Geriatrics

The results of our in-service exam came back while I was at home for the holidays and I did worse this year. Boo! I guess I should pay more attention when I am taking the test, eh? But I think last year I was half asleep and I did better! Must have been from all the studying I had done for Step 3 I took the couple months before that.

Anyhow, my results for geriatrics were by far the worst. I haven't done a geriatrics rotation yet, and I'm not really looking forward to it. The rotation in my hospital hasn't exactly gotten any rave reviews, and elderly patients are often complicated. There are only so many medication, you have to wonder how it's possible to remember to take 20 or 30 pills a day.

There is a 9 page chapter on geriatrics in Harrison's. The first weird fact that I saw was that alteration of genes involved in insulin signaling often lead to life extension. What?! I never knew this. Diabetes must be the root cause of all evil. Bwahahaha!

Altering gene expression of neurons in worms has also shown to extend lifespan. They also mention the whole calorie restriction thing and the mechanism being that is thought to be related in a family of genes called sirtuins.



The Timed Get Up and Go Test is when a patient gets up from sitting, walks 3m, turns around, walks back, and sits down again. Normally this should take less than 10 seconds. Another useful test is the Mini-Cog test which gives a patient 3 objects to remember, asks them to draw a clock, and then asks for object recall. A point is given for each object, and 2 for each clock. A score of 0-2 indicates dementia.

For dementia, Harrison's recommends using olanzapine (zyprexa) or risperidone. For depression they mention citalopram. With any anti-psychotics, watch out for extra-pyramidal side effects like bradykinesia, tremor, or rigidity. Trials of reductions in medications should be tried every 6 months.

Urinary incontinence is a risk factor for falls as these patients are often getting up to go to the bathroom in the middle of the night. Before looking into the 4 classic causes of incontinence (stress, urge, overflow, or mixed) there is a good mnemonic for reversible causes of urinary incontinence. The mnemonic is DRIIIPP which is

D - delirium
R - restricted mobility (illness, injury, gait disorder, restraint)
I - infection - acute, symptomatic, urinary tract infection
I - inflammation - atrophic vaginitis
I - Impaction - of feces
P - polyuria - diabetes, caffeine intake, volume overload
P - pharmaceuticals - diuretics, alpha adrenergic agonists or antagonists, anticholinergic agents (psychotropics, antidepressants, anti-parkinsonians)

There is some talk of pressure ulcers in this chapter. An ABI < 0.4 is a bad prognostic factor as a good blood supply is needed for good wound healing. Also, a brief summary of staging ulcers is as follows:



Stage I - skin is still intact
Stage II - partial thickness ulcer that involves epidermis and or dermis that is shallow.
Stage III - full thickness skin involvement with subcutaneous tissue involvement.
Stage IV - extensive destruction with necrosis or damage to the muscle, bone, or supporting structures.