GERIATRIC CONCERNS
From Johns Hopkins University School of Medicine’s Current Topics in Geriatrics, February 9-11, 2006
| SORE AND ACHING JOINTS IN THE ELDERLY —Philip Seo, MD, Assistant Professor, Division of Rheumatology,
Johns Hopkins University School of Medicine, Baltimore, MD
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| Joint examination: physician should develop system and do same examination on each patient, working distally to
proximally and comparing left to right; be aware of “big guy syndrome,” ie, joints of 6-ft stevedore from eastern Maryland
look big due to patient’s natural size; remember that true joint disease should hurt during active and passive range of
motion; pain only on active range of motion likely not true joint disease but tendinitis or muscle problem; because patients
try to compensate for poor joint motion by subtle body movements, keep one hand on joint while using other hand
to manipulate it
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| Diagnosis: 2 systems used: diagnosis by number of joints—monoarthritis (1 joint), oligoarthritis (2-4 joints) and polyarthritis
(>4 joints); monoarthritis usually indicates infection, crystal neuropathy, or fracture; diagnosis by size of
joint—large joints (hips, shoulders, knees); small joints (hands, feet); medium-sized joints (all others); rheumatoid arthritis
(RA), classically disease of small joints; most common diagnoses— osteoarthritis (OA) or crystalline arthropathies;
polymyalgia rheumatica not joint problem per se, but typically presents as joint problem (eg, morning stiffness in
shoulders or hips, elevated inflammatory marker)
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| Examination maneuvers: hands—if patient can push fingers together so no light visible between digits (finger curl),
good range of motion in proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints; check carpometacarpal
(CMC) joint at base of thumb; wrists—patient should be able to hyperextend, ie, bend wrist back ≈90 degrees; if not,
loss of joint space present; shoulders— bring arm forward across chest, then backwards; neck— OA affects C6; if patient
has numbness and tingling but not carpal tunnel syndrome, consider OA in neck; back—facet hypertrophy form of
OA that causes low back pain; ask patient to bend backwards and sway left and right to see if pain reproduced; foot—
grab foot and squeeze while patient seated; if this elicits pain, patient has loss of joint space from midfoot OA
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Crystalline Arthropathies
| Gout: disease of uric acid deposition; 2 clinical phenotypes; acute inflammatory arthritis—“touch-me-not” tenderness;
joint red hot and swollen; difficult to distinguish from septic arthritis; gout may cause acute tenosynovitis that looks like
cellulitis; tophaceous deposits—becoming less common with trend toward aggressive treatment; harmless but indicate
need for aggressive treatment due to high level of uric acid
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 | Risk factors for gout: 1) changes in fluid status, typically associated with hospitalizations or surgeries; 2) change in medications,
eg, patient newly diagnosed with hypertension and placed on diuretic; 3) dietary indiscretion (especially shellfish
and alcohol); 4) male sex (however, postmenopausal women can also be at high risk); 5) family history; 6) preexisting
coronary artery disease (CAD), hypertension, and diabetes
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| Caveats: serum uric acid misleading; uric acid can be normal to low in acute gouty attack, whereas some patients with asymptomatic
hyperuricemia for years may never develop gout; treatment can precipitate flare, eg, allopurinol can cause
patient to get worse in first few days; recurrent attacks lead to severe irreversible joint destruction
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| Pseudogout: disease of crystal deposition but, instead of uric acid crystals, involves calcium pyrophosphate; associated
with acute inflammatory arthritis and chondrocalcinosis; more muted than acute gout, making it mimic for other forms of
arthritis; hemochromatosis can be present, but rare in this age group; in patient newly diagnosed with pseudogout, think
about hypercalcemia, hyperparathyroidism, and hypothyroidism, all of which can precipitate attack
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| Milwaukee shoulder: disease of hydroxyapatite deposition; tends to affect shoulders and occasionally hip, ie, proximal
joints; attacks extra-articular structures, ie, leads to tendon rupture more frequently than to joint destructon
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Diagnostic Tests
| Radiographs: magnetic resonance imaging (MRI) used, but plain radiographs just as good and have advantage of multiple
images over time; easier to examine film on white board than to compare MRIs; x-rays of knees should be weight-
bearing; speaker tells patients he wants to see what knees look like when pain worst, and for many patients, this is
bending semi-flexed position
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| Radiographic changes: in OA—narrowing of medial joint space where pressure greatest; osteophytes; in hands, metacarpophalangeal
joints (MCPs) look relatively preserved, while DIP joints have almost no joint space; in gout— much
joint space destruction; large lesions classic
