Geriatrics Board Review
Daniel Pound, MD Clinical Professor Family and Community Medicine, UCSF Medical Director, UCSF Center for Geriatric Care
Doe wat je t’liefste doet
Carolina Origins
Emma Zuletta Otersen 1886 - 1976 Outline
Dementia, delirium, and depression Falls, osteopenia, and osteoporosis Hearing and functional impairment Urinary incontinence Age related changes in drug metabolism Medication prescribing with CKD Welcome to Medicare
Mrs. Jones 65 yr old retired teacher Diabetes HTN CHF atrial fib GERD Complains about husband’s hearing
Mr. Jones 65 yr retired airplane mechanic BPH insomnia anxiety URI symptoms Hard to hear women or to hear in crowds Not bothered by hearing loss
Which do you expect? Sensorineural loss Conductive loss Air = bone Air < bone Types of hearing loss
Sensorineural Conductive Age related presbycusis Obstructed canal Gradual onset Perforated or scarred TM Effect of noise exposure Otitis media High frequency (♀ voice) Worse in crowds
Air = bone on audiogram Air < bone on audiogram
Prescribe hearing aid or Treat underlying cause cochlear implant
Consonants or Vowels? He has mixed hearing loss
Sensorineural: curve slopes down to the right (high frequency) Conductive: air (O) worse than bone (X) conduction Treat conductive loss: Remove cerumen Antibiotic for otitis media Hearing aids
His sensorineural loss persists after abx Hearing loss is socially isolating Is patient is likely to use hearing aids? Yes: if patient is bothered by hearing loss No: if only his wife is bothered by hearing loss Side effects: discomfort, feedback, stigma No interventions proven to increase use
Cochrane Database Syst Rev. 2014;7:CD010342. Why Hearing Aids Don’t Work Incontinence
Mr. Jones has recent onset urine leakage Unpredictable leak day and night x 4 days Lower abdominal pain, no dysuria or fever Hydrocodone PRN back pain Diphenhydramine/pseudoephedrine OTC Guaifenesin with codeine PRN cough What type incontinence?
Urge Stress Mixed urge/stress Obstructive overflow Atonic overflow Functional
Keys = dribbling, BPH, opioid, cold meds PVR > 200 cc = Overflow Overflow etiology: two types
Too little tone Too much tone
Neuropathy Opioid Bladder tone Anticholinergic atonic
BPH Sphincter tone Alpha agonist obstructive Overflow treatment
to tone to tone Atonic Bladder tone Stop codeine Stop Benadryl Bethanechol? Obstructive Stop decongestant Sphincter tone Alpha blocker Finasteride Foley TURP? Mrs. Jones What Type Incontinence?
Mrs. Jones has chronic incontinence Leaks urine with cough or sneeze “Can’t get to the bathroom in time” G1P1 vaginal birth PVR 15 cc (normal is < 100 cc)
Keys = parous, Valsalva, urgency Mixed urge + stress etiology
Too little tone Too much tone
Overactive bladder Dementia, UTI? Bladder tone Bladder stone, tumor urge
Vaginal birth Prolapse Sphincter tone TURP, alpha blocker stress Mixed incontinence treatment
to tone to tone Urge Anticholinergic Bladder tone (oxybutynin) Sympathomimetic (mirabegron $$$) Stress Sphincter tone Kegel exercises Pessary ♀ Urethral sling surgery Anticholinergic Choices
Oxybutynin (Ditropan) and tolterodine (Detrol) best studied in elderly Sustained release or patch less side effects Newer M3 selective rx still cause dry mouth Trospium (Sanctura) Solifenacin (Vesicare) Darifenacin (Enablex) Tricyclic (nortriptyline, imipramine) side effects harder for elderly to tolerate Functional incontinence
Too little to function Dementia Cognition functional functional Poor vision Prompted voiding Vision (timed voiding) functional Bedside commode Slow gait Urinal Poor dexterity External catheter ♂ Mobility Restraints Sweat pants functional No restraints Urinary Incontinence
Too little Too much tone tone Atonic Neuropathy Overactive bladder Bladder Spinal cord disease Dementia Urge Anticholinergics Bladder stone Overflow Opioids Bladder tumor tone PVR < 100 cc PVR > 200 cc Mirabegron Bethanechol Childbirth BPH Sphincter- Prolapse Urethral stricture Obstructive Stress Prostate surgery Prostate cancer outlet Alpha blocker Alpha agonist Overflow PVR < 100 cc Finasteride Pessary PVR > 200 cc tone Foley catheter Bladder sling surgery Bedside commode Poor gait Urinal Poor vision Cognition- External catheter Functional Poor dexterity Sweat pants mobility Poor cognition Prompted voiding Bone Health
