Common Issues in the Elderly (Part II)AJAY ZACHARIAH, MD

2/24/2015

OsteoporosisRISK FACTORS, WORK UP, TREATMENT

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

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

DXA: Criteria for Screening

Dual-energy X-ray Absorptiometry Women

>65 y/o <65 y/o with both:

Postmenopausal

Clinical risk factors for fracture

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

T Score

Measured in standard deviations-1: Normal-1 to -2.5: Osteopenia< -2.5:

Osteoporosis< -2.5 + fracture: Severe

Osteoporosis

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

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

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%

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

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

Decision Making in the Elderly

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

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.

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

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”

Tube Feeding

Complications

ComplicationsAspirationDiarrheaMetabolic

HyperglycemiaMicronutrient deficiencyRefeeding syndrome

Constipation

Vaccinations

Elder Abuse

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

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 shortagesSource: National Elder Abuse Incidence Study (NEAIS) – 2812 community-dwelling elderly

Screening

Abbreviated ScreeningDo you feel safe where you live?Who prepares your meals?Who handles your checkbook?

Sexuality

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

Causes of Cessation: Women

Consequences Decline in libido

Decreased physiologic sexual response

Discomfort/dyspareunia

Decreased sexual frequency

Fatigue