medical problems
● Treatment principles
○ Limit changes in environment
○ Orienting tools: visualized clocks and calendars
○ Schedule regular office visits/home visits
○ Identify and treat comorbid conditions
○ Brain health: exercise, diet , stress reduction
○ Supervised exercise
○ Avoid anticholinergics Benadryl, Parkinson's meds, antipsychotics,
○ Set realistic goals
○ Limit prn psychotropic medications
○ Specify and quantify target behaviors
○ Maximize and maintain functioning

Diagnosing vertigo in the elderly

● Acute asymmetry of vestibular system
● Inner ear, nerve, medullary nucleus,
cerebellar connections
● Illusion of motion: self vs environment
● Spinning whirling tilting moving
● Most times hard to distinguish
● Time course
○ Vertigo is never continuous
○ Patient adapts and subsides
over weeks
○ Constant dizziness is
psychogenic, not vestibular
● Aggravating Factors
○ Spontaneous
○ Changes in head position
○ BPV vs postural Pre syncope –
if no change in BP or decreasing
blood flow
○ Vertiginous patients are petrified to move
● Associated Symptoms
○ Vertigo will have nystagmus and postural instability
○ Hearing loss…peripheral cause
○ Brainstem signs

1
 ● Dix Hallpike Maneuver diagnosis of BPPV

Pressure ulcer, venous stasis/prevention of pressure ulcers

● Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or
pressure in combination with shear
○ Superficial skin less susceptible to damage than deeper tissues
○ Related to immobility, poor fitted casts or medical equipment, malnutrition, reduced skin profusion,
sensory loss

1. 2. 3. 4.
● Complications:
○ Occasional heterotopic calcification.
○ Systemic amyloidosis due to the chronic inflammatory state arising from the ulcer.
○ Squamous cell carcinoma--chronic pressure ulcer with a non healing wound.
● General Care:
○ Control pain Oral non-opioid pain medications , Opioid analgesics, Topical local anesthetics (lidocaine)

2
 ○ Wound cleansing and dressing techniques may need to be reconsidered if they are causing severe pain
○ Treat infection
○ Optimize nutrition
○ Redistribute pressure
○ Supportive repair process: protein, calories,? Vitamin C, zinc, avoid cold, smoking, hydration
● Prevention:
○ Patients should be positioned and repositioned at least every two hours to relieve tissue pressure.
○ nonpowered support surfaces (eg, foam mattresses or overlays) for most patients with pressure ulcers
○ Air-fluidized large or multiple ulcers that preclude appropriate positioning.

Diagnostic workup for alzheimers

● Most common type of dementia
● Median Survival Time 3 to 12 years
● Greatest risk factors - age and family
history
○ previous head injury, female
sex, fewer years of
educational achievement
● Problems with retaining and learning
new information without benefit from
cueing is a hallmark (can’t retain info,
even if cues are given)
● Functional impairments
● Motor and sensory functions are
spared until late stages
● Visual spatial dysfunction going somewhere and forgetting where they are
● APOE 4 has highest risk and 3/3 has most protective effect
● Dx: no single test so far!
○ Neuritic plaques of amyloid protein, tau proteins in neurofibrillary tangles, neuronal loss
● Comprehensive patient evaluation
● Stages of dementia
○ Stage 1 - no functional decrement, normal adult
○ Stage 7 - speech limited to about six words in the course of an average day, progressive loss of ability to
walk, sit up, smile, hold head up, eligible for hospice, severe AD
● Imaging: Global atrophy, small hippocampal volumes (key role in formation of new memories), leukoaraiosis
(WBc deposits in the brain)
○ Cortex shrivels up - damaged areas involved in thinking, planning and remembering
○ Ventricles grow larger

delirium vs dementia (X2)

● Delirium
○ Acute Confusion over hours to days
○ Medical emergency
○ Can last 1-2 years
○ Criteria
■ Disturbed consciousness, disorientation

3
 ■ Cognitive change or perceptual disturbance
■ Motoric subtypes: hyper…hypoactive ...normal/mild
■ Rapid onset and fluctuating daily course
■ Evidence of a causal physical condition
○ Cholinergic deficiency, serotonin pathway disturbances
○ Reversible unless proven otherwise

○ Mnemonic for reversible causes of delirium

■ D…rugs antipsychotic, prednisone, pain meds
■ E…lectrolyte disturbances
■ L…ack of drugs
■ I…nfections
■ R…educed sensory input
■ I…tracranial
■ U…rine retention/fecal retention
■ M…yocardial/pulmonary
○ Treatment:
■ Identify potentially reversible causes (infection, impaction, uncontrolled pain, urinary retention,
medications, dehydration, and hypoxia)
■ Use low doses of non-sedating antipsychotic
● Actively dying, non ambulatory patients may benefit from sedating antipsychotic
■ Avoid benzodiazepines (makes older pt more agitated )
■ Nonpharmacologic approaches: minimizing noise, using an orientation board, mounting a visible
clock in the room, using simple communication and minimizing disruptions
● Dementia
○ Most common cause of mental decline in old age
○ Dementia and aging are not synonymous
○ progressive and disabling
○ Decline in 2 or more areas of Cognitive Functioning
○ Cause marked functional, social or occupational decline

4
Dealing with DNR
● Physician Orders for Life Sustaining Treatment (POLST)* : Constitute medical orders reflecting preferences for
cardiopulmonary resuscitation, medical interventions, antibiotics, and artificial hydration and transfer across care
settings
○ describe your wishes for health care but not an advanced directive
○ has a set of specific medical orders that a seriously ill person can fill in and ask their health care provider
to sign
○ signed by a qualified member of your health care team
● Do not resuscitate (DNR): instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a
patient's breathing stops or if the patient's heart stops beating

Hydrocephalus (normal pressure hydrocephalus) X2

● Clinical triad “wet, wobbly, and wacky”
○ Gait apraxia (1st and principal sx)
○ Dementia (inattention, psychomotor slowing ,executive dysfunction, recall)
○ Urinary incontinence
● Changes can occur any time
● Full triad may present only when dementia develops
● Related to CSF composition and changes in its absorption
● Accumulation of the CSF does not cause increased ICP
● Ventriculomegaly on Imaging
● Normal pressure cuz ventricles increase and brain shrinks.

multifactorial assessment in the elderly

● More than 50% of older adults have 3 or
more chronic diseases, referred to as
“multimorbidity”
● Multimorbidity is associated with
increased rates of death, disability,
adverse effects, institutionalization, use
of healthcare resources, and impaired
QOL
● Older adults with multimorbidity are
heterogeneous in terms of illness
severity, functional status, prognosis,
personal priorities, and risk of adverse
events
● Treatment of older adults with
multimorbidity requires a flexible
approach because of heterogeneity
among patients and inadequacy of most
clinical practice guidelines
● The 5 domains of evaluating and
managing older adults with
multimorbidity are to:

