Transcript Geriatric Gems - Barb Bancroft

Geriatric Gems
“Sex after ninety is like trying to shoot pool with
a rope. Even putting my cigar in its holder is a
thrill.” --George Burns
1
Let’s start with the 5 vital signs in the elderly—T,
P, R, BP, and weight
2
Temperature patterns in the elderly
• Loss of diurnal variation
• Contributes to sleep problems—diurnal variation and
melatonin secretion
• May not rise as rapidly with infections or as high
• A rise of greater than 1.5° C within 2 hours—consider sepsis
• Patients on neuroleptic drugs (central dopamine blockers)
such as haloperidal and/or the atypical antipsychotics*, tend
to have lower basal temperatures (always complaining of
“feeling cold”)
• *higher mortality rates in elderly on antipsychotics
3
Temperature patterns in the elderly
• Loss of subcutaneous fat (actually you don’t
LOSE the fat, you just move it to the internal
visceral organs) with age--difficulty
maintaining internal temperatures with
extremes of ambient temperature
• Hypothermia/hyperthermia
• “You’re not dead until you’re warm and dead.”
• Always check the thyroid gland—myxedema
coma + cold ambient temperature
4
Pulse-temperature dissociation
• Legionnaire’s (Legionella pneumoniae)
disease—atypical pneumonia characterized by
a pulse-temperature dissociation (pulse 80
with temp of 39.8°C [103.6°F]) + low serum
phosphorus and elevated LFT (Legionnaire’s
“triad”)—macrolides Rx of choice or
doxycycline vs. PCN for Strep pneumonia
5
Pulse/heart rate
• Bradycardia—hypothyroidism, dig, beta blockers (even topical
beta blocker eyedrops {Timoptic, Betoptic, etc.) can cause
bradycardia), calcium channel blockers such as verapamil and
diltiazem, and cholinergic drugs for AD--galantamine
(Razadyne), rivastigmine (Exelon), donepezil (Aricept)
• Palpitations with CHF, hyperthyroidism, AF
• Unexplained tachycardia (60 to 80 is the normal resting heart
rate)—consider hyperthyroidism, atrial fibrillation (which can
also be caused by hyperthyroidism)
• Tachycardia (loss of vagus nerve due to autonomic
neuropathy) and silent ischemia in diabetics
6
Anti-cholinergic drugs cause tachycardia and may precipitate
chest pain in the elderly patient with angina—normal
functions of acetylcholine
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Mentation (CNS)
Pupillary constriction (PNS)
Decreases heart rate (PNS)
Increases salivation (PNS)
Increases peristalsis (PNS)
Loosens urinary sphincter (PNS)
7
Anti-cholinergic drugs—side effects
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Confusion
Pupillary dilation (blurred vision, glaucoma)
Tachycardia (angina, possible MI)
Decreased salivation (dry mouth)
Decreased peristalsis in GI tract
(constipation)
• Tighten urinary sphincter (urinary retention)
8
Drugs for OAB (overactive bladder)—
anticholinergic effects
• oxybutynin (Ditropan)(Gelnique—topical
gel)(Oxytrol patch)
• Toterodine (Detrol LA); fesoterodine (Toviaz)
• Darifenacin (Enablex); solifenacin (Vesicare)
• Trospium (Sanctura)
• (Prescriber’s Letter, June 2009;16(6):36
9
Anti-cholinergic drugs—the usual suspects and some
surprises…
• Amitryptyline (Elavil)—the higher the dose, the
higher the risk of anti-cholinergic effects; Rx for
neuropathic pain vs. Rx for depression
• Hyoscyamine (Anaspaz, Atropine)
• Doxepin (Sinequan)
• Meclizine (Antivert)
• Captopril (Capoten), nifedipine (Procardia)
• Prednisolone
• dig, dipyridamole (Persantine)
• warfarin
• Furosemide (Lasix)
• isosorbide dinitrate (Isordil)
10
And then some…
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Paroxetine (Paxil)
Codeine
Oxycodone
Diphenhydramine
Fexofenadine (Allegra)
Hydroxyzine (Atarax)
Loratadine (Claritin)
dicyclomine (Bentyl)
Cimetidine (Tagamet), ranitidine (Zantac)
Haloperidol (Haldol)
11
Respirations
• Tagamet (cimetidine) and morphine—increased
bioavailability of morphine with a possible reduction in
respiratory rate to 4-6 per minute
• Fever and tachypnea in the older adult—consider an acute
pulmonary syndrome—
• Pulmonary embolism (over 85? 700 PE/100,000)
• Pneumonia—confusion, tachypnea, fever and shoulder pain—
referred pain due to a big “wet” lung*
• Pneumococcus (strep pneumoniae) is the most prevalent
pathogen; Strep pneumoniae and Legionella are the most
serious; (pneumococcal vaccine @ 65)
• Let’s go back to referred pain for a momento…
12
Referred pain…Let’s go back about 80 years…to
the embryo.
• Embryologic development and the
diaphragm—C3, C4
• Shared sensory afferents with somatic
structures—
• Diaphragm and the shoulder
13
Blood pressure—Ideal? 120/80, BUT…
• Depending on co-morbidities it may be kept
slightly higher in the elderly to avoid
hypotension, falls, and a broken hip
• But not TOO high as it is the MAJOR risk factor
for strokes (besides AGE)—66% of all strokes
are due to hypertension
• Keeping the blood pressure BELOW 140/90
prevents strokes, ACS, CHF, dementia, and
renal failure
14
Hypertension
• Systolic rises with age, diastolic tends to plateau or even
decrease during 6th decade
• Isolated systolic (ISH) is common (S > 140; D< 90) pulse
pressure increases in the same manner; high S, normal or low
D; elevated pulse pressure is increasingly recognized as an
important predictor of CAD/CVD
• Postural/orthostatic hypotension common—drop of > 20
mmHg S or 10 mm Hg D when rising from sitting position (one
of early signs of Parkinson’s disease)
15
Weight as a vital sign in the elderly
• Weight is a vital sign in the elderly
• Weight loss defined as? (≥ 5% of usual body weight over 12
months or less)
• Drugs and weight loss (dig, metformin, chemo)
• Drugs and weight gain-- insulin, sulfonylureas, SSRIs
(paroxetine/Paxil; fluoxetine/Prozac), corticosteroids, atypical
antipsychotics—clozapine/Clozaril and olanzepine/Zyprexa,
mirtazepine/Remeron
• Heart failure and weight gain
16
“The leading cause of hospitalization due to deteriorating heart failure
is excessive sodium intake.” (Arch Int Med 2001;161(19):2337-42)
• Weight gain and CHF—greater than 1 kg (2
lbs) per day—adjust diuretics; ?sign of
worsening heart failure or too much salt in the
diet?
