Common issues in the Elderly part 1

Joshua Huval M.D.

Gait Disturbances• SORT: KEY RECOMMENDATIONS FOR PRACTICE• Clinical recommendationEvidence ratingReferences• Gait and balance disorders are usually multifactorial in origin and require a comprehensive

assessment to determine contributing factors and targeted interventions.• C• Older adults should be asked at least annually about falls.• C• Older adults should be asked about or examined for difficulties with gait and balance at least once.• C• Older adults who report a fall should be asked about difficulties with gait and balance, and should

be observed for any gait or balance dysfunctions.• C• Exercise and physical therapy can help improve gait and balance disorders in older adults.• B• A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-

oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

Gait disturbances• Evaluation of Older Persons with Gait and Balance Disorders• History• Acute and chronic medical problems• Complete review of systems• Falls history (previous falls, injuries from falls, circumstances of fall, and associated symptoms)• Nature of difficulty with walking (e.g., pain, imbalance) and associated symptoms• Surgical history• Usual activity, mobility status, and level of function• Medication review• New medications or dosing changes• Number and types of medications• Physical examination• Affective/cognitive (delirium, dementia, depression, fear of falling)• Cardiovascular (murmurs, arrhythmias, carotid bruits, pedal pulse)• Musculoskeletal (joint swelling, deformity, or instability; limitations in range of motion involving the knees, hips, back, neck, arms, ankles, and feet; kyphosis; footwear)• Neurologic (muscle strength and tone; reflexes; coordination; sensation; presence of tremor; cerebellar, vestibular, and sensory function; proprioception)• Sensory (vision, hearing)• Vitals (weight, height, orthostatic blood pressure and pulse)• Gait and balance performance testing• Direct observation of gait and balance• Functional reach test• Timed Up and Go test• Presence of environmental hazards• Clutter• Electrical cords• Lack of grab bars near bathtub and toilet• Low chairs• Poor lighting• Slippery surfaces• Steep or insecure stairways• Throw rugs

Gait Disturbances• Functional Ambulation Classification Scale• CATEGORY DEFINITION• 0. Nonfunctional ambulation Patient cannot ambulate, ambulates in parallel bars only, or requires

supervision or physical assistance from more than one person to ambulate safely outside of parallel bars.• 1. Ambulator—dependent for physical assistance, level II Patient requires manual contact of no more

than one person during ambulation on level surfaces to prevent falling. Manual contact is continuous and necessary to support body weight as well as maintain balance and/or assist coordination.

• 2. Ambulator—dependent for physical assistance, level I Patient requires manual contact of no more than one person during ambulation on level surfaces to prevent falling. Manual contact consists of continuous or intermittent light touch to assist balance or coordination.

• 3. Ambulator—dependent for supervision Patient can physically ambulate on level surfaces without manual contact of another person, but for safety requires standby guarding of no more than one person because of poor judgment, questionable cardiac status, or the need for verbal cuing to complete the task.

• 4. Ambulator—independent on level surfaces only Patient can ambulate independently on level surfaces but requires supervision or physical assistance to negotiate stairs, inclines, or nonlevel surfaces.

• 5. Ambulator—independent Patient can ambulate independently on nonlevel and level surfaces, stairs, and inclines, without supervision or physical assistance from another person. Assistive devices, orthoses, and prostheses are allowed.

Gait Disturbances• Timed Up and Go test, the Berg Balance Scale, or the Performance-

Oriented Mobility Assessment (POMA).• Timed up and Go test - Patients are timed as they rise from a chair

without using their arms, walk 3 meters, turn, return to the chair, and sit down. – They are allowed to use their usual walking aid. A score of less than 10

seconds is considered normal, and 14 seconds or more is abnormal and associated with an increased risk of falls.38 Patients who perform the task in more than 20 seconds usually have more severe gait impairment. The Timed Up and Go test is a sensitive (87 percent) and specific (87 percent) measure for identifying older persons who are prone to falls.39 It correlates well with other more-detailed scales, but is quicker and easier to perform. Persons who have difficulty or demonstrate unsteadiness performing the Timed Up and Go test require further assessment, usually with a physical therapist, to help elucidate gait impairments and related functional limitations.

