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Week 5: Glucose metabolism disorders
Types of DM
Diagnostic criteria- there are 4 lab-based criteria to confirm DM: A1C, random plasma glucose, fasting plasma glucose, and 2-hr post load plasma glucose
- AIC of 6.5 or higher=diabetes - Random plasma glucose level of 200 WITH classic symptoms of hyperglycemia or a hyperglycemic crisis - Fasting plasma glucose level of 126 or higher on TWO occasions(fasting is defined as no caloric intake for at least 8 hrs - 2-hour post load plasma glucose level of 200 or higher during an OGTT, following consumption of a glucose load containing the equivalent of 75g of anhydrous glucose dissolved in water (OGTT is also used to screen for diabetes during pregnancy)
*** In the absence of unequivocal hyperglycemia results should be confirmed by repeat testing on a new blood sample without delay, preferably using the same type of test.***
*- All above- but confirmation of type 2 diabetes mellitus requires: two fasting blood glucoses ≥126 mg/dL or two random blood glucoses ≥200 mg/dL. - You do not screen for type 1 diabetes but you do screen for type 2 if an individual is overweight or obese, regardless of age, and for all adults aged 45 years and older. Tests should be repeated at a minimum of 3 year intervals
Initial Treatment-
Type 1- FIRST LINE: INSULIN. The initial goal of treatment for type 1 DM is to normalize the elevated blood glucose level. This is best accomplished by intensive insulin regimens to achieve
the following goals: plasma glucose levels of 80 to 130 mg/dL before meals, peak postprandial
Medication Side Effects
-Type 1:
Hypoglycemia is a common occurrence in patients with type 1 DM and occurs for a variety of reasons: excessive exogenous insulin, missed meals or inadequate food intake, excessive exercise, alcohol ingestion, drug interactions, or decreases in liver or kidney function. Signs and symptoms: diaphoresis, tachycardia, hunger, shakiness, altered mentation (ranging from an inability to concentrate to frank coma), slurred speech, and seizures. The ADA classifies hypoglycemia as a plasma glucose level of < 54 as serious, clinically significant hypoglycemia. A blood glucose level of 70 is considered a threshold level that requires intervention. Examples of appropriate foods: #1 choice: pure glucose, ½ cup fruit juice, 6oz regular soda (not diet or sugarless), 1 cup milk, or glucose tabs. Candy is only a last resort. Recheck glucose 15 minutes after treatment. Additional carbs can be given if glucose is still less than 70
-Type 2:
Metformin can cause: hypoglycemia esp in older adults, adverse reactions such as GI disturbances and metallic taste, and is contraindicated in renal disease so assess renal function prior to prescribing.
For other noninsulin agent adverse reactions see pg 929 Dunphy book
Treatment goals for older adults (Kennedy table 14-2).
Hbg A1C goals based on complications
Weight loss recommendation : Lifestyle modifications of weight loss and exercise are particularly important in lowering Hb A1c. exercise of even a modest nature can be beneficial in decreasing insulin resistance.
Risk factors -
Dm Type 1
gallbladder, and leukemia are also associated with obesity. Obese patients are also more likely to develop obstructive sleep apnea, gallbladder disease, fatty liver disease, and osteoarthritis. They will often have symptomatic varicose veins or GERD.
Week 6:
Urology and aging
UTI
- Urethritis and cystitis usually occur together - Infections can be acute, chronic, recurrent, complicated, or uncomplicated. - UTIs become chronic because of obstructions, antibiotic-resistant bacteria, or the presence of multiple strains of bacteria that are not susceptible to the antibiotic therapy prescribed. - A complicated UTI is either an acute or chronic infection that is accompanied by factors that predispose a patient to the infection or make treatment more difficult such as instrumentation (ie indwelling, suprapubic, or intermittent cath), underlying chronic disease, systemic symptoms, or pregnancy.
