A 75-year-old woman is accompanied by her daughter to your clinic. The daughter reports that her mother fell in her yard last week while watering flowers. Her mother suffered scratches and bruises but no serious injury. The daughter is concerned that her mother might fall again with serious injury. The patient has hypertension and osteoarthritis of the knees. She takes HCTZ, lisinopril, naproxen, and occasional diphenhydramine for sleep. The daughter reports some mild forgetfulness over the past 2 years. The patient gets up frequently at night to urinate.
Blood pressure is 142/78 lying and 136/74 standing. Pulse is 64 lying and standing. Except for some patellofemoral crepitance of the knees, her physical examination is normal. A Folstein Mini-Mental Status test is normal except that she only remembers two of three objects after 3 minutes (29/30). She takes 14 seconds to rise from sitting in a hard backed chair, walk 10 ft, turn, return to the chair, and sit down (timed up-and-go test, normal less than 10 seconds). CBC, chemistry profile, and thyroid tests are normal.
What is the next best step?
Falls in the elderly are common. Nearly one-third of community dwelling adults over 65 years of age fall at least once yearly. Minor imbalances are common in everyday life. Falling in the elderly is usually associated with decreased ability of the elderly to compensate for these imbalances. Agerelated declines in vestibular function, autonomic function, hearing and eyesight, and muscular strength all contribute to the inability of the elderly to correct for minor imbalances. Medical illnesses and medications may also contribute to this difficulty. The evaluation of falling in the elderly includes a careful history to exclude syncope, a careful medication history, and a review of medical conditions, which may aggravate falling. Persons who have fallen more than once in the last 6 months are at high risk of falling again. The timed up-and-go (TUG) test also predicts who is likely to fall again in the next year.
In an elderly person who presents with falling, evidence-based literature supports three measures to prevent future falls: elimination of medications with sedating and anticholinergic properties, elimination of environmental and structural hazards in the home, and physical therapy. Diphenhydramine has both sedating and anticholinergic effects.
In the absence of syncope and focal neurologic findings, CNS imaging, EEG, and Holter monitoring are unnecessary. Since the patient does not have orthostatic hypotension, discontinuing HCTZ is not indicated. Donepezil is indicated for dementia but not just forgetfulness.
A 78-year-old woman with mild renal insufficiency complains of pain in the right knee on walking. The pain interferes with her day-to-day activities and is relieved by rest. There is no redness or swelling. There is minimal joint effusion. An x-ray of the knee shows osteophytes and asymmetric loss of joint space. ESR and white blood cell count are normal.
Which of the following is the best initial management of this patient?
This patient has osteoarthritis. In addition to physical therapy, the best symptomatic treatment would be acetaminophen because it is frequently effective in providing pain relief and has an excellent safety profile in the elderly. Nonsteroidals should be avoided, at least initially, because they tend to cause gastrointestinal upset and impairment of renal function. Indomethacin is relatively contraindicated in the elderly because of its long half-life and central nervous system side effects. Intra-articular steroids are indicated for large effusions in joints unresponsive to first-line therapy. Arthroplasty is highly effective in treating osteoarthritis of a single joint and is not contraindicated in the elderly. Such surgery is usually considered if attempts at physical therapy, education, and pain control with pharmacotherapy do not provide adequate symptom relief.
An 82-year-old man is admitted to a long-term care facility after a right hemiplegic stroke. He is unable to walk and has limited ability to move himself in bed. He is frequently incontinent of urine. He has a past history of type 2 diabetes mellitus. On examination you note a 3-cm area of persistent erythema on the right buttock.
Which of the following treatments would you recommend at this time?
Pressure ulcers are a serious problem in the elderly. They result when skin is damaged by compression between a bony prominence and hard surface for prolonged periods. Pressure ulcers are classified using a standard staging system. A stage I ulcer consists of persistent erythema. A stage II ulcer is characterized by partial-thickness skin loss involving the epidermis or dermis or both. These ulcers are superficial. A stage III ulcer is characterized by full-thickness skin loss involving subcutaneous tissue but not extending through underlying fascia. A stage IV ulcer is a stage III ulcer that extends through fascia and results in damage to underlying structures such as muscle or bone. The treatment of all pressure ulcers includes frequent monitoring of the ulcer, modifying the support surface (such as prescribing a foam mattress), frequent repositioning, and keeping the skin dry and clean from urine and stool. Scheduled urinary voidings are preferable to Foley catheters, which increase risk for urinary tract infection. In order to remove devitalized tissue, debridement is recommended for stages II, III, and IV ulcers. Hydrocolloid gels are recommended for stages II and III ulcers. Neither of these interventions would be indicated for this patient’s stage I ulcer. All pressure ulcers eventually become colonized with bacteria. Local wound care is the first management of these infections. Topical antibiotics are reasonable if the ulcer is unimproved after 2 weeks of local wound care. Intravenous antibiotics are reserved for patients with cellulitis, sepsis, or underlying osteomyelitis.
A 65-year-old man has had symptoms of progressive cognitive dysfunction over a 1-year period. Memory and calculation ability are worsening. The patient has also had episodes of paranoia and delusions. Antipsychotic medication resulted in extrapyramidal signs and was stopped. The patient has recently complained of several months of visual hallucinations. There is no history of alcohol abuse.
Which of the following is the most likely diagnosis?
Lewy body dementia has been recently recognized as a specific type of dementia different from Alzheimer disease or Parkinson disease. On autopsy Lewy bodies are present throughout the brain, including the cortex. Mild Parkinsonism may or may not be present. Paranoia and delusions are more common than in Alzheimer disease, and treatment with antipsychotic drugs characteristically worsens the underlying condition. Visual hallucinations are characteristic of Lewy body dementia and uncommon in Alzheimer disease. Parkinson disease causes dementia late in its course, when the characteristic tremor, bradykinesia, and balance disturbance are easily recognized. Delirium is an acute confusional state that would not present with progressive cognitive deterioration or repeated hallucinations over time. Vascular dementia is characterized by stepwise progression (due to numerous lacunar strokes) and upper motor neuron signs.
An 80-year-old nursing home patient has become increasingly confused and unstable on her feet. On one occasion she has wandered outside the nursing home. In considering the issue of restraints for this individual,
which of the following is correct?
Restraints are being used less and less in nursing homes as their complications and alternatives become more appreciated. The four Ds— deconditioning, depression, disorientation, and decubiti—are all complications of restraints. A geri-chair is just another form of physical restraint and promotes the same difficulties. Effective alternatives to restraints usually require an individual care plan. In this case, alarm bells for the institution’s exits and evaluation of the patient’s gait would be important. All physical restraints, either wrist or ankle restraints, should be avoided if possible. Sedation leads to complications such as pneumonia and may, in fact, also promote falls.
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