Rapid review of medicine in old age

161 Pages·2008·3.524 MB·English

by  Michael Vassallo, S C Allen

Rapid Review of
Medicine
in Old Age
Dr Michael Vassallo
MD, FRCP(Lond), FRCP(Edin), DGM(Lond), M.Phil, PhD
Consultant Physician in General Internal Medicine and Geriatric Medicine
The Royal Bournemouth Hospital, Bournemouth, UK
and
Honorary Senior Clinical Lecturer, University of Southampton, UK
Professor Stephen Allen
BSc, MBChB, MD(Manc), FRCP(Lond), FRCP(Edin), MBA
Consultant Physician in General Internal Medicine and Geriatric Medicine
The Royal Bournemouth Hospital, Bournemouth, UK
Visiting Professor of Clinical Gerontology, Bournemouth University, Poole, UK
and
Honorary Senior Clinical Lecturer, University of Southampton, UK
MANSON
PUBLISHING
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Medical knowledge and best practice are constantly evolving as new research and experience contribute to our
understanding. While the authors have taken every effort to eliminate inaccuracies, readers are advised to consult the
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Acknowledgements
The authors wish to thank the following for permission to reproduce photographs: Michael Richardson (Figure 57),
University of Utah John Moran Eye Centre (Figure 26), Lithuanian Society of Gerontology and Geriatrics (Figure 16),
and National CJD Surveillance Unit (Figure 22b).
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ISBN 978-1-84076-090-3
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3
Preface
This book has two main purposes; formative case analysis The questions are mostly in best-of-five format, to
and self-assessment of medicine in old age. It presents reflect the current style of multiple choice questions used
clinicians with a series of clinical cases that form the basis in examination, though we have included some open
for discussion of the investigation and management of questions when that is more appropriate for the topic and
the patients. It also provides the trainee, or established as a basis for the tutorial sections. We have expanded
doctor, with a medium to help prepare for post-graduate many of the clinical stems to a size that is rather larger
examinations and clinical practice. We believe it will be than that encountered in examinations. This provides a
particularly useful to candidates taking the MRCP Part 2 platform for a sequence of questions in the longer cases
written examination, the DGM, and formal knowledge that improves the educational function of the book and
tests for specialist registrars in Geriatric Medicine, more rigorously tests the reader’s deductive thinking. We
General Medicine and Acute Medicine. have phrased some questions in the negative. This reflects
We have not attempted to write a comprehensive the reality of decision making in clinical practice, so we
textbook of geriatric medicine as the field is vast and overlaps believe it is justified. Some topics and themes appear
with many other specialties. Instead, we have chosen cases more than once; again, this is deliberate and serves to
that cover the main modes of presentation of acute illness in reinforce certain important messages.
old age, such as falls, confusion, incontinence, weight loss We have used the past tense for all the clinical stems,
and immobility, with examples from all the major systems. though we have made free with the present and past
These illustrate the complexity of diagnosis and treatment of tenses in the follow up sections according to the need for
medical illness in frail older people, and the need to think clarity, emphasis and a natural style. We hope the past
widely and laterally when caring for such patients. tense purists among the readership will forgive us for
All the cases are based on real people who have been taking that liberty.