Risk factors- Predisposing factors to the development of cystitis in older adults include indwelling catheters, urethral or condom catheters, incontinence (urinary and fecal), cognitive impairment, neurological conditions that impair bladder emptying, and diabetes (high pH=more alkaline), which can lead to neurogenic bladder. Poor hygiene, unprotected anal intercourse, sexual intercourse, immunosuppression, functional disability, sickle cell disease, prior antibiotic therapy, genetic predisposition, and functional or structural genitourinary tract abnormalities (including urethral strictures, uterine or bladder prolapse, ureteral weakness, and vesicoureteral reflux or renal calculi)
Gender:
▪ UTI rarely occurs in men younger than 50yo unless caused by urinary caths, anatomical abnormalities, of urinary tract, unprotected anal intercourse, or vaginal intercourse with a woman who has a bacterial infection. ▪ Cystitis is rare in men because the increased length and drier environment around the urethra contribute to less frequent bacterial colonization. In addition, prostatic fluid has inherent antibacterial prosperities. Thus, when UTI does occur, it is often associated with abnormal urethral anatomy or inadequate treatment of prostatitis ▪ - Men have a 20% incidence of UTI, with lifetime prevalence of 1%. After age 65 years, the rate of cystitis in men significantly increases, but is still approximately one-half that of. ▪ Incidence in postmenopausal women can range from 0.07/women/year to 0.13/women/year in women greater than 85 years old with great degrees in prevalence. ▪ -Community-dwelling men 70 years of age and older have a prevalence rate of ASB from 3.6% to 19%, whereas their institutionalized counterparts have a prevalence rate from 15% to 40% ▪ -Community-dwelling women 70 years of age and older have a prevalence rate of ASB from 10.8% to 16%, whereas their institutionalized counterparts have
Patho & Common bacteria
- Cystitis is a pathogenic invasion of the wall of the bladder, usually resulting from an ascending infection via the urethra, of bowel flora organisms from the perineum - The most common organism in adults of all ages is E. coli, which transcends across community dwelling and long-term care residing older adults. In women, approx. 80-90% of cases of uncomplicated UTI are a result of E.Coli. - The second most common cause (5-20%) of uncomplicated bacterial infections=Staphylococcus saprophyticus - Other less common bacteria but more prevalent in complicated UTI’s: Proteus mirabilis, Klebsiella, Enterobacter, Serratia, and Pseudomonas
Diagnostic Criteria
- Diagnosis of lower UTI is made based on the subjective complaints of the patient and a clean- catch midstream urine sample showing the presence of bacteria, especially if more than 100, organisms/mL of the same morphology are present in a sample from a female patient. - UTI is currently defined as a urine sample with greater than 100 organisms/mL in the presence of characteristic clinical symptoms. - Although urine culture is considered the gold standard with the greatest sensitivity for lab confirmation of URI, urinalysis with microscopy is also helpful and provides rapid results. UA typically indicates pyuria (>10 neutrophils per hpf on microscopic exam) and often the presence of RBC. Hematuria is common in UTI but not with urethritis or vaginitis, however blood in the urine is not a marker of complicated infection. - Bacteriuria and pyuria are the main laboratory clinical manifestations of cystitis - older adult, the presence of localized genitourinary symptoms (see Signal Symptoms) and pyuria on urinalysis are required for diagnosis - The presence of greater than 10^ 5 colony-forming units/mL of a single bacterium in a culture of freshly voided urine is generally considered to be a significant bacteriuria
Treatment
o Tx: Assess for cause ie. medication usage and fluid intake. Double voiding to empty residual urine from bladder
Risk factors: pelvic muscle weakness, multiparity, estrogen depletion, pelvic organ prolapse, diabetes, stroke, multiple sclerosis, Parkinson’ s disease, spinal cord injury, benign prostatic hyperplasia, UTI, fecal impaction, poor fluid intake or excessive fluid intake, smoking, cognitive impairment, depression, immobility or impaired mobility, environmental barriers, impaired dexterity, visual impairment, obesity, and high-impact physical activities. Incontinence can be a side effect of many medications, including cholinergics, anticholinergics, diuretics, antispasmodics, opiates, hypnotics, calcium channel blockers, ACE inhibitors, alcohol, and caffeine.
Gender: UI is twice as prevalent in women as in men, and the incidence increases with age, with institutionalized individuals, and those who have at least one deficit in ADLs ( Wagg et al., 2015 ; da Silva et al., 2012 ). Women are at higher risk for stress incontinence; however, overflow incontinence is more prevalent in men as a result of hyperplasia of the prostate gland.
