Geriatric Psychiatry Assessment Program

Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 1

Chapter 4: Medical Comorbidities

Sandra Swantek

Add renal question (Memantine)

Add infection question

1. Keep question and answers. Change reference to:

Yende S, Newman A , Sin D. Chapter 83. Chronic Obstructive Pulmonary Disease. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009.

2. Keep question and answers.

Rationale: The diagnosis of hypertension is established by demonstrating a SBP≥140mm HG and/or DBP ≥ 90 mm HG on at least two occasions. Criteria for categorizing BP vary. Specific BP goals have been recommended for persons with certain conditions such as diabetes, renal disease or coronary artery disease. Treatment of hypertension lowers the risk for cardiovascular disease, renal disease and stroke. Once the diagnosis of hypertension is made, a thorough history, physical examination and laboratory evaluation should be done to look for other cardiovascular risk factors, identifiable causes for hypertension and target organ damage. An ECG and fundoscopic examination are part of the work up, which also includes a thorough physical examination (vascular an neurological examination, urinalysis, laboratory measures of renal function, electrolytes and lipid panel).

Shapiro MA. Chapter 81. Hypertension. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009.

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011; 123: 2434 -2056 Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 2

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011; 123: 2434 -2056.

4. Keep question and answers.. Change reference to:

Chang AM, Halter Jb. Chapter 109. Diabetes Mellitus. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009.

Rich M. Chapter 78. Heart Failure. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009

6. Keep question and answers. Add reference:

Cheng S, Bell SM, Zieman SJ. Chapter 75. Aging and Atherosclerosis. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009.

Holbrook AM, Pereira JA, Labiris R, et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med. 2005; 165(10): 1096 -1106.

7. Keep question and answers. Change reference to: Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 3

Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin- aldosterone system. new Engl J Med. 2004; 351(23): 585 - 592.

Rich M. Chapter 78. Heart Failure. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009

2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with Peripheral Artery Disease (Updating the 2005 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124: 2020 -2045.

10. Keep question and answers.

Rationale: Despite the high prevalence of constipation in older adults, there is little evidence on which to base management decisions of this common condition. Every older adult who reports constipation deserves a careful clinical history and examination to rule out fecal impaction or other causes of constipation. Referral for consultation to rule out organic disease should be considered in an patient with positive findings such as weight loss, hematochezia, or anemia. The first step in treating constipation is a review of the patient's medications for medications including opioids, methadone, selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotic, antiparkinsonians, anticholinergics and over-the-counter medications such as antacids, iron supplements, etc. These medications should be limited or discontinued whenever possible. Medical conditions associated with constipation include diabetes, hypothyroidism, depression, dementia Parkinson's colon cancer, etc. The second step in the management of chronic Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 4

constipation involves nonpharmacologic measures (increased fluid, dietary fiber, and physical activity). There is a lack of good evidence to draw any conclusions regarding the comparative efficacy of different laxatives.

The recommended option is c.

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Harari D. Chapter 93. Constipation. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009

11. Keep question. Change reference to:

Hamer M, Batty GD, Seldenrijk A, Kivimaki M. Antidepressant medication use and future risk of cardiovascular disease: The Scottish Health Survey Eur Heart J. 2011;32(4):437-442.

Cohen HW, Gibson G, Alderman MH. Excess risk of myocardial infarction in patients treated with antidepressant medications: Association with use of tricyclic agents. Am J Med 2000; 108:2-8.

Roose SP. Considerations for the use of antidepressants in patients with cardiovascular disease.l Am Heart J. 2000; 140(4 Suppl): 84-88.

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13. A 72 year old female presents with complaint of fatigue, foot pain, interrupted sleep, and joint pain. The patient's daughter tells you that her mother is having problems with her memory. Physical exam reveals a 20 pound weight loss since the last annual visit. Since that time, the patient's spouse has died. When you ask for the cause of death, the daughter interjects, "He was on the down low." You order blood work and note leucopenia, normocytic anemia and transaminitis. Thyroid is normal. Which of the following best represents your differential? Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 5

a. Major depression

b. Cancer

c. Diabetes

d. HIV

Rationale: People ages 50 years and older make up a growing proportion of all of those living with HIV infection. The CDC now recommends near universal HIV screening, regardless of age. HIV patients over age 50 commonly report fatigue, pain in their hands or feet, sleep difficulty, muscle or joint pain and difficulties having sex. Common laboratory abnormalities include leucopenia, anemia and transaminitis. HIV testing should be considered in any patient with unexplained anemia, peripheral neuropathy, oral candidiasis, recurrent bacterial pneumonia, tuberculosis, herpes zoster and simplex. The phrase, "Down low" is a colloquialism which suggests that a man in a relationship with a woman is also having sexual relations with men while maintaining secrecy regarding his homosexual relations.

The recommended option is d.

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Justice AC. Chapter 128. Human Immunodeficiency Virus Infection. In: Halter JB, Ouslander JG Tinetti ME et al. Hazzard's Geriatric Medicine and Gerontology. Sixth edition. McGraw Hill Medical. New York; 2009

http://www.urbandictionary.com/define.php?term=down%20low

14. Persons with Parkinson's Disease (PD) treated with levodopa and bromocriptine or entacapone are most likely to experience which of the following:

a. Disinhibition

b. Anxiety

c. Depression

d. Euphoria Geriatric Psychiatry assessment Program Chapter 4 Medical Comorbidity 6

e. Cognitive impairment

Rationale: Treatment with levodopa and dopaminergic drugs (e.g. bromocriptine, entacapone) is associated with increased anxiety (10 - 15), euphoria (10%), and disinhibition (1%). Although Parkinson's disease is associated with a dementia, cognitive impairment is not associated with the medications used to treat Parkinson's.

The recommended option is b.

Coffey MJ, Gramann S. Chapter 29. Neuropsychiatric Disorders Associated with General Medical Therapies. In: Coffey CE, Cumming Jl. Textbook of Geriatric Neuropsychiatry (Third Edition). American Psychiatric Publishing, Inc. 2011. New York.