Geriatrics


Things to remember in Geri:

Power of Attorney

  • Standard power of attorney is null and void if the individual becomes incapacitated.
  • “Durable” power of attorney, specifically for medical affairs, allows the named individual to make medical decisions when the grantor is incapacitated.
     

Determining Capacity:

  • Decision-making capacity:
    • Assessment of the patient’s decision-making capacity should include determination of the patient’s ability to:
      • understand the recommended treatment and alternatives
      • appreciate how that information applies to their own situation
      • reason with that information, supported by facts and the patient’s own values
      • communicate and express a choice clearly
      • The patient should also be evaluated for depression, since untreated depression may affect decision-making capacity.
    • If the patient is judged to be incapable of making his or her own decision, then the patient’s living will or advance directives should be used when making end-of-life decisions
    • Generally a good idea to have two or more physicians independently confirm that the patient understands her decision.
       
  • Incompetence :
    • Incapacity is not the same as incompetency.
    • Incompetency is a decision made in court and is associated with the loss of legal rights.

Medicare

• Medicare will only pay for skilled, rehabilitative care in nursing homes (20 days after at least a three-day hospital stay; patient pays a co-payment of $152 per day for day 21-100 of skilled care)
• Medicare hospice benefit is for home hospice and does not include cost of inpatient care.
• Custodial nursing home care is paid for primarily out of patient’s “pocket.” Medicaid only pays after “spending down.”
• Surviving spouse is often allowed to keep the couple’s home, one car, and a very limited amount of other assets (as little as $3,000).
• Any asset transfer to family members other than a spouse must occur at least three years prior to the need for nursing home care (five years if in a trust).

Physician Quality Reporting System (PQRS) under Medicare Part B:
  • The Physician Quality Reporting System (PQRS) is currently voluntary under Medicare Part B.
  • It requires physicians to report predetermined quality indicators, but not the achievement of performance goals.
  • A variety of health care providers are eligible to participate (not just licensed physicians) in this program, which results in a bonus payment to those who complete it successfully.

Medicare Part-D eligibility for married couple:

  • In order for a married couple to qualify, both must qualify for Medicare Part A,  and
  • Both must be enrolled in a Part D plan, and
  • Their income must fall below 150% of the federal poverty level for a couple.
  • The Social Security Administration also looks at other resources to determine eligibility, including real property.
  • Medicaid recipients are automatically deemed eligible, and are not required to file an application.
  • It is not necessary for recipients to be eligible for Medicaid, however, or to be disabled.
  • A social worker is often helpful in the application process.

Impact of Multiple Chronic Diseases:

  • Nearly half of Medicare enrollees have at least 3 chronic conditions; > 20% have 5 or more.
  • Enrollees with at least 3 chronic conditions account for nearly 90% of Medicare’s annual budget.
  • Two-thirds of Medicare budget spent on 20% with 5 or more chronic diseases.

Medicare Hospice Service:

  • Pts CAN enroll in hospice while in NH, but Medicare hospice will NOT cover NH room and board.
  • Medicare WILL pay for Hospice service while in NH
  • Only medications related to Hospice diagnosis will be covered.
  • Unlimited number of 60-day extensions available
  • Covers bereavement for 13 months.
  • State and federal evaluation of hospice facility is required.

     

ADL/IADL

Activities of Daily Living are basic activities necessary for personal care, and include dressing, bathing, toileting, and transferring (SOR C). Other ADLs include . Meal preparation is an instrumental activity of daily living (IADL), whereas the ability to feed oneself is a basic ADL.
ADL (Activities of Daily Living) IADL ( instrumental activity of daily living)
  • Dressing
  • Bathing
  • Toileting
  • Transferring
  • Eating and drinking
  • Ambulating
  • Taking medications
  • Personal hygiene and
  • Positioning and changing positions in a bed or chair
  • Meal Preparation
    • If meal preparation is a patient’s only functional limitation, independence can still be maintained with delivered meal services such as Meals on Wheels.
  • Telephone
  • Shopping
  • Doing laundry
  • Making and keeping appointments
  • Writing letters or other correspondence
  • Taking part in social and leisure activities
  • Managing finances, and
  • Driving or arranging transportation.

 

Nursing Home Issues

Anorexia/Weight loss:
  • Common in pt living in NH + Dx of Cancer
  • How to improve appetite?
    • Eat WITH others
    • Give breakfast before morning medications
    • Exercise -- Stimulates appetits
    • Vision correction -- Improves appreciation of food.

