AFP Journal Review May 1, 2014 T. Lianne Beck, MD Assistant Professor Emory Family Medicine Residency Program
Articles • Unintentional Weight Loss in Older Adults • Evaluation of Scrotal Masses • Leukemia: An Overview for Primary Care
Pretest • https://nf.aafp.org/Assessment/Take/4945/Introduction/c
Unintentional Weight Loss in Older Adults • Unintentional weight loss (>5% reduction in body weight within 6-12 mos) occurs in 15% to 20% of older adults. • Associated with: • Functional decline in ADLs. • Increased in-hospital morbidity, • Increased risk of hip fracture in women • Increased overall mortality • Total body weight usually peaks at 60 years of age with small decreases of 0.2 to 0.4 lb per year after 70 years of age • Substantial weight changes should not be attributed to normal anorexia of aging.
Psychosocial Causes • Social factors associated with unintentional weight loss include: • Poverty • Alcoholism • Isolation • Financial constraints • Other barriers to obtaining food (e.g., impairment in activities of daily living, lack of assistance in grocery shopping or preparing meals).
DDX Helpful tools • Mnemonic - Meals on Wheels • Meds, emotional, alcohol, late-life paranoia, swallowing, oral factors, no money, wandering, hyper/hypo thyroid, parathyroid, hypoadrenalism, enteric/eating probs, low salt/cholesterol diet, stones, social issues. ` • 9 D's of weight loss in the elderly • dementia, dentition, depression, diarrhea, disease [acute and chronic], drugs, dysfunction [functional disability], dysgeusia, dysphagia
History and Physical Examination • Focus on amount of weight lost and time frame in which the weight loss occurred. • If no baseline weight is available, evidence of change in clothing size, confirmation of weight loss by a relative or friend, and a numerical estimate of weight loss can be used • Assess appetite • Thorough ROS focusing on cardiovascular, respiratory, and GI
Prescription and OTC Medications, including herbals • Social history to identify alcohol/tobacco and living situation • Screen for Depression and Dementia, Nutritional Assessment • Physical Exam focusing on weight w/o shoes, oral cavity, dentition, CV, Pulm, GI, Neuro
Screening tools For depression and dementia • The two-question Patient Health Questionnaire http://www.aafp.org/afp/2008/0715/p244.html • Geriatric Depression Scale http://www.aafp.org/afp/2011/1115/p1149.html • The Mini-Cognitive Assessment Instrument http://www.aafp.org/afp/2009/0315/p497.html
Mini Nutritional Assessment • Validated tool to help measure nutritional risk • Anthropometric measurements and general, dietary, and subjective assessments. • Scoring allows categorization of older adults as well nourished at risk, or malnourished. • http://www.mna-elderly.com/mna_forms.html
Telltale Symptoms, Possible Diagnoses, and Indicated Tests in Older Adults with Unintentional Weight Loss
Treatment • Focus on the underlying cause • Multidisciplinary approach (dentists; dietitians; speech, occupational, or physical therapists; and social service workers.) • Common strategies: • Dietary changes • Environmental modifications • Nutritional supplements • Flavor enhancers • Appetite stimulants (Megace, mirtazipine, cyproheptadine, marinol, HGH) have not been shown to reduce mortality and have significant adverse affects.
Evaluation of Scrotal Masses • 1% of emergency department visits • Clinically useful distinction between painful and painless scrotal masses. • Although painless masses are not uniformly benign, painful masses are much more likely to require urgent intervention • Prehn sign may suggest epididymitis but does not rule out testicular torsion. • US can reliably differentiate extratesticular masses from intratesticular masses. • With Doppler imaging, the sensitivity and specificity of US for testicular torsion range from 86% to 93%. • CRP > 24 mg per L to be 96% sensitive and 85% specific for epididymitis/orchitis.
Less common and benign masses • Spermatoceles • Epididymal cysts • Genital warts • Benign nevus • Epidermal cysts • Seborrheic keratosis • Angiokeratomas
Leukemia: An Overview for Primary Care • Common malignancy in children and adults • The age-adjusted incidence rate of leukemia in the United States is 12.8 per 100,000 persons each year. • The prevalence of leukemia is generally higher in whites and in males, and increases with age. • Approximately one in 70 persons develops leukemia in his or her lifetime • Risk Factors: Down syndrome, neurofibromatosis, exposure to ionizing radiation, exposure to benzene, household pesticide exposure in utero and in the first 3 yrs of life, obesity, prior hematologic malignancy
Surveillance Guidelines for Leukemia Survivors • ALL (chemotherapy and radiation only) • Annual CBC with differential up to 10 years after last treatment, electrolytes, creatinine, blood urea nitrogen, calcium, magnesium, and phosphorus levels, TFTs, UA • Echocardiography and EKG every 3-5 years if findings on pretreatment evaluation were abnormal, or if signs or symptoms of heart failure are present • Routine eye and dental examinations • CXR, PFTs, audiometry as needed based on symptoms • If treated before 1972, one-time hepatitis B surface antigen and hepatitis C antibody serum testing • If treated before 1993, one-time hepatitis C antibody serum testing
ALL (Treated with stem cell transplant): • CBC q 1-2 months x 3 yrs, then every 3-6 mo for up to 5 yrs, then annually • One year post-HSCT: CD4, immunoglobulin levels, BMD, ophtho evaluation • Annual electrolyte, creatinine, blood urea nitrogen, serum ferritin, urine microalbumin, vitamin D, glucose, A1C, testosterone (males) or FSH/LH (females); LFTs, UA, lipids, TFTs • Annual dental examination • If abnormal pre-HSCT pulmonary function test result, repeat as indicated with a change in clinical status • Age- and sex-specific cancer screening • Age-appropriate immunizations • If cranial or craniospinal irradiation use low threshold for neuroimaging for neurologic symptoms
AML (chemotherapy and radiation) • CBC q 1-2 months x 3 yrs, then every 3-6 mos for up to 5 yrs • ECHO and EKG every two years • Radionuclide angiography or multiple-gated acquisition scan and Holter monitoring every 5years • AML (stem cell transplant) • Same as for patients with ALL
CLL (monitored without treatment) • Routine history for symptoms that would prompt treatment • Routine PE, specifically evaluating for hepatosplenomegaly • Periodic CBCs: If progressive anemia or thrombocytopenia, refer to hematologist • Annual influenza vaccines • Pneumococcal vaccination every five years • Avoid live vaccines • Age- and sex-specific cancer screening • CLL (If treated) • Referral to cardiologist for baseline evaluation • Resting and stress ECHO(frequency depending on baseline findings and other cardiac risk factors)
CML (treated with a tyrosine kinase inhibitor) • CBC every 3 months: If neutropenia (ANC < 1,000 per μL [1.0 × 109 per L]) or thrombocytopenia (platelet count < 50 × 103 per μL [50 × 109 per L]), refer to hematologist • Monitor for adverse effects including diarrhea, fluid retention, gastrointestinal upset, headache, muscle cramps, rash • For patients treated with stem cell transplant • Same as for patients with ALL
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