NR 601 Comprehensive Final exam study guide and practice questions
2024 LATEST VERSION
How to conduct Mini-Cog-
• The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE
• The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function.
• It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administer
• The Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.
• Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words.
• A score of 0 to 2 is a positive screen for dementia
Causes of delirium in elderly-
• Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including
metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins.
• Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of
delirium in comparison with blood flow patterns after recovery.
• A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the
sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59)
Agnosia
• Loss of ability to identify objects
ADA criteria for diagnosing DM-
• FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
• 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using
a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*
• A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified
and standardized to the DCCT assay.*
• In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200
mg/dL (11.1 mmol/L).
• Urinary incontinence-
• Involuntary loss of urine from the bladder
▪ So common in women many consider it normal
▪ Common in older men w/ enlarged prostate
o Can affect quality of life
o Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt &
society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals
o Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in
placement
▪ URGENCY UI is greater in men
▪ STRESS UI is greater in women
o Terminology
▪ UI- Unintentional voiding, loss or leakage of urine
▪ Continuous incontinence-Continuous loss or leak of urine
▪ Increased daytime frequency-More frequent during day than considered normal
▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50
▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent
▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence
o Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics
o Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen
deficiency, hx of pelvic surgery, diuretics
Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics
o Physical changes w/ aging that contribute to UI
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,▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void
residual,Decrease in urethral blood flow
▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral
mucosal epithelium & increase in urethral sensation
▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms
- Initial clinical workup for UI in Men
o PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men
- UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen
status of pt, Pelvic prolapse, fistula,
-Cough test, Integrity of pelvic musculature, leaking of urine
▪ Full bladder
▪ Standing position
▪ Asked to cough
▪ If urine leak is observed, stress incontinence is confirmed
- Red flags in males
o Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain,
Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA
o Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria,
CVA tenderness,Nodular prostate,Any new neuro symptoms
- Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase
dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden
- 1st line management guidelines
o AHRQ guidelines for management of UI in women
▪ Behavioral therapy
▪ Lifestyle modification
▪ Try for 3 months before pharm management
o Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing
o Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods
o Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys
- Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training
- 2nd line management - Medication
o Antimuscarinic medication: 1st line for women
▪ Block the parasympathetic muscarinic receptors
▪ Inhibit involuntary detrusor contractions
▪ Side effects due to the effects on other muscarinic receptors
o Outcomes unpredictable and side effects common
o Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache
o AntimuscarinicsMechanism of action
● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions
(anticholinergic)
● CYP3A4 substrates
▪ Indications: UI and OAB
▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention
▪ Precautions:CNS depression,Caution in elderly
● Renal dosing
o CrCl <30
o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq)
▪ Also approved for UI and OAB
▪ Clinical trials – significant reduction in incontinence and micturations
● No anticholinergic s/e
▪ Mech of action
● Selectively stimulates beta-3 adrenergic receptors
● Relaxes smooth muscle – bladder
▪ Contraindications/caution: HTN- Do not use if SBP >180, DBP >100
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,▪ Avoid severe renal/liver disease
▪ Dose – 25-50mg PO QD
▪ CrCl <30 – max 25mg
- 2nd line of UI in Males – Alpha 1 blockers
o Men, not women!
o Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptors
o Used in men d/t high incidence of BPH in aging men
o Alpha antagonists
▪ Alpha 1A – prostatic smooth muscle relaxation
▪ 1B – vascular smooth muscle contraction
▪ 1D – bladder muscle contraction and sacral spinal cord innervation
o Meds
▪ Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence
▪ Terazosin SE: Asthenia, dizziness, postural hypotension
▪ Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough
▪ Alfuzosin- CrCl <30 use with caution, SE: Dizziness, URI
▪ Silodosin SE- Retrograde ejaculation
Differentials as cause for erectile dysfunction-
• Differential diagnosis:
o Vascular, Endocrine, Neurological, Neurovascular, Substance abuse, End-organ disease, Psychogenic,
Social causes (Kennedy-Malone 376)
Elder abuse
• Types-
o Physical, Emotional, Sexual, Neglect, Exploitation, Abandonment, Self-Neglect
• Risk Factors-
o Age, Gender, Cognitive Impairment, Living Arrangement, Social Isolation
• Signs of abuse-
o bruises, slap marks, unexplained burns, increased accidents, lack of hygiene, failure to meet medical
needs, weight loss, decubiti, changes in personality, decreased interaction, unexplained STD
• Provider responsibility in reporting abuse
o If you suspect elder abuse perform a physical exam and order any necessary tests.
o Include a cognitive screen.
o Document your findings. This includes what the patient says and your objective findings.
o You may need to interview your patient and the caregiver separately to see if the stories are the same.
o Be aware of your state laws regarding mandatory reporting of suspected abuse.