Medicare Hospice Service in NH:

  • Pts CAN enroll in hospice while in NH, but Medicare hospice will NOT cover NH room and board.
  • Medicare WILL pay for Hospice service while in NH
  • Only medications related to Hospice diagnosis will be covered.
  • Unlimited number of 60-day extensions available
  • Covers bereavement for 13 months.
  • State and federal evaluation of hospice facility is required.

Hospice

Pain Control
  • END-OF LIFE PAIN MANAGEMENT:
    •  NSAIDs
    • Opioid
    • Bisphosponate (for bone pain)
    • Radiotherapy OR Radiopharmacotherapy
       
  • PAIN MANAGEMENT COMPREHENSIVE TREATMENT PLAN:
    • Complete elimination of pain NOT a reasonable goal
    • Form personal goals
    • Physical Activity Improves perception of well-being
    • Adequate sleep
    • Stress


Medicare Hospice Service in NH:

  • Pts CAN enroll in hospice while in NH, but Medicare hospice will NOT cover NH room and board.
  • Medicare WILL pay for Hospice service while in NH
  • Only medications related to Hospice diagnosis will be covered.
  • Unlimited number of 60-day extensions available
  • Covers bereavement for 13 months.
  • State and federal evaluation of hospice facility is required.

Abuse of the Elderly

  • Although often the most obvious because of physical markers (bruising, lacerations, etc.), physical abuse has a lower prevalence than neglect
  • Numerous studies have documented increasing reports of elder abuse in recent years.
  • Although physicians and health care providers are mandated reporters in most states, less than a quarter of reports come from them.
  • It is estimated that only one in five cases of mistreatment are reported, and the proportion of reported cases of financial exploitation is even lower

Identifying At-Risk Elders:

  • Elder abuse and neglect not well studied; little data to identify best screening tool or effectiveness of screening.
  • Despite lack of evidence for screening, most states have statutes protecting elders from abuse or neglect (including self-neglect).
  • Adult protective services (APS) protects community dwelling; long-term care ombudsman programs (LTCOP) focus on nursing homes, assisted living, personal care homes.
  • Cognitively impaired women age > 80 at greatest risk.
  • Sedation (overmedication), skin tears, dehydration (Na > 147), malnutrition, fractures, pressure sores may be clues.
  • AMA recommended screening geriatric patients for abuse in all practice settings.

Bruises on Coumadin:

  • Usually No accidental bruising noted on:
    • Ears, neck, genitals, buttocks, or soles of the feet.
       

Screening Tools

  • Interview elderly patients by themselves.
  • Ask about family composition and living arrangements.
  • Ask directly about abuse, neglect, or exploitation.
      1. Do you feel safe where you live?
      2. Who prepares your meals?
      3. Who handles your checkbook?

The USPSTF’s stand on screening for abuse of the elderly or vulnerable adult is:
A. Screen all patients age > 80.
B. Screen all vulnerable patients age > 65.
C. Screen women age > 85.
D. Screen patients with dementia age > 70.
E. Insufficient evidence to recommend screening.

INFECTIOUS:

C. Difficile in the Elderly

  • Metronidazole for “mild to moderate” disease; vancomycin for “severe”
  • “Severe disease”:
    • 2 or more factors:
      • age > 60,
      • Temp > 38.3 C (101)
      • Albumin < 2.5
      • WBC > 15,000
      • Creatinine increase 50%
        OR
      • WBC > 15,000 and creatinine 1.5x baseline (no agreement on standard definition of severe disease)
         
OPHTHALMOLOGY:

Age-Related Macular Degeneration
(ARMD)

  • Leading cause of new blindness > 55 yo.
  • Macula has highest concentration of photoreceptors in retina.
  • Provides visual acuity and color vision; degeneration leads to loss of central vision (impairs reading, face recognition, driving).

Glaucoma

  • Characteristic optic neuropathy and visual field changes often, but not always, associated with increased intraocular pressure.

