Common issues in the Elderly
part 1
Joshua Huval M.D.
Gait Disturbances
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendationEvidence ratingReferences
Gait and balance disorders are usually multifactorial in origin and require a comprehensive
assessment to determine contributing factors and targeted interventions.
C
Older adults should be asked at least annually about falls.
C
Older adults should be asked about or examined for difficulties with gait and balance at least once.
C
Older adults who report a fall should be asked about difficulties with gait and balance, and should
be observed for any gait or balance dysfunctions.
C
Exercise and physical therapy can help improve gait and balance disorders in older adults.
B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or
case series. For information about the SORT evidence rating system, go to
Gait disturbances
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Evaluation of Older Persons with Gait and Balance Disorders
History
Acute and chronic medical problems
Complete review of systems
Falls history (previous falls, injuries from falls, circumstances of fall, and associated symptoms)
Nature of difficulty with walking (e.g., pain, imbalance) and associated symptoms
Surgical history
Usual activity, mobility status, and level of function
Medication review
New medications or dosing changes
Number and types of medications
Physical examination
Affective/cognitive (delirium, dementia, depression, fear of falling)
Cardiovascular (murmurs, arrhythmias, carotid bruits, pedal pulse)
Musculoskeletal (joint swelling, deformity, or instability; limitations in range of motion involving the knees, hips, back, neck, arms, ankles, and feet;
kyphosis; footwear)
Neurologic (muscle strength and tone; reflexes; coordination; sensation; presence of tremor; cerebellar, vestibular, and sensory function;
proprioception)
Sensory (vision, hearing)
Vitals (weight, height, orthostatic blood pressure and pulse)
Gait and balance performance testing
Direct observation of gait and balance
Functional reach test
Timed Up and Go test
Presence of environmental hazards
Clutter
Electrical cords
Lack of grab bars near bathtub and toilet
Low chairs
Poor lighting
Slippery surfaces
Steep or insecure stairways
Throw rugs
Gait Disturbances
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Functional Ambulation Classification Scale
CATEGORY DEFINITION
0. Nonfunctional ambulation Patient cannot ambulate, ambulates in parallel bars only, or requires
supervision or physical assistance from more than one person to ambulate safely outside of parallel
bars.
1. Ambulator—dependent for physical assistance, level II
Patient requires manual contact of no
more than one person during ambulation on level surfaces to prevent falling. Manual contact is
continuous and necessary to support body weight as well as maintain balance and/or assist
coordination.
2. Ambulator—dependent for physical assistance, level I
Patient requires manual contact of no
more than one person during ambulation on level surfaces to prevent falling. Manual contact
consists of continuous or intermittent light touch to assist balance or coordination.
3. Ambulator—dependent for supervision Patient can physically ambulate on level surfaces
without manual contact of another person, but for safety requires standby guarding of no more
than one person because of poor judgment, questionable cardiac status, or the need for verbal
cuing to complete the task.
4. Ambulator—independent on level surfaces only
Patient can ambulate independently on level
surfaces but requires supervision or physical assistance to negotiate stairs, inclines, or nonlevel
surfaces.
5. Ambulator—independent Patient can ambulate independently on nonlevel and level surfaces,
stairs, and inclines, without supervision or physical assistance from another person. Assistive
devices, orthoses, and prostheses are allowed.
Gait Disturbances
• Timed Up and Go test, the Berg Balance Scale, or the PerformanceOriented Mobility Assessment (POMA).
• Timed up and Go test - Patients are timed as they rise from a chair
without using their arms, walk 3 meters, turn, return to the chair,
and sit down.
– They are allowed to use their usual walking aid. A score of less than 10
seconds is considered normal, and 14 seconds or more is abnormal
and associated with an increased risk of falls.38 Patients who perform
the task in more than 20 seconds usually have more severe gait
impairment. The Timed Up and Go test is a sensitive (87 percent) and
specific (87 percent) measure for identifying older persons who are
prone to falls.39 It correlates well with other more-detailed scales, but
is quicker and easier to perform. Persons who have difficulty or
demonstrate unsteadiness performing the Timed Up and Go test
require further assessment, usually with a physical therapist, to help
elucidate gait impairments and related functional limitations.
