CONCERNS OF THE ELDERLY
From the 34th Annual Current Concepts in Geriatrics, sponsored by the Johns Hopkins University School of Medicine,
Baltimore, MD
| VENOUS INSUFFICIENCY —Jennifer A. Heller, MD, Assistant Professor of Surgery and Director, Johns Hopkins Vein
Center, Johns Hopkins University School of Medicine, Baltimore
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| Prevalence: correlated with increasing age, as is severity; 72% of women and 42% of men have manifestations of venous
disease by their 60s; 10 times more patients suffer from chronic venous insufficiency (CVI) than from peripheral arterial
disease
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| Pathophysiology: impaired vein valve function results in pooling of blood and ineffective return of venous blood to heart;
venous reflux manifestation of valvular destruction that increases ambulatory venous pressure in legs, initiating cascade
of events that manifests as varicose veins, edema, pain, itching, and ulcers
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| Varicose vein formation: several etiologies, including genetics (autosomal dominant trait with variable penetrance) and
deep venous thrombosis (DVT); DVT—injures venous endothelium, resulting in vein wall fibrosis; fibrotic wall does not
contract well, resulting in ambulatory venous hypertension; without DVT—varicose veins have increased collagen, decreased
elastin, altered matrix metalloproteinases (MMPs), and decreased endothelin; vein wall fibrosis decreases contractility
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| Risk factors: advancing age; genetics; female sex; pregnancy; oral contraceptive (OC) use; factors that do not influence
development—smoking; hypercholesterolemia; leg crossing; vitamin intake; point—exercise lowers risk
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| Symptoms: aching and feeling of “heavy” legs (worse at end of day and after prolonged sitting or standing); pain; burning
sensation due to venous neuropathy; itching due to cutaneous inflammation and hemosiderin deposition caused by stasis
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| Physical examination: perform arterial examination of extremities; examine venous system in sitting and standing positions;
assess for presence of venous cords and signs of thrombophlebitis, ie, areas of tenderness, induration, and warmth;
look for edema; inspect abdomen and pubis for dilated veins (suggests old ileofemoral thrombus); look for dilated veins
across medial or posterior buttocks or thighs (can arise from varicosities of pudendal or other pelvic vessels); check for
superficial venous hypertension as manifested by corona phlebectica (main sign; accumulation of telangiectasias around
ankle); other stigmata include venous dermatitis (hyperpigmentation, induration, eczema), venous ulceration, atrophie
blanche (whitish center sometimes surrounded by hyperpigmentation; ask patient if area site of healed ulcer), lipodermatosclerosis
(area of chronic inflammation and fibrosis, possibly with contracture of Achilles tendon)
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| Arterial vs venous ulceration: location (arterial ulcers on toes or feet; venous ulcers around medial malleolus); pain (patients
with chronic arterial insufficiency have intense pain at rest; intense pain rare in patients with venous ulcers); pulses
(absent with arterial ulcers; palpable with venous disease); comment—some patients have venous and arterial ulcers
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| Diagnostic testing: ultrasonography—both Doppler and duplex indicated for patients with concomitant venous and arterial
disease; for patients with venous insufficiency only, Doppler provides all information needed; Doppler and duplex
used to look for DVT and reflux; physical examination—evaluate for reflux with patient standing with extremity in nonweight-bearing
position; place compression cuff around leg and rapidly release (reflux occurs when cuff released); mild
reflux 0.5 to 2 sec; severe reflux >2 sec; normal veins do not reflux with this technique
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| Conservative therapy: always indicated first, unless patient has venous ulceration or bleeding varix; includes limb elevation
(“toes above nose” 20 min twice daily), skin care, leg exercises (including walking), and use of compression
stockings
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 | Compression therapy: decreases leg edema and venous hypertension; recommended compression 20 to 30 mm Hg; if
compliance at issue, may start with 15 to 20 mm Hg; Medicare does not cover
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| Indications for surgery: symptoms refractory to conservative therapy after 2 to 3 mo; thrombophlebitis (after it resolves);
bleeding varix; venous ulceration
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| Managing greater or lesser saphenous vein incompetence: stripping and ligation—largely outdated; significant
pain; slow recovery; newer minimally invasive procedures—include endovenous laser ablation and venous radiofrequency
ablation; both use percutaneous access through saphenous vein; laser ablation results in considerable postoperative
pain
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| Radiofrequency ablation: vein access usually done percutaneously at knee or calf; catheter then inserted into vein with electrodes