Presbycusis

Presbycusis is typically associated with the reduction in:
A. Hearing threshold at all frequencies
B. Hearing threshold at higher frequencies
C. Hearing threshold at lower frequencies
D. Hearing threshold at midrange frequencies
E. Speech discrimination only
RHEUMATOLOGY:

Polymyalgia Rheumatica

  • Rare < 50 yo, avg age 70
  • Bilateral aching/morning stiffness (> 30 minutes) for at least one month, and involving at least two of the following three areas:
    • Neck or torso
    • Shoulders or proximal regions of the arms, and
    • Hips or proximal aspects of the thighs.
  • Sed rate > 40 or elevated C-reactive protein

A 78-yo woman with history of osteoarthritis comes to your office for four-week history of early morning shoulder and hip discomfort. Labs are normal except for erythrocyte sedimentation rate of 52 mm/h.

You recommend the following treatment:
A. Indomethacin 25 mg bid
B. Naproxen 250 mg bid
C. Prednisone 60 mg daily
D. Prednisone 15 mg daily
E. Oxycodone 10 mg q 4h prn

Temporal Arteritis

Management

  • If there is a clinical suspicion of temporal arteritis, corticosteroids must be started immediately, while the workup is being conducted and before the results have been obtained.
  • A delay in treatment can result in permanent blindness

82-year-old male sees you because of a 2-month history of headache in the right temporal area. He says his right temple has also been tender to the touch, and his jaw hurts when he chews his food. On examination the right temporal artery seems thickened and is tender to palpation.
Which one of the following would be the most appropriate initial step?

A. An erythrocyte sedimentation rate
B. CT of the head
C. Beginning corticosteroids
D. Referral for rheumatologic evaluation
E. Referral for a temporal artery biopsy

 

CARDIOVASCULAR:

Postprandial Orthostatic Hypotension

  • Syndrome of orthostatic hypotension occurring 30-45 minutes after a meal.
  • May be ameliorated by caffeine or smaller meal.
  • Prevent by having patient remain seated for 45 minutes after meals and avoiding hypotensive medications at mealtime.
  • Postprandial hypotension or orthostasis is common in the elderly and should be considered in the differential diagnosis of near syncope or syncope.
  • Caring for patients in nursing homes may require rethinking of conventional wisdom (eg, small frequent meals not feasible).

An 84-yo woman has repeated falls due to near syncope in the nursing home, most often when she is returning to her room after lunch or dinner. Her medications include HCTZ 25 mg daily and lisinopril 10 mg daily for hypertension.

Your next step is:
A. Stop the hydrochlorothiazide.
B. Stop the lisinopril.
C. Start fludrocortisone.
D. Encourage the staff not to allow her to stand up for 45-60 minutes after a meal.
E. Begin offering smaller more frequent meals.

 

NUTRITION:

Tube Feeding

  • No evidence that feeding tubes reduce the risk of aspiration pneumonia, heal pressure wounds, improve nutritional status, or decrease mortality.
  • 2/3 placed during acute hospitalization with little discussion with family.
  • Transfer to ER for tube-related complications common.
  • Hand feeding often acceptable alternative.
    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007209.pub2/abstract (Cochrane Review 2009)
ENDOCRINE:

Apathetic Hyperthyroidism

  • Up to one third of elderly patients with hyperthyroidism do not have symptoms of sympathetic overactivity (tachycardia, tremor, nervousness, heat intolerance, increased appetite, more frequent stools, etc).
  • Elderly patients with Graves’ disease less likely to have goiter. Constipation common and 40% have pulse < 100.

A 75-yo woman has a one-month progressive decline in her baseline mental status. She has anorexia, constipation, intermittent nausea, and a 10-lb weight loss. More recently, she became nonverbal and was unable to ambulate at all and was using a wheelchair. She is disoriented and intermittently incontinent of urine.

Her affect is flat. HEENT exam normal. Neck supple, no goiter. Mucous membranes are dry. Coarse breath sounds in all lung fields. T 38.2 C, pulse 84/min, respiratory rate 20/min, blood pressure 152/81 mm Hg, and oxygen saturation 98% on room air.

What test is most likely to help with the diagnosis?