Gait Disturbances
• Interventions
– A multifactorial evaluation followed by targeted interventions for identified
contributing factors can reduce falls by 30 to 40 percent46 and is the most
effective strategy for falls prevention. However, evidence on the effectiveness
of interventions for gait and balance disorders is limited because of the lack of
standardized outcome measures determining gait and balance abilities.
• Gait disorders secondary to conditions such as arthritis, orthostatic hypotension,
Parkinson disease, vitamin B12 deficiency, hypothyroidism, heart rate or rhythm
abnormalities, or depression may respond to medical therapies.
• surgery may improve gait for patients with cervical spondylotic myelopathy,51 lumbar
spinal stenosis,52 normal-pressure hydrocephalus,53 or arthritis of the knee or hip.
• pacemakers in patients with carotid sinus hypersensitivity
• cataract surgery
• reduction in the number of medications or removing medications causing adverse effects
• mobility aids, such as canes or walkers (properly fitted to the person), can reduce load on
a painful joint and increase stability
• home safety programs provided by a trained health care professional appear to be
effective for persons at high risk of falls, such as those with a history of falls or other fall
risk factors.
Gait Disturbances
• http://www.aafp.org/afp/2010/0701/p61.htm
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Constipation
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SORT: KEY RECOMMENDATIONS FOR PRACTICEClinical recommendationEvidence ratingReferences
– Review the patient’s medication list to evaluate for medications that may cause constipation.
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– Encourage patients to attempt to have a bowel movement soon after waking in the morning or 30 minutes after
meals to take advantage of the gastrocolic reflex.
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– Increasing dietary fiber intake to 25 to 30 g daily may improve symptoms of constipation.
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– Encourage physical activity to improve bowel regularity.
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– If nonpharmacologic approaches fail, recommend increased fiber intake and/or laxatives to increase bowel movement
frequency and improve symptoms of constipation.
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– Biofeedback therapy is the treatment of choice for anorectal dysfunction.
– B
– Surgery is reserved for persistent and intractable constipation in patients who have been evaluated and proven to
have slow transit constipation.
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A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C =
consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT
evidence rating system, see page 2160 or http://www.aafp.org/afpsort.xml.
Constipation
• Rome II Criteria for Defining Chronic Functional Constipation in
Adults
• Two or more of the following for at least 12 weeks in the preceding
12 months:
• Straining in more than 25 percent of defecations
• Lumpy or hard stools in more than 25 percent of defecations
• Sensation of incomplete evacuation in more than 25 percent of
defecations
• Sensation of anorectal obstruction or blockade in more than 25
percent of defecations
• Manual maneuvers (e.g., digital evacuation, support of the pelvic
floor) to facilitate more than 25 percent of defecations
• Fewer than three defecations per week
Constipation
• PRIMARY CONSTIPATION– normal transit constipation- most common. In patients with functional
constipation, stool passes through the colon at a normal rate.
– slow transit -prolonged delay in the passage of stool through the
colon. Patients may complain of abdominal bloating and infrequent
bowel movement The causes for slow transit constipation are unclear;
mechanisms include abnormalities of the myenteric plexus, defective
cholinergic innervation, and anomalies of the noradrenergic neuromuscular transmission system
• anorectal dysfunction-Anorectal dysfunction may be an acquired
behavioral disorder, or the process of defecation may not have been
learned in childhood.10
• SECONDARY CONSTIPATION
Constipation
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SECONDARY CONSTIPATION
Causes of Secondary Constipation
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Endocrine and metabolic diseases
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Diabetes mellitus
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Hypercalcemia
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Hyperparathyroidism
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Hypothyroidism
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Uremia
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Myopathic conditions Amyloidosis
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Myotonic dystrophy
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Scleroderma
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Neurologic diseases Autonomic neuropathy
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Cerebrovascular disease
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Hirschsprung’s disease
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Multiple sclerosis
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Parkinson’s disease
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Spinal cord injury, tumors
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Psychological conditionsAnxiety
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Depression
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Somatization
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Structural abnormalities Anal fissures, strictures, hemorrhoids
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Colonic strictures
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Inflammatory bowel disease
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Obstructive colonic mass lesions
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Rectal prolapse or rectocele
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OtherIrritable bowel syndrome
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Pregnancy
Contipation
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Treatment
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FLUID INTAKE
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REGULAR EXERCISE
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The National Health and Nutrition Examination Survey found that a low physical activity level is associated with a
twofold increased risk of constipation. Another epidemiologic study showed that patients who are sedentary are
more likely to complain of constipation. Prolonged bedrest and immobility are often associated with constipation.
