Transcript Internal Medicine Board Review: Geriatrics

Alycia Cleinman MD
Assistant Professor
Geriatric Medicine
 77 yo man with few months of anorexia, weight loss
(10-15 #), nausea and diarrhea, malaise, fatigue, and
falls.
 PMHx: paroxysmal Afib, HTN, glaucoma
 Meds: Digoxin, lasix, lopressor, quinidine, ASA
 VS stable except pulse 42, regular. Otherwise
unremarkable exam.
 What could be cause of anorexia, wt loss, GI upset?
 Adverse drug reactions are increased 2-3x in
elderly
 strongly correlates with polypharmacy
 increased comorbidity
 drug-disease interaction
 altered pharmacokinetics related to body composition
changes and hepatic/renal alterations
 Adverse drug effects may be subtle
 Falls
 Anorexia
 Cognitive Impairment
 Fatigue
 Urinary Incontinence
 Constipation
 Body composition changes
 ↑ body fat
 ↓ body water
 ↓ serum albumin
 Changes in body composition can alter drug
distribution
 Larger volume for distribution
 Lipophilic
 eg Diazepam, trazodone
 Longer half life & duration action
 Smaller volume for distribution
 Hydrophilic
 Eg PCN
 Shorter half life & duration action
 Physiological changes
 Delayed gastric emptying
 Slowed GI motility
 Drug Absorption
 Slowed rate of absorption
 Lower peak concentrations
 Variable transdermal absorption
 CNS
 Age related changes
 ↓ blood flow & O2
 ↑ BBB permeability
 Increased sensitivity
 Anti-cholinergics & sedating medications
 Hyponatremia
 thiazide diuretics
 SSRI’s
 high-dose narcotics
 Hyperkalemia
 Potassium- sparing diuretics
 eg spironolactone
 ACE inhibitors, ARBs
 NSAIDs
 86 yo female with Alzheimer disease, GERD, and arthritis is
admitted to hospital after a fall resulted in a hip fracture.
She is very lethargic on your exam and her family reports
this is a change from her normal mental status
 Medications: donepezil, memantine, pantoprazole, tylenol
 Plus inpatient meds – morphine, promethazine,
diphenhydramine, cyclobenzaprine
 Which medications could be resulting in altered mental
status?
 What is best option for her pain?
 Potential Side effects
 confusion, gait instability, dry mouth, constipation, urinary
retention
 Medications with anti-cholinergic properties
 Anti-depressants (amitriptyline)
 Anti-spasmodics (oxybutynin, dicyclomine)
 Anti-histamines (diphenhydramine, hydroxyzine)
 Anti-emetics (phenergan)
 Anticholinergic drugs
 Narcotics
 Benzodiazepines
 L-dopa, bromocriptine
 prednisone
 NSAIDs
 cimetidine
 Warfarin
 Antibiotics (FQs), herbals, and other meds may
increase bleeding risk and increase INR
 SSRIs, SNRIs, tramadol, zyvox
 Combination can increase risk for serotonin
syndrome
86 yo man with CHF, AFib, and Parkinson Disease is under your care in a
NH. The nursing staff asks you to write an order for a physical restraint
while he is in a wheelchair. They report that over the last 2 weeks he has
become more confused at night with restlessness and that his gait is more
unsteady. When he tries to walk, he needs the assistance of a nurse’s aide.
Medications: Furosemide, Digoxin, Levodopa-Carbidopa,
Bromocriptine, Nitrate Patch, Diazepam
What could be contributing to his gait instability?
 PUD NSAIDs
 BPH  anticholinergics
 CKD NSAIDs
 Syncope or falls  Benzos, antidepressants, neuroleptics,
BP meds, oral hypoglycemics
 Prolonged QTc  fluoroquinolones, azithromycin,
SSRIs, antipsychotics
 Screening
 Hearing handicap inventory for the elderly
 10 item questionnaire - Impact of loss on daily activities
 Handheld otoscope with tone generator
 Presentation
 Tinnitus – can be early symptom
 Cognitive impairment
 Examine ear canals for impaction
 Ho TM sx or perforation – refer to ENT for removal
 Cerumenolytics – 40% effectives
 Medication review
 Lasix, salicylates, aminoglycosides, vancomycin
 Asymmetrical loss
 more concerning for a tumor
 Comprehensive audiologic assessment
 Personal amplifier/Adaptive equipment
 Hearing aids
 Bone anchored hearing aids
 Use if:
 Unilateral hearing loss
 Unable to tolerate hearing aid in canal
 Conductive/mixed hearing loss
 Cochlear implants
 Severe to profound hearing loss
