AGE-OLD PROBLEMS
From Current Topics in Geriatrics, sponsored by the Johns Hopkins University School of Medicine, Baltimore, MD
Educational Objectives
| The goal of this program is to improve the management of common geriatric conditions, such as venous thromboembolism,
delirium, and vitamin D deficiency. After hearing and assimilating this program, the clinician will be better
able to:
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 | 1. Use appropriate testing tools to identify deep venous thrombosis and pulmonary embolism (PE) in elderly patients.
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| 2. Work up patients with suspected PE, based on pretest clinical risk, ventilation-perfusion scan, and/or computed
tomography.
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| 3. List diagnostic criteria for delirium.
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| 4. Implement nonpharmacologic and pharmacologic therapy for delirium.
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| 5. Discuss risk factors and supplementation recommendations for vitamin D deficiency.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee 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 following has been disclosed: Dr. Haque
has received honoraria from Merck. Drs. Pearse and Leff and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Pearse, Leff, and Haque spoke in Baltimore, MD, at the 35th Annual Current Topics in Geriatrics, presented January
17-19, 2008, by the Johns Hopkins University School of Medicine. The Audio-Digest Foundation thanks the
speakers and the Johns Hopkins University School of Medicine for their cooperation in the production of this program.
| VENOUS THROMBOEMBOLISM —David B. Pearse, MD, Associate Professor of Medicine, Johns Hopkins University
School of Medicine, Baltimore, MD
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| Deep venous thrombosis (DVT): starts in calf; mostly self-limited; ≈25% of time, calf DVT extends to thigh; symptoms
and signs insensitive and nonspecific; ≈33% of symptomatic patients with classic history and examination have
DVT; many patients with extensive proximal thigh DVT asymptomatic
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| Proximal leg DVT: when untreated, mortality in first 3 mo 20% (due to pulmonary embolism [PE]); ≈50% of patients
who present with symptomatic DVT but no lung symptoms have high-probability ventilation-perfusion (V/Q) scans; in
patients with symptomatic PE and no leg symptoms, leg DVT can be found in ≤90% by venography or autopsy (gold
standards for diagnosis)
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| Pathogenesis: venous stasis; vessel wall damage; increased blood coagulability; common in elderly
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| Risk factors for venous thromboembolism (VTE): increasing age; recent surgery; major trauma; previous DVT;
pregnancy; oral contraception; medical conditions with immobility and hypercoagulability; heart failure (HF); myocardial
infarction; cancer; obesity; myeloproliferative disorders
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| Age at diagnosis: 75% of patients >60 yr of age; study found 11% cumulative probability of developing VTE in men at age
80 yr; risk factors for elderly inpatients—age >75 yr; previous VTE; limited mobility without immobilization; recent (<15
days) immobilization in chair or bed; HF; leg edema; stroke
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| Prophylaxis: PE often most serious complication (80% of deaths occur without warning); highly effective; study found
prophylaxis omitted in 50% of cases, incorrect in other 50%, and risk factors (eg, stroke, immobility) ignored; nonpreventable
DVT and PE occurred in orthopedic patients; make sure surgeon orders correct prophylaxis for patients undergoing
general surgery; all elderly inpatients at moderate to high risk; 30% of elderly inpatients correctly prophylaxed; 50% of
cases of DVT and PE in elderly occur in hospital or ≤3 mo after discharge (consider continuing prophylaxis after discharge);
low-dose unfractionated heparin (LDUH)—inexpensive; short-acting activator of antithrombin III; patients can
develop heparin-induced thrombocytopenia (HIT; monitor platelet counts); low molecular weight heparin (LMWH)—
longer-acting activator of antithrombin III; more effective in select group of patients; less HIT; cleared renally; mechanical
devices—used when heparin contraindicated; no good data about efficacy; last resort; fondaparinux—synthetic analogue;
long-acting; cleared renally; no HIT; approved for prophylaxis with hip and knee surgery (may be superior to LMWH);
high-risk patients—>60 yr of age undergoing minor surgery; >40 yr of age undergoing major surgery; use LDUH tid, or
LMWH with or without mechanical device; specific recommendations for orthopedic surgery shown to improve postoperative
complications; nonsurgical patients account for most cases of symptomatic VTE (many cases fatal); patients hospitalized
for medical illness at high risk for DVT and account for significant percentage of VTE cases; medical illness—for
patients at moderate risk, use LDUH bid, or lower-intensity LMWH; for patients at higher risk (eg, acute ischemic stroke)
who had thrombolytic therapy, wait 24 hr before giving high-intensity prophylaxis