Pathophysiology: The causes and management of UI are multifactorial, depending on the type of incontinence and also the severity and impact on quality of life for the individual. Anatomical changes, factors related to the individual ’ s medical history, lifestyle, and acute and chronic illnesses, in addition to medications, can result in incontinence that can be either reversible or a permanent condition. Cognitive as well as chronic mental illness, depression, and functional barriers to continence can also affect an individual’ s ability to maintain urinary continence
Dx and when to treat: urinalysis to rule out infection and renal abnormalities. presence of nitrites and leukocyte esterase in the urinalysis is usually indicative of an infectious process. culture and sensitivity should be ordered to ensure appropriate antimicrobial therapy.
Incontinence Mnemonic:
- DRIP ■ Delirium ■ Restricted mobility ■ Infection ■ Pharmaceuticals, polyuria - Mnemonic: DIAPERS ■ Delirium ■ Infection, impaction, inflammation ■ Atrophic vaginitis ■ Psychological, pharmaceuticals, psychotropics ■ Endocrine problem ■ Restricted mobility ■ Stoolimpaction
Causes of hematuria and proteinuria:
Urologic changes in male/female:
Sexuality and aging
STIs/Age related changes:
GSM: genitourinary syndrome of menopause
- Perimenopause refers to the time period before menopause when hormonal, physical,
- The perimenopause period (which is 2-8 years before and 1 year after the final
Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance. ED can also manifest as a lack of sexual desire or an inability to ejaculate. ED can result from many causes, including physiological, psychological, endocrinological, vascular, and neurologic etiologies. It is characterized as the inability to achieve an erection sufficient for intercourse for at least 3 months. In a broader sense, ED encompasses problems with arousal, libido, orgasm, sensation, and relationships
Diagnosis :
Treatment:
- If an organic cause cannot be found, these men will most likely benefit from behavioral based sex therapy - Nonpharmacologic interventions : vacuum constriction devices (takes 2 minutes, use pump, then put ring around base of penis to maintain erection), vasoactive therapy, penile prostheses (surgically implanted into the penis), and penile revascularization (mainly for men <45 yo whose impotence is mainly caused by severe pelvic trauma)
negligent act performed by a caregiver or another person that may cause harm or risk of harm to an older adult who is vulnerable.
Types of abuse:
- Common features of perpetrators committing elder abuse are partners or spouses living with the victim, history of alcohol or drug abuse, history of mental illness, history of unemployment, and being socially isolated. - The abused elder is more likely an older female who generally has a physical impairment and is in poor health. She may either live alone or with the abuser, or in a household with many members. - The abuser is generally found to be a male who has a history of past or current substance abuse, has mental health issues, is socially isolated, and has a history of past trouble with law enforcement - In 90% of cases (of abuse of adults aged 60 or older) the culprit is a family member. - These cases result in an increased risk of death for the vulnerable elder involved in the abuse Provider responsibilities in suspected abuse - If elder abuse is suspected, it is the health-care professional’s responsibility—and in most cases his or her legal obligation—to report this to either 911 or the state elder abuse hotline. Carefully collect information regarding the patient, using physical findings, patient’s functional abilities, testing results, and verbal information from the patient and his or her caregivers. Use the interdisciplinary team and speak with social workers, nursing staff, and others who may have interacted with the patient and caregiver. Document all findings, because they may be required to be presented in court later. Photograph suspicious injuries and measure or compare size of injury to familiar objects if ruler is not available. Be sure to f/u with case workers to determine outcome. It may take several reports before the true picture of abuse/neglect/etc can be investigated thoroughly and the elder moved to a safe environment.
Alzheimers most common form of dementia
Alzheimer’s disease (AD) is a progressive, neurodegenerative condition and the most common form of dementia. Progressive and irreversible cognitive decline; and an array of emotional and behavioral problems that result from cognitive decline. Impaired ability to learn new information or recall
previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function.