under the care of the authors, and almost all the photo- Michael Vassallo
graphs are from the original patients. Stephen Allen
Classification of Cases
Note: references are to case numbers and not page Infectious disease 1, 6, 7, 15, 20, 34, 40, 50, 63, 80,
numbers. 105, 107
Malignant disease 10, 19, 41, 47, 49, 36, 39, 60, 61, 67,
Cardiovascular disease 14, 33, 43, 53, 54, 55, 66, 88, 99, 79, 90, 98, 102
101 Mobility and independence 16, 75, 83, 103
Cerebrovascular disease 2, 13, 30, 44, 45, 109 Neurological disease 12, 22, 28, 31, 42, 80, 85, 97, 100
Dementia and psychiatric disorders 5, 8, 22, 29, 59, 84, Nutrition 56, 69, 106
95 Respiratory system disease 6, 23, 58, 89, 67, 107
Dermatology 4, 21, 30, 37, 39, 62, 71, 77, 78, 79, 81, Rheumatological and bone disease 4, 15, 23, 25, 32, 57,
82 63, 65, 68, 72, 73, 74, 76, 108
Drug and fluid management 3, 35, 43, 70, 87, 104 Trauma and falls 4, 9, 11, 27, 30, 32, 66, 86
Endocrine disorders 61, 104 Urological and renal disease 24, 34, 41, 42, 96
Gastrointestinal disorders 17, 18, 19, 20, 46, 47, 48, 50, Vascular disorders 7, 24, 38, 64, 72
51, 52, 58 Visual loss 26, 93, 94
Haematological disorders 91, 92
3
Abbreviations
AAA abdominal aortic aneurysm FAB Frontal Assessment Battery OGD oesophagogastro-
ACE angiotensin-converting FEV1 forced expiratory volume in duodenoscopy
enzyme 1 second PACI partial anterior circulation
ACE-I angiotensin-converting FVC forced vital capacity infarct
enzyme inhibitor GCS Glasgow Coma Scale PAH pulmonary artery
ADH antidiuretic hormone GDS Geriatric Depression Scale hypertension
ADL activities of daily living GFR glomerular filtration rate PEG percutaneous endoscopic
A II RA angiotensin II receptor GI gastrointestinal gastrostomy
antagonist GIT gastrointestinal tract PET positron emission
AIDS acquired GP general practitioner tomography
immunodeficiency HbAlc haemoglobin Alc PLMS periodic limb movement
syndrome HDL high density lipoprotein during sleep
ALT alanine aminotransferase HIV human immunodeficiency POCI posterior circulation infarct
AMD age-related macular virus PSA prostate-specific antigen
degeneration HLA human leukocyte antigen PXE pseudo-xanthoma
AMTS Abbreviated Mental Test HRT hormone replacement elasticum
Score therapy RA rheumatoid arthritis
ANCA antineutrophil cytoplasmic IgA (G) immunoglobulin A (G) RBC red blood cell
antibody (M) (M) REM rapid eye movement
APTT activated partial INR international normalized rTPA recombinant tissue
thromboplastin time ratio plasminogen activator
AST aspartate aminotransferase ISH isolated systolic SHEP systolic hypertension in the
ATP adenosine triphosphate hypertension elderly programme
BMD bone mineral density IVU intravenous urogram SIADH syndrome of inappropriate
BMI body mass index JVP jugular venous pressure secretion of antidiuretic
BP blood pressure LACI lacunar infarct hormone
CCB calcium channel blocker LDL low density lipoprotein SLE systemic lupus
CJD Creuzfeldt–Jakob disease MCH mean cell haemoglobin erythematosus
CK creatine kinase MCV mean cell volume SMD senile macular
CMV cytomegalovirus MGUS monoclonal gammopathy degeneration
CNS central nervous system of undetermined SS systemic sclerosis
COPD chronic obstructive (uncertain) significance SSRI selective serotonin reuptake
pulmonary disease MI myocardial infarction inhibitor
CREST calcinosis, Raynaud’s, MMSE Mini-mental State SYST- systolic hypertension in
oesophageal involvement, Examination EUR Europe
sclerodactyly, MR magnetic resonance TACI total anterior circulation
telangioectasia MRC Medical Research Council infarct
CRP C-reactive protein MRI magnetic resonance TB tuberculosis
CSF cerebrospinal fluid imaging TENS transcutaneous electrical
CT computed tomography MRSA methicillin-resistant nerve stimulation
CVA cerebrovascular accident Staphylococcus aureus TIA transient ischaemic attack
DEXA dual energy X-ray MSSU mid stream specimen of TIBC total iron binding capacity
absorptiometry urine TNF tumour necrosis factor
DNA deoxyribonucleic acid MTP metatarso-phalangeal TSH thyroid stimulating
DVT deep vein thrombosis NIHSS National Institutes of hormone
ECG electrocardiogram Health Stroke Scale T3 triiodothyronine
ECT electroconvulsive therapy NPH normal pressure UK United Kingdom
EEG electroencephalogram hydrocephalus UTI urinary tract infection
ERCP endoscopic retrograde NSAID nonsteroidal anti- ZN Ziehl–Neelsen
cholangio-pancreatography inflammatory drug
ESR erythrocyte sedimentation OA osteoarthritis
rate
4
Patients 1, 2
Patient 1
An 82-year-old woman was referred to hospital by her 150/90 mmHg. Examination of the cardiovascular
GP as an emergency. She had been acutely confused for system, respiratory system, and abdomen was otherwise
4 days. Prior to that she had complained of a headache normal. CNS examination was difficult because of the
for about 1 week and had had at least two rigors. About delirium but it was noted that she had an extensor
1 month before that she had suffered a severe upper plantar reflex on the right.
respiratory tract infection and was diagnosed by her GP
as having frontal sinusitis. Her previous medical history
included diet-controlled diabetes mellitus, hypertension,
gout, and intermittent depression. Her medication
Investigations (normal range)
consisted of slow-release diltiazem 120 mg/day,
allopurinol 300 mg and citalopram 20 mg at night.
