Clinical Medicine

Condition / Disease

Cause

Signs and Symptoms

Senescence

Changes that occur with age as a

result of biologic, psychologic, and
environmental factors as well as
lifestyle choices

Difficult to separate the purely biologic and

nonbiologic

Successful
(Healthy) Aging

Aging not accompanied by

debilitating disease and
disability

Challenges of
Geriatric Care

Difficulties with treating

geriatric patients

Geriatric
Screening
Tools

Quick methods of
assessing the quality of
life

Musculoskeletal
Changes in the
Elderly

Things that happen when

people get older

Skin / Hair
Changes

Things that happen when

people get older

Cardiovascular
Changes

Things that happen when

people get older

Pulmonary
Changes

Things that happen when

people get older

Maintaining an active
healthy life until death
Separating normal aging
from pathology
Multiple medications
Geriatric Depression
Scale
Activities of Daily Living Physical Self
Maintenance Scale

Do not experience many

of the unwanted
features of aging
Diversity of the elderly
population
Multiple chronic
diseases

Test

Laboratory
Result

Treatment

Medications

Other

Factors Influencing Longevity

Heredity
Lifestyle
Exposure to environmental toxins
Most elderly patients are cared for
by nongeriatricians

Get up and Go Test

Instrumental Activities
of Daily Living Scale

Folstein Mini Mental

Evaluation
Vision and Hearing Screening
(for sensory losses)
Degenerative joint
Bone mass
changes
Muscle mass
Foot problems
Decrease in stature
Lean body mass
Age Change
Bone density
Mobility
Consequence of Age
Osteopenia
Fractures
Diseases (not age)
Osteoarthritis
Wrinkling / sagging
Age Change
Hair loss and graying
Benign skin conditions
Consequence of Age
Appearance changes
Skin cancer
Diseases (not age)
Depression
Compliance
SBP
LVH
Age Change
-adrenergic
Baroreceptor and SA
node automaticity
Hypotensive
CO
Consequence of Age
Blunted stress response
Orthostatic
Syncope
Diseases (not age)
Heart failure
Heart block
Cough reflex
Age Change
FEV and FVC
Infection risk
Consequence of Age
Microaspiration
Resting PO2
Aspiration pneumonia
Diseases (not age)
Dyspnea
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Nephrologic
Changes

Things that happen when

people get older

Gastrointestinal
Changes

Things that happen when

people get older

Endocrine
Changes

Things that happen when

people get older

Immunologic
Changes

Things that happen when

people get older

Frailty
Syndrome

Endocrine changes leads

to increased
inflammation and cause
dysregulate other body
systems

Signs and Symptoms

10 mL / decade
creatinine clearance
Age Change
Sodium excretion and
conservation
Concentrating capacity
Need for medication
Consequence of Age
adjustment
Residual urine volume
UTI
Diseases (not age)
Renal failure
Incontinence
Acid
Colonic contractions
Age Change
Liver size and
blood flow
Delayed drug
Consequence of Age
metabolism
Constipation
Cirrhosis
B12 deficiency
Diseases (not age)
Osteoporosis
Fecal impaction
Postprandial glucose
impairment
Age Change
Lost nocturnal GH peaks
Testosterone
Vitamin D
Glucose with illness
Consequence of Age
Osteopenia
Diabetes mellitus
Diseases (not age)
Thyroid disorders
Impotenece
Decline in cell mediated
immunity
Age Change
Thymus atrophy
Autoantibodies
False (-) PPD
Consequence of Age
False (+) RF and ANA
Anemia
Diseases (not age)
Autoimmune disease
Muscle strength
Weight loss /
Walking speed
undernutrition /
Physical activity
sarcopenia
Endurance
Altered insulin
Altered clotting process
resistance
Micronutrient
Anemia
deficiencies