 with little/no benefit from aid
 Possible complication
 Meningitis
A 78-year-old F with PMH HTN is seen in clinic for her medicare wellness visit
reports falling once in past year. She tripped over her cat while going to the toilet
at night in poor lighting. She denied injuries, LOC, preceding symptoms.
Home Medications: lisinopril.
On physical examination, BP 138/85 mm Hg, negative orthostatics.
Which of the following is the next step in the management of this patient?
A
Assess gait and mobility
B
Discontinue lisinopril
C
Prescribe an exercise program
D
Provide a standard walker
E
Order Hip protectors
 Consequences
 Functional decline
 Fracture (10-15%)
 Head trauma/serious soft tissue injury (5%)
 MCC of injury-related death
 Increased use of medical services & NH placement
 Inquire about falls annually
 Take detailed history
 Circumstances, frequency
 Assess risk factors
 Home hazard, sensory impairment, dz, meds, etoh, pets
 Perform physical
 Gait assessment, orthostatics, vision
 Strength, ROM, sensation, proprioception, reflexes
 Focused Labs/Imaging
 Vitamin D, TFTs, Chemistry, B12
 MRI (Cervical, lumbar spine); Head CT
 Nerve conduction studies/EMG
 Timed Get-Up-and-Go test
 Get up from chair, walk 10ft, turn around & sit
 Less than 10 sec  normal
 10-20 sec  moderate fall risk
 >20 sec  high fall risk
 Balance assessment
 Pull test
 Semi-Tandem stance
 Tandem (heel-to-toe) walk
 POMA (Tinetti)
 Balance + Gait
 Antalgic gait
 Propulsion
 Festination
 Retropulsion
 Foot drop
 Steppage gait
 Freezing of gait
 Turn en bloc
 Medication review
 Appropriate footwear
 Assistive devices
 Treat vision impairment
 Life Alert systems
 Home safety evaluation (OT)
 Exercise
 Balance & resistance training
 Tai chi - ~50% reduction
 Vitamin D replacement/supplementation
 Osteoporosis evaluation and treatment if necessary
A 76 yo man with PMH mild dementia, macular degeneration is seen in clinic for follow-up.
His daughter reports she has concerns over his driving, as he confuses the gas & the brake
sometimes and has hit the mailbox. The patient reports he is a good driver and denies these
events. He has not had any recent traffic tickets or accidents with other vehicles. He scores
22/30 on the Mini–Mental State Examination. He lives in an area with nearby stores and his
family is able to drive him to places he needs to go.
Which of the following is the most appropriate recommendation regarding driving for this
patient?
A
B
C
D
Limit driving to daytime and local roads
Allow patient to continue driving without restriction
Instruct patient to immediately stop driving
Recommend a driving evaluation
 Vision impairment
 Restricted mobility
 Arthritis, foot drop, cervical dz
 Cognition (ie judgement)
 Neuropathy
 Parkinsonian diseases
 Rigidity
 Medication side effects
 Sedation (decreased reaction time), dizziness
 Office assessment
 Vision
 Fields & acuity
 Cognition
 Visuospatial, Executive function
 Musculoskeletal exam
 Strength; ROM of neck, trunk, & extremities
 Sensation & proprioception
 Driving assessment
 Driving rehabilitation specialist
 DMV
65 y/o F with PMH HTN c/o being more forgetful over the past 6 mo. She is losing items and
forgetting names of distant friends, which is new for her. She no longer is interested in
attending church or lunch with her girlfriends. She reports only sleeping 4 hours a night
and has lost 10lb over this time period. She denies depressed mood, hallucinations, or
gait changes.
Her physical exam is unremarkable; Mini-Mental State Examination (MMSE) score 23/30;
Geriatric depression screen (GDS) 15/30
Results from basic blood work, including thyroid function studies, are normal. An MRI of
the brain shows no abnormalities.
Which of the following is the most appropriate next step in management?
A
Start remeron
B
Start amitriptyline
C
Start paroxetine
D
Start donepezil
E
Start quetiapine
 Prevalence –
 6-10% primary care clinic
 12-20% NH residents
 Presentation in Elderly  Less frequently report depressed mood
 “Pseudo-dementia”
 Overlap with chronic illness in somatic symptoms
