ABIM Geriatrics Review

ABIM Geriatrics Review
July 17, 2014 B. Gwen Windham, MD MHS No Conflicts

Case 1. 78 yo college-educated man with PMH HTN is brought to you by his wife for complaints of visual hallucinations (VH) for 3 months. Wife says he is usually “in his right mind” but has periods of confusion and reduced alertness. Recently wandered outside at night & fell when he saw pigs in the yard. He was hospitalized, received risperidone and became hypotensive by records and “sleepy” by her report. Detailed VH persistently involve animals in yard. Wife endorses gradually worsening symptoms of repeating himself for past 6-12 months, withdrawing socially, & less involved in personal finances. He uses a cane, has had several falls recently, begun requiring help to dress. He is dependent with meal prep, finances, driving, shop, meds over past year. Accidents trying to park 1 yr ago ended his driving

Case 1. PE: BP 130/80 HR 80 No OH RR 14 95% O2sat
He is alert, oriented to person, time and city. His MMSE is 23/30. He has a slow, shuffling gait, no tremors, mild symmetric rigidity with extension in the upper extremities. No motor, sensory deficits. A clock drawing test is shown. Lab: CBC, complete metabolic panel, TSH, B12 normal. MRI brain shows mild generalized atrophy, no infarcts, hemorrhage, mass, hydrocephalus.

Case 1. What is this patient’s diagnosis?
Does this patient have dementia? Why or why not? 2 cognitive domains affected (AAAA+E): Amnesia, apraxia, agnosia, aphasia, executive dysfunction Impairs daily or social or occupational function Is a change from baseline Not delirium What is this patient’s diagnosis? Alzheimer’s disease Lewy Body dementia Mild Cognitive impairment Frontotemporal dementia

Lewy Body Dementia Criteria
Progressive cognitive decline, dementia (required) plus Core features (2 required for Probable LBD) Visual hallucinations, recurrent, detailed, early Fluctuations (change in alertness, attention) Parkinsonism early Suggestive Features REM Sleep Disorder (acting out dreams) Severe neuroleptic sensitivity (motor, consciousness, NMS, autonomic dysfxn) Low dopamine transporter uptake in BG Supportive Features Repeated Falls Syncope, transient loss of consciousness Low uptake with reduced occipital activity PET/ SPECT

Case 2 Mrs. D is a 78 YO woman who comes to clinic with her daughter. She is followed for DM and HTN. She has no new complaints. In reviewing her medications you note she is unsure of how she has been taking them. When asking her questions she often turns to her daughter to supply the answers. When the daughter is queried she reports that her mother seems a little forgetful, “like all people her age.”

Upon further questioning, the dtr endorses 1-2 yrs of Mrs
Upon further questioning, the dtr endorses 1-2 yrs of Mrs. D repeating the same question, misplacing items she cannot find later, & having difficulty thinking of words and using the remote control. She left food burning on the stove soon after Mrs. D’s husband died. Her husband always managed their finances, but after he died, her daughter began helping her after Mrs. D failed to pay some bills and other bills she paid twice. Mrs. D denies that she is having any significant problems and says she is doing as well as other people her age.

Mrs. D’s examination reveals excellent physical function with normal alertness, attention, strength, and gait. She has difficulty comprehending simple instructions during the examination. During the hour visit she tells you three times that she takes her dog on a walk daily. She scores 20/30 on the MMSE and has difficulty drawing a clock.

What should you do next? Begin donepezil 5 mg HS
Provide information on caregiver support groups and local services for patients with dementia Check TSH Offer hospice

Recommended for dementia evaluation
Medication review: e.g. narcotics, benzodiazepines, anticholinergics TSH Vitamin B12 Electrolytes and liver panel, Ca, CBC Uncontrasted CT/MRI brain - NPH, strokes, tumors RPR – in patients with specific risk factor

A 77-yr-old woman is brought to the office by her daughter because she has been seeing her dead husband and dead brother for the past 2 mo. She sometimes talks to them and they may respond to her. She has a 4-yr history of declining memory and impairment in shopping, paying bills, cooking. She now requires some assistance choosing appropriate clothing and is reminded of meals. She has a history of major depressive disorder but is neither sad nor apathetic on examination. There is no history of alcohol or substance abuse. Exam is notable for increasing rigidity in her arms that worsens with distraction and a mild shuffling gait. She has no tremor or other neurologic abnormality. Her score is 18/30 on the Mini-Mental State Examination. Laboratory tests are normal. CT shows cortical atrophy. Which of the following is the most likely explanation for her symptoms? Lewy body dementia B. Late-onset schizophrenia C. Major depressive disorder with psychotic features D. Parkinson's disease with dementia E. Alzheimer's disease

A 72yo retired elementary school teacher presents with complaint of “problems with my memory” for 5 years, worse x 3 months after car was stolen. She has been in a “low point” since. She has difficulty remembering where she put things, but finds them later, and difficulty recalling people’s names. 5 years ago she was started on donepezil. She is not aware that her memory is worse or better on donepezil. She lives alone and is independent in ADLs and IADLs; she says she forces herself to do them. She attends church less than in the past. She reports poor sleep, energy, & endorses psychomotor slowing. MMSE = 28/30. Her physical exam, TSH, B12, CBC, complete metabolic panel are normal.

What is the most likely diagnosis? Pseudodementia
What else might you do to confirm your diagnosis? Depression screen, e.g. PHQ, GDS “low point” for 3 weeks, anhedonia-quit exercising & attends church less, sleep difficulty, slower movements, decreased concentration Talk to daughter (collateral history)

70yo man with 3-4 years falls, usually backwards
70yo man with 3-4 years falls, usually backwards. PT noted rigidity, bradykinesia & suspected Parkinson Dz. Was then dx as Parkinson Disease Took Sinemet for a while but seemed to fall more Dropped cups when placing them on countertops, described by family as “missing” the surface PhD in English and Literature. He loved to tell stories & family noticed he stopped doing so, language became more sparse. Then he began coughing while eating, liquids leak from mouth, drools, lost 7 lbs, and is more forgetful. Lost interest in hobbies, appearance; crying spells Stopped doing finances

ROS: per HPI PE: No orthostasis. Few blinks, slow speech, bradykinesia, normal arm swing, no tremor, symmetric leadpipe rigidity, poor balance, falls backward. Impaired downward vertical gaze that is overcome with passive head movement. MMSE 20/30; abnormal clock drawing and cube copy.