Although patients should be encouraged to be as physically active as possible, there is no consistent evidence
that regular exercise relieves constipation.24 However, the Nurses’ Health Study,25 which followed a cohort of
62,036 women, found that physical activity two to six times per week was associated with a 35 percent lower risk
of constipation.
DIETARY FIBER INTAKE
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Adequate hydration is considered to be important in maintaining bowel motility. However, despite the belief that
a lack of fluid increases the risk of constipation, few studies have provided evidence that hydration is associated
with the incidence of constipation. Decreased fluid intake may play a greater role in the development of fecal
impaction.
Inadequate fiber intake is a common reason for constipation in Western society. A dietary diary may be helpful to
assess whether an adequate amount of fiber is consumed daily The daily recommended fiber intake is 20 to 35 g
daily. If fiber intake is substantially less than this, patients should be encouraged to increase their intake of fiberrich foods such as bran, fruits, vegetables, and nuts. Prune juice is commonly used to relieve constipation. The
recommendation is to increase fiber by 5 g per day each week until reaching the daily recommended intake.
BOWEL TRAINING
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Patients should be encouraged to attempt defecation first thing in the morning, when the bowel is more active,
and 30 minutes after meals, to take advantage of the gastrocolic reflex.
Constipation
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PharmacologicalAGENT
FORMULA/STRENGTH
ADULT DOSAGE COST*
Bulk laxatives
Methylcellulose (Citrucel) Powder: 2 g (mix with 8 oz liquid) One to three times daily $13.05 for 840 g
Tablets: 500 mg (take with 8 oz liquid)
2 tablets up to six times daily
$20.76 for 164 tablets
Polycarbophil (Fibercon)
Tablets: 625 mg 2 tablets one to four times daily $10.80 for 90 tablets
Psyllium (Metamucil)
Powder: 3.4 g (mix with 8 oz liquid) One to four times daily $12.55 for 870 g
Stool Softeners
Docusate calcium (Surfak) Capsules: 240 mg Once daily
$16.92 for 100 capsules
Docusate sodium (Colace) Capsules: 50 or 100 mg
50 to 300 mg† 50 mg: $14.50 for 60 capsules
100 mg: $17.71 for 60 capsules
Liquid: 150 mg per 15 mL
Liquid: $7.90 for 30 mL
Syrup: 60 mg per 15 mL
Syrup: $21.66 for 473 mL
Osmotic laxatives
Lactulose
Liquid: 10 g per 15 mL
15 to 60 mL daily†
$36.35 for 480 mL
Magnesium citrate
Liquid: 296 mL per bottle 0.5 to 1 bottle per day
$2.29 for 296 mL
Magnesium hydroxide (Milk of Magnesia)
Liquid: 400 mg per 5 mL 30 to 60 mL once daily† $2.64 for 12 fl oz
Polyethylene glycol 3350 (Miralax)
Powder: 17 g (mix with 8 oz liquid) Once daily
$25.34 for 12 packets
Sodium biphosphate (Phospho-Soda)
Liquid: 45 mL, 90 mL
20 to 45 mL daily $2.65 for 90 mL
Sorbitol Liquid: 480 mL 30 to 150 mL daily
$7.57 to $25 for 480 mL
Stimulant laxatives
Bisacodyl (Dulcolax)Tablets: 5 mg
5 to 15 mg daily $13.46 for 100 tablets
Cascara sagrada
Liquid: 120 ml 5 mL once daily $3.75 for 120 mL
Tablets: 325 mg 1 tablet daily
$4.50 for 100 tablets
Castor oil
Liquid: 60 ml
15 to 60 mL once daily† $8.35 for 120 mL
Senna (Senokot) Tablets: 8.6 mg 2 or 4 tablets once or twice daily $21.04 for 100 tablets
Prokinetic Agents
Tegaserod (Zelnorm)
Tablets: 2 mg, 6 mg
Two times daily‡ $169.15 for 60 tablets 2 mg or 6 mg
Constipation
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BULK LAXATIVES
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Bulk laxatives may contain soluble (psyllium, pectin, or guar) or insoluble (cellulose) products. Patients with functional normal transit
constipation benefit the most from treatment with bulk laxatives. However, patients with slow transit constipation or anorectal dysfunction
may not be helped by bulking agents. Bulk laxatives improve symptoms of constipation such as stool consistency and abdominal pain. As with
increased dietary intake of foods rich in fiber, bloating and excessive gas production may be a complication of bulk laxatives.