 Clinic setting  Initial visit then annual
 Nursing home  Within 2wk of admission then every 6 months
 Screening Instruments –
 PHQ-9
 GDS
 Evaluate for co-morbid conditions
 Hypothyroidism
 Substance abuse
 1st line – SSRI
 Preferred – sertraline, citalopram, escitalopram
 Paroxetine, fluoxetine (long half life)
 Beers criteria –
 TCA – anticholinergic, sedating, OH
 Preferred TCAs – nortriptyline, desipramine
 Weight loss or insomnia
 Mirtazapine QHS
 Aggressive acute phase treatment to bring about remission
 Follow-up in 4 weeks to re-assess
 Continuation tx to prevent relapse
 Additional 6mo after symptom remission
 Maintenance tx to prevent recurrence
 3 or more years for depression with psychosis, suicidality, or
recurrent episodes
 Addition of psychotherapy if psychosis or suicidal
A 65 y/o F with severe COPD is referred to palliative care clinic with
persistent complaints of dyspnea. She wears her oxygen at all times . On
exam – oxygen saturation 94%, clear lung fields bilaterally. An acceptable
quality of life for her would be to spend time with her dogs and husband
outside, without having constant dyspnea.
What should be done next in the management of this patient’s dyspnea?
a.
b.
c.
d.
Explain to her that oxygen saturation is in the mid 90’s and she does
not need to worry
Recommend addition of spironolactone
Recommend morphine immediate release elixir 2.5-5 mg every 4
hours as needed
Recommend she increase her oxygen from 2 to 4 liters
 Palliative care
 Goals
 Relieve physical/emotional suffering, optimize function,
assist with MDM for pts with advanced dz
 May be provided regardless of whether the patient is
receiving curative or disease-modifying treatment
 Hospice
 Comprehensive care for pts with life expectancy ≤6
months
 Dyspnea
 Opioids*
 Oral & parenteral effective
 Nebulized morphine not shown to be helpful
 Supplemental oxygen, cool air (fan)
 Benzo – if anxious
 Diuretics - if volume overloaded
 Increased respiratory secretions
 Atropine drops, glycopyrrolate, scopolamine,
Hyoscyamine
 Pain
 opioids
 alternative routes of delivery
 suppositories, transmucosal formulations, SC
 Bone pain
 NSAIDs*, steroids*
 Bisphosphonates, calcitonin, radiation (mets)
 Nausea/vomiting
 Haldol*, ondansetron, steroids
 Reglan (dysmotility), PPI/H2 Blocker (gastritis)
 Anti-histamines, antivan, phenergan – with caution
 Diarrhea
 Check for impaction
 Cholestyramine, octreotide
 Constipation
 Prophylactic bowel regimen if receiving opioids
 fecal softener (eg, docusate) + bowel stimulant (eg, senna,
bisacodyl)
 Can add
 osmotic laxative (eg, sorbitol, lactulose, or polyethylene glycol)
 Lubiprostone
 If no bowel movement for ≥4 days – check for
impaction/obstruction & consider enema
 opioid-induced constipation
 Methylnaltrexone
A 94 y/o F with moderate dementia, vision/hearing impairment was
hospitalized for CAP. She was started on Levaquin and 2 days into
her admission began “talking out of her head” according to her
family, which is a change from her baseline.
On exam - T 37.3C, BP 108/56 mmHg, HR 95/min, RR 16/min, O2 sat
94% on ambient air, thin, inattentive, lungs with rhonchi over
posterior right base (unchanged from admit), no focal deficits. All
home meds were continued on admission including: omeprazole,
rivastigmine, lorazepam PRN.
LABS normal serum electrolytes/glucose
Cr 1.4 (up from 1.2 on admission)
CBC with WBC 10 (down from 14 on admission)
UA negative
Which of the following would be the
best next step?
A
B
C
D
E
Haloperidol, restrain for safety
Change antibiotics, bedside observer
Olanzapine, head CT
Risperidone, EEG
Short acting benzodiazepine, head CT
 ~1/3 hospitalized elders have delirium
 50% present on admission
 Prevalence increased in ICU & hospice settings
 May persist for weeks to months in subset
 Older, dementia, functional impairment, multiple comorbidities; restraint use & delirium severity
 Independently associated with poor patient
outcomes
 Increased risk of death, institutionalization, & dementia
Confusion Assessment Method (CAM)