LAB: TSH, B12, CBC, complete metabolic panel, are normal
LAB: TSH, B12, CBC, complete metabolic panel, are normal. An MRI show age-appropriate atrophy, no infarcts, hemorrhage, mass, or hydrocephalus.

Most likely diagnosis? Progressive supranuclear palsy Gaze paresis + early falls*; often misdiagnosed as PD Many develop pseudobulbar palsy (dysarthria, dysphagia) Typically poor response to levodopa or more falls Symmetric parkinsonism, axial stiffness (neck stiff flex/ext), falls backwards, usually no rest tremor Cognitive impairment: early slowness of thought, difficulty synthesizing multiple ideas together moreso than forgetful and language d/o

65yo woman is brought to clinic July 2009 by daughters.
January 2009: Lived alone/independent in IADLs, walking for exercise in Jxn Med Mall Feb: began stumbling during walks Feb-April: Falls & balance problems, “lilting to the right”, leaning on others for support, and a “shuffling” gait April: admitted to OSH, diagnosed as Parkinson Disease, started on Sinemet, discharged to rehab April-June: More rapid decline, withdrawn, not interacting/talking, visual hallucinations, confused, voice “low”, mumbles Since June, lives in a nursing home, requiring full assistance with ADLs

Most likely diagnosis? Creutzfeldt-Jakob
Cardinal: Rapidly progressive mental deterioration and myoclonus Other: EPS: hypokinesia, cerebellar (nystagmus, ataxia) Corticospinal: hyperreflexia, Babinski, spasticity ABIM Board ? -> CSF finding of protein

What dementia syndrome best explains the following
Asymmetric rigidity, tremor, bradykinesia, narrow-based steps, stooped posture, and forward falls develop first, respond to levodopa and dopamine agonists, and are followed by cognitive problems and hallucinations >1 year later Parkinson Disease with dementia PD meds may worsen hallucinations Quetiapine often used Cholinesterase inhibitors

Difficulty initiating gait, moving/lifting feet, wide-based gait, followed by cognitive problems then urinary incontinence. Gait dyspraxia on exam Normal Pressure Hydrocephalus (wobbly, wacky, wet; “magnetic gait”) How is it diagnosed? Clinical, MRI/CT, LP with nl pressure and mL removal may improve gait dysfunction/cognitive (Fisher test); cisternography often used, low specificity 5% of older patients with dementia. 2-20/million persons incidence UTDate. Urinary urgency rather than incontinence may present early; incontinence usually later & assoc with lack of concern reflecting probable frontal lobe origin. Gait most common early dysfxn, most responsive to shunt, gait short steps, reduced stride and ht & cadence, broad base, outward feet rotation, several steps for slow turn, impaired postural stability. Negative Fisher does not rule out response to shunt; poor NPV, 30-50%.

What is the usual treatment for NPH?
Large volume LP, shunt (acetazolamine/digoxin may reduce CSF production) Rate of complications with shunt? 30% (stroke, subdural hematomas, infection, shunt failure) Response to shunt with long-term benefit? 25-80%, best if: <2yrs, typical gait & urinary symptoms, no multi-infarcts on MRI brain. Fisher test poor negative predictive value. Nl pressure, nl communication ventricles to aubarchnoid space, impaired reabsorption from SAS to superior sagittal sinus

A 64yo woman, described as “conscientious” and “prim and proper”, experiences increased appetite, weight gain, and is uncharacteristically flirtatious over the past year. She is aware of her actions but does not seem bothered by them. Her husband often reminds her to change her clothes and brush her teeth. Primitive reflexes, rigidity, and spasticity are present on exam. There are no significant cognitive abnormalities on initial screening but they develop later in her course. Frontotemporal dementia Behavioral Progressive nonfluent aphasia Semantic dementia

A 72yo man with PMH HTN, DM, hyperlipidemia begins having syncope and falls. He lives alone, and is independent in ADLs. His daughter notices his memory is worse since having these spells. He repeatedly asks the same question and is having trouble operating the microwave. No cardiac arrhythmias are identified on EKG or a 24-hour Holter. He has 4/5 strength of the right and 5/5 on left. MMSE 23/30, deficits clock and cube copy, recall, MRI shows a new thalamic infarct compared to MRI 2 years ago and diffuse moderate to severe white matter periventricular changes. Vascular cognitive impairment (vascular dementia)

Two Types of Vascular Dementia
Vascular Cognitive Impairment Details Vascular dementia (multi-infarct) Prevalence % of dementias Two Types of Vascular Dementia 1st type – Infarction of large arteries with clinical strokes with stepwise accrual of deficits. 2nd type – Atherosclerotic small vessel disease Subcortical pattern Preservation of naming May have mild Parkinsonism Commonly have concomitant Alzheimer’s disease with disease correlating best with neurofibrillar tangles

68yo college professor is evaluated for memory loss
68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses. He is currently writing a textbook and continues to teach courses without difficulty. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 29/30. TSH, B12, CMP, CBC, and CT head are normal. What should you do next? Reassure him Order an MRI brain Send for neuropsychological testing Obtain neurology consult

68yo college professor is evaluated for memory loss
68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses, and thinks he depends more on lists as reminders than in past. He has cut back on the number of courses he teaches but continues to perform well at work. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head are normal. What is his diagnosis? Early Alzheimer’s disease Pseudodementia Mild cognitive impairment Generalized anxiety disorder

Early Alzheimer’s disease Pseudodementia Mild cognitive impairment
68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses, and thinks he depends more on lists as reminders than in past. He has cut back on the number of courses he teaches but continues to perform well at work. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head are normal. What is his diagnosis? Early Alzheimer’s disease Pseudodementia Mild cognitive impairment Generalized anxiety disorder -MMSE range -No effect on function (social, work, ADL/IADLs) -No drug treatment -10-15% progress to dementia annually -Cognitive behavioral therapy may help

Behavioral problems in dementia 1st line treatment for behavioral problems: Environmental: 1. LOOK FOR TRIGGERS – pt may be uncomfortable due to cold bathroom, lack of modesty, aggressive caregiver 2. Other - redirection, distraction, remain calm, use soft calming voice, reassurance, avoid arguing, use simple single 1-step commands Pharmacologic treatment for behavioral decline (all off label): -Psychosis (more common in Lewy Body dementia)- Atypical antipsychotics have fewer extra pyramidal side effects than haloperidol. Quetiapine (seroquel), has least and if need one for Lewy Body or PD patients, choose this one. Black box for 1.6 increased risk of mortality. Avoid with increased QT intervals. -Depression (also for non-demented) Avoid trycyclics SSRIs preferred but may cause REM-sleep disorder (body-limb movements in REM sleep) in patients with Lewy-Body disorder -Anxiety (also for non-demented) Buspirone, SSRI or low dose atypical antipsychotics

