Chapter 21: Care of the Older Patient

An 83-year-old female patient whom you have followed for many years has just been admitted to a nursing home following a short hospitalization. Because of a steady decline in function and lack of family and social support, you and the patient have come to the realization that she can no longer safely live alone in her home, and her needs were too great for assisted living. Her medical problems include: congestive heart failure, chronic atrial fibrillation, osteoarthritis, and depression. Her current medications are: warfarin, furosemide, acetaminophen, calcium carbonate, lisinopril, metoprolol, and fluoxetine. Both the patient and the nursing staff report poor sleep and depressed mood for the last 2 weeks, and the nurses are asking for a sleep aid.

Question 21.1.1 What is the best next step in the management of her insomnia?

A) Add diphenhydramine 50 mg PO HS

B) Add diazepam 5 mg PO HS

C) Add amitriptyline 25 mg PO HS

D) Recommend increased activity during the day, avoidance of naps, warm milk before bed, and waking at the same time each morning

E) Add 2 shots of bourbon PO HS

Answer 21.1.1 The correct answer is "D." There are no great medicines for promoting sleep in elderly nursing home residents. Given the lack of efficacy data of most hypnotics coupled with the known adverse effects, a trial of good sleep hygiene should be undertaken first. "Good sleep hygiene" generally consists of the following: eliminate or reduce daytime naps, add daily activities, maintain a set waking time, increase aerobic exercise (but not within a few hours of bedtime), and maintain a quiet, comfortable sleeping environment. Nighttime rituals, such as meditation and warm milk, may help insomnia and are unlikely to cause any harm, but avoid the bourbon as alcohol interferes with normal sleep architecture (single malt scotch?? … maybe). If these initial efforts fail, a low dose of a hypnotic (e.g., zolpidem and zaleplon) or trazodone is an appropriate choice. Trazodone has fewer anticholinergic and blood pressure effects than other options, such as tricyclics and benzodiazepines, but should still be used with caution while monitoring for adverse effects. Diphenhydramine ("A") has powerful antihistaminic and anticholinergic properties that may result in increased confusion and falls. Diazepam ("B") has an exceptionally long half-life in elderly patients and may cause daytime somnolence. Amitriptyline ("C") is listed by the Centers for Medicare and Medicaid Services (CMS) as a medication to be avoided in nursing home patients due to high potential for severe adverse drug reactions (falls, constipation, etc.).

The nurses grudgingly accept your recommendation to try sleep hygiene ("Can't we just give her a pill?"), and over the next month your patient's sleep improves, as does her mood. There's one in the win column for the doctor! Unfortunately, she experiences two falls with minor injuries while ambulating in her room. Upon examination, you find normal vital signs, no orthostatic hypotension, and no focal neurological deficits.

Question 21.1.2 Which of the following is the most appropriate next step?

A) Discontinue warfarin

B) Employ bed and chair alarms

C) Obtain a computerized tomography (CT) scan of the head

D) Reduce or discontinue fluoxetine

E) Restrict activities and prescribe a wheelchair

Answer 21.1.2 The correct answer is "D." As often happens in life, there is no great answer here. Falls are usually multifactorial in origin, so simple interventions do not generally solve the problem. SSRIs have been shown (in imperfect studies) to increase the risk of falls in the elderly, so reducing or discontinuing fluoxetine is prudent, but you will have to watch for mood and anxiety symptoms. "A," discontinuing warfarin, may be appropriate if she continues to fall but this action is not likely to reduce her fall risk. "B," the use of bed and chair alarms, is helpful when patients have cognitive impairment and cannot remember to ask for help when getting up; however, these devices can act as tethers to further restrict a patient's movement. Likewise, further restriction of activities and mandatory wheelchair use may lead to deconditioning, loss of muscle strength, and an increased risk of falls. A CT scan of the head may be warranted if the patient sustained a head injury or had an abnormal neurological examination, but it's unlikely to determine the cause of her falls.

Over the next year, you observe a steady decline in your patient's function, with a series of falls despite interventions. Ultimately, your patient has a devastating thromboembolic stroke, which results in right hemiparesis and dysphagia. After a short hospital stay, she returns to the nursing home and undergoes therapy. You order a swallow study (which you will do for all stroke patients). She continues to have difficulty with her swallowing but is able to tolerate thickened liquids without aspirating. She has a 5% weight loss over the next 2 months, and her nurse reports poor oral intake. Her medications are now warfarin, furosemide, acetaminophen, calcium carbonate, and lisinopril.

Question 21.1.3 In this malnourished, elderly nursing home patient, which of the following interventions or diagnostic studies will most likely lead to improvement in her condition?

A) Admit to the hospital and initiate parenteral feeding

B) Refer for esophagogastroduodenoscopy (EGD)

C) Screen for depression

D) Add megestrol acetate

E) Add marijuana

Answer 21.1.3 The correct answer is "C." Depression is one of the most common causes of weight loss in the nursing home, and stroke survivors are at high risk for depression. Also, this patient has a history of depression with no current treatment (Remember? We stopped the fluoxetine earlier). Consider using a screening tool, such as the geriatric depression scale. A positive screen requires further investigation. Now that she is bedridden, falls are not as much of an issue, so an SSRI may be appropriate. "A" is incorrect. We are not sure of the patient's wishes regarding intravenous (IV) nutrition, and more conservative measures should be instituted before considering parenteral nutrition. "B" is incorrect. While an EGD may be important at some point, proceeding to EGD immediately is premature. "D," megestrol acetate, has been reported to improve food intake in patients with cancer cachexia, but its value in the nursing home is questionable, and it may be associated with an increased risk of mortality. "E" is also incorrect. Even if you practice in one of the tokin' states, we cannot have her lighting up in the nursing home.

You diagnose depression and initiate treatment. You also encourage the nursing staff to observe your patient while eating and assist her if necessary. You add a daily multivitamin. Her mood improves slightly and her weight stabilizes. However, over the next 6 months, your patient becomes more withdrawn and spends most of her time in bed. Because of her stroke, she is not very mobile, and she requires assistance with transfers and movement in bed. Ultimately, she develops a skin ulcer on her sacrum. Nursing staff reports a sacral pressure ulcer measuring 3 × 2 cm. There appears to be some interruption of the epidermis, like an abrasion.

Question 21.1.4 According to conventional staging criteria, what stage is this pressure ulcer?

A) Stage I

B) Stage II

C) Stage III

D) Stage IV

Answer 21.1.4 The correct answer is "B." Pressure ulcers (in older parlance, decubitus ulcers, pressure sores, or bed sores) are caused by unrelieved pressure resulting in damage to underlying tissue. Stage II ulcers are partial thickness injuries that are shallow and appear as open ulcers. Anatomic areas of concern in bed-bound patients include sacrum, coccyx, heels, and occiput. Chair-bound patients are more likely to develop ulcers over the ischial tuberosities. Risk factors for pressure ulcers include advancing age, immobility, moisture (e.g., urinary or fecal incontinence), malnutrition, and decreased sensory perception. Ulcers are staged by clinical appearance (see Table 21-1).

Because of miscommunication within the nursing home staff, the ulcer goes untended over the weekend. An alarmed nurse calls you to report full thickness skin loss. You arrange to visit the patient in the evening … here comes another "above and beyond" award.

Question 21.1.5 In the meantime, you prescribe what treatment?

A) Foam pad with occluding dressing (e.g., Allevyn, Mepilex)

B) Wet-to-dry dressing

C) Topical antibiotics

D) Transparent, occlusive dressing (e.g., Tegaderm)

E) Chemical enzyme debridement (e.g., Accuzyme)

Answer 21.1.5 The correct answer is "A." In treating pressure ulcers, there are several principles to follow: relieve pressure, protect the wound and surrounding skin from further trauma, maintain a clean wound bed, provide a moist wound environment, eliminate dead space, control exudates, ensure adequate nutrition, and diagnose and treat infection. Your patient's ulcer has worsened and is now at least stage III. Without further information, foam dressing is a safe choice for initial treatment of a stage III ulcer. Foam pads are useful for deeper wounds with moderate exudate and may also protect the wound from further pressure. In most cases, the wound should be kept moist, so wet-to-dry dressings are not appropriate (they also debride the wound of both necrotic and healthy tissues—ouch). If moist gauze packing is used, it should be kept moist with intermittent reapplication of saline or changed before drying. From the nurse's report, there is no evidence of necrosis, excessive drainage or infection, so debridement and antibiotics may not be helpful at this time. A transparent, occlusive dressing is used for stage II ulcers, but is insufficient for stage III or IV. In addition to dressing the wound, you should employ the following measures: repositioning every 1 to 2 hours, pressure-relieving mattress and cushions, and optimizing nutrition. Consultation with a wound care specialist or a surgeon may be necessary if these measures fail.

Question 21.1.6 Which of the following statements is NOT true about the evaluation and treatment of pressure ulcers?

A) A pressure ulcer covered by eschar cannot be staged until the eschar is removed.

B) If a pressure ulcer shows no signs of healing over 2 weeks, one should reevaluate wound management strategies and reexamine factors affecting the wound.

C) One should consider osteomyelitis or deep soft-tissue infection in a wound that is not healing.

D) Wound cultures should be obtained routinely to target antibiotics toward the organisms found.

E) In an otherwise clean wound that is not healing as expected, one should consider empiric therapy with topical antibiotics.

Answer 21.1.6 The correct answer is "D." The routine culturing of pressure ulcers is not recommended. Antibiotics are generally not useful since the organisms found are polymicrobial colonizers and not responsible for infection. Obviously, this does not hold true for patients with a true infection, and empiric therapy with topical antibiotics is indicated if a wound shows no improvement with good wound care.

Objectives: Did you learn to…

• Manage insomnia in elderly nursing home residents?

• Develop an approach to the problem of falls in nursing home residents?

• Identify nursing home residents at risk for malnutrition?

• Develop a treatment plan for malnutrition in the institutionalized elderly?

• Diagnose, evaluate, and manage pressure ulcers in the nursing home setting?

A 65-year-old male presents for a routine visit and you recommend pneumococcal vaccination (23-valent polysaccharide vaccine, Pneumovax). Your patient asks what the vaccine is supposed to do.

According to the best available evidence, you are able to say:

A) "This vaccine will reduce your risk of pneumococcal bacteremia."

B) "This vaccine will reduce your risk of pneumococcal pneumonia."

C) "This vaccine will reduce your risk of all types of pneumonia."

D) "This vaccine will reduce your risk of death from influenza."

E) "This vaccine will do all of the above."

The correct answer is "A." The 23-valent polysaccharide pneumococcal vaccine has only been shown effective in reducing the risk of pneumococcal bacteremia and meningitis. The vaccine does not appear to reduce the risk of pneumonia in general or even pneumococcal pneumonia in particular. Influenza vaccination decreases the risk of death due to influenza, but pneumococcal vaccination does not.

But what you should have done is offer this patient the pneumococcal conjugate vaccine (e.g., Prevnar) first. In 2014, the CDC recommended the 13-valent pneumococcal conjugate vaccine (PCV 13) for use in all patients over the age of 65 as a one-time dose. It should be administered to vaccine-naive individuals followed by the 23-valent polysaccharide pneumococcal vaccine (Pneumovax) 6 to 12 months later. For individuals who have been immunized with the 23-valent polysaccharide pneumococcal vaccine, it is recommended that the PCV 13 be given as a single dose at least 1 year after the last dose of the 23-valent polysaccharide pneumococcal vaccine.

