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					               Clinical Pearls:

             Laurence J. Robbins, MD
Associate Professor of Medicine University of Colorado Health Sciences
                         Center Denver, Colorado
         Associate Chief of Staff Geriatrics and Extended Care
                    Department of Veterans Affairs
        Eastern Colorado Health Care System Denver, Colorado
• None
                 Case #1
• An 85 yo with history of advanced
  dementia is brought to ER for 3 days of
  increasing weakness, now unable to
  stand on own (had been walking with
  cane), “leans” to left, less verbal, slightly
  more confused. Has fallen but last fall
  was 3 months ago.
• On exam his BP is 160/90. His speech is
  intelligible but nonsensical. Left hand
  grip is slightly weaker than right, equal
  leg strength. DTRs are brisk. Babinski
  response present bilaterally. He can
  stand with assistance but balance poor,
  unable to walk. Sensation in feet seems
  diminished. His medications include
  lisinopril 20 mg for hypertension,
  donepezil 10mg at bedtime for dementia.
   What is your next step?
• Stop the lisinopril and donepezil; see if
  his gait disorder improves
• Order serum B12 level
• Order nerve conduction study and EMG
• Order non contrast CT scan of head
• Check for asterixis and order LFTs
• 1 in 10 elderly have difficulty
• 20-25% >80 yo use mechanical gait
• 2/3 hospitalized elderly >75 yo
  have decline in mobility; at
  discharge, 2/3 of those pts not
  improved, 1/10 worse
Age-related gait changes
• Normal gait: toe off, swing phase, heel
  strike; only 25% time supported on both
• In healthy elderly, abnormal gait more
  prevalent with advancing age
• Often multifactor (75%); when single cause,
  musculoskeletal is most common
    Central Gait Disorder
• Slow, wide-based, shuffling, small-
  stepped, “magnetic,” difficulty turning
• When severe, truncal instability and
  can’t initiate a step; can’t stand
  without support; often few focal signs
• Most pts also have impaired cognition
• Differential Dx: “multi-infarct,” NPH,
  Subdural hematoma
• Central CNS lesions cause axial
  instability with few focal neurological
• Medication toxicity can mimic a central
  gait disorder
                   Case 2
• A 76 yo woman is brought to see you by her
  daughter who is concerned about her
  mother’s failing memory. Twelve months ago,
  the daughter took over management of her
  mother’s checkbook after she failed to pay
  bills. Her mother seems unable to knit,
  something she enjoyed for years. She has
  difficulty finding the right words to complete a
  thought. Only medication: temazepam 15mg
  bedtime prn
• On exam, the patient is a slender Caucasian
  woman who is engaging and seems alert. Her
  blood pressure is 155/85. Cranial nerves 2-12
  are intact. Motor strength is symmetrical, gait
  is normal. Sensation is normal, reflexes 2+, no
  pathologic reflexes. On mental status testing,
  she scores 25 out of 30 on the MMSE
  (abnormal <24). The daughter mentions that
  her mother has a master’s degree and taught
  high school history for 35 years. Lab tests
  (B12, TSH etc) are normal.
            Your next step:
• Explain to the daughter that her mother
  probably has early Alzheimer’s Disease
• Order an MRI
• Explain to the daughter that her mother is
  toxic from her temazepam and will be fine if
  the medication is stopped
• Order an RPR and EEG
• This is vascular dementia; begin treatment to
  lower BP <140/90 and add aspirin 81 mg daily
     DSM-IV Criteria for
     Alzheimer’s Disease
• Memory loss + one or more: aphasia,
  apraxia, agnosia, executive dysfunction
• Usually few motor signs apparent early
• Subtle behavioral and personality
  changes early
     ‘Average’ Dementia
• History, PE, mental status testing,
  comprehensive neuropsychological
• CBC, SMA 6, TSH, VDRL, B12, Folate,
  Calcium, U/A
• Genetic Testing
• Brain imaging (CT or MRI)
  Incidence and Causes of Dementia
    (Knopman et al, Arch Neurol 63:218, 2006)
• Record review of 560 consecutive patients
  newly diagnosed with dementia
• No cases of reversible dementia due to NPH,
  subdural hematoma, B12 deficiency,
  hypothyroidism, or neurosyphilis
• Conclusion: “None of the patients with
  dementia reverted to normal with treatment
  of the putative reversible cause.”