70yo Hispanic (or AA) woman has had increasing difficulty reading newspaper print for past 4-6 weeks. She has trouble following text & finding the next line. She rarely leaves her home. She has HTN, PVD, CVA 7yr ago, open-angle glaucoma 20 yr ago. She has had no follow-up care. What is the most likely cause of reading difficulty? New stroke Macular degeneration Retinal hemorrhage Open-angle glaucoma Retinal detachment

70yo Hispanic (or AA) woman has had increasing difficulty reading newspaper print for past 4-6 weeks. She has trouble following text & finding the next line. She rarely leaves her home. She has HTN, PVD, CVA 7yr ago, open-angle glaucoma 20 yr ago. She has had no follow-up care. What is the most likely cause of reading difficulty? New stroke Macular degeneration Retinal hemorrhage Open-angle glaucoma Retinal detachment -OAG: leading cause blindness in Hispanics, AA -early peripheral visual field (VF) loss, encroaches centrally in advanced disease -Remains at home – familiar to her, may not notice earlier peripheral VF loss -RH – acute, new large floater -CVA- wrong VF loss pattern -RD – sudden vision loss; can be missed if pt doesn’t notice due to compensation by good eye

An 83-yr-old woman is brought to the office by her daughter because the mother has become confused and forgetful for the past 6 months. Other than urinary incontinence, she has no medical problems. Her only medication is extended-release oxybutynin 10 mg for urge urinary incontinence which was started about 6 mo ago with improved symptoms of incontinence. The mother, when asked, has no new complaints about memory or cognition. MMSE is 23 of 30. The patient is inattentive, repeats herself during the interview, but exam is otherwise normal. Which of the following is the most appropriate next step? A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QID B. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeks C. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeks D. Discontinue oxybutynin 10mg ER; begin behavioral therapy for urinary incontinence

While most patients on anticholinergic bladder medications have no discernable cognitive effects, some will. Because the symptoms in this patient may be due to the medication – symptoms began after initiating this new medication – the drug should be discontinued. Cognitive adverse effects are related to peak med concentrations. IR agents with the same total dose as the ER drug could worsen this effect. Behavioral therapy is an effective therapy for urge incontinence. If the patient is not cognitively intact to fully participate in behavioral therapy, scheduled toileting may be of benefit. Behavioral therapy may include bladder training, prompted voiding, pelvic floor muscle exercises, biofeedback training. Which of the following is the most appropriate next step? A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QID B. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeks C. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeks D. Discontinue oxybutynin 10mg ER; begin behavioral therapy for urinary incontinence

An 86yo woman comes to the office for routine evaluation
An 86yo woman comes to the office for routine evaluation. She was the primary caregiver for her husband until his death 9 mo ago. She is somewhat fatigued and has a poor appetite but does not think that she is depressed. She has had some dizziness but no falls, and she has had occasional diarrhea with incontinence but no melena or hemato-chezia. PMH: atrial fibrillation, heart failure (EF 40%), and HTN. Medications include atenolol, digoxin, lisinopril, and warfarin. On examination, blood pressure is 118/66 mmHg. Ventricular heart rate is 56 beats per minute. She has lost 6.4 kg (14 lb; 9% of her body weight) over the last 6 mo. The remainder of the physical examination is not substantially changed from her last visit. Which of the following is most likely to identify the cause of weight loss A. Chest xray B. Fecal occult blood testing C. Serum digoxin level D. Home visit E. Depression Screening

Weight loss assessment in older adults should include medication review. Anorexia, diarrhea, and dizziness are common effects of digoxin toxicity. Bradycardia, ventricular arrhythmias, apathy, nausea, confusion, visual disturbances, depression are also seen and can lead to significant weight loss. There is some controversy regarding measuring digoxin levels: patients may have toxicity even with “normal” concentrations; nonetheless, higher concentrations correlate with greater adverse events. If subacute digoxin toxicity is suspected, a trial of tapering the dosage may be reasonable instead of measuring the serum concentration. Usual max daily dose is 0.125mg in older pts. FOBT is reasonable, but adverse effects of digoxin are more common and should be checked immediately. Depression screen may be positive, but depression should not be considered endogenous until digoxin toxicity is excluded; depression will likely be refractory until toxicity resolves. A home visit may determine if the patient is caring for herself and has quality nutrition available; however, poor living conditions could be due to depression and apathy caused by digoxin toxicity. Lung cancer can cause weight loss, but there is little else in this case to suggest lung pathology Which of the following is most likely to identify the cause of weight loss? A. Chest xray B. Fecal occult blood testing C. Serum digoxin level D. Home visit E. Depression Screening

An 88-yr-old woman with peripheral arterial disease is admitted to the hospital because she has gangrene in 2 toes and soft-tissue infection of her distal foot. She is a widow and lives alone; her daughter visits at least weekly. On admission, her blood pressure is 140/80 mmHg, respiratory rate is 16 breaths per minute, pulse is 90, and temperature is 38°C (100.4°F). She is acutely confused and inattentive. Her speech is rambling. Which of the following factors is most likely to increase her risk of in-hospital functional decline and nursing home placement? A. Marital status B. Race C. Gender D. Delirium

Factors that predict in-hospital functional decline (measured by ability to perform ADLs) and nursing-home placement include older age, IADL dependence , delirium and cognitive impairment, such as dementia. After a complete history that may necessitate calling caregivers or nursing homes for nursing home residents, the evaluation of acute mental status changes should include vitals including oxygen saturation, blood counts, electrolytes, evaluation for infection (pneumonia, UTI, sepsis) and review of medications and recent changes in medications. ROS and exam should assess presence of urinary or fecal impaction. Cardiac assessment (EKG or troponin) may be warranted. Which of the following factors is most likely to increase her risk of in-hospital functional decline and nursing home placement? A. Marital status B. Race C. Gender D. Delirium