Haemoglobin 15.5 g/dL (11.5–16)
On examination she was found to have a body
MCV 86 fL (80–96)
temperature of 38.2°C and was clearly disorientated in Total white cell count 28.2 ×109/L (4–11)
time and place. An attempted AMTS gave a result of Neutrophil count 25.5 ×109/L (1.5–7)
4/10. Her heart rate was 100 bpm and regular, BP ESR 62 mm/h (<30)
Serum sodium 144 mmol/L (137–144)
Serum potassium 4.1 mmol/L (3.5–4.9)
Serum urea 10.1 mmol/L (2.5–7.5)
Serum creatinine 94 µmmol/L (60–110)
1 List the most important differential diagnoses. Liver function tests and bone chemistry all
normal
2 Which of the following investigations was most
likely to provide firm diagnostic information? 3 The most likely explanation for this patient’s raised
A Plain radiography of the skull to show the air serum urea was:
sinuses. A Mild chronic renal failure.
B Blood cultures. B Dehydration.
C Plain chest radiograph. C Urate nephropathy.
D CT head scan. D An adverse drug reaction.
E Nasopharyngeal bacteriology swab. E A hypercatabolic state.
Patient 2
1 Which best describes the overall diagnosis?
An 84-year-old woman presented with a left hemiparesis.
A Hemispheric stroke.
On examination she was found to have the abnormality
B Weber’s syndrome.
below (2a, 2b). This was a new sign.
C Foville’s syndrome.
D Lateral medullary syndrome.
E Brainstem stroke.
2a 2b
2aFacial appearance of patient. 2bFacial appearance of patient.
5
Patients 1, 2
Patient 1 Answers
1The most important differential diagnosis in this case is a 1 1CT head scan
cerebral abscess. This is supported by the delirium, abnormal showing a
neurological findings, headache, high white cell count, and cerebral abscess.
preceding history of a severe upper respiratory tract infection
with sinusitis. Other diagnoses to be considered include an
aggressive cerebral tumour, though the high white cell count
would not be expected in that condition, and severe
persisting bacterial sinusitis, which could cause a delirium
and a leukocytosis but would not result in an extensor
plantar response. Of course, in an elderly person, mixed
pathology always needs to be considered.
2 DCT head scan.
A CT head scan is most likely to provide definitive
information in this clinical context. A cerebral abscess
typically causes a mass lesion with ring enhancement after Tutorial
the injection of contrast, and a substantial amount of
surrounding cerebral oedema. An example of this can be
Cerebral abscess is not a common condition but it is
seen in Figure 1. CT head scanning also enables an treatable and the consequences of delayed treatment
accurate view of the air sinuses of the skull and will also are catastrophic. Elderly patients are particularly
help to rule out other important differential diagnoses likely to present with delirium and falls and the
such as cerebral tumour. Blood cultures should be diagnosis can be clouded by co-pathologies. The
performed in such a case because, if positive, they provide typical symptoms are those described in this case.
useful information to guide antibacterial treatment. Plain The neurological signs depend on the position of the
abscess. A cerebral abscess can result from haemato-
radiographs of the skull to outline the air sinuses would
genous spread of bacteria from sepsis in almost any
probably show a persisting degree of sinus mucosal
part of the body, though the well-documented most
oedema and secretions but would not help to
common associations are with sinusitis, lung abscess,
differentiate the diagnosis further.
bronchiectasis, penetrating head trauma, middle ear
infection, severe head and neck skin and subc u-
taneous sepsis, and infection involving the intra -
cerebral venous sinuses.
