Case 1 - POGOe



Case 1: I’VE FALLEN AND I CAN’T GET UP

Authors:

Claudene George, MD, Assistant Professor of Medicine, Geriatrics Fellowship Program Director, Student Clerkship Director, Albert Einstein College of Medicine, Montefiore Medical Center

Laurie G. Jacobs, MD, Professor of Clinical Medicine and Vice Chair of Clinical and Educational Programs, Department of Medicine, Director, Jack and Pearl Resnick Gerontology Center, Albert Einstein College of Medicine, Montefiore Medical Center.

Chief complaint

An 84-year-old man was found by his daughter on the floor of his apartment after failing to answer the telephone for a day. He complained of pain in his left knee, but was otherwise confused and unable to explain what had occurred. He was brought to the hospital by ambulance and admitted.

Questions:

1. Which of the following is an incorrect statement about falls in the elderly?

a. Falls in the elderly are often due to a combination of intrinsic and extrinsic factors medications

b. Older adults should be asked at least once yearly about falls.

c. The incidence of falls decreases with age due to an overall decrease in mobility

d. Risk factors for falls include all of the following: a prior history of falls, cognitive impairment, psychotropic drugs, anemia, and lower extremity weakness.

e. b and d

Answer: c

Falls occur in 30-40% of community-dwelling elderly over the age of 65, 50% of those over age 80, and 30-60% of nursing home residents. They are often due to a combination of intrinsic factors (chronic illnesses, gait, strength, vision, medication effects, etc.) and extrinsic factors (environmental and activity-related factors). Older adults should be asked at least once yearly about falls. When evaluating falls, it is critical to obtain a careful history regarding the events surrounding a fall in order to direct the evaluation. Multiple risk factors have been identified and include a past history of a fall, age, cognitive impairment, female, lower extremity weakness, balance problems, psychotropic drug use, arthritis, history of stroke, orthostatic hypotension, dizziness, and anemia.

Past Medical/Surgical History – provided by the daughter

Myocardial infarction 10 years ago

Hypertension

Peptic ulcer disease with bleeding 20 years ago

Benign prostatic hypertrophy

Venous insufficiency

Bilateral cataract surgery 5 years ago

Left inguinal hernia repair 25 years ago

Medications:

aspirin 325 mg daily atenolol 50 mg daily one Multivitamin daily

Vitamin E 800 U daily terazosin 5 mg daily lisinopril 10 mg daily

Vitamin C 1000 mg daily Ginkgo biloba one capsule daily

Questions:

2. Which medication(s) most likely contributed to the fall risk in this patient?

a. atenolol

b. terazosin

c. lisinopril

d. a and b

e. all of the above

f. none of the above

Answer: e

Atenolol, a beta-blocker, can contribute to falls by causing hypotension and/or bradyarrythmias. Terazosin, an alpha-1 adrenergic receptor antagonist (peripherally acting alpha blocker), can cause orthostasis. Lisinopril, an ACE-inhibitor, can cause hypotension and contribute to falls. It generally does not cause orthostasis.

Social History – provided by the daughter

He lives alone and is able to care for himself. A woman cleans his apartment twice weekly and also does some shopping. His daughter is very involved and calls about every third day. He was a bookkeeper, retired at age 65 and became a widower at age 70. He manages his own finances and enjoys baseball on TV. He denies any recent change in appetite, has some rolls and coffee for breakfast, lunch at the senior center, and for dinner, he usually warms something left by his cleaning lady or eats at a restaurant near his home. He smoked 2 packs a day from age 20 to age 55 when he stopped after an episode of pneumonia. He rarely drinks more than one drink an evening. He does not exercise, and takes his medications as prescribed.

Physical Examination:

In the emergency room, his physical examination revealed a thin male who appeared alert but agitated and in moderate pain, lying on the stretcher.

His vital signs were:

Pulse 48 Weight 140 lbs

Blood pressure lying down 190/70 Height 5 ft. 9 in.

