common problems in geriatrics for orthopedic surgeons

1. Common Problems in Geriatrics for Orthopedic Surgeons Steven Zweig, MD Family and Community Medicine MU School of Medicine

3. Case 1 - 80 year old woman with hip fracture Hx- Lives alone, with some help from family. Forgetful of names and dates. Slipped on throw rug, found by nephew. No meds. No know medical illnesses. PE - cold, confused, agitated. Shortened externally rotated left leg. Pain with movement. Normal heart, lungs, neurological exam. Lab and x-ray - normal CBC, BMP. Displaced fracture of femoral neck. RX - hemiarthroplasty performed. Pt recovered from anesthesia, then became confused and agitated.

4. Delirium Disturbance of consciousness, with reduced ability to focus or shift attention Change in cognition (memory, language, disorientation) Develops over short time, may fluctuate Due to substance use or withdrawal, medical condition, or multiple causes

5. Work-up for Delirium Review hx of psych, dementia, alcohol Review of meds (esp. anticholinergic, autonomic, CNS) Use of glasses or hearing aids Evaluate pain management Physical exam for VS, neuro, skin, infections Mental status exam Lab and x-ray for infections (lung, urine), fluid and lytes, hypoxia, BS, new trauma, systemic dx

6. Mental Status Evaluation Confusion Assessment Method Presence of acute onset and fluctuating course and Inattention and either Disorganized thinking or Altered level of consciousness Mini mental state examination

7. Treatment of Delirium Reverse underlying problem Provide adequate pain relief Avoid high-risk meds (e.g. meperidine, anticholinergics, long-acting benzo) Maintenance of fluids and electrolytes Removal of restraints Removal of indwelling catheter

8. Treatment of Delirium (cont.) Orientation to new environment (sitters, increase light at dusk, familiar objects and people, frequent orientation) Small doses of haloperidol (0.5 mg) or lorazepam (0.5 mg) Consider with regard to rehabilitation Discharge planning

9. Case 2 - 76 year old woman with osteoarthritis Hx- Pt referred by FP for evaluation for joint replacement of right knee. Also has pain in other knee, back, and L shoulder. Until 2 mos ago, she was a vigorous community volunteer. Nurse found her to have poor balance, nearly falling. Hx of CHF with pneumonia 5 yrs ago. Meds include: Furosemide 40 mg, KCL 40 meq, digoxin .25 mg, flurazapam 30 mg prn for sleep, meclizine 25 mg tid prn for dizziness, oxybutinin 5 mg bid for stress incontinence, and clonidine 0.1 mg bid added recently for hypertension.

10. Case 2 (cont) PE - Patient is lethargic. Forgets the questions. Admits to continued pain in knees. BP 128/75, pule 68. Diffuse crepitus in both knees, pain with range of motion. Small effusion on right. Decreased abduction and external rotation in both shoulders but functional for daily activities. Lungs clear. Heart RRR without S3 gallop. No edema in lower extremities. The patient is prescribed ibuprofen, and when seen 2 weeks later she is worse. Alert and somnolent on exam. Daughter concerned about dementia.

11. What to do? You suspect delirium due to polypharmacy, call the FP - not a surgical candidate now Digoxin dose too high for most elderly BP low for hypertension, orthorstatic 20 mg- taper the clonidine and change furosemide to HCTZ Long acting benzodiazepine with active metabolite Antihistamine causes sedation and is anticholinergic Oxybutin is anticholinergic, can cause confusion

12. Altered Drug Distribution

13. Altered Drug Metabolism

14. Altered Renal Excretion GFR decreases 50% from age 30 to 80 yrs Often serum creatinine normal due to loss of lean muscle mass Calculate clearance as follows: CrCl = (140- age)(wt in kg)/72 (serum Cr) in women multiply x .85

15. Common Adverse Drug Reactions

16. Principles of Geriatric Prescribing Treat problems specifically - don�t use a drug if possible Start low, go slow, but use enough Review drug list at each visit Use side effects to benefit the patient When in doubt, stop the medication

17. Case 4- 75 year old woman with upper arm pain Hx: Brought to ER by 43 year old daughter who reports history of falls, including one yesterday. Wt loss of 35 pounds over 2 years, progressive disability. Pain worse. Daughter looks distraught and tired, describes mother as difficult. PE: Withdrawn older woman, older appearing. Poor hygiene and disheveled. BP 120/80, pulse 84 sitting; 100/70, pulse 96 standing. Alert, oriented, would not look up or cooperate with mental status testing. Bruises around wrist and ankles. Deformity and tenderness right upper arm and distal forearms. Pressure ulcer right heel.

18. Case 3 - cont. X- ray and lab findings: displaced spiral fracture of the right proximal humerus with callus. Bilateral malunited distal radius fractures. Osteopenic bones. Normal chest x ray. Differential Dx: Elder abuse, delirium, dementia, clotting disorder, severe osteoporosis, depression, alcoholism, gait disorder More info: Daughter answered for patient. Separate interviews revealed patient intimidated by daughter. Bruises due to restraints. Insufficient income for food or meds.

19. Elder Abuse Abuse can be physical, psychological, and financial or material harm 1 million cases reported each year; under-reporting due to denial, lack of knowledge

20. Risk factors Poor health, functional impairment of patient - reduces ability to seek help Cognitive impairment - aggression or disruptive behavior precipitates abuse Substance abuse or mental illness in abuser Dependence of abuse on victim External stressors - shared living, finances

21. Risk Factors Social isolation - reduces likelihood of detection and no supports History of violence in relationship may predict abuse Unexplained trauma, delays in seeking care, or excessive visits to ER or urgent care Disparities in histories from patient and suspected abuser

22. Management Report to Division of Aging Hotline - 800/235-5503 -even if only a suspicion of abuse Admit to provide proper medical care Consult social work for continuing communications/focused interventions Must respect the wishes of a capable patient

23. Tips for Coordinating Care Medicare home care - requires need for skilled nurse or PT Admission to SNF requires 3 day hospital stay - contact the NH physician to plan PPS means capitated reimbursement to SNFs Medicare does not cover costs of drugs Get SW involved if any care problems anticipated