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| Synovial fluid analysis: OA not truly inflammatory arthritis but white blood cell (WBC) count of 1000/mm3 considered
typical; >100,000 WBC/mm3 diagnostic of septic arthritis; enormous overlap between inflammatory arthritis and
septic arthritis, so difficult to make diagnosis from fluid alone; always send fluid for culture (especially important in elderly,
who can present atypically); absence of crystals does not rule out pseudogout; if suspected, do another arthrocentesis
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Drug Therapy for OA
| Acetaminophen: to date, drug of choice; antipyretic but not anti-inflammatory; doses up to 1 g q6h (probably peak of benefit);
severe toxicity possible, not only as acute overdose but also in patients who have taken it for long time; monitoring indicated
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| Cyclooxygenase (COX) inhibitors: true anti-inflammatory drugs; probably more effective than acetaminophen; less
gastrointestinal toxicity, but significant questions about cardiovascular risk with COX-2 inhibitors
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| Glucosamine and chondroitin sulfate: recent debate on benefits; Glucosamine/chondroitin Arthritis Intervention
Trial (GAIT)—large National Institutes of Health (NIH)-sponsored trial; results definitive; ≈1500 patients randomized
to glucosamine/chondroitin sulfate, celecoxib, or placebo; found no benefit of neutriceutical over placebo; some evidence
for improvement in patients with severe form of OA; rheumatologists think this probably due to statistical error
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| Doxycycline: study of ≈400 patients with unilateral knee OA (early inflammatory phase); doxycycline seemed to slow
loss of joint space, but patients could not tell difference; speaker reserving judgement
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| Capsaicin: derived from substance that makes chili peppers hot; promotes massive release of substance P, impairing ability
to transmit pain signals; avoids problems with taking additional systemic medication; speaker advises patients to try
on less sensitive part of body first and to persevere, since effect increases over time
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Medical Management of Gout
| Acute management: frequently need only nonsteroidal anti-inflammatory drugs (NSAIDs), since gout generally resolves
spontaneously; for larger joints, injections of corticosteroids; can mix triamcinolone 40 mg with 1% lidocaine; aspirate as
much joint fluid as possible so as not to dilute corticosteroid and because patients report relief from removal of extra joint
fluid
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| Long-term management: all roads lead to allopurinol; can try probenecid, but minimally effective in older patients
with renal insufficiency; typically start allopurinol at 200 mg; in older patients start at 100 mg and work up; want uric
acid levels lower than normal (<5 mg/dL ideal); some patients develop hypersensitivity reaction (eg, acute rash, fever;
stop drug immediately); cleared renally; febuxostat—new xanthine oxidase inhibitor; available soon; looks promising
for patients with chronic disease; not cleared renally
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| EVIDENCE ABOUT TUBE FEEDING —Colleen Christmas, MD, Assistant Professor of Medicine, Division of Geriatric
Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
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| Malnutrition in chronically ill elderly: standard approach measurement of markers of nutritional status, modification
of nutrient intake, and titration of nutritional therapy based on repeat measurement of nutritional markers
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| Studies on malnourished patients: 1992 prospective study—40 malnourished nursing home patients; given 123%
of calculated caloric need and 170% of estimated protein need by feeding tube; most still showed micronutrient deficiencies
and marasmic wasting; patients with sepsis—continue to lose lean body mass despite provision of high levels of
protein and calories; randomized trial of patients undergoing esophagectomy—randomized to nothing by mouth and
IV D5-W or tube feeding; at 2 wk, no difference between groups in weight, body composition, rates of transfusion, complications,
serum protein, electrolytes, or length of stay; conclusion—markers of nutritional status often normal in
healthy people with no nutrition for prolonged time, abnormal in unhealthy people given more than adequate nutrition,
and potently affected by inflammation and other illnesses, regardless of nutrient intake; markers not reliable (measure
sickness, impending death, and complications but not whether nutrition will fix problem)
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| Data about tube feeding: Feed Or Ordinary Diet (FOOD) Trial Collaboration— multicenter study; 859 patients
with acute dysphagic stroke randomized to early feeding tube vs waiting 1 wk; findings show no difference in survival,
recovery from stroke, length of stay, or complication rates; higher rate of gastrointestinal (GI) bleeding in early tube
group
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| Enteral or parenteral feeding: known that in critically ill patients, total parenteral nutrition (TPN) dangerous, ineffective
for improving outcomes, and associated with higher rates of infectious complications; Study to Understand
Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) study (2000)—found that nutritional
therapy by feeding tube of benefit only if patients in prolonged coma; enteral or parenteral feeding associated with reduced
survival in acute respiratory distress syndrome (ARDS) or multiple organ system failure with sepsis; enteral nutrition
associated with reduced survival in cirrhosis and chronic obstructive pulmonary disease (COPD)
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| Dementia: common indication for tube feeding in United States; mortality very high in demented patients with feeding
tubes (death 6-9 mo after placement); studies that looked at hand-fed vs tube-fed patients show better survival in hand-
fed patients
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| Outcomes other than survival: functional status—study looking at functional independence measures (FIM)
scores found functional status not improved by feeding tube placement (longest follow-up 18 mo), regardless of function
at time of placement; pressure sores—known that nursing homes with higher rates of pressure sores also have
higher rates of tube feeding; infection—increased colonization of oropharynx with pathogenic organisms after feeding
tube placed; infectious and noninfectious diarrhea may be caused by feeding tubes; aspiration pneumonia—in
most studies, tube feeding number one risk factor for development of aspiration pneumonia
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| Management of geriatric weight loss: take systematic approach; evaluate medications, looking for drugs that may
affect eating (eg, anticholinergic drugs cause dry mouth; sedatives may cause inattention at mealtimes; NSAIDs contribute
to anorexia; antipsychotics alter swallowing); look at oral hygiene; evaluate for depression; look for metabolic causes
of weight loss (eg, test for thyroid stimulating hormone [TSH]); obtain chest x-ray if history of smoking present; screen
for cancer; promote accessibility and palatability of food (eg, chocolate, condiments); compensatory feeding techniques
for stroke patients; frequent small meals; improvement of ambiance at mealtimes
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| How to advise family: if tube placed, good chance death near; at point where family asking about tube and patient terminal,
may need to readjust goals and emphasize palliative approach; evidence does not support utility of feeding tubes in
chronically ill elderly and dying people; talk about complications; disclose other options; explain that food refusal often
indication of end stage
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| WHAT IS FUTILE CARE? —Thomas E. Finucane, MD, Professor, Division of Gerontology and Geriatric Medicine,
Johns Hopkins University School of Medicine, Baltimore, MD
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| Study of quadriplegics: quality of life investigated for bedfast patients in regional spinal cord networks; C3 or higher
quadriplegics, from trauma, thinking clearly, no prospect for technologic relief (late 80s); patients mainly male and on
ventilators; 1-yr duration of condition; two thirds said quality of life good or excellent
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| SUPPORT trial: ≈5000 patients admitted to 5 top-notch medical centers with high probability of dying in hospital; responses
showed quality of life had no effect on patient’s desire to undergo cardiopulmonary resuscitation (CPR)
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| Prognosis: on days 1, 3, and 7 of hospitalization, physicians asked to estimate SUPPORT patients’ survival to 6 mo,
based on health information algorithms; patients had incurable metastatic cancer; physicians calculated 20% to 25%
chance of living 6 mo on third day before actual death; death highly unpredictable; people reluctant to give up fight
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| What does “futility” mean? for physician, generally means treatment should not be provided, despite family’s or patient’s
request; qualitative futility—treatment merely preserves permanent unconsciousness or cannot end dependence
on intensive medical care; however, young quadriplegics on ventilators disprove this definition; quantitative futility—
proposal that when physicians conclude through personal experience, peer experience, or empiric data that in last 100
cases, medical treatment useless, treatment be regarded as futile; if chance of treatment prolonging life <1%, treatment
futile
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| State court rulings: each state defines futility differently; in Maryland, term “futile” replaced by term “medically ineffective,”
meaning that “to a reasonable degree of medical certainty, a medical procedure will not prevent or reduce deterioration
of health or prevent impending death”; in Maryland, treatment futile if it fails to stop patient from dying; so, if patient in persistent
vegetative state, but CPR would prolong life, treatment not ineffective; bedside appraisal of resources using “socially
utilitarian” calculus not basis for decision about life-sustaining treatment
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Educational Objectives
| The goal of this program is to educate the listener on issues in joint disease, tube feeding, and treatment decisions in end-
stage care. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify joint disease and conduct joint examination.