A. Brain MRI
B. Urinalysis
C. EKG and troponin
D. TSH
E. Chest x-ray

 

UROLOGY :

Sexual Problems in Men

Physical Demands of Sex: (Palmieri et al. Am J Cardiol. 2007;100:1795-1801)
  • 19 men (55 +/- 8 yrs) treadmill exercise (Bruce protocol) vs sexual intercourse
  • HR & BP response with sex = Bruce stage II (7 METs or 75% of max exercise HR & BP: 6 min, 12% grade, 2.5 mph)
  • Exercise duration predicted intercourse duration (each minute on treadmill added one minute to duration of sex)

Impairments in Physical Activity Non-institutionalized Adults 70 Yrs Old:

  • Sexual intercourse with a known partner in familiar place = the ability to climb 1-2 flights of stairs

The most common cause of lack of sexual activity in older heterosexual couples is:
A. Female partner’s lack of interest
B. Female partner’s medical condition
C. Male partner’s lack of interest
D. Male partner’s medical condition
E. A and D

The most common reason for cessation of sexual intercourse reported by men:
A. Lack of interest
B. Erectile dysfunction
C. Performance anxiety
D. Premature ejaculation
E. Anorgasmia

Incontinence

Urge Incontinence
  • Most common type of urinary incontinence
  • Signs and symptoms:
    – Abrupt urgency
    – Frequency
    – Nocturia
    – Volume of leakage may be large or small

Treatment

  • Urge incontinence meds more effective when combined with behavioral therapy.
  • Usually do not ablate detrusor overactivity.
  • Efficacy similar; differ by side effects, cost.
  • Lack of response to one agent does not preclude response to another.
  • In men, check PVR before starting antimuscarinic medication to avoid making urinary retention worse.

[see Urinary incontinence ]


The most effective drug for urge incontinence is:
A. Oxybutynin.
B. Tolterodine.
C. Darifenacin (Enablex).
D. Trospium (Sanctura).
E. All are equally effective.

 NEUROLOGY

Stroke

Primary Prevention:
  • Physical Activity (at least 30 min/day) = Risk of CVA
  • Aspirin:
    • Men:
      • NOT recommended for first CVA prevention
      • Recommended to prevent CAD, CVA in the presenve of Risk factors.
    • Women:
      • Useful if pt has significant risk factors
  • Alcohol consumption:
    • Men = 2 drinks/day
    • Women = 1 drink/day
       
  • NO evidence that CRP adds any benefit
Cardiac Risk
Aspirin Women 55-79 when net benefit present (low risk of GI Bleed)
NO aspirin for primary prevention in men <45, women < 55.
NO recommendation for or against pt >80


 

Secondary Prevention:
Modifiable risk factor Therapeutic goals/recommendations
Hypertension BP < 140/90 mmHg (<130/80 for DM or CKD)
Diabetes mellitus (DM) Hemoglobin A1c ≤ 7%
Sympathomimetic abuse Abstinence
Smoking Smoking cessation
Daily alcohol use Men < 2 drinks; nonpregnant women ≤1 drink
Obesity Weight loss until waist circumference <35 inches for women and <40 inches for men
Physical inactivity ≥30 min moderate exercise most days
Symptomatic severe CAS CEA recommended for stenosis 70–99%
Symptomatic moderate CAS Consider CEA for stenosis 50–69%
Left ventricular thrombus Warfarin anticoagulation to INR 2.5 (2–3) for 3–12 months
Afib/Aflut Warfarin anticoagulation to INR 2.5 (range 2–3)
Rheumatic MV disease Warfarin anticoagulation to INR 2.5 (range 2–3)
Dilated cardiomyopathy Warfarin anticoagulation or antiplatelet therapy
HMG-CoA Reductase Inhibitors (statins) -Statins beneficial even with normal cholesterol levels and no CAD
  • Desire LDL <100 mg/dL or <70 mg/dL for very high risk patients* with multiple risk factors
Antiplatelet therapy (ASA, clopidogrel, or ASA-extended-release dipyridamole) All patients after a noncardioembolic stroke
Prosthetic heart valves Chronic anticoagulation to INR 2.5 (range 2–3)
Mitral valve prolapse/aortic stenosis Antiplatelet therapy
Sickle cell disease Exchange transfusion until Hgb S <30%
Cerebral vein thrombosis Anticoagulation to INR 2.5 (range 2–3) for 6 mo
Antiphospholipid syndrome Antiplatelet therapy or chronic anticoagulation to INR 2.5 (range 2–3) if multiple organs involved


 

Neurological Gait Disorders

  • Peripheral neuropathy: Distal sensory and motor signs only
  • Lumbosacral: Lesion below end of spinal cord (T12) = no upper motor neuron signs
  • Cervical: Upper motor signs; no cranial nerve or gray matter signs (eg, dementia)
  • Brain: cranial nerve and gray matter signs, extrapyramidal signs

