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An 86 y/o female with h/o Dm II and CKD is brought to the ED for SOB. She has a h/o advanced multi-infarct dementia, left parietal stroke, and ischemic cardiomyopathy with EF 20%. She resided in a nursing home for 2 years after falls at home led to a hip fracture. Since then, her functional status has declined and she has been confined to a bed. A stage II sacral decubitus ulcer has developed. Her family notes that her appetite has declined over the past 2 months. On exam, RR is 26, BP 180/70, BMI 17. A II/VI holosystolic murmur is heard best at the apex. Jugular venous pressure is 10cm H2O. There are crackles halfway up both lung fields posteriorly and 2+ edema. Labs reveal: *Hgb 9.6 *WBC 5600 *Platelets 343,000 *Na 130 *K 6.3 *Cl 107 *HCO3 16 * Ca 7.4 *Phos 6.7 *UA: ph 5.3. SG 1.011, 3+ protein, trace hgb, broad waxy casts • Which is the most appropriate treatment for this patient? • A. Hemodialysis • B. Peritoneal dialysis • C. Low protein diet • D. Palliative care
An 86 y/o female with h/o Dm II and CKD is brought to the ED for SOB. She has a h/o advanced multi-infarct dementia, left parietal stroke, and ischemic cardiomyopathy with EF 20%. She resided in a nursing home for 2 years after falls at home led to a hip fracture. Since then, her functional status has declined and she has been confined to a bed. A stage II sacral decubitus ulcer has developed. Her family notes that her appetite has declined over the past 2 months. On exam, RR is 26, BP 180/70, BMI 17. A II/VI holosystolic murmur is heard best at the apex. Jugular venous pressure is 10cm H2O. There are crackles halfway up both lung fields posteriorly and 2+ edema. Labs reveal: *Hgb 9.6 *WBC 5600 *Platelets 343,000 *Na 130 *K 6.3 *Cl 107 *HCO3 16 * Ca 7.4 *Phos 6.7 *UA: ph 5.3. SG 1.011, 3+ protein, trace hgb, broad waxy casts • Which is the most appropriate treatment for this patient? • A. Hemodialysis • B. Peritoneal dialysis • C. Low protein diet • D. Palliative care
A study on octogenarians on dialysis demonstrated poor outcomes in patients with poor functional status (defined as a Karnofsky score <40, especially in those with poor nutritional status and BMI <18). The probability of survival at 6 months in these patients was only 50%. Therefore, palliative care is the best choice for this patient. • Median survival on hemodialysis was 28.9 months in carefully selected, functionally independent octogenarians compared to 8.9 months in patients treated conservatively. Improved outcomes were associated with a Karnofsky score >40, early referral, and improved nutritional status as evidenced by BMI >22. • Outcomes on peritoneal dialysis are equivalent to hemodialysis in all populations except for diabetic women >65 y/o (mortality increased) • Poor nutritional status, while not a contraindication to dialysis, has been demonstrated as an independent predictor of poor survival on dialysis. • Health related quality of life is really only improved in those octogenarians with functional independence. • A low protein diet may assist in alleviating uremic symptoms but is relatively contraindicated in the setting of a decubitus ulcer.
Karnofsky Performance Status ScaleClassifies a patient’s functional impairment Aurora health care: Karnofsky score used as part of assessment for hospice In certain cancers and failure to thrive.
