13
Module 3 Guided
Questions
Lesson 1: Geriatrics for the PCP
1. What are the physiologic changes of aging? What kinds of problems are caused by these
changes?
• Vision: Presbyopia is caused by loss of elasticity of the lenses. Close vision is markedly
affected. Onset is during early to mid-40s. Can be remedied with “reading glasses” or bifocal
lenses. Cornea less sensitive to touch. Arcus senilis, cataracts, and glaucoma are more common.
Annual eye exams,
assess ability to read (driving, Rx
bottles) Arcus Senilis- check lipids
• Hearing: Presbycusis (Sensorineural Hearing Loss) Screen with audioscope or whisper test.
Refer to audiology if failed. Higher risk for cerumen impaction. Be aware of temp. hearing
loss inducing meds: ASA, Lasix
• Mouth: Receding gums and xerostomia (dry mouth) Decreased sensitivity of taste buds results in
decreased appetite. Dentures- do they fit?
Leukoplakia- check bottom lip, cheilitis, glossitis
• Neck: probably is not supple, masses are likely cancer. Check thyroid and TSH level, check
carotids
• Chest: BP 𝖳 r/t 𝖳 vascular resistance. Baroreceptors less sensitive to changes in position.
Decreased sensitivity of the autonomic nervous system. Blunted BP response. Decrease in
maximum heart rate. Higher risk of orthostatic hypotension. S4 heart sound a “normal finding”
in the elderly if not associated with heart disease. The left ventricle hypertrophies with aging (up
to 10% of thickness). ↓ Cough reflex, ↓ mobility= risk for PNA
• Extremities: Edema- does it resolve at night? Discoloration of lower extremities r/t chronic
edema.
Assess pulses, Heberden nodes,
foot abnormalities 𝖳 risk of falls.
• Abdomen/GI: Decreased efficiency in absorbing some vitamins and minerals by the small
intestines. Delayed gastric emptying. Higher risk of gastritis and GI damage from decreased
production of prostaglandins. Diverticula common. Large bowel (colon) transit time is
Page 1 of 13
, 13
slower.
Constipation more common. Increased risk of colon cancer (age greater than 50 years is strongest
risk factor). Fecal incontinence common due to drug side effects, underlying disease, and/or
neurogenic disorders. Fecal impaction may lead to small amount of runny soft stool. Laxative
abuse more common.
• GU/reproductive: Starting at the age of 40 years, the GFR starts to decrease. By age 70, up to
30% of renal function is lost. Renal clearance of drugs is less efficient. The serum creatinine is a
less reliable indicator of renal function in the elderly due to the decrease in muscle mass,
creatine production, and creatinine clearance. Serum creatinine can be in the normal range even
if renal function is markedly reduced. Risk for UTI 𝖳 r/t prostatic enlargement, atrophic vagina,
constipation, mobility issues. Remember early sign of UTI in geriatrics is confusion!
Ask about sexual activity, may need pharmacological support, may need STD education.
• MSK: Kyphosis: Compression fractures of vertebrae (a sign of osteoporosis). Deterioration of
articular cartilages common after age of 40. Stiffness in the morning. Osteoarthritis very
common. Muscle mass and muscle strength markedly decrease, with more muscle loss on the
legs compared with the arms. Osteoporosis and osteopenia common. Slower healing of fractures
due to decrease in the number of osteoblasts. Bone resorption is more rapid than bone deposition
in women compared with men (4:1). Remember to observe for symmetry in changes. Sarcopenia-
age related loss in muscle mass.
o Osteoporosis: deterioration of bone tissue caused by hormonal changes, calcium/vitamin
d deficiency, risk factors- patients on PPI, patients with anorexia/bulimia females, family
history, age; estrogen and testosterone deficiency (Turner’s), post-menopausal, kyphosis,
Caucasians and Asian, small frame people, cigarette, alcohol, caffeine, medication-
steroids anticonvulsants, thyroid supplements, eating disorder, sedentary life, Dx bone
mineral density >-2.5 osteoporosis, -1 to -2.5 is osteopenia- thinning bone TX first line is
bisphosphonates alendronate, Fosamax (sit upright for 30 min), calcium500 mg, vitamin
D thru food and supplementation, testosterone, wt bearing exercise
• Neuro: Cranial nerve testing may show differences in ability to differentiate color, papillary
response, and decreased corneal reflex. Decreased gag reflex. Deep tendon reflexes may be
decreased, watch for symmetry. Neurological testing may be impaired by medications
causing slower reaction times. Benign essential tremor more common. Tremor with rigidity-
think Parkinsons. Neuro exam is predictor of fall risk.
• Skin: Skin atrophy. Thinner epidermis, dermis, and subdermal fat. Less collagen (less elasticity).
Fragile skin and slower healing. Slower nail growth. Lower oil production and drier skin
(xerosis)
due to decrease in sebaceous and sweat gland activity. Fewer melanocytes leading to graying of
hair and vitamin D synthesis. Decrease in the skin’s sensory ability.
o Seborrheic Keratoses Soft wart-like skin lesions that appear “pasted on.” Mostly seen
on the back/trunk. Benign.
o Senile Purpura Bright purple-colored patches with well-demarcated edges. Located on
the dorsum of the forearms and hands. Lesions eventually resolved over several
weeks. Benign.
o Lentigines Also known as “liver spots.” Tan- to brown-colored macules on the dorsum of
the hands and forearms. Due to sun damage. More common in light skinned individuals.
Benign.
o Stasis Dermatitis Affects primarily lower legs and ankles secondary to chronic
edema (from PVD).
o Senile Actinic Keratosis Secondary to sun exposure; potential for malignancy.