Upper Motor Neuron Signs

  • Weakness (not complete paralysis) of a group of muscles (not a single muscle); minimal muscle atrophy
  • Increased muscle tone (spasticity, rigidity)
  • Hyperreflexia (+/- clonus)
  • Babinski response

Cervical Myelopathy

  • Cervical myelopathy usually due to degenerative spine changes; may have little neck pain and no radicular symptoms.
  • Upper motor neuron signs often present.
  • Paresthesias and loss of position sensation may be caused by cervical myelopathy but may also have peripheral neuropathy.
  • Surgery for Cervical Myelopathy
    • Better response to surgery if shorter duration, milder symptoms (better if not walker dependent pre-op)
       
  • Management:
    • Image neck (MRI) if candidate for surgery.
    • Check B12, TSH, glucose (since he has signs of posterior column sensory loss).
       

Parkinsonism

• Drug-induced parkinsonism can occur with medications not usually considered culprits (metoclopramide, valproic acid, prochlorperazine, etc).
 

Clinical

  • Resting tremor
  • Asymmetric rigidity/tremor, and
  • Response to levodopa best predict correct diagnosis of PD.

 

 

Restless Legs Syndrome

  • Marked disagreeable discomfort in the lower extremities that occurs only at rest and is immediately relieved by movement
  • 20% of pts > 80 yo; sleep disturbance freq.
  • Labs: Check serum ferritin; if low, give 2-month trial of iron replacement.
  • RX: Pramipexole 0.125 mg, Sinemet CR 50/200, clonazepam 0.5-1.0 mg, or oxycodone 5 to 10 mg hs.

An 80-yo complains of discomfort in his legs at night when trying to sleep, relieved by standing and walking. His only medication is prophylactic aspirin. The test most likely to reveal a treatable cause of his symptoms is:

A. Serum ferritin
B. Serum calcium
C. TSH
D. CPK

Acute and Chronic Cognitive Impairment

Delirium

Diagnostic Criteria for Delirium
  • Acute disturbance of cognition (inattention: can’t focus, shift, or sustain attention)
  • KEY: Rapid onset (hours to days), fluctuation.
  • Tactile or visual delusions common (auditory hallucinations rare)

Causes of Delirium

  • D Drugs (toxicity and withdrawal)
  • E Electrolyte disturbance
  • L Lack of drugs, liver disease
  • I Infection
  • R Reduced sensory input
  • I Intracranial
  • U Urinary retention/fecal impaction
  • M Myocardial/metabolic/pulmonary

Risk Factors for Delirium

  • Use of restraints
  • ≥ 4 medicines in 24 hours
  • Use of indwelling urinary catheter
  • History of dementia, stroke, or Parkinson’s disease.

Is Neuroimaging Always Needed?

  • Neuroimaging unnecessary if:
    • Clinical evaluation discloses an obvious treatable medical illness or problem.
    • No evidence of trauma or new focal neurologic signs.
    • Patient is arousable and able to follow simple commands

 

Normal” Aging Changes in Cognition

  • Slowing in rate at which information can be received and processed
  • Reduction in “explicit memory” (eg., the ability to recall a specific name, number, or location on demand)

Normal aging may be associated with which of the following?
A. Short-term memory loss
B. Difficulty with calculations
C. Word-finding difficulties
D. Difficulty remembering names
E. Reduction in vocabulary

Dementia

Criteria for Dementia

  • Acquired impairment of short- and long-term memory and at least 1 of the following:
    • Abstract thinking
    • Judgment
    • Language
    • Praxis
    • Visual recognition
    • Constructional abilities, or
    • Personality
  • Severe enough to interfere with daily function
  • Gradual decline and progression (ie, absence of delirium)

“Average” Dementia Evaluation

  • History, PE, mental status testing, comprehensive neuropsychological testing
  • CBC, BMP, TSH, VDRL, B12, folate, calcium, U/A
  • +/- Genetic testing
  • Brain imaging (CT or MRI)

Lifestyle and Dementia

  • Bronx Aging Study: Education and cognitive leisure activities “protective” against development of AD
  • 15 minutes aerobic exercise 3x/week reduces likelihood of dementia

76-yo woman is brought to see you by her daughter, who is concerned about her failing memory. Six months ago, the daughter took over management of her mother’s checkbook after she failed to pay bills. Her mother seems unable to knit, something she enjoyed for years. She has difficulty finding the right words to complete a thought.
What is your diagnosis?
A. This patient has dementia.
B. This patient is depressed.
C. This patient is delirious.
D. This patient has mild cognitive impairment.