at top to generate heat (85°-90°C; results in shortening and thickening of collagen fibers, destruction of endothelial
wall, and venous occlusion); procedure takes 10 to 15 min; before leaving patient, check with Doppler to ensure heat did
not propagate into deep venous system and that saphenous vein closed; advantages—earlier return to activities and work;
less pain and less bruising; lighter anesthesia; disadvantages—relatively new; standard surveillance protocols needed to
ensure veins remain occluded (speaker reexamines patients at 1, 3, 6, and 12 mo postoperatively)
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| Managing varicose vein branches: conventional stab phlebectomy—involves making small incisions on legs and pulling
veins out with hook; likely to leave behind vein segments that may become inflamed; takes up to 3 hr;
sclerotherapy—involves injecting agent (eg, foam, detergent, hypertonic saline, glycerin) into veins; complications include
DVT and pulmonary embolism; transilluminated powered phlebectomy (TRIVEX)—done under conscious sedation;
small incision made on leg close to varicosity; light placed under skin to visualize vein; after removal, give local
anesthesia to minimize postoperative pain, and place large compressive dressing around leg to decrease drainage; patients
typically have little pain; requires more anesthesia and more postoperative visits; possibility of dressing changes
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| SCREENING OCTOGENARIANS FOR BREAST CANCER —Danelle Cayea, MD, Assistant Professor of Medicine, Division
of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore
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| Opening remarks: decision on screening more complicated in older patients; affected by comorbidities, barriers to
screening, and patient preferences; consensus lacking on when to stop screening for various cancers
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| Two 80-yr-old women: patient 1—has well controlled type 2 diabetes, some osteoarthritis (OA) in knees, and hypertension;
independent in all basic and instrumental activities of daily living; walks 1 mile every other day; helps care for sister;
requests mammogram; patient 2—also has diabetes, OA, and hypertension, but has mild dementia, anxiety, and
depression; independent in basic activities of daily living, but does not drive, handle finances, or clean; quite sedentary;
daughter asks if mother due for mammogram
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| Quantitative factors in deciding whether to screen: life expectancy; patient’s risk of dying from screening-detectable
cancer during remaining lifetime; absolute benefits and risks of screening test; comments—determine if patient above
or below median life expectancy for age cohort; variables affecting life expectancy—number and severity of comorbid
conditions (eg, depression, dementia), self-reported health, functional impairment, and frailty
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| Comments: patient 1 has life expectancy of ≈13 yr, but patient 2 has life expectancy <5 yr; patient 1 has almost twice risk
of dying from screening-detectable breast cancer in remaining lifetime (2.4%), but overall risk of dying from it rather
low; risk of dying from screening-detectable cancer—determined by multiplying life expectancy by age-specific
breast cancer mortality rate
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| Absolute benefits and harms of screening: factors to consider include behavior of cancer in older people, accuracy of
particular screening test, and individual differences
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| Global statements about breast cancer in older women: tend to have slower-growing tumors that may not cause as
much morbidity and mortality (younger women tend to have worse histology and tumor markers); mammography may be
more sensitive because of decreased density of breast tissue (may lead to overdetection of insignificant lesions); specificity
of mammography in women in 40s about equal to that of women in their 70s; sensitivity increases with age when
women in 60s compared to women in 80s; older women tend to have longer asymptomatic period because tumors less aggressive
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| Data from studies on younger women: multiple randomized controlled trials—involved mammographic screening over
years; survival curves did not diverge until >5 yr; so 5 yr of screening required to achieve real benefit, perhaps because many
cancers do not cause death in 5 yr; risk and benefit—patients should be informed, that while everyone being tested experiences
risks and harms of test, only some experience benefit; population-based studies involving large numbers of women
>70 yr of age found that 77 to 86 in 1000 women have abnormal screening mammography, and of these, 86% had false-positive
result; also, 1 in 1000 with abnormal result had ductal carcinoma in situ (does not require treatment in this age group);
months after mammography, fear of having cancer persisted in women with abnormal result that required follow-up testing
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| Individual patient characteristics: consider risk factors (eg, family history of breast cancer, prolonged use of exogenous
estrogen therapy); women who have never been previously screened slightly more likely to benefit from screening; women