A 90-yr-old man is brought to the emergency department by his family because he has had an abrupt change in behavior. The patient moved into his daughter and son-in-law's house a few months ago, because he was no longer able to manage living alone. A few days ago, he became aggressive and angry, and hit his son-in-law for no apparent reason. He has also become incontinent in the last few days. He has multiple bruises, which the family suspects are from falling. History includes moderate dementia and benign prostatic hyperplasia. On examination, he is inattentive, blood pressure is 160/90 mmHg; all other vital signs are normal. He is demanding to be released from "prison'' and is aggressive with the staff. The physical examination is unremarkable. Although he is uncooperative with the neurologic examination, he appears to be moving all extremities well. Which of the following is the most appropriate next step? A. Bladder scan B. Lumbar puncture C. Electroencephalography D. CT of the brain E. BMP, CBC, urinalysis/culture, pulse oximetry

This patient demonstrates an acute change in cognition and behavior from his baseline deficits. Increased confusion, new falls, and new incontinence all suggest a new underlying illness or medication adverse event. An acute change in mental status may be the only sign of a serious acute illness. Even when the examination is unremarkable, metabolic abnormalities should be pursued, including chemistries, renal function, glucose, and oxygen saturation. Urinalysis and review of prescribed and OTC medications are indicated. The most common causes of acute confusion are medical illness, metabolic disturbance, and medications. Stroke, hemorrhage, meningitis, and encephalitis are much less common, and should be considered after more likely causes are excluded. Thus, LP is not part of the routine evaluation for delirium. Many OTC medications with strong anticholinergic properties (eg, diphenhydramine) are easily accessible and often misperceived by patients as safe, yet can cause delirium. In an older man with BPH, urinary retention can manifest as a change in mental status. However, medical illness, metabolic abnormalities, and medications are more common causes of delirium. EEG can demonstrate a pattern consistent with delirium but will not provide a diagnostic rationale for its cause, unless seizures are strongly suspected. Brain imaging is not recommended in absence of an abnormal neurological exam, but may be indicated if the patient's laboratory and other tests are unremarkable.

An 87yo woman comes to the office for a routine evaluation
An 87yo woman comes to the office for a routine evaluation. She reports that she has fallen once or twice a month for past 4 months. The falls occur at various times of the day and immediately after standing or standing for some time. She does not experience dizziness, lightheadedness, vertigo, palpi-tations, chest pain or tightness, focal weakness, loss of consciousness, or injury. She lives alone. PMH includes HTN and DJD of both knees. Medications are acetaminophen and hydrochlorothiazide. PE: T 98.6, BP 135/85 mm Hg without postural change, HR 72/min, RR 16. Visual acuity with glasses is 20/40 OD & 20/60 OS. Cardiopulmonary exam is normal. Knees have bony enlargement w/o warmth or effusion. On balance & gait screening with the “get up and go” test, the patient must use her arms to rise from the chair. Neuro exam is normal. MMSE is 26/30 (nl ≥24/30). Results of a complete blood count and blood chemistry studies are normal. Which of the following should be included as part of her management at this time? A. Begin risedronate B. Measure serum 25-hydroxyvitamin D level C. Prescribe hip protectors D. 24-hour electrocardiographic monitoring

Low Vitamin D associated with muscle weakness, functional impairment, falls, fractures. In RCT, replacement (goal >30ng/ml) may reduce risk of falling 20%. If the vitamin D level is low, this patient should take ergocalciferol or cholecalciferol, 50,000 units weekly for 6 to 8 weeks, followed by 800 to 1000 units of vitamin D daily along with calcium supplementation (at least 1200 mg of elemental calcium [diet plus supplementation]). Although vitamin D deficiency is common in the elderly, routine vitamin D level screening is not recommended. In the absence of clinical manifestations of osteoporosis (such as vertebral, hip, or wrist fracture) or a low bone mineral density measurement, use of medications such as risedronate to treat osteoporosis is not warranted. A Cochrane systematic review concluded that hip protectors are ineffective in preventing hip fractures in elderly persons who fall, partly as a result of limited patient acceptance and adherence because of discomfort. There is no proven value of performing routine 24-hour electrocardiographic monitoring in elderly persons who fall. A. Begin risedronate B. Measure serum 25-hydroxyvitamin D level C. Prescribe hip protectors D. 24-hour electrocardiographic monitoring

77yo man comes to the office for a 12-mos history of pain over the posterior right calf after prolonged standing or walking. At first, the pain occurred only after walking blocks, but it now occurs after <1 block. He has pain when he stands more than 10 minutes. The pain is relieved immediately with sitting. On exam, pulses are full in both legs. The skin is normal, with full skin hair throughout both legs. Bilateral straight leg raise tests are normal. There is good mobility of both hips without pain. There is mild weakness of the right great toe extensor, right hip abductor, & right hip extensor. Radiography of the lumbar spine shows diffuse degenerative changes of the lumbar disks & facet joints. There is evidence of mild to moderate osteoarthritis of the right hip. What is the most likely cause of this patient’s pain? A. Bone or joint disease of the hip B. Vascular insufficiency C. Lumbar spinal stenosis D. Ruptured popliteal cyst E. Metastatic cancer to the bone

This patient’s pain occurs after prolonged standing and walking, and is relieved immediately with sitting. Such a presentation is typical of lumbar spinal stenosis, and the weakness of the muscles of the right leg innervated by L-4, L-5 and L-5, S-1 is consistent with this diagnosis. The most appropriate next step in the evaluation of this patient would be to perform a diagnostic imaging test to look for signs of lumbar spinal stenosis. Hip disease can cause pain in the groin, buttock, thigh, and knee, but rarely in the lower leg. The distribution of pain and the normal hip examination make hip disease an unlikely cause of this patient’s pain, despite the abnormal hip radiograph. Calf pain while walking is a symptom of arterial insufficiency, but this patient has normal pulses and no skin findings, and pain on standing is rare in patients with arterial insufficiency. Although a ruptured popliteal cyst can cause acute calf pain, the prolonged duration of this patient’s pain, with progressive worsening over 12 months, suggests a different cause. This patient does not have a typical history of metastatic cancer. The association with position is unusual for a cancer, and the history of pain after walking that is relieved with sitting is not consistent with a tumor.

