Medicare covers who
Anyone 65 years and older
Any age with
- permanent disabilities receiving Social Security Disability payments
- end-stage renal disease
- amyotrophic lateral sclerosis
Medicare Part A
Hospital Insurance program
- inpatient hospital services
- short-term rehab (SNF/home health agency)
- hospice care
Medicare Part B
Supplementary
- physician, outpatient, home health, laboratory, and preventive services
Medicare Part C
Medicare Advantage program
- Allows enrollment in a private plan
- HMO, PPO, or private fee-for-service plan
- alternative to traditional fee-for-service
Part C is not separately financed
Medicare Part D
Outpatient prescription drug benefit
- delivered through private plans
- either standalone or Medicare Advantage drug plans
Part D generally = monthly premium
Medicaid
States having primary administrative responsibility, within national guidelines
- States can establish their own eligibility
- entitlement program = states must provide certain mandatory services to specified populations in order to receive federal funding
First line treatment for chronic venous insufficiency?
Compression stockings
- and elevation
Loop diuretics (Furosemide) - can cause hypokalemia so give potassium with it
In geriatric patients, abdominal complaints often come from where?
Organs outside the abdomen.
In geriatrics, how will appendicitis present?
In some cases, a low grade fever and general abdominal pain are the ONLY symptoms
Severe pain not likely unless appendix perforates
MC pressure ulcers
- Iliac crests
- Sacrum
- Greater trochanters
- Ischial tuberosity
- Lateral malleoli
MC in patients >70
4 key factors that cause pressure ulcers?
Pressure
Friction
Shearing
Maceration
Pressure ulcers Etiology/Risk Factors
- Intrinsic Factors
- Immobility/inactivity
- Incontinence
- Malnutrition
- Naturally aging skin
- PVD, DM (local ischemia)
- Dementia
How often do you turn the pt to avoid ulcers?
Every 2 hours is ideal
- Bedridden patients should have there head positioned no more than 30 degrees
Stages of pressure ulcer?
1 - Non blanching erethyma (skin intact)
2 - Partial thickness, Epidermis → dermis (blister/abrasion)
3 - Full thickness, Into subQ/facia (crater)
4 - Down to bone/tendon/muscle
Each and Every ulcer must be documented
Size, Location
Eschar, Granulation tissue
Exudate, Odor, Infection
Sinus Tracts, Undermining
Staging (I-IV)
Treatment for stage 1 and 2 pressure ulcers?
- Assess, manage and control pain
- manage local/distant infx (Silver Sulfa)
Clean (with NS only) and apply protective transparent dressing
Treatment for stage 3 and 4 pressure ulcers?
- Assess, manage and control pain
- manage local/distant infx (Silver Sulfa)
Irrigation, debridement of necrotic tissue, healing by secondary intent, appropriate dressings, or surgical closure
Ulcers that do not need debridement
If there are no signs of infection
- Heel ulcers with stable, dry eschar
- ± Stage I and II ulcers
Ulcer complications
Infection:
- Cellulitis, osteomyelitis, bacteremia, sepsis
Topical Abx if no healing after 14d with Silver Sulfadiazine
- May need surgical debridement
- Systemic Abx for advanced cellulitis, osteomyelitis, sepsis
Pending Cx, Abx should cover MRSA, anaerobes, enterococci and gram negative bacteria
Treatment for depression in elderly?
Zoloft (sertraline) 1st line safer with cardiac dz
- also used for PTSD and MDD
2nd line is SNRI - venlafaxine, desvenlafaxine, duloxetine
- Bupropion for tobacco cessation
- Mirtazapine = appetite stimulant and helps with insomnia
Titrate dose at 5 weeks
- can take 12 weeks for effect
Therapeutic dose x 6 weeks with no change
- consider augmenting with bupropion
Depression follow up/referral
Tx continued for 6 months
- if relapse occurs tx for 1-2 years or indefinitely
- D/C meds over 3 month period
Refer to psych if a SNRI and bupropion are not working
What SSRI has a FDA warning for QT prolongation
Citalopram
- QT prolongation at doses >40mg/day
Fluoroquinolones (Azithromycin) also cause QT prolongation
1st line drugs used for HTN
B blockers - not without CV disease
- good for systolic dysfunction and CAD
- bad with asthma/COPD, AV blocks
ACE inhibitors
- good for diabetics, CHF, LV dysfunction
- SE cough (try ARB), hyperkalemia (monitor), severe renal insufficiency
HCTZ
- SE: hypokalemia, hyperuricemia (gout), urinary frequency (night time fall risk)
Drugs used for HF
HFpEF Loop diuretic (furosemide) - SE = hyperkalemia (check 1wk after starting)
HFrEF
B blocker
- Good with HTN
- Bad with asthma/COPD AV blocks
ACE/ARB
- Good with HTN, DM, LV dysfunction
- SE cough (try ARB), hyperkalemia