Noticing advertisements for testosterone treatment to "make you a vital man again," one of your vivacious older female patients asks about testosterone for her husband wondering if it can make him 50 years old again.

Regarding sex hormone changes associated with aging, which of the following is true?

A) Leydig cells in the testes increase with aging

B) Total testosterone levels increase with aging

C) Sex hormone binding globulin levels increase with aging

D) Follicle-stimulating hormone levels are unchanged with aging

E) Luteinizing hormone levels decrease with aging

The correct answer is "C." Sex hormones in males over age 40 demonstrate declining total testosterone at a rate of 1% to 2% per year. Simultaneously, sex hormone binding globulin increases, resulting in a sharper decline in bioavailable testosterone. In response to low testosterone, follicle-stimulating and luteinizing hormone levels increase. Leydig cells (responsible for producing testosterone) decrease in number. Older males with subphysiologic testosterone levels are at increased risk of sexual dysfunction, osteoporosis, diminished lean body mass, depression, and inability to kill a mountain lion with their bare hands. Although controversial, some experts recommend testosterone supplementation in symptomatic males with low serum testosterone. Testosterone supplementation may (notice the word "may") improve strength, lean body mass, depressed mood, bone mineral density, and sexual function in aging males with documented low testosterone levels. Side effects of testosterone supplementation in older males include: cardiac disease, liver dysfunction, dyslipidemia, erythrocytosis, prostate tissue growth, acne, gynecomastia, and edema. If your patient is baleful and pushes the request for "T," point out that testosterone adds nothing to the treatment of erectile dysfunction beyond that benefit which is offered by tadalafil (Cialis), sildenafil (Viagra), etc. You can reassure him that he will be just as virile at age 98 without testosterone and will avoid the risk of worsening heart disease (Ann Intern Med. 2012;157:681).

A 79-year-old female patient, well known to you from 5 years of treating her hypertension, presents to your office for an "annual examination" and "medication refill". Her only medications are lisinopril, amlodipine, and acetaminophen. She's noticed some hearing loss over the last year, and wonders if she should blame her medications and not all those rock concerts she attended as a young adult. Oh, by the way, her gynecologist recently retired and she would now like you to assume that care, which apparently included all of her preventative care.

Question 21.2.1 Which of the following drugs is NOT associated with sensorineural hearing loss?

A) Ibuprofen

B) Aminoglycosides

C) Furosemide

D) Magnesium salicylate

E) Acetaminophen

Answer 21.2.1 The correct answer is "E." All of these drugs except for acetaminophen can cause hearing loss. Cisplatin, aminoglycoside antibiotics, and loop diuretics have been associated with hearing loss, as have salicylates (e.g., aspirin) and some of the other NSAIDs (e.g., ibuprofen and diflunisal) and chloroquine. This list is obviously not exhaustive.

Your patient then asks, "Do I have to keep getting mammograms and Pap smears?" She relates a history of normal annual mammograms and Pap smears for the past 20 years, as her previous physician hadn't changed her practice since The Backstreet Boys were popular. She had a hysterectomy for uterine fibromas and has been monogamous with her husband for 55 years. Her sister died of breast cancer. Using your magic crystal ball, you estimate her life expectancy at 10 years.

Question 21.2.2 Consistent with current guidelines, you recommend:

A) Continue Pap smears and pelvic examinations yearly

B) Discontinue mammography but perform clinical breast examinations every 2 years

C) Discontinue pelvic examinations but continue Pap smears

D) Discontinue Pap smears but offer mammography at 1- to 2-year intervals

Answer 21.2.2 The correct answer is "D." Tricky question. Screening decisions in the elderly should be individualized, and the patient's overall health status must be considered. This patient has very little risk of cervical, endometrial, or vaginal cancer (status post hysterectomy for a benign condition, low-risk sexual behavior, and a history of normal examinations); therefore, it is reasonable to discontinue Pap smears. Annual pelvic examination is more controversial, with the American Cancer Society (ACS) recommending it as a screening measure for ovarian cancer and the US Preventive Services Task Force (USPSTF) recommending against it.

Screening for breast cancer continues to be recommended for women with a 5 to 10 years life expectancy, but the optimal interval in older women is unknown: The American College of Physicians (kind of presumptuous name … what about FM? Are we not physicians?) and USPSTF recommend screening of aged 50 to 74 years every other year; our patient is 79. Whether this patient will benefit from mammography is unknown. There is a significant question of the "overdiagnosis" of breast cancer; this is cancer diagnosed by mammogram that would not ever have caused a problem for the patient (think of it as the equivalent of the diagnosis of prostate cancer in men … they may die with the cancer and not of the cancer) (e.g., JAMA Intern Med. Published online July 06, 2015. doi:10.1001/jamainternmed.2015.3043). Before ordering a mammogram, we need to have a discussion with our patients about what types of intervention they would want should a positive mammogram be noted.

Your patient is an overweight white female with no history of bone fracture. She has never had a bone mineral density test and asks if she should have one. You are unaware of any risk factors in her other than Caucasian race and postmenopause status.

Question 21.2.3 What do you tell her?

A) "You are not at risk for osteoporosis and should not be screened"

B) "All women over age 65 should be screened for osteoporosis regardless of risk"

C) "Take 1,000 mg of calcium per day to prevent osteoporosis. You'll be unbreakable—like Wolverine"

D) "Due to your risk factors, you should start a bisphosphonate, vitamin D, and calcium supplementation"

E) "Alcohol—and lots of it—will help decrease your risk of osteoporosis"

Answer 21.2.3 The correct answer is "B." The USPSTF currently recommends bone densitometry screening for all women of age 65 years and older. The National Osteoporosis Foundation recommends bone densitometry for postmenopausal females with one or more of the following risk factors: family history of osteoporosis, personal history of low trauma fracture, current smoking, or low body weight (<127 lb). Additional risk factors for osteoporosis include: female sex, Caucasian or Asian races, alcohol abuse (thus, "E" is wrong), sedentary lifestyle, and poor intake or absorption of calcium and vitamin D. Smoking is associated with osteoporosis. Diabetes, once thought to protect against osteoporosis, may actually increase the risk of falls and fractures in older adults. The preferred method for measuring bone density is dual-energy x-ray absorptiometry (DEXA). All postmenopausal women should consume 1,200 mg of elemental calcium per day in divided doses. The optimal amount of vitamin D is 400 to 800 IU/day. Weight-bearing exercises also strengthen bone. Bisphosphonates are indicated for treatment of osteoporosis and should not be used without a diagnosis (so "D" is incorrect).

Next, your patient asks whether any of her medications put her at risk for osteoporosis.

Question 21.2.4 Which of the following is LEAST likely to increase the risk of osteoporosis?

A) Glucocorticoids

B) Anticonvulsants

C) Sulfonylureas

D) Loop diuretics

E) Proton-pump inhibitors

Answer 21.2.4 The correct answer is "C." Sulfonylureas do not have a direct effect on bone mineralization. Glucocorticoids and anticonvulsants are known to increase bone turnover, resulting in increased risk of osteoporosis. Loop diuretics cause renal calcium wasting. There is an association between proton-pump inhibitor use and osteoporosis, possibly through reduced calcium absorption or direct effects on bone metabolism. There does not appear to be this same association with H₂-blockers such as famotidine. Additionally, heparin, methotrexate, cyclosporine, and gonadotropin-releasing hormone agonists may increase the risk of osteoporosis. Excessive amounts of levothyroxine can cause increased bone turnover. Thiazide diuretics are protective.

Your patient asks what causes osteoporosis.

Question 21.2.5 Although most osteoporosis in women is primary (idiopathic), which of the following cause(s) secondary osteoporosis?

A) Hypoparathyroidism

B) Multiple myeloma

C) Estrogen use

D) Hyperlipidemia

E) Overly ambitious, or perhaps calcium-addicted, Tooth Fairies

Answer 21.2.5 The correct answer is "B." About 70% of women have no identifiable cause for osteoporosis and therefore are diagnosed with primary (idiopathic) osteoporosis. Common causes of secondary osteoporosis include chronic corticosteroid use, alcoholism, GI disorders, hyperthyroidism, hyperparathyroidism (so, "A" is wrong), multiple myeloma, and primary renal diseases. Hyperlipidemia is not known to be associated with osteoporosis. Estrogen increases bone mineral density.

You encourage appropriate vitamin D and calcium intake as well as weight-bearing exercises. You plan to obtain a DEXA scan.

Question 21.2.6 Using DEXA scan results, osteoporosis is defined as:

A) A T-score of 2.5 standard deviations or more below the mean of a healthy young adult (≤−2.5).

B) A T-score from 1.0 up to 2.5 standard deviations below the mean of a healthy young adult (−1.0 up to −2.5).

C) A Z-score of 2.5 standard deviations or more below the mean of a healthy young adult (≤−2.5).

D) A Z-score from 1.0 up to 2.5 standard deviations below the mean of a healthy young adult (−1.0 up to −2.5).

Answer 21.2.6 The correct answer is "A." The T-score compares the patient's bone mineral density to that of young, healthy women (for female patients; male normative data is used for males). Osteoporosis is defined as a T-score of 2.5 standard deviations or more below the mean (≤−2.5). Osteopenia is defined as a T-score from 1.0 up to 2.5 standard deviations below the mean (−1.0 to −2.5). "C" is incorrect. The Z-score compares bone mineral density to that of age-matched controls. Therefore, it does not reflect the bone loss from baseline in a young healthy female, and it is not used for diagnosis. "D" is incorrect for the same reason.

Question 21.2.7 If you find that your patient has osteoporosis, you may consider using all of the following drugs to treat her osteoporosis EXCEPT:

A) Bisphosphonates (e.g., alendronate and risedronate)

B) Estrogens

C) Progesterone (e.g., Provera and Depo-Provera)

D) Vitamin D and calcium

E) Calcitonin

Answer 21.2.7 The correct answer is "C." Progesterones are not indicated for the treatment or prevention of osteoporosis. In fact, in young, healthy, premenopausal women, they are associated with a decrease in bone mineral density. This is because they suppress estrogen production (such as with Depo-Provera). All of the other options are acceptable choices in the treatment of osteoporosis.

She returns to discuss her test results, and her bone density is very low with her hip T-score 3.2 standard deviations below the mean (–3.2). You diagnose her with osteoporosis. "Are my bones like Swiss cheese?" she asks. No, you think. Swiss cheese has more calcium.

Question 21.2.8 Given that she is otherwise relatively healthy, what is the most appropriate initial therapy for her osteoporosis?

A) Alendronate (Fosamax) 70 mg PO weekly

B) Estrogen (e.g., Premarin) 0.625 mg PO daily

C) Teriparatide (Forteo) 20 g SC daily for 5 years

D) Zoledronic acid (Reclast) 5 mg IV every 3 months

Answer 21.2.8 The correct answer is "A." Bisphosphonates are the treatment of choice for osteoporosis. Alendronate, risedronate, and zoledronic acid have all been shown to reduce the risk of vertebral and hip fractures in persons with osteoporosis. Ibandronate only appears to lower vertebral fracture risk; therefore, it should not be your first choice. Side effects of bisphosphonates include hypocalcemia (more likely with IV administration, as with zoledronic acid, and in patients with vitamin D deficiency), nausea, esophagitis, osteonecrosis of the jaw (usually at higher doses, such as those used to treat cancer), and atypical femur fractures. Although you might be tempted to choose "D," zoledronic acid, due to this patient's more severe osteoporosis, there is no clear evidence that zoledronic acid is more effective than oral bisphosphonates. The IV route should be reserved for when the patient has failed oral bisphosphonate therapy for some reason—usually due to upper GI disease or side effects. Zoledronic acid can cause a "flu-like" illness, with diffuse myalgias and arthralgias for days after the infusion. "B" is incorrect as the safety data for bisphosphonates is superior to that for estrogen. "C" is incorrect for two reasons: teriparatide, a recombinant parathyroid hormone, is administered daily and carries a risk of osteosarcoma. For this reason its use is limited to 2 years, not 5. Teriparatide is effective at increasing bone density and reducing fracture risk, but the data is not nearly as robust as the data for bisphosphonates. It is not a first-line drug.

