TIS

Chapter 6
Geriatrics - Terms


Abulia

A condition that can arise from damage to the right (or both) parietal lobes leading to lack of attention or engagement by the environment. It may be confused with depression or dementia.

 

Activities of Daily Living - ADL's

The fundamental measure of functional independence: ADL's consist of Physical and Instrumental types.

 

Advanced Directive

Any indication of preferences for medical care written or stated before the person becomes unable to communicate wishes. A "Living Will" is one kind of advanced directive; A health care proxy, or durable power of attorney which designates a substitute decision maker, is another. Advanced directives can express desire to restrain medical intervention which living wills usually do, or to provide all life sustaining measures available.

 

Alzheimer's Disease

The most common, but by no means only, cause of dementia. AD is associated with amyloid plaques and neurofibrillary tangles in pathological examination of the brain. The disease becomes exponentially more likely to occur as age advances, but it is not an inevitable consequence of aging.

 

Amyloid Plaques

Microscopic collections of beta amyloid in the brain; a defining characteristic of Alzheimer's Disease.

 

Anhedonia

The state of being incapable of experiencing pleasure. Certainly one cardinal feature of depression, and perhaps THE cardinal feature.

 

Anomia

Difficulty or inability to place the correct name with a person or noun to with a thing. When an episode of anomia occurs people often say, "It's on the tip of my tongue Or "I'm blocking on the name Some degree of anomia is universal and becomes more frequent with age in normal people with no other signs or symptoms of dementia.

 

Aphasia

Inability to process language in the brain. Usually people with intermediate degrees of difficulty are said to have aphasia although a more precise term would be dysphasia. There are several types, which most clinicians divide into expressive and receptive, although more sophisticated and detailed diagnostic schema's are advocated by some.

 

Autonomy

The fundamental principle of ethics and law guiding decisions having to do with health care. The individual is free to determine his or her own fate and medical treatment.

 

Bayes' Theorem

A function that takes as inputs the prevalence of a condition and the sensitivity and specificity of a test meant to detect the presence of the condition. The output of the function is the probability of the condition given a positive test (the positive predictive value.)

 

Beneficence

The principle that a health care provider should do what is in the patient's best interest. This principle is usually subordinate to the principle of autonomy in recent decisions but a rear-guard action to defend it is mounted intermittently.

 

Benign Prostatic Hypertrophy

Enlargement, without cancer, of the prostate gland in males leading to "prostatism: the syndrome of frequency of urination, urination at night (nocturia) and dribbling of small quantities of urine without control or warning, (overflow incontinence)

 

Beta Amyloid

 

The stuff that is deposited in amyloid plaques. A genetic predisposition to over-production or insufficient metabolism of this material is the cause of Alzheimer's Disease in some well studied families and may be a cause or predisposition in Alzheimer's Disease in general.

 

Binswanger's Disease

A possible cause of dementia distinguished by damage to micro circulation in the white matter of the brain. The idea that is that sometimes vascular insufficiency of the brain causes dementia without producing actual infarcts as is the case in multi-infarct dementia. The existence and importance of Binswanger's Disease is controversial.

 

Broca's Area

An area of the frontal lobe of the cerebral cortex, almost always on the left, which integrates production of language. It is the site of damage in strokes that cause expressive, or Broca's Aphasia.

 

Broca's Aphasia

Aphasia associated with normal comprehension, but limited ability to produce speech. People with Broca's Aphasia are usually mute and require much encouragement even to try to speak. They have damage in Broca's area, almost always in the left cerebral cortex.

 

Capacity

In legal and ethical literature capacity refers to the ability of a person to make decisions for themselves at a given moment in time. Capacity may be impaired temporarily by disease, drugs, and severe fatigue. A physician may determine that a person lacks capacity to make a health care decision, for example, when a person arrives at an Emergency Room drunk but refuses medical evaluation. Loss of capacity is, by definition, temporary. Loss of competence is a more or less permanent state of the person and can only legally be determined by a judge.

 

Cerebrovascular Accident

A catastrophic event producing permanent damage to the brain because of an occlusion or rupturing of a blood vessel in the brain. About 85% are due to occlusion and 15% due to hemorrhage. The occlusive episodes are further divided into embolic and thrombotic although the picture is clouded because the majority are probably intravessel emboli. That means a clot forms in the blood vessel and breaks off to embolize the same vessel downstream.

 

Competence

The legal condition of being able to make decisions for oneself. An adult is presumed competent until a court (judge) decrees that he or she is not competent. Incompetence is considered a permanent condition and it is presumed to apply to all types of decisions although some changes are coming about in this area. When a person is judged incompetent, a guardian, is assigned by the court who makes all decisions for the person.