Gait Disturbances• Interventions

– A multifactorial evaluation followed by targeted interventions for identified contributing factors can reduce falls by 30 to 40 percent46 and is the most effective strategy for falls prevention. However, evidence on the effectiveness of interventions for gait and balance disorders is limited because of the lack of standardized outcome measures determining gait and balance abilities.• Gait disorders secondary to conditions such as arthritis, orthostatic hypotension, Parkinson

disease, vitamin B12 deficiency, hypothyroidism, heart rate or rhythm abnormalities, or depression may respond to medical therapies.

• surgery may improve gait for patients with cervical spondylotic myelopathy,51 lumbar spinal stenosis,52 normal-pressure hydrocephalus,53 or arthritis of the knee or hip.

• pacemakers in patients with carotid sinus hypersensitivity• cataract surgery • reduction in the number of medications or removing medications causing adverse effects • mobility aids, such as canes or walkers (properly fitted to the person), can reduce load on a

painful joint and increase stability• home safety programs provided by a trained health care professional appear to be effective

for persons at high risk of falls, such as those with a history of falls or other fall risk factors.

Gait Disturbances

• http://www.aafp.org/afp/2010/0701/p61.html

Constipation• SORT: KEY RECOMMENDATIONS FOR PRACTICEClinical recommendationEvidence ratingReferences

– Review the patient’s medication list to evaluate for medications that may cause constipation.– C– Encourage patients to attempt to have a bowel movement soon after waking in the morning or 30 minutes

after meals to take advantage of the gastrocolic reflex.– C– Increasing dietary fiber intake to 25 to 30 g daily may improve symptoms of constipation.– C– Encourage physical activity to improve bowel regularity.– B– If nonpharmacologic approaches fail, recommend increased fiber intake and/or laxatives to increase bowel

movement frequency and improve symptoms of constipation.– B– Biofeedback therapy is the treatment of choice for anorectal dysfunction.– B– Surgery is reserved for persistent and intractable constipation in patients who have been evaluated and

proven to have slow transit constipation.– BA = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 2160 or http://www.aafp.org/afpsort.xml.

Constipation• Rome II Criteria for Defining Chronic Functional Constipation in

Adults• Two or more of the following for at least 12 weeks in the preceding 12

months:• Straining in more than 25 percent of defecations• Lumpy or hard stools in more than 25 percent of defecations• Sensation of incomplete evacuation in more than 25 percent of

defecations• Sensation of anorectal obstruction or blockade in more than 25

percent of defecations• Manual maneuvers (e.g., digital evacuation, support of the pelvic floor)

to facilitate more than 25 percent of defecations• Fewer than three defecations per week

Constipation• PRIMARY CONSTIPATION-

– normal transit constipation- most common. In patients with functional constipation, stool passes through the colon at a normal rate.

– slow transit -prolonged delay in the passage of stool through the colon. Patients may complain of abdominal bloating and infrequent bowel movement The causes for slow transit constipation are unclear; mechanisms include abnormalities of the myenteric plexus, defective cholinergic innervation, and anomalies of the noradrenergic neuro-muscular transmission system

• anorectal dysfunction-Anorectal dysfunction may be an acquired behavioral disorder, or the process of defecation may not have been learned in childhood.10

• SECONDARY CONSTIPATION

Constipation• SECONDARY CONSTIPATION• Causes of Secondary Constipation

– Endocrine and metabolic diseases– Diabetes mellitus– Hypercalcemia– Hyperparathyroidism– Hypothyroidism– Uremia – Myopathic conditions Amyloidosis – Myotonic dystrophy – Scleroderma – Neurologic diseases Autonomic neuropathy– Cerebrovascular disease – Hirschsprung’s disease – Multiple sclerosis – Parkinson’s disease – Spinal cord injury, tumors– Psychological conditionsAnxiety – Depression – Somatization – Structural abnormalities Anal fissures, strictures, hemorrhoids – Colonic strictures– Inflammatory bowel disease– Obstructive colonic mass lesions– Rectal prolapse or rectocele – OtherIrritable bowel syndrome – Pregnancy

Contipation• Treatment

– Non pharmacologic-• FLUID INTAKE

– Adequate hydration is considered to be important in maintaining bowel motility. However, despite the belief that a lack of fluid increases the risk of constipation, few studies have provided evidence that hydration is associated with the incidence of constipation. Decreased fluid intake may play a greater role in the development of fecal impaction.