Before she leaves the office, you present your patient with literature on living wills and durable power of attorney for healthcare (DPOA-HC).

Question 21.2.9 Which of the following is CORRECT regarding advance healthcare planning?

A) The Joint Commission requires that patients be asked about their advance directives on admission to the hospital.

B) A DPOA-HC can override a patient's decision regarding treatment.

C) Once the patient has signed a living will, no further changes can be made regarding treatment decisions.

D) A DPOA-HC must be a family member or blood relative.

Answer 21.2.9 The correct answer is "A." The Joint Commission requires that patients be asked about their advance directives on admission to the hospital. Advance directives can take many forms but are usually manifest in one of two ways: through a living will or a DPOA-HC. The purpose of a living will is to instruct healthcare decision-making in future events when the patient may not be able to communicate his or her wishes. These documents often contain brief clinical scenarios with patient preferences for life-sustaining measures. In contrast, a DPOA-HC is not as limited and can address situations not foreseen in a living will. If the patient becomes unable to participate in healthcare decision-making, then the DPOA-HC is instructed to exercise substituted judgment, using the patient's previously stated healthcare preferences, to help direct future care. The DPOA-HC is appointed by the patient and can be a family member or another adult. The DPOA-HC cannot override a patient's decision in healthcare matters, as such an action would violate patient autonomy.

Objectives: Did you learn to…

• Identify and implement appropriate preventive health services for older females?

• Discuss issues related to breast and gynecologic cancer screening?

• Define appropriate criteria for osteoporosis screening and identify risk factors?

• Recognize the important and complementary roles of DPOA and advance directives?

Which of the following statements is INCORRECT regarding preventive health in older adults?

A) Although the optimal interval for vision screening is undetermined, many professional organizations recommend vision and glaucoma screening every 1 to 2 years in persons over age 65

B) In women at high risk for breast cancer, tamoxifen reduces the risk of cancer by almost 50%

C) The American Cancer Society (ACS) and American College of Obstetrics and Gynecology (ACOG) recommend screening ultrasound for ovarian cancer in all women over the age of 60

D) Although Pap smears are not generally recommended for elderly women, the distribution of cervical cancer cases is bimodal, with peaks at 35 to 39 years and 60 to 64 years

The correct answer is "C." In fact, ACOG, the USPSTF, and the American College of Physicians specifically recommend against ultrasound screening for ovarian cancer in asymptomatic women. All other statements are correct.

An 82-year-old male patient presents to your office for confusion. His wife reports that he was in his usual state of health until 3 days ago. At that time, he developed abdominal pain and felt feverish. He then began to have a dry, hacking cough. On examination, his temperature is 100.3°F and blood pressure is 118/56 mm Hg. He is pale and lethargic but in no acute distress. He is oriented to person only. Other than mild upper abdominal tenderness, there are no additional findings on examination. This patient appears to have a new onset of confusion. You suspect delirium.

Question 21.3.1 Which of the following is true with regard to delirium and dementia?

A) In delirium it is rare to find an underlying medical cause

B) A primary feature of delirium is inattention

C) Dementia is characterized by an acutely fluctuating course

D) Delirium only occurs in patients with dementia

E) They are the same. After all, memory is but an ephemeral light in the long shadow of time

Answer 21.3.1 The correct answer is "B." The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) provides the diagnostic criteria for delirium. A diagnosis of delirium requires the following criteria: disturbance of consciousness with reduced ability to focus attention; disorientation, memory deficit, or another change in cognition that cannot be accounted for by a preexisting dementia; acute onset with fluctuating course (often changing throughout the day); and evidence that the disturbance is caused by an underlying medical condition or drug use. Not all signs and symptoms of delirium are present in every patient with delirium, nor will they be present at the same time. Delirium can be confused with dementia, depression, or psychosis. Patients with delirium may present as agitated, psychotic, somnolent, or withdrawn (these are the tough ones to recognize). Dementia is more chronic in nature with an insidious onset. Dementia progresses over time and usually cannot be reversed. Often delirium is treatable or reversible if the underlying medical condition is identified and treated. Patients with dementia usually have intact attention, whereas patients with delirium have markedly impaired attention. Patients with dementia have "poverty of thought," which implies decreased content of their thoughts. Patients with delirium may have a rich content to their thoughts, but the thoughts are disordered.

With further history from the patient's wife, you find that he has coronary artery disease, diabetes mellitus type 2, hypertension, and benign prostatic hyperplasia.

Question 21.3.2 Which of the following is the most useful question to elicit risk factors for delirium?

A) "Does the patient have any drug allergies?"

B) "Does the patient use tobacco?"

C) "Does the patient use alcohol?"

D) "Does the patient have edema?"

E) "Does the patient use acetaminophen?"

Answer 21.3.2 The correct answer is "C." Studies have consistently identified the following risk factors for delirium: advancing age, preexisting dementia, underlying structural brain disease other than dementia, uncorrected impairment in vision or hearing, multiple chronic illnesses, polypharmacy, the use of physical restraints, history of alcohol abuse, male gender, and functional impairment.

While hypoxia (due to myocardial infarction, pulmonary embolus, or any other source) may lead to delirium, tobacco use alone does not predispose a patient to develop delirium. In isolation, knowledge about edema, acetaminophen use, or drug allergies is less helpful. Questioning about alcohol use will help to identify patients who have a tendency to overuse alcohol, putting themselves at risk for delirium. Also, delirium may result from alcohol withdrawal.

Question 21.3.3 The appropriate evaluation of the patient with delirium includes which of the following?

A) Evaluation of metabolic causes such as electrolytes and glucose

B) Evaluation for infection such as pneumonia

C) Evaluation of a patient's medications

D) Evaluation of oxygen saturation

E) All of the above

Answer 21.3.3 The correct answer is "E." Causes of delirium are protean, often acting together in a multifactorial manner, and are best considered by a systematic approach. Metabolic causes include electrolyte disturbances (don't forget calcium), hypoglycemia, and hypoxia. Numerous infections may lead to delirium. Neurologic causes include head trauma, meningitis, and vasculitis. Many medications cause delirium including anticholinergics, antidepressants, sedative–hypnotics, and steroids. Dehydration and prerenal azotemia may lead to delirium. See Table 21-2.

You reach for the "shotgun" (metaphorically, we hope) and order a bunch of tests. The chest radiograph shows a left lower lobe consolidation. The abdominal film shows a nonspecific bowel gas pattern. The white blood cell (WBC) count is 12,700/mm³, blood urea nitrogen 36 mg/dL, creatinine 1.5 mg/dL, and glucose 150 mg/dL. The remainder of the blood counts and chemistries are normal. With the exception of trace ketones, the urinalysis is within normal limits. Cultures will not be available for at least 24 hours. The ECG shows normal sinus rhythm. With the available information, you decide to admit this patient for treatment of delirium due to pneumonia and dehydration.

You are called in the middle of the night for agitated behavior and noncompliance with nursing care. The patient has pulled out his IV and struck a nurse.

Question 21.3.4 You appropriately prescribe which of the following interventions?

A) Administer haloperidol 0.5 mg PO

B) Administer haloperidol 1 mg IV

C) Apply physical restraints

D) Administer morphine 5 mg IV

E) Lorazepam 1 mg PO for the patient, 0.5 mg for the nurse

Answer 21.3.4 The correct answer is "A." Most of the time, delirium DOES NOT require any pharmacologic treatment. However, this patient is at risk of harming himself and others due to his agitated delirium, so some action must be taken. Agitated delirium causes physiologic and psychologic stress on the patient, results in interference with medical care, and portends a poorer prognosis. The incidence of delirium in hospitalized patients of all ages is 30%, and the incidence in postoperative patients may approach 50%. Agitated delirium should be treated quickly, and haloperidol is the treatment of choice. In older patients, drug clearance decreases, so low doses of antipsychotic medication should be administered initially. As the geriatricians say, "Start low and go slow." Increasing doses of oral haloperidol can be given every 30 minutes if the patient continues to have agitation. "B" is incorrect because IV haloperidol is associated with a greater degree of QT prolongation; PO or IM haloperidol is preferred. "C" is incorrect; physical restraints may lead to patient injury and may worsen delirium. Restraints should only be applied when absolutely necessary and for as short a duration as possible. "D" is incorrect because we have no reason to believe the patient is in pain, and administering narcotics could worsen his delirium. However, pain can certainly result in agitation, so keep it in mind. Finally, "E" is wrong for at least two reasons: there is a substantial risk of paradoxical agitation with benzodiazepine administration in demented elders, and you should not prescribe controlled substances to staff nurses.

You reflect on the fact that primary prevention of delirium is probably more effective than treatment. For this patient, delirium must now be treated, but you try to avoid this complication in your hospitalized older patients.

Question 21.3.5 You know that research has shown a reduction in delirium in hospitalized older patients when which of the following strategies is employed?

A) Increased sedative medication use for sleep deprived patients

B) Early mobilization for immobilized patients

C) Cholinesterase inhibitor (e.g., donepezil) therapy for cognitively impaired patients

D) Physical restraints for combative patients

E) Music therapy for depressed patients

Answer 21.3.5 The correct answer is "B." Identifying risk factors and targeting interventions to reduce or eliminate risk factors can prevent delirium. Because one patient may have numerous risk factors for delirium and because delirium is usually a multifactorial syndrome, a multicomponent intervention strategy is warranted.

An often-cited study by Inouye et al. (1999) demonstrated the effectiveness of this strategy. In the study, sleep-deprived patients received a warm drink, relaxing music, and back massage at bedtime. Unit-wide noise reduction was implemented. Early ambulation and active range-of-motion exercises were employed for bed-bound patients. All patients were encouraged to ambulate. Cognitively impaired patients received orienting stimuli and cognitively stimulating activities. Patients with hearing and visual impairments received portable amplifying devices and visual aids, respectively. Investigators used a protocol for early recognition and treatment of dehydration. There was no specific therapy for depression or combativeness. As you can see, the preventative strategies for delirium must also be broad as no one treatment has been singularly effective.

The Confusion Assessment Method (CAM) is an evidence-based tool that could have helped you identify delirium sooner in your patient. It takes into account onset, inattention, disorganized thinking, disorientation, and other important factors. See https://www.healthcare.uiowa.edu/igec/tools/cognitive/CAM.pdf for a worksheet to calculate CAM. Using CAM takes just a few minutes and is, of course, easier and much safer than waiting to find him walking his imaginary dragon through the hospital ward while carrying a half-filled bedpan.

Question 21.3.6 Which of the following statements about delirium is true?

A) Bed rails and restraints are effective in preventing injury in the patient with delirium

B) Atypical antipsychotics (e.g., olanzapine and risperidone) can be used to treat delirium

C) Diphenhydramine is a good choice for a sleep aid in patients who are prone to developing delirium

D) A feeding tube (e.g., Dobhoff tube) should be used in the patient who is not eating in order to prevent delirium.