EMOLLIENT LAXATIVES
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Emollient laxatives or stool softeners, (e.g., docusates), lower surface tension, allowing water to enter the bowel more readily. They are
generally well tolerated but are not as effective as psyllium in the treatment of constipation. Stool softeners are ineffective in chronically ill
older adults. May be more useful for anal fissures or hemorrhoids with painful defecation. Mineral oil not rec due to aspiration and dec fat
soluble vitamins
OSMOTIC LAXATIVES
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Saline or osmotic laxatives are hyperosmolar agents that cause secretion of water into the intestinal lumen by osmotic activity.
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MC are magnesium hydroxide (Milk of Magnesia), oral magnesium citrate, and sodium biphosphate (Phospho-Soda).
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relatively safe because they work within the colonic lumen and do not have a systemic effect.
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electrolyte imbalance within the colonic lumen and may precipitate hypokalemia. fluid and salt overload, and diarrhea.
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Caution in patients with congestive heart failure and chronic renal insufficiency. Chronic use = Hypermag in renal insufficiency
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Alternatives are: sorbitol, lactulose, and polyethylene glycol (PEG) 3350. Sorbitol and lactulose are undigestible agents that are metabolized
by bacteria into hydrogen and organic acids. Poor absorption of these agents may lead to flatulence and abdominal distention. In a
multicenter trial31 of 164 patients, lactulose was found to be more effective in producing a normal stool by day seven compared with
laxatives compared with dulcolax/senna. PEG more effective with less flatulence and softer stool than lactulose.
STIMULANT LAXATIVES
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Stimulant laxatives include products containing senna and bisacodyl. These laxatives increase intestinal motility and secretion of water into
the bowel. Cramping due to increased peristalsis.
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Caution with suspected intestinal obstruction.
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Chronic use of stimulant laxatives containing anthraquinone may cause Melanosis coli. This condition is benign and may resolve when the
stimulant laxative is discontinued.
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Lower Cost and more effective than Lactulose increasing frequency and consistency and lower cost.
PROKINETIC AGENTS
Colchicine and misoprostol-for slow transit constipation neither FDA approved-Needs larger studies
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tegaserod (Zelnorm)-used in women with IBS with constipation in smaller studies that showed no better symptom relief although more
frequent BMs
Constipation
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Biofeedback
– mainstay of treatment for patients with anorectal dysfunction.
– Biofeedback- emphasizes normal coordination and function of the anal-sphincter and pelvicfloor muscles.
– Patients receive visual and auditory feedback by simulating an evacuation with a balloon or
silicon-filled artificial stool.
– overall success rate of 67 percent.
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Surgery
– Only patients who have been evaluated by physiologic testing and proven to have slow colonic
transit constipation benefit from surgery.
– A subtotal colectomy with ileorectostomy is the procedure of choice Complications after
surgery may include small bowel obstruction, recurrent or persistent constipation, diarrhea,
and incontinence.
– Surgery generally is not recommended for constipation caused by anorectal dysfunction.
– The relationship between rectocele and constipation is not entirely clear. Surgical correction is
reserved for patients with large rectoceles that alter bowel function.44
Vision Impairment
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
CLINICAL RECOMMENDATION EVIDENCE RATING
All persons older than 65 years should be screened periodically for vision problems. C
All older persons with diabetes should have a dilated eye examination within one year of diabetes
diagnosis, and at least annually thereafter. C
Tight control of glucose and blood pressure lowers the risk of progressive diabetic retinopathy. A
Controlling blood pressure in older persons with and without diabetes may reduce the risk of
ischemic vascular complications that can cause vision loss. B
Smoking is linked to several causes of progressive visual impairment; smoking cessation counseling
should be a routine aspect of care for older persons. B
Antioxidant and zinc supplements, alone or in combination, do not prevent or delay onset of agerelated macular degeneration. A
Antioxidant and zinc supplementation may delay the progression of age-related macular
degeneration in some persons with advanced disease. B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case
series. For information about the SORT evidence rating system, go to
http://www.aafp.org/afpsort.xml.