• REGULAR EXERCISE– The National Health and Nutrition Examination Survey found that a low physical activity level is associated with a

twofold increased risk of constipation. Another epidemiologic study showed that patients who are sedentary are more likely to complain of constipation. Prolonged bedrest and immobility are often associated with constipation. Although patients should be encouraged to be as physically active as possible, there is no consistent evidence that regular exercise relieves constipation.24 However, the Nurses’ Health Study,25 which followed a cohort of 62,036 women, found that physical activity two to six times per week was associated with a 35 percent lower risk of constipation.

• DIETARY FIBER INTAKE– Inadequate fiber intake is a common reason for constipation in Western society. A dietary diary may be helpful to assess

whether an adequate amount of fiber is consumed daily The daily recommended fiber intake is 20 to 35 g daily. If fiber intake is substantially less than this, patients should be encouraged to increase their intake of fiber-rich foods such as bran, fruits, vegetables, and nuts. Prune juice is commonly used to relieve constipation. The recommendation is to increase fiber by 5 g per day each week until reaching the daily recommended intake.

• BOWEL TRAINING– Patients should be encouraged to attempt defecation first thing in the morning, when the bowel is more active, and 30

minutes after meals, to take advantage of the gastrocolic reflex.

Constipation• Pharmacological-• AGENT FORMULA/STRENGTH ADULT DOSAGE COST*• Bulk laxatives• Methylcellulose (Citrucel) Powder: 2 g (mix with 8 oz liquid)One to three times daily $13.05 for 840 g• Tablets: 500 mg (take with 8 oz liquid) 2 tablets up to six times daily $20.76 for 164 tablets• Polycarbophil (Fibercon) Tablets: 625 mg 2 tablets one to four times daily $10.80 for 90 tablets• Psyllium (Metamucil) Powder: 3.4 g (mix with 8 oz liquid) One to four times daily $12.55 for 870 g• Stool Softeners• Docusate calcium (Surfak) Capsules: 240 mg Once daily $16.92 for 100 capsules• Docusate sodium (Colace) Capsules: 50 or 100 mg 50 to 300 mg† 50 mg: $14.50 for 60 capsules

100 mg: $17.71 for 60 capsules Liquid: 150 mg per 15 mL Liquid: $7.90 for 30 mL

Syrup: 60 mg per 15 mL Syrup: $21.66 for 473 mL• Osmotic laxatives• Lactulose Liquid: 10 g per 15 mL 15 to 60 mL daily† $36.35 for 480 mL• Magnesium citrate Liquid: 296 mL per bottle 0.5 to 1 bottle per day$2.29 for 296 mL• Magnesium hydroxide (Milk of Magnesia) Liquid: 400 mg per 5 mL 30 to 60 mL once daily† $2.64 for 12 fl oz• Polyethylene glycol 3350 (Miralax) Powder: 17 g (mix with 8 oz liquid) Once daily $25.34 for 12 packets• Sodium biphosphate (Phospho-Soda) Liquid: 45 mL, 90 mL 20 to 45 mL daily$2.65 for 90 mL• Sorbitol Liquid: 480 mL 30 to 150 mL daily $7.57 to $25 for 480 mL• Stimulant laxatives• Bisacodyl (Dulcolax) Tablets: 5 mg 5 to 15 mg daily $13.46 for 100 tablets• Cascara sagrada Liquid: 120 ml 5 mL once daily $3.75 for 120 mL Tablets: 325 mg 1 tablet daily $4.50 for 100 tablets• Castor oil Liquid: 60 ml 15 to 60 mL once daily† $8.35 for 120 mL• Senna (Senokot) Tablets: 8.6 mg 2 or 4 tablets once or twice daily $21.04 for 100 tablets• Prokinetic Agents• Tegaserod (Zelnorm) Tablets: 2 mg, 6 mg Two times daily‡ $169.15 for 60 tablets 2 mg or 6 mg

Constipation• BULK LAXATIVES

– Bulk laxatives may contain soluble (psyllium, pectin, or guar) or insoluble (cellulose) products. Patients with functional normal transit constipation benefit the most from treatment with bulk laxatives. However, patients with slow transit constipation or anorectal dysfunction may not be helped by bulking agents. Bulk laxatives improve symptoms of constipation such as stool consistency and abdominal pain. As with increased dietary intake of foods rich in fiber, bloating and excessive gas production may be a complication of bulk laxatives.

