Common Problems in Geriatrics for Orthopedic Surgeons

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Common Problems in Geriatrics for Orthopedic
Surgeons

• Steven Zweig, MD
• Family and Community Medicine
• MU School of Medicine

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Goals

• Recognize the importance of aging physiology in
  the development and treatment of specific
  problems
• Prevent and treat delirium
• Recognize the significance of polypharmacy
• Identify patients at risk for elder abuse

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Case 1 - 80 year old woman with hip fracture

• Hx- Lives alone, with some help from family.
  Forgetful of names and dates. Slipped on throw
  rug, found by nephew. No meds. No know medical
  illnesses.
• PE - cold, confused, agitated. Shortened
  externally rotated left leg. Pain with movement.
  Normal heart, lungs, neurological exam.
• Lab and x-ray - normal CBC, BMP. Displaced
  fracture of femoral neck.
• RX - hemiarthroplasty performed. Pt recovered
  from anesthesia, then became confused and
  agitated.

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Delirium

• Disturbance of consciousness, with reduced
  ability to focus or shift attention
• Change in cognition (memory, language,
  disorientation)
• Develops over short time, may fluctuate
• Due to substance use or withdrawal, medical
  condition, or multiple causes

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Work-up for Delirium

• Review hx of psych, dementia, alcohol
• Review of meds (esp. anticholinergic, autonomic,
  CNS)
• Use of glasses or hearing aids
• Evaluate pain management

• Physical exam for VS, neuro, skin, infections
• Mental status exam
• Lab and x-ray for infections (lung, urine), fluid
  and lytes, hypoxia, BS, new trauma, systemic dx

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Mental Status Evaluation

• Confusion Assessment Method
• Presence of acute onset and fluctuating course
  and
• Inattention and either
• Disorganized thinking or
• Altered level of consciousness
• Mini mental state examination

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Treatment of Delirium

• Reverse underlying problem
• Provide adequate pain relief
• Avoid high-risk meds (e.g. meperidine,
  anticholinergics, long-acting benzo)
• Maintenance of fluids and electrolytes
• Removal of restraints
• Removal of indwelling catheter

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Treatment of Delirium (cont.)

• Orientation to new environment (sitters, increase
  light at dusk, familiar objects and people,
  frequent orientation)
• Small doses of haloperidol (0.5 mg) or lorazepam
  (0.5 mg)
• Consider with regard to rehabilitation
• Discharge planning

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Case 2 - 76 year old woman with osteoarthritis

• Hx- Pt referred by FP for evaluation for joint
  replacement of right knee. Also has pain in other
  knee, back, and L shoulder. Until 2 mos ago, she
  was a vigorous community volunteer. Nurse found
  her to have poor balance, nearly falling. Hx of
  CHF with pneumonia 5 yrs ago. Meds include
  Furosemide 40 mg, KCL 40 meq, digoxin .25 mg,
  flurazapam 30 mg prn for sleep, meclizine 25 mg
  tid prn for dizziness, oxybutinin 5 mg bid for
  stress incontinence, and clonidine 0.1 mg bid
  added recently for hypertension.

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Case 2 (cont)

• PE - Patient is lethargic. Forgets the questions.
  Admits to continued pain in knees. BP 128/75,
  pule 68. Diffuse crepitus in both knees, pain
  with range of motion. Small effusion on right.
  Decreased abduction and external rotation in both
  shoulders but functional for daily activities.
  Lungs clear. Heart RRR without S3 gallop. No
  edema in lower extremities.
• The patient is prescribed ibuprofen, and when
  seen 2 weeks later she is worse. Alert and
  somnolent on exam. Daughter concerned about
  dementia.

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What to do?

• You suspect delirium due to polypharmacy, call
  the FP - not a surgical candidate now
• Digoxin dose too high for most elderly
• BP low for hypertension, orthorstatic 20 mg-
  taper the clonidine and change furosemide to HCTZ
• Long acting benzodiazepine with active metabolite
• Antihistamine causes sedation and is
  anticholinergic
• Oxybutin is anticholinergic, can cause confusion

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Altered Drug Distribution
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Altered Drug Metabolism
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Altered Renal Excretion

• GFR decreases 50 from age 30 to 80 yrs
• Often serum creatinine normal due to loss of lean
  muscle mass
• Calculate clearance as follows CrCl
  
• (140- age)(wt in kg)/72 (serum Cr)
• in women multiply x .85

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Common Adverse Drug Reactions
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Principles of Geriatric Prescribing

• Treat problems specifically - dont use a drug if
  possible
• Start low, go slow, but use enough
• Review drug list at each visit
• Use side effects to benefit the patient
• When in doubt, stop the medication

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Case 4- 75 year old woman with upper arm pain

• Hx Brought to ER by 43 year old daughter who
  reports history of falls, including one
  yesterday. Wt loss of 35 pounds over 2 years,
  progressive disability. Pain worse. Daughter
  looks distraught and tired, describes mother as
  difficult.
• PE Withdrawn older woman, older appearing. Poor
  hygiene and disheveled. BP 120/80, pulse 84
  sitting 100/70, pulse 96 standing. Alert,
  oriented, would not look up or cooperate with
  mental status testing. Bruises around wrist and
  ankles. Deformity and tenderness right upper arm
  and distal forearms. Pressure ulcer right heel.

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Case 3 - cont.

• X- ray and lab findings displaced spiral
  fracture of the right proximal humerus with
  callus. Bilateral malunited distal radius
  fractures. Osteopenic bones. Normal chest x ray.
  
• Differential Dx Elder abuse, delirium, dementia,
  clotting disorder, severe osteoporosis,
  depression, alcoholism, gait disorder
• More info Daughter answered for patient.
  Separate interviews revealed patient intimidated
  by daughter. Bruises due to restraints.
  Insufficient income for food or meds.

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Elder Abuse

• Abuse can be physical, psychological, and
  financial or material harm
• 1 million cases reported each year
  under-reporting due to denial, lack of knowledge

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Risk factors

• Poor health, functional impairment of patient -
  reduces ability to seek help
• Cognitive impairment - aggression or disruptive
  behavior precipitates abuse
• Substance abuse or mental illness in abuser
• Dependence of abuse on victim
• External stressors - shared living, finances

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Risk Factors

• Social isolation - reduces likelihood of
  detection and no supports
• History of violence in relationship may predict
  abuse
• Unexplained trauma, delays in seeking care, or
  excessive visits to ER or urgent care
• Disparities in histories from patient and
  suspected abuser

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Management

• Report to Division of Aging Hotline -
  800/235-5503 -even if only a suspicion of abuse
• Admit to provide proper medical care
• Consult social work for continuing
  communications/focused interventions
• Must respect the wishes of a capable patient

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Tips for Coordinating Care

• Medicare home care - requires need for skilled
  nurse or PT
• Admission to SNF requires 3 day hospital stay -
  contact the NH physician to plan
• PPS means capitated reimbursement to SNFs
• Medicare does not cover costs of drugs
• Get SW involved if any care problems anticipated