An 87 y/o wheelchair-bound woman is evaluated during a routine examination. She is accompanied by her son. The patient lives in a residential living setting in her own apartment and has recently become socially isolated, no longer visiting with friends, eating in the common dinning room, or finding enjoyment from watching television. Her medical history includes coronary artery disease and osteoporosis, for which she takes HCTZ, metoprolol, aspirin, calcium carbonate and alendronate. On exam, she appears well groomed and has a friendly demeanor. Her pulse is 70, BP 127/75, and BMI 18. She is A&O x3 and able to ambulate wit assistance. Neuro exam is notable for resting tremor of right hand but no other focal findings. Lab studies including CBC, chemistry and TSH are normal. Results of Five-Item geriatric depression screen are 1/5. • What is the most appropriate management option for addressing her current symptom? • A. Assess hearing and vision • B. Discontinue HCTZ • C. Initiate sertraline • D. Schedule neuropsychologic testing
An 87 y/o wheelchair-bound woman is evaluated during a routine examination. She is accompanied by her son. The patient lives in a residential living setting in her own apartment and has recently become socially isolated, no longer visiting with friends, eating in the common dinning room, or finding enjoyment from watching television. Her medical history includes coronary artery disease and osteoporosis, for which she takes HCTZ, metoprolol, aspirin, calcium carbonate and alendronate. On exam, she appears well groomed and has a friendly demeanor. Her pulse is 70, BP 127/75, and BMI 18. She is A&O x3 and able to ambulate with assistance. Neuro exam is notable for resting tremor of right hand but no other focal findings. Lab studies including CBC, chemistry and TSH are normal. Results of Five-Item geriatric depression screen are 1/5. • What is the most appropriate management option for addressing her current symptom? • A. Assess hearing and vision • B. Discontinue HCTZ • C. Initiate sertraline • D. Schedule neuropsychologic testing
A common reason for social isolation in the elderly is functional decrease in vision and/or hearing. Hearing and vision assessments are easy to conduct and helpful prior to further evaluation. • Elderly patients who take more than four prescription medications are at increased risk for falls and may need to receive fewer medications. However reducing the patient’s meds at this time is unlikely to address her current symptoms. • Depression is a possible explanation for her increasing social isolation but a score of <2 on the Five-Item Geriatric Depression Screen is considered a negative result and does not necessitate initiation of antidepressant therapy. • Neuropsychiatric testing may be indicated, but a clinical cognitive assessment could first be done in the office with a mini-mental status exam.
Cut off score of 11 is 84% sensitive and 95% specific for depression. One proposal is to consider 0-10 as normal and 11+ as a sign of possible depression. Cognitive impairment reduces the sensitivity and specificity of this test. Sensitivity and specificity were maintained when used in those with MMSE of 15+ (84 and 91%, respectively)
A 70 y/o woman is hospitalized with aspiration pneumonia. She has difficulty walking over the past 3-4 years. She now frequently falls and has been using a walker for 1 year. Her speech is unintelligible and she has poor vision. She was briefly treated with carbidopa-levodopa without improvement. On exam, she looks anguished, has difficulty with down gaze, and is severely dysarthric. She is rigid throughout but more so in the neck and has moderate bradykinesa and impaired gait and postural reflexes. • What is the most likely diagnosis? • A. Parkinson’s disease • B. Progressive supranuclear palsy • C. Normal pressure hydrocephalus • D. Amylotrophic lateral sclerosis
A 70 y/o woman is hospitalized with aspiration pneumonia. She has difficulty walking over the past 3-4 years. She now frequently falls and has been using a walker for 1 year. Her speech is unintelligible and she has poor vision. She was briefly treated with carbidopa-levodopa without improvement. On exam, she looks anguished, has difficulty with down gaze, and is severely dysarthric. She is rigid throughout but more so in the neck and has moderate bradykinesa and impaired gait and postural reflexes. • What is the most likely diagnosis? • A. Parkinson’s disease • B. Progressive supranuclear palsy • C. Normal pressure hydrocephalus • D. Amylotrophic lateral sclerosis
Progressive supranuclear palsy is a rare brain disorder characterized by parkinsonism (bradykinesia and rigidity) with early gait and balance involvement, vertical gaze palsy with downward gaze abnormalities, severe dysarthria, and dyphagia. Bradykinesia and rigidity are typically symmetrical whereas they often start as unilateral phenomenon in Parkinson’s disease. The most obvious sign of the disease is the inability to aim the eyes properly. The key to diagnosis is early gait instability and difficulty moving the eyes. It is often misdiagnosed because it’s symptoms are very much like Parkinson’s disease, Alzheimer’s dementia, and Creutzfeldt-Jakob disease. The most common complications are choking and pneumonia (secondary to dysphagia) and head injury or fractures secondary to falls. • Parkinson’s disease is unlikely given the lack of response to dopaminergic medications, early gait and balance impairment, and lack of asymmetry. • Normal pressure hydrocephalus has the classic triad of gait impairment, cognitive decline, and urinary incontinence (wet, wobbly, wacky) • ALS presents with weakness, muscle atrophy, and fasciculations.