• EMOLLIENT LAXATIVES– Emollient laxatives or stool softeners, (e.g., docusates), lower surface tension, allowing water to enter the bowel more readily. They are

generally well tolerated but are not as effective as psyllium in the treatment of constipation. Stool softeners are ineffective in chronically ill older adults. May be more useful for anal fissures or hemorrhoids with painful defecation. Mineral oil not rec due to aspiration and dec fat soluble vitamins

• OSMOTIC LAXATIVES– Saline or osmotic laxatives are hyperosmolar agents that cause secretion of water into the intestinal lumen by osmotic activity. – MC are magnesium hydroxide (Milk of Magnesia), oral magnesium citrate, and sodium biphosphate (Phospho-Soda).– relatively safe because they work within the colonic lumen and do not have a systemic effect. – electrolyte imbalance within the colonic lumen and may precipitate hypokalemia. fluid and salt overload, and diarrhea. – Caution in patients with congestive heart failure and chronic renal insufficiency. Chronic use = Hypermag in renal insufficiency– Alternatives are: sorbitol, lactulose, and polyethylene glycol (PEG) 3350. Sorbitol and lactulose are undigestible agents that are metabolized

by bacteria into hydrogen and organic acids. Poor absorption of these agents may lead to flatulence and abdominal distention. In a multicenter trial31 of 164 patients, lactulose was found to be more effective in producing a normal stool by day seven compared with laxatives compared with dulcolax/senna. PEG more effective with less flatulence and softer stool than lactulose.

• STIMULANT LAXATIVES– Stimulant laxatives include products containing senna and bisacodyl. These laxatives increase intestinal motility and secretion of water into

the bowel. Cramping due to increased peristalsis. – Caution with suspected intestinal obstruction.– Chronic use of stimulant laxatives containing anthraquinone may cause Melanosis coli. This condition is benign and may resolve when the

stimulant laxative is discontinued.– Lower Cost and more effective than Lactulose increasing frequency and consistency and lower cost.

• PROKINETIC AGENTS• Colchicine and misoprostol-for slow transit constipation neither FDA approved-Needs larger studies

– tegaserod (Zelnorm)-used in women with IBS with constipation in smaller studies that showed no better symptom relief although more frequent BMs

Constipation• Biofeedback

– mainstay of treatment for patients with anorectal dysfunction. – Biofeedback- emphasizes normal coordination and function of the anal-sphincter and

pelvic-floor muscles. – Patients receive visual and auditory feedback by simulating an evacuation with a

balloon or silicon-filled artificial stool. – overall success rate of 67 percent.

• Surgery– Only patients who have been evaluated by physiologic testing and proven to have slow

colonic transit constipation benefit from surgery. – A subtotal colectomy with ileorectostomy is the procedure of choice Complications

after surgery may include small bowel obstruction, recurrent or persistent constipation, diarrhea, and incontinence.

– Surgery generally is not recommended for constipation caused by anorectal dysfunction.

– The relationship between rectocele and constipation is not entirely clear. Surgical correction is reserved for patients with large rectoceles that alter bowel function.44

Vision Impairment• SORT: KEY RECOMMENDATIONS FOR PRACTICE• CLINICAL RECOMMENDATION EVIDENCE RATING• All persons older than 65 years should be screened periodically for vision problems. C• All older persons with diabetes should have a dilated eye examination within one year of diabetes

diagnosis, and at least annually thereafter. C• Tight control of glucose and blood pressure lowers the risk of progressive diabetic retinopathy. A

• Controlling blood pressure in older persons with and without diabetes may reduce the risk of ischemic vascular complications that can cause vision loss. B

• Smoking is linked to several causes of progressive visual impairment; smoking cessation counseling should be a routine aspect of care for older persons. B

• Antioxidant and zinc supplements, alone or in combination, do not prevent or delay onset of age-related macular degeneration. A

• Antioxidant and zinc supplementation may delay the progression of age-related macular degeneration in some persons with advanced disease. B

• A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Vision Impairment

• Snellen Chart• The Early Treatment of Diabetic Retinopathy

Study (ETDRS) chart (ftp://ftp.nei.nih.gov/charts/EC02_300.tif)

• Inquiring about specific symptoms and the functional impact of vision loss should be a part of the vision screening process To Id functional adaptation or impairment.