Alzheimer’s Disease

Criteria for Alzheimer’s Disease
  • Memory loss plus 1 or more:
    • Aphasia: can’t come up with words, substitutes words, new words
    • Apraxia: has difficulty using utensils, tools
    • Agnosia: doesn’t recognize familiar people; gets lost in familiar surroundings
    • Executive dysfunction: can’t manage checkbook, use computer
  • Usually few motor signs apparent early
  • Subtle behavioral and personality changes early

Features Inconsistent with Alzheimer’s Disease

  • Sudden onset
  • Focal neurological findings
  • Seizures, early marked change in personality/behavior
  • Gait disorder early in disease course

The hallmarks of Alzheimer’s disease are:
A. Memory loss, personality change, delusions
B. Memory loss, ataxia, mood changes
C. Memory loss, aphasia, apraxia, agnosia, executive dysfunction
D. Memory loss, depression, abulia
E. Memory loss, acalculia, spasticity

Neurocognitive Disorder

  • Complaint of memory impairment
  • Objective memory loss (adjusted for age and education)
  • Preserved general cognitive function
  • • Intact activities of daily living
  • High risk of developing dementia (5%-10% annually) but 40%-70% do not progress

 

76-yo ex-college professor complains that his memory just isn’t as good as it was. Daughter confirms that he has more difficulty remembering discussions that took place earlier in the day. He’s still paying bills and doing the crossword puzzles. His mental status screening test shows minimal impairment.
What is your diagnosis?
A. This patient has dementia.
B. This patient is depressed.
C. This patient is delirious.
D. This patient has minor neurocognitive disorder
E. This patient is normal for his age.

Depression vs Dementia

CLUE

  • Patient comes in alone complaining about memory = depression.
  • Patient brought in by loved one who complains about patient’s memory = dementia.

“Pseudodementia”
(Dementia Syndrome of Depression)

  • Some depressed elderly patients will have objective evidence of impaired cognition that improves with Rx.
  • Clues include inconsistent performance on mentalstatus testing, “I don’t know” instead of near miss.

When Dementia Mimics Depression: Abulia

  • Diffuse frontal lobe disease (eg, vascular dementia) associated with apathy, lack of motivation, flat affect.
  • Dementia and primitive reflexes usually present (eg, grasp reflex, palmomental response).
  • Abulic patient may seem to enjoy activities if others initiate them.

Vascular dementia

  • Subcortical or mixed dementia
  • Stepwise progression, prior strokes, focal neuro symptoms/signs
  • Preserved personality but “emotional incontinence” or apathy common
  • Definitive diagnosis difficult

80 yo with 12 mos of becoming more sedentary, slowed movement, unsteady gait, 2 falls, no injury. Stepwise progression of deficits. Uses walker. Speech diminished in volume, less distinct. Can’t manage finances. No change in mood or personality. Diabetic, smoker, hypertensive. Flat affect. Muscle tone increased, right grip weak, asymmetric reflexes, no tremor. 23/30 on MMSE (deficits in memory and calculations).

The most likely diagnosis is?
A. Alzheimer’s disease
B. Pick’s disease
C. Huntington’s disease
D. Parkinson’s disease
E. Vascular dementia

 

Diffuse Lewy body dementia

  • Dementia, parkinsonism, and visual hallucinations (may develop severe EPS if prescribed neuroleptics).

A 69-yo man has developed rigidity, a short-stepped gait, and masked facies. He also has become more forgetful (MMSE = 19). His family thinks he sees things that aren’t real.

The most likely diagnosis is?
A. Pick’s disease
B. Alzheimer’s disease
C. Diffuse Lewy body dementia
D. Progressive supranuclear palsy
E. Parkinson’s disease and depression

 

Frontotemporal Dementia

  • Pick’s disease and non-specific degeneration of frontal lobes; corticobasal dementia, progressive supranuclear palsy (“Parkinson plus” syndromes)
  • Behavioral problems early (disinhibition and/or profound apathy) plus aphasia (can’t come up with words, substitutes words, new words).
  • Memory and visuospatial problems later.