Respiratory rate 20 Temperature 99( F

Questions:

3. Why is the systolic blood pressure elevated?

a. This patient has essential hypertension and has not taken his medication

b. Systolic hypertension is expected with normal aging

c. This patient is anxious and in pain

d. All of the above

e. a and c are correct

f. b and c are correct

Answer: e

Although cross-sectional studies have shown that blood pressure, particularly systolic blood pressure, increases with age, however, the threshold values that define high blood pressure are not altered for age. Blood Pressure may be elevated in response to a disease process (secondary hypertension) or be due to essential hypertension. High blood pressure in the aged is viewed as a disease process, rather than normal aging (as it does not occur in everyone), with an associated increase in risk for adverse outcomes (coronary heart disease, congestive heart failure, stroke, peripheral vascular disease, and renal disease). Although the etiology of essential hypertension is not known, changes in peripheral vascular resistance are central to the development of hypertension in the elderly. Resistance may be due to vascular occlusion, and/or changes in vascular (-adrenergic-mediated smooth muscle dilatation during normal aging. In addition, there may be an expanded extracellular volume, especially in black and elderly hypertensives, which may correspond to a low plasma renin and a high sensitivity to dietary sodium.

Questions:

4. Why may his heart rate be slow?

a. Normal heart rate declines with age

b. the atenolol slows the heart rate

c. he may have sinus node disease

d. all of the above

e. a and c are correct

f. b and c are correct

Answer: f

Basic sinus-node function (i.e. heart rate, sinus node recovery time, and sinoatrial conduction time) does not change with age. Maximal heart rate declines with aging. The sinoatrial node becomes more fibrotic with advancing age and sinus node dysfunction is common in the elderly, but often does not cause any symptoms. When symptomatic, it is often referred to as the “sick sinus syndrome,” which includes persistent, severe and inappropriate sinus bradycardia, episodes of sinoatrial block, sinus arrest, or both, cessation of sinus rhythm or long pauses with failure of subsidiary pacemakers, etc. Atenolol, a beta1-selective blocker, reduces the sinus rate at rest and with exercise.

Physical Examination continued:

Skin examination: Two large areas (10cm diameter) of ecchymoses (red to purple) on left thigh and left side of back and multiple small tan, scaly, waxy, raised lesions that appear pasted on or stuck on his chest and back. (3-5 cm diameter)

Questions:

5. The large ecchymoses look acute and are attributed to the fall. The ecchymoses on the arms appear older. The physician is concerned that there might be a bleeding tendency. The patient takes ginkgo, vitamins C and E, in addition to her other medications. Which of the agents listed below could contribute to the bruising? More than one answer can apply.

a. ginkgo biloba

b. vitamin C

c. vitamin E

d. atenolol

e. aspirin

f. all of the above

Answer: a, c, e

Ginkgo biloba and vitamin E both increase bleeding tendency due to anti-platelet effects. Usually neither of these will cause bruising or bleeding even though both can raise bleeding times. Because he is on aspirin, the combination causing platelet inhibition and prolonged bleeding time may be the cause. Bleeding from vitamin E is usually only a problem in patients taking warfarin. Vitamin C is required for the synthesis of collagen crosslinks that help maintain capillary walls. Elderly patients who are not eating fruits or fresh vegetables may be at risk for inadequate vitamin C intake. Finding bruising should prompt questions about dietary intake. Recommend citrus fruits at least once a week (preferably more) for the vitamin C and bioflavenoids.

Questions:

6. This skin lesions on his chest and back are likely to be:

a. basal cell carcinoma

b. squamous cell carcinoma

c. actinic keratosis

d malignant melanoma

e seborrheac keratosis

f healing ecchymosis

Answer: e

Seborrheic keratosis is a common noncancerous skin growth noted in older adults. The lesions can be black or brown in appearance and appear on the chest, back, or face. Theses lesions are waxy, scaly, and have a “stuck on or “pasted on appearance.

Patients should seek medical help if the lesions change in appearance or size over a short period of time, become painful, or bleed

Physical Examination, continued:

Only pertinent negative or positive findings as reported

Head, ears, eyes, nose and throat: slight ptosis on right, bilateral lens implants, discs not well visualized

Neck: no jugular venous distension or bruits. Thyroid not palpable. No lymphadenopathy

Chest: symmetrical excursions, scattered ronchi, particularly at the left base

Heart: PMI (point of maximal impulse) slightly displaced laterally, normal S1, S2, +S3, regular rate and rhythm, no murmurs, rubs

Abdomen: soft, no masses palpable.

Rectal: slightly decreased tone, large amount of firm brown stool, guaiac negative, prostate symmetrical and enlarged, firm but not hard

Extremities: left lower extremity externally rotated and shorter, 2+edema bilaterally, brawny discoloration of ankles and lower legs to midcalf.

Pulses: dorsalis pedis 1+ bilaterally

Impression and Plan:

Based upon this examination, the patient is admitted for a presumed hip fracture. Radiographs, laboratory testing and an EKG is ordered.