• Diuretics should be adjusted to maintain
euvolemia as reflected by daily-recorded
weights that are within 1 kg (2.2 lbs) of the
patients predetermined dry weight
17
What is senescence??
• The rate of deterioration of the structure and
function of body parts
• The 1% rule
• Functional reserve of tissues is 4-10 x greater
than baseline (the amount needed just to
function)
• Peak functional capacity at 24
• 6 good years
18
Senescence and normal aging...
•
Peak at 24, 6 good years, gradual decline to baseline; more rapid decline
with chronic disease (DM, COPD)
FC%
Baseline function
1yr
30
75 yrs
19
Senescence and normal aging...
•
More rapid decline with chronic disease (DM, COPD)
FC%
Baseline function
1yr
30
75 yrs
20
Senescence and normal aging...
•
Gender differences—the ovary (51.3 +/- 2.7)
FC%
Baseline function
1yr
30
75 yrs
21
Example of livin’ “on the
edge/baseline…”
• One of the compensatory mechanisms in
heart failure is an adrenal surge of
epinephrine to boost the strength of
contraction and increase the heart rate
• However, epinephrine also “remodels” the
heart…remodel = enlarge…resulting in
cardiomegaly and an increased risk of sudden
cardiac death due to ventricular dysrhythmias)
22
Beta blocker use in CHF
• Traditionally beta blocker use was a big “no, no”
for patients with heart failure…why would you
want to decrease the strength of contraction and
decrease the heart rate in a failing heart…
• In the “old” days, beta blockers were known to
precipitate heart failure in patients with
hypertension…one of the reasons that beta
blockers are no longer first line therapy for
hypertension
• BUT…
23
Beta blockers to the rescue
• Beta blockers (“olols, alols, ilols”) may initially
worsen heart failure symptoms when they are
used to prevent “remodeling” of the heart
post-MI or in the patient with CHF
• However, beta blockers actually improve
survival rates and quality of life when used in
CHF patients
• Carvedilol (Coreg), metoprolol succinate
(Lopressor)
24
Example of “livin’ on the edge…”
• Acetylcholine in the CNS is the
neurotransmitter of cognition; as we
age the blood-brain barrier becomes
more lipid-soluble and drugs can enter
the brain with greater ease
• Drugs with “anti-cholinergic” effects can
cause confusion and memory loss
25
RENAL FUNCTION…
• Glomerular filtration rate (GFR)—120-125 ml/min at
age 25; decreases by ~1% per year;
– 75-year-old = 1.2 mL/min x 45 years = 53
mL/min; 120-53=67 mL/min in a HEALTHY 75year-old (not taking into account weight,
ethnicity, or gender)
– BUT, a GFR of 60-89 mL/min=mild renal
insufficiency
– a GFR of less than 60 mL/min/1.73 m2 represents
a loss of more than half of normal kidney
function
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Nephrotoxic drugs and the elderly
• Antibiotics (aminoglycosides)
(the ears and the kidneys)
• Radiocontrast dyes (Metformin)
• ACE inhibitors (“prils”) are especially dangerous if
renal blood flow is compromised—renal artery
atherosclerosis (stenosis)
• NSAIDs combined with ACE inhibitors in the elderly
may precipitate acute renal failure—HOW?
27
The healthy kidney
•
Afferent arteriole
(normally vasodilated
(via prostaglandins)
• Blood entering
glomerulus
• Glomerulus→filter
• Efferent arteriole
(normally vasoconstricted
(via angiotensin 2)
Prostaglandins –
blocked by NSAIDs
filter
Angiotensin
2—blocked
by ACE --
Toilet
28
The combination of ACE inhibitors and NSAIDs can
precipitate acute renal failure
• NSAIDs block prostaglandins and vasoconstrict the
afferent arteriole decreasing blood flow to the
glomerulus (prostaglandins are more important in
the aging kidney than in younger kidneys—hence the
high risk with NSAIDs in the elderly and not in a 20year-old)
• ACE inhibitors block ACE and the production of
angiotensin 2—blocking angiotensin 2 vasodilates
the efferent arteriole of the kidney
• Decreased blood IN and increased blood OUT =
decreased filtration and acute renal failure
29
More on NSAIDs in the elderly…
• NSAIDs and fluid retention (due to vasoconstriction
of the afferent arteriole)—especially the long-acting
nonselective NSAIDs (piroxicam/Feldane)
• NSAIDs can counteract the positive effects of thiazide
diuretics for blood pressure control
• Why? Opposing actions
• NSAIDs can exacerbate HF symptoms due to sodium
and water retention (+peripheral edema); can also
increase K+ levels
30
More on NSAIDS in the elderly…
• In addition to all of the above, one must worry about the GI
effects of the NSAIDs…the older the patient, the higher the
risk, especially with the non-selective NSAIDS
• GI complications are 3-10x more common in users of
nonselective NSAIDs than in nonusers
• Use celecoxib (selective COX-2) if possible (also decreases risk
of lower GI bleeding as well as perforations, obstructions and
bleeds in upper GI)
• Use PPI with nonselective NSAIDS and coxib if over 75
• Celecoxib does NOT affect platelets so can be used up to and
following surgical procedures
•
(Stillman MJ, Stillman MT. Choosing nonselective NSAIDs and selective COX-2
inhibitors in the elderly: A clinical use pathway. Geriatrics 2007;62(2):26-34.