Lumbar spinal stenosis – pain on standing or going down stairs
Lumbar spinal stenosis – pain on standing or going down stairs. Relieved with sitting or bending forward (grocery cart). Distal pulses normal & warm (not PAD). Hair loss can be due to aging. Likely have weakness on exam. SLR normal. Treat with physical therapy unless it is impairing walking ability (i.e. independent ambulatory older pt begins having back pain, weakness, using walker over short period of time. Exam and hx c/w LSS, refer to Neuro. Delayed surgery leads to permanent functional impairment. Vetebral compression fractures – acute back pain often without neuro symptoms. Typically older woman opening window, getting turkey out of oven. Pain control. Conservative treatment = vertebroplasty in RCT Herniated lumbar disc – dermatomal defects. (+) SLR test. “Sciatica”– pain in the buttock radiates down the back of the leg. May occur from vertebral fracture, disc protrusion, or osteophytes.

74yo man with 3mos generalized itching, worse in colder weather, recurs every winter. Hx HTN, only medication is lisinopril for past several years. Moisturizing cream provides little relief. No other new detergents, creams, skin products. On exam, skin has dry scaling diffusely on trunk and extremities resembling “cracked porcelain” with red fissures forming irregular reticular pattern. Which is the most likely cause: A. Drug eruption B. Xerosis C. Scabies D. Psoriasis E. Contact dermatitis

A. Drug eruption B. Xerosis C. Scabies D. Psoriasis E
A. Drug eruption B. Xerosis C. Scabies D. Psoriasis E. Contact dermatitis Most common cause of generalized itching in older adults. Worse in low humidity and cold. More severe disease is inflamed with red fissures. Treatment includes humidifier indoors, reduce frequency and length of bathing, warm not hot water, mild & moisturizing soaps (Dove), emollients on wet skin after bathing especially with lactic acid (5 or 12%) or urea (10% to 20%). Mild topical steroid in severe cases may be used. Do not use oil in bath – fall hazard! -Exclude systemic disease (DM, liver/kidney) & lymphoproliferative dz. -Consider drug eruptions in symmetric outbreak – good drug hx rx and OTC. Usually w/i 1st week of new drug; PCN can be later. -Scabies – burrows, look between fingers -Psoriasis – well-defined erythematous plaques, adherent silvery scale, knees, elbows, scalp, trunk -Contact dermatitis – hx of exposure rather than seasonal. Can be chronic which may be assoc with lichenification with satellite papules, redness, excoriation

An 81yo woman recently admitted to a nursing facility is frequently incontinent of urine. History includes Alzheimer's disease and lumbosacral stenosis. Meds include calcium, vitamin D, and acetaminophen. The patient's family states that her UI has remained essentially unchanged for the past 6 mo. The patient is unable to give a detailed history and denies bladder problems. Observations by the nursing staff suggest a diagnosis of overactive bladder with urge incontinence. On exam, there is no evidence of severe atrophic vaginitis, pelvic prolapse, or fecal impaction. Catheterization reveals PVR of 40 mL. Urinalysis shows 3+ bacteria and 6 WBCs per high-power field; the culture grows >100,000 CFU E. coli, sens to cephalexin. Which of the following is the most appropriate next step? A. Oxybutynin 2.5mg q 8h B. Tolterodine 4mg/d C. Cephalexin D. Prompted voiding program E. Urodynamic testing

Prompted voiding is the most appropriate intervention for this patient
Prompted voiding is the most appropriate intervention for this patient % of nursing-home (NH) patients respond well to this behavioral protocol, and responsiveness can generally be determined after a trial of 3-5 days. Some patients benefit from the addition of a bladder relaxant (eg. oxybutynin or tolterodine); due to potential adverse events of their anticholinergic properties, these meds should be used as an adjunct to a toileting program. These meds may worsen cognitive impairment or precipitate delirium in patients with dementia and should be used only in selected patients who have bothersome overactive bladder symptoms, who do not respond to a toileting program alone, and who demonstrate both tolerance of and responsiveness to the medication. In chronically incontinent NH patients with stable symptoms who have no other signs of infection, eradicating bacteriuria does not reduce the severity of incontinence, even if there is pyuria. Moreover, treating asymptomatic bacteriuria in older adults is not recommended. Urodynamic testing is not contraindicated, even in frail NH patients, but the results would not change the initial approach to management

A 92-year-old woman is S/P open-reduction internal fixation repair of a fractured right hip a few days earlier and now has a 4 cm × 4 cm area on the right lateral buttock with a blood-filled blister that remains intact with surrounding dark tissue. Which of the following is the most effective management for this finding? A. Hyperbaric therapy B. Electromagnetic therapy C. Surgical debridement D. Turn patient every 2 hours; avoid pressure on affected area

A 92-year-old woman is S/P open-reduction internal fixation repair of a fractured right hip a few days earlier and now has a 4 cm × 4 cm area on the right lateral buttock with a blood-filled blister that remains intact with surrounding dark tissue. Which of the following is the most effective management for this finding? A. Hyperbaric therapy B. Electromagnetic therapy C. Surgical debridement D. Turn patient every 2 hours; avoid pressure on affected area This wound is a suspected deep-tissue injury ulcer (SDTI) – localized area of intact skin that may be purple, maroon, or blood filled blister and may quickly progress to severe Stage 3-4 ulcer. They are treated like Stage 1 pressure ulcers. A 2010 National Pressure Ulcer Advisory Panel consensus conference recommends turning patients every 2 hours as a guideline but not as a standard of care. Turning schedules may be lengthened depending on patient characteristics and pressure relief surfaces

A 72-year-old man who has metastatic colon cancer is admitted to a hospice inpatient facility because of complete bowel obstruction and failure to thrive. He has been unable to tolerate oral food or fluids for several days because of nausea and vomiting, and he has significant pain throughout the day. The hospice admitting nurse documents a large sacral pressure ulcer measuring 11 cm × 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed muscle, undermining of the edges, and a tunneling tract that extends another 2 cm. Within the ulcer, there is necrotic material and a significant amount of exudate with a foul odor that permeates the room. The treatment plan includes placement of a specialized bed overlay, application of absorptive dressings, and medicine for pain control. Shortly thereafter, family members tell staff that the wound odor makes spending time in the patient’s room very difficult, and they ask if something can be done.