Test

Laboratory
Result

Treatment

Medications

Other

Screen to identify risk

Initiate exercise and nutrition

programs

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Dementia

Vascular
Dementia

Cause

Signs and Symptoms

Early Stage
Social interactions
Reduced verbal output
Loss of interest
Spontaneous interest
Slowed movement
Inattention
Apathy
Loss of motivation
Change of judgment
Altered concept of time
Mild memory loss
Work performance
Change in language
decline
comprehension
Obvious changes in
Hygiene changes
behavior
Irritabilty
Fear of leaving familiar places
Middle Stage
Early symptoms more
Loss of self-help skills
noticeable
Gait disorders
memory more
Change in memory and Loss of
Long periods of inactivity
pronounced
thinking significant
Visual retention deficits
Language deficits
Confusion
Disorientation
enough to interfere with
Paranoia
Delusions
daily living
Apparent non-compliant Unable to cooperate
behavior
Wandering
Infection risk
Late Stage
Loss of body function
Infections
Balance and walking
Nonambulatory
problems
Lack of recognition
Memory loss
Unable to leave alone
Need for 24 hour nursing
Weight loss
care
Risk Factors
Age
Family history
Genetic mutations for
Head trauma
Alzheimer's disease
Hormone replacement
Cardiovascular risk
therapy
factors
Education level
Risk Factors
Damage to blood vessels from
Age
History of heart attack,
small strokes reduces circulation
Atherosclerosis
strokes, or mini strokes
which deprives the brain of vital
Cholesterol
BP
Diabetes
oxygen and nutrients
Smoking
A-fib

Test

Laboratory
Result

Treatment

Medications

MMSE

Consider trial of drug therapy

MOCA

Treat underlying medical conditions

Short Blessed
"S" Words
Animals

Tacrine

Avoid using drugs with CNS side

effects

SLUMS Exam

Encourage physical and mental

activity
Memory testing Use memory aids (if possible)

Donepezil

Emphasize good nutrition

Clock Drawing

Patient and family education

Provide social service information to
patient and family

Neuro-psychological Testing

Other
Potentially Reversible or Arrestable
Conditions
Hypothroidism
Vitamin B12 deficiency
Neurosyphillis
Subdural hematoma
Vascular disease
Space-occupying lesions
Normal pressure hydrocephalus
Depression
Protective Factors
Leisure activities
Aerobic and strength training
Educational attainment
Reduction of cardiovascular factors
Head trauma protection

Rivastigmine

Provide family counseling

Wandering

Koening
Depression
Scale

Geriatric
Depression
Scale

Patient Health
Questionnaire
9

Identify and
Manage
Complications

Behavioral
disorders
Depression

Galantamine

Agitation
Mood evaluation
Incontinence
Provide ongoing care

Memantine

Medical therapy (does not stop or

reverse disease)

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Levels of consciousness
are altered

Delirium

Acute confusional state

Excessive sensitivity to
light and sounds
Inattention
Rambling speech

Increased anxiety,
Use of medications that
agitation, or aggression
increase risk
Memory changes, confusion, or
hallucinations
Hypo- /
Hallucinations ("unreal")
hyperattentiveness
Intense feelings of fear, anxiety,
and suspicion

Typical / atypical antipsychotics

CAM

Evaluation

Relief

Embarrassment

Fear

May not disclose what

happened
Confusion Assessment Method
(requires 1 and 2 with 3 or 4 for diagnosis)
Acute onset and
Disorganized thinking (3)
fluctuating course (1)
Altered level of
Inattention (2)
consciousness (4)
Changes in sleep

Changes in appetite

Poor concentration

Loss of energy

Benzodiazepines
(reserved for withdrawl / refractory
symptoms)
Reality orientation
Environment
Attend to sensory
needs

REASSURE with
Non-Drug
Approaches

Depression

Stimulating
cognitive activities
therapeutic
activities
Sufficient liquids
Use of short,
simple sentences
Reassurances
Exercise daily
Improving their
quality of life

Geriatric
Depression
Scale Modified

Goals of
Treatment

Reducing the risk

of suicide
Reducing
premature deaths

Depression

State of low mood and

aversion to activity that
can affect a person's
thoughts, behavior,
feelings, and sense of
well-being.

Lack of interest

Self-esteem

Hopelessness

Movement changes

Koenig
Depression
Scale

Thoughts of death
Etiologies
Genetic (-ish)

Stressful life changes

Medications

Alcohol

Seasonal changes

Chemical imbalance

Other
Predisposing Risk Factors (top 5)
Advanced age
Preexisting dementia
History of stroke
Parkinson disease
Multiple comorbidities
Precipitating Risk Factors (top 5)
New acute medical problem
Exacerbation of chronic problem
Surgery / anesthesia
New psychoactive medication
Acute stroke

Haldol prophylaxis
(in high-risk hip fracture patients)