E) Shouting, "You don't have a dragon! They aren't real!" helps to prevent complications of delirium

Answer 21.3.6 The correct answer is "B." Atypical antipsychotics can be used in the treatment of delirium, but nonpharmacologic methods (e.g., bedside sitter and redirection) should be used first. "A" is incorrect because bed rails and restraints actually increase the risk and severity of injury in the patient with delirium. Restraints are used as a last resort. "C" is incorrect. Diphenhydramine is a particularly poor choice because of its anticholinergic side effects, which can exacerbate or cause delirium. Trazodone would be better. Melatonin and the melatonin agonist ramelteon have shown some ability to reduce the risk of delirium but only when started prior to the onset of symptoms and only in small trials. "D" is incorrect, as anyone who has done inpatient work knows: the feeding tube and the Foley are often the first to get yanked! "E" is also no good. Never argue with a patient about his delusion. You will not win.

Objectives: Did you learn to…

• Define delirium?

• Describe the signs and symptoms of delirium?

• Distinguish delirium from dementia?

• Identify causes and risk factors for delirium?

• Treat and prevent delirium?

In the early morning hours, a 78-year-old female presents to the emergency department complaining of right buttock and hip pain. Several hours before her arrival, she fell in the bathroom of her daughter's home. She recalls standing on a floor mat, leaning her head back to drink a glass of water, and then hitting the ground. She denies loss of consciousness. Her daughter was at the scene quickly and found the patient awake, alert, and moving all extremities. Her vital signs are normal. Other than right hip tenderness, her examination is unremarkable.

Question 21.4.1 Which of the following is most likely to assist you in determining the cause of her fall?

A) CT scan of the head

B) ECG

C) Additional history

D) Serum chemistry profile

E) CBC

Answer 21.4.1 The correct answer is "C." If there's an option for "more history," it's usually the right answer. History is one of the most important factors in determining the etiology of a fall. Ten percent of falls in older persons can result in serious injury, such as a hip fracture or subdural hematoma. Falls in elderly patients are typically multifactorial in nature. Randomized clinical trials demonstrate a reduction in the occurrence of falls in community-dwelling elders when healthcare personnel engage in a multifactorial risk assessment with targeted management. Such an approach requires a thorough history.

Question 21.4.2 All of the following are risk factors for falls in elderly EXCEPT:

A) Use of four or more medications

B) Orthostatic hypotension

C) Attempting tai chi, for which good balance is required

D) Environmental hazards (e.g., poor lighting or uneven walking surfaces)

Answer 21.4.2 The correct answer is "C." In fact, doing tai chi has been shown to reduce the risk of falls in the elderly. All of the others listed increase the risk of falling. Additional risk factors for falls include history of a fall in the last year, impaired balance and gait, poor vision (acuity <20/60), decreased muscle strength, and syncope or arrhythmia. Still more risk factors: poor lighting, lack of grab bars and handrails, cluttered floor, restraint use, and improper bed height.

Question 21.4.3 During your examination, which of the following physical maneuvers is most likely to assist you in evaluating the risk of future falls?

A) Get-up-and-go test

B) Test for pulsus paradoxus

C) Osler maneuver

D) Lumbar spine flexibility test

E) Test for nystagmus

Answer 21.4.3 The correct answer is "A." The "timed get-up-and-go-test" is a commonly used method of assessing disability and fall risk in geriatric assessment. From a seated position, the patient is instructed to stand up, walk 3 m (approximately 10 ft), turn around, and return to her chair. An adult with no disability should be able to complete this test in <10 seconds. Increasingly longer time to perform the test is associated with increasing fall risk. While performing the test, assess the patient's sitting balance, transition from sitting to standing, gait and steadiness, and quickness with turning. While potentially useful in the evaluation, the other tests listed are not directly associated with fall risk. The Osler maneuver may be helpful in finding cases of pseudohypertension and should be checked in patients who are having falls associated with position changes despite normal or even high blood pressures as measure by sphygmomanometer. The Osler maneuver is performed by blowing up the blood pressure cuff until the radial pulse is absent. Then see if you can palpate a sclerotic, noncompressible, radial artery. If so, the Osler test is positive and the patient may have pseudohypertension.

After a thorough history, you perform a complete workup, including ECG, radiology studies, and appropriate laboratory tests. You find that the fall was caused by environmental factors (poor lighting and a loose throw rug) rather than an organic cause intrinsic to the patient. Fortunately, x-ray of her hip is negative for fracture. The patient asks how exercise might help her avoid future falls.

Question 21.4.4 Which of the following is the best answer?

A) Physical therapist supervision is essential to have an effective fall prevention program

B) In elderly patients, the effect of exercise on falling is unknown

C) Strength training has a greater effect than balance training on reducing fall risk

D) Unsupervised balance and strength training is effective in reducing fall risk

E) Group exercise is more effective than exercising alone to prevent falls

Answer 21.4.4 The correct answer is "D." There is no particular type of exercise that seems to prevent falls to a greater degree than any other type of exercise. Strength, balance, and gait training all appear to be important. Exercise programs have been shown to benefit elders at risk for falls. Although initial instruction by a therapist may be helpful, a physical therapist need not supervise all exercises. Patients are able to perform exercises targeted toward fall prevention at home, and they do not need to be part of an exercise group. A meta-analysis of the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials found that combined balance and strength training reduces the risk of falls in community-dwelling elders.

You recommend strength and balance exercises to the patient, but she is worried and says, "My heart's too old for exercise."

Question 21.4.5 You assure her that light exercises are safe and then review normal age-related cardiovascular changes, which include:

A) Reduced ventricular compliance

B) Reduced maximal heart rate

C) Reduced response to sympathetic nervous stimulation

D) Increased atrial filling

E) All of the above

Answer 21.4.5 The correct answer is "E." Even in the healthy elderly without signs of vascular disease, there are important changes in the cardiovascular system. Maximum cardiac output is reduced, mostly through reduced maximal heart rate; thus the equation:

Additionally, there is reduced response to sympathetic stimulation, with less chronotropic and inotropic response to stress. Reduced ventricular compliance results in increased atrial filling volume and pressure, increased left atrial size, and increased dependence on atrial contraction for ventricular filling. However, endurance training may improve cardiac output, and active older adults have a higher cardiac output compared with sedentary persons of the same age.

Because of her right hip pain, you consider giving the patient an ambulatory device for temporary use. She has good upper extremity strength, can bear some weight on the right, but needs improved stability.

Question 21.4.6 Which of the following devices would be most appropriate in this setting?

A) Wheeled walker

B) Forearm crutches

C) Walk cane (hemi-walker)

D) Imperial walker

E) Multiple-legged cane (quad cane)

Answer 21.4.6 The correct answer is "E." Ambulatory devices are employed with the following goals: improve mobility, decrease the risk of falling, and relieve discomfort associated with acute or chronic musculoskeletal and neurologic conditions. An inappropriately selected device can increase energy expenditure and the risk for falls. Canes widen a patient's base, resulting in increased stability. They are typically used for balance, not weight bearing. Multiple-legged canes—called "quad canes" because of the presence of four tips—provide a more stable base and some weight bearing, when compared with standard, single-tipped canes. Walk canes are useful for patients who require full weight bearing on one arm, as in a stroke survivor with loss of lower extremity function. Crutches, either forearm or axillary, are used for patients who cannot bear any weight on one leg.

Walkers can support a patient's weight, provide lateral stability, and expand a patient's support base. Standard walkers, those with four rubber tips, provide the greatest support and are helpful in cases of ataxia. Front-wheeled walkers are useful for patients with a fast gait, such as a festinating gait in parkinsonism. Also, a front-wheeled walker is easier to manipulate than a standard walker. Four-wheeled walkers should be used when the patient requires some increased stability but does not need as much weight-bearing as a standard walker would provide. Patients with mild-to-moderate Parkinson disease may benefit from four-wheeled walkers. In this case, the patient requires only improved stability and slight assistance with bearing weight. Of the available choices, the multiple-legged cane is the best option. A single-tipped cane may have been a reasonable choice as well. If you chose answer "D," you—like one of the editors—are a Star Wars nerd.

Unfortunately, you do not have access to a multiple-legged cane for your patient. But you do have a supply of adjustable single-tipped aluminum canes available.

Question 21.4.7 If you were to provide her with a cane, what method would you use to fit the cane?

A) Allow the patient to fit the cane length to her comfort level.

B) Select a device with a length equal to the distance from the floor to the greater trochanter of the femur.

C) Fit the cane length so that the handle comes to rest at the patient's waist.

D) Select a device with a length equal to the distance from the floor to the fingertips with the arm relaxed.

E) Extend the cane to its maximum length, giving it the appearance of a shepherd's crook or wizard's staff.

Answer 21.4.7 The correct answer is "B." You should fit a cane for a patient by selecting a device that reaches from the floor to the greater trochanter of the femur. Another option is to fit the cane so that it reaches the flexor crease of the wrist when the arm is extended to the side. A properly fitted ambulatory device should be comfortable, allowing the patient to stand erect without excessive forward flexion of the spine. Excessive forward flexion occurs when the device is too short and can result in increased risk of falling. Also, to obtain maximum efficiency from the upper extremities, the device should not be too long. The usual recommendation is to have a device fitted so that the elbow is flexed at 15% to 30% when the cane is in use. This is done by measuring as noted above.

Objectives: Did you learn to…

• Recognize the morbidity associated with falls in older people?

• Evaluate causes and risks of falls in this population?

• Implement appropriate interventions for falling patients?

• Assess gait abnormalities that may lead to falls?

• Select ambulatory devices for appropriate patients?

If a patient is having difficulty walking due to left-sided leg weakness due to osteoarthritis of the hip, in which hand should a cane be used?

A) Left hand

B) Right hand

C) Either hand

D) Both hands simultaneously

E) No cane should be prescribed; a wheelchair is preferred

The correct answer is "B." Whenever a cane is used to support lower leg function limited by weakness or pain, the cane should be used in the hand contralateral to the affected side (left side weak, right hand gets the cane). This enables the patient to maintain normal arm swing while advancing the cane and the affected leg at the same time to reduce the weight-bearing forces on the affected limb during the step.

A 69-year-old female with no complaints presents to your office with her two daughters. Further history from her daughters reveals that the patient was widowed 4 years ago, now lives alone, and has experienced memory loss over the last 2 years. One daughter has taken over the patient's checkbook and is responsible for paying the bills. She has noticed that her mother often wears the same clothes and bathes infrequently—new and unfortunate habits for her. The past medical history includes hypothyroidism and hypertension. Family history is significant for depression and memory problems in the patient's mother prior to her death from "old age." The patient takes chlorthalidone, levothyroxine, and acetaminophen as needed.

Physical examination reveals a thin, elderly female in no distress. She is alert but does not correctly identify the year. She describes her mood as "happy" most of the time. The remainder of the examination is unremarkable. You suspect dementia.

Question 21.5.1 Which of the following is true regarding the diagnosis of dementia?