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| 2. Treat osteoarthritis and the crystalline arthropathies.
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| 3. Evaluate evidence for and against tube feeding and respond to questions of families of elderly patients with malnutrition.
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| 4. Discuss the meaning of “quality of life” and “futile treatment.”
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| 5. Consider issues for physicians making decisions and counseling families about terminally ill patients.
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Discussed in this Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several trade names]
Allopurinol [Aloprim, Zyloprim]
Celecoxib [Celebrex]
Chondroitin (chondroitin sulfate)
Febuxostat (investigational)
Glucosamine Sulfate
Lidocaine HCl (several trade names)
Probenicid
Triamcinolone acetonide (several trade names)
Suggested Reading
Bolin K et al: The family as the health producer–when spouses act strategically. J Health Econ 21:475, 2002; Canapp
SO et al: Examination of synovial fluid and serum following intravenous injections of hyaluronan for the treatment of osteoarthritis
in dogs. Vet Comp Orthop Traumatol 18:169, 2005; Demaerel P: Magnetic resonance imaging of spinal
cord trauma: a pictorial essay. Neuroradiology 48:223, 2006; Epub 2006 Mar 21. Finucane TE: "Quality," nutrition,
and pressure ulcers. Arch Intern Med 162:100, 2002; Finucane TE: Care of patients nearing death: another view. J Am
Geriatr Soc 50:551, 2002; Heland M: Fruitful or futile: intensive care nurses’ experiences and perceptions of medical
futility. Aust Crit Care 19:25, 2006; Lazaruk T: The CPR question. Can Nurse 102:22, 2006; Living, dying and the
law. NY Times (Print):A14, 1995; Mikuls TR et al: Medication errors with the use of allopurinol and colchicine: a retrospective
study of a national, anonymous Internet-accessible error reporting system. J Rheumatol 33:562, 2006; Patel R
et al: The diagnosis of prosthetic joint infection: current techniques and emerging technologies. Clin Orthop Relat
Res:55, 2005; Pennington C: To PEG or not to PEG. Clin Med 2:250, 2002; Rowden AK et al: Acetaminophen poisoning.
Clin Lab Med 26:49, 2006; Schlesinger N: Diagnosis of gout: clinical, laboratory, and radiologic findings. Am J
Manag Care 11:S443, 2005; Simanek V et al: The efficacy of glucosamine and chondroitin sulfate in the treatment of
osteoarthritis: Are these saccharides drugs or nutraceuticals? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub
149:51, 2005; Slomka J: Withholding nutrition at the end of life: clinical and ethical issues. Cleve Clin J Med 70:548,
2003; Werner P et al: Nurses’ and social workers’ attitudes and beliefs about and involvement in life-sustaining treatment
decisions. Health Soc Work 29:27, 2004; Wu CW et al: New developments in osteoarthritis. Clin Geriatr Med
21:589, 2005;
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Christmas, Finucane, and Seo spoke at the 33rd Annual Current Topics in Geriatrics, held February 9-11, 2006,
in Baltimore, MD, sponsored by the American Geriatrics Society and Johns Hopkins Geriatrics Education Center.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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