5
 ○ Consider patient preferences
○ Interpret relevant evidence
○ Consider prognosis
○ Consider clinical feasibility
■ Education and assessments must be ongoing, multifaceted, and individualized, and delivered via
a variety of methods and settings, because patients generally do not recall discussion with
clinicians.
○ Optimize therapies and care plans

various types of, management of incontinence X5

● Involuntary leakage of urine
● Acute causes of UI
○ D…elirium
○ R… estricted mobility, retention
○ I… infection, inflammation, impaction
○ P… olyuria (diabetes), prescriptions (diuretics)

● Sudden Onset of Pelvic Pain:

○ Constant, worsened or improved with voiding
○ Hematuria
○ Neoplastic
○ Neurologic Disease
● LUTS : Lower urinary tract symptoms
○ Frequency
○ Nocturia
○ Slow stream
○ Hesitancy
○ Interrupted voiding
○ Terminal dribbling
● Initial evaluation
○ Determine Incontinence type
■ Stress, Urge, Mixed, Functional (can’t make it to the bathroom in time so pee themselves), OAB
aka overactive bladder(frequency and urgency without UI)
○ Medical Conditions/ Medications

6
● Physical Exam
○ Functional Status (mobility, dexterity)
○ Mental Status
○ MALE GU:
■ Prostate exam
■ If not circumcised→ Check for phimosis, paraphimosis, balanitis
○ FEMALE GU:
■ Atrophic vaginitis
■ Pelvic support: cystocele, rectocele, prolapse
○ Physical Exam Findings
■ Bladder distention
■ Cord compression
■ Rectal mass or impaction
■ Sacral root integrity (anal sphincter tone, anal wink, perineal sensation)
■ Volume overload, edema
● Testing
○ Voiding diary
○ Measurement of postvoid residual (PVR) urine volume
■ US
■ Straight catheterization
■ >200 ml, repeat
■ >200 ml: detrusor weakness, neuropathy, meds, fecal impaction
○ Cotton swab test
○ Cough stress test
○ Cystoscopy
○ Urodynamic studies
○ Labs: UA, Urine C&S, Serum glucose and Ca if polyuria, Renal Function Test , B12 if retention, urine
cytology
● Treatment
○ Contributing Factors
■ Environment: adequate access
■ Mentation: prompted toileting
■ Manual Dexterity
■ Optimize medical conditions: HF, COPD, Cough
■ Mindful Medications
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 ■ Mobility: adaptive environment
○ Life modifications
■ Weight loss… stress>urge
■ Dietary changes ..ETOH, Caffeinated, carbonated beverages , not more than 64 oz of liquids,
avoid beverages before bedtime
■ Treat constipation, bladder pressure, urethral obstruction
■ Smoking cessation
○ Pelvic Floor Exercises (Kegel Exercises)
■ All types
■ Inhibits detrusor contractions
■ 8-12 contractions for 8-10 seconds each TID for 15-20 weeks
○ Bladder training
■ Urge incontinence, stress
■ Timed Voiding…voiding diary and then schedule
■ Can take 6 weeks
○ Topical Vaginal Estrogen
■ For stress and urge incontinence with vaginal atrophy
■ 3 months
○ Stress incontinence tx
■ Pessaries … especially in prolapse
■ Pharmacologic: no FDA approved drugs! ****
■ Duloxetine
■ Mechanical Devices
■ Surgery…high cure rates in SUI
○ urgency/OAB tx
■ Antimuscarinics
● Tolterodine {Detrol}
● Oxybutinin*** fewest SE of dry mouth and constipation
● Darifenacin {Enablex}
● Trospium {Sanctura}
● Fesoterodine {Toviaz}
● Solifenacin {Vesicare}
● SS:Dry mouth, Constipation, Blurred vision, Tachycardia, Drowsiness, Decreased
cognition
■ Beta-3 Agonist: Mirabegron SE: hypertension, HA, Tachycardia, AF
■ Acupuncture, botulinum toxin (detrusor muscle), nerve stims
■ Surgery
○ Overflow incontinence
■ Bladder Outlet obstruction
● Previous sx
● Large cystocele or uterine prolapse
■ Detrusor Underactivity
● Stop drugs
● Treat constipation
● Sacral nerve stimulation
● CIC…clean intermittent catheterization

8
 ● CIC for spinal cord injury
● Cognitive impairment and incontinence
○ Look for other factors: functional, comorbidities, medications
○ Goals of care : End of Life
○ Non pharm: prompted voiding, scheduled toileting
○ Drugs should be used with caution due to side effects
○ Chronic Foley
■ EOL, Sacral Ulcers, Chronic retention, Bacteriuria

distinguish among the types of dementia

● Vascular neurocognitive disorder (VND) → vascular dementia
○ Cognitive deficits secondary to vascular damage in the brain
○ No specific neuropsychological profile
○ Impairments correlate areas of ischemia, bleed, vasculitis
■ CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and
leukoencephalopathy)
● Inherited: small vessel stroke, progressive dementia, extensive white matter changes
seen in MRI
○ Abrupt onset
○ Stepwise deterioration or gradual
○ Imaging: Cortical or subcortical changes on MRI
○ Gait disturbance: increased tone, DTR, +Babinski, gait apraxia “magnetic gait”
○ Emotional lability with depressive mood, weeping or laughter, delirium
○ Personality changes: apathy, disinhibition, or worsening of egocentricity, paranoia, irritability
● Lewy Body Dementia
○ 2nd most common dementia
○ DEMENTIA PLUS AT LEAST ON OF THE FOLLOWING
■ Fluctuating mental status with deficits in attention
■ Detailed visual hallucinations (see little people)
■ Parkinsonian signs : facial immobility, axial instability, TD
■ REM sleep Disorder
■ Severe sensitivity to neuroleptic medications
■ Delusions
■ EPS
■ Visuospatial disparities are out of proportion of the cognitive deficits
■ Syncope ,transient LOC
■ Falls
○ Presence of parkinsonian rigidity and bradykinesia at time of the dx of dementia may clue you to LBD.
○ Pill rolling tremor is usually present prior to cognitive impairment
○ Eosinophilic inclusion bodies : LEWY BODIES: found in the basal ganglions