A) The diagnosis is rarely missed in the primary-care setting

B) To diagnose dementia, impairment in executive function must be present

C) To diagnose dementia, impairment in memory must be present

D) Alzheimer disease (AD) is a diagnosis of exclusion

E) Neuroimaging is essential in the diagnosis of dementia

Answer 21.5.1 The correct answer is "C." One of the necessary components in order to make a diagnosis of dementia is memory impairment. "A" is incorrect. In contrast to delirium and depression, the onset of dementia is insidious. Symptoms often go unrecognized for months to years prior to diagnosis. Although the patient may complain of confusion or memory loss, family members are more likely to provide the chief complaint and history. During the initial phases of a dementing illness, patients and family members may attribute cognitive changes to normal aging. In early cognitive impairment, memory symptoms may wax and wane. However, symptoms of dementia can be differentiated from occasional normal lapses based on their increasing severity. For example, it is normal to forget an acquaintance's name, but clearly abnormal to forget a spouse's name. "B" is incorrect. Many patients with dementia have impaired executive functioning (e.g., judgment, reasoning, and planning), but the presence of impaired executive functioning is not a requirement. "D" is incorrect, as AD is diagnosed by a specific set of clinical criteria. DSM-V provides diagnostic criteria for dementia and AD, making AD a diagnosis of inclusion rather than exclusion. "E" is incorrect. Dementia is a clinical diagnosis and does not require neuroimaging for confirmation. Experts and professional medical associations differ in their recommendations regarding the use of neuroimaging in dementia. In general, neuroimaging is recommended if dementia occurs in the following scenarios: onset before age 65, sudden onset, presence of focal neurologic signs, and suspicion of normal pressure hydrocephalus (NPH), which includes urinary incontinence, gait disturbance, and cognitive impairment.

You use several office assessment tools to further characterize the memory loss. She scores 23/30 on the Folstein Mini-Mental State Exam, missing orientation and recall items. Clock drawing is grossly abnormal. Her geriatric depression scale is 3 positive responses out of 15 (positive screen is 5/15 or greater). She performs all basic activities of daily living (ADLs) independently, but has voluntarily given up driving and control of her finances.

Question 21.5.2 Regarding assessment tools used in the evaluation of memory loss, which of the following statements is most accurate?

A) The Mini-Mental State Exam (MMSE) evaluates executive function and visual-spatial skills

B) Formal neuropsychological testing offers no benefit over the MMSE for detecting dementia

C) The use of a screening tool for depression is not helpful in the evaluation of memory loss

D) Clock drawing evaluates executive function and visual-spatial skills

E) The MoCA evaluates the ability to discern a chocolate coffee beverage from regular coffee

Answer 21.5.2 The correct answer is "D." Clock drawing can be used to evaluate executive function as well as visual-spatial skills. Clock drawing is a simple test that takes 1 minute or less to perform. The patient is asked to draw a clock face and set the hands to 2:50 or 11:10. This test requires planning and visual-spatial ability on the part of the patient—two areas that are incompletely evaluated by the MMSE. A normal clock does not rule out dementia, but an abnormal clock is suggestive of cognitive impairment. There are several scoring systems, and the sensitivity and specificity for dementia are as high as 87% and 82%, respectively.

"A" and "B" are incorrect. The MMSE is a 30-point scale, with the cutoff for dementia between 24 and 26. The MMSE can be performed in a few minutes and tests memory, orientation, language, construction, and concentration. The MMSE does not test prosody (expressive and receptive inflection of vocalization) or executive function and, as a result, has poor sensitivity for early cognitive impairment in some individuals. Performance on the MMSE is strongly correlated with education; therefore, there may be false-positives in undereducated patients and false-negatives in highly educated individuals. Compared with the MMSE, formal neuropsychological testing assesses a broader array of cognitive functions, and it identifies behavioral abnormalities and assesses mood disorders. It can also help to differentiate between types of dementia. In general, neuropsychological testing is the most sensitive and specific cognitive assessment tool, but it is time-consuming and requires a high level of expertise to administer and interpret.

"C" is incorrect because depression may cause memory problems, especially in the elderly, and depression screening should be included in the workup of memory concerns. Depression often coexists with dementia, and treatment of depression may improve memory problems. It is also important to keep in mind that depression commonly is the first presenting sign for memory problems. "E" is incorrect. See the related Helpful Tip for more on the MoCA.

So far, you have collected the following information on this patient: MMSE score 23/30, impairment in driving and managing finances, disorientation to time, but intact abilities to cook, clean, and care for herself.

Question 21.5.3 Using conventional staging for AD, how would you categorize this patient's dementia?

A) Mild

B) Moderate

C) Severe

D) Terminal

E) Insufficient information to determine the stage

Answer 21.5.3 The correct answer is "A."

• Mild AD symptoms include impaired memory, mild personality changes, and mild disorientation (MMSE 19–24)

• Moderate AD symptoms include aphasia, apraxia, insomnia, and increasing confusion (MMSE 10–19)

• Severe AD symptoms include severe memory loss, motor impairment, and loss of some basic ADLs (e.g., urinary incontinence and feeding difficulties) (MMSE <10)

• Symptoms of terminal AD include immobility, dysphagia, and increasing susceptibility to infections

Question 21.5.4 Which of the following findings would most likely cause you to search for a diagnosis other than AD in a patient presenting with memory impairment?

A) Paranoid behavior

B) Apraxia

C) Poor judgment

D) Aphasia and personality changes

E) Bradykinesia and rigidity

Answer 21.5.4 The correct answer is "E." Bradykinesia and rigidity are features of parkinsonism, which, in the setting of memory loss, should prompt consideration of Lewy body dementia or Parkinson disease. Paranoid behavior, delusions, and hallucinations can all occur with more severe AD. Aphasia, apraxia, and personality changes typically occur later in AD but can be initial complaints in atypical presentations of AD. In order to diagnose dementia, impairment in memory must be present along with at least one of the following:

• Aphasia (language disturbance)

• Apraxia (impaired motor abilities despite intact motor function)

• Agnosia (impaired ability to identify objects despite intact sensation)

• Disturbance in executive function (e.g., planning, judgment, and insight)

The diagnostic criteria for dementia require that these cognitive disturbances result in functional impairments that represent a significant change from a previous level of functioning.

Although you strongly suspect AD in this patient, you consider other types of dementia as well. Suppose this patient presented with urinary incontinence and ataxia in addition to her current findings.

Question 21.5.5 Which of the following diagnoses would be most likely?

A) Creutzfeldt–Jakob disease

B) Lewy body dementia

C) Normal pressure hydrocephalus (NPH)

D) Pick disease

E) Walking corpse syndrome

Answer 21.5.5 The correct answer is "C." NPH classically presents with dementia, gait ataxia, and urinary incontinence. When detected early, it responds to ventriculoperitoneal shunting and is thus a reversible cause of dementia. However, the dementia is rarely fully reversible. Gait abnormalities typically occur first and are the most likely to improve with removal of cerebrospinal fluid (CSF). The diagnosis of NPH is supported by findings on brain MRI, and it is confirmed by symptom improvement after CSF removal. Incidentally, NPH is a misnomer since intermittent CSF pressure elevations have a pathophysiologic role in the disease. "E" is a real thing, but not the right answer. Walking corpse syndrome is a rare psychiatric illness in which the patient is under the delusion that he is dead. Keep reading to learn why the other foils are wrong.

You've got this patient stuck in your head (perhaps with superglue?). On morning rounds in the hospital, your colleague asks your opinion on a patient with frontotemporal dementia (FTD).

Question 21.5.6 You think it is unlikely that your patient has FTD because she does not have:

A) Depression

B) Disinhibition

C) Hemiplegia

D) Rapidly progressing dementia

E) Tremors and hallucinations

Answer 21.5.6 The correct answer is "B." FTDs (including Pick disease) constitute a heterogeneous group of neurodegenerative disorders that have the common pathologic finding of cortical degeneration in frontal areas of the brain. Typical features of these dementias include an insidious onset and a slowly progressive course. Patients have impairments in judgment and insight. They are disinhibited and socially inappropriate. Patients may present with anxiety, depression, delusions, or emotional indifference. "A" is incorrect. Depression frequently coexists with many types of dementia but does not define one particular type. "C" is incorrect; the presence of hemiplegia in a patient with dementia should bring to mind vascular causes. "D" is incorrect because rapidly progressing dementia is the hallmark of prion disease, such as Creutzfeldt–Jakob disease. "E" is incorrect as tremors, hallucinations, and memory loss are consistent with Lewy body dementia (named for its characteristic pathological finding—the presence of Lewy bodies in the brain stem and cortex). Clinical features consist of cognitive impairment, detailed visual hallucinations, fluctuation in alertness, and motor symptoms of parkinsonism.

The elevator is stuck on your way back from making your rounds, giving you more time to consider dementia.

Question 21.5.7 Which of the following is NOT consistent with the diagnosis of vascular dementia?

A) Diabetes

B) Tobacco use

C) Diffuse slowing or normal electroencephalogram (EEG)

D) Normal brain MRI

E) History of carotid endarterectomy

Answer 21.5.7 The correct answer is "D." A normal MRI essentially rules out vascular dementia. Features suggestive of vascular dementia include a stepwise deterioration in cognitive function, onset of cognitive impairment with stroke, infarcts and white matter changes on neuroimaging, and focal neurologic findings on examination. There are no well-defined criteria for clinically diagnosing vascular dementia, and available rating scales have poor predictive value when compared with autopsy as the diagnostic standard. Known vascular disease (like carotid artery disease) and vascular risk factors, such as diabetes, hypertension, and smoking, support the diagnosis.

Finally back in your office with coffee in hand, you decide to evaluate for reversible causes for this patient's dementia, and you consider ordering laboratory tests.

Question 21.5.8 Which of the following laboratory tests is NOT indicated in the initial evaluation for reversible causes of dementia?

A) Cyanocobalamin (vitamin B12)

B) Liver enzymes

C) CBC

D) CSF analysis

E) Thyroid function tests

Answer 21.5.8 The correct answer is "D." When evaluating a newly diagnosed case of dementia, one must consider infectious, metabolic, toxic, and inflammatory etiologies. Therefore, the minimal required laboratory tests should include CBC, serum glucose and electrolytes, vitamin B12, and renal, liver, and thyroid function tests. Further laboratory tests should be obtained as clinical suspicion indicates. In the appropriate patient, one might obtain urinalysis, urine toxicology screen, HIV antibody assay, and CSF analysis. Because of the extremely low incidence of neurosyphilis in modern times, routine testing for syphilis is no longer required but should be considered in the appropriate setting. Neuroimaging is not a required part of every workup but may be helpful in some patients. See Table 21-3.

Blood chemistries, blood counts, thyroid hormone levels, vitamin B12 level, and liver enzymes are in the normal range. A noncontrast CT scan of the brain shows nonspecific "age-related" changes (that was helpful!). The patient and her family return to discuss the test results. You begin to educate them about AD and dementia in general. The two daughters are concerned that other family members may be at risk for developing AD.

Question 21.5.9 Which of the following is the strongest risk factor for developing AD?

A) Age

B) Apolipoprotein E 4 (APOE 4) allele

C) Family history

D) Head trauma

E) Low educational level

Answer 21.5.9 The correct answer is "A." As with many diseases, age is the greatest risk factor for developing AD. Among persons 65 to 69 years old, the incidence of AD is 1%. In persons 85 years and older, the incidence rises to 8%. All of the other answer options are associated with an increased risk of AD but not to the same degree as age.

Family history is another factor strongly associated with developing AD. By age 90, almost half of persons with first-degree relatives with AD develop the disease. There are genetic risk factors as well. Mutations on chromosomes 1, 14, and 21 are known risk factors for AD. Trisomy 21 is a risk factor for developing AD at an earlier age (often by age 50). APOE 4 allele increases risk and decreases age-of-onset of AD in a dose-related fashion, with the greatest risk present in persons homozygous for APOE 4.

Other potential risk factors include a history of head trauma, lower educational achievement, female gender, and depression. Postmenopausal estrogens may actually increase the risk of dementia. Hypertension, diabetes, and hyperlipidemia are associated with dementia, and controlling these diseases might reduce the risk of developing dementia in the future, but the evidence is not strong. Increased physical, mental, and social activities may reduce cognitive decline in later years.