Questions:

7. What findings suggest that the patient has a hip fracture?

a. knee pain

b. left leg externally rotated

c. left leg shortening

d. all of the above

e. a and c

f. b and c

g. none of the above

Answer:d

Hip fractures primarily occur as femoral neck fractures (intracapsular), intertrochanteric, or subtrochanteric. Patients with hip fractures typically report hip pain on weight bearing following a fall, and on physical exam the leg is often foreshortened and externally rotated. Hip pain can be referred to the knee, and vice versa.

Hip Radiograph:

Interpretation: right proximal femur fracture, osteopenia

Questions:

8. Is the fall sufficient to cause a hip fracture, or should a “pathologic fracture” ie. due to metastatic disease or infection in the bone, be considered in this patient?

a. If the medical evaluation is negative (history, physical and routine laboratory testing), the fall is sufficient to have caused a fracture in a patient with osteopenia. No further evaluation is needed

b. An MRI of the hip is needed prior to surgery to rule out another cause of fracture in an elderly person.

c. A biopsy at surgery should be done to rule out malignancy or infection

d. A bone scan should be done prior to surgery to identify an areas of other bone disease and rule out another cause of fracture

e. All of the above

f. None of the above

Answer: a

90% of hip fractures are associated with falls. Fractures occurring without any trauma may be suspicious. The history of a malignancy which can metastasize to bone or laboratory data suggestive of malignancy or multiple myeloma would necessitate further investigation. In addition, radiographic findings can suggest a pathologic fracture rather than osteoporosis and a simple fracture. Otherwise, further investigation is not necessary unless their history, physical examination, or laboratory testing suggest other disease.

Physical Examinaton, continued:

Neurologic examination: alert, agitated, moving around stretcher. Able to provide name, uncertain about location and date, unable to retell events leading up to admission. Somewhat uncooperative with commands. Poor hearing. Can provide name of daughter but not telephone number. Cranial nerves intact except for ptosis on the right and poor hearing. Slightly decreased sensation in lower extremities. Reflexes 1+ in right knee and elbows. Too much pain in left side to examine. Normal tone. No tremor.

Hospital Course:

Surgery (ORIF-open reduction and internal fixation) is contemplated for the next day. During the pre-operative assessment, the patient becomes combative when his left leg is moved. He is still confused about today’s date and the sequence of events leading up to his hospitalization, but appears to understand when he is told that his hip is broken and that an operation to fix it is recommended. When the resident tells him he will not be able to walk again without surgery, he yells “NO SURGERY!” and refuses to speak or listen further.

Although the surgery is not an emergency, patient outcomes are better if it is undertaken as soon after the fracture as possible. The attending has arranged time on the Operating Room schedule for the next day. The resident leaves the bedside to call the patient’s daughter.

Questions:

9. Requirements for informed consent to or refusal of treatment include:

• Decisional capacity (the ability to understand one’s medical situation, weight the benefits, burdens and risks of treatment options, apply personal values, make a decision that is consistent over time, and communicate the decision)

• Disclosure by care providers of sufficient information relevant to the decision

• Understanding of the information disclosed

• Voluntariness in acting without coercion or compulsion

In this circumstance, which of the criteria are lacking?

a. decisional capacity

b. full disclosure

c. understanding

d. voluntariness

e. all of the above

f. A, B and C

g. A and C

h. None of the above are lacking

Answer: f

Capacity is considered decision specific, meaning that patients may have the ability to make some decisions and not others. Capacity may also fluctuate, being more evident at some times than others. In the above scenario, it is unclear whether this patient has decisional capacity for this decision at this time. Because he refused to listen to the resident’s explanation, he has not been fully informed of the benefits, burdens and risks of surgery. Thus, his refusal, while voluntary, cannot be considered informed.

Hospital Course:

The resident calls the daughter who is very concerned. The resident explains that the surgery involves general anesthesia and the placement of a pin in the hip. Common complications include bleeding which may require blood transfusion and infection. The benefits include pain relief and regaining of the ability to walk following rehabilitation. The daughter says that “surgery sounds like the right thing to do; and it doesn’t sound like Dad to refuse. He is always cooperative and quiet, spends his time reading the New York Times and doing the crossword, and has had surgery before, so that he should know what it involves.”