9
● Frontotemporal dementia: Pick’s disease
○ Age of onset 50-60 ; Third most common; Consider genetic testing
○ Atrophy in the frontal & temporal lobes of the brain, Spares parietal and occipital lobes
○ Memory and Visuospatial spared which can tell apart from AD
○ Problems with behavior, insight, judgement more than memory
○ 3 Main types
■ Behavior variant frontotemporal dementia (bvFTD): Prominent changes in personality,
interpersonal relationships and conduct , or executive function
■ Primary progressive aphasia (PPA):
● Affects language skills, speaking, writing and comprehension
○ Disturbances of motor (movement or muscle) function.
■ Amyotrophic lateral sclerosis (ALS),
○ Behavioral symptoms
■ Disproportionate impairments in reasoning and judgement
■ Problems with executive function
■ Perseveration
■ Social disinhibition
■ Compulsive eating
■ Utilization behavior
○ Language symptoms
■ Aphasia, dysarthria (physical ability to speak properly is impaired (e.g., slurring), Message is
normal)
○ Emotional symptoms
■ Apathy, emotional (pseudobulbar affect), social-interpersonal
○ Movement symptoms
■ Dystonia, tremor (shakiness, usually of the hands), clumsiness, apraxia, neuromuscular weakness
● Wernicke/Korsakoff Syndrome:
○ Vit B1 thiamine deficiency, ETOH use, severely malnourished, dialysis
○ Anterograde amnesia: vivid confabulation (make up stories)

10
 ○ Doesn’t really respond to thiamine therapy
● Creutzfeldt -Jakob Disease (CJD) aka mad cow disease
○ Rare and fatal neurologic disorder caused by prion
○ One form is related to bovine spongiform encephalopathy called Mad Cow Disease
○ Rapidly progressive with myoclonus( involuntary muscle jerk) and progressive motor dysfunction
○ akinetic mutism in late stages
○ Dx: CSF, Biopsy, Autopsy
○ No treatment, death is in one year
● Huntington’s Chorea
○ Triad: emotional, cognitive and motor disturbances
○ Motor: (choreiform movements) dance like involuntary movements, clumsiness, slurred speech
● Chronic Traumatic Encephalopathy (Dementia Pugilistica): cognitive, behavioral, motor
● AIDS dementia
○ like AD, including the plaque deposits

Manifestations of fecal impaction

● Person’s inability to sense and respond to the presence of stool in the rectum
● Symptoms: pain ,vomiting, nausea, diarrhea
● DX: DRE, Abdominal X-Ray
● Management:
○ Disimpaction
○ Bowel regimen
● Bowel Obstruction:
○ Causes: Direct intraluminal obstruction by tumor, malignant infiltration of the bowel wall, external
compression of the bowel wall, dysmotility, fecal impaction, adverse effects of radiation treatment,
volvulus, and adhesions from previous surgeries
○ Up to 50% of patients with ovarian and GI cancers have malignant bowel obstruction
○ Patients diagnosed with malignant bowel obstruction have a median survival of 3 months
○ High symptom burden with hypersalivation, nausea, vomiting, colicky abdominal pain, anorexia, and
weight loss
○

Common Cancers in the elderly

● Melanoma
○ Begin as pigmented macules and become more irregular or color and may become elevated
○ Depth of invasion: critical prognostic factor
■ Breslow thickness scale used for invasion depth
○ Clinical criteria
■ Diameter larger than 6 mm
■ Variation in color (red, white, and blue areas within a brown-black lesions),
■ Irregular border, and irregular surface topography
○ Four classes of tumor, node, metastasis (TNM) classification
● Lentigo Maligna Melanoma (5 %)
○ Mostly in elderly
○ Peaks 70s-80s
○ Better prognosis than other melanomas

11
● Skin cancer is almost 20 times more common in older adults than in those who are middle-aged.
○ If an older adult has had prior skin cancer or multiple actinic keratoses, he or she is at higher risk for
additional skin cancers
■ Actinic keratosis
● Direct precursors to invasive squamous cell
carcinoma
● Appears at sun-exposed areas
● Appear as rough, gritty, scaly, pink-red, poorly
circumscribed macules
● Slightly tender w/ keratotic horny projections
● Treatment:
○ Cryotherapy or topical chemotherapy with fluorouracil, masoprocol, or imiquimod
cream
● Basal Cell Carcinoma
○ Most common human malignancy
○ Low incidence of metastasis
○ Symptoms:
■ Begins as smooth firm papules in sun exposed areas, not usually
pigmented
■ Pearly or translucent w/ overling telangiectasias
○ Treatment:
■ Surgical resection
■ Moh’smicrographic surgery
● Breast cancer
○ Screening: discuss the pros and cons of mammography every 2 years (≥ 10-year life
expectancy), Perform clinical breast exam (CBE) periodically
■ Might not be beneficial for women >75 years
■ women with < 10 years of remaining life expectancy are exposed to immediate harms of
screening with little chance of benefit
● Colorectal cancer
○ Screen in those 50-75 with average risks
■ Stool based tests (every year: gFOBT, FIT, every 1 or 3 years: FIT-DNA)
■ Direct visualization tests (every 10 years: Colonoscopy, every 5 years: CT colonography, Flexible
sigmoidoscopy; or Flexible sigmoidoscopy every 10 yr plus FIT every year)
○ screening adults 76-85 yrs should be individualized taking into account patient health and screening
history
○ Not recommend screening adults ≥85 yr old, because risks outweigh benefits (risk of
Perforation, dehydration)
○ Important to consider life expectancy before recommending colorectal screening because those with <
10 years of remaining life expectancy have little benefit
● Cervical cancer
○ stopping screening after age 65 for women who have had adequate prior screening regardless of sexual
history or new sexual partners and are not otherwise at high risk of cervical cancer
○ Adequate screening = Three consecutive negative or 2 consecutive negative HPV results within 10 years
before cessation of screening, with the most recent test within 5 years

12
 ○ high-grade cervical lesions significantly declines after middle age (SOE=A) and that the risk of false-
positive tests resulting in invasive procedures is increased
○ Older women who have undergone total hysterectomy with removal of the cervix and who do not have a
history of cervical intraepithelial neoplasia grade 2 or 3 or cervical cancer should not be screened
● Prostate cancer
○ discussing potential benefits and possible harms of screening with men >50 years who have >10-15 year
life expectancy
● Lung cancer
○ annual screening for lung cancer with low-dose computed tomography (LDCT) in adults 55–74 years old
or 55–80 years old who have a 30 pack-year smoking history and currently smoke or have quit within the
past 15 years is now recommended (SOE=A)
○ Screening should stop when a patient has not smoked for 15 years or life expectancy has declined such
that curative lung surgery would not be performed

The common skin manifestations among the elderly

● Intrinsic (Natural aging process)
○ Collagen production slows
○ Elastin: (the substance that enables skin to snap back into place)has a bit less spring
○ Dead skin cells do not shed as quickly
○ While these changes usually begin in our 20s, the signs of intrinsic aging are typically not visible for
decades.
○ Skin is thin, pale, lax
■ Loss of underlying fat, leading to hollowed cheeks and eye sockets as well as noticeable loss of
firmness on the hands and neck
■ Bones shrink away from the skin due to bone loss, which causes sagging skin
○ Nail plate thins, the half moons disappear, and ridges develops
○ Decreased maximal function
○ Decreased reserve capacity
○ Increased fragility
○ Decreased immune response
○ Thermoregulation, wound healing, epidermal turnover
○ Structurally skin
■ Thinned epidermis
■ Decreased vascularity
■ Thinning appearance of skin

Diagnosing skin disorders in the elderly

● Complete medical history, paying particular attention to the medications being taken
● Bathing habits and exposure to harsh detergents and other irritants
● Entire cutaneous surface should be examined with adequate lighting
● Key points:
○ Scabies should be considered in the differential diagnosis of older adults with
a nonspecific pruritic skin irritation.
○ Bullous pemphigoid is the most common immune-mediated blistering
disease affecting older adults; the lesions are typically noted on the trunk and
extremities.

