An 86-year-old woman lives home alone. Her husband died 2 years ago; since then her self-care has deteriorated. She has lost weight and has become increasingly frail. She has fallen on several occasions and appears bewildered when faced with simple household decisions. Physical examination shows no focal neurological deficits and a Folstein Mini-Mental Status score of 19 (out of possible 30). A workup for reversible causes of dementia is negative, and treatment in a balance disorder clinic is not helpful because the patient cannot remember her instructions. The patient appears in your office, accompanied by her daughter, who is concerned about her mother’s safety. She inquires about nursing home placement but is worried about the financial implications of this decision.
Which of the following statements is true?
Medicare is a federally sponsored health insurance program for the elderly (age > 65). Medicare part A provides for acute hospitalization and some subacute and transitional services. Medicare part B, which requires a monthly premium, pays the fees of doctors and certain other health providers. Medicare part D covers some prescription drug costs. Although Medicare covers some groups of nonelderly patients (eg, chronic dialysis patients, disabled patients), it does not pay for long-term custodial care even in the elderly. Medicare will provide payment for hospice care if the patient has an estimated life expectancy of less than 6 months.
Medicaid is a welfare program to provide health care monies to the indigent. Whereas Medicare is administered by the federal government, Medicaid is administered by the states (often, however, using pass-through funds from the federal government). The eligibility threshold for Medicaid, therefore, varies from state to state. Generally, adults who qualify for Medicaid must be very poor with few available assets (requirements for coverage of children and pregnant women are somewhat more lenient). Medicaid provides few transitional services, but does pay for chronic nursing home care. The decision to place a frail parent in assisted living, nursing home, or Alzheimer unit is a difficult one for many families. Still, 30% of frail elderly are in chronic nursing facilities, often at a monthly cost of $3000 to $6000. Over 50% of patients above age 90 are unable to care for themselves at home.
A frail 80-year-old nursing home resident has had several episodes of syncope, all of which have occurred while she was returning to her room after breakfast. She complains of light-headedness and states she feels cold and weak. She takes nitroglycerin in the morning for a history of chest pain, but denies recent chest pain or shortness of breath.
Which of the following is the best initial test?
Postprandial hypotension has been increasingly recognized in the frail elderly. In one study, a quarter of all patients had a reduction in systolic blood pressure of greater than 20 mm Hg. Much of the decrease is attributed to splanchnic blood pooling. Those on nitrates and other drugs that cause postural hypotension are at greatest risk. Older patients with this condition should avoid large meals. Diagnosis is confirmed by monitoring blood pressure after eating. Carotid studies are indicated in those with focal weakness/numbness or amaurosis fugax suggestive of focal carotid disease; this woman’s symptoms instead suggest global brain underperfusion. Cardiac arrhythmia is unlikely to cause the symptoms described. Arrhythmic symptoms are usually of sudden onset and are typically not preceded by warning symptoms such as coldness and light-headedness. If initial evaluation is negative a Holter monitor may be of value. CT scan is rarely helpful in the evaluation of syncope in a patient without focal neurologic findings. In the absence of clinical features to suggest seizure, EEG is not recommended in the diagnostic workup of syncope.
A 78-year-old woman with mildAlzheimer disease falls at home and suffers a left hip fracture. She is admitted to the hospital and undergoes a left total hip replacement. Postoperatively she is D5W and treated with meperidine for pain, diphenhydramine for sleep, and prophylactic ranitidine. On the second postoperative day, she pulls out her Foley catheter and her IV. On examination blood pressure is 150/90, pulse rate is 80, and temperature 36.7°C (98°F). Oxygen saturation on room air is 92%. She is markedly confused and appears agitated. She has no focal neurologic findings. Laboratory testing reveals:
What is the best next step in her management?