 

Congestive Heart Failure

Failure of the pump function of the heart resulting in congestion of the lungs and/or the body in general. Congestive heart failure is increasing in elderly people and hospitalizaitions for it are increasing and among the most common reasons for admission of elderly persons.

 

Consent

The act by which a person agrees to something. In medicine this refers to medical treatment. Consent is not a piece of paper. Consent is the act of agreeing and the signed paper serves as evidence that agreement occurred.

 

Contra lateral

The opposite side, usually referring to lesions of the nervous system in relation to the deficit they cause. For example, a CVA causes paralysis contra lateral to the damage in the brain. Contra lateral is is contra lateral in meaning to ipsilateral.

 

Creutzfeldt-Jakob Disease

An illness causing dementia probably caused by a protein that produces an infection, or "prion." It is related to the animal diseases Scrapie and Mad Cow Disease and Kuru. It may have a very long incubation period but the clinical course is usually more rapid than Alzheimer's and is associated with movement disorders and ataxia. See prion.html for more information.

 

Cryogenics

The word means study of very low temperatures, but in the context of geriatrics, it refers to the unproved method of deep freezing the body at death in the hopes that technology to successfully thaw and treat the terminal illness will be discovered in the future.

 

Delirium

Acute, usually reversible, global loss of cognitive function. Usually due to infection, drugs, or failure of a major organ system other than the brain. Clinically associated with clouding of consciousness. To be distinguished from dementia

 

Dementia

Chronic, progressive, usually irreversible, global loss of cognitive function. Usually due to disease of the brain such as Alzheimer's disease and Multiple infarct disease among others. Clinically associated with no loss of alertness or clouding of consciousness. To be distinguished form delirium.

 

Depression

Psychiatric syndrome characterized by anhedonia, feelings of sadness, hopelessness, helplessness, guilt, and frequently thoughts of suicide. Physical manifestations include weight loss, (particularly common in the elderly) sleep disturbance, constipation and lethargy. Depressed elderly people often think their memory and concentration are impaired, but it usually is not if they can be stimulated unless dementia or delirium co-exist. Production of language in general and thoughts or ideas are decreased in depression; depression may be mistaken for dementia.

 

Durable Power of Attorney for Health Care

The legal instrument used by most states to identify who makes decisions for a person when that person is incapacitated. A "Power of Attorney" with no descriptor does NOT confer power to make health care decisions, but does confer power to control property. Sometimes the durable power of attorney is called the durable power of attorney for health care which is useful because durability itself is not the issue for health care providers. As far as health care decisions go, a durable power of attorney for health care has the same effect as a health care proxy.

 

Dysphagia

Difficulty with swallowing. Dysphagia is probably the most common underlying cause of death among the people with dementia. It leads to aspiration pneumonia which is the proximate cause of death.

 

Dyspraxia

Neurological term for lack or co-ordination, but dyspraxia doesn't appear as clumsiness. Dyspraxic individuals may perform small portions of a motion over and over. They may raise the spoon to the mouth many times. When attempting to walk, they sometimes look like their foot is stuck to the ground. They often have trouble letting go once they have gripped something. They have just as much trouble stopping a thing as starting it. Dyspraxic walking is often confused with Parkinson's gait and the two do resemble each other: In Parkinson's the steps are small and fast, while the dyspraxic person repeats a piece of a step over and over.

 

Euthanasia

A term that is best avoided. To some it means "a good death" as the original Greek word did, but due to the use of the word by the Nazi regime to justify programs of killing of the disabled and other undesirables, the word carries a heavy burden of negative connotation. Usually those who use "euthanasia" when others would use "assisted suicide" are rhetorically attacking the latter.

 

Executive Function

Neurologically speaking, the cognitive function that puts various impulses and subroutines in order. If you think of the mind as a society of various voices all clamoring for attention, the executive function is the thing that decides which one is in charge at the moment. A person with deficit of executive function is might see a chair across the room and sit down on the floor. They knew what the chair was and was for and that they wanted to sit down, but they couldn't put first things first and walk over, then turn around then sit down. People with executive function deficits can be very frustrating to work with because they may be able to do every single task you ask them to do, but they cant put together even the simplest sequence. They can do everything but think. They often cling to other people "Velcro? personality" - somehow knowing that they need another executive to constantly guide them.

 

Functional Incontinence

Of the clinical syndromes associated with urinary incontinence, the least treatable, and in some settings, the most common. When a person's bladder works but they can't get to the toilet because of dementia, loss of physical mobility or because they are physically restrained, they develop functional incontinence.