13
Herpes zoster
● Following initial infection (varicella), VZV establishes permanent latent infection in dorsal root and cranial nerve
ganglia
● Years to decades later VZV reactivates and spreads to skin through peripheral
nerves causing pain and a unilateral vesicular rash in a dermatomal distribution
● Advancing age: great risk factor for reactivation of latent VZV with increasing
morbidity
● Dysesthesias(tingling) precede eruption of macules to papules into vesicles
● Affects unilateral dermatomal distribution
○ If vesicles appear more than 20in an outside dermatome, it is termed
disseminated zoster and requires hospitalization
● Thoracic dermatomes mostly affected
● Postherpetic neuralgia occurs with increasing incidence with advanced age. Its severity and duration are
particularly more marked with increased age as well.
● Diagnosis:
○ Clinical
○ Tzanck smear
○ Viral cultures
○ Immunoperoxidase, immunofluorescence
○ Enzyme immunoassay
● Vaccine:
○ Zoster vaccine live (ZVL, Zostavax) has been in use since 2006
○ Recombinant zoster vaccine (RZV, Shingrix), has been in use since 2017 and is recommended by ACIP as
the preferred shingles vaccine… 2 doses

Manifestations and management of BPH

● Leads to urinary retention
● Treatment
○ Tamsulosin (flomax) - symptoms relief “to maximize flow”
○ Finasteride - size reduction
● TCAs are inappropriate in a pt with BPH

End of life management/hospice care

● Hospice: Specialized palliative care limited to patients who meet two criteria:
○ Their life expectancy is <6 months if their disease takes its natural course,
○ They (or their proxies) have elected to focus on comfort measures and forgo curative treatment
● Has to validated by two health care professionals
● Patients agree to forego curative treatments* and agree that the care plan for the terminal illness will be managed
by hospice
● Palliative care on the other hand is offered simultaneously with all other appropriate medical treatment
● End of life signs
○ Constipation
○ Nausea and vomiting
○ Diarrhea
○ GI obstruction
○ Anorexia and cachexia
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 ○ Delirium
○ Dyspnea
○ Cough
○ Loud respiration
○ Depression
○ Enteral feeding is not recommended at the end of life as it does not improve quality of life (at the end of
life don’t really feel hungry)

assessing nutrient intake

● Anthropometrics
○ Anthropometric measurements are often used for assessing nutritional status of older adults
○ Includes measures of weight and height: Body mass index (BMI) = weight in kg/height in m2
○ Unintended weight loss of 10 pounds in the preceding 6 months is a useful indicator of morbidity
○ Predictive of: Functional limitations, Health care charges, Need for hospitalization
● Nutritional intake
○ Inadequate nutritional intake has been defined as average intake of food groups, nutrients, or energy 25%
to 50% below a threshold level of the RDI(recommended daily intake)
○ Problems with obtaining food commonly contribute to inadequate nutritional intakes among older adults
● Labs
○ Albumin: The prognostic value of low albumin (<3.5 g/dL) is used as a marker for injury, disease, or
inflammation, risk indicator for morbidity and mortality
○ Serum cholesterol: Low cholesterol levels (<160 mg/dL) are often detected in individuals with serious
underlying disease such as malignancy, may reflect a pro-inflammatory condition, community-dwelling
older adults with both low albumin and low cholesterol have higher rates of morbidity and mortality than
those with either low albumin or low cholesterol alone
● Drug nutrient interactions
○ Certain medications, such as digoxin and phenytoin, even at therapeutic levels, can cause anorexia in
older adults
○ Some medications can reduce intake by causing inattention, dysphagia, dysgeusia, or xerostomia
○ Medications that precipitate constipation can also reduce appetite
● Multi-item tools for nutrition screening
○ The Nutrition Screening Initiative:
■ Three interdisciplinary tools to screen for nutrition risk and help evaluate the nutritional status of
older adults
■ Identifies risk but does not diagnose malnutrition
○ Mini-nutritional assessment
■ Evaluates the risk of malnutrition among frail older adults
○ Simplified Nutrition Assessment Questionnaire
■ identifying those at risk of weight loss

measurement of prognosis/management of osteoporosis/screening for osteoporosis

Osteoporosis
● Compromised bone strength
● BMD of -2.5 DD or more below that of your individual→ T SCORE
● Score between -1 to -2.5 SD→ Osteopenia
● Risk factors:

15
 ○ Female gender
○ Age
○ Family history of osteoporosis or fracture
○ Small body frame and low body weight
○ Caucasian, Asian, or Hispanic/Latino (although African Americans may also be at risk)
○ History of fracture
○ Low levels of sex hormones
■ Low estrogen levels in women, including menopause
■ Low levels of testosterone and estrogen in men
○ Diet→ Low calcium intake, Low vitamin D intake, Excessive intake of protein,
sodium, and caffeine
○ Inactive lifestyle
○ Smoking
○ Excess alcohol use
○ Certain medications
○ Certain diseases and conditions
● Screening for Men:
○ Age ≥70 years
○ Age 50 to 69 years with clinical risk-factor profile
○ Fracture after age 50 years
○ Condition or medication (glucocorticoids) associated w/ low bone mass or bone loss
○ Being considered for pharmacologic therapy for Osteoporosis
○ Not receiving therapy (in whom evidence of bone loss would lead to treatment)
● Assessment:
○ Patient's personal and family history
○ Physical examination findings
○ Laboratory values: Vitamin D levels
○ Results of Bone Mineral Density (BMD) testing
■ -2.5SD or lower
■ BMD → femoral neck, in addition to the other validated clinical risk factors
○ FRAX TOOL
■ Incorporates non-Bone Mineral Density (BMD) clinical risk factors
■ Estimates risk and probability of fracture in the next 10 years in untreated patients ages 40 to 90
years of age.
● Diagnostic Criteria:
○ Z-SCORE: Relationship between the patient's BMD and the expected BMD for the patient's age and sex
○ T-SCORE: Difference between the patient's score and the expected norm is expressed in standard
deviations (SDs) above and below the mean
● Management:
○ Nonpharmacologic interventions:
■ Exercise
■ Other lifestyle interventions, such as smoking cessation; reduction or elimination of alcohol and
caffeine
■ Measures to prevent falls
○ Individualized pharmacologic interventions:
■ Calcium : 1200 mg/d for woman >50, men >70, 1000mg/d for men <70