This patient has postoperative delirium, characterized by acute onset of confusion and agitation. Frequently the level of consciousness fluctuates. Postoperative delirium is common in the elderly. Males are affected more commonly than females. Delirium occurs more frequently in elderly patients with preexisting dementia, history of alcohol abuse, and memory impairment. Persons with postoperative delirium should receive a careful history that includesmedication review, a focused physical examination, and laboratory testing. Laboratory testing should be directed toward excluding electrolyte disturbance, infection, and hypoxemia. The most common treatable causes of delirium are related to medications and electrolyte disturbances. Medicines with anticholinergic and sedating effects should be avoided. Commonly prescribed drugs with anticholinergic properties include diphenhydramine, tricyclic antidepressants, oxybutynin, and H2 blocking agents. Management of postoperative delirium includes looking for underlying precipitating factors, correcting electrolyte disturbances, discontinuing aggravating medications, removing indwelling devices, avoiding physical or pharmacologic restraints, early mobilization, and the use the orienting stimuli such as clocks and calendars. Postoperative delirium is a serious condition and is associated with increased mortality, prolonged hospital stay, and more frequent nursing home placement after hospitalization. Structural central nervous system disease is an uncommon cause of postoperative delirium, so CT scanning would not be the first test ordered. Pulmonary embolism can cause delirium by causing hypoxia; since this patient’s oxygen saturation is normal, lung scan would not be indicated. Infection can cause postoperative delirium, but this patient’s normal temperature and white blood cell count militate against an infectious cause. Restraints and benzodiazepines often make delirium worse. If pharmaco-therapy is required, haloperidol is usually the first choice.
A 78-year-old man complains of slowly progressive hearing loss. He finds it particularly difficult to hear his grandchildren and to appreciate conversation in a crowded restaurant. On examination, ear canal and tympanic membranes are normal. Audiology testing finds bilateral upper-frequency hearing loss with difficulty in speech discrimination.
Which of the following is the most likely diagnosis?
Presbycusis is the most common cause of sensorineural hearing loss in the elderly. Probably the result of cochlear damage over time, it is characterized by bilateral high-frequency hearing loss above 2000 Hz. Diminished speech discrimination is more apparent compared to other causes of hearing loss. Both Ménière’s disease and chronic otitis media are causes of hearing loss in the elderly; they usually present as unilateral hearing loss. Acoustic neuroma is uncommon and also causes unilateral neurosensory hearing loss. Otoscopy should always be used to rule out hearing loss associated with cerumen impaction in the elderly patient.
A 76-year-old man complains of memory difficulties. He has trouble remembering where he parks his car at the supermarket and struggles with the names of new acquaintances. He has no trouble managing his finances, can readily recall the names of close friends and family members, and does not get lost in familiar settings. He has hypertension managed with an ACE inhibitor and takes acetaminophen for knee pain. He is optimistic and enjoys life. His general physical examination is normal. On the Folstein Mini-Mental State Exam, he scores 27 out of a possible 30 points. He only recalls one out of three objects after a 5-minute interval. Tests of language, calculation, and executive function are normal.
What is your best course of management for this patient?
This patient has age-related mild cognitive dysfunction (MCI). He has a deficit in only one area of cognition, (ie, memory) with intact language, visuospatial, and executive functions and is not disabled in activities of daily living. Although 10% of such patients progress to frank dementia each year, some will improve, so progression is not inevitable. Although mental activities such as crossword puzzles have been anecdotally felt to prevent cognitive decline, there is no definitive evidence than any intervention affects the natural history of MCI. Most patients with overt dementia lose insight along with memory and do not notice their own memory deficit.
Workup for treatable causes of cognitive decline (ie, CNS imaging, electrolytes, thyroid, and B12 levels) is indicated in patients with frank dementia, but not in those with MCI. Depression can present as self-reported memory problems but should cause other symptoms such as anhedonia. Neuropsychological testing can be helpful in complicated cases but is expensive and not used routinely. Although donepezil is usually the initial therapy in Alzheimer disease, it has not been proven to prevent progression of MCI to overt dementia.
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