      Potentially Reversible
       (Larson et al, 307 cognitively impaired outpatients)

•   DRUGS                                        16
•   HYPOTHYROID                                  7
•   HYPERPARATHYROID                             3
•   B12 DEFICIENCY                               2
•   SUBDURAL HEMATOMA                            2
•   OTHER                                        3
•   TOTAL                                        31 (10%)
Reversibility of Drug-induced
      (Larson, Ann Int Med 107:169, 1987)
• >50% who stop medication will improve
• Often a single medication implicated
• Patients with drug-induced cognitive
  impairment were also three times more
  likely to fall
• Most offending drugs taken for several
  years prior to diagnosis
   Medications That May
     Impair Cognition
• Everything we prescribe…except
  acetaminophen and docusate
• Most often psychoactive meds or
  those with anticholinergic side effects
• “Discontinue amitriptyline (Elavil)” is
  always the correct answer on boards.
 Drugs impairing cognition
• Anticholinergics (e.g., Benadryl,
  Artane, Ditropan, Elavil, etc.)
• Anticonvulsants (Dilantin, Neurontin,
  Valproate, etc)
• Muscle relaxers (Soma, Flexeril, etc.)
• Antiemetics (Compazine, Reglan, etc)
• Dig, Catapres, amantadine, Cordarone
• Benzodiazepines, Antipsychotics
• The diagnosis of Alzheimer’s Disease can
  be made with confidence if a patient has
  short term memory loss, at least one of
  the other characteristic signs of AD,
  gradual progression >one year and normal
  gait/neuro exam
• Reversible dementia is rare; medications
  are the leading cause of reversible
  cognitive impairment
                   Case 3
• A 71 yo complains of a three week history of
  numbness in the fingers of his right hand and
  “dropping” utensils. His health is general
  good. Three years ago, he accepted a job
  operating heavy machinery in Belize. A
  painful left knee limited his mobility. Two
  years ago, he began having more difficulty
  walking . He started to fall more frequently.
  He finally quit his job and returned to the US
  about 10 months ago.
• Since his return he has not been very
 active and has begun using a cane
 because of his right knee pain, severe
 chronic low back pain and weakness. He
 has some mild neck discomfort. Frequent
 falls have continued at night .
• On exam, his mental status is normal. He
  now uses a wheeled walker for ambulation
  and has a stiff-legged gait and he complains
  of low back pain. He has some upper and
  lower extremity increased tone. He has
  moderate bilateral lower ext weakness. He
  has hyperreflexic patellar responses
  bilateral. His right hand grip is strong but
  rapid alternating movement is clumsier in
  the right hand. Position sense is impaired
  in his toes. Babinski responses are present.
      What is your next step?
• Order an MRI of his lumbosacral spine.
•   Order an MRI of his thoracic spine
•   Order an MRI of his cervical spine
•   Order an MRI of his brain
•   Order B12, RPR, A1C, folate and serum
Neurological Gait Disorders

• Peripheral neuropathy : distal sensory and
  motor signs only
• Lumbosacral: lesion below end of spinal
  cord (T12) = no upper motor neuron signs
• Cervical: upper motor signs: no cranial
  nerve or gray matter signs (e.g., dementia)
• Brain: cr n and gray matter signs, EPS
 Upper motor neuron signs
• Weakness (not complete paralysis) of a
  group of muscles (not a single muscle);
  minimal muscle atrophy
• “Clasp-knife” spasticity
• Hyperreflexia (+/- clonus)
• Spread of reflexes
• Babinski response
• Cervical myelopathy usually due to
  degenerative spine changes; may have
  little neck pain & no radicular symptoms
• Upper motor neuron signs often present
• Paresthesias and loss of position sensation
  may be caused by cervical myelopathy but
  may also have peripheral neuropathy
  Case 3: Management
• Image neck (MRI) if candidate for
• Check B12, TSH, glucose
• Upper motor neuron signs = lesion
  above T12
• Cervical myelopathy may be present in
  the absence of severe neck pain
                Case 4
• An 80 yo man is referred for evaluation
  of “possible depression; is he a Ritalin
  candidate?” He’s accompanied by his
  wife who describes how much more
  difficulty ambulating he’s had since
  esophagectomy for cancer 18 months
  ago. His medications include
  hydrochlorthiazide, lisinopril and
• On exam, his blood pressure is 140/90.