A 75 y/o woman is evaluated for gradual vision loss in the left eye. She notes that colors appear faded, it is difficult to recognize faces, and it is difficult to see in rooms without good lighting. She denies eye pain. Her medical history is significant for a 15 pack-year smoking history, HTN, and DM II. On physical exam, the pulse is 70 and is BP 125/85. The ophthalmoscopic exam shows soft drusen clustered within the central macula and well defined areas of retinal pigment epithelium loss. • Which of the following is the most likely diagnosis? • A. Cataracts • B. Proliferative diabetic retinopathy • C. Dry age-related macular degeneration • D. Wet age-related macular degeneration • E. Open-angle glaucoma
A 75 y/o woman is evaluated for gradual vision loss in the left eye. She notes that colors appear faded, it is difficult to recognize faces, and it is difficult to see in ro0oms without good lighting. She denies eye pain. Her medical history is significant for a 15 pack-year smoking history, HTN, and DM II. On physical exam, the pulse is 70 and is BP 125/85. The ophthalmoscopic exam shows soft drusen clustered within the central macula and well defined areas of retinal pigment epithelium loss. • Which of the following is the most likely diagnosis? • A. Cataracts • B. Proliferative diabetic retinopathy • C. Dry age-related macular degeneration • D. Wet age-related macular degeneration • E. Open-angle glaucoma
The clinical history and findings in this patient suggest dry age-related macular degeneration (AMD). AMD is the leading cause of blindness in the US for those >65 y/o. It is a degenerative disorder of the retinal pigment epithelium and neurosensory retina. Risk factors in this patient include female gender, white race, older age, and smoking history. Dry AMD is non-neovascular. • Patients typically have unilateral symptoms of gradual or sudden central vision loss. It is diagnosed by exam, revealing soft drusen, pigmentary abnormalities, and well defined areas of retinal pigment loss (geographic atrophy). • Patients with cataracts typically have cloudy or blurry vision, a perception of faded colors, difficulty with night vision, and frequent changes in eyeglass prescriptions. Risk factors for cataracts are the same as those for AMD. The cataract exam is notable for lens opacity rather than retinal findings. • Proliferative diabetic retinopathy is characterized by microaneurysms, cotton wool spots, dilated retinal vessels, and new retinal vessels. • Wet (neovascular) AMD is characterized by an exudatived process of choroidal neovascularization. • Open angle glaucoma patients have elevated intraocular pressure and optic disc cupping.
Wet Macular Degeneration (neovascular) Wet AMD only accounts for 15% of cases but is responsible for most of The severe vision loss. New fragile blood vessels grow into the macula And leak fluid or blood. This distorts the macula causing central vision blurring.