Differentials as cause for hematuria- Differentials per class notes
• Dietary substances
o Caffeine, spices, Tomatoes, chocolate, alcohol, Citrus, soy sauce, & some herbal meds
• Medication
o Beta-lactam antibiotics, sulfonamide, NSAIDs, Cipro, allopurinol, Tagamet, & dilantin
• Anticoagulation and papillary necrosis
o Coumadin, Heparin, aspirin, & NSAIDs
• Glomerular nephritis
• Hydrocarbons (glue, paint) NSAIDs
• Urolithiasis
• menses
Terazosin use(s)-
• Alpha blocker for BPH. 1-10 mg P.O. nightly.
• Caution in those with cataracts and in elderly.
• Side effects
o hypotension, priapism, dizziness, dyspnea, tachycardia.
• 2nd Line Management of UI in males
***Alpha 1 Blockers
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, • Pharmacologic agents for men with urinary incontinence differ from women;
• Alpha 1 blocker antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha 1 blockers
*Lifestyle changes and Behavioral Management are first-line but when not effective alpha 1 blocker is initiated;
*This difference in choice of medication for men is due to the high incidence of BPH associated with aging men
• Alpha 1 Adrenergic Receptor antagonists
• Alpha 1A- Prosthetic smooth muscle relaxation
• Alpha 1B- Vascular smooth muscle contraction
• Alpha 1D -Bladder muscle contraction and sacral spinal cord innervation
UTIs in men and women
UTI treatment guidelines
BPH-
• Progressive, benign hyperplasia of prostate gland tissue
• Etiology/incidence-
o Cause is uncertain, About 50% of men have it by 60, By age 85, 90% have it
o Most common cause of bladder outlet obstruction in men over 50
• Symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate gland
• Signs/Symptoms-
o Gradual worsening of the following, Frequency, urgency, urge incontinence, Nocturia, dysuria, Weak
urinary stream, dribbling, hesitancy, Sensation of full bladder even after voiding, Retention
• Diff Dx-
o Urethral stricture, Prostate or bladder cancer, Neurogenic bladder, Bladder calculus, Acute or chronic
prostatitis, Bladder neck contractor, Medications that affect micturition
• Physical findings-
o Abdomen,May have distended bladder secondary to retention; Prostate,Nontender w/ asymmetric or
symmetrical enlargement, gross enlargement atypical, Consistency is smooth, rubbery (eraser), Nodules
may be present
• Differentiation from BPH and CA needs biopsy
• Tests/Findings
o UA-No hematuria or UTI, Urinary flow rate, Voided volume and peak urinary flow rate (uroflowmetry)
may detect obstruction flow, Abdominal US – rules out upper tract patho, PSA, Consider PVR urine
volume, Cr to assess renal function, elevated levels suggest urinary retention or underlying renal disease –
refer this patient
• Treatment/Management-
o Refer men who have the following,
▪ Refractory urinary retention who have failed one attempt at cath removal,
▪ Recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder,
diverticula, or renal insufficiency related to BPH,
▪ Consider referral if complications exist or if patients have severe symptoms
• Management-
o Men who have no indications for surgery,
▪ Discuss risks/benefits of all options, Watchful waiting (observation), Behavioral techniques to
reduce symptoms, Limit fluid after dinner,
▪ Avoid medications such as Antidepressants, Antiparkinson drugs, Antipsychotics,
Antispasmodics, Cold meds, Diuretics
• Medication Treatments
o Alpha adrenergic blocker – for smaller prostates
o 5-alpha adrenergic blocker – larger prostates
o Combo therapy is an alpha-adrenergic blocker and finasteride is used now for men w/ large prostates
• Surgery has the best chance for relief of symptoms, but greater risks
• Follow up:
o Teach signs/symptoms of retention and obstruction,
o If observing for now, recheck every 6-12 months,
o In use of meds, recheck in 4-6 weeks,
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