Distinguishing features-
Subjective
Objective
Seizures, dysphagia Incontinence Groaning, moaning, grunting
Treatment:
- The principles of management of AD are directed toward slowing progression of the disease pharmacologically, protecting physical health, providing emotional support, and maintaining optimal function through prevention or reduction of excess disability - Maintaining as much normalcy as possible in relationships and everyday activities may be the most effective way to prevent the development of excess disability (defined as the difference between the observed function and the actual underlying impairment). - Both patient and family need assistance in understanding and coping with AD. - Support group attendance can be helpful but should be relevant to the stage of the disease. - Anxiety and depression should be recognized and treated vigorously. - Legal and financial planning and discussion of future care options should take place early in the disease course. - Attention to good nutrition, exercise, and preventive care (imms, dental, vision, hearing care) is important. - A comprehensive, multidimensional treatment plan for dementia includes biological, psychotherapeutic, social, family, and pharmacological interventions - Biological Interventions: Treat underlying medical disorders with medications, medical or surgical procedures, and ongoing evaluation and management as indicated. - Psychotherapeutic Interventions: Include behavioral management, reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration, simulated presence therapy, reality orientation, skills training, recreation and art therapy, exercise, and aromatherapy. - Social Interventions: Include a functional and safety assessment, environmental modifi cations, assessment for abuse and neglect, provision of supervision and home health care, cleaning and meal services, assessment for appropriate level of care, fi nancial and estate planning, and legal provisions for power of attorney. - Family Interventions: Include caregiver education, training and support, respite care, and support groups. - Pharmacological : - Medications may improve cognitive function in mild to mod AD - At the time of dx: treat with cholinesterase inhibitors - Antipsychotics should be used with caution and reserved for pts who exhibit persistent disruptive or dangerous behavior - The failure to institute timely pharmacologic management in pts with AD may result in a more rapid need for institutionalization, an increase in aggression, further difficulty with ALDs, and further cognitive decline - Pharmacotherapy: Cholinesterase inhibitors (ChEIs) are the cornerstone of pharmacological therapy, with the aim to enhance or preserve cognitive and behavioral status. o Acetylcholine is important for the functioning of brain cells involved in memory, thought, and judgment, and brain levels are significantly decreased in those with AD.
o ChEIs inhibit breakdown of acetylcholine, which increases levels within the brain; this mechanism of action may improve or delay a decline in memory. ChEIs are effective in approximately 30% of patients and are not curative, preventive, or disease-reversing agents. o The choice of ChEI is based on the patient ’s clinical presentation and comorbid conditions. The three commonly prescribed ChEIs are donepezil, rivastigmine, and galantamine o ChEIs are nausea, vomiting, dyspepsia, anorexia, diarrhea, insomnia, vivid dreams, fatigue, increased urination, and cramps
- Another medication approved to treat dementia is memantine (Namenda), an N -methyl-D- aspartate (NMDA) receptor antagonist. Memantine assists in regulating high levels of glutamate in the brain, typically found in AD. o Common side effects include headache and constipation, and an uncommon side effect is confusion. o Memantine is excreted through the kidneys, and caution is advised in patients with renal impairment. o Combination therapy of memantine with a ChEI is a good strategy, because these medications work differently
Dementia- Dementia is a neurocognitive disorder. Dementia is defined as a clinical syndrome with global cognitive decline from a previous level of baseline function that interferes with activities of daily living (ADLs)
Distinguishing features:
- Cognitive changes include confusion, disorientation (as to time, place, person), and impaired short term memory. Personality changes psychiatric symptoms, problem behaviors, and changes in daily functioning. - Symptoms vary from person to person, and cognitive deficits cause significant impairment in social and occupational functioning, impaired ability to care for oneself, and altered behavioral patterns. - Signs/symptoms progress from memory loss to impaired executive functioning, language deficits, coordination, and perception with total or partial loss of the ability to recognize familiar people or objects. - Impairment in memory and learning (amnestic) is the typical presentation for AD and neuropsychiatric symptoms almost always occur. - Noncognitive Behavioral Symptoms of Dementia: Apathy, Agitation, aggression, Combativeness, Delusions, hallucinations, Depression, anxiety, Disinhibition/sexual behaviors, Emotional lability, Irritability, Wandering, Sleep disturbances, Sundowning - Onset is insidious, course long and progressive, duration months to years, awareness clear, alertness normal, orientation is impaired. thought process: poor, abstract thinking, diminished thoughts; poor judgment, difficulty with word finding/verbalizing. Perception frequent misperceptions. Psychomotor behavior normal, apraxia. Sleepwake cycle fragmented, disturbed and revered. Associated features affected superficial, labile, inapproatied, may be in attempt to conceal deficits. mental status test increase effort to find appropriate replies, frequent near miss answer, word searching - Common: Alzheimer’s disease (AD) is the most common cause of dementia Etiology: