Clinical Case 2

Report
ABIM Geriatrics Review
July 17, 2014
B. Gwen Windham, MD MHS
[email protected]
No Conflicts
Case 1.
78 yo college-educated man with PMH HTN is brought to you by his
wife for complaints of visual hallucinations (VH) for 3 months. Wife
says he is usually “in his right mind” but has periods of confusion
and reduced alertness. Recently wandered outside at night & fell
when he saw pigs in the yard. He was hospitalized, received
risperidone and became hypotensive by records and “sleepy” by her
report. Detailed VH persistently involve animals in yard. Wife
endorses gradually worsening symptoms of repeating himself for
past 6-12 months, withdrawing socially, & less involved in personal
finances. He uses a cane, has had several falls recently, begun
requiring help to dress. He is dependent with meal prep, finances,
driving, shop, meds over past year. Accidents trying to park 1 yr ago
ended his driving
Case 1.
•
PE: BP 130/80 HR 80 No OH RR 14 95% O2sat
•
He is alert, oriented to person, time and city. His MMSE is
23/30. He has a slow, shuffling gait, no tremors, mild
symmetric rigidity with extension in the upper extremities.
No motor, sensory deficits. A clock drawing test is shown.
•
Lab: CBC, complete metabolic panel, TSH, B12 normal. MRI
brain shows mild generalized atrophy, no infarcts,
hemorrhage, mass, hydrocephalus.
11:10
Case 1.
•
Does this patient have dementia? Why or why not?
– 2 cognitive domains affected (AAAA+E):
•
Amnesia, apraxia, agnosia, aphasia, executive
dysfunction
– Impairs daily or social or occupational function
– Is a change from baseline
– Not delirium
• What is this patient’s diagnosis?
A.
B.
C.
D.
Alzheimer’s disease
Lewy Body dementia
Mild Cognitive impairment
Frontotemporal dementia
Case 1.
•
Does this patient have dementia? Why or why not?
– 2 cognitive domains affected (AAAA+E):
•
Amnesia, apraxia, agnosia, aphasia, executive
dysfunction
– Impairs daily or social or occupational function
– Is a change from baseline
– Not delirium
• What is this patient’s diagnosis?
A.
B.
C.
D.
Alzheimer’s disease
Lewy Body dementia
Mild Cognitive impairment
Frontotemporal dementia
Lewy Body Dementia Criteria
 Progressive cognitive decline, dementia (required)
plus
 Core features (2 required for Probable LBD)



Visual hallucinations, recurrent, detailed, early
Fluctuations (change in alertness, attention)
Parkinsonism early
 Suggestive Features



REM Sleep Disorder (acting out dreams)
Severe neuroleptic sensitivity (motor, consciousness, NMS,
autonomic dysfxn)
Low dopamine transporter uptake in BG
 Supportive Features



Repeated Falls
Syncope, transient loss of consciousness
Low uptake with reduced occipital activity PET/ SPECT
Case 2
Mrs. D is a 78 YO woman who comes to clinic
with her daughter. She is followed for DM and
HTN. She has no new complaints. In reviewing
her medications you note she is unsure of how
she has been taking them. When asking her
questions she often turns to her daughter to
supply the answers. When the daughter is
queried she reports that her mother seems a
little forgetful, “like all people her age.”
Upon further questioning, the dtr endorses 1-2
yrs of Mrs. D repeating the same question,
misplacing items she cannot find later, & having
difficulty thinking of words and using the remote
control. She left food burning on the stove soon
after Mrs. D’s husband died. Her husband always
managed their finances, but after he died, her
daughter began helping her after Mrs. D failed to
pay some bills and other bills she paid twice.
Mrs. D denies that she is having any significant
problems and says she is doing as well as other
people her age.
Mrs. D’s examination reveals excellent physical function
with normal alertness, attention, strength, and gait. She
has difficulty comprehending simple instructions during
the examination. During the hour visit she tells you
three times that she takes her dog on a walk daily. She
scores 20/30 on the MMSE and has difficulty drawing a
clock.
What should you do next?
A. Begin donepezil 5 mg HS
B. Begin donepezil 10 mg HS
C. Provide information on caregiver support
groups and local services for patients with
dementia
D. Check TSH
E. Offer hospice
What should you do next?
A. Begin donepezil 5 mg HS
B. Begin donepezil 10 mg HS
C. Provide information on caregiver support
groups and local services for patients with
dementia
D. Check TSH
E. Offer hospice
Recommended for dementia evaluation
– Medication review: e.g. narcotics,
benzodiazepines, anticholinergics
– TSH
– Vitamin B12
– Electrolytes and liver panel, Ca, CBC
– Uncontrasted CT/MRI brain - NPH, strokes, tumors
– RPR – in patients with specific risk factor
A 77-yr-old woman is brought to the office by her daughter because she has
been seeing her dead husband and dead brother for the past 2 mo. She
sometimes talks to them and they may respond to her. She has a 4-yr history
of declining memory and impairment in shopping, paying bills, cooking. She
now requires some assistance choosing appropriate clothing and is reminded
of meals. She has a history of major depressive disorder but is neither sad nor
apathetic on examination. There is no history of alcohol or substance abuse.
Exam is notable for increasing rigidity in her arms that worsens with distraction
and a mild shuffling gait. She has no tremor or other neurologic abnormality.
Her score is 18/30 on the Mini-Mental State Examination. Laboratory tests are
normal. CT shows cortical atrophy.
Which of the following is the most likely explanation for her symptoms?
A.
B.
C.
D.
E.
Lewy body dementia
Late-onset schizophrenia
Major depressive disorder with psychotic features
Parkinson's disease with dementia
Alzheimer's disease
A 77-yr-old woman is brought to the office by her daughter because she has
been seeing her dead husband and dead brother for the past 2 mo. She
sometimes talks to them and they may respond to her. She has a 4-yr history
of declining memory and impairment in shopping, paying bills, cooking. She
now requires some assistance choosing appropriate clothing and is reminded
of meals. She has a history of major depressive disorder but is neither sad nor
apathetic on examination. There is no history of alcohol or substance abuse.
Exam is notable for increasing rigidity in her arms that worsens with distraction
and a mild shuffling gait. She has no tremor or other neurologic abnormality.
Her score is 18/30 on the Mini-Mental State Examination. Laboratory tests are
normal. CT shows cortical atrophy.
Which of the following is the most likely explanation for her symptoms?
A.
B.
C.
D.
E.
Lewy body dementia
Late-onset schizophrenia
Major depressive disorder with psychotic features
Parkinson's disease with dementia
Alzheimer's disease
•
•
•
•
•
A 72yo retired elementary school teacher presents with
complaint of “problems with my memory” for 5 years, worse x
3 months after car was stolen. She has been in a “low point”
since. She has difficulty remembering where she put things, but
finds them later, and difficulty recalling people’s names.
5 years ago she was started on donepezil. She is not aware that
her memory is worse or better on donepezil.
She lives alone and is independent in ADLs and IADLs; she says
she forces herself to do them.
She attends church less than in the past. She reports poor
sleep, energy, & endorses psychomotor slowing.
MMSE = 28/30. Her physical exam, TSH, B12, CBC, complete
metabolic panel are normal.
•
What is the most likely diagnosis?
– Pseudodementia
• What else might you do to confirm your diagnosis?
– Depression screen, e.g. PHQ, GDS
•
•
“low point” for 3 weeks, anhedonia-quit exercising &
attends church less, sleep difficulty, slower movements,
decreased concentration
Talk to daughter (collateral history)
• 70yo man with 3-4 years falls, usually backwards. PT
noted rigidity, bradykinesia & suspected Parkinson
Dz. Was then dx as Parkinson Disease
• Took Sinemet for a while but seemed to fall more
• Dropped cups when placing them on countertops,
described by family as “missing” the surface
• PhD in English and Literature. He loved to tell stories
& family noticed he stopped doing so, language
became more sparse. Then he began coughing while
eating, liquids leak from mouth, drools, lost 7 lbs,
and is more forgetful. Lost interest in hobbies,
appearance; crying spells
• Stopped doing finances
• ROS: per HPI
• PE: No orthostasis. Few blinks, slow speech,
bradykinesia, normal arm swing, no tremor,
symmetric leadpipe rigidity, poor balance, falls
backward. Impaired downward vertical gaze
that is overcome with passive head
movement. MMSE 20/30; abnormal clock
drawing and cube copy.
11:10
• LAB: TSH, B12, CBC, complete metabolic
panel, are normal. An MRI show ageappropriate atrophy, no infarcts, hemorrhage,
mass, or hydrocephalus.
• Most likely diagnosis?
– Progressive supranuclear palsy
• Gaze paresis + early falls*; often misdiagnosed as
PD
• Many develop pseudobulbar palsy (dysarthria,
dysphagia)
• Typically poor response to levodopa or more falls
• Symmetric parkinsonism, axial stiffness (neck stiff
flex/ext), falls backwards, usually no rest tremor
• Cognitive impairment: early slowness of thought,
difficulty synthesizing multiple ideas together
moreso than forgetful and language d/o
– 65yo woman is brought to clinic July 2009 by
daughters.
– January 2009: Lived alone/independent in IADLs,
walking for exercise in Jxn Med Mall
– Feb: began stumbling during walks
– Feb-April: Falls & balance problems, “lilting to the
right”, leaning on others for support, and a
“shuffling” gait
– April: admitted to OSH, diagnosed as Parkinson
Disease, started on Sinemet, discharged to rehab
– April-June: More rapid decline, withdrawn, not
interacting/talking, visual hallucinations, confused,
voice “low”, mumbles
– Since June, lives in a nursing home, requiring full
assistance with ADLs
Most likely diagnosis?
– Creutzfeldt-Jakob
• Cardinal: Rapidly progressive mental
deterioration and myoclonus
• Other:
– EPS: hypokinesia, cerebellar (nystagmus, ataxia)
– Corticospinal: hyperreflexia, Babinski, spasticity
•
ABIM Board ? -> CSF finding of 14-3-3 protein
What dementia syndrome best explains the following
– Asymmetric rigidity, tremor, bradykinesia,
narrow-based steps, stooped posture, and
forward falls develop first, respond to
levodopa and dopamine agonists, and are
followed by cognitive problems and
hallucinations >1 year later
– Parkinson Disease with dementia
• PD meds may worsen hallucinations
• Quetiapine often used
• Cholinesterase inhibitors
What dementia syndrome best explains the following
– Difficulty initiating gait, moving/lifting feet, wide-based
gait, followed by cognitive problems then urinary
incontinence. Gait dyspraxia on exam
– Normal Pressure Hydrocephalus (wobbly, wacky, wet;
“magnetic gait”)
– How is it diagnosed?
– Clinical, MRI/CT, LP with nl pressure and 20-50 mL
removal may improve gait dysfunction/cognitive
(Fisher test); cisternography often used, low specificity
– What is the usual treatment for NPH?
– Large volume LP, shunt (acetazolamine/digoxin may
reduce CSF production)
– Rate of complications with shunt?
– 30% (stroke, subdural hematomas, infection, shunt
failure)
– Response to shunt with long-term benefit?
– 25-80%, best if: <2yrs, typical gait & urinary symptoms,
no multi-infarcts on MRI brain. Fisher test poor
negative predictive value.
What dementia syndrome best explains the following
– A 64yo woman, described as “conscientious” and
“prim and proper”, experiences increased appetite,
weight gain, and is uncharacteristically flirtatious
over the past year. She is aware of her actions but
does not seem bothered by them. Her husband
often reminds her to change her clothes and brush
her teeth. Primitive reflexes, rigidity, and spasticity
are present on exam. There are no significant
cognitive abnormalities on initial screening but they
develop later in her course.
– Frontotemporal dementia
• Behavioral
• Progressive nonfluent aphasia
• Semantic dementia
What dementia syndrome best explains the following
– A 72yo man with PMH HTN, DM, hyperlipidemia
begins having syncope and falls. He lives alone, and is
independent in ADLs. His daughter notices his memory
is worse since having these spells. He repeatedly asks
the same question and is having trouble operating the
microwave. No cardiac arrhythmias are identified on
EKG or a 24-hour Holter. He has 4/5 strength of the
right and 5/5 on left. MMSE 23/30, deficits clock and
cube copy, recall, MRI shows a new thalamic infarct
compared to MRI 2 years ago and diffuse moderate to
severe white matter periventricular changes.
– Vascular cognitive impairment (vascular dementia)
• Vascular Cognitive Impairment
– Details
• Vascular dementia (multi-infarct)
– Prevalence 11.3-20.1% of dementias
Two Types of Vascular Dementia
• 1st type – Infarction of large arteries with clinical strokes with
stepwise accrual of deficits.
• 2nd type – Atherosclerotic small vessel disease
• Subcortical pattern
• Preservation of naming
• May have mild Parkinsonism
• Commonly have concomitant Alzheimer’s disease with
disease correlating best with neurofibrillar tangles
68yo college professor is evaluated for memory loss. He
forgets students’ names more than in past, misplaces
keys and glasses. He is currently writing a textbook and
continues to teach courses without difficulty. He is
independent in ADLs and IADLs. His wife concurs with the
history. His exam is normal. Depression screen is normal.
MMSE 29/30. TSH, B12, CMP, CBC, and CT head are
normal. What should you do next?
A.
B.
C.
D.
Reassure him
Order an MRI brain
Send for neuropsychological testing
Obtain neurology consult
68yo college professor is evaluated for memory loss. He
forgets students’ names more than in past, misplaces
keys and glasses. He is currently writing a textbook and
continues to teach courses without difficulty. He is
independent in ADLs and IADLs. His wife concurs with the
history. His exam is normal. Depression screen is normal.
MMSE 29/30. TSH, B12, CMP, CBC, and CT head are
normal. What should you do next?
A.
B.
C.
D.
Reassure him
Order an MRI brain
Send for neuropsychological testing
Obtain neurology consult
68yo college professor is evaluated for memory loss. He forgets
students’ names more than in past, misplaces keys and glasses, and
thinks he depends more on lists as reminders than in past. He has
cut back on the number of courses he teaches but continues to
perform well at work. He is independent in ADLs and IADLs. His
wife concurs with the history. His exam is normal. Depression
screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head
are normal. What is his diagnosis?
A.
B.
C.
D.
Early Alzheimer’s disease
Pseudodementia
Mild cognitive impairment
Generalized anxiety disorder
68yo college professor is evaluated for memory loss. He forgets
students’ names more than in past, misplaces keys and glasses, and
thinks he depends more on lists as reminders than in past. He has
cut back on the number of courses he teaches but continues to
perform well at work. He is independent in ADLs and IADLs. His
wife concurs with the history. His exam is normal. Depression
screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head
are normal. What is his diagnosis?
A.
B.
C.
D.
Early Alzheimer’s disease
Pseudodementia
Mild cognitive impairment
Generalized anxiety disorder
-MMSE 24-26 range
-No effect on function (social, work,
ADL/IADLs)
-No drug treatment
-10-15% progress to dementia annually
-Cognitive behavioral therapy may help
Behavioral problems in dementia
1st line treatment for behavioral problems:
Environmental:
1. LOOK FOR TRIGGERS – pt may be uncomfortable due to cold bathroom, lack of
modesty, aggressive caregiver
2. Other - redirection, distraction, remain calm, use soft calming voice, reassurance,
avoid arguing, use simple single 1-step commands
Pharmacologic treatment for behavioral decline (all off label):
-Psychosis (more common in Lewy Body dementia)- Atypical antipsychotics have
fewer extra pyramidal side effects than haloperidol. Quetiapine (seroquel), has least
and if need one for Lewy Body or PD patients, choose this one. Black box for 1.6
increased risk of mortality. Avoid with increased QT intervals.
-Depression (also for non-demented)
-Avoid trycyclics
-SSRIs preferred but may cause REM-sleep disorder (body-limb movements in REM
sleep) in patients with Lewy-Body disorder
-Anxiety (also for non-demented)
-Buspirone, SSRI or low dose atypical antipsychotics
70yo Hispanic (or AA) woman has had increasing difficulty
reading newspaper print for past 4-6 weeks. She has
trouble following text & finding the next line. She rarely
leaves her home. She has HTN, PVD, CVA 7yr ago, openangle glaucoma 20 yr ago. She has had no follow-up care.
What is the most likely cause of reading difficulty?
A.
B.
C.
D.
E.
New stroke
Macular degeneration
Retinal hemorrhage
Open-angle glaucoma
Retinal detachment
70yo Hispanic (or AA) woman has had increasing difficulty
reading newspaper print for past 4-6 weeks. She has
trouble following text & finding the next line. She rarely
leaves her home. She has HTN, PVD, CVA 7yr ago, openangle glaucoma 20 yr ago. She has had no follow-up care.
What is the most likely cause of reading difficulty?
-OAG: leading cause blindness in Hispanics, AA
-early peripheral visual field (VF) loss,
A.
B.
C.
D.
E.
New stroke
Macular degeneration
Retinal hemorrhage
Open-angle glaucoma
Retinal detachment
encroaches centrally in advanced disease
-Remains at home – familiar to her, may not
notice earlier peripheral VF loss
-RH – acute, new large floater
-CVA- wrong VF loss pattern
-RD – sudden vision loss; can be missed if pt
doesn’t notice due to compensation by good eye
An 83-yr-old woman is brought to the office by her daughter because
the mother has become confused and forgetful for the past 6 months.
Other than urinary incontinence, she has no medical problems. Her
only medication is extended-release oxybutynin 10 mg for urge urinary
incontinence which was started about 6 mo ago with improved
symptoms of incontinence. The mother, when asked, has no new
complaints about memory or cognition. MMSE is 23 of 30. The patient
is inattentive, repeats herself during the interview, but exam is
otherwise normal.
Which of the following is the most appropriate next step?
A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QID
B. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeks
C. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeks
D. Discontinue oxybutynin 10mg ER; begin behavioral therapy for
urinary incontinence
While most patients on anticholinergic bladder medications have no
discernable cognitive effects, some will. Because the symptoms in this
patient may be due to the medication – symptoms began after initiating
this new medication – the drug should be discontinued. Cognitive
adverse effects are related to peak med concentrations. IR agents with
the same total dose as the ER drug could worsen this effect. Behavioral
therapy is an effective therapy for urge incontinence. If the patient is
not cognitively intact to fully participate in behavioral therapy,
scheduled toileting may be of benefit.
Behavioral therapy may include bladder training, prompted
voiding, pelvic floor muscle exercises, biofeedback training.
Which of the following is the most appropriate next step?
A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QID
B. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeks
C. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeks
D. Discontinue oxybutynin 10mg ER; begin behavioral therapy for
urinary incontinence
An 86yo woman comes to the office for routine evaluation. She was the
primary caregiver for her husband until his death 9 mo ago. She is somewhat
fatigued and has a poor appetite but does not think that she is depressed.
She has had some dizziness but no falls, and she has had occasional diarrhea
with incontinence but no melena or hemato-chezia. PMH: atrial fibrillation,
heart failure (EF 40%), and HTN. Medications include atenolol, digoxin,
lisinopril, and warfarin. On examination, blood pressure is 118/66 mmHg.
Ventricular heart rate is 56 beats per minute. She has lost 6.4 kg (14 lb; 9% of
her body weight) over the last 6 mo. The remainder of the physical
examination is not substantially changed from her last visit.
Which of the following is most likely to identify the cause of weight loss
A. Chest xray
B. Fecal occult blood testing
C. Serum digoxin level
D. Home visit
E. Depression Screening
Weight loss assessment in older adults should include medication review. Anorexia,
diarrhea, and dizziness are common effects of digoxin toxicity. Bradycardia, ventricular
arrhythmias, apathy, nausea, confusion, visual disturbances, depression are also seen and can
lead to significant weight loss. There is some controversy regarding measuring digoxin levels:
patients may have toxicity even with “normal” concentrations; nonetheless, higher
concentrations correlate with greater adverse events. If subacute digoxin toxicity is suspected,
a trial of tapering the dosage may be reasonable instead of measuring the serum
concentration. Usual max daily dose is 0.125mg in older pts.
FOBT is reasonable, but adverse effects of digoxin are more common and should be checked
immediately. Depression screen may be positive, but depression should not be considered
endogenous until digoxin toxicity is excluded; depression will likely be refractory until toxicity
resolves. A home visit may determine if the patient is caring for herself and has quality
nutrition available; however, poor living conditions could be due to depression and apathy
caused by digoxin toxicity. Lung cancer can cause weight loss, but there is little else in this case
to suggest lung pathology
Which of the following is most likely to identify the cause of weight loss?
A. Chest xray
B. Fecal occult blood testing
C. Serum digoxin level
D. Home visit
E. Depression Screening
An 88-yr-old woman with peripheral arterial disease is admitted
to the hospital because she has gangrene in 2 toes and soft-tissue
infection of her distal foot. She is a widow and lives alone; her
daughter visits at least weekly.
On admission, her blood pressure is 140/80 mmHg,
respiratory rate is 16 breaths per minute, pulse is 90, and
temperature is 38°C (100.4°F). She is acutely confused and
inattentive. Her speech is rambling.
Which of the following factors is most likely to increase her risk of
in-hospital functional decline and nursing home placement?
A. Marital status
B. Race
C. Gender
D. Delirium
Factors that predict in-hospital functional decline (measured by ability
to perform ADLs) and nursing-home placement include older age, IADL
dependence , delirium and cognitive impairment, such as dementia.
After a complete history that may necessitate calling caregivers
or nursing homes for nursing home residents, the evaluation of acute
mental status changes should include vitals including oxygen saturation,
blood counts, electrolytes, evaluation for infection (pneumonia, UTI,
sepsis) and review of medications and recent changes in medications.
ROS and exam should assess presence of urinary or fecal impaction.
Cardiac assessment (EKG or troponin) may be warranted.
Which of the following factors is most likely to increase her risk of inhospital functional decline and nursing home placement?
A. Marital status
B. Race
C. Gender
D. Delirium
A 90-yr-old man is brought to the emergency department by his family because he has
had an abrupt change in behavior. The patient moved into his daughter and son-inlaw's house a few months ago, because he was no longer able to manage living alone.
A few days ago, he became aggressive and angry, and hit his son-in-law for no
apparent reason. He has also become incontinent in the last few days. He has multiple
bruises, which the family suspects are from falling. History includes moderate
dementia and benign prostatic hyperplasia.
On examination, he is inattentive, blood pressure is 160/90 mmHg; all other vital signs
are normal. He is demanding to be released from "prison'' and is aggressive with the
staff. The physical examination is unremarkable. Although he is uncooperative with the
neurologic examination, he appears to be moving all extremities well.
Which of the following is the most appropriate next step?
A. Bladder scan
B. Lumbar puncture
C. Electroencephalography
D. CT of the brain
E. BMP, CBC, urinalysis/culture, pulse oximetry
A 90-yr-old man is brought to the emergency department by his family because he has
had an abrupt change in behavior. The patient moved into his daughter and son-inlaw's house a few months ago, because he was no longer able to manage living alone.
A few days ago, he became aggressive and angry, and hit his son-in-law for no
apparent reason. He has also become incontinent in the last few days. He has multiple
bruises, which the family suspects are from falling. History includes moderate
dementia and benign prostatic hyperplasia.
On examination, he is inattentive, blood pressure is 160/90 mmHg; all other vital signs
are normal. He is demanding to be released from "prison'' and is aggressive with the
staff. The physical examination is unremarkable. Although he is uncooperative with the
neurologic examination, he appears to be moving all extremities well.
Which of the following is the most appropriate next step?
A. Bladder scan
B. Lumbar puncture
C. Electroencephalography
D. CT of the brain
E. BMP, CBC, urinalysis/culture, pulse oximetry
This patient demonstrates an acute change in cognition and behavior from his
baseline deficits. Increased confusion, new falls, and new incontinence all
suggest a new underlying illness or medication adverse event. An acute change
in mental status may be the only sign of a serious acute illness. Even when the
examination is unremarkable, metabolic abnormalities should be pursued,
including chemistries, renal function, glucose, and oxygen saturation. Urinalysis
and review of prescribed and OTC medications are indicated. The most
common causes of acute confusion are medical illness, metabolic disturbance,
and medications. Stroke, hemorrhage, meningitis, and encephalitis are much
less common, and should be considered after more likely causes are excluded.
Thus, LP is not part of the routine evaluation for delirium. Many OTC
medications with strong anticholinergic properties (eg, diphenhydramine) are
easily accessible and often misperceived by patients as safe, yet can cause
delirium. In an older man with BPH, urinary retention can manifest as a change
in mental status. However, medical illness, metabolic abnormalities, and
medications are more common causes of delirium. EEG can demonstrate a
pattern consistent with delirium but will not provide a diagnostic rationale for
its cause, unless seizures are strongly suspected. Brain imaging is not
recommended in absence of an abnormal neurological exam, but may be
indicated if the patient's laboratory and other tests are unremarkable.
An 87yo woman comes to the office for a routine evaluation. She reports that she
has fallen once or twice a month for past 4 months. The falls occur at various times
of the day and immediately after standing or standing for some time. She does not
experience dizziness, lightheadedness, vertigo, palpi-tations, chest pain or tightness,
focal weakness, loss of consciousness, or injury. She lives alone. PMH includes HTN
and DJD of both knees. Medications are acetaminophen and hydrochlorothiazide.
PE: T 98.6, BP 135/85 mm Hg without postural change, HR 72/min, RR 16. Visual
acuity with glasses is 20/40 OD & 20/60 OS. Cardiopulmonary exam is normal. Knees
have bony enlargement w/o warmth or effusion. On balance & gait screening with
the “get up and go” test, the patient must use her arms to rise from the chair. Neuro
exam is normal. MMSE is 26/30 (nl ≥24/30).
Results of a complete blood count and blood chemistry studies are normal.
Which of the following should be included as part of her management at this time?
A. Begin risedronate
B. Measure serum 25-hydroxyvitamin D level
C. Prescribe hip protectors
D. 24-hour electrocardiographic monitoring
Low Vitamin D associated with muscle weakness, functional impairment, falls,
fractures. In RCT, replacement (goal >30ng/ml) may reduce risk of falling 20%. If the
vitamin D level is low, this patient should take ergocalciferol or cholecalciferol,
50,000 units weekly for 6 to 8 weeks, followed by 800 to 1000 units of vitamin D
daily along with calcium supplementation (at least 1200 mg of elemental calcium
[diet plus supplementation]). Although vitamin D deficiency is common in the
elderly, routine vitamin D level screening is not recommended. In the absence of
clinical manifestations of osteoporosis (such as vertebral, hip, or wrist fracture) or a
low bone mineral density measurement, use of medications such as risedronate to
treat osteoporosis is not warranted.
A Cochrane systematic review concluded that hip protectors are ineffective in
preventing hip fractures in elderly persons who fall, partly as a result of limited
patient acceptance and adherence because of discomfort. There is no proven value
of performing routine 24-hour electrocardiographic monitoring in elderly persons
who fall.
A. Begin risedronate
B. Measure serum 25-hydroxyvitamin D level
C. Prescribe hip protectors
D. 24-hour electrocardiographic monitoring
77yo man comes to the office for a 12-mos history of pain over the
posterior right calf after prolonged standing or walking. At first, the pain
occurred only after walking 10-12 blocks, but it now occurs after <1 block.
He has pain when he stands more than 10 minutes. The pain is relieved
immediately with sitting. On exam, pulses are full in both legs. The skin is
normal, with full skin hair throughout both legs. Bilateral straight leg raise
tests are normal. There is good mobility of both hips without pain. There is
mild weakness of the right great toe extensor, right hip abductor, & right
hip extensor. Radiography of the lumbar spine shows diffuse degenerative
changes of the lumbar disks & facet joints. There is evidence of mild to
moderate osteoarthritis of the right hip.
What is the most likely cause of this patient’s pain?
A.
B.
C.
D.
E.
Bone or joint disease of the hip
Vascular insufficiency
Lumbar spinal stenosis
Ruptured popliteal cyst
Metastatic cancer to the bone
77yo man comes to the office for a 12-mos history of pain over the
posterior right calf after prolonged standing or walking. At first, the pain
occurred only after walking 10-12 blocks, but it now occurs after <1 block.
He has pain when he stands more than 10 minutes. The pain is relieved
immediately with sitting. On exam, pulses are full in both legs. The skin is
normal, with full skin hair throughout both legs. Bilateral straight leg raise
tests are normal. There is good mobility of both hips without pain. There is
mild weakness of the right great toe extensor, right hip abductor, & right
hip extensor. Radiography of the lumbar spine shows diffuse degenerative
changes of the lumbar disks & facet joints. There is evidence of mild to
moderate osteoarthritis of the right hip.
What is the most likely cause of this patient’s pain?
A.
B.
C.
D.
E.
Bone or joint disease of the hip
Vascular insufficiency
Lumbar spinal stenosis
Ruptured popliteal cyst
Metastatic cancer to the bone
This patient’s pain occurs after prolonged standing and walking, and is relieved immediately
with sitting. Such a presentation is typical of lumbar spinal stenosis, and the weakness of
the muscles of the right leg innervated by L-4, L-5 and L-5, S-1 is consistent with this
diagnosis. The most appropriate next step in the evaluation of this patient would be to
perform a diagnostic imaging test to look for signs of lumbar spinal stenosis.
Hip disease can cause pain in the groin, buttock, thigh, and knee, but rarely in the lower leg.
The distribution of pain and the normal hip examination make hip disease an unlikely cause
of this patient’s pain, despite the abnormal hip radiograph.
Calf pain while walking is a symptom of arterial insufficiency, but this patient has normal
pulses and no skin findings, and pain on standing is rare in patients with arterial
insufficiency.
Although a ruptured popliteal cyst can cause acute calf pain, the prolonged duration of this
patient’s pain, with progressive worsening over 12 months, suggests a different cause.
This patient does not have a typical history of metastatic cancer. The association with
position is unusual for a cancer, and the history of pain after walking that is relieved with
sitting is not consistent with a tumor.
Lumbar spinal stenosis – pain on standing or going down stairs. Relieved
with sitting or bending forward (grocery cart). Distal pulses normal & warm
(not PAD). Hair loss can be due to aging. Likely have weakness on exam. SLR
normal. Treat with physical therapy unless it is impairing walking ability (i.e.
independent ambulatory older pt begins having back pain, weakness, using
walker over short period of time. Exam and hx c/w LSS, refer to Neuro.
Delayed surgery leads to permanent functional impairment.
Vetebral compression fractures – acute back pain often without neuro
symptoms. Typically older woman opening window, getting turkey out of
oven. Pain control. Conservative treatment = vertebroplasty in RCT
Herniated lumbar disc – dermatomal defects. (+) SLR test.
“Sciatica”– pain in the buttock radiates down the back of the leg. May occur
from vertebral fracture, disc protrusion, or osteophytes.
74yo man with 3mos generalized itching, worse in colder weather,
recurs every winter. Hx HTN, only medication is lisinopril for past
several years. Moisturizing cream provides little relief. No other
new detergents, creams, skin products. On exam, skin has dry
scaling diffusely on trunk and extremities resembling “cracked
porcelain” with red fissures forming irregular reticular pattern.
Which is the most likely cause:
A. Drug eruption
B. Xerosis
C. Scabies
D. Psoriasis
E. Contact dermatitis
A. Drug eruption
B. Xerosis
C. Scabies
D. Psoriasis
E. Contact dermatitis
Most common cause of generalized itching in older adults. Worse in low humidity and
cold. More severe disease is inflamed with red fissures. Treatment includes humidifier
indoors, reduce frequency and length of bathing, warm not hot water, mild &
moisturizing soaps (Dove), emollients on wet skin after bathing especially with lactic
acid (5 or 12%) or urea (10% to 20%). Mild topical steroid in severe cases may be used.
Do not use oil in bath – fall hazard!
-Exclude systemic disease (DM, liver/kidney) & lymphoproliferative dz. -Consider drug
eruptions in symmetric outbreak – good drug hx rx and OTC. Usually w/i 1st week of
new drug; PCN can be later.
-Scabies – burrows, look between fingers
-Psoriasis – well-defined erythematous plaques, adherent silvery scale, knees, elbows,
scalp, trunk
-Contact dermatitis – hx of exposure rather than seasonal. Can be chronic which may
be assoc with lichenification with satellite papules, redness, excoriation
An 81yo woman recently admitted to a nursing facility is frequently
incontinent of urine. History includes Alzheimer's disease and
lumbosacral stenosis. Meds include calcium, vitamin D, and
acetaminophen. The patient's family states that her UI has remained
essentially unchanged for the past 6 mo. The patient is unable to give a
detailed history and denies bladder problems. Observations by the
nursing staff suggest a diagnosis of overactive bladder with urge
incontinence.
On exam, there is no evidence of severe atrophic vaginitis, pelvic
prolapse, or fecal impaction. Catheterization reveals PVR of 40 mL.
Urinalysis shows 3+ bacteria and 6 WBCs per high-power field; the
culture grows >100,000 CFU E. coli, sens to cephalexin.
Which of the following is the most appropriate next step?
A. Oxybutynin 2.5mg q 8h
B. Tolterodine 4mg/d
C. Cephalexin
D. Prompted voiding program
E. Urodynamic testing
An 81yo woman recently admitted to a nursing facility is frequently
incontinent of urine. History includes Alzheimer's disease and
lumbosacral stenosis. Meds include calcium, vitamin D, and
acetaminophen. The patient's family states that her UI has remained
essentially unchanged for the past 6 mo. The patient is unable to give a
detailed history and denies bladder problems. Observations by the
nursing staff suggest a diagnosis of overactive bladder with urge
incontinence.
On exam, there is no evidence of severe atrophic vaginitis, pelvic
prolapse, or fecal impaction. Catheterization reveals PVR of 40 mL.
Urinalysis shows 3+ bacteria and 6 WBCs per high-power field; the
culture grows >100,000 CFU E. coli, sens to cephalexin.
Which of the following is the most appropriate next step?
A. Oxybutynin 2.5mg q 8h
B. Tolterodine 4mg/d
C. Cephalexin
D. Prompted voiding program
E. Urodynamic testing
Prompted voiding is the most appropriate intervention for this patient. 2540% of nursing-home (NH) patients respond well to this behavioral
protocol, and responsiveness can generally be determined after a trial of 35 days. Some patients benefit from the addition of a bladder relaxant (eg.
oxybutynin or tolterodine); due to potential adverse events of their
anticholinergic properties, these meds should be used as an adjunct to a
toileting program. These meds may worsen cognitive impairment or
precipitate delirium in patients with dementia and should be used only in
selected patients who have bothersome overactive bladder symptoms,
who do not respond to a toileting program alone, and who demonstrate
both tolerance of and responsiveness to the medication. In chronically
incontinent NH patients with stable symptoms who have no other signs of
infection, eradicating bacteriuria does not reduce the severity of
incontinence, even if there is pyuria. Moreover, treating asymptomatic
bacteriuria in older adults is not recommended. Urodynamic testing is not
contraindicated, even in frail NH patients, but the results would not change
the initial approach to management
A 92-year-old woman is S/P open-reduction internal fixation repair of a
fractured right hip a few days earlier and now has a 4 cm × 4 cm area on
the right lateral buttock with a blood-filled blister that remains intact with
surrounding dark tissue.
Which of the following is the most effective management for this finding?
A. Hyperbaric therapy
B. Electromagnetic therapy
C. Surgical debridement
D. Turn patient every 2 hours; avoid pressure on affected area
A 92-year-old woman is S/P open-reduction internal fixation repair of a
fractured right hip a few days earlier and now has a 4 cm × 4 cm area on
the right lateral buttock with a blood-filled blister that remains intact with
surrounding dark tissue.
Which of the following is the most effective management for this finding?
A. Hyperbaric therapy
B. Electromagnetic therapy
C. Surgical debridement
D. Turn patient every 2 hours; avoid pressure on affected area
This wound is a suspected deep-tissue injury ulcer (SDTI) – localized area
of intact skin that may be purple, maroon, or blood filled blister and may
quickly progress to severe Stage 3-4 ulcer. They are treated like Stage 1
pressure ulcers. A 2010 National Pressure Ulcer Advisory Panel consensus
conference recommends turning patients every 2 hours as a guideline but
not as a standard of care. Turning schedules may be lengthened
depending on patient characteristics and pressure relief surfaces
A 72-year-old man who has metastatic colon cancer is admitted to a
hospice inpatient facility because of complete bowel obstruction
and failure to thrive. He has been unable to tolerate oral food or
fluids for several days because of nausea and vomiting, and he has
significant pain throughout the day. The hospice admitting nurse
documents a large sacral pressure ulcer measuring 11 cm × 10 cm,
with a depth of 4 cm. There is surrounding erythema, exposed
muscle, undermining of the edges, and a tunneling tract that
extends another 2 cm. Within the ulcer, there is necrotic material
and a significant amount of exudate with a foul odor that permeates
the room. The treatment plan includes placement of a specialized
bed overlay, application of absorptive dressings, and medicine for
pain control.
Shortly thereafter, family members tell staff that the wound odor
makes spending time in the patient’s room very difficult, and they
ask if something can be done.
A 72-year-old man who has metastatic colon cancer is admitted to a hospice
inpatient facility because of complete bowel obstruction and failure to thrive.
He has been unable to tolerate oral food or fluids for several days because of
nausea and vomiting, and he has significant pain throughout the day. The
hospice admitting nurse documents a large sacral pressure ulcer measuring 11
cm × 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed
muscle, undermining of the edges, and a tunneling tract that extends another
2 cm. Within the ulcer, there is necrotic material and a significant amount of
exudate with a foul odor that permeates the room. The treatment plan
includes placement of a specialized bed overlay, application of absorptive
dressings, and medicine for pain control.
Which of the following is the best next step to reduce odor of the ulcer?
A. Turn patient every 2 hours
B. Apply topical metronidazole gel
C. Place potpourri in the room
D. Perform surgical debridement
A 72-year-old man who has metastatic colon cancer is admitted to a hospice
inpatient facility because of complete bowel obstruction and failure to thrive.
He has been unable to tolerate oral food or fluids for several days because of
nausea and vomiting, and he has significant pain throughout the day. The
hospice admitting nurse documents a large sacral pressure ulcer measuring 11
cm × 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed
muscle, undermining of the edges, and a tunneling tract that extends another
2 cm. Within the ulcer, there is necrotic material and a significant amount of
exudate with a foul odor that permeates the room. The treatment plan
includes placement of a specialized bed overlay, application of absorptive
dressings, and medicine for pain control.