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(In addition to NSAIDs), certain calcium channel
blockers can also cause/exacerbate peripheral edema
• Peripheral calcium channel blockers cause
peripheral edema due to their strong
peripheral vasodilating effects (the “dipines”)
• Felodipine (Plendil) is the worst of the bunch;
amlodipine (Norvasc) is the best of the bunch
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Water loss and aging
• Decrease in total body water stores
• Decreased volume of distribution
• Increased drug toxicity with water-soluble drugs—dig for
example
• Encourage fluid intake
(loss of response to thirst receptors)
• Exception: patients w/ CKD or CHF (not more than 800 - 1500
mL per day for CHF patients)
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Herbal products…
• Have your patients taken any herbal products that
can interfere with diuretics or dig? Most of the
herbal diuretics can cause low sodium (seizures), low
potassium (muscle cramping, arrhythmias), and low
magnesium (arrhythmias)
• Dandelion (Pissenhüt), licorice, St. John’s wort
• Herbal laxatives also decrease total body K+ stores
and can cause dig toxicity
• (K+ and dig compete for receptors on myocardium—
dig toxicity with hypokalemia)
34
Dehydration in the elderly
• Decreased collagen, elastic tissue, and water
• FYI, estrogen maintains collagen health
• (Wolff EF, et al. Long-term effects of hormone
therapy on skin rigidity and wrinkles. Fertility
Sterility 2005 Aug; 84:285-8.)
• What are the signs and symptoms of
dehydration in the elderly?
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Decreased collagen and elastic tissue with aging
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Shrunken eyeballs?
Poor skin turgor?
Where do you check skin turgor in the elderly?
What are some other consequences of the loss of
collagen, elastic tissue and water?
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Intervertebral discs are made from collagen, elastic
tissue and water
• Loss of collagen, water, and elastic tissue
resulting in disc shrinkage
• Loss of height (change in size and shape of
chest cavity)
• How many inches can you lose with disc
shrinkage?
37
Combine the disc shrinkage with compression
fractures of osteoporosis—loss of trabecular bone
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Compression fracture of vertebrae
• Vertebral bodies with the loss of height with
compression fractures
• How many inches can you lose with vertebral
compression fractures?
• Vertebral compression fractures + disc
shrinkage =
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Other fractures due to osteoporosis
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Neck of the femur—broken hip
What is the prognosis after a broken hip?
Radius of the wrist (Colles fracture of the wrist)
Do men have osteoporosis? YES, and they have a
worse prognosis after a hip fracture
• One in 2 women and one in four men over age 50
will have an osteoporosis-related fracture in her/his
remaining lifetime
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Osteoporosis
• Skin, aging and vitamin D conversion
• Check Vitamin D levels! Low vitamin D =
increased risk for balance problems and falls
(and joint and muscle pain)
• Vitamin D deficiency—levels of 25hydroxyvitamin D below 25 ng per milliliter
are associated with an increased risk of hip
fracture in men and women older than 65
• Muscle aches, bone aches, joint aches and
pains may be due to low vitamin D
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Digression--prevention and treatment of
osteoporosis
• Weight-bearing exercise 5 x per week
• Stimulates bone remodeling with osteoblasts
and osteoclasts
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Prevention/treatment of osteoporosis
• Calcium—1200-1500 mg/day; best way to get
calcium is to eat calcium-fortified foods
• Vitamin D—1000-2000 IU per day
• Foods—broccoli florets, sardines, milk, yogurt
• Calcium supplements are only beneficial if taken
consistently**
• Calcium supplements interfere with synthroid
43
Drugs to prevent and treat osteoporosis
• Alendronate (Fosamax) (most potent
bisphosphonate)
• Risedronate (Actonel)
• Ibandronate (Boniva)
• Can your patient follow directions for the
bisphosphonates?
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Bisphosphonate therapy
• EXPERIENCE-BASED MEDICINE—give a 1-year holiday to
relatively low risk women (no fx, young and healthy,
active, with BMD that is not horribly low
• 2) Do NOT tend to stop risedronate as it has a shorter
half-life and there are NO DATA on cessation except
after 3 years of use and BMD goes down rapidly after
stopping
• 3) 5 years on ALN then stop for up to 5 years without
losing too much BMD; after stopping measure urinary
NTX or serum CTX in 6 months; if elevated above ideal,
restart ALN. If ok, she starts ALN after a one year
holiday. ALN is retained longer in bone than other BS
Carolyn Becker, MD, Master Clinician, Harvard University,
Cambridge MA
45
Other drugs for osteoporosis
• Evista (raloxifene)—antagonist in breast and
uterus; agonist in bone; increased risk of DVT
• What about tamoxifen? Antagonist in breast
and brain; agonist in uterus and bone: not
approved for osteoporosis
• Calcitonin (Miacalcin)—has some opiod-like
properties and is useful for the pain of
vertebral fractures
Other drugs for osteoporosis
• Forteo (teriparatide)—for treatment of osteoporosis
and for use in preventing steroid-induced
osteoporosis (boosts osteoblasts and blocks steroids
effects on the bone)(better results compared to
Fosamax)
• Reclast (zoledronic acid)—15’ infusion x 1 per year
decreases vertebral fractures by 70%; hip by 41%
• Denosumab (Prolia) – new monoclonal antibody to
boost bone building
• And don’t forget the best bone builder of all
1% rule and the INCREASE in size of the prostate
gland
• Benign prostatic hypertrophy—alpha one receptors
on the smooth muscle of the prostate
• Treatment of BPH—alpha one blockers—tamsulosin
(Flomax)** generic; silodosin (Rapaflo), doxazosin ER
(Cardura XL)
• Prostate cancer—risk increases with age
• Protect that prostate!
• Vitamin D and prostate protection
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PSA testing for prostate cancer
• The controversy continues
• What are the cut-off levels?