Question 21.5.10 The patient and family ask about medications to treat AD. Which of the following statements is TRUE?

A) All studies show that vitamin E supplementation improves cognition and prevents further neuron loss in AD.

B) Ginkgo biloba and cholinesterase inhibitors have a synergistic effect, improving cognition in AD.

C) Cholinesterase inhibitors do not prevent neuron loss in AD.

D) Cholinesterase inhibitors maintain cognition at baseline levels for 2 years after initiation of therapy; after that time, patients decline slowly.

E) Memantine is considered first-line therapy for mild cognitive impairment and early dementia.

Answer 21.5.10 The correct answer is "C." Cholinesterase inhibitors do not prevent neuron loss. Results with vitamin E have been inconsistent, and some studies have found a slightly higher risk of death in those on high-dose vitamin E (400 IU/day), primarily in those with coronary artery disease. Given the low cost and potential benefits of vitamin E, it may still be reasonable to use in combination with a cholinesterase inhibitor in AD at a dose of <400 IU/day if the patient or family is so inclined. There is no evidence to support the use of ginkgo biloba in AD. As of 2015, there are just two classes of drugs FDA approved for AD. Cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine, and tacrine) represent the larger class of available pharmacotherapy used to treat mild-to-moderate AD. Studies suggest that cognitive decline may stabilize for 3 to 6 months after which there is steady loss of cognition. By 9 to 12 months, there is no difference in decline between those on therapy and those on placebo. The other class has only one medication, memantine, which is an N-methyl D-aspartate (NMDA) antagonist used to treat moderate-to-severe AD. NMDA antagonists and cholinesterase inhibitors are often prescribed in combination; however, there seems to be no benefit to combining these drugs. Memantine appears to do nothing for mild dementia and has shown very minimal (some might say clinically insignificant) difference in moderate-to-severe dementia.

Using your favorite clinical decision aid, the Ouija board, you decide to start the patient on a cholinesterase inhibitor.

Question 21.5.11 In your discussion about the medication, you tell the patient and her family:

A) "These drugs are indicated for treating all types of dementia"

B) "These drugs offer no benefit in moderate Alzheimer dementia"

C) "These drugs are proven to reverse memory loss"

D) "These drugs are proven to reduce mortality"

E) "Gastrointestinal intolerance is one of the most common side effects of these drugs"

Answer 21.5.11 The correct answer is "E." There is no shortage of controversy when it comes to medications for dementia. However, the side effects are indisputable. Gastrointestinal intolerance—with nausea, anorexia, and diarrhea—is the most common. Also, cholinesterase inhibitors have a "vagotonic" action, which can cause bradycardia and syncope and worsen cardiac conduction abnormalities. To minimize adverse events, the dose of cholinesterase inhibitor should be increased only after the patient has been on a stable dose for 4 to 6 weeks.

There are statistical differences in the outcomes measured for AD patients on cholinesterase inhibitors, but are these changes clinically significant? There is no difference in performance of ADLs, time to nursing home placement, etc. "A" is incorrect. Mostly, these drugs are used in AD. Their use in Lewy body and vascular dementia is off-label but may be worth a try; there is some data to support cholinesterase inhibitors for these patients. However, there is no evidence to support their use in FTDs (e.g., Pick disease). "B" is not true. Most studies of cognitive effects of cholinesterase inhibitors have occurred in mild-to-moderate AD (MMSE 10–24). "C" and "D" are incorrect. Compared with placebo, cholinesterase inhibitors delay further cognitive and functional decline but neither reverse dementia nor affect mortality. In cholinesterase inhibitor studies of mild-to-moderate dementia, there is typically a 3-point difference on the MMSE between treatment and placebo groups at 6 months. This finding is due to a loss of thinking abilities in the placebo group and a delay in that loss in the treatment group.

One year later, the patient returns with her daughter, with whom she now lives. The daughter reports disturbing symptoms that occur nightly. The patient wakes up in the middle of the night and wanders the house, becoming confused and agitated. With a subtle nod toward her mother, the daughter states, "I just can't take much more of this."

Question 21.5.12 After inquiring about pain and any changes in health status and finding none, your initial recommendation is to:

A) Employ soft restraints only during the night

B) Consider environmental changes including more daytime structured activities through an adult day care center

C) Initiate an antipsychotic before bedtime

D) Initiate a sedative–hypnotic before bedtime

Answer 21.5.12 The correct answer is "B." Treating behavioral issues in patients with AD can be very challenging. Further history must explore the possibility of pain-related agitation, decline in comorbid conditions or new health conditions, such as occult infection, and any medication changes that may be playing a role. If a treatable cause is not identified, then environmental change is the best initial recommendation. Adding structured daytime activities may facilitate a better sleep–wake cycle. Adult day care programs exist that specialize in day care for elderly people including patients with dementia. Adult day care can provide structured activities during the day, along with respite for the daughter who is obviously asking for extra support. Although medications are sometimes needed, "C" and "D" are incorrect for initial treatment in this case. Once environmental changes have failed or there are other immediate health risks involved, then medications may be necessary. Antipsychotics currently offer the only drug treatment for behavioral symptoms in dementia; however, there are no great choices. Haloperidol, risperidone, and olanzapine are used most often. See Table 21-4 for selected medications used to treat behavioral symptoms in dementia. Sedatives, such as benzodiazepines, often result in paradoxical agitation in elderly patients with dementia. "A" is incorrect. Restraints should be avoided in most cases, even soft restraints. Although they are sometimes required to prevent harm to the patient or caretakers, restraints are known to result in worsened agitation and an increased risk of fall, injury, and rhabdomyolysis.

Despite the addition of adult day programming, medication became necessary. Haloperidol, or "vitamin H," nightly has resolved the agitation. Although you may have increased your patient's risk of dying (as seems to occur when antipsychotics are used in dementia), her daughter is thrilled with the result. Three months later she returns with concerns about depression. The patient spontaneously cries several times per day, her appetite is poor, and she has no desire to leave the house or even get dressed most days.

Question 21.5.13 Since a pill worked last time, her daughter wants to know what antidepressant is most effective for depression in patients with dementia?

A) Citalopram

B) Mirtazapine

C) Sertraline

D) None of the above

Answer 21.5.13 The correct answer is "D." There are very few quality studies available to guide treatment of depression in patients with dementia. The available evidence shows no difference between antidepressant therapy and placebo. The diagnosis of depression in a patient with dementia is complicated, since dementia causes apathy, sleep disturbance, appetite loss, and social withdrawal. If depression is suspected in a patient with dementia, a prudent approach would be to employ nonpharmacologic therapy and then provide an empiric trial of an antidepressant.

Over time, as the patient's dementia progresses, you reevaluate end-of-life issues and advance directives. With the support of her family, the patient decides not to have cardiopulmonary resuscitation.

Question 21.5.14 In end-stage AD, which of the following is correct?

A) Malnutrition is the most common cause of death in patients with severe dementia

B) Hospitalization for pneumonia in patients with severe dementia improves morbidity and mortality

C) In severe dementia, gastrostomy tube feeding prevents aspiration

D) To increase comfort, dehydrated patients with severe dementia should receive IV hydration

E) In advanced AD, treatment of infections with oral and IV antibiotics is equally efficacious

Answer 21.5.14 The correct answer is "E." Hospitalization for demented patients with pneumonia is a wash. The number of patients saved by the use of IV antibiotics is offset by an increase in death and functional deterioration as a result of the hospitalization. Thus, on balance, oral and IV antibiotics are equally efficacious in the treatment of infections in these patients; therefore, severely homebound patients with dementia or nursing home residents should be treated in their usual environment rather than hospitalized if the family agrees. "A" is incorrect. The majority of patients with dementia die of infection, not malnutrition. "B" is incorrect as noted above. "C" is incorrect. Even in moderate-to-severe AD, feeding tubes can be useful in the acute setting. But the tube should be removed and natural feeding resumed as soon as the acute event passes. Permanent gastrostomy tube feeding is not recommended in patients with severe or terminal dementia. Tube feeding does not prolong life, prevent aspiration, or promote weight gain in advanced dementia. Although many patients with advanced dementia are malnourished and dehydrated, these conditions do not appear to cause discomfort. Hand feeding is as effective as any other means for providing nutrition and can lead to rewarding interactions for both the patient and the caregiver.

Objectives: Did you learn to…

• Identify symptoms, signs, and diagnostic criteria for dementia?

• Describe different types of dementia and how they are diagnosed?

• Evaluate the patient with dementia, considering the potential causes of dementia?

• Describe potential benefits and limitations of current pharmacologic therapy for AD?

• Describe the natural course of AD?

• Manage a patient with end-stage AD?

A 71-year-old male whom you have known since starting your practice recently suffered a stroke, resulting in language deficits and right hemiparesis. His medical history is significant for hypertension, hyperlipidemia, ulcer requiring partial gastrectomy (remote), and coronary artery disease. He quit tobacco and alcohol 5 years ago. He is retired and widowed. After a 3-day hospitalization, he appears stable enough for discharge. His medications include aspirin, metoprolol, lisinopril, and atorvastatin. Prior to entering a nursing home to receive skilled nursing care and therapies, the patient wants to know who will pay for the services. He has Medicare parts A and B.

Question 21.6.1 You are able to assure him:

A) Medicare will cover all expenses indefinitely regardless of personal financial resources

B) Medicaid will cover all of the expenses for the first 100 days of skilled care regardless of personal financial resources

C) Medicare will cover part of the expenses for the first 100 days of skilled care regardless of personal financial resources

D) Medicare requires a hospital stay of 7 days or longer prior to entering a nursing home for skilled care

E) Medicaid and Medicare do not cover nursing home expenses under any circumstances

Answer 21.6.1 The correct answer is "C." Medicare Part A, which provides some healthcare for patients 65 years and older if they qualify for Social Security benefits, will pay all costs for skilled care for the first 20 days and part of the costs thereafter up to a total of 100 days per calendar year. This Medicare benefit includes rehabilitation (e.g., physical therapy, occupational therapy, and speech therapy) and skilled nursing care (e.g., nursing home, skilled care facility, and rehabilitation hospital) after a hospital stay of at least 3 days. This benefit is contingent upon the patient having an appropriate diagnosis and rehabilitation potential, and continuing to show improvement during the time the benefit is in place. Medicare does not provide extended nursing home coverage. Medicaid will provide extended nursing home care if a person's assets and income are below a certain threshold, which varies from state to state. Note: Although Medicare Part B will pay for physician visits to nursing home patients, Medicare does not pay for nursing or other care directly related to permanently living in a nursing home.

Although he received fairly intensive physical, occupational, and speech therapies, your patient does not regain much function. He has only minimal movement in the right arm and complains of pain in the right shoulder. A radiograph of the right shoulder shows degenerative changes. The nursing staff administers acetaminophen 650 mg PO when the pain is severe, yet he continues to complain of shoulder pain. You involve physical therapists in his care to reduce the risk of chronic dislocation of the shoulder.

Question 21.6.2 In order to control his pain, which of the following is the most appropriate to add as a scheduled, and presumably chronic, medication?