Vision Impairment• Disease-Specific Eye Evaluation in Older Persons• DISEASE OR CONDITION RECOMMENDED SCREENING PROTOCOL• Age-related macular degeneration No established screening protocol• Cataracts No established screening protocol• Glaucoma Insufficient evidence to recommend for or against routine

screening in the general population; consider periodic screening with tonometry and automated visual field testing in high-risk groups (e.g., black persons, persons with strong family history)16

• Diabetics and without retinopathy or with minimal nonproliferative retinopathy– Dilated eye examination within one year of diabetes diagnosis, and annually thereafter

• Persons with diabetes and stable nonproliferative retinopathy– Dilated eye examination every six to 12 months17

• Persons with diabetes and unstable proliferative retinopathy or macular edema– Dilated eye examination every two to four months, depending on degree of disease and visual

impairment17

Vision Impairment• Diabetic retinopathy is one of the leading causes of blindness in persons older than 40 years in North America. 2

– classified as nonproliferative or proliferative• with or without macular edema. • Up to 10 percent of persons newly diagnosed with diabetes will have retinopathy within one year of diagnosis. In persons with severe nonproliferative

diabetic retinopathy, the risk of progression to vision-threatening proliferative retinopathy within one year is 50 to 75 percent.• Treatment-panretinal laser photocoagulation

• Cataracts – leading cause of blindness worldwide– most common cause of low vision (but not blindness) in the United States. – can be readily detected with a handheld ophthalmoscope during vision screening. – IF do not cause significant visual impairment may be followed medically. – If the cataract is suspected of causing impaired vision, referral to an ophthalmologist is warranted.

• Open-angle glaucoma Natural history and progression poorly understood. – Forty percent of persons with vision-threatening primary open-angle glaucoma have normal intraocular pressures, and the glaucoma

will be missed by intraocular pressure measurements alone.– Complete screening for open-angle glaucoma should include pressure measurement and automated visual field testing. – The USPSTF does not recommend for or against routine screening for glaucoma in older adults, but recognizes that some subgroups at

higher risk (e.g., black persons) may benefit from periodic screening.– Treatment-Multiple drugs. Go read about if interested. Lowering intraocular pressure is their goal.

• Age-related macular degeneration (AMD) responsible for nearly 60 percent of blindness in adults of European descent older than 65 years.2

– AMD is classified as • wet(neovascularorexudative)or• dry(non-neovascular or nonexudative). • The Amsler grid may be used as a screening test for AMD. The grid detects linear distortion, metamorphopsia, and central scotomas, which are

characteristic of AMD. The patient is instructed to look at the grid and report any wavy lines or areas that are missing or distorted.• Treatment-Retinal photodynamic therapy/Pegaptanib (Macugen) and ranibizumab (Lucentis)-VEGF inhib via injection ongoing trials

Vision Impairment

• Age-related macular degeneration (AMD) responsible for nearly 60 percent of blindness in adults of European descent older than 65 years.2

– AMD is classified as • wet(neovascularorexudative)or• dry(non-neovascular or nonexudative). • The Amsler grid may be used as a screening test for AMD. The grid

detects linear distortion, metamorphopsia, and central scotomas, which are characteristic of AMD. The patient is instructed to look at the grid and report any wavy lines or areas that are missing or distorted.

• Treatment-Retinal photodynamic therapy/Pegaptanib (Macugen) and ranibizumab (Lucentis)-VEGF inhib via injection ongoing trials

Vision Impairment

Vision Impairment• Prevention of Vision Loss

– Aggressive management of chronic medical disorders in older persons can help preserve vision. Smoking cessation, limiting exposure to ultraviolet light, and (possibly) dietary changes and selected use of antioxidant or trace mineral supplements may preserve vision in older persons.