16
 ■ Vitamin D3 supplementation : 800-1000 units
■ Bisphosphonates: alendronate, etidronate, ibandronate, pamidronate, risedronate, zoledronic acid
(IV)
■ Calcitonin nasal spray : Analgesic effect in acute fx
■ Raloxifene(selective estrogen receptor modulator)
■ Teriparatide(parathyroid hormone)
● Measurement of Prognosis:
○ Changes in bone mineral density
○ Improve in mobility and daily functioning
○ Decrease degree of pain
○ Decrease incidence of serious complications, such as fractures

assessing a patient of chemotherapy

hearing assessment
● Age related changes that can interfere w/ hearing
○ External ear canal: Walls become thin
○ Cerumen: Becomes drier, more tenacious increasing likelihood of impaction
○ Eardrum: Thickens, appears duller
○ Cochlea: Hair cells and fibrocytes in the organ of Corti are lost, basilar membrane stiffens, auditory
structures calcify, cochlear neurons are lost
○ Stria vascularis: Capillaries thicken, endolymph
production decreases, Na+ K+ ATPase activity
decreases
● Types of hearing loss:
○ Conductive
■ cerumen impaction/FB
■ Otosclerosis→ bone harding
■ Cholesteatoma→ tumor
■ Tympanic membrane perforation
■ Middle ear effusion
○ Sensorineural
■ Most often from age, noise damage, or ototoxicity(mycin drugs & lasix)
■ presbycusis→ symmetrical
■ Cochlear disease
■ Genotype
■ Vascular disease
○ Mixed
● Tools to test hearing:
○ Audiogram: graph representing hearing thresholds
● Hearing loss detection
○ Hearing Handicap Inventory for the Elderly—Screening Version
○ Whisper Test: performed from 2 feet away
○ Handheld otoscope with a tone generator
○ Apps and online hearing tests
● Evaluation:

17
 ○ Examine ear canals with otoscope to exclude obstruction such as cerumen impaction or effusion; loss of
about 40 dB
○ Review medication list for potential contributors
■ Aspirin
■ Nsaids
■ Loop diuretics (furosemide)
■ Antibiotics (aminoglycosides ex: gentamicin, streptomycin, neomycin)
■ Cancer rx: cyclophosphamide, cisplatin, bleomycin

sleep apnea and it’s implications on sleep and pt well-being

● 5 apneic or 10 hypoapneic/apneic episodes /hour
● Two types:
○ Central→ cessation of respiratory effort
○ Obstructive Sleep Apneas → Airflow cessation due to upper airway closure despite
adequate respiratory muscle effort
■ Mild: Apnea-Hypopnea Index (AHI 5-15)
■ Moderate : 15-30
■ Severe : >30
○ Mixed: features of both
● Factors: Male sex, obesity, hypothyroidism, COPD, Neurodegenerative disorders, CVA/HF,
HTN, A.fib, Asian, hypothyrodism, ↑neck circumference, smoking, fam hx,
● Altered cardiopulmonary function
● Predicts future strokes and cognitive impairment
● All cause mortality
● Clinical features:
○ Excessive Daytime sleepiness
○ Snoring
○ Choking or gasping on Awakening
○ Morning headache
○ Nocturia
● Evaluation:
○ Epworth Sleepiness Scale
○ documents daytime sleepiness
● Management:

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significant side effects of some of the medications commonly used by the elderly/ The assessment of medications used
by elderly: SE and contraindications
Osteoporosis drugs:
● bisphosphonates:
○ Alendronate: Avoid in cr clearance 35 ml/min, CI in GERD
○ Risedronate : Hypersensitivity, Inability to sit or stand upright for 30 minutes creatinine clearance <30
mL/min
○ bandronate : creatinine clearance <30 mL/min
■ Zoledronic Acid (derivitative): hypocalcemia , hypersensitivity, CrCl<35 mL/min
● Calcitonin : HSN
● Raloxifene : h/o venous thromboembolism or retinal vein thrombosis.
● Teriparatide : Hyperparathyroidism or hypercalcemia , Bone metastases or skeletal malignancies
● Boxed warning for those at increased risk of osteosarcoma (patients with Paget's disease, increased alkaline
phosphatase, open epiphyses or prior external beam or implant radiation therapy of the skeleton)
Urinary Incontinence meds:
● Antimuscarinics
○ Tolterodine {Detrol}
○ •Oxybutinin*** fewest SE of dry mouth and constipation
○ Darifenacin {Enablex}
○ Trospium{Sanctura}
○ Fesoterodine{Toviaz}
○ Solifenacin{Vesicare}
● Beta-3 Agonist: Mirabegron SE: hypertension, HA, Tachycardia, AF
Meds that can cause UI:

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Medications to Avoid in the Older Adults:
● Alprazolam (Xanax),Diazepam (Valium), Benadryl, Ambien→ ↑risk of falls
Drugs that impair temperature regulation:
● anticholinergic drugs and many antipsychotic medications
○ chlorpromazine (1stgen.), ETOH, ASA, Tylenol
DRUG TREATMENT FOR UNDERNUTRITION SYNDROMES:
● Mirtazipine: Caution with doses >15 mg/d due to hepatic and renal insufficiency
● Cyproheptadine: Can cause confusion
● Megestrol: On Beers List. Increased risk of DVT, fluid retention, edema, and CHF exacerbation. May negate effects
of exercise on strength and function
● Dronabinol: Somnolence and dysphoria
● Human Growth Hormone: Contraindicated in cancer states. Hyperglycemia and fluid retention
● Anabolic Steroids: no significant improvement in strength, function, or a reduction in fractures

vestibular deficit, visual deficit, somatosensory deficit

● Cataracts
○ Opacity or clouding of the lens on exam
○ Tx: Surgery (90 % ACHIEVE 20/40 VISION)

● Age related macular degeneration

○ Degenerative changes to the central macular area of the retina that result in atrophy, hemorrhage,
exudates, fibrovascular scars, or cyst formations , yellow plaques: drusen
○ Visually: distortions, decrease in the visual acuity, decrease in color recognition, loss of contrast, absolute
or relative area of no vision (scotoma)
○ Types: DRY vs. WET

