1. Common Issues in the Elderly (Part II) AJAY ZACHARIAH, MD 2/24/2015

2. Osteoporosis RISK FACTORS, WORK UP, TREATMENT

3. Risk Factors  Female  Less bone mass gained during puberty  Abrupt loss of estrogen later in life  Slender/Short Stature (less than 58 kg [127 lb])  Previous history of fracture  Family history of hip fracture  Caucasian  Long term glucocorticoid use  >80 years old  Decline of osteocytes with age  85% of female nursing home residents >80 y/o have osteoporosis  Alcohol and Cigarette Use  Rheumatoid Arthritis

8. FRAX  WHO 10 year risk assessment (2008)  Validated with 40 cohorts and 1 million patient-years  http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9

10. DXA: Criteria for Screening  Dual-energy X-ray Absorptiometry  Women  >65 y/o  <65 y/o with both:  Postmenopausal  Clinical risk factors for fracture

11. DXA: Criteria for Screening  Men  Signs of low bone mass  radiographic osteopenia  history of low trauma fractures  loss of more than 1.5 inches in height  risk factors for fracture  Standard risks  Androgen deprivation therapy for prostate cancer  Hypogonadism  primary hyperparathyroidism  intestinal disorders

12. T Score  Measured in standard deviations  -1:Normal  -1 to -2.5: Osteopenia  < -2.5:Osteoporosis  < -2.5 + fracture:Severe Osteoporosis

13. Treatment: Non-pharmacologic  Supplementation: Vitamin D and Calcium (see next slide)  Diet  If pt has Celiac disease -> gluten-free diet  No recommendations for protein intake  Exercise  Enjoyable, weight-bearing  High-intensity not required  Smoking Cessation  Recommendations are valid for ALL post-menopausal women

14. Vitamin D and Calcium  Diagnosis of Osteoporosis -> Test 25 OH Vitamin D  more stable compared to 1-25 OH in serum  Treatment  Post menopausal women with Osteoporosis: 1200 mg calcium (total of diet and supplement) and 800 IU vitamin D daily  Others: 1000 mg calcium (total of diet and supplement) and 600 IU vitamin D daily  Recheck vitamin D level in 3-4 months

15. Treatment: Pharmacologic  Who: post-menopausal women or men >50 y/o who have:  Recent hip or vertebral fracture  T-score ≤-2.5 (DXA) at the femoral neck or spine  exclude secondary causes  Combination of:  T-score between -1 and -2.5  FRAX 10 year risk of  Hip fracture: ≥3%  Any major fracture ≥20%

16. Treatment: Pharmacologic  Postmenopausal women  First line: Oral Bisphosphonates  Efficacy  Low Cost  Long term safety data  Alendronate (generic) or risedronate  Second Line  GI Intolerance to bisphosphosphonates  Zoledronic acid (Reclast): 5mg IV every years  Others: denosumab, PTH, raloxifene

17. Treatment: Monitoring  Check BMD after 2 years of therapy  If stable/improved, may check “less often”.  If worsened or pt has new medical condition (ex. Bowel resection), should check “more often”  “Least significant change" (LSC)  Varies by densitometer  Change in BMD is only significant if > LSC

18. Decision Making in the Elderly

19. Advance Care Planning (ACP)  ACP:  Patient’s current condition and prognosis reviewed  Likely medical dilemmas presented  Options discussed  Ideal:  Clinicians, patient, and loved ones involved  Iterative and longitudinal  Legally Recognized Advance Directives (ADs):  Living Will  Durable Power of Attorney for Health Care

20. Advance Care Planning (ACP)  Living Will:  Document patient preferences for life sustaining treatments and resuscitation  DPAHC: Durable Power of Attorney for Health Care  A.k.a. Healthcare Proxy Designations  Signed legal document authorizing another person to make medical decisions in the event the patient loses decisional capacity.

21. Advance Care Planning (ACP)  Benefits of ACP (per Prospective and Randomized Trials)  Higher rates of completion of ADs  Increased likelihood that clinicians and families understand and comply with a patient’s wishes  Reduced hospitalization at end of life  Less intensive treatments at end of life  Increased use of hospice services  Increased likelihood patient will die in his preferred place

22. Capacity: Assessment  Can reason and deliberate treatments and consequences  Explains choice by referencing goals and values  If unable, difficult to consider the patient fully capacitated  “Acting himself”  Behavior is consistent with previous thinking  If “change of heart”, must still be able to reference past preferences.  If patient made living will refusing refusing care before incapacitation: wishes are “definitive”

23. Tube Feeding

24. Complications  Complications  Aspiration  Diarrhea  Metabolic  Hyperglycemia  Micronutrient deficiency  Refeeding syndrome  Constipation

25. Vaccinations

27. Elder Abuse

28. Risk Factors  Advanced age: >80 y/o  19 % of the elderly population  50% of financial exploitation, physical abuse and psychological abuse  Female  African American  Disability/poor mobility  Medical History: hip fracture/stroke

29. Risk Factors  Social isolation  Low socioeconomic status: education and income  External family stressors: Ex. Illness, low socioeconomic status, death in the family  Unfavorable caretaker characteristics: Caretaker mental illness, substance abuse, history of violent or antisocial behavior, depression or financial dependency  Institutional staffing shortages Source: National Elder Abuse Incidence Study (NEAIS) – 2812 community-dwelling elderly

30. Screening  Abbreviated Screening  Do you feel safe where you live?  Who prepares your meals?  Who handles your checkbook?

31. Sexuality

33. Causes of Cessation: Women  Function  Atrophy of urogenital tissue leading to decreased uterine and vaginal size  Decreases in vaginal lubrication and vasocongestion  Decline in the erotic sensitivity of nipple, clitoral, and vulvar tissue during sexual activity  Declines in testosterone production

34. Causes of Cessation: Women  Consequences  Decline in libido  Decreased physiologic sexual response  Discomfort/dyspareunia  Decreased sexual frequency  Fatigue