Page 2 of 13
Module 3 Guided
Questions
Lesson 1: Geriatrics for the PCP
1. What are the physiologic changes of aging? What kinds of problems are caused by these
changes?
• Vision: Presbyopia is caused by loss of elasticity of the lenses. Close vision is markedly
affected. Onset is during early to mid-40s. Can be remedied with “reading glasses” or bifocal
lenses. Cornea less sensitive to touch. Arcus senilis, cataracts, and glaucoma are more common.
Annual eye exams,
assess ability to read (driving, Rx
bottles) Arcus Senilis- check lipids
• Hearing: Presbycusis (Sensorineural Hearing Loss) Screen with audioscope or whisper test.
Refer to audiology if failed. Higher risk for cerumen impaction. Be aware of temp. hearing
loss inducing meds: ASA, Lasix
• Mouth: Receding gums and xerostomia (dry mouth) Decreased sensitivity of taste buds results in
decreased appetite. Dentures- do they fit?
Leukoplakia- check bottom lip, cheilitis, glossitis
• Neck: probably is not supple, masses are likely cancer. Check thyroid and TSH level, check
carotids
• Chest: BP 𝖳 r/t 𝖳 vascular resistance. Baroreceptors less sensitive to changes in position.
Decreased sensitivity of the autonomic nervous system. Blunted BP response. Decrease in
maximum heart rate. Higher risk of orthostatic hypotension. S4 heart sound a “normal finding”
in the elderly if not associated with heart disease. The left ventricle hypertrophies with aging (up
to 10% of thickness). ↓ Cough reflex, ↓ mobility= risk for PNA
• Extremities: Edema- does it resolve at night? Discoloration of lower extremities r/t chronic
edema.
Assess pulses, Heberden nodes,
foot abnormalities 𝖳 risk of falls.
• Abdomen/GI: Decreased efficiency in absorbing some vitamins and minerals by the small
intestines. Delayed gastric emptying. Higher risk of gastritis and GI damage from decreased
production of prostaglandins. Diverticula common. Large bowel (colon) transit time is
Page 1 of 13
, 13
slower.
Constipation more common. Increased risk of colon cancer (age greater than 50 years is strongest
risk factor). Fecal incontinence common due to drug side effects, underlying disease, and/or
neurogenic disorders. Fecal impaction may lead to small amount of runny soft stool. Laxative
abuse more common.
• GU/reproductive: Starting at the age of 40 years, the GFR starts to decrease. By age 70, up to
30% of renal function is lost. Renal clearance of drugs is less efficient. The serum creatinine is a
less reliable indicator of renal function in the elderly due to the decrease in muscle mass,
creatine production, and creatinine clearance. Serum creatinine can be in the normal range even
if renal function is markedly reduced. Risk for UTI 𝖳 r/t prostatic enlargement, atrophic vagina,
constipation, mobility issues. Remember early sign of UTI in geriatrics is confusion!
Ask about sexual activity, may need pharmacological support, may need STD education.
• MSK: Kyphosis: Compression fractures of vertebrae (a sign of osteoporosis). Deterioration of
articular cartilages common after age of 40. Stiffness in the morning. Osteoarthritis very
common. Muscle mass and muscle strength markedly decrease, with more muscle loss on the
legs compared with the arms. Osteoporosis and osteopenia common. Slower healing of fractures
due to decrease in the number of osteoblasts. Bone resorption is more rapid than bone deposition
in women compared with men (4:1). Remember to observe for symmetry in changes. Sarcopenia-
age related loss in muscle mass.
o Osteoporosis: deterioration of bone tissue caused by hormonal changes, calcium/vitamin
d deficiency, risk factors- patients on PPI, patients with anorexia/bulimia females, family
history, age; estrogen and testosterone deficiency (Turner’s), post-menopausal, kyphosis,
Caucasians and Asian, small frame people, cigarette, alcohol, caffeine, medication-
steroids anticonvulsants, thyroid supplements, eating disorder, sedentary life, Dx bone
mineral density >-2.5 osteoporosis, -1 to -2.5 is osteopenia- thinning bone TX first line is
bisphosphonates alendronate, Fosamax (sit upright for 30 min), calcium500 mg, vitamin
D thru food and supplementation, testosterone, wt bearing exercise
• Neuro: Cranial nerve testing may show differences in ability to differentiate color, papillary
response, and decreased corneal reflex. Decreased gag reflex. Deep tendon reflexes may be
decreased, watch for symmetry. Neurological testing may be impaired by medications
causing slower reaction times. Benign essential tremor more common. Tremor with rigidity-
think Parkinsons. Neuro exam is predictor of fall risk.
• Skin: Skin atrophy. Thinner epidermis, dermis, and subdermal fat. Less collagen (less elasticity).
Fragile skin and slower healing. Slower nail growth. Lower oil production and drier skin
(xerosis)
due to decrease in sebaceous and sweat gland activity. Fewer melanocytes leading to graying of
hair and vitamin D synthesis. Decrease in the skin’s sensory ability.
o Seborrheic Keratoses Soft wart-like skin lesions that appear “pasted on.” Mostly seen
on the back/trunk. Benign.
o Senile Purpura Bright purple-colored patches with well-demarcated edges. Located on
the dorsum of the forearms and hands. Lesions eventually resolved over several
weeks. Benign.
o Lentigines Also known as “liver spots.” Tan- to brown-colored macules on the dorsum of
the hands and forearms. Due to sun damage. More common in light skinned individuals.
Benign.
o Stasis Dermatitis Affects primarily lower legs and ankles secondary to chronic
edema (from PVD).
o Senile Actinic Keratosis Secondary to sun exposure; potential for malignancy.
Page 2 of 13