• A PSA of greater than 4 ng/mL is generally accepted
as the cutoff level for biopsy in the general
population
• Age-adjusted PSA cutoff values are as follows:
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PSA testing
• 2.5 to 3.5 ng/mL and over for 41- 50-year old patients
• 3.5 to 4.5 ng/mL and over for patients who are 50-60-years
old
• 4.5 to 5.5 ng/mL and over for those who are 60 to 70 years
old
• 5.5-6.5 ng/mL for men in their 70s
• For African-American men, the diagnostic range is shifted
downward
• PSA velocity
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PSA velocity and percent free PSA
• Measures changes in PSA concentrations over time
• A level of 0.75 ng/mL/y and over is an indication for a biopsy
• A low value for the percent free PSA means that more of the
increased PSA is present in bound form. This indicates a
greater likelihood of cancer, because most of the increased
PSA present in prostate cancer is in the bound, not unbound
form
• Biopsy and tissue histology make the diagnosis
• The above tests help guide the decision to perform a bx
(J Urol Oct 2004;172:1297; Patient Care Sept 1, 2005))
1% rule—but instead of a decrease, an
INCREASE by 1% per year of clotting factors
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Increased risk of clotting in the elderly
Biological rhythms and clotting—early a.m.
DVTs most common in elderly; increased risk for PE
7:30 a.m. for PE symptoms
7-10 a.m. for MI presentation
Wake up with a “stroke in progress”
Window for tPA for ischemic strokes
Warfarin (Coumadin) is a VERY popular drug in the
over 70 group
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Triple antithrombotic therapy
• Scenario—72 y.o. patient who needs clopidogrel
and aspirin after a coronary stent; plus warfarin
for atrial fibrillation, DVT, and a mechanical heart
valve
• Red clots—RBCs and fibrin that form in veins and
the atrium (DVT and mural thrombus)—treat w/
warfarin
• White clots—triggered by platelet aggregation in
the arteries
• Warfarin? ASA? And clopidogrel (Plavix)?
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• Aim for the lower end of the INR target of 2.0 to
3.0
• Try to stop clopidogrel as soon as it’s safe—often
after 4 weeks after a bare-metal stent or one year
for a drug-eluting stent—this can vary
• Use the low-dose 81 mg of aspirin
• Prescribe GI prophylaxis for patients with risk
factors of GI bleeding
• PPIs and clopidogrel
(Prescriber’s Letter, September 2009)
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1% rule—an increase in body fat
• Retention of lipid-soluble drugs
• Half-life (T1/2) of diazepam (Valium) is the
patient’s “age, in hours”
25-year old = 25 hours
75-year old = 75 hours
Use shorter-acting benzodiazepines should be used
in the elderly (Restoril, Serax, Ativan (lorazepam),
Xanax, Halcion (triazolam)
Start low and go slow…(heard that before?)
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Neurology of aging…
• 5% loss of cerebral weight in females by 70
• 10% loss in men (men start out with a bigger
brain, however)
• By 80, 17-20% loss
• Selected areas are the frontal lobes and the
medial temporal lobes
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Loss of hippocampal cell function
• Loss of recent memory
• This is the first neurologic function to go with
the aging process
• Benign forgetfulness
• Mild cognitive impairment
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What is mild cognitive impairment? (MCI)
• Borderline state—individuals are not demented, but they
perform worse than their peers
• They sense that they are forgetful, and somebody close to
them has probably noticed it, too; (repetition of questions
and comments; misplacing things—relying more on notes
and calendars, forgetting meds, familiar persons; word
finding difficulties;
• Demanding task – new technology may prove challenging;
10-15% per year evolve to clinical Alzheimer’s disease vs.
normal elderly who do so at a rate of 1-2% per year
• Should we use rivastigmine/ Exelon or donepezil/Aricept or
galantamine/Razadyne?? Memantine/Namenda? Ongoing
study at the National Institute of Aging
• Montreal Cognitive Assessment (www.mocatest.org)
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What can you do?
• What drugs accelerate the process? Booze,
nicotine, marijuana
• Hypertension accelerates the process
• Can anything help? Lower BP; B vitamins?
Omega-3 fatty acids? Blueberries? Olive oil?
Use it or lose it? Do all of those crossword
puzzles REALLY work?
• Do the “statin” drugs help?
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What can you do?
• Exercise? YES (increase blood flow to brain
boosts neurogenesis)
• Brain food? YES, foods that protect against
oxidative stress and foods that protect against
inflammation
60
Reduction in prefrontal lobe function with the
aging brain…
• Personality changes
• Decreased ability to concentrate on the
task at hand
• Anti-social, regressive behavior (the loss
of tact)
• Hostile behavior
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“MOTHER” is responsible for your
behavior…your prefrontal lobe is your “mom”
• What’s the only word a mother needs to
know?
• NO, Stop, Don’t, Negative…she is inhibitory
• Socialization, judgment, insight
• You learn through inhibitory influences
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With a dementing process…
• Mom is no longer responsible for “sociable
behavior” (bilateral frontal lobes)
• Sexual indiscretions
• The world becomes the bathroom
• Clothing is optional
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Alzheimer (s) disease or DAT
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The Alzheimer’s brain
Cortical atrophy
Sulcal widening
Atrophy of gyri
“feathering”
Brain weight
90% decline in Ach
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Prevention?
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Do all of those crossword puzzles really work?
Exercise?
Mediterranean diet?
Turmeric? Curry?
Statin drugs? Neurogenesis?
Pathology—5 to 20 years before the 1st
symptom of memory loss
• Beta-amyloid plaques (BAP)—sticky globs
outside the cells; abnormal processing and
cleaving of amyloid precursor protein—
earliest indication of the development of
dementia
66
It takes “tau” to tangle…1 to 5 years
before first symptom
• Neurofibrillary tangles—tangled microtubules inside
the cells; tau protein helps to stabilize the
microtubules and thus, maintain the integrity of the
neuron
• Neuronal degeneration
• Tau and FTD
• BAPtists vs TAUists
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Alzheimer’s…risk factors
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Aging? YES
Genetics? Yes
Chromosomes 1, 7, 14, 21
APOE4
Early onset (before 50)and late onset (65 and older)
Shared risk factors with cardiovascular disease
Hypertension
Inflammation
Oxidation
Estrogen/Testosterone?