  The patient has a flat affect and blinks
  little. He has severe seborrhea. He
  slowly rocks bath and forth in his chair
  when asked to stand but is unable to
  propel himself to a standing position.
  When helped up to a standing position,
  he has trouble initiating his gait, then
  takes a few small steps and freezes.
      What is your next step?
•   Stop all of his medications.
•   Stop the metoclopramide
•   Begin carbidopa/levodopa 50/200 CR tid
•   Order an MRI of the brain
•   Begin an SSRI to treat his depression
 Prevalence of Parkinsonism
• Accounts for 10% of gait disorders
• Community elderly >65; Gait abn
  & 1or more signs of parkinsonism:
         15%65-74 yo
         30%75-84 yo
         50%> 85 yo
         Clinical Features
•   Tremor
•   Rigidity
•   Bradykinesia
•   Gait disorder
•   (Also, blunted postural reflexes
    and autonomic dysfunction)
     Differential diagnosis
•   Idiopathic Parkinson’s Disease 85%
•   Drug-induced (e.g. Reglan) 7-9%
•   Parkinson-plus syndromes 4%
•   Vascular parkinsonism 3%
• Drug-induced parkinsonism can occur
  with medications not usually considered
  culprits (metoclopramide, valproic acid,
  prochlorperazine, etc.)
• Resting tremor, asymmetric
  rigidity/tremor, and response to
  Levodopa best predict correct diagnosis
  of PD
                 Case 5
• The same 80 yo patient returns one week
  later after withdrawal of
  metoclopramide. He now can stand
  without assistance but still has difficulty
  initiate his gait and walks with small
  steps. His wife describes how he
  sometimes gets “stuck” in doorways as
  he goes from room to room.
• On exam, he still has significant diffuse
  rigidity, right greater than left. His gait is
  festinating. He has obvious bradykinesia.
  Both the patient and wife feel that his
  parkinsonism is improved but his
  function is still limited. They ask about
  medications that might help.
     You make the following
• Carbidopa/levodopa 10/100 tid
• Pramipexole 0.5 mg tid
• Carbidopa/levodopa 50/200 controlled
  release bid
• Amantadine 100 mg bid
• Carbidopa/levodopa 25/100 tid
  When to start drug Rx in the
• Functional decline: dominant side more
  affected, interference with ADLs and gait
Why delay drug treatment?
• Medications often associated with side
  effects in elderly
• cost of medication is high
    Treatment Principles
• Most medication reduce symptoms
• Very modest evidence that disease
  progression may be slowed
• Narrow therapeutic/toxic window
• Most effect achieved through
       Medications for PD
• Anticholinergics      • Carbidopa/L-dopa
  (e.g., Artane,          (Sinemet)
  Cogentin)             • Dopamine agonists
• Amantadine              (e.g., Parlodel,
  (Symmetrel)             Mirapex, etc.)