Most useful bedside assessment tool
Requires presence of 1 + 2 + (3 or 4)
1.
2.
3.
4.
Acute change in mental status & fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
CAM - ICU



Designed for non verbal/vent dependent pts
Sensitivity lower than traditional CAM
Under-recognition is HUGE


Standardized screening of ICU, post-op, very elderly pts

Daily; aids in recognition of hypoactive delirium
 Baseline risk
 Advanced age
 Dementia
 Impairment with ADLs
 High medical comorbidity
 Lab abnormalities
 Dehydration, sodium, thyroid
 Some evidence
 Males, sensory impairment (hearing, vision), depression,
alcohol abuse
 Acute risk
 Medications
 sedating, anticholinergic
 withdrawl
 Indwelling devices &
 Surgery

 Uncontrolled pain

 Anemia

 Bed rest


restraints
Infection
Stroke
MI
Urinary retention
Fecal impaction
 FIRST STEP
 Take a history – patient, support staff, family
 Includes chart review
 Full physical exam
 THEN Targeted labs, imaging, other diagnostics
 REMEMBER
 Typically multiple contributing factors
 Medications
 BEERS Criteria
 Effect OR withdrawl
 Infections
 Fluid balance
 Dehydration, heart failure
 Electrolyte Disturbances
 Sensory deprivation
 Eyeglasses, hearing aids/amplifiers
 Elimination issues
 Fecal impaction, urinary retention
 Impaired CNS oxygenation
 Anemia, hypoxia, hypotension
 Severe pain
 ALL
 CBC, chem8
 Consider
 UA, UDS, LFTs, ABG
 CXR, EKG, cultures, troponin
 EEG if seizure activity
 LP if meningitis suspected
 Head CT/Brain MRI
 if head trauma suspected or focal findings on neuro exam
 Behavioral Interventions
 Family visitation
 Daily reorientation
 Sleep-wake schedule
 Avoid unnecessary interventions at night
 Limit tethers & ties
 Pharmacologic Intervention
 Low dose, short term antipsychotics
 Haldol, risperidone, olanzapine, seroquel
 Remember to check EKG to evaluate QT interval
 What do I do if they have prolonged QT interval??
 Remember to taper off as soon as possible
 Avoid 1st generation antipsychotics in LBD & PD
 Opt for seroquel
 Ativan – IF benzo or ETOH withdrawl
 Urinary incontinence
 Scheduled toileting program
 Immobility/Falls
 Physical therapy – MOBILIZE THAT PATIENT
 Avoid restraints – they are NOT your friend
 Opt for 1:1 sitter
 Pressure ulcers
 Mobilization – can I hear it again?!
 Repositioning if immobile
 Monitor pressure points
 Sleep disturbance
 Sleep hygiene is your best option
 Feeding disorders
 Assist with meals
 Aspiration precautions
 Nutritional supplements at snacks
 Environment
 Noise reduction, lighting, familiar objects
 Cognitive reconditioning
 Reorientation TID
 ADL performance
 Family education/support
 Time for discharge
 Providing support services at home or facility
 Hospital Elder Life Program (HELP)
 Interventions/Risk factors
 Cognitive impairment
 Sleep deprivation
 Immobility
 Visual/Hearing impairment
 Dehydration
A 75-yo M is admitted to rehab after having a stroke 2 wk ago. He has residual right-sided
paralysis, aphasia & urinary incontinence. He spends most of the day in bed or in a chair and
needs assistance with all ADLs. The patient has a poor appetite, cannot use his right arm to
feed himself, and is eating only half his meals. He also has intermittent urinary incontinence.
Which of the following is the most appropriate intervention for preventing pressure ulcers in this
patient?
A
B
C
D
E
An air-fluidized bed
A doughnut cushion when seated
A foam mattress overlay
Bladder catheterization
Massage of skin over pressure points
 Any process rendering immobility for extended time
period
 Intrinsic risk factors
 Age, poor nutritional status, decreased arteriolar blood
pressure
 Extrinsic risk factors
 Friction, shear, moisture, urinary or fecal incontinence
 Skin care (Limited evidence)
 Daily skin inspection
 Skin cleaning with mild agent; Moisturizer
 Do NOT massage over bony prominences
 Avoid skin exposure to wound drainage, urine, feces,
perspiration
 Nutrition (inconsistent studies)
 Do NOT OVER-supplement pts with protein, vitamin,
mineral supplements
 evidence is lacking if no deficiency
 Optimal nutrition is part of national pressure ulcer
prevention guidelines
 Mechanical off-loading