Vision Impairment
• Snellen Chart
• The Early Treatment of Diabetic Retinopathy
Study (ETDRS) chart
(ftp://ftp.nei.nih.gov/charts/EC02_300.tif)
• Inquiring about specific symptoms and the
functional impact of vision loss should be a
part of the vision screening process To Id
functional adaptation or impairment.
Vision Impairment
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Disease-Specific Eye Evaluation in Older Persons
DISEASE OR CONDITION RECOMMENDED SCREENING PROTOCOL
Age-related macular degeneration No established screening protocol
Cataracts
No established screening protocol
Glaucoma
Insufficient evidence to recommend for or
against routine screening in the general
population; consider periodic screening with
tonometry and automated visual field testing
in high-risk groups (e.g., black persons, persons
with strong family history)16
Diabetics and without retinopathy or with minimal nonproliferative retinopathy
– Dilated eye examination within one year of diabetes diagnosis, and annually thereafter
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Persons with diabetes and stable nonproliferative retinopathy
– Dilated eye examination every six to 12 months17
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Persons with diabetes and unstable proliferative retinopathy or macular edema
– Dilated eye examination every two to four months, depending on degree of disease and visual
impairment17
Vision Impairment
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Diabetic retinopathy is one of the leading causes of blindness in persons older than 40 years in North America. 2
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classified as nonproliferative or proliferative
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Cataracts – leading cause of blindness worldwide
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most common cause of low vision (but not blindness) in the United States.
can be readily detected with a handheld ophthalmoscope during vision screening.
IF do not cause significant visual impairment may be followed medically.
If the cataract is suspected of causing impaired vision, referral to an ophthalmologist is warranted.
Open-angle glaucoma Natural history and progression poorly understood.
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with or without macular edema.
Up to 10 percent of persons newly diagnosed with diabetes will have retinopathy within one year of diagnosis. In persons with severe
nonproliferative diabetic retinopathy, the risk of progression to vision-threatening proliferative retinopathy within one year is 50 to
75 percent.
Treatment-panretinal laser photocoagulation
Forty percent of persons with vision-threatening primary open-angle glaucoma have normal intraocular pressures, and the
glaucoma will be missed by intraocular pressure measurements alone.
Complete screening for open-angle glaucoma should include pressure measurement and automated visual field testing.
The USPSTF does not recommend for or against routine screening for glaucoma in older adults, but recognizes that some
subgroups at higher risk (e.g., black persons) may benefit from periodic screening.
Treatment-Multiple drugs. Go read about if interested. Lowering intraocular pressure is their goal.
Age-related macular degeneration (AMD) responsible for nearly 60 percent of blindness in adults of European
descent older than 65 years.2
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AMD is classified as
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wet(neovascularorexudative)or
dry(non-neovascular or nonexudative).
The Amsler grid may be used as a screening test for AMD. The grid detects linear distortion, metamorphopsia, and central scotomas,
which are characteristic of AMD. The patient is instructed to look at the grid and report any wavy lines or areas that are missing or
distorted.
Treatment-Retinal photodynamic therapy/Pegaptanib (Macugen) and ranibizumab (Lucentis)-VEGF inhib via injection ongoing trials
Vision Impairment
• Age-related macular degeneration (AMD) responsible
for nearly 60 percent of blindness in adults of
European descent older than 65 years.2
– AMD is classified as
• wet(neovascularorexudative)or
• dry(non-neovascular or nonexudative).
• The Amsler grid may be used as a screening test for AMD. The grid
detects linear distortion, metamorphopsia, and central scotomas,
which are characteristic of AMD. The patient is instructed to look
at the grid and report any wavy lines or areas that are missing or
distorted.
• Treatment-Retinal photodynamic therapy/Pegaptanib (Macugen)
and ranibizumab (Lucentis)-VEGF inhib via injection ongoing trials
Vision Impairment
Vision Impairment
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Prevention of Vision Loss
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Aggressive management of chronic medical disorders in older persons can help preserve vision. Smoking cessation, limiting exposure to
ultraviolet light, and (possibly) dietary changes and selected use of antioxidant or trace mineral supplements may preserve vision in older
persons.
AGGRESSIVE BLOOD GLUCOSE CONTROL
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Intensive control of blood glucose has been shown to reduce the progression of diabetic retinopathy in persons with type 1 and type 2
diabetes.
