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Clinical Pearls:

Clinical Pearls:. Geriatrics Laurence J. Robbins, MD Associate Professor of Medicine University of Colorado Health Sciences Center Denver, Colorado Associate Chief of Staff Geriatrics and Extended Care Department of Veterans Affairs Eastern Colorado Health Care System Denver, Colorado.

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Clinical Pearls:

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  1. Clinical Pearls: Geriatrics Laurence J. Robbins, MD Associate Professor of Medicine University of Colorado Health Sciences Center Denver, Colorado Associate Chief of Staff Geriatrics and Extended Care Department of Veterans Affairs Eastern Colorado Health Care System Denver, Colorado

  2. Disclosures: • None

  3. Case #1 An 85 yo with history of advanced dementia is brought to ER for 3 days of increasing weakness, now unable to stand on own (had been walking with cane), “leans” to left, less verbal, slightly more confused. Has fallen but last fall was 3 months ago.

  4. On exam his BP is 160/90. His speech is intelligible but nonsensical. Left hand grip is slightly weaker than right, equal leg strength. DTRs are brisk. Babinski response present bilaterally. He can stand with assistance but balance poor, unable to walk. Sensation in feet seems diminished. His medications include lisinopril 20 mg for hypertension, donepezil 10mg at bedtime for dementia.

  5. What is your next step? • Stop the lisinopril and donepezil; see if his gait disorder improves • Order serum B12 level • Order nerve conduction study and EMG • Order non contrast CT scan of head • Check for asterixis and order LFTs

  6. Epidemiology • 1 in 10 elderly have difficulty walking • 20-25% >80 yo use mechanical gait aid • 2/3 hospitalized elderly >75 yo have decline in mobility; at discharge, 2/3 of those pts not improved, 1/10 worse

  7. Age-related gait changes • Normal gait: toe off, swing phase, heel strike; only 25% time supported on both feet • In healthy elderly, abnormal gait more prevalent with advancing age • Often multifactor (75%); when single cause, musculoskeletal is most common

  8. Central Gait Disorder • Slow, wide-based, shuffling, small-stepped, “magnetic,” difficulty turning • When severe, truncal instability and can’t initiate a step; can’t stand without support; often few focal signs • Most pts also have impaired cognition • Differential Dx: “multi-infarct,” NPH, Subdural hematoma

  9. Pearls • Central CNS lesions cause axial instabilitywith few focal neurological signs • Medication toxicity can mimic a central gait disorder

  10. Case 2 • A 76 yo woman is brought to see you by her daughter who is concerned about her mother’s failing memory. Twelve months ago, the daughter took over management of her mother’s checkbook after she failed to pay bills. Her mother seems unable to knit, something she enjoyed for years. She has difficulty finding the right words to complete a thought. Only medication: temazepam 15mg bedtime prn

  11. On exam, the patient is a slender Caucasian woman who is engaging and seems alert. Her blood pressure is 155/85. Cranial nerves 2-12 are intact. Motor strength is symmetrical, gait is normal. Sensation is normal, reflexes 2+, no pathologic reflexes. On mental status testing, she scores 25 out of 30 on the MMSE (abnormal <24). The daughter mentions that her mother has a master’s degree and taught high school history for 35 years. Lab tests (B12, TSH etc) are normal.

  12. Your next step: • Explain to the daughter that her mother probably has early Alzheimer’s Disease • Order an MRI • Explain to the daughter that her mother is toxic from her temazepam and will be fine if the medication is stopped • Order an RPR and EEG • This is vascular dementia; begin treatment to lower BP <140/90 and add aspirin 81 mg daily

  13. DSM-IV Criteria for Alzheimer’s Disease • Memory loss + one or more: aphasia, apraxia, agnosia, executive dysfunction • Usually few motor signs apparent early • Subtle behavioral and personality changes early

  14. ‘Average’ Dementia Evaluation • History, PE, mental status testing, comprehensive neuropsychological testing • CBC, SMA 6, TSH, VDRL, B12, Folate, Calcium, U/A • Genetic Testing • Brain imaging (CT or MRI)

  15. Incidence and Causes of Dementia(Knopman et al, Arch Neurol 63:218, 2006) • Record review of 560 consecutive patients newly diagnosed with dementia • No cases of reversible dementia due to NPH, subdural hematoma, B12 deficiency, hypothyroidism, or neurosyphilis • Conclusion: “None of the patients with dementia reverted to normal with treatment of the putative reversible cause.”

  16. Potentially Reversible Dementias(Larson et al, 307 cognitively impaired outpatients) • DRUGS 16 • HYPOTHYROID 7 • HYPERPARATHYROID 3 • B12 DEFICIENCY 2 • SUBDURAL HEMATOMA 2 • OTHER 3 • TOTAL 31 (10%)

  17. Reversibility of Drug-induced Dementia(Larson, Ann Int Med 107:169, 1987) • >50% who stop medication will improve • Often a single medication implicated • Patients with drug-induced cognitive impairment were also three times more likely to fall • Most offending drugs taken for several years prior to diagnosis

  18. Medications That May Impair Cognition • Everything we prescribe…except acetaminophen and docusate • Most often psychoactive meds or those with anticholinergic side effects • “Discontinue amitriptyline (Elavil)” is always the correct answer on boards.