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| Effects of advanced age on diagnosis: DVT—fewer symptoms; increase in D-dimer; immobility; hip fracture;
stroke; previous DVT; PE—different symptom complex; indeterminate V/Q scans; increased renal failure from intravenous
(IV) contrast; less tolerance for smaller emboli; increased risk for bleeding
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| D-dimer testing: enzyme-linked immunosorbent assay (ELISA) most sensitive (97%; few false-negative results); many
false-positive results because D-dimer elevated in DVT, PE, surgery, trauma, cancer, disseminated intravascular coagulation
(DIC), pregnancy, and infection; useful only when negative; PE more prevalent and D-dimer less specific in geriatric
patients; less useful in older patients; <5% of patients ≥80 yr of age have normal D-dimer levels
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| B-mode compression ultrasonography (US): test of choice; visualizes noncompressible clot in proximal veins of
leg; less sensitive in calf; accuracy not affected by age; highly sensitive and specific in patients with leg symptoms (eg,
pain, swelling); 50% sensitive in patients with asymptomatic proximal DVT (negative result does not rule out DVT); “if
it’s positive, it’s a true positive”; cannot be used on patients with cast, painful leg, or extreme obesity
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| Computed tomography (CT) and magnetic resonance imaging (MRI): visualize inferior vena cava, pelvis,
thigh, and calf; can be used on extremely obese patients and patients with injury or cast on leg; CT of leg—as accurate as
US when combined with spiral chest study; uses nephrotoxic contrast; MRI—no risk for nephrotoxicity; at least as sensitive
as US in thigh; more expensive
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| Diagnosis of DVT: use Wells’ prediction score (low [≤0]; intermediate [1-2]; high [≥3]) to determine clinical risk; low risk—
perform D-dimer testing (if negative, no further testing required); intermediate or high risk—perform US (if positive, patient
has DVT; if negative, repeat in 1 wk [rule out DVT if negative])
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| PE in geriatric population: lower incidence of pleuritic pain; higher incidence of syncope and cyanosis
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| Diagnosis of PE: V/Q scanning—well characterized; 100% sensitive when perfusion scan normal; no contrast dye; no
breath-holding required; accurately detects recurrent PE; nonspecific (most abnormal scans falsely positive); high-probability
and normal scan patterns useful, but less commonly seen (problem increases with advanced age); spiral CT—
becoming more dominant; rapid; provides additional diagnostic information; accuracy not age-dependent; uses contrast
dye; older systems require breath-holding; difficult to determine whether PE new or old; difficult to estimate loss of vascular
surface area in lung; single-detector CT—inaccurate beyond third pulmonary vessel generation; many false-positive
and false-negative results; multidetector CT—more accurate; using ≥64 detectors accurate to sixth vessel generation;
better resolution; can detect PE in periphery of lung with reasonable accuracy
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| Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II): evaluation of multidetector
(4 and 8) CT; PE considered present based on V/Q scanning, angiography, and venous US of legs; concordant results—in
patients with high or intermediate risk for PE and positive CT, positive predictive value of CT >90%; in patients with intermediate
or low risk and negative CT, negative predictive value of CT >90%; discordant results—in patients with low risk
and positive CT (nearly 25% of patients), positive predictive value of CT 38% (ie, most results likely falsely positive); in patients
with high risk and negative CT (rare), negative predictive value of CT 61%
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| Current algorithm for work-up of PE: if Wells’ prediction score low and D-dimer normal, no further work-up required;
increased D-dimer requires imaging study of lung (if chest x-ray normal, use V/Q scanning; if chest x-ray abnormal,
reasonable to use spiral CT); low pretest risk—if V/Q scanning normal or intermediate, no further work-up
required; high-probability V/Q scan discordant result (perform additional testing); if spiral CT negative (especially multidetector
CT), no further work-up required; if distal spiral CT positive, consider additional testing; if proximal spiral CT
positive (eg, clot in main pulmonary artery), reasonable to diagnose PE and start treatment; intermediate pretest risk—D-
dimer testing recommended (if normal, no further work-up required); if V/Q scan normal, no further work-up required;
high-probability V/Q scan sufficient to diagnose PE; negative spiral CT sufficient to rule out PE; in patients with positive
distal spiral CT, “be careful, may not be true positive”; positive proximal spiral CT sufficient to diagnose PE; high pretest
risk—if V/Q scan normal, no further work-up required; positive spiral CT or high-probability V/Q scan sufficient to diagnose
PE; perform additional testing when V/Q scan indeterminate or spiral CT negative
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| DELIRIUM —Bruce A. Leff, MD, Associate Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore,