Question:

10. This patient’s ability to provide informed consent is uncertain. Should the daughter provide consent so that surgery can be undertaken now?

a. Surgery should be done now without consent because of the seriousness of his condition

b. The daughter should be asked to provide consent, and if she agrees, surgery may be done now despite the patient’s refusal

c. Unless it is an emergency, surgery should be delayed and further discussions can occur at a later time.

d. Surgery cannot be done at any time because he has refused, and he should be sent to a nursing home for pain control and rehabilitation.

Answer: c

Physicians’ obligations are sometimes in conflict. They must honor the patient’s autonomy by respecting their decisions about care, but they must also provide treatment that is in the patient’s best interest and protect him from harm. A patient’s refusal of recommended treatment should signal the beginning, not the end, of discussion(s) to determine the level of decisional capacity, the degree to which information has been received and understood, and the presence of other barriers, such as language or hearing problems, depression, delirium or fear. Based on his daughter’s description, this patient’s refusal is uncharacteristic and may not represent his authentic wishes. Unless his condition requires emergency surgery, which can proceed without consent, the issue of consent should be revisited at a later time, perhaps when his daughter can be present to support his decision-making.

Admission laboratory data:

Complete Blood Count: hemoglobin 12.3 (14-18) g/dl hematocrit 34% (42-52%) White Blood Cell count 7.8 (4.8-10.8) k/uL

Chem: Na 147 (135-145) mEq/L

K 3.8 (3.5-5.0) mEq/L

CO2 25 (24-30) mEq/L

Cl 105 (98-108) mEq/L

Gluc 200 mg/dl

BUN 41 (10-26) mg/dl

Creat 1.8 (0.5-1.5) mg/dl

Question:

11. The elevation in glucose in this patient at this time is most likely due to:

a. Metabolic changes of aging causing hyperglycemia

b. diabetes mellitus type II

c. stress

d. all of the above

e. a and c are correct

f. b and c are correct

Answer: c

The prevalence of diabetes mellitus is 7-10% of adults over age 65, and increases with age. An increasing ratio of fat to lean body mass contributes to a decrease in insulin sensitivity. Although the number of insulin receptors is unchanged, insulin-mediated glucose uptake is reduced. Studies have shown fasting plasma glucose levels increases by 1-2 mg/dl/decade after age 50. The criteria for the diagnosis of diabetes mellitus are the same as for other adults. Our patient has random elevation in glucose while ill. At this time, it can be attributed to stress, but may require further investigation in the future. Metabolic changes of aging should not elevate plasma glucose, to this level. This one random glucose in our patient does not yet meet the criteria for DM.

Hospital Course:

The patient is given acetaminophen and oxycodone for pain every four hours as needed, diphenhydramine for sleep and well as intravenous hydration. All previous medications are discontinued. A foley catheter is placed and the leg put in traction. The nurse calls the resident at 10 pm to return after he was uncooperative with using a bedpan and intentionally pulled out his intravenous line (IV). When the resident returns to the bedside at 11, he finds the patient lethargic and replaces the IV.

Question:

12. This patient’s agitation is due to:

a. dementia

b. delirium

c. depression

d. all of the above

e. A and B are correct

f. A and C are correct

g. None of the above

Answer:b

There is no evidence at present that this patient suffers from depression or dementia according to the history provided by his daughter. Delirium involves a disturbance of consciousness associated with impaired attention. This may be evident by a “waxing and waning level” of alertness seen in this patient. Those with dementia, although more susceptible to the development of delirium, usually remain alert although they may have difficulty concentrating on a task or may become agitated at times.

Question:

13. What may be contributing to this patient’s agitation?

a. dehydration

b. oxycodone

c. diphenhydramine

d. all of the above

e. a and c

f. none of the above

Answer:d

Almost any medical illness and many medications can contribute to delirium. This includes conditions associated with cerebral hypoperfusion (eg. Conditions causing hypotension, etc), cerebral hypoxia (eg. Pneumonia, COPD, CHF, etc), dehydration, electrolyte disturbance, hypo- and hyperglycemic states, infection, fever, pain, CNS processes, intoxication or withdrawal states, or other drug effects. Anticholanergic medications, such as diphenhydramine, are particularly associated with delirium as a deficit of central cholinergic transmission is frequently found in delirious patients and can worsen their condition.

