Case Presentation

OGUEJIOFOR, LILIAN, M.D.

Beghe, Claudia, M.D.

September 18, 2009

C/C

• 89 YO male with h/o dementia, HTN hypothyroidism presenting at the clinic for 3 months f/u:

• Recent Fall

• Increased confusion

HPI

• Slippery ground/ ‘ knees gave away ‘

• No CP/palpitation/dizziness

• No LOC• + pain, swelling and redness to B/L knees

• Unrestricted mobility

• No use of assistive ambulatory device

HPI

• Recently more forgetful

• Visual hallucination• No gait abnormality

• No urinary symptoms

PMH

Dementia: reffered to Geri clinic for PC in 2001

- Initial presentation to ER under Baker Act- confusion

- missing x 2 days

- Arrested for armed threats in public place

PMH

- Decline in cognitive function x 3 years

- Confusion, difficulty recognizing family members

- Some assistance with ADLs

- H/o wandering

PMH

• Hypothyroidism

• Hypertension

• Hyperlipidemia• Arthritis

SOCIAL HISTORY

- Lived alone in trailer

- Vet of pearl habour

- Auxillary police officer, “repair man”- Assistance by step-son and friends

- ALF residence now

- Stepson surrogate decision maker

- No tobacco, ETOH,illicit drug use

ROS

• Very mild residual knee pain

• Hearing impairment; wears hearing aids

• Hand tremor• No visual impairments

• No urinary/fecal incontinence

• No depression

• Functional limitations: requires prompting to perform some ADLs and take meds

• Mobility: ambulates unassisted• Nutrition: recent weight loss after URI,

now improved

P/E

• VSS• GEN: moderately well nourished,

pleasant, cooperative, NAD, oriented to person and place, euthymic affect, nml speech, occasional tangential thought process and ?insight/judgement but overall attentive, no psychotic features, recent mem. Imp.

• HEENT: normocephalic, EOMI• CV: S1S2, RRR, no m/r/g

• RESP: CTAB

• ABD: BS+, soft, NT

• MMSK: no joint swelling/pain, good ROM• NEURO: non focal, neg rhomberg, intact

gait

A/P

• Fall: multifactorial

• Dementia : ? Cognitive decline

• Hypothyroidism• Anemia

• Health maintenance: COLORECTAL CANCER SCREENING

CASE TWO

• 88 YO CF presented to USF clinic to establish pc

• HTN, hypothyroidism, hyperlipidemia• Regular pcp f/u with no hospitalisations,

ER

visits or other complications

- no complaints

• SH: Lives with son x 10 years since death of husband, homemaker, no tobacco/ETOH use

• FH: longevity; breast cancer (sister in her 60s), siblings alive and well

ROS

• Mild, non-limiting forgetfulness

• Hearing impairment

• No functional limitations; fully independent in all ADLs

• Ambulates unassisted: exercises regularly, climbs stairs, dances

• No depression/sleep disorders

P/E

• Well groomed, well nourished, NAD, pleasant, engaging, good intellect, insight and judgement

• HEENT: normocephalic, atraumatic, no JVD, no LAD, no thyromegaly

• CV: S1S2,RRR, no m/r/g

• RESP: CTAB

• ABD: BS+, soft, NT

• EXT: no edema

• MMSK: normal ROM, no joint swelling• NEURO: non focal, nml gait

A/P

• HTN

• Hypothyroidism

• Hyperlipidemia• Health maintenance:

• UTD with mammogram ( refused this year’s since has had > 30 mammograms)

• Colonoscopy “many years ago”• ?PAP

TO SCREEN OR NOT TO SCREEN

FOR COLORECTAL CANCER?

COLON CANCER

• 2/3 of colon cancer cases occur in pts aged 65 and over

• With advancing age, there is greater likelihood of right-sided lesions and presentations with anemia rather than pain

• Medicare will pay for a screening colonoscopy every 10 yrs for all beneficiaries

BENEFITS

• Among patients at average risk who undergo screening colonoscopy, 0.5 to 1% have colon cancer and 5 to 10% have advanced neoplasia that can be removed.

• In case-control studies, colonoscopy is associated with reductions in the incidence of and mortality from colorectal cancer.

RISKS

• Adverse events is 3 to 5 events per 1000 colonoscopies : perforation, bleeding

• With advancing age and coexisting conditions, the risks associated with colonoscopy increase and the benefit diminishes because of a shorter life expectancy.

COLORECTAL CANCER SCREENING

• Decisions should be made on an individual basis:

• What effect will a diagnosis of cancer have on a person’s quality of life and functional status?

• How acceptable is a positive screening test for a patient since it will lead to further evaluation?

COLONOSCOPY AND DEMENTIA

• “Dementia is an independent predictor of inadequate colonoscopy prep.”

• The American Journal of Gastroenterology (2001) 96, 1797–1802; doi:10.1111/j.1572-0241.2001.03874.x

• “colonoscopy in nonagenerians …carries a significantly higher failure rate. Functional decline was found to be a significant predictive factor for failed colonoscopy”

• Journal of Clinical Gastroenterology: April 2007 - Volume 41 - Issue 4 - pp 388-393doi: 10.1097/01.mcg.0000225666.46050.78Alimentary Tract: Clinical Research

• If cancer is discovered, are the treatment options such as surgery, chemotherapy,acceptable, feasible and effective?

• Sreening threshold should probably be lower for patients at higher riskfor colon cancer ( FH, IBD )

• The USPSTF conclusion:

- screening should not be routinely recommended in persons older than 75 years;

- screening should not be recommended at all in persons older than 85 years, even though the risk of colorectal CA and adv. polyps continues to increase with age.

• ROBUST ELDERLY;/ FUNCTIONALLY INDEPENDENT/ LIFE EXPECTANCY > 5-10 YRS IF < 85 YRS- Colonoscopy probably recommended

• FRAIL/MODERATELY DEMENTED/END OF LIFE / >85 YRS;

/ LIFE EXPECTANCY < 2-5 YRS - Avoid colonoscopy

• WOULD AVOID COLORECTAL CANCER SCREENING IN BOTH PAITENTS BASED ON AGE ( both cases ) AND MOD. DEMENTIA/COMPROMISED FUNCTIONAL STATUS ( case #1 )

FURTHER REFERENCES

• NEJM Volume 361:1179-1187 Number 12 September 17,2009

• Ann Intern Med.2009;150:849-857• UpToDate

• Geriatric Review Syllabus, Sixth Edition

• ACP CLINICAL GUIDEPATH, Health Malintainance

THANK YOU