A) Acetaminophen

B) Oxycodone

C) Gabapentin

D) Aspirin

E) Naproxen

Answer 21.6.2 The correct answer is "A." The point here is that scheduled acetaminophen is better for chronic pain than PRN dosing. Acetaminophen is the safest analgesic of those listed. It may provide sufficient pain relief—if given scheduled (e.g., 1,000 mg PO TID). If it does not, then another medication may be added. "B" is incorrect as a first step as narcotics can cause confusion, sedation, urinary retention, and falls, and they have been associated with an increased mortality risk in the elderly. However, this patient has a history of an ulcer, and a narcotic analgesic may be a reasonable medication to add after acetaminophen. "C" is incorrect. Gabapentin is indicated for postherpetic neuralgia and is more useful for neuropathic pain (although not very useful there either; tricyclics are better). "D" and "E" are incorrect. Aspirin and NSAIDs must be used with caution in the elderly due to increased risks of silent GI bleeding, fatal GI bleeding, and kidney injury. NSAIDs are typically not first-line agents for arthritis pain in this age group and probably offer no greater pain relief than acetaminophen. Also, consider topical therapies for pain, including capsaicin. Nonpharmacologic modalities should be employed as well, including massage, exercises, and physical therapy.

A nurse calls to report that your patient has developed lethargy, decreased appetite, and a temperature of 37.8°C. Your first thought is, "So? That's not a fever."

Question 21.6.3 And then you realize that:

A) An elevated temperature in older persons is most often due to changes in basal body temperature regulation

B) Oral antibiotics will not be sufficient to treat this infection

C) Antibiotics will not be necessary to treat this condition

D) Absence of significant fever in the elderly does not rule out serious bacterial infections

Answer 21.6.3 The correct answer is "D." Older persons, especially frail elders and nursing home patients, often have lower basal body temperatures compared with younger persons and may not mount as great a febrile reaction to infection. A temperature >38.1°C in a frail elder is most likely associated with a serious bacterial or viral infection. Absence of significant fever does not rule out serious bacterial infections. "C" is incorrect. With the available information, it is difficult to say with any certainty if the patient has an infection treatable with antibiotics. If he did, oral antibiotics are often appropriate in the nursing home setting, even when treating pneumonia.

With a decline in his function and a mildly elevated temperature, you plan to evaluate this patient for infection. According to the nursing staff, there are no other residents with apparent infections. Your patient has not developed any focal symptoms (e.g., cough, dysuria, diarrhea, or site-specific pain).

Question 21.6.4 Which of the following tests will be LEAST helpful?

A) CBC

B) Urinalysis with microscopic examination

C) Stool culture

D) Chest radiograph

E) Blood oxygen saturation (pulse oximetry)

Answer 21.6.4 The correct answer is "C." He is not having diarrhea so a stool culture is not likely to be of benefit. This is not a black-or-white area, but there are some principles and expert opinions to follow. Patient and family wishes regarding care must be known prior to initiating an evaluation, therapy, or hospital transfer. While the elderly may have a serious infection with only slight or even no leukocytosis, a normal WBC count on CBC will reduce suspicion for serious bacterial infection. Even without specific urinary symptoms, urinalysis is recommended because of the high incidence of UTI in this population. Remember, however, that asymptomatic bacteriuria can occur in up to 50% of women and 40% of men living in long-term care facilities and treating this confers no benefit. Blood oxygen saturation below the normal range (<90% on room air) may indicate serious respiratory illness; in the setting of hypoxia, a chest radiograph is recommended.

Question 21.6.5 Regarding infectious diseases in nursing home settings, which of the following is correct?

A) If the influenza vaccine is administered within 24 hours of an outbreak, patients require no further prophylaxis

B) All residents who are carriers of methicillin-resistant Staphylococcus aureus (MRSA) must be treated with appropriate antibiotics

C) Most cases of bacteremia are caused by infected skin ulcers

D) New residents should receive a two-step tuberculin skin test, unless positive on the first test

E) All residents who are carriers of Clostridium difficile must be treated with appropriate antibiotics

Answer 21.6.5 The correct answer is "D." The incidence of tuberculosis is relatively high in the older population, as is mortality from the disease. Institutionalized elders should be screened for tuberculosis with the two-step tuberculin skin test. A two-step test involves repeating the tuberculin skin test 1 to 3 weeks after an initial negative test (<10 mm induration). Anergy testing is no longer recommended. The test is positive if the induration is 10 mm or more.

"A" is incorrect. In a nursing home, an influenza outbreak can have devastating results, with a mortality rate up to 30%. In the event of an outbreak, even residents who received the vaccine should receive antiviral prophylaxis (see Chapter 8 for more). Only about 30% to 50% of nursing home residents will develop an adequate antibody response to the influenza vaccine, and that response takes up to 2 weeks after administration to develop. "B" and "E" are incorrect. Residents who are carriers of MRSA or C. difficile will not benefit from eradication if they are not infected. In addition, they may return to a carrier state quickly after antibiotic treatment; therefore, antibiotic treatment of these carrier states is not recommended. "C" is incorrect because UTIs are the most common cause of bacteremia in nursing home residents.

Over the next year, the patient has increasing difficulty with cognition. He begins to experience urinary incontinence several times per day, necessitating the use of a pad. A midstream clean-catch urinalysis shows bacteria and WBCs (2–4 WBC/hpf) but is negative for glucose and nitrites. His post-void residual bladder volume is 80 cc.

Question 21.6.6 Which of the following is true regarding the potential cause of and therapeutic intervention for urinary incontinence in this patient?

A) The most likely cause is obstruction from the benign prostate hyperplasia, and an alpha-blocker will improve the incontinence

B) The most likely cause is immobility, and scheduled voiding is indicated

C) The most likely cause is detrusor hyperactivity, and an indwelling catheter is indicated

D) The most likely cause is stress incontinence, and pelvic floor muscle strengthening (Kegel exercises) is indicated

E) The most likely cause is bacteriuria, and antibiotics will improve the incontinence

Answer 21.6.6 The correct answer is "B." Urinary incontinence is incredibly frequent in nursing home residents, with a rate of up to 50%. As with many other geriatric syndromes, incontinence is often multifactorial or the result of decreased physical and/or cognitive functions. A frequent cause of urinary incontinence in nursing home residents is immobility due to severe physical impairment, dementia, or both. In this setting, the initial treatment of choice is prompted voiding every 2 hours when the patient is awake. Also, fluid and caffeine intake should be monitored and adjusted to reduce urine output without causing dehydration.

"A" is incorrect. Although there is no information about the patient's prostate size, he has a relatively normal post-void residual volume, making overflow incontinence from outlet obstruction less likely. A post-void residual volume greater than 300 mL would be more concerning for urinary retention. "C" is incorrect—or at least the diagnosis of detrusor hyperactivity cannot be made on the basis of current information. The patient has not been fully evaluated with urodynamic tests, so it is difficult to determine whether his incontinence is stress-type or urge-type. If he has urge-type incontinence due to detrusor hyperactivity, an indwelling bladder catheter is not appropriate. Detrusor hyperactivity can often be treated successfully with pharmacotherapy (anticholinergic medications). It is important to be mindful of the anticholinergic side effects, which include falls, confusion, constipation, dry mouth, and urinary retention and could ultimately be more detrimental than the incontinence.

"D" is also not likely. Stress incontinence is less common in men than women, and urine loss is typically associated with increased abdominal pressure (e.g., coughing, sneezing, and lifting). Finally, "E" is incorrect. The presence of bacteria in the urine is a common finding in nursing home patients. In general, bacteriuria without symptoms (the main symptom we look for being fever rather than incontinence) should not be treated. Studies have demonstrated little or no improvement in incontinence after treating asymptomatic bacteriuria in elderly nursing home patients.

Although his urinary incontinence improves, your patient develops difficulty with loose stools and occasional fecal incontinence. The stools are quite watery with no blood or melena. Aside from occasionally abdominal cramping, he feels well. He has no new neurologic symptoms.

Question 21.6.7 Which of the following is the most likely cause of fecal incontinence in this situation?

A) Infectious diarrhea

B) Ulcerative colitis

C) Decreased anal sphincter tone

D) Fecal impaction

Answer 21.6.7 The correct answer is "D." In nursing home residents with limited physical mobility, overflow incontinence due to fecal impaction is most likely. Nursing home patients are often taking medications that contribute to constipation as well. Even with a stool softener and/or a laxative, constipation may still result. A fecal impaction can be treated with an enema, stool softeners, laxatives, and dietary changes, but sometimes requires manual disimpaction (where's a medical student when you need him?). Decreased sphincter tone may occur as a result of neurologic insult, but this patient was previously continent of stool. Although infection might be causing incontinence, there are no other symptoms of infection. The onset of inflammatory bowel disease is usually seen in younger populations, often with blood in the stools, making ulcerative colitis less likely.

As a result of your patient reporting physical abuse of another patient by the nursing staff, an investigation is under way in the nursing home.

Question 21.6.8 Reflecting on elder abuse and neglect, you realize which of the following is true?

A) Up to 75% of nursing aides in nursing homes have seen or heard of a resident being abused or neglected

B) A "dependent elder" is defined as anyone living in a nursing home

C) Approximately 70% of elder abuse and neglect occurs in nursing homes

D) There is a universally accepted definition of elder abuse and neglect, which is codified in federal law

E) Elder abuse is widely defined as "purposeful physical harm of anyone over the age of 65 years"

Answer 21.6.8 The correct answer is "A." In some studies, high rates of mistreatment have been found in nursing homes, with up to 75% of nursing aides witnessing or hearing about acts of abuse. However, it is not known whether nursing home residents are at greater risk than community-dwelling dependent elders. "B" is incorrect. The definition of "dependent elder" is not consistent, and may apply to elders who are cognitively impaired, physically debilitated, or financially dependent. Nursing home residents are frequently dependent; however, living in a nursing home itself is not sufficient to establish that a person is a dependent elder. "C" and "D" are incorrect. The study of elder abuse and neglect (also referred to as elder mistreatment) suffers from lack of a universally accepted definition, variations in laws between states, and inherent difficulties in obtaining accurate reports of abuse. Therefore, attempts to determine the incidence of elder abuse and neglect have resulted in wide variations. "E" is incorrect. Elder abuse may include physical harm, sexual abuse, psychological abuse, neglect, or financial exploitation. Although all states now have laws addressing elder mistreatment, those laws vary between states, and healthcare providers are encouraged to know the laws in their area.

As your patient's cognitive impairment progresses, he becomes more withdrawn and uncooperative with nursing care, such as bathing. A nurse calls to ask, "Shouldn't he be on risperidone or something to improve his behavior?"

Question 21.6.9 According to the Omnibus Budget Reconciliation Act of 1987 (OBRA), antipsychotic medication is indicated for demented patients with:

A) Repetitive, bothersome behavior (e.g., name calling)

B) Continuous crying out and screaming

C) Uncooperative behavior (e.g., refusing to eat and bath)

D) All of the above

Answer 21.6.9 The correct answer is "B." One goal of OBRA was to decrease the inappropriate use of antipsychotic medications in nursing home residents. In patients with dementia, antipsychotic medications may be appropriately administered in the following settings: agitated, belligerent acts that present a danger to the patient or other residents; psychotic symptoms (delusions, hallucinations, paranoia); and continuous crying out and screaming (lasting 24 hours or longer). Attempts to redirect the patient should always be employed first. You should also attempt to uncover occult causes of agitation, such as infection or pain. Once behavior control is attained, assess whether the antipsychotic can be reduced in dose or discontinued. According to OBRA, inappropriate indications for antipsychotic medication include restlessness, uncooperative behavior, poor self-care, or repetitive and bothersome actions.

Objectives: Did you learn to…

• Describe some common Medicare/Medicaid reimbursement issues for nursing home care?

