Common Issues in the Elderly

Question 1

When will Medicare pay for skilled rehab care in nursing homes? Which part of medicare pays?

Answer 1

• they will pay for 20 days after at least a 3 day hospital stay
• pt pays copay of $168 per day for day 21-100

Question 2

How long before the need for nursing home care do a patients assets need to be transferred to family members other than the spouse?

Answer 2

3 years

5 years if in a trust

Question 3

Treament for lumbar spinal stenosis - surgical or nonsurgical recommended?

Answer 3

Conservative nonsurgical treatments are more appropriate

Question 4

Which antipsychotic has lowest risk of Extrapyramidal toxicity?

Answer 4

Quetiapine (seroquel)

best choice in elderly if you have to

Question 5

When should medications for parkinsonism be initiated in the elderly?

Answer 5

When there is functional decline - interference of symptoms with ADLs and gait

Question 6

What is a common mimic of diarrhea in the elderly?

Answer 6

Fecal impaction where liquid stool passes around a fecolith

Question 7

What is the most common cause of irreversible vision loss in the elderly?

Answer 7

Age related macular degeneration –> loss of central vision which impairs reading, face recognition, driving

Question 8

How do you diagnose polymyalgia rheumatica?

Answer 8

History:
- bilateral aching/morning stiffness (> 30 min) for at least 1 month
- involves at least two of the following three: neck or torso, shoulder/proximal arms, hips/proximal thighs
Lab:
- ESR > 40 or elevated CRP

associated with temporal arteritis

Question 9

Treatment of polymyalgia rheumatica

Answer 9

• Low dose prednisone (15 mg daily)
• high dose prednisone (60 mg) when accompanied by temporal arteritis
• may start steroids before temporal artery biopsy (positive within 1 week after starting steroids)

Question 10

Definition of osteopenia (t score)

Answer 10

T SCORE -1 to -2.5 SD

Question 11

Definition of osteoporosis (t score)

Answer 11

T score < -2.5 SD

Question 12

Definition of severe osteoporosis

Answer 12

T score < -2.5 SD + one or more fractures

Question 13

Who needs bone mineral density testing according to the USPSTF?

Answer 13

• women age > 65 yo

- women age 50-64 yo based on risk factors

Question 14

What is the most common site in the spine for osteoporotic fractures?

Answer 14

T10-T12

Question 15

When screening for secondary causes of osteoporosis, which tests should you obtain?

Answer 15

• CBC
• albumin/total protein
• alk phos (myeloma, cancer)
• serum creatinine (CKD)
• calcium, phos (hyperparathyroid)
• TSH (hyerthyroidism)
• testosterone (men; hypogonadism)

Question 16

Who needs treatment for osteoporosis?

Answer 16

Postmenopausal women and men > 50 yo

• hip or vertebral fx
• prior fractures and low bone mass
• T score < -2.5 after appropriate eval for secondary cuases
• T score -1 to -2.5 if high risk (eg glucocorticoid use)

Question 17

What is the USPSTF recommendation regarding daily supplementation of Vit D and ca for postmenopausal women to prevent fx?

Answer 17

• not recommended

This recommendation does not address women with osteoporosis

Question 18

What are contraindications to bisphosphonate therapy?

Answer 18

• esophageal strictures, achalasia
• unable to be upright
• renal failure with CrCl < 35
• hypocalcemia (common side effect)

Question 19

Treatment for osteoporotic bone pain

Answer 19

intranasal calcitonin

• can use up to 6 months
• prescribe Ca and Vit D