 

Geriatrics

The medical specialty dealing with diseases of elderly people and special problems of aging. Gerontology is the academic basic science which studies age and aging. The two words are related exactly as psychiatry and psychology. Health care providers practice geriatrics; Ph.D. practice gerontology.

 

Gray Matter

Substance in the brain rich is nerve cell bodies as opposed to white matter which is made up of the axons.

 

Health Care Proxy

An Advanced Directive which designates a particular person to make health care decisions when the person involved becomes incapacitated. It is identical to a Durable Power of Attorney for Health Care for practical purposes.

 

Homeostasis

The tendency of many physiological systems to maintain some constant state. A thermostat is a homeostatic mechanism that maintains more or less constant temperature in a house.

 

Hormone Replacement Therapy - HRT

Although other therapies could qualify, this term refers to replace estrogen and progesterone to women at and after menopause. Controversy has swirled around this treatment for many years, but recent evidence suggests that benefits to bone density and reduction of heart disease outweigh risks of breast and endometrial cancer in most women.

 

IADL's

See Instrumental Activities of Daily Living.

 

Inter Nuclear Palsy

A condition in which the vision is preserved but the ability of the person to turn the eyes to see something is impaired. People with this condition often have wide open, "hyperalert" eyes and owl-like head movements with the eyes fixed and movement of the head to change gaze. In Supra-nuclear palsy there is loss upward gaze; in inter nuclear palsy there is loss of all directions of gaze.

 

Instrumental Activities of Daily Living

Activities that require use of tools or tasks specific to a given cultural environment. For example, driving a car, using the phone and paying bills are instrumental activities of daily living. They are less fundamental to health and well-being than Physical Activities of Daily living.

 

Internal Capsule

 

Ipsilateral

"On the same side." Contra lateral in meaning to contra lateral.

 

Left Ventricular Hypertrophy

Increased mass of muscle in the left ventricle. The hypertrophy tends to be concentric in older people and in the septum in younger people. LVH is associated with heart attacks and eventual congestive heart failure. It is a consequence of hypertension.

 

Lewey Body Dementia

A dementia associated with a many Lewey bodies which are particular pathological findings. Lewey bodies were previously associated exclusively with Parkinson's Disease but are found in autopsied brains of people with dementia not associated with Parkinson's Disease as well. They account for most of the cases of dementia which were mistakenly diagnosed as Alzheimer's Disease in life in at least one series.

 

Living Will

An Advance Directive that states what a person wishes to have done under specified circumstances when they cannot speak for themselves. For example: "If I am in a permanent vegetative state with no reasonable chance of recovery,. I wish that all life prolonging technology, including feeding, be withdrawn." It may also state general philosophical positions such as "I value freedom from pain and dignity over prolonged life." Typically living wills assert desires to restrain medical intervention such as those above but they may state opposite views as well.

 

Metaplasia

Change of cells from one differentiated type to another, for example, change from normal skin to hair follicle.

 

Mixed effect treatment

A term applied to a medical treatment which is intended to relieve pain or other symptom but carries a high risk of death. A mixed-effect treatment is legally and,in most systems, ethically permissible. To be distinguished from a treatment whose only intent is the ending of life; such treatments are illegal almost everywhere and unethical in most systems.

 

Motor Cortex

The pre-sylvian cortex of the cerebrum. When this area is damaged, the person becomes paralysed on the contralateral side of the body.

 

Multiple Infarct Dementia

Dementia caused by multiple infarcts (areas of damage done by lack of blood supply.) Single infarcts cannot cause dementia unless they are so massive as to be life threatening, although specific deficites such as aphasia,dyspraxia or loss of spatial awareness can result from single lesions. This is because memory and other cognitive functions are implemented diffusely throughout the brain.

 

Neurofibrillary tangles

Microscopic pathologic findings common in the brains of people with Alzheimer's Disease and other conditions. They are formed by double helices of Tau protein

 

Normal Pressure Hydrocephalus - NPH

One of the treatable causes of dementia. The triad of dementia, ataxia and urinary incontinence is classically described although incontinence is not always found. The gait disturbance is characterized by wide-based gait with "magnetic" feet - the patient has trouble lifting the feet off the ground.

 

OBRA Regulations

The Omnibus Budget Reconcilliation Act of 1987 mandated regulation of practices in nursing homes. There are a range of items including restriction on use of physical restraints and providing privacy and confidentiality of nursing home patients. But the regulations which most directly affect the physician involve use of psychotropic drugs. In particular, psychotropic drugs must have a justifying diagnosis, must be monitored with log of target behavior and efforts to reduce or eliminate the drug must be made, among other regulations.

 

Osteoarthritis

Very common form of arthritis affecting the weight-bearing joints and hands of elderly people. It is not associated with significant inflammation.