A 64-yo man is brought in by his family after exposing himself in public. He has been urinating in the kitchen sink and refuses to bathe. His MMSE is 26/30. He has some wording finding difficulties.

The most likely diagnosis is:
A. Alzheimer’s disease
B. Frontotemporal dementia
C. Diffuse Lewy body dementia
D. Vascular dementia
E. Creutzfeldt-Jakob disease

Normal Pressure Hydrocephalus

  • Clinical triad of (wacky, wobbly, and wet):
    • Dementia
    • Ataxia
    • Urinary incontinence 
  • Frequency of NPH and response to shunt surgery controversial
  • Ataxia most responsive; dementia probably least responsive

A 76-yo man has increasing difficulty walking. He complains that his feet seem stuck together. He has mild memory loss. He has urge urinary incontinence.

You order the following test:
A. TSH
B. CT scan
C. Carotid ultrasound
D. EEG
E. Cystoscopy

Creutzfeldt-Jakob Disease

  • Rapidly progressive dementia over several months with myoclonus
  • Frequently have periodic synchronous bi- or triphasic sharp wave complexes on EEG
  • Tend to be younger patients
  • Transmissible (viral-like “prions”)
  • Rare (1 per million in US)
  • “Variant” CJD = mad cow disease

An 84-yo woman has developed rapidly progressive dementia over 4 months. She has a low-grade fever, is very rigid, and has myoclonic jerks when startled. EEG shows triphasic sharp wave complexes.
This pattern is consistent with which diagnosis?
A. Creutzfeldt-Jakob Disease
B. Subdural hematoma
C. Cerebral vasculitis
D. HIV dementia
E. Herpes encephalitis


Immunization for Elderly

  • Per USPSTF, give one pneumococcal vaccine after age 65 (whether or not one received prior to age 65).

[ Preventive Medicine ]

Unique Geriatric Pharmacologic Issues

Risk Factors for Drug SE

  • 6 or more concurrent chronic conditions
  • 12 or more doses of drugs/day
  • 9 or more medications
  • Potential drug interactions:
    • 6% on 2 meds, 50% on 5 meds, approx. 100% on 8 meds)
  • Prior adverse drug event
  • Low body weight or low BMI
  • Age 85 or older
  • Estimated CrCl < 50 mL/min

Beers’ Other Top Drugs to Avoid

  • Diphenhydramine, hydroxyzine, and first-generation antihistamines
  • Clonidine
  • Amiodarone, dronedarone, class 1 antiarrhythmic drugs
  • Digoxin > 0.125 mg daily
  • All benzodiazepines
  • Glyburide, chlorprompramide
  • Indomethacin, meperidine

Errors

Prescription Errors
  • > 20% of ambulatory older adults receive at least one potentially inappropriate drug (eg, 1/5 receiving cholinesterase inhibitor for Alzheimer’s also take anticholinergic drug).
  • Nearly 4% of office visits and 10% of hospital admissions result in prescription of medications classified as never or rarely appropriate.

Monitoring Errors

  • Example: 12%-63% of patients taking ACE inhibitor had inadequate monitoring of K or Cr.
  • Preventable ADEs: “
    • Most ADEs do not result from improper choices of drugs or drug doses but instead represent known side effects of drugs that have a rightful place in the therapeutic armamentarium.”

Over-the-Counter Medication

  • Elderly account for 13%-15% of the population but account for 40% of all OTC purchases.
  • May not consider these “medications” and may not report to physician because no prescription required.
  • Increasing array of OTCs leads to increased risk of unsuspected ADR, drug interactions (eg, antihistamine/adrenergics can precipitate urinary retention).

Drugs Impairing Cognition

  • Everything we prescribe … except:
    • Acetaminophen and Docusate.
  • Most often psychoactive meds or those with anticholinergic side effects.
  • Discontinue amitriptyline” is always the correct answer on boards.

Specific Drugs:

  • Anticholinergics (eg, diphenhydramine, trihexyphenidyl, oxybutynin)
  • Anticonvulsants (phenytoin, gabapentin, valproate)
  • Muscle relaxers (carisoprodol [eg, Soma], cyclobenzaprine [eg, Flexeril])
  • Antiemetics (prochlorperazine, metoclopramide)
  • Digoxin, clonidine, amantadine, amiodarone
  • Benzodiazepines, antipsychotics

 


Source: AAFP Review Course