Which of the following is the best next step to reduce odor of the ulcer?
A. Turn patient every 2 hours
B. Apply topical metronidazole gel
C. Place potpourri in the room
D. Perform surgical debridement
A 67-year-old man asks about hospice care because he has considerable pain and
nausea related to stage 4 pancreatic cancer. He is on chemotherapy, but his
condition is declining. His oncologist offers another course of chemotherapy,
which would cause uncomfortable adverse effects but possibly increase his life
expectancy 2–3 months. The patient lives at home and is debilitated to the point
that he needs assistance to bathe. He is currently enrolled in traditional Medicare
Parts A and B. He has no other health insurance. If the patient switches his
insurance status to Medicare hospice benefits, which of the following services will
not be covered?
(A) Nonpalliative chemotherapy
(B) Home-health aide to assist with bathing
(C) Hospital bed for his home
(D) Grief counseling for his wife
He is currently enrolled in traditional Medicare Parts A and B. He has no other health
insurance. If the patient switches his insurance status to Medicare hospice benefits,
which of the following services will not be covered?
(A) Nonpalliative chemotherapy
(B) Home-health aide to assist with bathing
(C) Hospital bed for his home
(D) Grief counseling for his wife
To qualify for Medicare hospice benefits, two physicians (one of whom is usually the
hospice medical director) must certify that the patient has a terminal condition with a
life expectancy of ≤6 months. Given the patient’s condition and functional status, he
has a prognosis of <6 months and would thus qualify for hospice benefits. Once he
waives Medicare Part A coverage for the terminal illness and signs up for Medicare
hospice benefits, he would be eligible for a number of services not covered under
traditional Medicare, including medications related to pain and other uncomfortable
symptoms, home-health aides, durable medical equipment such as a hospital bed,
physical therapy, occupational therapy, speech therapy, grief counseling for the patient
and family, and respite care. The hospice benefits do not cover hospitalization for or
curative treatment of the terminal illness; the benefits would possibly cover palliative
chemotherapy if it were deemed necessary to reduce the patient’s suffering.
A 72-year-old man with a history of metastatic non–small-cell lung cancer is
hospitalized for worsening shortness of breath. The cancer was diagnosed 6 months
ago when he underwent evaluation for a persistent cough. CT of the chest and
abdomen demonstrated a right lower lobe mass with a large, right-sided pleural
effusion and liver metastases. Despite thoracentesis and chemotherapy, disease has
progressed, and he continues to have large pleural effusions that require thoracentesis
almost every 2 weeks. He is independent in his activities of daily living and enjoys short
outings with his wife when his dyspnea is controlled.
Which of the following is the best management option for his recurrent pleural
effusions?
(A) Chemotherapy with erlotinib
(B) Placement of an indwelling pleural catheter
(C) Placement of a pleuroperitoneal shunt
(D) Pleurodesis with a sclerosing agent
(E) Routine outpatient thoracentesis every 2 weeks
A 72-year-old man with a history of metastatic non–small-cell lung cancer is
hospitalized for worsening shortness of breath. The cancer was diagnosed 6 months
ago when he underwent evaluation for a persistent cough. CT of the chest and
abdomen demonstrated a right lower lobe mass with a large, right-sided pleural
effusion and liver metastases. Despite thoracentesis and chemotherapy, disease has
progressed, and he continues to have large pleural effusions that require thoracentesis
almost every 2 weeks. He is independent in his activities of daily living and enjoys short
outings with his wife when his dyspnea is controlled.
Which of the following is the best management option for his recurrent pleural
effusions?
(A) Chemotherapy with erlotinib
(B) Placement of an indwelling pleural catheter
(C) Placement of a pleuroperitoneal shunt
(D) Pleurodesis with a sclerosing agent
(E) Routine outpatient thoracentesis every 2 weeks
Recurrent malignant effusions cause dyspnea and distress in patients with metastatic cancer. Affected
patients typically have a poor prognosis and limited life expectancy. Goals of care should focus on palliation
of dyspnea and improving quality of life.
Initial management of pleural effusion is therapeutic thoracentesis. Patients with recurrent effusions
require an intervention with durable effect and minimal discomfort. Given this patient’s recurrent large
effusions, extensive tumor burden, and good functional status when his dyspnea is controlled, an indwelling
pleural catheter is the preferred approach. These catheters may be placed in the inpatient or outpatient
setting; they require intermittent drainage, either by a healthcare professional or by the patient or a family
member who has been trained. Patients have reported improved quality of life, including improved mobility
and symptom control, and ease of management. Some patients experience spontaneous pleurodesis.
Erlotinib is a tyrosine kinase inhibitor that has been shown to improve progression-free survival in patients
with metastatic non–small-cell lung cancer. The patient may be a candidate for erlotinib, but management of
his recurrent, large malignant effusions requires an intervention that will provide ongoing relief.
Pleuroperitoneal shunts are occasionally indicated for patients with intractable effusions and trapped
lungs. The shunt drains pleural fluid into the abdomen via a subcutaneous reservoir that the patient must
pump throughout the day. Cost, limited efficacy, and frequent malfunctions all limit the shunt’s usefulness.
The shunt also places the patient at risk of development of malignant ascites.
Pleurodesis with a sclerosing agent is another common strategy for recurrent malignant pleural effusions.
A sclerosing agent (such as talc, doxycycline, or bleomycin) is instilled through a chest tube or insufflation at
thoracoscopy in the inpatient setting. Pleurodesis is less successful in patients with heavy tumor burden and
decreased expandability of the lung (eg, trapped lung, or abnormal relationship between the visceral and
parietal pleural surfaces). Given this patient’s tumor burden and recurrent large-volume effusions, an
indwelling pleural catheter is preferable to pleurodesis.
Routine outpatient thoracentesis is appropriate for patients with a life expectancy limited to weeks. It is
not appropriate for this patient because of his current functional status. Routine thoracentesis is associated
with an increased risk of pneumothorax, infection, and loculation.
An 85-year-old woman is hospitalized for acute nausea, vomiting, and abdominal pain. She has stage IV
ovarian cancer. On examination, there is moderate abdominal distension and diffuse tenderness; there are
no bowel sounds. CT of the abdomen and pelvis demonstrates progressive carcinomatosis and nearcomplete obstruction at two points in her jejunum. A nasogastric tube is placed, and she is started on
intravenous fluids and intravenous ondansetron around the clock, dexamethasone 4 mg q6h, and octreotide
drip. Her gynecologic oncologist states that neither surgery nor chemotherapy will improve her condition,
except possibly a diverting gastrostomy. A bedside meeting is held with the patient and her family. The
patient refuses further procedures and asks to be made comfortable. She and her family understand that,
without any intervention, she will die within the next few days.
Her code status is changed to “do not resuscitate,” and plans are made to discharge her home on hospice in
the morning. The nasogastric tube and the octreotide drip are discontinued. The dexamethasone,
intravenous fluids, and supplemental oxygen by nasal cannula are continued. Intravenous morphine sulfate
drip 1 mg/h is begun. Within 2 hours, the patient reports improved pain control and is drowsy but
arousable. A fever develops overnight, and the next morning she is unresponsive and tachypneic, with
audible respiratory secretions and chest congestion.
Which of the following is the most appropriate next step?
(A) Discontinue intravenous fluids.
(B) Increase oxygen to 4 L/min via face mask.
(C) Start acetaminophen 650 mg orally q6h.
(D) Decrease morphine dosage to 0.5 mg/h.
(E) Discharge on home hospice.