Post-Delirium Symptoms
Continue thinking about
delirium

Medications

Physiologic
Environmental
Pharmacologic
Prevention
Psychosocial
More effective
than treatment
No medications are FDA approved for
use in delirium

Disorganized thinking
Sudden or acute onset
and fluctuating course

Treatment

Patient Health
Questionnaire 9

Antidepressants
(newer ones work better)
Screening tool

Start low and go slow with medical

therapy
Medication
Side Effect
Effexor
BP
Influence cardiac
Celexa
function
SSRI / Effexor
Hyponatrimia
Psychotherapy
Electroconvulsive therapy
Exercise

Recognizing and treating depression

in older adults can be more difficult
to other health conditions,
medication side effects, and life
events
Predisposing Factors (top 5)

Widowed
Previous depression
Paxil
Neurological changes
Major physical illness
Precipitating Factors (top 5)
Bereavement
Moving
Adverse life event
Prozac
Chronic stress
Social isolation
Adjustment Disorder
Emotional or behavioral symptoms in
response to an identified stressor
occuring 3 months of the onset of
Tricyclic
the stressor
Antidepressants
Bereavement
Reaction to the death of a loved one
Selective
Serotonin
Reuptake
Inhibitor

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Suicide

Substance
Abuse

Sexual Health
in Older Adults

Cause

Older adults have the

highest rates of suicide of
any age group in the US

Most commonly in the

form of alcohol abuse
and misuse

Signs and Symptoms

Laboratory
Result

Warning Signs
Talking about suicide or
Preoccupation with
intent to die
death
Preoccupied with
Plan is present with
thoughts of impending
lethal means available
death / suicide
Statements of
Suddenly happy and
hopelessness,
calmer after depression
helplessness, or
symptoms
worthlessness
Expresses despair,
hopelessness, pessimism
Giving things away
about future
Risk Factors
Mental disorders
Previous suicide attempt
Major physical illness
Alcohol and substance
Hopelessness
abuse
Social isolation
Impulse aggressive
Career, financial,
tendencies
relational, or social loss
BP, arrhythmias, and
Stroke
heart attack
Impaired immune
system
Cirrhosis
Bone density
GI bleeding
Depression, anxiety, and
Malnutrition
other mental health
Used to self-medicate
problems
sleep disturbances
Early Onset Drinkers
Drink to cope with
Short
Majority of older adults
psychosocial or medical
Michigan
problems
Alcoholism
Depression
Screening Test
Bipolar disease
Thought disorders
Continue their established drinking patterns as
- Geriatric
they age
Late Onset Drinkers
of older adults
Appear psychologically
and physically healthier
More likely to
drinking in response to
Often milder and more
recent losses
amenable to treatment

Testosterone

Estrogen

More rapid but less

intense orgasm

Changes in the bedroom

as people get older

Test

Slower arousal and less

intense

Occassional lack of
orgasm with intercourse Vaginal elasticity and
lubrication
Longer refractory period
Thinning of the vaginal
May have little interest
walls
in frequency
Fewer and less intense
May be more emotional
orgasmic contractions
after sex

Treatment

Medications

Other
Risk by Racial Groups (high to low)
Non-Hispanic whites
Asian and Pacific islanders
Hispanics
Non-Hispanic blacks
White 85 years old are most
likely to die by suicide
Protective Factors
Restricted access to lethal methods
Family and community support
Effective / appropriate clinical care
Easy access to clinical interventions
Support from ongoing medical and
mental health care relationships

Age-specific, supportive, and

nonconfrontational group treatment
that aims to build or rebuild the
client's self-esteem
Focus on coping with depression,
loneliness, and loss

Screening tool

Presciption Abuse
Hydrocodone
Oxycontin
Illegal Drug Abuse
Marijuana
Cocaine
Crack

Focus on rebuilding the client's social

support network

Appropriate pace and content of

treatment
Linkages with medical services,
services for the aging, institutional
settings for referral into and out of
treatment, and case management
Antidepressants
Change / Remove
Antipsychotics
Affecting
AntiHTNs
Medications
GERD medications
Alcohol
Long-held
Influencing
assumptions
Psychosocial
Partner gap
Changes
Sex preferences
Impact of medical conditions /
medications
Treatments and alternatives to
address sexual needs

Diseases Affecting Sexual Health

Hypertension
Diabetes
Heart attack
Hysterectomy
Incontinence
Arthritis
Stroke
Mastectomy
Prostatectomy
Neurologic diseases