68
Diagnostic features…
• Hallmark is memory impairment
• Apraxia—inability to carry out a motor
function in the absence of paralysis
• Auditory and/or visual agnosias
• Impaired executive functioning—planning,
organizing, abstracting (judgment/problem
solving)
• Abstraction
• Significant impairment in occupational
functioning
69
Other causes of dementia
• Vascular dementia—severe depression is
more common in patients with vascular
dementia; psychotic symptoms, particularly
delusions have been described in vascular
dementia
• Binswanger’s dementia—hx of hypertension;
progressive motor, cognitive, mood and
behavioral changes over 5-10 years; apathetic;
disoriented, vague, inattentive, early-onset
urinary incontinence and gait disturbances
• Pick’s disease (fronto-temporal dementia)
70
Other causes of dementia
• Parkinson’s dementia
• Lewy-Body dementia—recurrent visual
hallucinations; fluctuating cognitive
impairment; Parkinsonism features
• Creutzfeldt-Jakob disease—myoclonus,
seizures, ataxia; rapid progression
71
Other causes of dementia
• Nutritional dementia (B12 deficiency)--(B12 --lower
limits 200 pg/mL but patients with dementia and
levels less than 300 pg/mL should be given a trial of
B12); reversible
• Hypothyroidism
• Cancer
• Neurosyphilis—Argyll-Robertson pupil;
accommodates but doesn’t react to light
• Huntington’s disease
72
Evaluation of dementia
• Toxic/metabolic (B12, folic acid, TSH, RPR, glucose),
(Lyme, HIV, liver toxicity)
• Structural – MRI, CT scan (tumors, strokes, normal
pressure hydrocephalus), PET, SPECT studies
• Psychiatric illness
• Neurodegeneration – neuropsychiatric testing for
brain mapping (Alzheimer’s and hippocampal loss—
difficulty encoding new information; FTD—frontal w/
violence, mood swings)
73
Treatment for acetylcholine deficiency…
• Acetylcholinesterase inhibitors such as donepezil (Aricept)—
inhibit the breakdown of ACH in the brain; helps about 50-70
percent of the patients, but effects are modest; think back to
what the patient was doing 7-8 months ago; reprieve only
lasts a few months
• Others—galantamine (Razadyne, Razadyne ER), rivastigmine
(Exelon)(patch is well-tolerated)
• Reminyl was renamed Razadyne to avoid errors with the
diabetes drug, Amaryl (glimepiride)…mistakes led to
hospitalizations and deaths
• Donepezil and rivastigmine—vascular/Parkinson’s, LBD;
galantamine w/ vascular dementia
74
Benefits of cholinesterase inhibitors?
• Many clinicians doubt the practical significance of
response to ChEIs; however, other reports show that
ChEIs have significant efficacy in the treatment of
neuropsychiatric symptoms in AD patients.
• A meta-analysis involving 7954 patients
demonstrated that the numbers needed to treat
(NNT) for 1 additional patient to experience benefit
in the area of cognition were 7 for stabilization or
better, 12 for minimal improvement or better, and 42
for marked improvement.
75
Benefits of cholinesterase inhibitors?
• Other tangible clinical outcomes:
delayed nursing home admission by as much as 21
months with donepezil (Aricept); Donepezil (Aricept) ;
also slows the progression of atrophy of the
hippocampus in the brains of patients with AD—
suggesting a neuroprotective effect of this particular
ChEI.
• Galantamine (Razadyne) and donepezil (Aricept) have
also been shown to be neuroprotective by preventing
neuronal apoptosis (programmed cell suicide).
76
Namenda (memantine)
• Namenda, {Ebixa }(memantine)—decreases excessive
activation of NMDA receptor by glutamate; offers
modest benefits to patients with Alzheimer’s disease
• Who is glutamate? Excitatory transmitter that plays a
major role in memory and learning; continuous
stimulation of the NMDA receptor leads to increased
calcium influx and ultimate damage to the neuron;
Memantine allows normal glutamate fx; blocks
excessive excitation
• Mild to severe AD as an add-on
77
Delirium—key features
• Disturbance of consciousness and attention
• Change in cognition not better accounted for
by dementia
• Symptoms and signs developing over a short
period of time (hours to days)
• Fluctuation of symptoms and signs
• Evidence that the disturbances are caused by
the physiological consequences of medical
conditions
78
Delirium in the elderly
• 1-2% of community dwelling; 10-22% of
hospitalized inpatients, 58% of nursing home
patients
• 15-26% of elderly with delirium die
• Cause of death is the underlying cause of
delirium
• Treating delirium improves cognitive
dysfunction
79
Pathophysiology of Delirium
• Widespread reduction in oxidative
metabolism leading to neurotransmitter
deficiency and/or dysfunction
• Increased levels of cytokines (acute
inflammatory mediators released by the
immune system—IL-1, IL-2, IL-6, TNF-alpha)
caused by illness, physical stresses or both—
leading to impaired neurotransmitter
dysfunction
80
Suspect delirium if…
• The patient is unable to focus attention on the
conversation you initiate
• The patient gives bizarre answers to questions
• The patient cannot spell the word “WORLD”
forward and backwards (inattention)
• Forget the “serial 7s”—try for 3s OR
• Ask the patient to add a quarter, dime, nickel,
and penny
81
“Assume that the onset of delirium in the old
person is due to infection.”—Clifton Meador, M.D.
• Pneumonia—decreased oxygenation to brain
• Listen to the base of the lungs
• A few basilar crackles can be normal in the
very old patient
• “hairy backs”
82
Also consider a urinary tract infection as the
cause of acute delirium…
•
•
•
•
Check the urinary tract
Urinalysis
WBCs in urine, WBC casts in the urine
Estrogen and the urinary tract; pH of urine
and pH of vagina
• Topical estrogen and a reduction in urinary
tract infections
83
Polypharmacy and delirium…
• The blood brain barrier in the elderly is more permeable to
drugs
• Narcotics
• Benzodiazepines (a note on Valium and Librium in the elderly)
• Any drugs with “anti” as their first name…Anticholinergics,
anti-histamines, antihypertensives, antipsychoticcs,
antiparkinsonism, antianxiety, antidepressants
• And more…
• Tagamet, steroids, acetaminophen, diuretics, meperidine,
amantidine
• Sudden withdrawal of drugs
84
Other causes of delirium…check lab tests for…
•
•
•
•
•
•
•
•
•
Low sodium
High or low potassium
High calcium (cause in elderly?)