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A 10-year poststudy analysis of survivors in the U.K. Prospective Diabetes Study (UKPDS) showed a persistent and significant 24 percent
decrease in relative risk of microvascular events in the intensive blood glucose control group, even if tight glucose control was subsequently
lost.
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It is challenging to apply this evidence to older persons with diabetes because older adults are particularly susceptible to hypoglycemia with
tight glucose control.
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Therapy must be individualized to the patient; as a general rule, blood glucose in older persons with diabetes should be as tightly controlled
as possible while avoiding hypoglycemia and its attendant risks.
BLOOD PRESSURE MANAGEMENT
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Aggressive blood pressure control with a target of less than 150/85 mm Hg is likely to be vision preserving in older persons, especially those
with diabetes.
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The UKPDS demonstrated that lowering blood pressure to below 150/85 mm Hg in persons with diabetes reduces the risk of progressive
diabetic retinopathy, irrespective of A1C level.
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A 10 mm Hg decrease in systolic blood pressure provided an 11 percent relative risk reduction in the incidence of photocoagulation or
vitreous hemorrhage; however,
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unlike intensive blood glucose control, blood pressure lowering must be sustained over time to preserve any benefit. 34,35
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Hypertension (with or without a diagnosis of diabetes) is associated with a higher risk of ischemic eye events, such as central retinal vein
occlusion.
Smoking Cessation
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Smoking has been linked to a variety of causes of visual impairment in older persons, including AMD,cataracts,and progressive diabetic
retinopathy.For ophthalmic health, as well as numerous other benefits, older persons who smoke should be advised to quit and offered
smoking cessation counseling.
LIPID MANAGEMENT
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Hyperlipidemia is an independent risk factor for central retinal artery and vein occlusion. Only observational studies so far.
Vision Impairment
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ULTRAVIOLET LIGHT EXPOSURE
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DIET AND SUPPLEMENTS
A Cochrane meta-analysis reviewed three large prospective clinical trials of antioxidant supplements or zinc to
prevent or delay the onset of AMD, and found no demonstrable benefit.42
The Age-Related Eye Disease Study (AREDS) enrolled 3,640 persons with established AMD in a four-arm,
randomized, prospective clinical trial of antioxidant supplementation, antioxidants plus zinc, zinc plus copper, and
placebo. High-risk persons (those with more advanced disease at enrollment) randomized to the antioxidants plus
zinc group had statistically significant preservation of vision compared with the placebo group (estimated odds
reduction of 27 percent).
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Cumulative ultraviolet light exposure is linked to the development of cataracts.Older adults should be advised to consider the
routine use of sunglasses that filter out ultraviolet light when driving or engaged in outdoor activity.
Important caveats are attached to the use of these supplements. Excessive intake of vitamins A and E, especially in smokers, has
been linked with an increased risk of lung cancer, and possibly higher rates of congestive heart failure.Reanalysis of the AREDS
data suggests that zinc supplementation is associated with an increased risk of hospitalization for urologic problems.46
There are no prospective or randomized trials of anti-oxidant supplementation for prevention or treatment of eye
diseases other than AMD. Observational studies have shown conflicting association between high levels of dietary
intake of antioxidants and cataract formation.47
Routine antioxidant or mineral supplementation in all older adults for prevention of AMD or other eye diseases
cannot yet be recommended until ongoing, prospective trials clarify who may benefit and what harms, if any,
might result from long-term supplementation. There is encouraging evidence, which needs to be further validated,
that specific antioxidant and zinc supplementation (the regimen used in AREDS) may preserve vision in some
persons with advanced AMD.
Question
• An 82-year-old female with terminal breast cancer has
been admitted to hospice care. She is
• having severe pain that you will manage with opioids.
• Which one of the following would be appropriate to
recommend for preventing constipation?
• A) Fiber supplements
• B) Docusate (Colace)
• C) Metoclopramide (Reglan)
• D) Polyethylene glycol (MiraLax)
• E) No preventive measures, and treatment only if
constipation develops
Answer
• ANSWER: D
• Constipation is a very common side effect of opioids that
does not resolve with time, unlike many other
• adverse effects. Constipation is easier to prevent than to
treat, so it is important to start an appropriate
• bowel regimen with the initiation of opioid therapy. Fiber
supplements and detergents (such as docusate)
• are inadequate for the prevention of opioid-induced
constipation. Metoclopramide is used for nausea and
• increases gastric motility, but is not indicated in the
treatment of constipation. Polyethylene glycol,
• lactulose, magnesium hydroxide, and senna with docusate
are all appropriate in this situation.