with ≥3 comorbid conditions more likely to die from other causes, even if they develop screening-detectable breast cancer
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| Patient attitudes: many elderly people fearful about cancer and consequences of treatment, having grown up at time before
development of modern treatments; some people desire screening simply for “peace of mind” from negative test,
while others “would be worried to death” if test abnormal; in general, older adults just as likely as younger patients to
want curative treatments, if possible; one half to one third of older patients desire discussions with physicians about life
expectancy; however, majority think physicians do not accurately estimate life expectancy; 75% of patients think benefit
from screening immediate, not realizing that benefits of screening occur over years; two thirds to 75% of people feel that
those demented or functionally impaired (ie, others, not themselves) should be screened indefinitely
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| Screening issues: age ≥90 yr generally accepted as indication for no more screening; screening generally not sought by
patients near death; if told that test inaccurate, most say they would not want to be screened; older patients more likely to
accept physician’s advice about screening, although ≈20% of those asked would continue to be screened, even if physician
advised against screening
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| Patients with extra challenges: health literacy declines with age, so physician should try to determine how much patient
really understands; in triad interviews involving physician, patient, and caregiver, patients less likely to offer opinion if
caregiver pushes for test; often easier for patients to make screening decision if benefits and risks discussed in absolute
terms
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| Recommendations for two 80-yr-old women: mammography may be reasonable for patient 1, but not patient 2
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| MEDICAL MANAGEMENT OF ELDERLY SURGICAL PATIENT —K. Eric DeJonge, MD, Section Director, Geriatric
Unit, Washington Hospital Center, Washington, DC
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| Case of Mrs. B: 99-yr-old woman; presents to emergency department (ED) with dragging left leg for 1 day and some new
confusion; no history of fall, loss of consciousness, or other symptoms; previously ambulatory; positive urinalysis in
ED; has history of chronic atrial fibrillation, hypertension, and mild memory impairment; appetite good; no known
coronary, pulmonary, or renal disease, and no diabetes; taking warfarin (Coumadin); admitted from ED with diagnosis
of urinary tract infection (UTI) and dehydration; computed tomography (CT) of head completed and results pending;
subsequently sustains fall in hospital room, striking head, and fracturing hip; CT shows acute right frontal stroke; x-ray
shows acute intertrochanteric left hip fracture
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| Follow-up: physician discusses dual problems with family and explains possible options for managing fracture (eg, surgery,
bed rest, and pain management); orthopedist described immobility risks (pulmonary infection, sacral ulcers,
DVT, UTI, functional decline)
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| Key principles in management: each patient unique; consider functional status, disease states, and priorities; determine
if surgery emergent or elective (Mrs. B falls into in-between “urgent” category); determine level of surgical risk (low,
medium, high); delineate goals of surgery; list and assess all patient risks and strive to reduce or prevent them prior to
surgery; consider use of preoperative β-blockers (2 studies suggest they significantly reduce risk for cardiovascular
events, including fatal MI)
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| More on Mrs. B: ability to compensate impaired (due to age and disease states); pros of doing surgery—avoidance of
long-term bed rest and narcotic use to minimize pain; facilitation of rehabilitation for stroke; Mrs B’s risks—nonsinus
rhythm, acute stroke, delirious state, and advanced age; comments—hip fracture surgery medium-risk procedure; objectives
of surgery to relieve pain, allow patient to bear weight and to begin stroke rehabilitation
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| Preoperative care: involved stabilization of 5 key organ systems and discussions on how to prevent adverse events during
and after surgery
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| Surgical procedure: involved minimizing incision size and duration of surgery, giving regional instead of general anesthesia
(usually does not change long-term mortality, blood loss or delirium, but reduces risk for DVT, slightly decreases
30-day mortality, and reduces pulmonary complications)
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| Postoperative care: involved programs to prevent pressure ulcers and minimize delirium (includes maintaining volume
status and brain perfusion, adequate oxygenation and glucose, minimizing drugs, avoiding chemicals and toxins that
can cause encephalopathy, and avoiding sensory overload or deprivation); risk factors for delirium—include prior
brain disease, impaired vision, serum urea nitrogen (BUN)/creatinine ratio >18, and severe comorbidities