Hypoglycemia (insulin, sulfonylureas—not metformin
alone); hyperglycemia
TSH —hyper/hypo
LFTs
BUN, Creatinine
Hypoxia, hypercarbia
MI, Stroke with aphasia
85
Other considerations…
• ETOH withdrawal—3rd to 5th day after last
drink—due to dopamine rebound (11th-14th
day increased risk of thromboembolism)
• Fecal impaction
• Urinary retention
• Transfer to unfamiliar surroundings—ICU,
hospital, nursing home
• Sundowning –sensory deprivation in
unfamiliar surroundings
86
Depression…
• More common than dementia
• Often co-exists with dementia
• May appear withdrawn, uncooperative or
intermittently agitated
• Functionally or cognitively impaired
• May prolong recovery from illness due to lack
of cooperation
87
The usual neurovegetative signs of depression are
unreliable in the elderly…(The SALSA signs)
• Sleep disturbances, appetite changes, low, self
esteem, and anhedonia (lack of interest in day-to-day
activities)
• There is NO significant illness or medical condition in
late life that does NOT impinge upon sleep, appetite
or energy or sense of vitality
• Usual aging also brings changes in sleep patterns and
energy expenditure…
• If within 10 minutes…
• Geriatric Depression Scale
88
Stroke and depression
• Left cerebral cortex with damage to frontal
pole=depression (especially seen with stroke
patients; high risk within 1st 2 years after
stroke)
• SSRIs for ischemic stroke patients
• Sertraline (Zoloft) and escitalopram (Lexapro)
are excellent choices
89
Movement disorders…
• The basal ganglia—
• Paired nuclei at the base of
the brain
• 50:50 balance between
acetylcholine and dopamine
• Gamma-amino butyric acid
(GABA) keeps dopamine in
check
Caudate nucleus
Globus pallidus
Substantia nigra
Subthalamic nucleus
90
The BASAL GANGLIA…
• Control of movement, initiation and cessation
of movement
• Postural reflexes—the righting reflex
• Dopamine levels decrease with aging
gradually—we all slow down
• Dopamine loss of greater than 80% results in
signs and symptoms of Parkinson’s disease
91
Clinical symptoms
• Anosmia (loss of smell)(may predate Parkinson’s
disease by a decade)
• Resting tremor (70%)—unilateral or bilateral
• Rigidity (vs. spasticity of stroke patients)
• Loss of voluntary movements (spontaneous)
• Bradykinesia (check gait)
• Postural instability (sternal push)
• Progression to dementia is common (40-60%)
92
Peripheral neuropathy--stocking glove
distribution—dermatone distribution
• 3 major causes in the elderly?
• DM, B12 deficiency, B1 (thiamine deficiency)
93
Exam for peripheral neuropathy
• Check the DTRs (50% of the elderly have lost
the Achilles reflex)
• Acute tendonitis with the fluoroquinolones
(the “floxacins”)
• Loss of lower motor neurons in the lumbar
area of spinal cord greater than loss in cervical
area—weaker legs than arms with aging
• Get up out of a chair? Use arms? Check gait.
94
Herpes zoster—Shingles—Hell’s fire
• Treat acute pain? One of the “cyclovirs” +
prednisone
• Treat chronic pain? Post-herpetic neuralgia;
try single therapy first with either
Gabapentin (Neurontin) or
(nortriptyline)(Pamelor/ Norpramin)
• If they don’t work as single therapy, combine
the two drugs for better response
95
Zostavax at age 60; why?
•
•
•
•
•
•
•
•
•
•
10—0.5%
20—1.3%
30—2.7%
40—4.8%
50—7.5%
60—11.9%
70—19.7%
80—31.8%
90—46.1%
Donahue JG, et al. Archives of Internal Medicine, 1995.
96
Special senses…
• Vision—accelerated loss between 50-69
• Loss of retrobulbar fat and reduction of eye
mass
• Shrunken eyeballs—loss of upward gaze and
peripheral vision
• Decreased lens elasticity with presbyopia
97
Hearing…
• Greater than 25% of all patients over 65 have a
significant hearing loss
• Accelerated loss after 40; greater loss of high
frequency tones; sound localization problems
• Selective hearing loss; wearing a hearing aid; public
perception
• The evolution of hearing products:
17th century, The Ear Horn; wearable hearing aid in
1935, weighed 2.5 pounds
98
Taste and smell…
•
•
•
•
Questionable loss of taste;
Decreased number of taste buds
Decreased saliva
Atrophy of the olfactory bulbs (90 percent of
what we perceive as taste is actually smell)
• Smell and memory
99
The Cardiovascular system and aging
• Increased prevalence of CV disease with age
• Persons over 65 account for 65% of all
cardiovascular hospitalizations
100
The aging heart…
• 1% rule--maximal O2 consumption and cardiac
output decrease by 1% per year;
• Heart rate does not decrease with age
• Decreased heart rate reserve and maximum
attainable heart rate; decreased contractile
reserve—increased risk of CHF
101
The aging heart and vascular system
• Decline in sinus node function—increased risk
for sick sinus syndrome; increased risk for
atrial fibrillation and atrial flutter; impaired
chronotropic responsiveness—increased need
for pacemaker
• Endothelial dysfunction—increased risk for
atherosclerosis; increased risk of heart
disease and cerebrovascular disease
102
The aging heart and vascular system…
• Increased vascular stiffness—increased
systolic BP with widened pulse pressure;
increased afterload
• Increased myocardial stiffness—impaired LV
filling; increased risk for diastolic heart failure
with preserved LV systolic function
103
Chronic heart failure
• Compensatory mechanisms—KIDNEY senses
low volume, low pressure
• Increased renin-angiotension-aldosterone—
resulting in increased preload and afterload
• The failing heart cannot tolerate the increased
preload and afterload—enter the ACE
inhibitors and spironolactone (Aldactone) to
inhibit angiotensin and aldosterone
104
Pitting edema—consider CHF
• Pitting at the ankles
• 4.5 kg of excess fluid (10 pounds)
105
Fluid overload—jugular vein distention
• Check the RIGHT jugular vein in the older
patient—WHY?