MD
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| Delirium: acute decline in attention and cognition; inattention cardinal feature; studies suggest 60% to 80% of patients in intensive
care units (ICUs) may be delirious; incidence among general hospitalized patients, 50% to 60%; ≈60% of delirium unrecognized
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| Diagnosis: Confusion Assessment Method (CAM)—acute onset and fluctuating course, inattention, and either disorganized
thinking or altered level of consciousness; acute onset and fluctuating course—history critical; be suspicious if patient
called “poor historian,” presents as “social admission,” reported to have stroke but neurologic examination normal, or
if patient uncooperative with neurologic examination; patient “out of it”; multiple observations and talking with family
helpful; inattention—determine whether patient has difficulty focusing attention, is easily distracted, has difficulty keeping
track of what is said, and/or has reduced ability to maintain attention to external stimuli and to shift attention to new
stimuli; questions need to be repeated (patient’s attention wandering); perseveration; test by asking patient to repeat series
of digits or words or to recite months backwards; can also test with Folstein Mini-Mental State Examination (MMSE); disorganized
thinking—determine whether patient’s speech disorganized or incoherent; rambling; irrelevant conversation; illogical
flow of ideas; altered level of consciousness—drowsiness (aroused by voice command); stupor (aroused by
physical contact); do not confuse with tiredness; not diagnostic—disorientation to person, place, or time; memory impairment;
change in sleep-wake cycle; perceptual disturbance; change in psychomotor activity
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| Risk factors: visual impairment; severity of illness; preexisting cognitive impairment; dehydration; precipitating
factors—restraints; malnutrition; adding >3 medications; Foley catheter; iatrogenic complications
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| Hospital-based prevention: reality orientation (eg, place clock and calendar in room); nonpharmacologic interventions
for sleep (eg, glass of warm milk); early mobilization protocol; glasses and hearing aids; adequate volume repletion;
study found incidence of delirium reduced by ≈40%; no change in recurrence rate or severity
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| Evaluation and management: make diagnosis; cognitive evaluation (using, eg, CAM or MMSE); search for underlying
etiology; history—look for symptoms suggestive of acute illness (eg, nausea, vomiting, anorexia); review medications
(eg, determine whether new medicine started or stopped); medications that cause delirium—sedatives and
hypnotics; anticholinergics; nonsteroidal anti-inflammatory drugs; proton pump inhibitors; etiology—physical examination;
no evidence-based approach to diagnosis based on laboratory evaluation; targeted work-up; complete blood cell
count (CBC); chemistry panel; chest x-ray; electrocardiography (ECG); brain imaging studies for patients with history of
head trauma, focal neurologic changes, or recent fall
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| Treatment: nonpharmacologic—avoid bed rest orders and restraints; encourage early mobilization; availability of hearing
aids, glasses, and dentures; minimize psychoactive medications; pharmacologic—for severe agitation that interrupts care or
poses threat; literature supports use of antipsychotic agents over benzodiazepines; haloperidol (Haldol; 1-2 mg [repeat in 1
hr if indicated]) as effective as risperidone (Risperdal); proactive geriatric consultation to prevent delirium—>100 patients
undergoing surgery for hip fracture randomized to usual care or proactive geriatric consultation (included daily visits and
recommendations from geriatrician and team and pain treatment); no difference in length of stay, but rate of delirium lower
in intervention group (rate of severe delirium significantly lower)
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| Haloperidol prophylaxis: study of haloperidol bid vs placebo found no change in incidence of delirium, but severity
and duration of delirium lower in patients who received haloperidol; study included geriatric proactive consultation, so
unclear whether benefits due to haloperidol or to geriatric proactive consultation, or to both; “not our practice to use prophylactic
antipsychotics; I don’t think the evidence is there yet”
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| Postoperative delirium and pain: study strongly suggests that pain in delirious patients should be treated as inciting
element to delirium; do not use meperidine (Demerol)
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| VITAMIN D DEFICIENCY —Uzma Jalal Haque, MD, Assistant Professor of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD
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| 1,25-dihydroxyvitamin D3: active form of vitamin D; regulates calcium homeostasis by intestinal absorption and bone
resorption of calcium; maintains apoptosis and cell differentiation; many tissues possess ability to activate 25-hydroxyvitamin
D; potent immunomodulator