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 ■ DRY: 90%, slow gradual vision loss, may convert to wet form, retinal pigment with drusen
■ WET: Neovascular type, rapid visual loss, early intervention from dry to wet saves vision.
○ Tx: AREDS2 preparation
● Glaucoma
○ Optic cupping and nerve damage ; loss of peripheral
visual fields
○ Increased IOP (intraocular pressure)
○ Primary open angle glaucoma MC
● Diabetic retinopathy
○ Microaneurysms, Dot/Blot Hemorrhages, Proliferative
Retinopathy. Ischemia, Vitreous hemorrhage
○ Splotched patches in visual fields
Tx: Tailor glycemic control based on comorbidities and life expectancy
● Red eye
○ Eye with vascular congestion, acute and allergic conjunctivitis, symptoms of photophobia
● Dry eye syndrome
○ Sx: Itchy, sandy eyes, visual disturbance
● Vestibular deficits
○ Presyncope
■ Prodrome of fainting or near faint
■ Orthostatic hypotension
○ Disequilibrium
■ Sense of imbalance with walking
○ Syncope
■ Abrupt and transient loss of consciousness associated with absence of postural tone
■ Complete and usually rapid spontaneous recovery
■ Classification: vasovagal, cardiac, orthostatic medication induced, seizure, stroke TIA, others
● Somatosensory deficits
○ Peripheral sensory problems (e.g., visual, proprioceptive) → high-stepping or
slapping gait
○ Rhomberg testing with the patient’s eyes closed (cerebellar, dorsal column, and proprioception function
○ Check sensation—light touch , vibration, proprioception
○ Standing or walking tandem (heel-to-toe) is a sensitive screening test 20% can do this task without
difficulty
○ Stand on one foot
○ Berg Balance Scale (time consuming…for PT)
○ Functional reach

physiological deficits with age and Normal aging vs loss of function due to pathologies
● Normal age related physiologic change and their consequence
○ Arterial stiffening → HTN
○ Absence of estrogen → osteoporosis
○ Not all changes are bad
■ Autoimmune disease MAY “burn out” in later life
● Loss of homeostatic reserve → hyperthermia
○ Best example of loss of homeostatic reserve: temperature dysregulation

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● Cardiovascular system
○ Delay in LV filling, depends on diastolic atrial contraction for filling → S4
○ Resting HR decreases, decreased adrenergic response
○ LA, LV Mass size increases, LV Compliance reduced
○ MV/AV stiffen, decreased arterial wall compliance
○ Aorta dilates, walls thicken and medial walls calcify
○ Systolic pressures increase and fall slightly in the 80-90s, Diastolic pressures increases with weight and
then decrease.
○ HR decreases due to the loss of sinus node pacemaker cells up to 90%
○ Pathology
■ Atherosclerosis
■ Vascular stiffness—causes LV stiffness, impaired diastolic filling DIASTOLIC HF, HTN
■ Cardiac Output decreases
■ Maximal HR decreases
■ MC Arrhythmia: Atrial Fibrillation
■ Postural hypotension: large meals, infections which depress water and salt intake, volume
depleting stressors
■ Narrowed homeostatic capacity: PH, SE of meds, CV instability during illness.
● Respiratory system
○ Age related changes can resemble emphysema
○ Stiffening of chest wall and muscle weakness
○ Decreased flow rates, FEV1, and Vital Capacity
○ Loss of elastic recoil → barrel chest
○ Maximum breathing capacity..40% ↓
○ 50% ↓ in O2 and CO exchange capacity
○ Dyspnea is mainly due to age related mechanical changes that occur and inability to clear blood from
lungs and a decline in resting pulmonary function to hypoxia
○ Pathology
■ Early appearance of dyspnea
■ Indicate a warning signal for underlying medical conditions: MI< CHF, COPD, PE, cancer
● Gastrointestinal system
○ Broad series of changes
○ Symptoms are usually delayed due to the redundancy of overall GI function
○ Slower production of dentine
○ Root pulp shrinkage
○ Jaw bone density ↓
○ Taste and Smell ↓ with rising threshold for salt, sweet, and certain proteins
○ Decreased gastric emptying
○ Liver weight declines
○ Reduction in small intestine surface area → Decline in Colonic function
○ Motility to rectosigmoid area not affected
○ Distally ..its slowed
○ Stool frequency declines
○ Hardness increases
○ Diverticula increases due to decreased fiber intake and greater pressure in the colonic tissues
○ Pathology
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 ■ Periodontal disease, GERD, colon cancer, constipation, gastric empty delay/early satiety, hepatic
metabolism, diverticulosis/diverticulitis
■ Signs of obstipation: delirium, nausea, and vomiting
● Renal and urinary system
○ 1/3 decrease in renal size
○ Blood flow decline 1%/year
○ Cortical nephrons vs. Medullary nephrons
■ Decrease salt excretion, Dec GFR, Dehydration
■ Cortical nephrons drop out and sclerose more than medullary →
hyperfiltration syndrome which limits concentrating capacity
○ Bladder more irritable
○ Delay in salt excretion /orthostatic changes
○ Increased bladder residual volume
○ Atrophy of urethral and vaginal tissues
○ Enlarging prostate gland
○ Asymptomatic bacteriuria and UTI
○ Pathology
■ Dehydration increases morbidity…mc disorder
■ Vomiting/diarrhea → isotonic dehydration
■ Fever → hypertonic dehydration
■ Diuretics → hypotonic dehydration
■ UTI
● Endocrine system
○ Growth hormone, renin, starts to fall
○ Thyroid hormones and calcitonin constant
○ PTH levels increase in women
■ May be related to the renal ability
○ Adrenal glands …same
○ Dehydroepiandrosterone declines up to 90%
■ Decreases immune and cardiac function
○ Insulin content is increased but response blunted
○ Ovaries… estrogen, progesterone, prolactin
○ Testosterone …declines
○ Thyroid disease increases with age
○ Pathology
■ Menopause…most common
■ Hyperparathyroidism
■ Osteoporosis
■ GH: Decreased muscle strength, thinning bones/skin, increased fat
■ Dehydroepiandrosterone …immune and CVS
■ Sexual function preserved but increase in refractory period, time to arousal and loss of tissue
turgor
● Age related immune system and syndrome
○ Decreased size of thymus
○ Antibody responses are less robust and less long lasting, autoantibodies increase with age
○ Decreased functional T-cell & B-cell

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 ○ Increased mortality/morbidity with Flu/PNA/C diff
○ Reactivation of infections: TB, HZV
○ Good Thing: less chance of autoimmune diseases!
● Hematopoietic system and age related syndrome
○ No change in pluripotent stem cell, erythroid, myeloid cells
○ Less able to respond to demands
○ Older marrow responds less to erythropoietin
○ Less potency of neutrophils
○ No specific syndromes, clinical observance of impaired hematopoiesis during stress
● Musculoskeletal system and syndrome
○ Weight / Height decreases
○ Body Fat increases
○ Bone loss post menopause
○ Loss of elasticity in tendons and ligaments
○ Loss of muscle mass pathologies
■ Osteoporosis, sarcopenia (up to 80%), falls, OA, RA, fracture
● Nervous system
○ Anatomical brain decreases after 60
○ Cerebral blood flow decreases by 20%- age 30-70
○ Sleep patterns tend to change, resulting in a decrease in Stage IV (deep) sleep, an increase in Stage I
(light) sleep, and an increase in the number of nighttime awakenings.
○ Prone to subdural hematomas
○ Delirium in response to stress
○ Pathology
■ Sleep apnea
● Integumentary system
○ Thinning of subcutaneous tissue
○ Dermis and epidermis adhere loosely so skin feels looser and tendency to blister
○ Risk for friction burns, ulceration
○ UV light increases the risk of skin cancer
○ Wound repair rates are increased
○ Changes in skin cell size and shape
○ Pathology
■ Basal Cell Ca ■ Skin thinning, hair loss
■ Rosacea ■ Diminished sweating poses
■ Xerosis threat
■ Thermoregulatory changes ■ Pressure sores
● Vision
○ Decreased visual acuity due to narrow pupils, fewer rods
○ The lens tends to yellow and opacify, which influences color perception.
○ There is a decrease in light and dark adaptation.
○ The lens tends to lose elasticity, which increases the distance of focusing.
○ Less neurotransmitter synthesis and receptors
○ Eye lens thicken and stiffen—farsightedness
○ Reduced ability to see colors
○ Decline in the transmission of light