Safe sex
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Abuse

Elder
Mistreatment

Mistreatment of
older people

CV and pulmonary
disease

Neurological disease

Causes of
Immobility in
Older Adults

Depression

Common etiologies of
immobility

Urinary Incontince

Deep tissue

Muscle and fate

Bone

Pressure Sore

History of falls or fear of

falling

Treatment

Medications

Report suspected elder mistreatment

Refer and Coordinate
Respite care
Substance rehab

Support
Staffing
Counseling
Support groups
Communication
Environmental
Develop system for follow up
Prevention of Venous Thrombosis
Limb ROM
Ambulation
Adequate hydration
Avoid local pressure / frequent turns
Avoid dependent leg position
Support stockings
Intermittent pneumatic pressure
Low dose heparin / anticoagulation

Stage I

Stages I and II
Avoid pressure and moisture
Prevent further injury to tissue
Intensive local skin care with normal
saline
Stage III
Debrie necrotic tissue
Cleanse and dress wound
Culture wound
Possible topical antimicrobials
Stage IV
Tissue biopsy
Systemic antimicrobials for cellulitis
and osteomyelitis
Potent surgical repair

Observable
pressure-related
alteration of intact skin

Other
Challenges to Identifying Elder
Mistreatment
Age-associated changes
Disease processes
Cognitive impairment reporting
Protecting abuser
Privacy
2nd hand reports

Education

Orthostatic hypotension

Partial thickness skin loss

involving epidermis
dermis
Full thickness skin loss
Stage III
with damage or necrosis
of SQ tissue
Stage IV
Full thickness skin loss with extensive destruction,
tissue necrosis or damage to muscle, bone, and
supporting structures
Stage II

Bedsores

Cognitive decline

Dehydration
Apathy
Energy
Confusion
Dry, sore mouth
Dry, fragile skin
Urinary stasis / infection
Constipation / impaction

Laboratory
Result

Document details

Pushing striking,
Force-feeding
slapping, pinching, etc.
Incorrect positioning
Sexual coercion or
Improper use of physical
assault
restraints or meds
Red Flags of Bruising
On head, neck, lateral
Bruises 5 cm
Consistent with child
right arm, or posterior
abuse injuries
torso
Inquire about all large "Are you safe? Are you
bruises
afraid?"
Neglect
Meals
Withholding Health
Hydration
Maintenance Care
Hygiene
Medications
Failure to provide
Failure to provide safety
assistive devices
precautions
Exploitation
Inappropriate use of resources for personal gain,
use of his / her money for personal expenses, and
withdrawal of care until funds or property are
given
Withdrawl of care,
Abandonment
support, and resources
Joint pain

Test

Complications of Immobilization
Stiffness / contractures
Loss of muscle mass and strength
Loss of bone mass
Decline in balance capacity
Socialization
Dependence / institutionalization
Complications of Severe Immobility
Thrombosis
Pneumonia
Dehyrdation
Urinary retention / incontinence /
infection
Constipation / incontinence /
impaction
Pressure sore
Predisposing Factors
Prolonged positioning with pressure
on bony prominence
Shear forces
Friction
Moisture

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Acuity
Vision Changes That
Lead to Falls

Fall

Palliative Care

Aging of
Americans

Unintention event or
disturbance of balance
that results in a failure to
maintain an upright
posture during daily
activities

Area of healthcare that

focuses on relieving and
preventing the suffering
of patients

Characteristics of the
aging American
population

Test

Laboratory
Result

Tinetti
Assessment
Gait Speed

Dark adaptation
Timed Up and
Go

Diminished vestibular
Joint proprioceptive
Single Leg
righting response
sense
Stance
Postural Control Changes Leading to Falls
Slower reactions
More likely to step
Short Physical
Lateral instability
Longer latencies
Organization of activation disrupted
Performance
Attention Demands
Battery
Age differences in
Difficulty in allocating
balance are increased by
attention
STEADI
cognitive tasks
Instability
4-Stage
Loss of independence
Consequences of Fear of
Balance
Lower quality of life
Falling
Screen
Lower life satisfaction
Symptom
management
Unbound by point in the
trajectory
Allows transitions
Goals of care are communicated
End of life care only
Hospice
When family is angry
No options left
Palliative Care is not
Abdication of the patient
When you need the DNR
/ DNAR
Early Palliative Care Guidelines
Illness understanding
Symptom management
and education
Coping with
Decision-making
life-threatening
illness
35 million people
> age 65