• MAO Inhibitor         • COMT inhibitors
  (Eldepryl, Azilect)     (e.g., Comtan)
 Carbidopa/levodopa (Sinemet)
• Most effective med for gait (bradykinesia,
  rigidity); tremor response variable
• Carbidopa prevents peripheral breakdown of
  levodopa; > 75 mg daily for max effect
• Begin 25/100 bid or tid; may switch to 10/100
  or 25/250 as dose increased; avg patient
  needs @ 500 to 1000mg L-dopa/day
• Avoid taking with food
             Sinemet CR
• Controlled release tablet has delayed onset
  and longer duration (25/100 or 50/200)
• May reduce dosing frequency by 1/3
• Only 80% absorbed (total dose higher); taken
  with food improves absorption
• Twice the cost of generic carbidopa/L-dopa
• Useful at bedtime for better overnight control
• Carbidopa/levodopa is the most effective
  medication for Parkinson’s Disease and
  optimizing dose before adding other drugs is
  appropriate for the elderly
• Anticholinergics & amantadine have little role
  in treated elderly PD patients; COMT
  inhibitors are very expensive for modest gain;
  dopamine agonist more likely to cause
                Case 6
• An 84 yo woman has repeated falls in the
  nursing home, often when she is
  returning to her room after lunch or
  dinner. Her medications include hctz 25
  mg daily and lisinopril 10 mg daily for
      What would you do?
• Stop the hydrochlorthiazide
• Stop the lisinopril
• Start fludrocortisone
• Encourage the staff not to allow her to
  stand up for 45-60 minutes after a meal
• Begin offering smaller more frequent
Postprandial Orthostatic Hypotension

• Syndrome of orthostatic hypotension
  occurring 30-45 minutes after a meal
• May be ameliorated by caffeine or smaller
• Prevent by having patient remain seated fro
  45 minutes after meals and avoiding
  hypotensive medications at mealtime
• Post prandial hypotension or orthostasis
  are common in the elderly and should be
  considered in the differential diagnosis of
  near syncope or syncope
• Caring for patients in nursing homes may
  require re-thinking of conventional
  wisdom (e.g., small frequent meals not
                Case 7
• A 76 year old woman has suffered a left
  CVA leaving her right arm and right leg
  weak. Two weeks after her CVA she is
  transferred to your nursing home for
  further rehabilitation. She seems very
  discouraged, cries easily and the
  therapists note that she seems depressed,
  and lacks motivation to participate in
  therapy & remain on active rehab status.
      What would you do?
• Do not start medication; this is a
  transient effect of the stroke
• Begin an SSRI
• Begin a tricyclic antidepressant
• Consult psychiatry
• Begin methylphenidate
• Post stroke depression 30-50%
• Traditional antidepressants may take weeks to
  become effective
• Methylphenidate 5mg 7am and 12 noon,
  titration up to 20 mg bid
• Response in <48 hours in 80% of pts
• SSRIs, Remeron (mirtazepine) may be added;
  ECT for refractory depression
     Principles of medication
• Cochrane review (26 randomized trials)
  showed little difference in efficacy between
  medications for Rx of geriatric depression
• Start lower (general half the dose of
  younger patients) but may need to go to
  same therapeutic range to achieve efficacy
• Phone contact within 2 weeks re: tolerance
• Visit within 4-6 weeks to discuss response,
  dose increase
     Duration of treatment
• Six to 12 months after remission for first
  episode of depression (relapse rate
  higher in elderly)
• Data on risks/benefits of treatment
  longer than 2 years lacking for patients
      Drug Treatment of
     Geriatric Depression
• SSRIs are preferred initially (better
  tolerated, not more effective)
• Side effects include anorexia, nausea;
  rarely, tremor or hyponatremia
• SNRIs (serotonin-norepinephrine reuptake
  inhibitors such as Effexor-velafaxine or
  Cymbalta-duloxetine) more expensive, not
  clearly more effective
  Tricyclic antidepressants
• At least as effective as other agents but more side
  effects (anticholinergic)
• Older tricyclics such as amitriptyline (Elavil) or
  imipramine (Tofranil) never used
• ‘Newer’ tricyclics such as nortriptyline (Pamelor)
  or desipramine (Norpramin) better tolerated;
  blood levels useful; begin 10 to 25 mg; avoid if
  prolonged qT on EKG
• More dangerous in overdose; worsen dementia