3 B Dehydration.
Treatment consists of drainage of the abscess when
this is surgically feasible (though very small abscesses
do not always require this), antibiotic treatment and
dexamethasone to suppress the cerebral oedema in the
The patient has been acutely confused and febrile for
early stages. Antibiotic treatment should be guided,
several days. Under such conditions elderly patients are
whenever possible, by bacteriological specimens and
particularly prone to become dehydrated. The slightly
prevailing sensitivity patterns. Since cerebral abscesses
high urea accompanied by a creatinine that is still within
have been described with a very wide range of
the normal range and haemoglobin and sodium levels organisms including Gram-positive, Gram-negative,
towards the top of the normal range are all consistent with and anaerobic, it is important to use broad-spectrum
a moderately dehydrated state. The patient might also be treatment if no specific bacterium has been isolated. It
hypercatabolic and the increased nitrogen turnover under is good practice to discuss all cases of cerebral abscess
those conditions can contribute to a high serum urea. The with a neurosurgical team. In some patients the
patient’s drug therapy does not include any medication accompanying evidence of infection may be less clear
cut, in which case it can be difficult to determine
expected to cause renal impairment. There is a history of
whether a ring-enhancing lesion on CT is due to
gout that could cause some background renal impairment
cerebral abscess or a cerebral tumour. In such cases, a
or indeed, be the result of such a condition, though that is
biopsy to sample the lesion is helpful. Because elderly
less likely, in this context, than dehydration to be the
patients with cerebral abscess often have other co-
reason for the raised urea. pathologies, it is important to optimize the medical
management of those other conditions to improve the
chances of a good outcome from treating the abscess.
6
Patients 3, 4
Patient 2 Answer
nerve). The pyramidal tract fibres would not have
1 BWeber’s syndrome.
crossed over at this level and damage to these fibres in
the midbrain leads to a contralateral hemiparesis. The
combination of these physical signs is known as
The above pictures show a complete right-sided ptosis ‘Weber’s syndrome’. The most likely aetiology is a
and the eye is deviated down and laterally, indicating a cerebrovascular event but alternative pathology such as a
third cranial nerve palsy. This suggests a lesion in the midbrain tumour or demyelination can cause the same
midbrain (location of the nucleus of the third cranial clinical picture.
Patient 3
An 85-year-old woman was referred to clinic. She had
1 What is the intervention that is most likely to help
had four falls over the previous 3 months. She had a past
reduce this woman’s falls?
history of ischaemic heart disease and OA, pre -
A Refer for early cataract surgery.
dominantly affecting the knees. She was taking co-
B Provide her with a walking stick.
dydramol when required, with good symptom control.
C Refer her for a knee replacement.
She denied any loss of consciousness, dizziness, or
D Review her medication.
vertigo and claimed that her falls were due to loss of
E Refer for physiotherapy.
balance. She was an independent woman and managed
to carry out her activities of daily living with a little help
from her daughter. A MMSE was 27/30. On
examination she had early cataracts. The knees were
2 What would be the most important change to the
osteoarthritic but no joint instability was identified.
medication that needs to be considered?
There were normal heart sounds with a 10 mmHg drop
A Give digoxin.
in systolic BP on standing. On neurological examination
B Add warfarin.
there was generalized MRC grade 4/5 muscle weakness
C Start donepezil.
but no focal signs. An ECG showed atrial fibrillation
D Start fludrocortisone.
with a rate of 84 bpm. A radiograph of the knees showed
E Stop co-dydramol.
mild osteoarthritic changes.
Patient 4
A 79-year-old woman presented with a history of
1 How would you best manage the patient’s risk of
frequent falls at home. She had an extensive past medical
future fractures?
history including chronic obstructive pulmonary disease,
A Perform a DEXA scan before starting treatment.
angina, heart failure, OA, and a recent fractured left hip
B Prescribe calcium supplementation daily.
treated by insertion of a dynamic hip screw. She
C Prescribe calcium and vitamin D3 daily.
complained of dizziness but no loss of consciousness or
D Prescribe risedronate weekly and
vertigo. Her medication consisted of a Combivent
calcium/vitamin D3 daily.
inhaler, isosorbide mononitrate, lisinopril, aspirin, and
E Prescribe strontium ranelate with calcium daily.
lactulose. On examination she was frail and it was felt
that she had a persisting risk of falls.
