Common conditions seen in primary care for older adults?
Dry eyes / keratitis sicca
Lid abnormalities: drooping lids (blepharoptosis), lid malposition (ectropion/entropion) → lubrication, surgery if severe (vision impaired)
Conjunctivitis: referral if severe
Chalazion
Herpes simplex / zoster ophthalmicus
Charles Bonnet syndrome
Low-vision rehabilitation options?
Available to <20/60
Improve lighting, Reading materials with bold or large fonts. Read only on Black/white contrast
Magnifiers (high plus spectacles, Closed-circuit TVs, Telescopic devices)
Eccentric viewing (for ARMD w/central macular patho: training to use off center fixation (looking out of corner of eye)
Complete vision loss:Talking devices/Braille
Phone apps provide magnification, money recognition, dictation.
Dry eyes (keratitis sicca)
dec tear production with aging
Redness, foreign body sensation, reflex tearing
oft associated w/blepharitis
tx: artificial tears at daytime
Severe: ointment at night or topical cyclosporine A 0.2% form underlying inflammatory cause
lid malposition or lid exposure
Ocular lube and refer for surgical repair.
Age-related loss of elasticity & tensile strength with aging
Blepharoptosis = drooping eyelid
Blepharochalasis = drooping brow
- can cause cosmetic deformity if severe-impairs vision.
Ectropion = lid eversion
Entropion = lid inversion
- May cause discomfort
Tx- various surgical procedure
Conjunctivitis
Allergic → itching: avoid allergen, cold compress, topical/systemic antihistamine
Viral → watery discharge, supportive tx w/artificial tears, refer to ophtho if vision significantly affected
Refer if severe or corneal involvement
Charles Bonnet Syndrome
Visual hallucinations Occurs with significant visual impairment
Patient knows they are not real
Cognition intact
May be elementary shapes or complex ex: children/animals
When d/c is directly home
Follow up appointment
Warning s/s to watch for with instructions on who to contact
Clinical discipline contacted to provide service in home
Reconciled med list
When discharge is to another care setting
Nature of new institution
ID of new attending physician (if known)
Expected frequency of provider visits
Helpful tools for pt and caregiver: care transitions program transitional care and intervention
Olfactory chemo sensory perception
Smell declines with age
Affect men more
Impaired olfaction in older people = risk factor for eating spoiled food or failing to notice gas leaks or domestic fires
Chemosensory Perception: Taste Perception
saltiness and sweetness is blunted with advancing age.
playing a role in a person’s tendency to oversalt foods or crave sweets.
• Some drugs that have an effect on saliva may also affect taste.
Infective endocarditis
caused by organisms found only in mouth.
• if at elevated risk should be counseled to optimize daily oral hygiene to Dec gingival inflammation and bacterial access to bloodstream
• ppx abx coverage recommended only in high-risk situations
• For invasive dental tx in a patient on anticoagulant regimen, as long as the INR is 3.5 or lower, risks of uncontrolled oral hemorrhage is minimal and outweighed by the protective effects of anticoagulation.
Impact of hearing loss
Assumed to be benign profundly affects QOL
Contributes to fam discord/social isolation/anger/depression/loss of self esteem
Tx can improve QOL by facilitating family/friend/caregiver interactions
Categories of hearing loss based on cause
Conductive (loss is when bone conduction is > air conduction in Rinne test. And lateralization goes to the affected ear on Webber test)
sensorineural
mixed
Conductive hearing loss
External ear patho (cerumen impaction/foreign body)
Middle ear patho (otosclerosis/ cholesteatoma, TM perforation, middle ear effusion)
Sensory presbycusis
loss of sensory hair cells (carries signals) in basal end of the cochlea.
Slow progressive loss, beginning with the higher frequencies (can hear low voice better)
Difficulty hearing in background noise (crowd/restaurant)
tx: amplification
strial presbycusis
from atrophy of stria vascularis
- onset in 20s-60s
-mild-mod HL in most frequencies
- good speech discrimination
tx: amplification (hearing aids)
neural presbycusis
cochlear neuronal loss of 50% or >
- poor speech discrimination
- amplification isn’t successful
cochlear conductive presbycusis
caused by changes in the cochlea itself. from mass, or stiffness to age related changes, or spiral ligament atrophy.
Audiogram descends gradually over five octaves.
Speech discrimination is impaired.
sleep probs epidemiology in OA
-common esp those w/multimorbidity/psych illness
- 1/2 of community dwelling OA use otc/rx sleeping med
- insomnia more common in women at all ages
Epidemiology of sleeping difficulty
most problematic = falling asleep
2nd: nighttime awakening
3rd early morning waking and then daytime sleepiness
sleep study eval
polysomnography indicated if primary sleep disorder suspected (sleep apnea, narcolepsy, periodic limb mvmt disorder, violent/unusual behaviors during sleep, other sleep sx that don’t respond to tx
- in home portable monitor: screens for sleep apnea
- wrist activity monitors: estimate sleep vs. wakefulness. useful more in nursing homes, because they can identify circadian rhythms sleep disorders