• Cheaper than SNRIs for depression + pain
             Other agents
• Buproprion (Wellbutrin) ‘activating’ and may
  be useful: caution: lowers seizure threshold
• Mirtazapine (Remeron); allegedly more
  sedating, weight gain
• Trazodone (Desyrel) less effective; ? useful
  when insomnia prominent (begin 50 mg)
• Most effective for severe psychomotor
  retardation when rapid response
  needed (e.g., rehab setting)
• Methylphenidate (Ritalin): begin 5 mg
  bid at 7am and 12 noon
• May be added to SSRI
                Dosing SSRI
•   Fluoxetine (Prozac) 5-10 mg daily (60mg)
•   Citalopram (Celexa) 10 mg daily (40mg)
•   Sertraline (Zoloft) 25mg daily (200mg)
•   Paroxetine (Paxil) 10mg pm (40 mg)
•   Escitalopram (Lexapro) 5mg daily (20mg)
•   Fluvoxamine (Luvox) 25mg pm (200mg)
 Dosing other anti-depressants
• Buproprion 100 mg daily (450mg divided)
• Mirtazapine (Remeron) 7.5mg pm (60mg)
• Venlafaxine (Effexor) 37.5 mg daily (200mg
• Duloxetine (Cymbalta) 20mg daily (60mg
    Medication cost per 30 days
      * (Walmart List: $4/30 days or $10/90 days)
•   Fluoxetine $15-40 *
•   Sertraline $20-30
•   Citalopram $15-30 (break tabs) *
•   Paroxetine $12-30 *
•   Lexapro $85-90
•   Mirtazapine $50-100
•   Buproprion $65-150
•   Effexor $50-120
•   Duloxetine $120-260
 Electroconvulsive therapy
• Still useful for refractory depression or
  depression with severe psychosis
  (used more commonly in elderly)
• Usual response in 6-12 treatments
• Post Rx confusion lasts up to an hour;
  usually no long term sequelae
• Unilateral ECT may cause less
  confusion but may be less effective
• Late life depression is common and morbid;
  screen for it routinely (anhedonia, mood)
• Both drug treatment and non-drug
  management can be helpful
• Antidepressant drugs are equally effective;
  side effect profiles vary and drive selection
  (methylphenidate for more rapid response)
• Successful drug treatment requires close
  follow up, reassurance and willingness to
  increase dose to therapeutic level
                 Case 8
• A 72-year-old woman comes to your office
  to seek your advice. Her health has been
  good since an uncomplicated myocardial
  infarction 3 years ago. Her daughter, a
  social worker, has encouraged her to
  transfer the title for her home to her
  children to protect it for her family if she
  were to need nursing home care. Her
  husband died two years ago and she is
  now the sole owner of the family home.
• She wonders if “all of this is really
  necessary” because she has “Medigap”
  insurance and this would cover her
  nursing home care along with her
  Medicare. She also says that if she ever
  needed to live permanently in nursing
  home, she would not want to be kept
  alive and she understands that Medicare
  covers hospice care.
            Is she correct?
• Her Medicare C (Medigap) covers nursing home
• A trust will immediately protect the home for
  her family so she could wait until she needs
  nursing home
• Despite the home being her only significant
  asset, she would have to surrender it to be
  covered for long term care under Medicaid.
• If her physician documented a life-expectancy <
  6 mo, Medicare would cover the cost of nursing
  home care as a hospice benefit
•   At 65 yo, 43% chance of nursing home stay
•   Medicare will only pay for skilled,
    rehabilitative care in nursing homes (20 days
    after at least a three day hospitalization;
    patient pays a co-payment of $100+ for each
    day after that, limited to 100 days per
•   Custodial nursing home care is paid for
    primarily out of the patient’s “pocket.”
    Medicaid only pays after patients have
    “spent down” their own assets.
• Surviving spouse is often allowed to keep the
  couple’s home, one car and a very limited
  amount of other assets (as little as $3000)
• Any asset transfer to family members other
  than a spouse must occur at least three years
  prior to the need for nursing home care (five
  years if in a trust)
• Physicians must understand the limits of
  Medicare coverage (e.g., hospice coverage
  is a home hospice benefit; nursing home
  benefits limited to skilled need and <21
  days after 3 days in hospital)
• The decision to purchase long term care
  insurance decisions requires careful
  scrutiny of coverage limits

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