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| Vitamin D deficiency: may increase risk for colon, breast, and prostate cancer and certain autoimmune diseases; may
be risk factor for incident cardiovascular disease; rickets reappearing in United States; estimated 1 billion people worldwide
may be affected; can present with nonspecific aches, pain, and fatigue (therefore often misdiagnosed); populations
at risk—elderly; housebound or institutionalized individuals; people who work mostly indoors; blacks; people living in
areas at higher northern latitudes; Boston study found vitamin D deficiency in 32% of young (18-29 yr of age) population
at end of winter
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| Factors that alter synthesis of vitamin D: use of sunscreen; melanin; aging skin; zenith angle of sun—angle at
which sunlight crosses atmosphere and hits earth’s surface; when angle more oblique (eg, during winter, in areas of
higher northern latitude, or during early morning or late evening), fewer UV-B photons reach earth’s surface
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| Dietary sources of vitamin D: fatty fish (eg, salmon, mackerel); cod liver oil; fortified products (eg, milk, yogurt, cereals)
poor sources because of variable vitamin D content
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| Assessing vitamin D status: 25-hydroxyvitamin D best indicator of vitamin D stores; 30 ng/mL required for optimal
skeletal health (likely to increase over next several years)
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| Musculoskeletal pain: greater aches, pains, and flares in patients with rheumatoid arthritis (RA) seen during winter; association
with vitamin D deficiency well documented, particularly in Asian immigrant population; study could not associate
low levels of vitamin D with increased marker of RA activity; lower levels of vitamin D inversely associated with disability;
study showed patients with higher levels of vitamin D had lower number of tender joints, lower C-reactive protein (CRP),
lower disease activity scores, and lower functional disability
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| Supplementation: vitamin D deficiency—causes hyperparathyroidism; may lead to osteopenia, osteoporosis, osteomalacia,
and rickets; prevalence high in adults with and at risk for osteoporosis; fractures—meta-analysis found fractures
prevented in patients given 700 to 800 IU of vitamin D daily; falls—meta-analysis suggested 22% reduction in falls with
vitamin D supplementation (data insufficient to determine level required to achieve benefits); current recommendations
(400 IU/day; 600 IU/day for patients >65 yr of age) inadequate; adults need 800 to 1000 IU/day in absence of satisfactory
sun exposure (arms and legs exposed to sunlight for 10-15 min between 10:00 AM and 3:00 PM , 2-3 times/wk; moderate
use of tanning beds reasonable alternative); important to advise patients that excessive sunlight or tanning exposure can
increase risk for skin cancer; if vitamin D level <30 ng/mL, give ergocalciferol (available in 50,000-IU capsule; 1 capsule/wk
for 8 wk, then recheck level [repeat course for 8 more weeks if indicated]); maintain adequate levels with cholecalciferol
(1000 IU/day) or ergocalciferol (monthly or twice monthly); check levels annually during winter or early
spring
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| Vitamin D toxicity: rare; hypercalcemia rare; 4000 to 6000 IU/day of cholecalciferol for 3 to 6 mo not shown to cause
hypercalcemia or toxicity (caution, elderly patients with hyperparathyroidism may develop hypercalcemia)
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Suggested Reading
Broe KE et al: A higher dose of vitamin d reduces the risk o.falls in nursing home residents: a randomized, multiple-
dose study. J Am Geriatr Soc 55:234, 2007; Cutolo M et al: Vitamin D in rheumatoid arthritis. Autoimmun Rev 7:59,
2007; Geerts WH et al: Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 126:338S, 2004; Harris SS et al: Vitamin D insufficiency and hyperparathyroidism in a
low income, multiracial, elderly population. J Clin Endocrinol Metab 85:4125, 2000; Inouye SK et al: Clarifying confusion:
the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113:941, 1990; Kalisvaart
KJ et al: Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-
controlled study. J Am Geriatr Soc 53:1658, 2005; Morrison RS et al: Relationship between pain and opioid analgesics
on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 58:76, 2003; Qaseem A et al: Current
diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of
Family Physicians and the American College of Physicians. Ann Fam Med 5:57, 2007; Righini M et al: Effects of age on
the performance of common diagnostic tests for pulmonary embolism. Am J Med 109:357, 2000; Rosendaal FR et al:
Venous thrombosis in the elderly. J Thromb Haemost 5 Suppl 1:310, 2007; Stein PD et al: Diagnostic pathways in acute
pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology 242:15, 2007; Stein PD et al: Multidetector
computed tomography for acute pulmonary embolism. N Engl J Med 354:2317, 2006; Vieth R et al: Efficacy
and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J Clin Nutr 73:288, 2001; Weitz JI
et al: New anticoagulant drugs: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest
126:265S, 2004.
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