• AGGRESSIVE BLOOD GLUCOSE CONTROL– Intensive control of blood glucose has been shown to reduce the progression of diabetic retinopathy in persons with type 1 and type 2 diabetes.

– A 10-year poststudy analysis of survivors in the U.K. Prospective Diabetes Study (UKPDS) showed a persistent and significant 24 percent decrease in relative risk of microvascular events in the intensive blood glucose control group, even if tight glucose control was subsequently lost.

– It is challenging to apply this evidence to older persons with diabetes because older adults are particularly susceptible to hypoglycemia with tight glucose control.

– Therapy must be individualized to the patient; as a general rule, blood glucose in older persons with diabetes should be as tightly controlled as possible while avoiding hypoglycemia and its attendant risks.

• BLOOD PRESSURE MANAGEMENT– Aggressive blood pressure control with a target of less than 150/85 mm Hg is likely to be vision preserving in older persons, especially those with

diabetes. – The UKPDS demonstrated that lowering blood pressure to below 150/85 mm Hg in persons with diabetes reduces the risk of progressive diabetic

retinopathy, irrespective of A1C level.– A 10 mm Hg decrease in systolic blood pressure provided an 11 percent relative risk reduction in the incidence of photocoagulation or vitreous

hemorrhage; however, – unlike intensive blood glucose control, blood pressure lowering must be sustained over time to preserve any benefit.34,35

– Hypertension (with or without a diagnosis of diabetes) is associated with a higher risk of ischemic eye events, such as central retinal vein occlusion.• Smoking Cessation

– Smoking has been linked to a variety of causes of visual impairment in older persons, including AMD,cataracts,and progressive diabetic retinopathy.For ophthalmic health, as well as numerous other benefits, older persons who smoke should be advised to quit and offered smoking cessation counseling.

• LIPID MANAGEMENT– Hyperlipidemia is an independent risk factor for central retinal artery and vein occlusion. Only observational studies so far.

Vision Impairment• ULTRAVIOLET LIGHT EXPOSURE

– Cumulative ultraviolet light exposure is linked to the development of cataracts.Older adults should be advised to consider the routine use of sunglasses that filter out ultraviolet light when driving or engaged in outdoor activity.

• DIET AND SUPPLEMENTS• A Cochrane meta-analysis reviewed three large prospective clinical trials of antioxidant supplements or zinc to

prevent or delay the onset of AMD, and found no demonstrable benefit.42

• The Age-Related Eye Disease Study (AREDS) enrolled 3,640 persons with established AMD in a four-arm, randomized, prospective clinical trial of antioxidant supplementation, antioxidants plus zinc, zinc plus copper, and placebo. High-risk persons (those with more advanced disease at enrollment) randomized to the antioxidants plus zinc group had statistically significant preservation of vision compared with the placebo group (estimated odds reduction of 27 percent).– Important caveats are attached to the use of these supplements. Excessive intake of vitamins A and E, especially in smokers,

has been linked with an increased risk of lung cancer, and possibly higher rates of congestive heart failure.Reanalysis of the AREDS data suggests that zinc supplementation is associated with an increased risk of hospitalization for urologic problems.46

• There are no prospective or randomized trials of anti-oxidant supplementation for prevention or treatment of eye diseases other than AMD. Observational studies have shown conflicting association between high levels of dietary intake of antioxidants and cataract formation.47

• Routine antioxidant or mineral supplementation in all older adults for prevention of AMD or other eye diseases cannot yet be recommended until ongoing, prospective trials clarify who may benefit and what harms, if any, might result from long-term supplementation. There is encouraging evidence, which needs to be further validated, that specific antioxidant and zinc supplementation (the regimen used in AREDS) may preserve vision in some persons with advanced AMD.

Question

• An 82-year-old female with terminal breast cancer has been admitted to hospice care. She is

• having severe pain that you will manage with opioids.• Which one of the following would be appropriate to

recommend for preventing constipation?• A) Fiber supplements• B) Docusate (Colace)• C) Metoclopramide (Reglan)• D) Polyethylene glycol (MiraLax)• E) No preventive measures, and treatment only if

constipation develops

Answer• ANSWER: D• Constipation is a very common side effect of opioids that does not

resolve with time, unlike many other• adverse effects. Constipation is easier to prevent than to treat, so it is

important to start an appropriate• bowel regimen with the initiation of opioid therapy. Fiber

supplements and detergents (such as docusate)• are inadequate for the prevention of opioid-induced constipation.