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 ○ Vitreous jelly become liquefied and mobile
○ There is a decline in contrast sensitivity and an increase in sensitivity to glare
○ Pathology
■ Cataracts, glaucoma, macular degeneration
● Hearing
○ Presbycusis: high sound frequencies lost, impaired speech discrimination
■ Sensorineural hearing loss
■ Hearing loss may result in depression, social isolation, and other psychosocial and functional
problems
○ Excess cerumen which occludes the ear canal
○ Hair cells tend to be lost in the organ of Corti.
○ Cochlear neurons tend to be lost.
○ Stiffening, thickening, and calcification occur in multiple components of the auditory apparatus.
● Oral cavity
○ 40 % of >65 year olds are edentulous… mostly due to neglect
○ Risk of Caries
○ Gingival Recession
○ Loss of jaw bone density
○ Older persons may have decreased sensitivity to taste.
○ Most loss in the sense of taste occurs as a result of medications or systemic illness decrease in appetite
and weight loss

medications associated with reduced incidence of delirium post-operatively

● MC complication on post surgical older adults
● 7 causes : advanced age, dementia, functional impairment, ETOH abuse, electrolyte abn, intrathoracic sx, AA sx
● Peak incidence 2nd post op day
● Post op meds: benzos, opioids especially meperidine (should not be given to elderly)
● Low hematocrit, especially <30%
● CABG increased risk
● Nonpharmalogic management
○ Ensure safety
○ Sitters: family members as first line
○ Physical restraints
● Pharmacologic management (antipsychotics)
○ Haldol
■ Need rapid control, relatively nonsedating, few hemodynamic effects, QT prolongation (avoid IV
use), check EKG
○ Quetiapine - LBD, PD, AIDS related , or EPS, and delirium
○ Olanzapine
○ Risperidone

Wills and power of attorney

● Both are advanced directives which are legal documents that allow you to spell out your decisions about end-of-
life care ahead of time
● living will: is a legal document used to state certain future health care decisions only when a person becomes
unable to make the decisions and choices on their own. The living will is only used at the end of life if a person is

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 terminally ill (can't be cured) or permanently unconscious. The living will describes the type of medical treatment
the person would want or not want to receive in these situations. It can describe under what conditions an
attempt to prolong life should be started or stopped. This applies to treatments including, but not limited to
dialysis, tube feedings, or actual life support
● Medical power of attorney: legal document in which you name a person to be a proxy (agent) to make all your
health care decisions if you become unable to do so. Before a medical power of attorney can be used to guide
medical decisions, a person's physician must certify that the person is unable to make their own medical
decisions

Meds used to Manage dyspnea

● Treat underlying cause, but do not delay symptom management
● Opioids are the most effective treatment agent (ex. morphine). Act by decreasing the perception of dyspnea and
do not affect respiratory drive. Both oral (sublingual) and parenteral formulations are effective
● Use O2 if saturation < 90% but use cautiously with patients who retain CO2
● Cool air across the face by fan or an open window to stimulate 5th cranial (trigeminal) nerve & reduce dyspnea
● Benzodiazepines control anxiety but not dyspnea

Reducing the risks of falls

● A fall has occurred when an individual comes to rest inadvertently on the ground or to a lower level without LOC
● USPTFS 3 risk factors for falls
○ History of falls
○ History of mobility problems
○ Poor performance on the timed Get up and go Test
● Risk factors include the use of psychotropic drug
● Modifiable risk factors
○ Polypharmacy
○ Gait problems: exercises, Tai Chi
○ Vision; hearing: first cataract surgery; glasses, hearing aids
○ Postural hypotension: no real evidence ; vol, salt, stockings, Florinef
○ HR/Rhythm Abnormalities
○ Vitamin D deficiency: 800-1000 IU
○ Foot Wear
○ Home Hazards
● Prevention
○ Review medical status and medications
○ Home Assessment
○ Home Modifications
○ Timely PT/OT evaluations and treatment
■ Aerobic, resistance training, gait and balance training

ADL
● BATTLE: Bathing, Ambulation (getting around inside), Toileting, Transfers (getting out of bed), Eating, Dressing
● Maintaining incontinence, grooming

Grieving

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Montreal Cognitive Assessment Test (MOCA)
● Out of 30, <26 concerning
● Includes: visuospatial/executive, naming, memory, language, abstraction, delayed recall, (orientation optional)

Minnesota Multiphasic Personality Inventory – II

● most widely used psychometric test for measuring adult psychopathology in the world
● screen for personality and psychosocial disorders in adults (i.e., over age 18) and adolescents age 14 to 18. It is
also frequently administered as part of a neuropsychological test battery to evaluate cognitive functioning.
● assessing mental health problems (i.e. depression, anxiety, post-traumatic stress disorder), personality
characteristics (i.e. psychopathy) and general personality traits such as anger, somatization, hypochondriasis,
‘type A behaviour’ addiction potential, poor ego strength and many others.

Thematic Apperception Test

● is a projective psychological test intended to evaluate a person's patterns of thought, attitudes, observational
capacity, and emotional responses to ambiguous test materials.
● Evaluates personality and should not be used in the differential diagnosis of mental disorders

Wechsler Adult Intelligence Scale

● an intelligence test, any score from 90 to 109 is considered to be in the average intelligence range.