Dry Macular Degeneration (non-neovascular) Fabulous Factoid: drusen is a German word for stones or pebbles
Diabetic Retinopathy Cotton wool spots, micro-hemorrhages, and neovascularization
A 72 y/o woman undergoes preoperative evaluation one week before elective total hip-replacement surgery. Her history is significant for stable CAD, occasional angina, HTN, and hyperlipidemia. Medications include metoprolol, aspirin, isorbide dinitrate, amlodipine, and atorvastatin. She lives alone, is fully independent, and does all her own household chores. She had been walking 2 miles in 45 minutes 5-6 days weekly until her hip pain became too severe 3 months ago. On physical exam, the pulse is 66 and BP is 130/65. The remainder of her examination is unremarkable. The EKG is normal. • Besides stopping aspirin 1 week before surgery and continuing metoprolol and atorvastatin until the morning of surgery, which of the following is the best approach to perioperative management of her amlodipine and nitrates? • A. Stop amlodipine and oral nitrates • B. Stop amlodipine; give oral nitrates the morning of surgery • C. Stop amlodipine and oral nitrates; give transdermal nitrate the morning of surgery • D. Give amlodipine and oral nitrates the morning of surgery
A 72 y/o woman undergoes preoperative evaluation one week before elective total hip-replacement surgery. Her history is significant for stable CAD, occasional angina, HTN, and hyperlipidemia. Medications include metoprolol, aspirin, isorbide dinitrate, amlodipine, and atorvastatin. She lives alone, is fully independent, and does all her own household chores. She had been walking 2 miles in 45 minutes 5-6 days weekly until her hip pain became too severe 3 months ago. On physical exam, the pulse is 66 and BP is 130/65. The remainder of her examination is unremarkable. The EKG is normal. • Besides stopping aspirin 1 week before surgery and continuing metoprolol and atorvastatin until the morning of surgery, which of the following is the best approach to perioperative management of her amlodipine and nitrates? • A. Stop amlodipine and oral nitrates • B. Stop amlodipine; give oral nitrates the morning of surgery • C. Stop amlodipine and oral nitrates; give transdermal nitrate the morning of surgery • D. Give amlodipine and oral nitrates the morning of surgery
B-blockers, oral nitrates, and most antihypertensive meds should be continued the morning of surgery and restarted as soon as the patient is eating. Abrupt discontinuation appears to increase the risk for post-op complications • ACE inhibitors and ARBs have been associated with intraoperative hypotension and should be held the morning of surgery. • The inflammatory and plaque-stabilizing effects of statins appear to reduce the risk for post-operative cardiac complications and should be continued the morning of surgery and restarted when patients are eating. • Oral nitrate formulations should be continued the morning of surgery. Post-op IV nitroglycerin or transdermal formulations can be used until the patient is eating.
A 77 y/o man who wears glasses is evaluated for symptoms of increasing visual glare when is out at night, but reports no problems with bright sunlight, reading, or watching television. He no longer drives because he lives in a downtown condominium and prefers to walk and use public transportation. His history is negative for diabetes, corticosteroids, or smoking. His corrected visual acuity is 20/25 in each eye. Direct ophthalmoscopy reveals bilateral red reflexes with central opacities, but the optic disks and retinal vessels are normal. • Which of the following is the most appropriate management for this patient’s visual symptoms? • A. Cataract extraction • B. Vitamin E supplementation • C. B-Carotene supplementation • D. Monitoring of visual status • E. Topical ophthalmic prostaglandin
A 77 y/o man who wears glasses is evaluated for symptoms of increasing visual glare when is out at night, but reports no problems with bright sunlight, reading, or watching television. He no longer drives because he lives in a downtown condominium and prefers to walk and use public transportation. His history is negative for diabetes, corticosteroids, or smoking. His corrected visual acuity is 20/25 in each eye. Direct ophthalmoscopy reveals bilateral red reflexes with central opacities, but the optic disks and retinal vessels are normal. • Which of the following is the most appropriate management for this patient’s visual symptoms? • A. Cataract extraction • B. Vitamin E supplementation • C. B-Carotene supplementation • D. Monitoring of visual status • E. Topical ophthalmic prostaglandin
The presence of a red reflex, central opacity, and visible fundus is consistent with an immature nuclear cataract. Extraction is indicated when the visual deficits impair quality of life, but this patient has only minimal visual problems and well corrected visual acuity. There4fore, monitoring is the most appropriate strategy. • Randomized trials have shown that vitamin E supplements do not prevent the development or progression of senile cataracts. • B-carotene supplementation reduces the risk of cataracts in smokers but is not recommended because several cancer prevention trials found that it increase the risk for lung cancer. • Topical ophthalmic prostaglandins are first-line therapy for primary open-angle glaucoma. However these patients typically present with a red, painful eye.