Question
• You are the attending physician at a long-term care facility. A new
resident, an 85-year-oldfemale, presents for an initial evaluation.
Upon reviewing her history, you find that she is on 18 different
medications. Until you can obtain additional history and medical
records, you decide to stop or decrease some of her medications
and monitor her response.
• Which one of the following would be most appropriate to stop or
decrease initially?
• A) Sertraline (Zoloft), 25 mg daily
• B) Acetaminophen/diphenhydramine (Tylenol PM), 500 mg/25 mg
daily
• C) Dipyridamole/aspirin (Aggrenox), 200 mg/25 mg daily
• D) Digoxin, 0.125 mg every other day
• E) Omeprazole (Prilosec), 20 mg daily
Answer
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ANSWER: B
Polypharmacy is common in the elderly population, but the use of numerous medications is necessary in
some elderly patients. However, some medications have been identified as having a considerably higher
potential to cause problems when prescribed to elderly patients.
In the case described, acetaminophen/diphenhydramine would be an appropriate medication to stop
initially. The older antihistamines cause many adverse CNS effects such as cognitive slowing and delirium
in older patients. These effects are more pronounced in elderly patients with some degree of preexisting
cognitive impairment. The anticholinergic properties of older antihistamines produce effects such as dry
mouth, constipation, blurred vision, and drowsiness. The sedative effect of older antihistamines also
increases the risk of falls. Hip fracture and subsequent death have been reported in patients who use older
antihistamines such as diphenhydramine.
Sertraline is an SSRI, a preferred class for the treatment of depression in the elderly compared to the
tricyclic antidepressants, which are associated with several side effects. Dipyridamole is associated with
hypotension in elderly patients, but it benefits some individuals by preventing strokes. It can be used in
the elderly, but patients should be monitored for side effects. Therefore, until further information is
obtained, it is appropriate to continue the dipyridamole/aspirin in this patient.
When used in elderly patients with heart failure, digoxin should be given in a dosage no greater than 0.125
mg daily; the low dosage used in this individual should not be considered inappropriate until the reason
for its use is clarified. While omeprazole can cause problems in the elderly with long-term use, 20 mg/day
is a relatively low dose and the decision to discontinue its use should be delayed until more history is
available.
Question
• A 72-year-old female presents with a 2-month history of constipation. She
says she has to strainto evacuate at least half the time and reports that
her stools have become clay-like in consistencyand narrower in caliber. At
least half the time she has the sensation that evacuation is notcomplete,
and she has occasionally used manual maneuvers to complete evacuation.
She had anormal colonoscopy 8 years ago.An abdominal examination is
normal, and stool with a clay-like consistency is palpated duringa rectal
examination. No prolapse is seen with straining, and the anal wink is
present. Screeninglaboratory tests indicate a mild microcytic, hypochromic
anemia.
• Which one of the following would be most appropriate at this time?
• A) A trial of lactulose
• B) Lifestyle modifications
• C) Phosphosoda enemas
• D) Colonoscopy
• E) Pelvic floor muscle exercises
Answer
• ANSWER: D
• This patient has several red flags that require complete
colon evaluation with endoscopy: age >50, achange in stool
caliber, and obstructive symptoms. Other red flags include
heme-positive stools, anemiaconsistent with iron
deficiency, and rectal bleeding. Malignancy should be
eliminated as a possiblediagnosis prior to initiating any
treatment. Biofeedback training is used to manage pelvic
floor dysfunctioncaused by incoordination of pelvic floor
muscles during attempted evacuation. Common symptoms
includeprolonged or excessive straining, soft stools that are
difficult to pass, and rectal discomfort. The other options
are appropriate management strategies once malignancy
has been eliminated as a possibility.
Question
• You see a 75-year-old male for his Medicare annual
wellness visit. Which one of the following satisfies the
Medicare requirement for vision screening?