A 72-year-old man who has metastatic colon cancer is admitted to a hospice inpatient facility because of complete bowel obstruction and failure to thrive. He has been unable to tolerate oral food or fluids for several days because of nausea and vomiting, and he has significant pain throughout the day. The hospice admitting nurse documents a large sacral pressure ulcer measuring 11 cm × 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed muscle, undermining of the edges, and a tunneling tract that extends another 2 cm. Within the ulcer, there is necrotic material and a significant amount of exudate with a foul odor that permeates the room. The treatment plan includes placement of a specialized bed overlay, application of absorptive dressings, and medicine for pain control. Which of the following is the best next step to reduce odor of the ulcer? A. Turn patient every 2 hours B. Apply topical metronidazole gel C. Place potpourri in the room D. Perform surgical debridement

A 67-year-old man asks about hospice care because he has considerable pain and nausea related to stage 4 pancreatic cancer. He is on chemotherapy, but his condition is declining. His oncologist offers another course of chemotherapy, which would cause uncomfortable adverse effects but possibly increase his life expectancy 2–3 months. The patient lives at home and is debilitated to the point that he needs assistance to bathe. He is currently enrolled in traditional Medicare Parts A and B. He has no other health insurance. If the patient switches his insurance status to Medicare hospice benefits, which of the following services will not be covered? (A) Nonpalliative chemotherapy (B) Home-health aide to assist with bathing (C) Hospital bed for his home (D) Grief counseling for his wife

He is currently enrolled in traditional Medicare Parts A and B
He is currently enrolled in traditional Medicare Parts A and B. He has no other health insurance. If the patient switches his insurance status to Medicare hospice benefits, which of the following services will not be covered? (A) Nonpalliative chemotherapy (B) Home-health aide to assist with bathing (C) Hospital bed for his home (D) Grief counseling for his wife To qualify for Medicare hospice benefits, two physicians (one of whom is usually the hospice medical director) must certify that the patient has a terminal condition with a life expectancy of ≤6 months. Given the patient’s condition and functional status, he has a prognosis of <6 months and would thus qualify for hospice benefits. Once he waives Medicare Part A coverage for the terminal illness and signs up for Medicare hospice benefits, he would be eligible for a number of services not covered under traditional Medicare, including medications related to pain and other uncomfortable symptoms, home-health aides, durable medical equipment such as a hospital bed, physical therapy, occupational therapy, speech therapy, grief counseling for the patient and family, and respite care. The hospice benefits do not cover hospitalization for or curative treatment of the terminal illness; the benefits would possibly cover palliative chemotherapy if it were deemed necessary to reduce the patient’s suffering.

A 72-year-old man with a history of metastatic non–small-cell lung cancer is hospitalized for worsening shortness of breath. The cancer was diagnosed 6 months ago when he underwent evaluation for a persistent cough. CT of the chest and abdomen demonstrated a right lower lobe mass with a large, right-sided pleural effusion and liver metastases. Despite thoracentesis and chemotherapy, disease has progressed, and he continues to have large pleural effusions that require thoracentesis almost every 2 weeks. He is independent in his activities of daily living and enjoys short outings with his wife when his dyspnea is controlled. Which of the following is the best management option for his recurrent pleural effusions? (A) Chemotherapy with erlotinib (B) Placement of an indwelling pleural catheter (C) Placement of a pleuroperitoneal shunt (D) Pleurodesis with a sclerosing agent (E) Routine outpatient thoracentesis every 2 weeks

Recurrent malignant effusions cause dyspnea and distress in patients with metastatic cancer. Affected patients typically have a poor prognosis and limited life expectancy. Goals of care should focus on palliation of dyspnea and improving quality of life Initial management of pleural effusion is therapeutic thoracentesis. Patients with recurrent effusions require an intervention with durable effect and minimal discomfort. Given this patient’s recurrent large effusions, extensive tumor burden, and good functional status when his dyspnea is controlled, an indwelling pleural catheter is the preferred approach. These catheters may be placed in the inpatient or outpatient setting; they require intermittent drainage, either by a healthcare professional or by the patient or a family member who has been trained. Patients have reported improved quality of life, including improved mobility and symptom control, and ease of management. Some patients experience spontaneous pleurodesis. Erlotinib is a tyrosine kinase inhibitor that has been shown to improve progression-free survival in patients with metastatic non–small-cell lung cancer. The patient may be a candidate for erlotinib, but management of his recurrent, large malignant effusions requires an intervention that will provide ongoing relief Pleuroperitoneal shunts are occasionally indicated for patients with intractable effusions and trapped lungs. The shunt drains pleural fluid into the abdomen via a subcutaneous reservoir that the patient must pump throughout the day. Cost, limited efficacy, and frequent malfunctions all limit the shunt’s usefulness. The shunt also places the patient at risk of development of malignant ascites Pleurodesis with a sclerosing agent is another common strategy for recurrent malignant pleural effusions. A sclerosing agent (such as talc, doxycycline, or bleomycin) is instilled through a chest tube or insufflation at thoracoscopy in the inpatient setting. Pleurodesis is less successful in patients with heavy tumor burden and decreased expandability of the lung (eg, trapped lung, or abnormal relationship between the visceral and parietal pleural surfaces). Given this patient’s tumor burden and recurrent large-volume effusions, an indwelling pleural catheter is preferable to pleurodesis Routine outpatient thoracentesis is appropriate for patients with a life expectancy limited to weeks. It is not appropriate for this patient because of his current functional status. Routine thoracentesis is associated with an increased risk of pneumothorax, infection, and loculation.

An 85-year-old woman is hospitalized for acute nausea, vomiting, and abdominal pain. She has stage IV ovarian cancer. On examination, there is moderate abdominal distension and diffuse tenderness; there are no bowel sounds. CT of the abdomen and pelvis demonstrates progressive carcinomatosis and near-complete obstruction at two points in her jejunum. A nasogastric tube is placed, and she is started on intravenous fluids and intravenous ondansetron around the clock, dexamethasone 4 mg q6h, and octreotide drip. Her gynecologic oncologist states that neither surgery nor chemotherapy will improve her condition, except possibly a diverting gastrostomy. A bedside meeting is held with the patient and her family. The patient refuses further procedures and asks to be made comfortable. She and her family understand that, without any intervention, she will die within the next few days. Her code status is changed to “do not resuscitate,” and plans are made to discharge her home on hospice in the morning. The nasogastric tube and the octreotide drip are discontinued. The dexamethasone, intravenous fluids, and supplemental oxygen by nasal cannula are continued. Intravenous morphine sulfate drip 1 mg/h is begun. Within 2 hours, the patient reports improved pain control and is drowsy but arousable. A fever develops overnight, and the next morning she is unresponsive and tachypneic, with audible respiratory secretions and chest congestion. Which of the following is the most appropriate next step? (A) Discontinue intravenous fluids. (B) Increase oxygen to 4 L/min via face mask. (C) Start acetaminophen 650 mg orally q6h. (D) Decrease morphine dosage to 0.5 mg/h. (E) Discharge on home hospice.

