AFP Journal Review May 1, 2014

1. AFP Journal Review May 1, 2014 T. Lianne Beck, MD Assistant Professor Emory Family Medicine Residency Program

2. Articles • Unintentional Weight Loss in Older Adults • Evaluation of Scrotal Masses • Leukemia: An Overview for Primary Care

3. Pretest • https://nf.aafp.org/Assessment/Take/4945/Introduction/c

4. Unintentional Weight Loss in Older Adults • Unintentional weight loss (>5% reduction in body weight within 6-12 mos) occurs in 15% to 20% of older adults. • Associated with: • Functional decline in ADLs. • Increased in-hospital morbidity, • Increased risk of hip fracture in women • Increased overall mortality • Total body weight usually peaks at 60 years of age with small decreases of 0.2 to 0.4 lb per year after 70 years of age • Substantial weight changes should not be attributed to normal anorexia of aging.

5. Etiologies of Unintentional Weight Loss in Older Adults

6. Psychosocial Causes • Social factors associated with unintentional weight loss include: • Poverty • Alcoholism • Isolation • Financial constraints • Other barriers to obtaining food (e.g., impairment in activities of daily living, lack of assistance in grocery shopping or preparing meals).

7. Medication Adverse Effects That May Lead to Weight Loss

8. DDX Helpful tools • Mnemonic - Meals on Wheels • Meds, emotional, alcohol, late-life paranoia, swallowing, oral factors, no money, wandering, hyper/hypo thyroid, parathyroid, hypoadrenalism, enteric/eating probs, low salt/cholesterol diet, stones, social issues. ` • 9 D's of weight loss in the elderly • dementia, dentition, depression, diarrhea, disease [acute and chronic], drugs, dysfunction [functional disability], dysgeusia, dysphagia

9. History and Physical Examination • Focus on amount of weight lost and time frame in which the weight loss occurred. • If no baseline weight is available, evidence of change in clothing size, confirmation of weight loss by a relative or friend, and a numerical estimate of weight loss can be used • Assess appetite • Thorough ROS focusing on cardiovascular, respiratory, and GI

10. Prescription and OTC Medications, including herbals • Social history to identify alcohol/tobacco and living situation • Screen for Depression and Dementia, Nutritional Assessment • Physical Exam focusing on weight w/o shoes, oral cavity, dentition, CV, Pulm, GI, Neuro

11. Screening tools For depression and dementia • The two-question Patient Health Questionnaire http://www.aafp.org/afp/2008/0715/p244.html • Geriatric Depression Scale http://www.aafp.org/afp/2011/1115/p1149.html • The Mini-Cognitive Assessment Instrument http://www.aafp.org/afp/2009/0315/p497.html

12. Mini Nutritional Assessment • Validated tool to help measure nutritional risk • Anthropometric measurements and general, dietary, and subjective assessments. • Scoring allows categorization of older adults as well nourished at risk, or malnourished. • http://www.mna-elderly.com/mna_forms.html

14. Telltale Symptoms, Possible Diagnoses, and Indicated Tests in Older Adults with Unintentional Weight Loss

15. Treatment • Focus on the underlying cause • Multidisciplinary approach (dentists; dietitians; speech, occupational, or physical therapists; and social service workers.) • Common strategies: • Dietary changes • Environmental modifications • Nutritional supplements • Flavor enhancers • Appetite stimulants (Megace, mirtazipine, cyproheptadine, marinol, HGH) have not been shown to reduce mortality and have significant adverse affects.

16. SORT: KEY RECOMMENDATIONS FOR PRACTICE

17. Evaluation of Scrotal Masses • 1% of emergency department visits • Clinically useful distinction between painful and painless scrotal masses. • Although painless masses are not uniformly benign, painful masses are much more likely to require urgent intervention • Prehn sign may suggest epididymitis but does not rule out testicular torsion. • US can reliably differentiate extratesticular masses from intratesticular masses. • With Doppler imaging, the sensitivity and specificity of US for testicular torsion range from 86% to 93%. • CRP > 24 mg per L to be 96% sensitive and 85% specific for epididymitis/orchitis.

20. Less common and benign masses • Spermatoceles • Epididymal cysts • Genital warts • Benign nevus • Epidermal cysts • Seborrheic keratosis • Angiokeratomas

23. Leukemia: An Overview for Primary Care • Common malignancy in children and adults • The age-adjusted incidence rate of leukemia in the United States is 12.8 per 100,000 persons each year. • The prevalence of leukemia is generally higher in whites and in males, and increases with age. • Approximately one in 70 persons develops leukemia in his or her lifetime • Risk Factors: Down syndrome, neurofibromatosis, exposure to ionizing radiation, exposure to benzene, household pesticide exposure in utero and in the first 3 yrs of life, obesity, prior hematologic malignancy

27. Surveillance Guidelines for Leukemia Survivors • ALL (chemotherapy and radiation only) • Annual CBC with differential up to 10 years after last treatment, electrolytes, creatinine, blood urea nitrogen, calcium, magnesium, and phosphorus levels, TFTs, UA • Echocardiography and EKG every 3-5 years if findings on pretreatment evaluation were abnormal, or if signs or symptoms of heart failure are present • Routine eye and dental examinations • CXR, PFTs, audiometry as needed based on symptoms • If treated before 1972, one-time hepatitis B surface antigen and hepatitis C antibody serum testing • If treated before 1993, one-time hepatitis C antibody serum testing

28. ALL (Treated with stem cell transplant): • CBC q 1-2 months x 3 yrs, then every 3-6 mo for up to 5 yrs, then annually • One year post-HSCT: CD4, immunoglobulin levels, BMD, ophtho evaluation • Annual electrolyte, creatinine, blood urea nitrogen, serum ferritin, urine microalbumin, vitamin D, glucose, A1C, testosterone (males) or FSH/LH (females); LFTs, UA, lipids, TFTs • Annual dental examination • If abnormal pre-HSCT pulmonary function test result, repeat as indicated with a change in clinical status • Age- and sex-specific cancer screening • Age-appropriate immunizations • If cranial or craniospinal irradiation use low threshold for neuroimaging for neurologic symptoms

29. AML (chemotherapy and radiation) • CBC q 1-2 months x 3 yrs, then every 3-6 mos for up to 5 yrs • ECHO and EKG every two years • Radionuclide angiography or multiple-gated acquisition scan and Holter monitoring every 5years • AML (stem cell transplant) • Same as for patients with ALL

30. CLL (monitored without treatment) • Routine history for symptoms that would prompt treatment • Routine PE, specifically evaluating for hepatosplenomegaly • Periodic CBCs: If progressive anemia or thrombocytopenia, refer to hematologist • Annual influenza vaccines • Pneumococcal vaccination every five years • Avoid live vaccines • Age- and sex-specific cancer screening • CLL (If treated) • Referral to cardiologist for baseline evaluation • Resting and stress ECHO(frequency depending on baseline findings and other cardiac risk factors)

31. CML (treated with a tyrosine kinase inhibitor) • CBC every 3 months: If neutropenia (ANC < 1,000 per μL [1.0 × 109 per L]) or thrombocytopenia (platelet count < 50 × 103 per μL [50 × 109 per L]), refer to hematologist • Monitor for adverse effects including diarrhea, fluid retention, gastrointestinal upset, headache, muscle cramps, rash • For patients treated with stem cell transplant • Same as for patients with ALL

33. Summary of the SPIKES Steps for Delivering Bad News

37. Examples of Empathic, Exploratory, and Validating Responses

38. Resources for Disease Prognosis, Hospice Eligibility, and Medicare Hospice Benefit Services