Mrs. Jones asks about bone density test FH mother died in SNF after hip fracture Menopause age 48 (i.e., not early) DEXA at age 50 was low normal T - 0.9 No prior fractures, smoking, or steroids 3 drinks per day, Caucasian race 5’ 6” 135 lb. BMI 21
Who to screen
National Osteoporosis Foundation Women > 65 and men > 70 Postmenopausal women <65 or men 50-70: only if concern based on risk factors
USPSTF (for board exams) Women >65 (younger women whose risk >= 65 yr. old white woman w/o other risk factors) Insufficient evidence to recommend for men Medicare DEXA coverage >65
Postmenopausal women Men only if: Osteopenia or vertebral fracture on X-ray Taking or starting steroids Primary hyperparathyroidism Already taking osteoporosis drugs Not covered by Medicare for men just based on prostate cancer therapy Osteoporosis Risk Factors
Age Personal history of Gender fracture Low BMI Parental history of hip fracture Current smoking Secondary Alcohol 3 or more drinks per day osteoporosis : Rheumatoid arthritis Low femoral neck Hyperparathyroidism BMD Oral steroid use Her femur neck results
Age 50 T -1.0 Normal
Age 65 T -1.5 Osteopenia
Age 70 T -1.9 Osteopenia
Age 75 T -2.5 Osteoporosis Who to treat
Osteoporosis Clinical diagnosis (hip or vertebral fracture) DEXA diagnosis (T ≤ - 2.5) Osteopenia (-1 > T > - 2.5) if other risk factors that predict 10-year risk of either: ≥3 % risk of hip fracture, or ≥20 % risk of major osteoporotic fracture These risk rates = cost effective to treat
FRAX for osteopenia
Age 65 @ 135 lb. 66 inch Age 70 @ 130 lb. 65 inch Her FRAX results
Age 50 T -1.0 FRAX N/A (normal DEXA)
Age 65 T -1.5 1.5% hip 19% major
Age 70 T -1.9 6.5% hip 21% major
Age 75 T -2.5 FRAX N/A (osteoporosis) Osteoporosis Treatment
Calcium 1200 mg elemental total (incl diet) Ca carbonate inexpensive Ca citrate better absorbed if high gastric pH Vitamin D3 800 – 1000 IU Weight bearing exercise Avoid tobacco and alcohol Fall prevention Osteoporosis drug therapy Bisphosphonate
Alendronate (po) or zoledronic acid (IV) Prevent hip + spine fractures Contraindicated if GFR < 30 (po) or 35 (IV) Side effects: Esophagitis (sit up after taking) Musculoskeletal pain Osteonecrosis of jaw (rare) Atypical femur fractures (rare)
More expensive therapies
Used if intolerant of, contraindication to, or continued fractures with bisphosphonates Denosumab (Prolia) anti-RANKL antibody Prevents hip + spine fractures Subcu Q6mo, caution if GFR < 30 (hypoCa) Teriparatide (Forteo) anabolic PTH Prevents spine + non-spine fractures Not specifically proven to prevent hip fracture Subcu daily x2 years ($72,000 total for 2 yrs)
Less attractive therapies
Nasal calcitonin Prevents spine fractures, not proven for hip Causes small increased risk for cancer Short term use as analgesic for spine fracture Raloxifene (Evista) SERM Prevents spine fractures, not proven for hip Prevents breast cancer Not used in elderly due to risk for thrombi
Her treatment
T -1.0 Normal GFR 70 calcium D exercise T -1.5 FRAX 1.5% / 19% GFR 55 same T -1.9 FRAX 6.5% / 21% GFR 40 add bisphosphonate for % risk T -2.5 Osteoporosis GFR 25 stop bisphosphonate for GFR Mr. Jones falls
Falls getting up from bed to toilet at night Minor injuries Diazepam, hydrocodone, or Flexeril (cyclobenzaprine) PRN back pain Zolpidem PRN insomnia Terazosin at bed time
Multifactorial and Serious
Intrinsic causes Extrinsic causes Abnl gait/balance Environment hazards Weakness Medications Neuropathy Vestibular Precipitating factors Orthostatic ↓BP Syncope Vision loss Acute illness
10% risk major injury 2% risk death
Medicines That Cause Falls
Sedation Orthostatic hypotension Opioids Antihypertensives Benzodiazepines Alpha blockers for BPH Other sleeping pills Nitrates Antipsychotics Antipsychotics Antidepressants Tricyclics Antiemetics Trazodone Antihistamines Anticholinergics Muscle relaxers Antiparkinsonian Fall Interventions
PT for strength + balance Tai Chi (strength + balance) Stop psychotropic rx Address home hazards Multifactorial assessment Cataract surgery x1 for poor vision Vitamin D 800 IU/day per USPSTF Emergency Response Alert Texting For Seniors
BFF = Best Friend Fell FWIW = Forgot Where I Was TTML = Talk To Me Louder ROFLACGU = Rolling On Floor Laughing And Can’t Get Up His Fall Prevention Plan
Refer PT Change terazosin to tamsulosin Vision 20/50 eye exam for cataracts Reduce or stop sedating medications Avoid diazepam (Valium) in elderly Fat soluble half-life 4-5 days Avoid muscle relaxers (SOMA or Flexeril) Excess sedation >> minimal pain relief Mrs. Jones falls
Falls going up step from garage to kitchen Painful buttock hematoma, no head bleed Daughter flies in from LA, reports she is unsteady, confused, has urine odor 80 yr 115 lb. 64 inches 19.7 BMI 108/55 Meds glyburide, oxybutynin, famotidine, clonidine, digoxin 0.25mg, apixaban, alendronate creatinine 1.9 A1C 6.8
Precipitating causes of fall
Rx acute illness (UTI ↓ functional reserve) Check for orthostatic hypotension Supine vs standing up x3 minutes Systolic ↓ 20 or diastolic ↓10 = abnormal Elderly have less ability to increase pulse rate Accept less strict targets (DM, HTN) Adjust drugs based on weight loss Adjust drugs based on GFR Age related drug changes
Body mass ↓ Body water ↓ Body fat ↑ GFR ↓ Serum albumin ↓ Gastric absorption unchanged Liver metabolism +/- decreased Water soluble drugs: ↑ potent (digoxin) Protein bound drugs: ↑ potent (phenytoin) Fat soluble drugs: ↑ half-life (diazepam) Avoid with low GFR
Glyburide (GFR <60: hypoglycemia) NSAIDs (<60: fluid retention / CHF, AKI) Chlorpropamide (Diabenese) (<50: ↓ BS) Bisphosphonates (<30-35: adynamic bone) Septra (<30: hyperkalemia, AKI) Nitrofurantoin (<30: ineffective for UTI) Newer anticoagulants (<25-30: ↑ bleeding) ↓ Dose To Avoid CKD toxicity
Gabapentin (GFR <60: sedation) Famotidine (<50: delirium) Digoxin (<50: delirium, anorexia) > 0.125mg/day almost always toxic in elderly Metformin (30-45: lactic acidosis) Allopurinol (<30: hypersensitivity rash) Simvastatin (<30: myopathy)
Her CKD medication changes
Creatinine 1.9 = GFR 25 Stop her glyburide, accept A1C < 8 - 8.5 Prefer glipizide if oral agent needed Stop digoxin 0.25mg, beta block instead Change apixaban to warfarin Stop alendronate Stop famotidine, prefer PPI (but PPI →↓Ca, ↓Mg, ↓B12, ↓Fe, fracture, C diff, pneumonia)
Her cognitive evaluation
Patient denies memory problems MMSE 24/30 (recall 1/3) college educated Never drove, husband is driver Patient handles bills without problems Too much pain to cook or do housework Daughter helping to bathe due to pain No tremor or rigidity, EOMI, gait antalgic
Dementia vs MCI
Dementia Mild cognitive Cognitive impairment impairment Short term memory Cognitive impairment At least one other area Intact function Language Visual spatial Risk to progress to Executive Alzheimer’s: Apraxia 16% over 3 years Worse than prior
Impaired function Neurology 2004;63(1):115. Assessing Function
IADLs: lost early ADLs: lost late Finances Bathing Medications Dressing Transportation Transferring Housework Feeding Shopping Toileting Cooking Continence Using telephone Things you did when Things you did to get you went to college ready to come today
Her evaluation = MCI
MMSE 24 < median for years of education Education years 0-4 5-8 9-12 >12 Age 70-74 21 26 28 29 Age 75-79 21 26 27 28 Age 80-84 19 25 26 28 Age >=85 20 24 26 28 No missed bills (at least none we know of) Resumes ADLs as pain resolves
Mild Cognitive Impairment Medicines That Cause Confusion Sedation Anticholinergic Antidepressants Tricyclics Antipsychotics Antipsychotics Antiemetics Antiemetics Antihistamines H1 antihistamines Opioids (Benadryl) Muscle relaxers H2 antihistamines (Cimetidine) Benzodiazepines Oxybutynin (Ditropan) Other sleeping pills Loperamide (Imodium) Other Dicyclomine (Bentyl) Prednisone, digoxin Central antiHTN drugs
Avoid Anticholinergic Drugs
Anticholinergic Not Anticholinergic Diphenhydramine Fluticasone (Flonase) (Benadryl) Melatonin Cimetidine (Tagamet) Omeprazole (Prilosec) Amitriptyline (Elavil) Citalopram (Celexa) Loperamide (Imodium) Bismuth (Kaopectate) Promethazine Ondansetron (Zofran) $ (Phenergan)
Medicines she should stop
Risk of confusion from Famotidine Clonidine Digoxin Oxybutynin Hip Fracture
Her daughter returns to town after she is hospitalized for hip + vertebral fractures Severe postoperative pain on POD #1 Husband visits POD #2 morning, she is withdrawn and not complaining Daughter visits POD #2 evening, she has pulled out her IV and is disoriented and restless Hip Fracture
1 year outcomes: 20% die 40% unable to walk independently 80% need help with 1+ ADL You consider teriparatide injections since she fractured after taking bisphosphonates Nasal calcitonin may help vertebral fracture pain during next 2 months Pain Rx With Stage 4 CKD
Oral NSAIDs and COX-2 contraindicated Topical NSAIDs, oral acetaminophen ok Toxic metabolites accumulate from: Morphine, oxycodone, codeine, meperidine Less risk from Tramadol, fentanyl, methadone, hydromorphone, buprenorphine Reduce doses of gabapentin, pregabalin Delirium Is Common
Up to 50% hospitalized older patients Up to 50% postoperative patients Up to 60% nursing home patients Up to 90% in ICU
Hyperactive (agitated) delirium is obvious Hypoactive (withdrawn) delirium is just as serious but is often not recognized Delirium Risk Factors
Older age Sensory impairment Male Psychoactive drugs Dementia Alcohol Prior delirium Dehydration Depression Malnutrition Many medications Functional Many medical dependence problems Immobility Confusion Assessment Method (CAM) Diagnose delirium in hospital based on: Acute onset, fluctuating course and Inattention (distractible) and Either one of these two: Disorganized thinking (rambling, illogical) Altered level of consciousness (hyperalert/vigilant or drowsy/lethargic)
Delirium Evaluation
Look for underlying causes Medications implicated in 40% of cases Check CBC, chemistries, LFT, CXR, UA, EKG CT not usually needed unless focal findings Look for constipation, urinary retention Not all cases will have an obvious cause
Delirium Management
Treat underlying causes Address dehydration, pain, infection Reorientation, early mobilization Maintain regular sleep hours Use hearing aids, glasses Use sitter, not restraints Haloperidol if agitation prevents medical care and endangers patient or others
Watch out for QTc interval
Antipsychotics prolong QTc interval Check baseline EKG first Caution if combining haloperidol with: Amiodarone, sotalol, quinidine, flecainide Fluconazole, ketoconazole Fluoroquinolones (ciprofloxacin etc.) Macrolides (azithromycin etc.) Tricyclic > citalopram, fluoxetine Methadone After Her Fracture
IV fentanyl (no toxic metabolites in CKD) Fentanyl patch (fat soluble) is not effective since she is cachectic Family visit with her during day No vital signs checked at night Cancel standard PRN Benadryl order She develops “blister” on right heel and redness on sacrum
Decubitus Ulcer Risk Factors
Intrinsic Extrinsic Immobility Friction (skin rubbing Immobility or sliding against bed surface) Immobility Shear (bone pulling Malnutrition against tissues when Poor skin perfusion lying still at inclined Sensory loss angle in bed) Incontinence/moisture Decubitus Ulcer Stages
Assign stage only after full extent is known Stage 1 intact red skin Stage 2 partial skin loss Wound base is red or pink Stage 3 into subcutaneous tissue Wound base may be red, white, yellow Stage 4 down to bone, tendon, or muscle Unstageable: brown/black eschar visible What Color Is Wound Base? Stage 2 = Any other color = Always red or pink Stage 3 or worse Her decubitus wounds