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| Prevention plan: early mobility; rapid discharge planning; intensive medication review
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| Postoperative period: enoxaparin started 24 hr after procedure; orders given for early mobility and 24-hr family presence in
private room (to help feed patient and avoid use of restraints)
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| What happened to Mrs. B after surgery: 1-hr surgery; heart rate labile; confusion continued, leading to poor po intake
and anorexia; anticoagulation therapy discontinued because of hematoma and ecchymosis; blood transfusions given;
stage 2 sacral ulcers and increased leg edema on operated (left) side; by day 3 or 4 after surgery, patient able to get out of
bed and stand by chair, but not ambulating; 14 days after surgery, patient alert and attentive and transferred to subacute
rehabilitation unit; 6 wk later, patient sent home, where she subsequently developed acute DVT in left leg (operated
side); placed on warfarin; 5 mo after surgery Mrs. B died, having never been ambulatory, but having been home with
family and kept reasonably comfortable
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Suggested Reading
Alguire PC, Mathes BM: Chronic venous insufficiency and venous ulceration. J Gen Intern Med 12:374, 1997; Beaupre
LA et al: Best practices for elderly hip fracture patients: a systematic overview of evidence. J Gen Intern Med 20:1019, 2005;
Berliner E et al: A systematic review of pneumonic compression for treatment of chronic venous insufficiency and venous
ulcers. J Vasc Surg 37:539, 2003; Brunner LC et al: Hip fractures in adults. Am Fam Physician 67:3, 2003; Edwards AG
et al: Personalized risk communication for informed decision making about taking screening tests. Cochrane Database Syst
Rev (4):CD001865, 2006; Elmore JG et al: Screening for breast cancer. JAMA 295:1245, 2005; Ely JW et al: Approach to
leg edema of unclear etiology. J Am Board Fam Med 19:148, 2006; Feig SA: Screening mammography controversies: resolved,
partly resolved, and unresolved. Breast J 11(Suppl 1):S3, 2005; Green BB, Taplin SH: Breast cancer screening controversies.
J Am Board Fam Pract 16:233, 2003; Gregg EW: Physical activity, falls, and fractures among older adults: a
review of the epidemiologic evidence. J Am Geriatr Soc 48:883, 2000; Jeanneret C et al: Greater saphenous vein stripping
with liberal use of subfascial endoscopic perforator vein surgery (SEPS). Ann Vasc Surg 17:539, 2003; Korn P, Heller JA et
al: Why insurers should reimburse for compression stockings in patients with chronic venous stasis. J Vasc Surg 35:950,
2002; Lasheen AE et al: Closed subfascial ligation of incompetent perforating veins of the lower extremities. Surg Today
34:1057, 2004; Legg LA et al: Occupational therapy for patients with problems of activities of daily living after stroke. Cochrane
Database Syst Rev (4):CD003585, 2006; Martinez MJ et al: Phlebotonics for venous insufficiency. Cochrane Database
Syst Rev (3)CD003229, 2005; Meisssner HI et al: Promoting cancer screening: learning from experience. Cancer
101(5 Suppl):1107, 2004; Passman MA et al: Combined endovenous ablation and transilluminated powered phlebectomy:
is less invasive better. Vas Endovascular Surg 41:41, 2007; Patel NP et al: Current management of venous ulceration. Plast
Reconstr Surg 117(7 Suppl):254S, 2006; Rao SS: Prevention of falls in older patients. Am Fam Physician 72:82, 2005; Ratcliffe
J et al: Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized
clinical trial. Br J Surg 93:182, 2006; Sharif MA et al: Endovenous laser treatment for long saphenous vein
incompetence. Br J Surg 93:831, 2006; Tzilinis A et al: Chronic venous insufficiency due to great saphenous vein incompetence
treated with radiofrequency ablation: an effective and safe procedure in the elderly. Vasc Endovascular Surg 39:341,
2005.
Cultural and Linguistic Resources
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its website. Please visit this site: www.audiodigest.org/ CLCresources.
Educational Objectives
| The goals of this program are to improve management of venous insufficiency of the lower extremities and medical management
of elderly surgical patients, and to offer some informal guidelines for breast cancer screening in elderly patients.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Evaluate patients with chronic venous insufficiency of the legs.
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| 2. Describe conservative and surgical treatment for patients with venous insufficiency.
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| 3. Advise women in their 80s on the benefits and risks of screening mammography.
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| 4. Explain the benefits and risks of cancer screening in older people.
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| 5. Manage the elderly surgical patient with medical comorbidities.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Cayea, DeJonge, and Heller were recorded at the 34th annual Current Concepts in Geriatrics, sponsored by the Johns
Hopkins University School of Medicine, held February 15-17, 2007, in Baltimore, MD. The Audio-Digest Foundation
thanks the speakers and the Johns Hopkins University School of Medicine for making this program possible.
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