• Manage chronic pain in the nursing home?

• Describe an appropriate evaluation for the nursing home resident with fever?

• Recognize infectious disease issues commonly presenting in the nursing home?

• Develop an appropriate strategy for the evaluation and management of urinary and fecal incontinence in nursing home residents?

• Recognize the impact of elder abuse and neglect? Implement appropriate measures for agitated behavior in the nursing home?

Which of the following is true about drug therapy in the elderly?

A) GI absorption is substantially decreased in the elderly

B) Sedative–hypnotic drugs should be given an 8-week trial without interruption for anxiety in the elderly

C) Mirtazapine (Remeron) causes anorexia and weight loss in the elderly

D) Compared with young adults, the volume of distribution of fat-soluble drugs is increased in the elderly

The correct answer is "D." The volume of distribution of fat-soluble drugs is relatively increased in the elderly due to a loss of muscle mass and proportionately more fat mass. Therefore, fat-soluble drugs, like diazepam, have a greater relative volume of distribution, while water-soluble drugs, like alcohols, will have a relatively smaller volume of distribution. "A" is incorrect because drug absorption does not change substantially with aging. "B" is incorrect. Sedative–hypnotic drugs should be used only for short-term therapy of 2 to 4 weeks because of the risk of falls and other adverse effects; this is true for both community-dwelling elders and those in nursing homes. "C" is incorrect because mirtazapine can actually increase appetite and lead to weight gain in the elderly. For this reason, it can be useful in patients who are depressed and not eating well.

Your next patient is an 83-year-old male familiar to your clinic, who presents for routine care. He has hypertension, hyperlipidemia, and osteoarthritis. He has been widowed for 10 years and continues to live independently in an apartment in the same town as his daughter. He stopped smoking 30 years ago, but continues to drink alcohol. He denies any problems related to his drinking, but you inquire anyway and ask specifically how much he drinks. His routine includes three shots of whiskey per day. He says he likes drinking one shot before his daily walk and the other two shots after he returns. He finds the routine very motivating and keeps him in shape.

Question 21.7.1 In regard to his drinking behavior, you are aware that:

A) Older adults accumulate significantly lower blood alcohol levels than younger adults due to decreased absorption

B) Drinking three shots per day should not be any concern as long as his liver function tests are normal

C) Alcohol consumption can reduce the availability of nutrients such as zinc, vitamins A, B1, B2, B6, B12, and folate

D) The lifetime prevalence of alcoholism for men age ≥65 is less than 5%, but should still be screened for routinely

E) The standard screening CAGE questionnaire for drinking problem behavior has not been validated in older adults

Answer 21.7.1 The correct answer is "C." Alcohol consumption can reduce the availability of nutrients such as vitamins A, B1, B2, B6, B12, zinc, and folate. Alcoholic patients often present with malnutrition, poor self-care, and alcohol-related illnesses such as anemia, peptic ulcer disease, diabetes, hypertension, liver disease, neuropathy, and cognitive impairment. Checking for deficiencies may be warranted in this situation depending on your patient's other dietary intake. "A" is incorrect. Older adults accumulate significantly higher blood alcohol levels than younger adults. A young adult's blood alcohol level will be approximately 0.03% after "one drink" (1.5 oz of distilled liquor, 5 oz of wine, or 12 oz of beer); whereas in a 75-year-old, the level may rise as high as 0.08%, which is the legal limit for intoxication in many states. "B" is incorrect. Drinking behavior should be questioned regardless of liver function tests.

The National Institute on Alcohol Abuse and Alcoholism has identified drinking more than one alcoholic beverage per day as potential problem drinking in older adults. "D" is incorrect. The lifetime prevalence of alcoholism for men aged ≥65 is higher, at approximately 14%; while women aged ≥65 have a prevalence of 1.5%. Denial of the problem is more frequent in older patients, and impairments in functioning related to alcohol use may not be recognized until serious complications arise. "E" is incorrect. Diagnosis of alcohol abuse and dependence in older adults is challenging. Brief screening tools such as the CAGE questionnaire (Table 21-5) have been validated in the older population and could be used in this situation. A positive response to any CAGE questions suggests drinking problem.

In this case, your patient denies any drinking problems and his CAGE screen is negative. Still, you advise him to cut back to one drink per day or less and plan to follow up. As you review the patient's basic ADLs and instrumental activities of daily living (IADLs), he is independent in all basic ADLs and most IADLs. He walks daily, eats three small meals per day, and maintains a steady weight around 180 lb (BMI = 25 kg/m²). He manages his own finances, prepares his own meals, but usually has his daughter do the grocery shopping for his convenience. When you ask about transportation, he reports that he mostly drives to get around town to the golf club, social events, and the post office when needed. He denies any vision or hearing problems.

Just as a review (this is a review book, after all)…

Basic activities of daily living (ADLs) include: bathing, dressing, toileting, maintaining continence, grooming, feeding, and transferring.

Instrumental activities of daily living (IADL) include: shopping for groceries, driving or using public transport, using the telephone, performing housework, doing home repairs (not climbing on the roof … changing light bulbs and such), preparing meals, doing laundry, taking medications, handling finances.

Question 21.7.2 In order to keep him healthy, safe, and functional, you appropriately recommend:

A) Indoor walking only

B) Weight loss

C) Periodic screening for hearing impairment

D) Restricted driving

E) Intensive weight-lifting and aerobic workouts

Answer 21.7.2 The correct answer is "C." The Institute of Medicine, recommends audiometric testing once between ages 40 to 59, 60 to 74, and 75 and over. In this case, asking about hearing difficulty and testing with a whispered-voice out of the field of vision periodically is a reasonable approach for hearing screening. However, the USPSTF updated its recommendations for office screening in 2012 and concluded that current evidence is insufficient for audiometric office-based testing for hearing loss in asymptomatic older adults. "A" and "E" are incorrect. Daily exercise including walking indoors or outdoors in safe environments (weather permitting) should be encouraged in all age groups, but intensive training does not appear to add extra benefit to function or overall health. "B" is incorrect. His current weight is adequate, and he is at risk for malnutrition if he has drinking problem, so he does not need to lose weight. "D" is incorrect. Safety is a concern due to the increasing number of older drivers, their higher crash rate per mile driven, and their increased likelihood of serious injury and death. However, most seniors prefer automobile transportation to keep active in the community and should continue to drive. In this case, without specific concerns, there is no need to recommend restricted driving.

One month later, your patient's daughter calls to inform you that he fell and broke his left hip while vacationing with the family in California. He had total hip arthroplasty (THA) and is still in the hospital recovering. Now they are trying to make arrangements to bring him home. The discharge planner has identified a local nursing home that can provide rehabilitation, but some of the family would like for him to return to his apartment.

Question 21.7.3 In regard to recovery after hip surgery, you inform the daughter that:

A) Rehabilitation after hospital discharge results in better outcomes for patients with hip fracture

B) Rehabilitation can only be provided inpatient at a hospital or nursing home, not at home

C) Surgical repair in elderly patients should be delayed if possible (>72 hours after injury) to reduce 1-year mortality and other complications

D) Early mobilization after hip surgery is recommended in younger patients, but in older patients weight bearing is usually delayed at least 5 days after surgery to allow proper healing

Answer 21.7.3 The correct answer is "A." Studies show that rehabilitation immediately after hospital discharge appears to result in superior outcomes for patients with hip fracture or stroke. "B" is incorrect. Rehabilitation can be provided in either inpatient (i.e., hospital or skilled nursing facility) or outpatient settings (clinic, day hospital or home). For inpatient care, patients must be able to participate in rehabilitation that includes a minimum of 3 hours of therapy 5 days per week. Care usually involves an interdisciplinary team including nurses and various therapists. Home-based services can provide part-time or intermittent therapy as prescribed by a physician. "C" is incorrect. Early surgical repair (<24 hours after fracture) is ideal and has been shown to reduce 1-year mortality and complications such as pressure ulcers and delirium. Delay for medically unstable patients may be necessary. "D" is incorrect. Early mobilization is the standard of care for both hip and knee arthroplasty in younger and older adults. Weight bearing often begins on the second postoperative day.

Your patient and his daughter agree that rehabilitation locally sounds like the best plan.

Question 21.7.4 The goals of rehabilitation include:

A) Restore function

B) Help patients compensate for and adapt to functional losses

C) Prevent secondary complications

D) Maximize potential for participation in social, leisure, or work roles

E) All of the above

Answer 21.7.4 The correct answer is "E." These are all goals of rehabilitation.

The patient returns to the local nursing home for inpatient rehabilitation. Despite wonderful progress with physical therapy, he is unable to ambulate without using a cane. He is frustrated that he cannot walk on his own, and is concerned that all this walking and exercise is going to damage the recently surgically repaired hip joint.

Question 21.7.5 You can tell him that:

A) He does not need to restrict his activity because the hip prosthesis is well designed for bending, walking, and climbing stairs

B) His frustration is likely a major depressive disorder and will require medication treatment

C) He should continue the exercises because the advantages outweigh the low risks of surgical failure

D) He should not expect full recovery even with exercise, because nearly every patient requires an assistive device to walk after total hip replacement

Answer 21.7.5 The correct answer is "C." Whether correction is with screws, partial repair, or complete joint replacement, early weight bearing is usually tolerable with low rates of surgical failure and helps to counteract the poor outcomes clearly associated with prolonged inactivity. As noted in a previous question, early mobilization and continued exercise are the keys to preventing further decline and loss of function. "A" is incorrect. After total hip replacement, patients should avoid certain motions such as bending over to tie shoes and crossing legs when seated. Oftentimes a raised toilet seat is also recommended to reduce the load placed on the hip prosthesis in extreme flexion. Walking and general range of motion exercises should be encouraged as tolerated. "B" is incorrect. Depression is not uncommon after a disabling injury such as hip fracture. However, this patient's frustration may or may not reflect clinical depression and should be further evaluated before starting medication. "D" is incorrect. Although hip fractures carry approximately 5% in-hospital mortality and a mortality of approximately 25% in the year following fracture, about 75% of survivors recover to prior level of function. Up to 50% of these patients require an assistive device, but certainly not everyone.

After 2 more weeks, your patient is now functioning well enough to return home. He can transfer independently and ambulates with a cane for support. Prior to discharge, the rehabilitation team would like to assess his home environment.

Question 21.7.6 The occupational therapy practitioner on the team:

A) Provides a comprehensive assessment wherever the patient is employed based on his/her occupation, which does not typically include the home environment

B) May provide training for specific adaptive equipment for patients to enhance performance in everyday activities and promote independence

C) Is a skilled professional who has completed an occupational therapy training program after completion of high school

D) Is licensed to write prescriptions in most states, primarily for pain control

Answer 21.7.6 The correct answer is "B." Occupational therapists (OTs) provide training for specific adaptive equipment to enhance performance in everyday activities and promote independence. They also provide guidance to family members and caregivers if needed. "A" is incorrect. OTs provide home or job-site assessment, regardless of employment status or occupation. "C" is incorrect. OTs are skilled professionals whose education includes the study of human growth and development with an emphasis on the social, emotional, and physiological effects of illness and injury. One must have earned a bachelor degree or beyond to enter the field of occupational therapy. There are also occupational therapy assistants who generally earn an associate degree and practice under the supervision of a trained OT. "D" is incorrect since OTs do not have license to prescribe medications.

Objectives: Did you learn to…

• Identify and screen for drinking problem in the older patient?

• Promote early rehabilitation after hip fracture repair?

• Describe some aspects of rehabilitative services?