An 85-year-old woman is hospitalized for acute nausea, vomiting, and abdominal pain. She has stage IV
ovarian cancer. On examination, there is moderate abdominal distension and diffuse tenderness; there are
no bowel sounds. CT of the abdomen and pelvis demonstrates progressive carcinomatosis and nearcomplete obstruction at two points in her jejunum. A nasogastric tube is placed, and she is started on
intravenous fluids and intravenous ondansetron around the clock, dexamethasone 4 mg q6h, and octreotide
drip. Her gynecologic oncologist states that neither surgery nor chemotherapy will improve her condition,
except possibly a diverting gastrostomy. A bedside meeting is held with the patient and her family. The
patient refuses further procedures and asks to be made comfortable. She and her family understand that,
without any intervention, she will die within the next few days.
Her code status is changed to “do not resuscitate,” and plans are made to discharge her home on hospice in
the morning. The nasogastric tube and the octreotide drip are discontinued. The dexamethasone,
intravenous fluids, and supplemental oxygen by nasal cannula are continued. Intravenous morphine sulfate
drip 1 mg/h is begun. Within 2 hours, the patient reports improved pain control and is drowsy but
arousable. A fever develops overnight, and the next morning she is unresponsive and tachypneic, with
audible respiratory secretions and chest congestion.
Which of the following is the most appropriate next step?
(A) Discontinue intravenous fluids.
(B) Increase oxygen to 4 L/min via face mask.
(C) Start acetaminophen 650 mg orally q6h.
(D) Decrease morphine dosage to 0.5 mg/h.
(E) Discharge on home hospice.
This patient’s condition has declined further, and death is imminent.
Tachypnea and increased respiratory secretions are common at the end of life.
The intravenous hydration is likely contributing to her symptoms. When the
goal of care is to maximize comfort, all unnecessary intravenous fluids should
be discontinued (SOE=B). Anticholinergic medications such as scopolamine
patches, glycopyrrolate, and atropine drops can be used for control of
respiratory secretions and could be considered for this patient.
Opioids are important adjuncts in the management of terminal dyspnea. This
patient’s morphine sulfate dosage will likely need to be increased, not
decreased, if her tachypnea does not improve with discontinuation of fluids
and addition of an anticholinergic agent.
An increase in oxygen supplementation and use of a face mask will not relieve
the patient’s chest congestion and respiratory secretions. Rather, the increased
airflow and placement of a mask may cause more discomfort. Treatment of
her fever with around-the-clock acetaminophen is inappropriate because of
her vomiting. The patient is actively dying and has uncontrolled symptoms. She
cannot be discharged on home hospice in this condition, because she will likely
die within the next 1-3 days.
An 88-year-old man undergoes evaluation because he has a wound on
his left heel that, despite optimal therapy, has progressed over the
course of a few weeks. History includes advanced Parkinson disease. He
lives in a nursing home, is mainly bedbound, and requires total
assistance with activities of daily living. His nutritional status is poor and
there is evidence of frequent aspiration, but his family has declined
artificial feeding tubes on his behalf.
On physical examination, the wound measures 4 cm × 4 cm × 3
cm and drains moderate amounts of pus. An inserted cotton tip easily
extends to the calcaneus bone. Using the nomenclature of the National
Pressure Ulcer Advisory Panel, which of the following best describes the
wound?
A. Stage IV pressure ulcer
B. Stage III pressure ulcer
C. Kennedy terminal ulcer
D. Skin failure
An 88-year-old man undergoes evaluation because he has a wound on
his left heel that, despite optimal therapy, has progressed over the
course of a few weeks. History includes advanced Parkinson disease. He
lives in a nursing home, is mainly bedbound, and requires total
assistance with activities of daily living. His nutritional status is poor and
there is evidence of frequent aspiration, but his family has declined
artificial feeding tubes on his behalf.
On physical examination, the wound measures 4 cm × 4 cm × 3
cm and drains moderate amounts of pus. An inserted cotton tip easily
extends to the calcaneus bone. Using the nomenclature of the National
Pressure Ulcer Advisory Panel, which of the following best describes the
wound?
A. Stage IV pressure ulcer
B. Stage III pressure ulcer
C. Kennedy terminal ulcer
D. Skin failure
Proper assessment is important for preventing and treating pressure ulcers. Also known
as pressure sores, bedsores, and decubitus ulcers, pressure ulcers are created by
pressure, friction, and shearing forces. In the National Pressure Ulcer Advisory Panel
(NPUAP) revised staging system, stage IV refers to ulcers that penetrate to bone. This
patient has a stage IV pressure ulcer. Even with an optimal healing environment, the
wound may take months to years to heal properly. In the NPUAP staging system, stage
III refers to full-thickness ulcers that extend into subcutaneous tissues without visible
bone, tendon, or muscle.
The Kennedy terminal ulcer, first described in the literature in 1989, refers to a pressure
ulcer that some people develop as they are dying. Kennedy terminal ulcer is typically
located on the sacrum; is pear-, butterfly-, or horseshoe-shaped with irregular borders;
and is red, yellow, black, or purple. It usually starts as a blister or a stage II ulcer and
rapidly progresses to stage III or stage IV. Because this patient’s ulcer is located on his
heel, it likely is not a Kennedy terminal ulcer.
First described in 1991, skin failure refers to the underlying skin and tissue damage that
occurs at the end of life as a consequence of hypoperfusion. According to an NPUAP
consensus, skin failure is separate from pressure ulcers and therefore is not included in
the staging system.
A 68-year-old woman is transferred to a medical ward after being
treated in the intensive care unit for respiratory failure due to COPD.
During an examination, the nurse notices an area of skin breakdown on
the patient’s coccyx. It is 3 cm × 4 cm with a depth of 1 cm and has
minimal slough. The wound edges are hyperemic, but there is no sign of
undermining. Wound exudate is minimal, and there are no systemic
signs of infection.
Which of the following is the most appropriate treatment for this
wound?
A. Alginate dressing
B. Hydrocolloid dressing
C. Transparent film
D. Wet-to-dry dressing
A 68-year-old woman is transferred to a medical ward after being
treated in the intensive care unit for respiratory failure due to COPD.
During an examination, the nurse notices an area of skin breakdown on
the patient’s coccyx. It is 3 cm × 4 cm with a depth of 1 cm and has
minimal slough. The wound edges are hyperemic, but there is no sign of
undermining. Wound exudate is minimal, and there are no systemic
signs of infection.
Which of the following is the most appropriate treatment for this
wound?
-Thin red rim normal in healing wounds
A. Alginate dressing
-Look for cellulitis with fever, tenderness, warmth,
erythema especially if worsening; erythema may not
B. Hydrocolloid dressing
be obvious in dark skin
C. Transparent film
-Abx for cellulitis should target gram positive organisms
D. Wet-to-dry dressing
-Consider alginate products for soupy, exudative
wounds, may reduce bacteria
-Silver nitrites in dressing are anti-bacterial
-Don’t remove eschars on heels
-Don’t cover infected or exudative wounds
This wound has minimal slough, indicating that the ulcer penetrates into the subcutaneous fat tissue.
Because no muscle, tendon, or bone is visible, it is a stage III pressure ulcer. The description of minimal
exudates and the lack of systemic infection indicate that the wound is not infected. Hydrocolloid dressings
are recommended for noninfected stage III ulcers (SOE=B).
The following steps promote healing of pressure ulcers:
• Reduce interface pressures through use of pressure reduction surfaces and frequent turning of the patient.
• Assess nutritional status and supplement as needed.
• Debride necrotic tissue through mechanical, enzymatic, autolytic, or sharp methods.
• Apply a dressing that helps to protect the wound bed, reduce pressure, maintain moisture, and promote
migration of growth factors that aid healing.
Wound dressings are important in pressure ulcer healing for several reasons: they minimize contact with
contaminants, maintain a moist environment, promote growth of granulation tissue, and reduce shear and
friction forces. Research on the effects of wound dressings on healing rates show that most dressings have
equal efficacy (SOE=B). The NPUAP guidelines indicate which dressings to use based on certain factors: stage
of the ulcer, amount of exudates, quality of the tissue in the ulcer bed, and condition of the tissue
surrounding the ulcer bed.