12.4% of US population

Up from 4.1% in 1990

1.6 hospital days /

person / year

6.8 provider contacts /

person / year

3.0 medications /
person

Over age 65 is 12%

Age 45 - 64 is 34%
Common Conditions
Arthritis (49%)
Hypertension (36%)
Hearing loss (30%)
Heart disease (27%)
Diabetes mellitus (12.5%)
Dementia (10%)
From 1990

Medications

Living space
Outside
Bathroom
(particularly
clutter)
Bedroom
Observation of performance
(critical)
Referral to physical therapy
(if gait and balance issues)
Gait training / education on
device use
Review and modify medications
Withdrawal of psychotropic
medication
Exercise programs
Treat postural hypotension
Modify environmental hazards
Treat cardiovascular disorders
Exercise
Introduce the Topic
"I would like to have some consultants
from the Palliative Care Team visit
with you"
Emphasize that it is a good team to
have on board if / as disease
progresses and goals of care change
"Hope for the best and prepare for
the worst"
Palliative Care in the Trauma and
Surgical ICU
Prevention
Through
Environmental
Modification

Depth perception

Sensitivity to glare

Treatment
Screening

Screening tool

Other
30% of people > 65 fall / year
50% of people > 80 fall / year
Gait / balance, weakness, and
dizziness are the major causes of falls
in nursing homes
Environmental factors are the main
etiology of falls in the community
Risk Factors (top 6)
Fear of falling
Medications
Reduced sensation
Bowel and bladder incontinence
Distractions
Muscle weakness
Gait Speed
Normal - 1.7 m / sec
Substantially meaningful unit 0.10 m / sec
Small meaningful unit - 0.05 m / sec
Risk over 2 years for baseline gait
speed 0.7 m / sec

Family meeting with MD and RN 72

hours of admission
Integrate palliative care performance
measures into morbidity and
mortality conference and peer review
Appreciate perspectives of older adult
Address barriers to communication
Assess cognition
Assess mobility
Assess function
Address the patient
Address the environment
Hearing / vision
Recognize
problems
Limitations
Language
problems
Outline the plan for assessment

Life Expectancy of 65 Year Olds

- 16.3 years
- 19.2 years
Ratios of :
> 65 years old - 1.5 : 1
> 85 years old - 2.5 : 1
Marital Status
- 45% widowed
- 74% married
Heart disease and cancer are the
leading causes of death.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Memory loss
Problems with language
Poor judgement

Warning Signs
in Older Adults

When you need to be

concerned

Disorientation to time
and place
Performing complex
tasks
Personality changes

Gait Changes Associated

With Aging

Risk Factors for

Falls

Slowing down when

people get older

Things that can

contribute to a fall

Misplacing things
Learning new
information
Changes in mood and
behavior

Poor sense of direction

Loss of initiative

Slower gait speed

Shorter broader-based
stride

Reliance on double
support is increased

Flat foot landing

Age > 80 years

History of falls

Medications

4
Psychotropic

Visual deficit

Impaired ADL

Depression
Arhtritis

Cognitive impairment
Muscle weakness

Balance deficits

Gait deficits

Foot problems

Use assistive devices

Correlates with ADLs and independence

Timed "Get Up
and Go"

Validated for use with

elderly patients

Activities of
Daily Living

Tasks that allow an

individual to live
independently

Non-Specific
Presentations of
Disease in Older
Adults

Signs and symptoms that

are common with
diesease of the eldery

Procedure
Rise from chair
Walk 10 feet
Turn and return to chair
Sit down
Advanced
Volunteer work
Hobbies
Employment
Caregiving
Instrumental
Cooking
Medication use
Cleaning
Shopping
Transport
Phone
Yard work
Finances
Basic
Eating
Grooming
Bathing
Toileting
Dressing
Walking
Transferring
Continence
Weight loss / failure to
Weakness / fatigue
thrive
Falls
Immobility
Incontinence
Cognition changes
Social crisis

Mood change

Treatment

Medications

History Taking
Chronology of
Medical
symptoms
Medication
Family
Social and Cultural
Substances
Sleep
Physical Exam
Appearance and
BP, rhythm, signs
behavior
of atherosclerosis
Focal neurologic
signs
Extrapyramidal
signs
Ask about mood
Cognitive Exam
Mini-mental
Mini-Cog
status exam