Hospital course:

In the morning the resident returns and the patient is coherent and cooperative. The resident explains the reasons for surgery and the risks. The patient agrees, and that afternoon undergoes open reduction and internal fixation of the hip. After surgery, pain medication, low molecular weight heparin and slow mobilization occur. The foley catheter is discontinued. Two days later, the patient is noted to have a fever of 101.8 and is confused and unable to urinate. Physical examination reveals a respiratory rate 12, BP 140/70, HR 72 and regular, clear chest, dependent edema, and hard stool in the rectum. The surgical wound is clean but an ulcer, 3 cm in diameter, is present to a depth through the skin but not down to bone or muscle is present on the sacrum. The base is pale white with surrounding erythema and yellow-red discharge.

Questions

14. Which of the following are likely causes of fever in this patient ?

a. urinary tract infection

b. pressure ulcer

c. deep venous thrombosis

d. pneumonia

e. all of the above

f. a, b, and c

g. a and c

h. none of the above

Answer: f

Despite discontinuation of the foley catheter (the use of which is associated with the development of bacteriuria), his prostatic hypertrophy and fecal impaction can lead to urinary retension and predispose to an infection. A pressure ulcer does not usually produce fever unless infection is present. The surrounding erythema may indicate cellulitis. Deep venous thromboses (DVT) are a common complication of hip fracture surgery for which low molecular weight heparin prophylaxis is often used. Nevertheless he still may develop a DVT. The respiratory rate is the most predictable sign of pulmonary infection. Pneumonia, although a common postoperative complication, appears less likely with a normal chest examination and respiratory rate.

Question:

15. What stage is the ulcer by the National Pressure Ulcer Advisory Panel classification?

a. stage I

b. stage II

c. stage III

d. stage IV

Answer: c

The National Pressure Ulcer Advisory Panel classification is:

Stage I Nonblanchable skin erythema

Stage II Breakdown into dermis

Stage III Ulcer extends from subcutaneous depth to fascia

Stage IV Ulcer extends from depth of the fascia to bone

Question:

16. Should the discharge be cultured before starting antibiotics?

a. yes

b. no

Answer: b

An infected ulcer is diagnosed by a foul smell, greenish or yellow discharge from a sinus track, scant granulation, and dull whitish or pink base, with erythema in surrounding skin beyond ulcer margins which may be warm, tender and swollen (cellulitis). The surfaces of all ulcers are colonized by bacteria; therefore, ulcer cultures should not be performed routinely. Only clearly purulent discharge, usually from sinus tract, should be cultured. Otherwise, qualitative culture of tissue below the ulcer surface, collected under sterile conditions, is more definitive.

Hospital Course:

The urinary tract infection is treated with oral antibiotics. Local wound care is done for the pressure ulcer. Physical therapy is begun and the patient begins to walk with a walker, but cannot manage to get up on his own or go to the bathroom. The social worker recommends that he go to a short term rehabilitation program in a local nursing home which would be paid for by his Medicare benefit. He refuses, stating he wants to get back to his apartment and doesn’t want a stranger there. The social worker explains that Medicare will cover home care services including physical therapy several times a week and an aide for a few hours a day, but that it is not safe for him to go home in this state without help. He says he understands that he cannot get around well yet and would get more therapy in the rehab facility, but he is sick of “being institutionalized and misses his privacy.” He will allow a physical therapist to come refuses to spend money on hiring extra help and will not allow the nurse or the aide to come “and bother him.”

Questions:

17. What discharge plan can be made?

a. He should be sent to the rehabilitation facility for a short stay over his objections

b. He should be sent home with the home care physical therapy, and information about the other services provided through home care and how to hire help

c. He should be kept in the hospital until he can get to the bathroom safely

d. His daughter should be told to stay with him as he won’t allow a stranger

e. His daughter should be told to employ extra help for him and pay for it since he won’t

Answer: b

Although you should recommend care that you feel is optimal for your patients, if they have decisional capacity, they cannot be compelled to follow your plan and have to be allowed to make decisions that you do not agree with. Under Medicare, you cannot keep the patient in the hospital beyond his need for acute care. The days may be “disallowed” and the patient may be asked to pay for his stay beyond this juncture. The patient’s daughter is not legally responsible for his care and cannot be compelled pay for it. With the patient’s consent, you may discuss his care with her, and she may volunteer to do so. You can also continue to discuss these issues after his discharge, through the home care staff (physical therapist, social worker and nurse).

Hospital Course:

The patient is discharged home with home care. His daughter volunteers to stay over night with him and he agrees. A bedside commode is ordered, along with grab bars for the bathroom. An office visit is planned for ten days later, and his daughter plans to continue telephone contact. His ability to transfer and ambulate improves quickly, and he is able to move about the home with a walker and quad cane after two weeks.

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