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Toronto Notes 2019 Differential Diagnoses of Common Presentations
History and Physical Exam
• history:previousfallsand/orgaitinstability,inquireaboutintrinsic,extrinsicandsituationalfactors, associated symptoms, loss of consciousness, medication and alcohol use, change in medications
• haveawitnesspresentifpossibleforinterview
• physical exam: Orthostatic blood pressure, cardiac, visual acuity, examination of feet and footwear,
Performance-Oriented Assessment of Mobility, Timed Up-and-Go Test, MSK, neurologic
Investigations
• comprehensivegeriatricassessmenttoidentifyallpotentialcauses
• CBC, electrolytes, BUN, creatinine, glucose, Ca2+, TSH, B12, urinalysis, cardiac enzymes, ECG, CT head
(as directed by history and physical), coagulation profile
• bone densitometry (DEXA) in all women and men >65 yrs old
Prevention
• multidisciplinary,multifactorial,health,andenvironmentalriskfactorassessmentandintervention programs in the community
• musclestrengthening,balanceretraining,andgroupexerciseprograms(e.g.TaiChi)
• homehazardassessmentandmodification(e.g.removelooserugsandtrippinghazards,addshower
bars and stair railing, improve lighting)
• prescriptionofvitaminD1000IUdaily
• taperingorgradualdiscontinuationofpsychotropicmedication
• posturalhypotension,heartrate,andrhythmabnormalitiesmanagement
• eyesight (cataract surgery) and footwear optimization
• compression socks
Malnutrition
Definition
• nouniformlyaccepteddefinitionofmalnutritioninolderadults.Somecommonlyuseddefinitions include the following:
■ involuntary weight loss (community: ≥2% over 1 mo, >10 lbs over 6 mo, or ≥4% over 1 yr; nursing home: ≥5% over 1 mo, ≥10% over 180 d)
■ hypoalbuminemia (community: ≤38 g/L; hospital: ≤35 g/L), hypocholesterolemia (<4.1 mmol/L)
■ other features include: insufficient energy intake, loss of muscle mass, fluid accumulation (e.g.
edema), loss of subcutaneous fat, decreased hand-grip function
Etiology
• nutritional
■ decreased assimilation: impaired transit, maldigestion, malabsorption
■ decreased intake: financial, psychiatric (depression), cognitive deficits, anorexia associated with
chronic disease, functional deficits (e.g. difficulty shopping, preparing meals or feeding oneself due
to functional impairment)
• stress:acuteorchronicillness/infection,chronicinflammation,abdominalpain
• mechanical: dental problems, dysphagia
• age-relatedchanges:appetitedysregulation,decreasedthirst
• mixed: increased energy demands (e.g. hyperthyroidism), abnormal metabolism, protein-losing
enteropathy
Clinical Features
• history
■ recent or chronic illness
■ depression, GI symptoms
■ functional disability: impaired ADLs and IADLs
■ social factors: economic barriers, dental problems, and living situation (e.g. living alone) ■ constitutional symptoms (e.g. recent weight loss)
• physicalexam
■ BMI <23.5 in males, <22 in females should raise concern
■ temporal wasting, muscle wasting, presence of triceps skin fold ■ assess cognition
Investigations
• CBC,electrolytes,Ca2+,Mg2+,PO43–,creatinine,LFTs(albumin,INR,bilirubin),B12,folate,TSH, transferrin, lipid profile, urinalysis, ESR, CXR
Treatment
• directtreatmentatunderlyingcauses
• dietarymodification:highcaloriefoods,oralnutritionalsupplementation:patientspecificmeal
replacement products (e.g. EnsureTM, GlucernaTM, NeproTM), food/drink thickeners (e.g. Thicken-UpTM),
vitamins/minerals (e.g. B12, calcium, vitamin D)
• referral: speech language pathologist, nutritionist
Geriatric Medicine GM5
Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis JAMA 2017;318(17):1687-99.
Objective: To assess the potential effectiveness of interventions for preventing falls.
Methods: RCT of fall-prevention interventions for adults ≥65 yr.
Results/Conclusions: Exercise alone (OR 0.51, 95% CI 0.33-0.79), exercise +vision assessment/treatment (OR 0.17, 95% CI 0.07-0.38), exercise + vision assessment/ treatment +environmental assessment/modification (OR 0.30, 95% 0.13-0.70), and comprehensive geriatric assessment + Ca2+ and Vitamin D supplementation (OR 0.12, 95% CI 0.03-0.55) were each associated with lower risk of injurious falls.
Will My Patient Fall?
JAMA 2007;297:77-86
Purpose: To identify the prognostic value of risk factors for future falls among older patients.
Study Selection: Meta-analysis of prospective cohort studies of risk factors for falls.
Results: 18 studies were included. Clinically identifiable risk factors were identified across 6 domains: orthostatic hypotension, visual impairment, impairment of gait or balance, medication use, limitations in basic or instrumental activities of daily living, and cognitive impairment. The estimated pretest probability of falling at least once in any given yr for individuals 65 yr and older was 27% (95% CI 19-36%). Patients who have fallen in the past yr are more likely to fall again (LR2.3-2.8). Best predictors of future falls were disturbances in gait of balance (LR 1.7-2.4), while visual impairment, impaired cognition and medication were not reliable predictors.
Conclusions: Screening for risk of falling during the clinical examination begins with determining if the patient has fallen in the past yr. For patients who have not previously fallen, screening consists of an assessment of gait and balance. Patients who have fallen or who have a gait or balance problem are at higher risk of future falls.
Impact of Medication Classes on Falls Risk in Geriatrics (Odds Ratios)
• Antidepressants (1.68)
• Neuroleptics/Antipsychotics (1.59)
• Benzodiazepines (1.57)
• Sedatives/ Hypnotics (1.47)
• Antihypertensive agents (1.24)
• NSAIDs (1.21)
• Diuretics (1.07)
• β-blockers(1.01)
Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med
2009:169(21):1952-60
Etiology of Malnutrition in the Elderly
MEALS ON WHEELS Medications Emotional problems Anorexia
Late-life paranoia
Swallowing disorders
Oral problems
Nosocomial infections
Wandering/dementia related activity Hyperthyroid/Hypercalcemia/Hypoadrenalism Enteric disorders
Eating problems Low-salt/Low-fat diet Stones