Metoclopramide is used for nausea and• increases gastric motility, but is not indicated in the treatment of

constipation. Polyethylene glycol,• lactulose, magnesium hydroxide, and senna with docusate are all

appropriate in this situation.

Question• You are the attending physician at a long-term care facility. A new

resident, an 85-year-oldfemale, presents for an initial evaluation. Upon reviewing her history, you find that she is on 18 different medications. Until you can obtain additional history and medical records, you decide to stop or decrease some of her medications and monitor her response.

• Which one of the following would be most appropriate to stop or decrease initially?

• A) Sertraline (Zoloft), 25 mg daily• B) Acetaminophen/diphenhydramine (Tylenol PM), 500 mg/25 mg daily• C) Dipyridamole/aspirin (Aggrenox), 200 mg/25 mg daily• D) Digoxin, 0.125 mg every other day• E) Omeprazole (Prilosec), 20 mg daily

Answer• ANSWER: B• Polypharmacy is common in the elderly population, but the use of numerous medications is necessary in• some elderly patients. However, some medications have been identified as having a considerably higher• potential to cause problems when prescribed to elderly patients.• In the case described, acetaminophen/diphenhydramine would be an appropriate medication to stop• initially. The older antihistamines cause many adverse CNS effects such as cognitive slowing and delirium• in older patients. These effects are more pronounced in elderly patients with some degree of preexisting• cognitive impairment. The anticholinergic properties of older antihistamines produce effects such as dry• mouth, constipation, blurred vision, and drowsiness. The sedative effect of older antihistamines also• increases the risk of falls. Hip fracture and subsequent death have been reported in patients who use older• antihistamines such as diphenhydramine.• Sertraline is an SSRI, a preferred class for the treatment of depression in the elderly compared to the• tricyclic antidepressants, which are associated with several side effects. Dipyridamole is associated with• hypotension in elderly patients, but it benefits some individuals by preventing strokes. It can be used in• the elderly, but patients should be monitored for side effects. Therefore, until further information is• obtained, it is appropriate to continue the dipyridamole/aspirin in this patient.• When used in elderly patients with heart failure, digoxin should be given in a dosage no greater than 0.125• mg daily; the low dosage used in this individual should not be considered inappropriate until the reason• for its use is clarified. While omeprazole can cause problems in the elderly with long-term use, 20 mg/day• is a relatively low dose and the decision to discontinue its use should be delayed until more history is• available.

Question• A 72-year-old female presents with a 2-month history of constipation. She says

she has to strainto evacuate at least half the time and reports that her stools have become clay-like in consistencyand narrower in caliber. At least half the time she has the sensation that evacuation is notcomplete, and she has occasionally used manual maneuvers to complete evacuation. She had anormal colonoscopy 8 years ago.An abdominal examination is normal, and stool with a clay-like consistency is palpated duringa rectal examination. No prolapse is seen with straining, and the anal wink is present. Screeninglaboratory tests indicate a mild microcytic, hypochromic anemia.

• Which one of the following would be most appropriate at this time?• A) A trial of lactulose• B) Lifestyle modifications• C) Phosphosoda enemas• D) Colonoscopy• E) Pelvic floor muscle exercises

Answer• ANSWER: D• This patient has several red flags that require complete colon

evaluation with endoscopy: age >50, achange in stool caliber, and obstructive symptoms. Other red flags include heme-positive stools, anemiaconsistent with iron deficiency, and rectal bleeding. Malignancy should be eliminated as a possiblediagnosis prior to initiating any treatment. Biofeedback training is used to manage pelvic floor dysfunctioncaused by incoordination of pelvic floor muscles during attempted evacuation. Common symptoms includeprolonged or excessive straining, soft stools that are difficult to pass, and rectal discomfort. The other options are appropriate management strategies once malignancy has been eliminated as a possibility.

Question

• You see a 75-year-old male for his Medicare annual wellness visit. Which one of the following satisfies the Medicare requirement for vision screening?