  19. Drugs impairing cognition • Anticholinergics (e.g., Benadryl, Artane, Ditropan, Elavil, etc.) • Anticonvulsants (Dilantin, Neurontin, Valproate, etc) • Muscle relaxers (Soma, Flexeril, etc.) • Antiemetics (Compazine, Reglan, etc) • Dig, Catapres, amantadine, Cordarone • Benzodiazepines, Antipsychotics

  20. Pearls • The diagnosis of Alzheimer’s Disease can be made with confidence if a patient has short term memory loss, at least one of the other characteristic signs of AD, gradual progression >one year and normal gait/neuro exam • Reversible dementia is rare; medications are the leading cause of reversible cognitive impairment

  21. Case 3 • A 71 yo complains of a three week history of numbness in the fingers of his right hand and “dropping” utensils. His health is general good. Three years ago, he accepted a job operating heavy machinery in Belize. A painful left knee limited his mobility. Two years ago, he began having more difficulty walking . He started to fall more frequently. He finally quit his job and returned to the US about 10 months ago.

  22. Since his return he has not been very active and has begun using a cane because of his right knee pain, severe chronic low back pain and weakness. He has some mild neck discomfort. Frequent falls have continued at night .

  23. On exam, his mental status is normal. He now uses a wheeled walker for ambulation and has a stiff-legged gait and he complains of low back pain. He has some upper and lower extremity increased tone. He has moderate bilateral lower ext weakness. He has hyperreflexic patellar responses bilateral. His right hand grip is strong but rapid alternating movement is clumsier in the right hand. Position sense is impaired in his toes. Babinski responses are present.

  24. What is your next step? • Order an MRI of his lumbosacral spine. • Order an MRI of his thoracic spine • Order an MRI of his cervical spine • Order an MRI of his brain • Order B12, RPR, A1C, folate and serum creatinine

  25. Neurological Gait Disorders • Peripheral neuropathy : distal sensory and motor signs only • Lumbosacral: lesion below end of spinal cord (T12) = no upper motor neuron signs • Cervical: upper motor signs: no cranial nerve or gray matter signs (e.g., dementia) • Brain: cr n and gray matter signs, EPS

  26. Upper motor neuron signs • Weakness (not complete paralysis) of a group of muscles (not a single muscle); minimal muscle atrophy • “Clasp-knife” spasticity • Hyperreflexia (+/- clonus) • Spread of reflexes • Babinski response

  27. CERVICAL MYELOPATHY • Cervical myelopathy usually due to degenerative spine changes; may have little neck pain & no radicular symptoms • Upper motor neuron signs often present • Paresthesias and loss of position sensation may be caused by cervical myelopathy but may also have peripheral neuropathy

  28. Case 3: Management • Image neck (MRI) if candidate for surgery • Check B12, TSH, glucose

  29. Pearls • Upper motor neuron signs = lesion above T12 • Cervical myelopathy may be present in the absence of severe neck pain

  30. Case 4 • An 80 yo man is referred for evaluation of “possible depression; is he a Ritalin candidate?” He’s accompanied by his wife who describes how much more difficulty ambulating he’s had since esophagectomy for cancer 18 months ago. His medications include hydrochlorthiazide, lisinopril and metoclopramide.

  31. On exam, his blood pressure is 140/90. The patient has a flat affect and blinks little. He has severe seborrhea. He slowly rocks bath and forth in his chair when asked to stand but is unable to propel himself to a standing position. When helped up to a standing position, he has trouble initiating his gait, then takes a few small steps and freezes.

  32. What is your next step? • Stop all of his medications. • Stop the metoclopramide • Begin carbidopa/levodopa 50/200 CR tid • Order an MRI of the brain • Begin an SSRI to treat his depression

  33. Prevalence of Parkinsonism • Accounts for 10% of gait disorders • Community elderly >65; Gait abn & 1or more signs of parkinsonism: 15% 65-74 yo 30% 75-84 yo 50% > 85 yo

  34. Clinical Features • Tremor • Rigidity • Bradykinesia • Gait disorder • (Also, blunted postural reflexes and autonomic dysfunction)

  35. Differential diagnosis • Idiopathic Parkinson’s Disease 85% • Drug-induced (e.g. Reglan) 7-9% • Parkinson-plus syndromes 4% • Vascular parkinsonism 3%

  36. Pearls • Drug-induced parkinsonism can occur with medications not usually considered culprits (metoclopramide, valproic acid, prochlorperazine, etc.) • Resting tremor, asymmetric rigidity/tremor, and response to Levodopa best predict correct diagnosis of PD

  37. Case 5 • The same 80 yo patient returns one week later after withdrawal of metoclopramide. He now can stand without assistance but still has difficulty initiate his gait and walks with small steps. His wife describes how he sometimes gets “stuck” in doorways as he goes from room to room.

  38. On exam, he still has significant diffuse rigidity, right greater than left. His gait is festinating. He has obvious bradykinesia. Both the patient and wife feel that his parkinsonism is improved but his function is still limited. They ask about medications that might help.

  39. You make the following recommendation: • Carbidopa/levodopa 10/100 tid • Pramipexole 0.5 mg tid • Carbidopa/levodopa 50/200 controlled release bid • Amantadine 100 mg bid • Carbidopa/levodopa 25/100 tid

  40. When to start drug Rx in the elderly? • Functional decline: dominant side more affected, interference with ADLs and gait Why delay drug treatment? • Medications often associated with side effects in elderly • cost of medication is high

  41. Treatment Principles • Most medication reduce symptoms • Very modest evidence that disease progression may be slowed • Narrow therapeutic/toxic window • Most effect achieved through dopamine

  42. Anticholinergics (e.g., Artane, Cogentin) Amantadine (Symmetrel) MAO Inhibitor (Eldepryl, Azilect) Carbidopa/L-dopa (Sinemet) Dopamine agonists (e.g., Parlodel, Mirapex, etc.) COMT inhibitors (e.g., Comtan) Medications for PD

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