 Minimize friction/shear
 Reposition q2H
 Use of bed positioning devices
 Do NOT use seating cushions (ie doughnuts)
 Support surfaces (pressure redistribution device)
 Use with any pt at risk
 No one surface superior but all superior to standard mattress
 Two types of devices
 Static: foam, static air, gel/water
 Dynamic: alternating air, low air loss, air fluidized
 Which to use?
 Static is less expensive so used in most
 Use dynamic IF:
 “bottoming out” (surface compressed to <1 inch)
 Reactive hyperemia despite static support use
 Dynamic airflow potential adverse effects
 Dehydration, sensory deprivation, difficulty with mobilization
 Suspected Deep Tissue Injury
 Purple with intact skin/blister
 Stage I
 Non blanching erythema
 Stage II
 Partial thickness loss of dermis
 Stage III
 Full thickness tissue loss
 Stage IV
 Exposed bone, tendon, or muscle
 Suspected Deep Tissue Injury
 Purple with intact skin/blister
 Stage I
 Non blanching erythema
 Stage II
 Partial thickness loss of dermis
 Stage III
 Full thickness tissue loss
 Stage IV
 Exposed bone, tendon, or muscle
A 77-year-old F is transferred to SNF after a 2-wk hospital stay for hip fracture repair. Her
hospital course was complicated initially by a lower gastrointestinal hemorrhage and
subsequent bacteremia from an intravenous line.
Her vital signs are within normal limits. She is alert and oriented to person and date. She appears
thin. She has a 4 x 5 cm pressure ulcer over her presacral area that extends through the skin,
but no muscle or bone is exposed. The ulcer is debrided with little exudates. There is minimal
surrounding erythema.
Which of the following is indicated for the pressure ulcer?
A
B
C
D
E
Calcium Alginate dressing
Hydrocolloid dressing
Short course of systemic antibiotics
Silver sulfadiazine cream
Vacuum-assisted closure device
 Location
 Drainage
 Stage
 Necrosis
 Area
 Granulation
 Depth
 Cellulitis
 Transparent film
 i.e. tegaderm
 Stage I & II
 c/i if draining or suspected infection
 Foam island
 i.e. allevyn, lyofoam
 Stage II & III; with lo-mod exudate
 c/i if excessive exudate or dry/crusted
 Hydrocolloids
 i.e. duo-derm, tegasorb
 Stage II & III; with lo-mod drainage
 Good for autolytic debridement
 remains in place 3-5 days
 c/i poor skin integrity, infection, packing
 Alginate
 i.e. AlgiDERM, Sorbsan, Algosteril
 Stage III, IV; excessive drainage
 c/i dry/min drainage, superficial with maceration
 Hydrogel
 Gel or sheet – Intrasite, vigilon, restore
 Stage II, III, IV
 c/i macerated, excess exudate
 Gauze packing (moistened with saline)
 Stage III/IV
 c/i deep wounds, tunneling
 Silver dressings
 ie aquacel Ag, silvadene
 Malodorous wounds; hi exudate; suspected local infection; slow healing
 c/i systemic infection, cellulitis, fungus, skin necrosis, leukopenia,
interstitial nephritis
 Recommendations
 Wet-to-dry discouraged
 Hydrocolloid preferred
 Require fewer dressing changes; block bacteria; maintain
moist environment
 Pick a dressing based on stage, amount of wound
exudate, suspected infection
 Performed if necrotic, devitalized tissue present – as it prevents healing
 Four types
 Mechanical: wet-to-dry, hydrotherapy
 Can remove vitalized tissue; painful

Enzymatic: topical agent
 Use if no infection present; damage surrounding skin

Autolytic: synthetic dressings allow self digestion
 Use if no infection present & no other method tolerated; takes longer for effect

Sharp: scalpel, scissors, forceps, laser
 Quick, effective; use if infection present

Biosurgery: Maggot or larva therapy
 Good for those who cannot tolerate surgery
 Surgical Repair
 Viable option for stage III & IV ulcers
 Types
 Direct closure, skin grafting, skin flaps, musculocutaneous flaps, free
flaps
 Diet/Nutritional Supplements
 Controversial; limited evidence
 Dietary recommendations –
 30-35 calories/kg/d
 1.25-1.5g of protein/kg/d
 Amino acids may assist
 Argine, glutamine, cysteine
 New problem – blame a drug
 Falling elders – give vitamin D, order PT, home
safety evaluation (OT)
 Preferred drugs
 Anti-depressants
 Citalopram, escitalopram, remeron, sertraline
 Pain medication
 Tylenol, tramadol
 Insomnia
 Zolpidem, trazodone, remeron