This patient’s condition has declined further, and death is imminent
This patient’s condition has declined further, and death is imminent. Tachypnea and increased respiratory secretions are common at the end of life. The intravenous hydration is likely contributing to her symptoms. When the goal of care is to maximize comfort, all unnecessary intravenous fluids should be discontinued (SOE=B). Anticholinergic medications such as scopolamine patches, glycopyrrolate, and atropine drops can be used for control of respiratory secretions and could be considered for this patient. Opioids are important adjuncts in the management of terminal dyspnea. This patient’s morphine sulfate dosage will likely need to be increased, not decreased, if her tachypnea does not improve with discontinuation of fluids and addition of an anticholinergic agent. An increase in oxygen supplementation and use of a face mask will not relieve the patient’s chest congestion and respiratory secretions. Rather, the increased airflow and placement of a mask may cause more discomfort. Treatment of her fever with around-the-clock acetaminophen is inappropriate because of her vomiting. The patient is actively dying and has uncontrolled symptoms. She cannot be discharged on home hospice in this condition, because she will likely die within the next 1-3 days.

An 88-year-old man undergoes evaluation because he has a wound on his left heel that, despite optimal therapy, has progressed over the course of a few weeks. History includes advanced Parkinson disease. He lives in a nursing home, is mainly bedbound, and requires total assistance with activities of daily living. His nutritional status is poor and there is evidence of frequent aspiration, but his family has declined artificial feeding tubes on his behalf. On physical examination, the wound measures 4 cm × 4 cm × 3 cm and drains moderate amounts of pus. An inserted cotton tip easily extends to the calcaneus bone. Using the nomenclature of the National Pressure Ulcer Advisory Panel, which of the following best describes the wound? A. Stage IV pressure ulcer B. Stage III pressure ulcer C. Kennedy terminal ulcer D. Skin failure

Proper assessment is important for preventing and treating pressure ulcers. Also known as pressure sores, bedsores, and decubitus ulcers, pressure ulcers are created by pressure, friction, and shearing forces. In the National Pressure Ulcer Advisory Panel (NPUAP) revised staging system, stage IV refers to ulcers that penetrate to bone. This patient has a stage IV pressure ulcer. Even with an optimal healing environment, the wound may take months to years to heal properly. In the NPUAP staging system, stage III refers to full-thickness ulcers that extend into subcutaneous tissues without visible bone, tendon, or muscle. The Kennedy terminal ulcer, first described in the literature in 1989, refers to a pressure ulcer that some people develop as they are dying. Kennedy terminal ulcer is typically located on the sacrum; is pear-, butterfly-, or horseshoe-shaped with irregular borders; and is red, yellow, black, or purple. It usually starts as a blister or a stage II ulcer and rapidly progresses to stage III or stage IV. Because this patient’s ulcer is located on his heel, it likely is not a Kennedy terminal ulcer. First described in 1991, skin failure refers to the underlying skin and tissue damage that occurs at the end of life as a consequence of hypoperfusion. According to an NPUAP consensus, skin failure is separate from pressure ulcers and therefore is not included in the staging system.

A 68-year-old woman is transferred to a medical ward after being treated in the intensive care unit for respiratory failure due to COPD. During an examination, the nurse notices an area of skin breakdown on the patient’s coccyx. It is 3 cm × 4 cm with a depth of 1 cm and has minimal slough. The wound edges are hyperemic, but there is no sign of undermining. Wound exudate is minimal, and there are no systemic signs of infection. Which of the following is the most appropriate treatment for this wound? A. Alginate dressing B. Hydrocolloid dressing C. Transparent film D. Wet-to-dry dressing

A 68-year-old woman is transferred to a medical ward after being treated in the intensive care unit for respiratory failure due to COPD. During an examination, the nurse notices an area of skin breakdown on the patient’s coccyx. It is 3 cm × 4 cm with a depth of 1 cm and has minimal slough. The wound edges are hyperemic, but there is no sign of undermining. Wound exudate is minimal, and there are no systemic signs of infection. Which of the following is the most appropriate treatment for this wound? A. Alginate dressing B. Hydrocolloid dressing C. Transparent film D. Wet-to-dry dressing -Thin red rim normal in healing wounds -Look for cellulitis with fever, tenderness, warmth, erythema especially if worsening; erythema may not be obvious in dark skin -Abx for cellulitis should target gram positive organisms -Consider alginate products for soupy, exudative wounds, may reduce bacteria -Silver nitrites in dressing are anti-bacterial -Don’t remove eschars on heels -Don’t cover infected or exudative wounds

This wound has minimal slough, indicating that the ulcer penetrates into the subcutaneous fat tissue. Because no muscle, tendon, or bone is visible, it is a stage III pressure ulcer. The description of minimal exudates and the lack of systemic infection indicate that the wound is not infected. Hydrocolloid dressings are recommended for noninfected stage III ulcers (SOE=B). The following steps promote healing of pressure ulcers: • Reduce interface pressures through use of pressure reduction surfaces and frequent turning of the patient. • Assess nutritional status and supplement as needed. • Debride necrotic tissue through mechanical, enzymatic, autolytic, or sharp methods. • Apply a dressing that helps to protect the wound bed, reduce pressure, maintain moisture, and promote migration of growth factors that aid healing. Wound dressings are important in pressure ulcer healing for several reasons: they minimize contact with contaminants, maintain a moist environment, promote growth of granulation tissue, and reduce shear and friction forces. Research on the effects of wound dressings on healing rates show that most dressings have equal efficacy (SOE=B). The NPUAP guidelines indicate which dressings to use based on certain factors: stage of the ulcer, amount of exudates, quality of the tissue in the ulcer bed, and condition of the tissue surrounding the ulcer bed. Alginate dressings are intended for wounds that have moderate to heavy exudates (SOE=B). Blood and exudates are absorbed to create a gel that protects wound surfaces. Because the wound in this case has minimal exudates, alginate dressings are not the best treatment option. A transparent film dressing is semipermeable, retains moisture, and is adhesive. It can provide autolytic debridement or cover other dressings for larger wounds as a secondary dressing. It is intended to reduce friction for stage I and II pressure ulcers (SOE=C). Transparent film dressing is contraindicated for wounds with exudates or suspected infection. Because the wound described in this case has an exudate, albeit minimal, transparent film is inappropriate as a sole agent for the wound. Wet-to-dry dressings are not recommended for treatment of pressure ulcers, because they may cause damage to healthy, granulating tissue (SOE=C) and cause pain with dressing changes.