Sacrum has Stage 1 intact red skin Change to air mattress Turn every 2 hours to prevent tissue ischemia Keep skin clean from urine or feces Heel has deep tissue injury Intact ecchymotic skin with boggy underlying damaged tissue Heel tissue turns to black eschar later Float heel so it does not touch the bed Heel DTI Unstageable
Decubitus Ulcer Debridement
Remove dead tissue to prevent infection Sharp debridement (with analgesia) Enzymatic debridement with collagenase ointment (Santyl) Autolytic debridement with hydrocolloid (Duoderm) dressing in place for 3-7 days NOT wet to dry dressings (harmful / painful) Do not debride dry eschar on heel, or if patient terminal not expected to survive
Further Cognitive Decline
After 2 months in SNF her cognition has declined further, MMSE 18/30 She cannot remember PT exercises Able to walk, dexterity good Cannot coordinate dressing herself (ADL) More confused and agitated later in day Both dementia and delirium have impaired recall and can have some fluctuations Delirium vs. Dementia
Delirium Dementia Onset Acute Insidious
Attention Impaired Intact
Fluctuations Prominent Less prominent
Prognosis Transient Irreversible
Acuity Emergency Chronic Quote from Norman Wisdom Dementia Differential Dx
Rule out delirium or reversible causes Medication induced Test labs for causes of delirium Also check B12 and TSH Test HIV, RPR only if other risk factors CT imaging controversial but recommended by American Academy of Neurology Other than medications and thyroid, most “reversible” causes do not actually reverse
Dementia Causes
Alzheimer’s most common: 70% Insidious ↓ language, memory, visualspatial Lewy Body second most common Parkinsonism, fluctuations, hallucinations Vascular dementia stepwise decline Often co-exists with Alzheimer’s Frontotemporal in younger patients Disinhibition, executive dysfunction Dementia Progression
Early stage Late stage
Gait ↓ Memory ↓ Alzheimer’s Rigidity
Tremor Parkinson’s Gait ↓ Memory ↓ Rigidity Hallucinations Lewy Body Gait ↓ Memory ↓ Rigidity Dementia Care Plan
Help with ADLs Provide safe supervised environment Simplify communication and instructions Avoid sedatives and anticholinergics Treat vascular risk factors Caregiver support Medications of only modest benefit
Dementia Medications
Acetylcholinesterase inhibitors Donepezil (Aricept), rivastigmine, galantamine Increase acetylcholine in synapses Opposite of anticholinergic (ie, oxybutynin) Side effects nausea, diarrhea, anorexia, incontinence, bradycardia, syncope NMDA receptor blocker Memantine (Namenda) for moderate to severe dementia Agitation in Dementia
Satisfy hunger, thirst Treat constipation, bladder retention Address overstimulation, understimulation Assume presence of pain based on pathology (i.e., if you would sense pain) Empiric analgesic trial (even opioids) Antipsychotics (older and newer) increase mortality in dementia J Amer Geriatr Soc 2002;50:S205-S240
Husband at home
Daughter is worried that Mr. Jones is developing dementia He quit driving to see wife at SNF Complains of headache and fatigue MMSE 24/30, some “don’t know” answers Denies sad mood No alcohol Depression in Elderly
More common when isolated, dependent, with illness, pain, or cognitive impairment Anhedonia > sad mood in elderly Somatic complaints common, may overlap with symptoms of other diseases Minor (subsyndromal) depression has similar consequences as major depression Older white men at highest risk for suicide
His Evaluation
Endorses little interest or pleasure Geriatric Depression Scale positive for boredom, helplessness, worthlessness Encourage socialization (Senior Center) Offer counseling SSRI usually first choice (few side effects) Mirtazapine good for insomnia/anorexia Conclusions: Keeping Up With Mr. & Mrs. Jones Functional status reflects changes in medical conditions Impairments in mobility and cognition require more coordination of care Older patients take more medications and are often at risk for side effects Accommodating for chronic illness improves QOL as primary goal for elderly Geriatrics Board Review [email protected]
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