 

Osteoporosis

Common disease of elderly women (predominantly, although men are by no means spared.) Loss of bone, both mineral and protein matrix underlies the condtion. Fractures, particularly of the hip, wrist and vertebrae commonly result from oseoporosis.

 

Overflow Incontinence

The clinical syndrome associated with urinary incontinence that occurs when outflow obstruction exists, most commonly from prostate disease in males. The bladder greatly distends, urine dribbles in frequent, almost constant, small amounts, often without the person being aware of its passing and certainly with ability to control. The condition may be distressing at first with constant feeling of distention, but when chronic, the person may not be aware of being "full at all.

 

Parkinson's Disease

A common disease associated with old age characterized by a slow tremor, difficulty initiating movements, slow movements, a characteristic gait with small rapid steps. Autonomic nervous system malfunction and, in about 50% of cases, dementia, complicate the picture. The cause is damage to the dopaminergic pathways in the brain. Treatment wit L-Dopa is very effective but may not affect the course of the illness favorably.

 

Pharmacodynamics

Pharmacodynamics refers to how a drug interacts with a receptor. Changes in pharmacodynamics affect how potent the drug effect is when the amount available at the receptor is constant.

 

Pharmacokinetics

Pharmacokinetics refers to what happens to a drug one it has been administered: how is it absorbed, distributed and excreted. Changes in pharmacokinetics affect the amount of drug available at the receptor site.

 

Physical Activities of Daily Living- PADL

The fundamental things everybody does every day to live. I think of them as the things you have to do before you go to work or school every day, no matter who you are or what kind of culture you come from. Various authors use different formulations but the big five PADL's are:

* Eating
* Walking
* Transferring (from bed to chair)
* Toileting
* Dressing and Grooming

 

Power of Attorney: - POA

A legal document conferring the power to represent another in legal actions including access to funds and paying debts. Durable power of attorney is used in health care to mean a person with power to make health care decisions for another.

 

Polymyalgia Rheumatica - PMR

A condition almost exclusive to the geriatric population associated with elevated erythrocyte sedimentation rate and pain and weakness of the shoulder and hip girdle muscles. PMR is highly correlated with temporal arteritis, an inflammation of the temporal artery with a high risk of blindness. Treatment with steroids has been shown to decrease the risk of blindness.

 

Progressive Supra nuclear Palsy - PSP

A disease characterized by Parkinson's Disease like symptoms combined with failure of upward gaze and other ocular movement problems. It is usually rapidly progressive.

 

Prosody

Expression of emotions through tone of voice or facial movement. Prosody is integrated in the right parietal lobe of most people and thereby not impaired in most aphasias. Deficits in prosody may be expressive or receptive. Prosody deficit may be very difficult for family members to accept and deal with and counseling them may be very useful.

 

Psychotropic Drugs

Drugs used for modification of behavior or treatment of psychiatric disease. The classification is important because OBRA regulations apply specifically to them. The types of psychotropic drugs are:

* Antipsychotics
* Antidepressants
* Sedative/hypnotics

 

Sensory Cortex

The cerebral cortex posterior to the Sylvian fissure.When damage, changes in sensation on the contralateral side of the body result.

 

Stress Incontinence

Urinary incontinence associated with loss urine when intra-abdominal pressure rises such as while coughing, sneezing, or laughing. It arises from incompitence of the urinary sphincter and is most common in parous women who have abnormal anatomy of the bladder or urethra. It is rare in men except after surgery to the prostate.

 

Stroke

Basically a cerbrovascular accident. The term comes from the idea of "stroke by the hand of God."

 

Substituted Judgment

The principle that when a substitute is called upon to make decisions, that substitute should base their decisions on what the person would have wanted if they could speak. Substituted judgment is replacing the "best interest" standard for substitute decision makers.

 

Urinary Incontinence

One of the most common handicaps of elderly people and one that may be under treated. There are five clinical syndromes of urinary incontinence:

* Urge: irresistable urge to pass urine
* Overflow: nearly constant, often unsensed dribbling
* Stress: leakage during periods of high intra abdominal pressure
* Functional: inability to perform the act of getting to the bathroom and so on.
* Mixed: You can figure this one out, I bet.

White Matter

The parts of the brain which are made up mostly of axons and contain few neuron cell bodies. The cables of the brain rather than the central processing units.

 

Wiernickes Aphasia

Aphasia characterized by fluent but unintelligible speech often containing sound and work substitutions. (paraphrasias.) Weirnicke's aphasia arises from damage to receptive centers for language in the posterior temporal lobe. It is much more unusual than expressive, or Broca's aphasia.


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