An 85yo is hospitalized 6d for PNA, then 15d in skilled rehab center, then has home health (HH) 2x a week for 3 weeks. He takes 5 Rx meds, sees PCP monthly for follow-up. Insurance is Medicare A & B. Hospital bill is $5,000, rehab $3,000, HH $500, meds $120/month. Which of these will account for greatest out-of-pocket expenses over 3 months? A. Hospitalization B. Nursing home rehab C. Home health D. Prescription medications

M’care Part A: 100% inpatient expenses covered for 60d per 90d benefit period after deductible met ($1,184 per 90d period 2013) & $296/d days 61-90/benefit period. 20days of skilled rehab paid 100% if preceded by 3d hospitalization, $148/d for days per benefit period. Part B: 80% outpatient expenses including HH services (PT, RT, RN, SP, OT) after deductible (2013 $147) Part D: drug plan, variable income-based premium rates A. Hospitalization B. Nursing home rehab C. Home health D. Prescription medications

FALLS TIPS: -Take complete history, including circumstances of fall, associated symptoms, environmental risks (tripping) -Review medications and eliminate sedative/hypnotics -Check 25-OH Vitamin D, treat if <30ng/ml -Check and treat orthostasis -Check vision, cognition, gait, strength and balance, cardiovascular, neurological systems, look for musculoskeletal abnormalities -Physical therapy if weakness or imbalance detected -Tai Chi useful in RCT -Timed Up and Go <10 seconds low risk falls; >20 sec high risk -New falls, brisk reflexes, weakness on UE exam, may have neck pain, think cervical stenosis

Preventive Health Measures Available for Older Adults and Recommended Use Consider remaining life expectancy, comorbidities, cognitive & functional status Robust (≥5 years remaining life expectancy) Frail (<5 years remaining life expectancy) Moderate dementia (2–10 years remaining life expectancy) End of life (<2 years remaining life expectancy) Cost Effectiveness Cancer screening Mammography Every 2 years Not recommended (NR) Consider NR Somewhat cost-effective for women <80 years old, may be cost-effective for women ≥80 years old in top quartile of life expectancy. Pap smear May stop after age 65 Cost-effective to stop Prostate-specific antigen Discuss pros/cons if life expectancy >10 years, may stop at age 75 Uncertain Fecal occult blood test Yearly, may stop at age 75 Cost-effective Colonoscopy Every 10 years, may stop at age 75

Preventive Health Measures Available for Older Adults and Recommended Use Consider remaining life expectancy, comorbidities, cognitive & functional status Robust (≥5 years life expectancy) Frail (<5 years life expectancy) Moderate dementia (2–10 years life expectancy) End of life (<2 years life expectancy) Cost Effectiveness Dexa (bone density) At least once after age 65 (W), or age 60 if high risk; 70yo (M) Consider NR Cost-effective Blood glucose Screen if sustained BP >135/80 mmHg or when results would affect CVD prevention (lipids, aspirin) Uncertain; optimal interval unknown, 3yrs? Cholesterol Consider in those with additional risk factors Uncertain Abdominal US Once for men who ever smoked Ask about falls in previous year Yearly

Preventive Health Measures Available for Older Adults and Recommended Use Consider remaining life expectancy, comorbidities, cognitive & functional status Immunizations Robust (≥5 years life expectancy) Frail (<5 years life expectancy) Moderate dementia (2–10 years life expectancy) End of life (<2 years life expectancy) Cost Effectiveness Influenza Yearly Cost-effective Pneumococcal Once after age 65 Tetanus (Tdap once as an adult) Booster every 10 yr Herpes Zoster Once after age 60

Beers Criteria: “Potentially” Inappropriate Medications in Elderly
Systemic review of adverse drug effects in the elderly developed by an expert panel Updated regularly (J Am Ger Soc 60: 616, 2012) Examples Anticholinergics: 1st generation antihistamines Antiparkinson agents: bentropine Antispasmodics: scopolamine, hyoscyamine Antithrombotics: short acting oipridamole Anti-infective: nitrofurantoin CV A1 blocker, doxazocin, terazocin, prazocin Central A1: clonidine, methyldopa Antiarrythmics: amiodorone, sotalol, propafenone, digoxin>0.125 mg/d, immediate release nifedipine

Beers Criteria: “Potentially” Inappropriate Medications in Elderly
Examples continued CNS: amitriptyline, doxepin >6 mg/d Antipsychotics: long list, including thorazine Barbiturates: long list Benzodiazepines: many, including oxazepam, temazepam Non-benzodiazipine hypnotics: zolpidem, zaleplon Endocrine: testosterone, dessicated thyroid, sliding scale insulin, megestrol, glyburide, chlorpropamide GI: metoclopramide NSAIDs: most, including ASA for primary prevention Muscle relaxants: most, including carisprodol, cyclobenzaprine

A 70 yo woman with minimal cognitive dysfunction, severe orthostatic hypotension, postprandial hypotension, constipation, dry mouth, bradykinesia, symmetric rigiditiy, and tremor with movement. She does not respond to levodopa-carbidopa. MRI – no infarcts or hydrocephalus; marked hypointensity of striatum and linear hyperintensity lateral to putamen on T2 suggests iron deposition and supports the diagnosis (vs. Parkinson) Multiple System Atrophy: prominent features by subtype Shy-Drager Syndrome: dysautonomia Striatonigral degenertion: anterocollis, pyramidal dysfxn Olivopontocerebellar atrophy: cerebellar ataxia, limb dyssynergia, kinetic tremor Hallmarks of MSA=parkinsonism poorly responsive to levodopa, varying degrees autonomic (severe OHypo, postprandial hypotn, anhidrosis w/thermoregulatory dysfxn, poor lacrimation/salivation, constipation, impotence, bladder emptying, incontinence), cerebellar, pyramidal tract dysfunction (hyperreflexia, Babinski,

“Reversible” Dementia
What are examples of “reversible” dementias? B12 deficiency, neurosyphillis, thyroid disorder, pseudodementia, medications, encephalopathies, tumors, NPH, subdural hematoma How often is a reversible etiology identified? How many respond to treating underlying cause? 20% of dementia referrals. Of these, 10% improve. ~1% resolve

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