Other
Differential Diagnosis of Cognitive
Impairment
Delirium
Depression
Dementia
Mild memory disorders

Living Space Factors

Throw rugs
Carpet edges
Objects on floor
Cords and wires
Lighting
Waxed floors
Outside Factors
Cracked sidewalk
Weather
Bathroom Factors
Wet surfaces
Clutter
Bedroom Factors
Inadequate
High bed
Poorly placed
lighting
lighting switches
High cabinets
Normal

10 - 20 seconds

Assess all older patients for fall risk

Utilize physical performance
assessment

Abnormal

> 20 seconds
Refer proactively
Ask or observe ADLs

ADL Performance
Screen

Ease of reaching
distal LEs
Use of
compensatory
strategies
(like slippers)
State of
toe nails
Briskness with
which task is
completed
Altered Presentation of Disease
"Silent" presentation
(infection, surgical abdomen, MI)
Depression without sadness
Apathetic thyrotoxicosis
Nondyspneic pulmonary edema
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

AMS
Hypothermia
Peritonitis

Abdominal
Pain in Elderly

Unusual presentations of
abdominal pain that
frequently requires acute
management

Obstruction
Vascular Process
Nonspecific Abdominal
Pain

Long Term
Care

Broad set of paid and

unpaid services for
persons who need
assistance due to chronic
illness, physical, or
mental disability

Test

Laboratory
Result

Treatment

Medications

Other

Hypotension
Dyspnea
Localized
Generalized
Partial
Complete
Ischemia
AAA
MI
Pneumonia
Drugs
Constipation

Goals of LTC
Provide a safe and supporative environment for
chronically ill and dependent people
Restore and maintain the highest possible level of
functional independence
Preserve individual autonomy
Maximize quality of life, perceived well-being, and
life satisfaction
Provide comfort and dignity for terminally ill
patients and their loved ones
Stabilize and delay progression, whenever
possible, of chronic medical conditions

Rate of Nursing Home Use

Ages 65 - 74 - 1%
Ages 74 - 85 - 5%
Ages 85 - 20%

Prevent acute medical and iatrogenic illnesses and

identify and treat rapidly when they occur

Levels of Long
Term Care

ICFs in NC

Common
Problems in
Long Term
Care

Levels from most care

required to least

State requirements for

assisted living facilities

Frequent problems seen

in long term care

Hospital
Nursing home (SNF)
Group housing for 2
unrelated individuals
Assisted Living (ICF)
1 meal / day and
housekeeping
Adult day care
Home with services
Home alone
24 hour assistance

8 hours of coverage
daily by a RN

No requirement for 24 hour skilled

nursing services

Adult Care Home

Housing management provides 24
hour scheduled and unscheduled
personal care services
Family Care Home
Same services as ACH
Only 2 - 6 people in residence

FL-2 Form
Used to determine appropriate level
of care
Unique to NC
Addresses ADLs, diet, and mobility
Guideline for initial admission orders

Neuropsychiatric
Dementia
Wandering
Agitation
Aggression
Depression
Neurological
Stroke
Parkinsonism
Multiple sclerosis

Brain / spinal cord injury

Functional Disabilities
Stroke
Hip fracture
Joint replacement
Amputation
Geriatric-related
Chronic pain
problems
Iatrogenic disorders
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Adverse Events