• The left inominate vein dumps into the left
jugular; this vein may be compressed between
an elongated and unfolded aortic arch and the
back of the sternum; increased mechanical
pressure of the inominate vein may lead to
increased left jugular vein distention
continuously—i.e. falsely distended
106
“Funny things happen in the middle of the
night…”
• Nocturia
• Paroxysmal nocturnal dyspnea
• Orthopnea
107
Other signs of heart failure
•
•
•
•
•
Pulmonary rales
Hepatojugular reflex
Hepatomegaly
S3 (third heart sound)
Listening to heart sounds
108
A quick primer on listening to the heart…the
easy way (5th ICS, MCL for S2)
109
Listening to the heart…
• S3 heard immediately after S2
• In other words, it is a diastolic sound
• Indicates an elevated left ventricular diastolic
pressure
• Nothin’ that a little Lasix won’t cure
110
The valves…
•
•
•
•
Calcification with aging
Aortic and mitral valves primarily
Which valve is the most diseased valve?
New valves before 60 think rheumatic heart
disease
• 60-70 think congenital heart disease
• After 70—plumb tuckered out…
111
Atrial fibrillation
• Greater than 10% over 80; median age 75; AF reduces CO by
10-15 %
• Fibrillation potentiates clot formation and results in 2-5 fold
greater risk for embolic stroke (embolism)
• % of strokes attributable to atrial fibrillation is < 2% under 60;
20% over 80
• Can occur as a part of normal aging via minor, patchy scarring
that occurs in the atria; these areas of scarring disrupt the
normal circuitry
• Other causes—hyperthyroidism, hypertension, CHF, valvular
heart disease (mitral and aortic), electrolyte imbalances
(check Mg+), diabetes, rheumatic heart disease, ETOH (2% AF
due to 2 drinks daily in women), congenital abnormalities
112
Goals of treating AF
• Controlling heart rate rather than rhythm
• Optimal rate at rest—60-80; with mod. exertion 90-115
• Controlling rate reduces complications, and is better
tolerated than controlling rhythm
• Approach applies mainly to newly detected atrial fib
• Beta blockers—atenolol (Tenormin), metoprolol (Lopressor,
Toprol), diltiazem or verapamil (too much constipation—not
a good choice)—slow conduction through the AV node
• Digoxin is a secondary choice
113
Goals of treating AF
• Antiarrhythmics are also an option—mostly for patients who
are highly symptomatic when they aren’t in normal sinus
rhythm—amiodarone (Cordarone, Pacerone)—most effective,
but serious side effects; very long half life (1-2 months); takes
days or even weeks before a therapeutic level is reached;
reserved for patients who don’t respond to other drugs,
propafenone (Rhythmol), flecainide (Tambocor), sotalol
(Betapace), dofetilide (Tikosyn)
• And, as always, warfarin…long-term anticoagulation with
warfarin reduces risk of stroke by 66%;
• INR – 2-3; mitral valve disease or mechanical prosthetic
valves—INR 2.5 to 3.5
• ASA 325 mg/day with net reduction of stroke of ~20%
114
Warfarin (Coumadin)/dabigatran
(Pradaxa)
• Atrial fibrillation, prevention of DVT and PE
• When adding or subtracting a drug, check the
INR within 4 days
• Usual maintenance dose is 2-10 mg/day
115
Coumadin (warfarin sodium)…
• Drugs that are sulfa-based knock Coumadin
off its binding sites—TMP/SFX
(Septra/Bactrim), celecoxib (Celebrex),
thiazide diuretics, and more…can make
Coumadin more “toxic”—increased bleeding
• Conazoles and Coumadin—even topical
miconazole can increase the INR and cause
bleeding (Heart Watch. May 2001)
• The “green stuff” and warfarin
116
Kiss my aspirin…
• Aspirin is indicated for all patients with acute CHD regardless
of age and should be continued indefinitely in all patients with
documented CHD; 81.5 – 100 mg per day for chronic use
• Recommended dosage in acute setting is 160-325 mg daily
• How about healthy postmenopausal women and aspirin?
• Overall protection for strokes, but appeared to be highest
protection in 65 and older; also significantly reduced MI in
over 65 group (N Engl J Med, March 31, 2005)
• ASA is absolutely recommended in women and men with
established heart disease, regardless of age
117
Aspirin
• Can ibuprofen be used with aspirin?
• Take aspirin first thing in a.m. (note: evening
dose may reduce BP in hypertensive patients)
• Take ibuprofen 2 hours later
• Use Aleve (naprosyn) if an NSAID is required
on a daily basis
118
Clopidogrel (Plavix)
• Inhibits ADP-induced platelet aggregation via
the glycoprotein IIb IIIa complex
• Irreversible action
• Reduces CV events in established CVD
patients—75 mg daily
• Give to patients with ACS (unstable angina
and NSTEMI patients)—300 mg loading dose
and then 75 mg daily with 75-325 mg of ASA
• Losec (omeprazole) and esomeprazole
(Nexium) and clopidogrel (other PPIs?)
119
Nitroglycerin—can I blow up with NTG?
• Oral, extended release (Nitro-Bid, Nitroglyn, Nitrong,
Nitrong SR, Nitro-Time
• Sublingual NTG—NitroQuick, Nitrostat
• Translingual—Nitrolingual
• IV—Nitro-Bid IV, Tridil
• Topical—Deponit, Minitran, Nitrodisc, Nitro-Dur,
Transderm-Nitro
• Transmucosal—Nitrogard
• Cannot use with the ED drugs
120
Remember…
• The combination of an ED drug with a nitrate
can be deadly
121
The ED drugs
• Side effects
• Can you have a heart attack during sex?
• Only if…
122
A major reproductive difference…
• Women get all the eggs they are ever
going to have prior to birth
(not exactly, but almost--)
• However, our ovaries die at 51.3 +-2.7
years
123
HOW MANY EGGS/FOLLICLES DO WE GET?