• A) Questioning the patient about vision changes
• B) Use of the Amsler grid to detect age-related macular
degeneration
• C) Use of the Snellen eye chart to evaluate visual acuity
• D) Use of an ophthalmoscope to detect cataracts
• E) Use of tonometry to detect glaucoma
Answer
• ANSWER: C
• Although Medicare does not pay for an “annual physical,” it does
provide for annual preventive screening services, including a
complete health history and an array of screening measures for
depression, fall risk, cognitive problems, and other challenges. The
physical examination conducted as part of the annual wellness visit
includes measurement of blood pressure and weight, a vision
check, and hearing evaluation, as well as additional elements
depending on the individual’s health risks. While questioning the
patient or caregiver regarding perceived hearing difficulties may
suffice when screening for hearing loss, screening for vision loss
requires use of a standard screening tool. Documentation of visual
acuity by use of the Snellen chart is an accepted means of screening
for visual acuity in the primary care setting (SOR A). Vision
screening will not pick up age-related macular
• degeneration or cataracts, however.
Question
• Most of the gait disturbances identified in
geriatric patients in the outpatient primary care
setting are related to which one of the following?
• A) Sensory ataxia
• B) Parkinson’s disease
• C) Osteoarthritis
• D) Multiple strokes
• E) Myelopathy
Answer
• ANSWER: C
• Problems with gait and balance increase in frequency with advancing age
and are the result of a variety of individual or combined disease processes.
Findings may be subtle initially, making it difficult to make an accurate
diagnosis, and knowing the relative frequencies of primary causes may be
useful for management. A cautious gait (broadened base, slight forward
leaning of the trunk, and reduced arm swing) may be the first
manifestation of many diseases, or it may just be somewhat physiologic if
not excessive.In the past, a problematic gait abnormality in an elderly
person was generally termed a senile gait if therewas no clear diagnosis; it
is more accurate, however, to describe this as an undifferentiated gait
problemsecondary to subclinical disease. From the long list of potential
causes, arthritic joint disease is by far themost likely to be seen in the
family physician’s office, accounting for more than 40% of total cases. It
mostfrequently causes an antalgic gait characterized by a reduced range of
motion. The patient favors affectedjoints by limping or taking short, slow
steps.
Question
• A 67-year-old white male with hypertension and chronic
kidney disease presents with the recentonset of excessive
thirst, frequent urination, and blurred vision. Laboratory
testing reveals a1c fasting blood glucose level of 270
mg/dL, a hemoglobin A of 8.5%, a BUN level of 32
mg/dL,and a serum creatinine level of 2.3 mg/dL. His
calculated glomerular filtration rate is 28mL/min.
• Which one of the following medications should you start at
this time?
• A) Glipizide (Glucotrol)
• B) Metformin (Glucophage)
• C) Glyburide (DiaBeta)
• D) Acarbose (Precose)
Answer
• ANSWER: A
• It is recommended that metformin be avoided in
patients with a creatinine level >1.5 mg/dL for men
or>1.4 mg/dL for women. Glyburide has an active
metabolite that is eliminated renally. This
metabolitecan accumulate in patients with chronic
kidney disease, resulting in prolonged hypoglycemia.
Acarboseshould be avoided in patients with chronic
kidney disease, as it has not been evaluated in these
patients.Glipizide does not have an active metabolite,
and is safe in patients with chronic renal disease.
Question
• A 68-year-old white female with a several-year history of wellcontrolled essential hypertensionand a history of acute myocardial
infarction 2 years ago is brought to the emergency
departmentcomplaining of sudden, painless, complete loss of vision
in her left eye that began 1 hour ago.Her vital signs are stable, and
her blood pressure is 148/90 mm Hg. Her corrected visual acuityis:
left—absent, with no light perception; right—20/30. The external
eye examination is entirelyunremarkable. A retinal examination
reveals the findings shown in Figure 5.
• The most likely diagnosis is
• A) acute narrow-angle glaucoma
• B) optic neuritis
• C) retinal hemorrhage
• D) central retinal artery occlusion
• E) central retinal vein occlusion
Answer
• ANSWER: D
• The retinal findings shown are consistent with central
retinal artery occlusion. The painless, unilateral,sudden
loss of vision over a period of seconds may be caused
by thrombosis, embolism, or vasculitis.Acute narrowangle glaucoma is an abrupt, painful, monocular loss of
vision often associated with a redeye, which will lead
to blindness if not treated. In persons with optic
neuritis, funduscopy reveals ablurred disc and no
cherry-red spot. Occlusion of the central retinal vein
causes unilateral, painless lossof vision, but the retina
will show engorged vessels and hemorrhages.