• A) Questioning the patient about vision changes• B) Use of the Amsler grid to detect age-related

macular degeneration• C) Use of the Snellen eye chart to evaluate visual

acuity• D) Use of an ophthalmoscope to detect cataracts• E) Use of tonometry to detect glaucoma

Answer• ANSWER: C• Although Medicare does not pay for an “annual physical,” it does provide for

annual preventive screening services, including a complete health history and an array of screening measures for depression, fall risk, cognitive problems, and other challenges. The physical examination conducted as part of the annual wellness visit includes measurement of blood pressure and weight, a vision check, and hearing evaluation, as well as additional elements depending on the individual’s health risks. While questioning the patient or caregiver regarding perceived hearing difficulties may suffice when screening for hearing loss, screening for vision loss requires use of a standard screening tool. Documentation of visual acuity by use of the Snellen chart is an accepted means of screening for visual acuity in the primary care setting (SOR A). Vision screening will not pick up age-related macular

• degeneration or cataracts, however.

Question

• Most of the gait disturbances identified in geriatric patients in the outpatient primary care setting are related to which one of the following?

• A) Sensory ataxia• B) Parkinson’s disease• C) Osteoarthritis• D) Multiple strokes• E) Myelopathy

Answer• ANSWER: C• Problems with gait and balance increase in frequency with advancing age and

are the result of a variety of individual or combined disease processes. Findings may be subtle initially, making it difficult to make an accurate diagnosis, and knowing the relative frequencies of primary causes may be useful for management. A cautious gait (broadened base, slight forward leaning of the trunk, and reduced arm swing) may be the first manifestation of many diseases, or it may just be somewhat physiologic if not excessive.In the past, a problematic gait abnormality in an elderly person was generally termed a senile gait if therewas no clear diagnosis; it is more accurate, however, to describe this as an undifferentiated gait problemsecondary to subclinical disease. From the long list of potential causes, arthritic joint disease is by far themost likely to be seen in the family physician’s office, accounting for more than 40% of total cases. It mostfrequently causes an antalgic gait characterized by a reduced range of motion. The patient favors affectedjoints by limping or taking short, slow steps.

Question• A 67-year-old white male with hypertension and chronic kidney

disease presents with the recentonset of excessive thirst, frequent urination, and blurred vision. Laboratory testing reveals a1c fasting blood glucose level of 270 mg/dL, a hemoglobin A of 8.5%, a BUN level of 32 mg/dL,and a serum creatinine level of 2.3 mg/dL. His calculated glomerular filtration rate is 28mL/min.

• Which one of the following medications should you start at this time?

• A) Glipizide (Glucotrol)• B) Metformin (Glucophage)• C) Glyburide (DiaBeta)• D) Acarbose (Precose)

Answer

• ANSWER: A• It is recommended that metformin be avoided in

patients with a creatinine level >1.5 mg/dL for men or>1.4 mg/dL for women. Glyburide has an active metabolite that is eliminated renally. This metabolitecan accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia. Acarboseshould be avoided in patients with chronic kidney disease, as it has not been evaluated in these patients.Glipizide does not have an active metabolite, and is safe in patients with chronic renal disease.

Question• A 68-year-old white female with a several-year history of well-controlled

essential hypertensionand a history of acute myocardial infarction 2 years ago is brought to the emergency departmentcomplaining of sudden, painless, complete loss of vision in her left eye that began 1 hour ago.Her vital signs are stable, and her blood pressure is 148/90 mm Hg. Her corrected visual acuityis: left—absent, with no light perception; right—20/30. The external eye examination is entirelyunremarkable. A retinal examination reveals the findings shown in Figure 5.

• The most likely diagnosis is• A) acute narrow-angle glaucoma• B) optic neuritis• C) retinal hemorrhage• D) central retinal artery occlusion• E) central retinal vein occlusion

Answer

• ANSWER: D• The retinal findings shown are consistent with central

retinal artery occlusion. The painless, unilateral,sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis.Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a redeye, which will lead to blindness if not treated. In persons with optic neuritis, funduscopy reveals ablurred disc and no cherry-red spot. Occlusion of the central retinal vein causes unilateral, painless lossof vision, but the retina will show engorged vessels and hemorrhages.