Get-up-and –Go Test

● Technique: Direct patient to do the following
● Rise from sitting position → Walk 10 feet → Turn around → Return to chair and sit down
● Interpretation
○ <10 seconds: Normal
○ ≥14 seconds: Indicates high risk for falls
○ <20 seconds to complete test: Adequate for independent transfers and mobility
○ >30 seconds to complete test: Suggests higher dependence and risk of falls

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The use and value of the clock test (mini cog)
● Clock draw and the 3-item recall : very sensitive
● screen people for signs of neurological problems, such as Alzheimer’s and other dementia
● measure of spatial dysfunction and neglect
● 1. recall 3 words (out of 3)
● 2. clock drawing test (out of 2, all or none)
● total out of 5, anything under a 3 needs further cognitive testing

Medical and psychiatric evaluation

Assessing for dementia

● Be alert with early symptoms so that you can
anticipate the progressive stages and decline ◊
● Consensus guidelines for diagnosis… not so
much for treatment!
● Interview and clinical assessment of both
patient and reliable informant! In the office
● Functional status
● Patterns of alcohol use
● LABS
○ CBC, TSH, B12, Folate, Serum Calcium, LFTs, Renal function tests, Electrolytes, HIV, ? Syphilis,
○ Genetic testing, and commercial Alzheimer blood tests?
○ Identifies reversible causes!
● NEUROIMAGING
○ Not really recommended
○ Consider if <65, symptoms <2 years, focal/asymmetric deficit, NPH, recent fall or head trauma.
○ CT without contrast, MRI , PET only if dx is uncertain after routine testing!
○ Role of EEG—J-C, or other viral encephalopathies
● COGNITIVE TESTING
○ Influenced by educational level
○ Increase efficacy of testing by evaluating everyday memory function

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 ● MINICOG: Clock draw and the 3-item recall : very sensitive
● Mini Mental Status Exam (Copy righted)
● MOCA (Montreal Cognitive Assessment) 10 minutes, 30 questions, >26 is normal
● SLUMS = St. Louis University Mental Status Exam
● Short IQCODE = Short Informant Questionnaire on Cognitive Decline in the Elderly
● AD8 = Eight-item Informant Interview to Differentiate Aging and Dementia

Manifestations of parkinson’s dz and the associated neurotransmitters

● PD: progressive disorder of the nervous system that affects movement.
● Lewy bodies
● Have preserved recent memory
● NT: dopamine, acetylcholine
● Typical progressive motor signs and symptoms of PD (motor goes first)
○ Bradykinesia
○ Rigidity
○ Tremor resting
○ Impaired posture and balance
○ Loss of automatic movements (blinking, smiling or swinging your arms)
○ Speech changes
○ Writing changes
● General slowing and inability to perform executive function task

Work up for depression in the elderly

● Older adults are more preoccupied with somatic sx than depressed mood
● ANHEDONIA (loss of pleasure)
● DSM V criteria (may not be effective tool for eldery)
○ Depressed mood*
○ Loss of interest or pleasure in activities*
○ Weight loss/gain, increase/decrease in appetite.
○ Sleep disturbance
○ Psychomotor agitation or retardation
○ Fatigue or loss of energy
○ Feeling of worthlessness or inappropriate guilt
○ Difficulties with concentration and decision making
○ Recurrent thoughts of death or suicide
● PATIENT HEALTH QUESTIONNAIRE FOR SCREENING : PHQ-2
○ Over the past 2 weeks, have you had little interest and pleasure in doing things?
○ Over the past 2 weeks, have you often been bothered by feeling down, depressed or hopeless?
○ SCORING
■ 0 : NOT AT ALL, 1 : SEVERAL DAYS, 2 : MORE THAN HALF THE DAYS, 3 : NEARLY EVERY DAY
■ SCORE ≥ 3 HIGH PROBABILITY OF DEPRESSIVE DISORDER
● Tx: Preferred agents : sertraline and citalopram
○ First Line: SSRI ; consider Sertraline

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 ■ SSRI may manage disinhibitions and compulsive behaviors of FTD
■ Mirtazapine for sedating effects, weight gain
■ Escitalopram problem is drug-drug interactions
■ Fluoxetine has long t1/2, so taper is easier b/c in the system for a long time
● SE: Diabetes insipidus
■ Paxil has mild sedative effect
■ Trazodone is what MD uses as sleep aid (insomnia)
■ Sertraline/Zoloft is MD’s go-to drug
○ Second Line: Venlafaxine, Duloxetine, Mirtazapine, Bupropion

○ Third Line: Augment 1st or 2nd with aripiprazole or quetiapine; SSRI with buspirone, or bupropion

Management of alzheimers
● Acetylcholinesterase inhibitors
○ Donepezil (Aricept)
■ Mild to Moderate : AD
○ Rivastigmine (Exelon)
■ Mild to moderate; AD, PD
○ Galantamine (Reminyl, Razadyne)
■ Mild to Moderate; AD
■ Renal excretion
○ Side effects - nausea, vomiting, diarrhea, dizziness, headache, muscle cramps
○ Use carefully if gastric ulcer, heart disease, chronic lung disease present
○ Warn against unrealistic expectations
○ Watch for return of insight leading to depression or anxiety
● Memantine
○ moderate to severe stages of AD

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 ○ slowing in cognitive and functional decline and decrease in agitation
○ Side effects - headaches, dizziness, constipation
○ Do not use in kidney disease or seizure disorders
● Antidepressants and antipsychotics
○ Olanzapine, aripiprazole, risperidone, quetiapine
○ Antipsychotics for delusions, hallucinations, paranoia
○ DLB psychosis : rivastigmine, or one of the above
○ EPS as a side effect: tremor, rigidity

Assessment and monitoring of vision loss

● Legal blindness 20/200 or worse in the better eye
● Acuity testing
○ Near vision: Rosenbaum card held at 14’’
○ Far vision: Snellen chart at 20’
● Visual fields (Confrontation)
● Ophthalmoscopy
● Emergent referral for ACUTE VISION CHANGE
● Medication that cause visual disturbance (amiodarone, minocycline, sildenafil, tamoxifen)
● Biennial Full Eye Examinations for people over 65 year old
● Annual Exam in patients with Diabetes, and Retinopathy
● Conditions associated with visual impairment
○ Refractive Error(shape of eye that doesn’t bind light correctly)
■ Most common cause of visual impairment
■ 20% of IADL Dysfunction
○ Types
■ Myopia (nearsightedness),
■ Hyperopia (farsightedness)
■ Presbyopia (loss of near vision with age)
■ Astigmatism
○ Symptoms
■ Blurred vision is the most common symptom of refractive errors. Other symptoms may include:
■ Double vision
■ Haziness
■ Glare or halos around bright lights
■ Squinting
■ Headaches
■ Eye strain

Measurement of prognosis
● Guiding principle: Frame management decisions within the context of risks, burdens, benefits, and prognosis
● Prognosis = remaining life expectancy, functional status, QOL (quality of life)
● Discussion of prognosis can serve as an introduction to difficult conversations
○ Facilitate decision-making, advance care planning
○ Address patient preferences, treatment rationales, and therapy prioritization
● Prognosis informs, but does not dictate, management decisions within the context of patient preferences

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○ The time horizon to benefit for a treatment may be longer than the individual’s projected life span, raising
the risk of polypharmacy and drug-drug and drug-disease interactions
○ Screening tests, too, may be non-beneficial or even harmful if the time horizon to benefit exceeds
remaining life expectancy, especially because associated harms and burdens increase with age and
comorbidity

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