Alginate dressings are intended for wounds that have moderate to heavy exudates (SOE=B). Blood and
exudates are absorbed to create a gel that protects wound surfaces. Because the wound in this case has
minimal exudates, alginate dressings are not the best treatment option.
A transparent film dressing is semipermeable, retains moisture, and is adhesive. It can provide autolytic
debridement or cover other dressings for larger wounds as a secondary dressing. It is intended to reduce
friction for stage I and II pressure ulcers (SOE=C). Transparent film dressing is contraindicated for wounds
with exudates or suspected infection. Because the wound described in this case has an exudate, albeit
minimal, transparent film is inappropriate as a sole agent for the wound.
Wet-to-dry dressings are not recommended for treatment of pressure ulcers, because they may cause
damage to healthy, granulating tissue (SOE=C) and cause pain with dressing changes.
An 85yo is hospitalized 6d for PNA, then 15d in skilled rehab
center, then has home health (HH) 2x a week for 3 weeks. He
takes 5 Rx meds, sees PCP monthly for follow-up. Insurance is
Medicare A & B. Hospital bill is $5,000, rehab $3,000, HH
$500, meds $120/month. Which of these will account for
greatest out-of-pocket expenses over 3 months?
A. Hospitalization
B. Nursing home rehab
C. Home health
D. Prescription medications
M’care Part A: 100% inpatient expenses covered for 60d per
90d benefit period after deductible met ($1,184 per 90d
period 2013) & $296/d days 61-90/benefit period. 20days of
skilled rehab paid 100% if preceded by 3d hospitalization,
$148/d for days 21-100 per benefit period.
Part B: 80% outpatient expenses including HH services (PT, RT,
RN, SP, OT) after deductible (2013 $147)
Part D: drug plan, variable income-based premium rates
A. Hospitalization
B. Nursing home rehab
C. Home health
D. Prescription medications
FALLS TIPS:
-Take complete history, including circumstances of fall, associated
symptoms, environmental risks (tripping)
-Review medications and eliminate sedative/hypnotics
-Check 25-OH Vitamin D, treat if <30ng/ml
-Check and treat orthostasis
-Check vision, cognition, gait, strength and balance, cardiovascular,
neurological systems, look for musculoskeletal abnormalities
-Physical therapy if weakness or imbalance detected
-Tai Chi useful in RCT
-Timed Up and Go <10 seconds low risk falls; >20 sec high risk
-New falls, brisk reflexes, weakness on UE exam, may have neck
pain, think cervical stenosis
Preventive Health Measures Available for Older Adults and Recommended Use
Consider remaining life expectancy, comorbidities, cognitive & functional status
Robust (≥5 years
remaining life
expectancy)
Frail (<5 years
remaining life
expectancy)
Moderate dementia
(2–10 years remaining
life expectancy)
End of life (<2 years
remaining life
expectancy)
Cost Effectiveness
Cancer screening
Mammography
Every 2 years
Not recommended Consider
(NR)
NR
Somewhat costeffective for
women <80 years
old, may be costeffective for
women ≥80 years
old in top quartile
of life expectancy.
Cost-effective to
stop
Pap smear
May stop after age NR
65
NR
NR
Prostate-specific
antigen
Discuss pros/cons if NR
life expectancy >10
years, may stop at
age 75
NR
NR
Uncertain
Fecal occult blood
test
Yearly, may stop at NR
age 75
NR
NR
Cost-effective
Colonoscopy
Every 10 years, may NR
stop at age 75
NR
NR
Cost-effective
Preventive Health Measures Available for Older Adults and Recommended Use
Consider remaining life expectancy, comorbidities, cognitive & functional status
Robust (≥5 years life
expectancy)
Frail (<5 years life Moderate dementia
expectancy)
(2–10 years life
expectancy)
End of life (<2 years
life expectancy)
Cost Effectiveness
Dexa (bone density) At least once after age 65 Consider
(W), or age 60 if high risk;
70yo (M)
NR
NR
Cost-effective
Blood glucose
Screen if sustained BP
NR
>135/80 mmHg or when
results would affect CVD
prevention (lipids, aspirin)
Consider in those with
NR
additional risk factors
NR
NR
Uncertain; optimal
interval unknown,
3yrs?
NR
NR
Uncertain
Abdominal US
Once for men 65-75 who
ever smoked
NR
NR
NR
Cost-effective
Ask about falls in
previous year
Yearly
Yearly
Yearly
Yearly
Uncertain
Cholesterol
Preventive Health Measures Available for Older Adults and Recommended Use
Consider remaining life expectancy, comorbidities, cognitive & functional status
Immunizations
Robust (≥5 years life
expectancy)
Frail (<5 years life
expectancy)
Moderate dementia (2– End of life (<2 years life
10 years life expectancy)
expectancy)
Cost Effectiveness
Influenza
Yearly
Yearly
Yearly
Yearly
Cost-effective
Pneumococcal
Once after age 65
Once after age 65
Once after age 65
Once after age 65
Cost-effective
Tetanus (Tdap
once as an adult)
Booster every 10 yr Booster every 10 yr Booster every 10 yr
Booster every 10 yr
Cost-effective
Herpes Zoster
Once after age 60
Once after age 60
Cost-effective
Once after age 60
Once after age 60
Beers Criteria: “Potentially” Inappropriate Medications in Elderly
• Systemic review of adverse drug effects in the elderly developed by an
expert panel
• Updated regularly (J Am Ger Soc 60: 616, 2012)
• Examples
– Anticholinergics: 1st generation antihistamines
– Antiparkinson agents: bentropine
– Antispasmodics: scopolamine, hyoscyamine
– Antithrombotics: short acting oipridamole
– Anti-infective: nitrofurantoin
– CV
• A1 blocker, doxazocin, terazocin, prazocin
• Central A1: clonidine, methyldopa
• Antiarrythmics: amiodorone, sotalol, propafenone, digoxin>0.125
mg/d, immediate release nifedipine
Beers Criteria: “Potentially” Inappropriate Medications in Elderly
• Examples continued
– CNS: amitriptyline, doxepin >6 mg/d
– Antipsychotics: long list, including thorazine
– Barbiturates: long list
– Benzodiazepines: many, including oxazepam, temazepam
– Non-benzodiazipine hypnotics: zolpidem, zaleplon
– Endocrine: testosterone, dessicated thyroid, sliding scale insulin,
megestrol, glyburide, chlorpropamide
– GI: metoclopramide
– NSAIDs: most, including ASA for primary prevention
– Muscle relaxants: most, including carisprodol, cyclobenzaprine
What dementia syndrome best explains the following
•
•
A 70 yo woman with minimal cognitive dysfunction, severe
orthostatic hypotension, postprandial hypotension, constipation,
dry mouth, bradykinesia, symmetric rigiditiy, and tremor with
movement. She does not respond to levodopa-carbidopa. MRI –
no infarcts or hydrocephalus; marked hypointensity of striatum
and linear hyperintensity lateral to putamen on T2 suggests iron
deposition and supports the diagnosis (vs. Parkinson)
Multiple System Atrophy: prominent features by subtype
– Shy-Drager Syndrome: dysautonomia
– Striatonigral degenertion: anterocollis, pyramidal
dysfxn
– Olivopontocerebellar atrophy: cerebellar ataxia, limb
dyssynergia, kinetic tremor
“Reversible” Dementia
– What are examples of “reversible” dementias?
– B12 deficiency, neurosyphillis, thyroid disorder,
pseudodementia, medications, encephalopathies,
tumors, NPH, subdural hematoma
– How often is a reversible etiology identified? How
many respond to treating underlying cause?
– 20% of dementia referrals. Of these, 10% improve.
~1% resolve

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