Week 4 - Musculoskeletal and Skin Disorders Flashcards
Functional assessment
evaluation of ongoing medical comorbidities, premorbid functional status, current function, living situation and equipment, caregiver support, and patient functional goals
Lawton IADL scale
The Lawton IADL scale was developed by Lawton and Brody in 1969 to assess the more complex ADLs necessary for living in the community
- shopping
- cooking
- finances
- driving
Domains of geriatric care
mental, physical, functional, socio-economic
Nutritional assessment should be triggered if a patient has how much weight loss?
more than 5% in 6 months
Geriatric screening tools
- International Prostate Symptoms Score – for diagnosing urinary obstruction
- Patient Health Questionnaire–2 – screening for depression (all patients)
- If + use Patient Health Questionnaire–9 or the 15-item Geriatric Depression Scale
- Katz index for ADLs10 and the Lawton scale for IADLs.11
- Clinician’s Guide to Assessing and Counseling Older Drivers1
- AD-8 – changes in behavior which may indicate cognitive problems
- Neuropsychiatric Inventory Questionnaire (NPI-Q)
- Montreal Cognitive Assessment (MoCA
- Snellen chart 20/40 is visual impairment
- o Timed Up and Go (TUG) test18 is an assessment of gait and lower leg function – if more than 12 seconds, high fall risk
- Cognitive screening tools
- mini-cog (3-item recall and clock drawing1
- if mini cog is + MoCA, Mini Mental State Exam (MMSE) – requires training
- Short Form-36 Health Survey22 (SF-36), - quality of life tool
- Mini nutritional assessment
Gout
Iinflammatory reaction to monosodium urate (MSU) crystals deposited in the joint, is associated with hyperuricemia
Gout s/s
Pain, heat and swelling in one or more joints. Usually big toe, non-symmetrical.
First metatarsal phalangeal join- more likely to involve small joints and develop tophi more rapidly and in unusual locations
Gout treatments
NSAIDs, colchicine allopurinol, steroids or intraarticular injection. Diet low in red meats and seafood (purines).
Diagnostic criteria for gout
- an SU level >7 mg/dL in men or >6 mg/dL in women
- the presence of tophi;
- the presence of MSU crystals in SF or tissues;
- a history of painful joint swelling with abrupt onset and remission
S/S of Osteoporosis
- height loss >4 cm,
- rib-pelvis distance <2 finger-breadths
- inability to touch the occiput to the wall when standing with heels to the wall.
Risk factors for Osteoporosis
- DM
- Corticosteroid use
- Radiation
- smoking
DXA results for osteoporosis
T-score of ≤2.5 standard deviations below the mean of a young reference group is positive for osteoporosis
DXA results for osteopenia
T-score between 1.0 and 2.5
Non pharmacological treatment for osteoporosis
- Supplementation with Ca and Vit D
- Exercise
- Fall prevention
- Adequate caloric intake
- 1000mg of Calcium to age 50 (women) or 70 (men), 1200mg daily over those ages
Osteoporosis management is recommended for which patients?
- Pts with hip or vertebral fracture
- BMD T-scores ≤−2.5,
- BMD T-scores between −1.0 and −2.5 and a 10-year probability of hip fracture >3% or 10-year probability of major osteoporotic fracture >20%
Pharmacological treatments for Osteoporosis
Antiresorptive agents AKA bisphosphonates – slow the remodelling process to increase bone density –> continue treatment for 5 years
* (alendronate, risedronate, ibandronate)
* Zolendronic acid- once yearly dose
Anabolic agents (teriparatide, abaloparatide)
Other (raloxifene, estrogen,)
How to monitor patients with osteoporosis
- Regular height measurements
- DXA scans 1-3 years
- Fracture risk assessment
- assessment for treatment compliance and side effects.
Signs and symptoms of OA
- Asymmetrical joint swelling
- Hebreden and bouchards nodes
- joint pain and stiffness for 10-15 min after rest
- DIP, PIP, hips, knees, neck, back
Treatment for OA
- Weight loss
- Exercise
- Brace/splinting
- Tai Chi/Qi Gong
- Acupunture
- Tyelnol
- NSAIDS – for hand, knee hip
- Steriod injections
Labs for OA
- ANA - negative
- RF - negative
- ESR - normal
- CRP - normal
Imaging for OA
Xrays show joint space narrowing, osteophytes, subchondral sclerosis, and cystic changes
Signs and symptoms of RA
Joints affected symmetrically Warmth and swelling at joints
Joint pain and stiffness in the morning for 2-3 hours
Labs for RA
ANA - positive RF - positive (32-89%) ESR - elevated at onset
Treatment for RA
Disease modifying antirheumatic drugs (DMARDS) – can do triple therapy, requires lab testing every 8-12 weeks for monitoring
* Methotrexate
* Sulfasalazine
* Hydroxychloroquine (avoid in macular degeneration)
Biologicals (can reactivate hep B and C and TB)
* Humira (adalimumab)
* Enbrel (etanercept)
Xray findings for RA
Loss of articular space, multiple erosions, juxtaarticular osteopenia, and ulnar deviation.
Treatment of gout
Uric acid lowering therapy with 2-3 acute attacks, renal complications or presence of tophi xanthine oxidase inhibitors – uric acid less thatn 6mg/dL
Lifestyle
* Avoid alcohol, avoid purines (shellfish and organ meats)
Pharmacological
* Allopurinol (safe to titrate up despite renal insufficiency) urate lowering
* Febuxostat if no response to allopurinol
Prophylaxis
o Colchicine 0.6mg daily
o Low dose steroids
Pseudogout
calcium pyrophosphate dehydrate (CPPD) crystal deposition in joints
Treatment for pseudogout
NSAIDs, intraarticular steroids
Timed up and go test
Stand up from chair, walk 10 feet and return to chair.
An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.
Onset of herpes zoster
Prodrome of unilateral pain or pruritus followed by corresponding dermatomal vesiculopustular eruption within days to a week
Is someone with herpes zoster contagious?
The host is contagious during the prodrome (via respiratory route) and through direct contact until the lesions become dried and crusted
Diagnosis for herpes zoster
Clinical presentation
- Polymerase chain reaction (PCR) is a rapid, sensitive, and specific assay
Vaccines for herpes zoster
For patients over 50:
* Zostavax (attenuated live virus - not for immunocomprimised patients)
* Shingrix (recombinant, 2-doses)
Treatment for herpes zoster
- Antiviral therapy within 72 hours of rash onset
- Caution with CKD
- IV therapy with ocular involvement, immunosuppression, suspected meningitis or sepsis
- Acyclovir, famciclovir, valcyclovir
Post herpetic neuralgia
PHN is a debilitating chronic neuropathic pain condition that can persist for months to years after zoster rash resolution. PHN occurs most commonly in older patients with zoster, probably as a function of immunosenescence.
Treatment with gabapentin and lyrica.
All treatments for OA
- acetaminophen
- Topical capsaicin
- Referral to physical therapy
- Referral to occupational therapy
- Referral to orthopedics
- Follow-up with NP in one month
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Low-impact exercises
All treatment for RA
- Referral to rheumatology
- Low-dose oral corticosteroids
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Low-impact exercises