•
•
•
•
•
•
•
At 6 months gestation ________________
At birth _____________
At age 30 ___________
At age 50 __
The age of an egg is YOUR age!
Could you possibly get pregnant at 50?
How do eggs meet their demise? Apoptosis
and primary ovarian failure—as the follicles
drop out, the FSH rises—trying to stimulate
the ovary to produce more eggs…rising FSH
levels signal impending doom of the ovary
124
Do guys get all the sperm they’re going to get at
birth?
• Nooooooooooo…
• Men produce sperm PRN until the day they
die
• Sperm is only 75-90 days old when freshly
ejaculated
• However, there are some interesting
differences…
125
• The sperm of a 20-year-old vs. the sperm of an 80year-old
• Swimming prowess
• The germ cells that make the sperm and DNA
mutations
• Older fathers and mental illness
126
Gender-specific aging changes
Estrogen has over 300 functions in the body
Reproductive functions
Skin integrity
Vasodilation
Anti-oxidant
Boosts HDLs, decreases LDLs
Builds bone
Calms the hypothalamus
127
The Endocrine system
• Type 2 diabetes—aging and pancreatic islet cell
dysfunction; insulin resistance and beta cell
dysfunction—
• 50% are over 60; 18% are 65-75; 40% over 80 have
diabetes
• DM type 2 is also considered a Cardiovascular
disease—signs and symptoms of atherosclerosis
• 4 out of 5 diabetics die from CV complications—
heart failure, MI, stroke, peripheral arterial disease
128
The Geriatric Patient and blood glucose control
• Blood sugars? (may want to keep the HbA1C in
the 7-8 range)—hypoglycemia can break a hip
• Consider co-morbidities before aggressively
treating—8 years needed benefit of glycemic
control in reducing microvascular complications
• 2-3 years for benefit from BP and lipid control for
reducing macrovascular complications
• Life expectancy?
129
The Endocrine system
• Hypothyroidism—20% of women over 65; what are
the first clinical signs of hypothyroidism?
Cardiovascular and neurologic
• Synthroid and drugs and supplements
• Hyperthyroidism—consider hyperthyroidism as an
underlying cause of atrial fibrillation in the elderly—
weight loss, fatigue and atrial fibrillation—usually
due to a multinodular goiter
130
The GI system
• The acute abdomen—abdominal pain is the
second most common medical complaint in ER
in patients over 65
• Appendicitis—rate of perforation in the
elderly is 50%; may NOT have “board-like”
rigidity
131
The GI system—the acute abdomen
• Biliary tract disease—some researchers
suggest that biliary tract disease is the most
common diagnosis in elderly patients
• Bowel obstruction--~12% of cases of
abdominal pain in elderly persons; large
bowel? Cancer; small bowel? Adhesions from
previous surgeries and hernias
132
The GI system—the acute abdomen
• Gastroenteritis—should be considered as first and foremost a
diagnosis of exclusion in the elderly patient with vomiting and
diarrhea;
• approx. 50% of the cases of missed appendicitis were initially
thought to be simple gastroenteritis; serious morbidity in
patients over 70 (2/3 of gastroenteritis deaths occur in
patients over 70)
• Malignancy--~10% of patients discharged from the ED with
nonspecific abdominal pain will eventually receive a diagnosis
of cancer (deDombal FT, Matharu SS, Staniland JR, et al.
Presentation of cancer to hospital as ‘acute abdominal pain’.
Br J Surg. 1980;67(6):413-416.
133
The GI tract--constipation
• Definition? 3 per day to 3 per week
• Constipation—causes?
Drugs—anticholinergic, opiods
fluid and fiber intake?
laxative abuse—prune abuse
dementia-- “the neglect of the call to stool”…
cancer of the colon
decreased activity
134
Respiratory system
•
•
•
•
Increased risk of pneumonia
Tuberculosis—cardinal symptoms?
COPD and dyspnea
The BNP test to differentiate dyspnea from
CHF vs. COPD
135
BNP—B-type natriuretic peptide
• Peptide produced by the heart in response to fluid build-up
secondary to inefficient pumping; determines whether COPD
or CHF is the cause of dyspnea—15 minute blood test
correctly diagnoses CHF in 95% of the cases without ordering
CXR or ECG
• BASEL study (Brain Natriuretic Peptide for Acute Shortness of
Breath Evaluation)—heart failure ruled out if BNP level was
less than 100 pg/mL; if BNP greater than 500 pg/mL heart
failure was the most likely cause of symptoms
• Prognostic value?—35% increase in mortality for every 100
pg/mL increase in BNP levels among heart failure patients
(Doust JA, et al. BMJ 2005 Mar 19;330:625-33)
• Nesiritide –Natrecor infusions—vasodilation and natriuresis
136
Cancer in the elderly
• Accumulation of DNA mutations over the
years
• Skin—sun exposure over the years; squamous
cell carcinoma, basal cell carcinoma, and
malignant melanoma
137
ABCDEFs…of malignant melanoma
• Asymmetry; appearance of a new lesion (over
40)
• Border—irregular, notched; bleeding
• Color variation, change in size, shape, color
• Diameter—6mm or more
• Elevation, Erythema
• Funny feeling
138
Lung cancer
• Umbrella term--bronchogenic carcinoma
• Non-small cell carcinomas
Squamous cell carcinoma
Adenocarcinoma
Large cell
• Small cell (oat cell)
139
Colon cancer
• Time of day for colonoscopy is important
• Starting at age 50
140
Breast cancer—3 major risks
• Being female
• AGE
• Family history of premenopausal breast
cancer—mother, sister, daughter
141
Breast ductal linings—prolonged hormone
stimulation
Age 20 – 1/2044
Age 30 – 1/249
Age 40 – 1/67
Age 50 – 1/36
Age 60 – 1/29
Age 70 – 1/24
Age 80 – 1/11
Age 90 – 1/8
• LIFETIME exposure to
hormones—womb to tomb
142
Thank you… stay healthy, age well, and have a
nice day.
• Barb Bancroft, RN, MSN
www.barbbancroft.com
[email protected]
143