7
Patients 3, 4
Patient 3 Answers
1 ERefer for physiotherapy. 2 BAdd warfarin.
There is evidence that physiotherapy can reduce the Digoxin is useful to control the ventricular rate in patients
frequency of falls in patients with limb weakness. In the with atrial fibrillation. It has no role in chemically
history there is nothing to suggest that there was any cardioverting the patient or maintaining sinus rhythm.
significant visual impairment so cataract surgery is not This patient has a controlled ventricular rate therefore
indicated at this stage. The walking stick may be helpful digoxin is not required. The patient has nonrheumatic
but there is no experimental evidence that this should be atrial fibrillation; this increases the risk of stroke by about
a routine intervention. The patient does not have arthritis four times. Warfarin has been shown to substantially
severe enough to warrant a knee replacement. She may reduce this risk. This is a difficult decision and the benefit
benefit from a change in medication to take alternative to patients of prescribing warfarin must outweigh the risk
analgesics such as a NSAID. Alternatively, one can of having further falls, with consequent severe bleeding,
consider a corticosteroid joint injection. Reviewing her while on warfarin. This therapeutic dilemma should be
medication is an important part of her management. discussed with the patient who needs to make an
Patients taking more than four medications are more informed decision whenever possible, and the outcome of
likely to have falls. In addition co-dydramol does have such a decision should be recorded. This patient has mild
sedating side-effects that might predispose to falls. cognitive impairment, though based on current
However, in this case the medication does not seem to be recommendations, she would not be thought to warrant
causing significant side-effects and therefore changing it an antidementia drug. Postural hypotension is deemed
is unlikely to reduce her falls. significant if there is a 20 mmHg drop in systolic and a
Physiotherapy for muscle strengthening, and gait and 10 mmHg drop in diastolic BP. The postural hypotension
balance training, have been shown in various clinical trials demonstrated in this case was less than that. Another
that included elderly community dwelling females to be important consideration is that fludrocortisone is not a
effective at reducing falls. This, therefore, is the first line therapy for postural hypotension and, if used,
intervention most likely to be effective in this case. should be carefully monitored because of the possible
side-effects it can cause, particularly those due to salt and
water retention. Co-dydramol causes drowsiness as a side-
effect but there is nothing to suggest that this was the
case in the patient described.
Patient 4 Answer
would qualify for treatment, making the DEXA scan
1 D Prescribe risedronate weekly and calcium/
unnecessary. Calcium alone has not been shown to be
vitamin D3 daily.
effective at reducing hip fractures. Calcium and vitamin
D3 combined has been shown to be effective as primary
prevention, though recent studies have failed to show
Although a DEXA scan is the investigation of choice to any benefit in the secondary reduction of fractures.
make a diagnosis of osteoporosis, in this case it is neither Bisphosphonates have been shown to be effective at
necessary (because she has had a low-impact fracture) reducing hip fractures. They are normally prescribed in
nor appropriate in view of her age and frailty (there are conjunction with calcium and vitamin D3. A once
no agreed normal values for such patients), and the OA weekly preparation is much more convenient. Patients
can interfere with the scan result. Guidelines by the are probably more likely to be compliant with a weekly
Royal College of Physicians (4) state that patients who bisphosphonate. Strontium is useful for patients unable
have had fractures and are osteopenic (T score of -1 to - to take a bisphosphonate. It causes a predisposition to
2.5) should be treated for osteoporosis. This patient’s thromboembolism so is currently not regarded as a first
osteoporosis risk factor status makes her almost certainly line choice.
at least osteopenic. As she had a fragility fracture she
8
Patient 5
4
Frail, increased fall risk Risk factors Previous fragility fractures
+/– housebound
Basic
Measure BMD (DEXA hip +/– spine) investigations Elderly
Normal Tscore Osteoporosis
>–1 Tscore <–2.5
Osteopenia Tscore
Calcium + –1 to –2.5 Life style advice
vitamin D Offer treatment
Falls risk: Bisphosphonate
assessment/ Calcitonin
advice and Life style advice HRT
consider hip Reassure Treat if previous Raloxifene (females)
protectors Life style advice fracture Calcium + vitamin C
4Algorithm for the management of known or suspected osteoporosis. (Adapted from guidelines of the Royal College
of Physicians.)
Patient 5
A 73-year-old man presented in clinic, accompanied by 5a
his wife. They had noticed he was increasingly forgetful.
On examination he had a MMSE of 24/30. A ‘Get up
and Go’ Test showed marked ataxia. He was noted to be
wearing a sheath urinal. A CT head scan performed soon
after this initial assessment is shown (5a).
1 What is usually the first clinical sign of this
disorder?
A Gait disturbance.
B Urinary incontinence.
C Faecal incontinence.
D Dementia.
E Hemiparesis.
5aCT head scan taken soon after initial assessment.
9