Pharmacokinetic
Changes

Beer's List

Top Drug
Interactions in
Seniors
Narrow
Therapeutic Index

Generic Examples /
Brand Name

Mechanism of Action

Indications

Pharmacokinetics

Contraindications

Adverse Effects

Monitoring / Other

85 years old
Depression
Risk factors for

BMI < 22
5 medications
Multiple pharmacies
adverse events
Dementia
Renal impairment
Absorption
Absorption of drugs
Secretion of HCl
requiring acidic
environment
Transit Time Through
Time for passive
GI Tract
absorption in small
Absorption of
Calcium
Medications Requiring
Iron
Active Transport
Vitamin B12
Blood Flow to
HF patients may have
GI Tract
absorption
Changes in drug
Distribution
properties in the
Digoxin
elderly
Ethanol
Total Body Water
Lithium
Lidocaine
Oxazepam
Body Fat
t
Monitor drug
Albumin with
concentrations closely
protein-bound drug
Metabolism
Liver is primary site
Start with lowest dose
Excretion
Renal
Adjust medications
Anticholinergics
1st gen. antihistamines
GI antispasmodics
Short-acting
dipyridamole
Nitrofurantoin
Terazosin
Doxazosin
Clonidine
Prazosin
Amiodarone
Antiarrhythmics
Criteria to identify
Digoxin
Spironolactone
inappropriate
Short-acting nifedipine
Amitriptyline
Imipramine
Doxepin (> 6 mg)
medications in
Antipsychotics
Barbituates
elderly nursing home Benzodiazepines
for
Non-benzos for sleep
patients
sleep
NSAIDs
Toradol
Meperidine
Muscle relaxants
Sliding scale insulin
Megestrol
Testosterone
Metoclopramide
Cimetidine
Estrogens
NSAIDs
Coumadin (Warfarin)
Antibiotics
Dilantin
Frequent drug
ACE Inhibitors (Lisinopril Potassium supplement
and Altace)
Aldactone
interactions for older
Amiodarone
Digoxin
adults
Verapamil
Cipro
Theophylline
Levaquin
Narrow range between
Digoxin
Phenytoin
concentration providing clinical
Theophylline
Warfarin
benefit and concentration
Carbamazepine
Cyclosporine
providing risk
Levothyroxine
Lithium

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Generic Examples /
Brand Name

Mechanism of Action

Indications

tacrine

Cholinesterase
Inhibitor

donepezil
rivastigmine

Pharmacokinetics
A: Oral and SQ
D: With meals (Exelon)

Blocks
acetylcholinesterase
enzyme

Alzheimer's disease

galantamine

NMDA
Antagonist

memantine

Vitamin E

Binds preferentially to the

NMDA receptor-operated
cation channels and blocks
the excitatory effect of
glutamate

Alzheimer's disease

Moderate dementia (use

in combination with
cholinesterase inhibitor)

Antioxidant

Maintained cognition
(only verified by 1 study)

Selective irreversible
MAO-B inhibitor

Alzheimer's disease

Non-medical ways to
deal with behavior
disturbances

Stimulatory activities
Redirection
Simple tasks
Sleep hygiene
Visual cues
Exercise
Remove mirrors
Remove distractions
Soothing music

A: Oral
D: Daily

Contraindications

Adverse Effects

Hypersensitivity
Jaundice (tacrine only)

Nausea / vomiting (rivastigmine)

Diarrhea (rivastigmine)
Dizziness (rivastigmine)
Headache (rivastigmine)
LFTs (donepezil)
Insomnia (donepezil)
Syncope
Hip fractures
Associated with pacemakers
Dizziness (7%)
Confusion (6%)
Headache (6%)
Constipation (5%)
Cough (4%)
Hypertension (4%)
Bleeding
Heart failure (when > 400 IU)

Monitoring / Other
Drug Interactions
Anticholinergics
blockers

Behaviors may worsen after

discontinuation, and users may
not regain previous level of
higher function
Monitor adverse effect after 2
weeks

D: 5 mg BID

Selegiline

Anipryl

Non-Pharmacologic
Treatment for Behavior
Disturbances

Haloperidol

Haldol

1st generation
antipsychotic

Behavior disturbances

aripiprazole

2nd Generation
Antipsychotics

olanzapine
quetiapine

Behavior disturbances

risperidone
ziprasidone

Drug-Induced
Cognitive
Impairment

Medications
assoicated with
delirium
"ACUTE CHANGE
IN MS"

Antiparkinson's
Corticosteroids
Urologic
(antispasmodics)
Theophylline
Emesis (anti-)
Cardiovascular
(antiarrythmics)
H2 blockers (cimetidine)

Extrapyramidal effects
Tardive dyskinesia
Orthostatic hypotension
QT prolongation
Metabolic effects
Sedation
Extrapyramidal effects
(risperidone)
Tardive dyskinesia
(risperidone)
Orthostatic hypotension
QT prolongation (ziprasidone)
Metabolic effects
Sedation (quetiapine)

Anticholinergics
NSAIDs
Geropsychotropic
EtOH
Insomnia medications
Narcotics
Muscle relaxantss
Seizure medications

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Alzheimer's Disease
Class
Acetylcholinesterase
Inhibitor
NMDA Antagonist

Generic Name
donepezil
rivastigmine
galantamine
memantine

Brand Name
Aricept
Exelon
Razadyne
Namenda