ABIM Geriatrics Review

1. ABIM Geriatrics Review July 17, 2014 B. Gwen Windham, MD MHS gwindham@umc.edu No Conflicts

2. Case 1. 78 yo college-educated man with PMH HTN is brought to you by his wife for complaints of visual hallucinations (VH) for 3 months. Wife says he is usually “in his right mind” but has periods of confusion and reduced alertness. Recently wandered outside at night & fell when he saw pigs in the yard. He was hospitalized, received risperidone and became hypotensive by records and “sleepy” by her report. Detailed VH persistently involve animals in yard. Wife endorses gradually worsening symptoms of repeating himself for past 6-12 months, withdrawing socially, & less involved in personal finances. He uses a cane, has had several falls recently, begun requiring help to dress. He is dependent with meal prep, finances, driving, shop, meds over past year. Accidents trying to park 1 yr ago ended his driving

3. Case 1. • PE: BP130/80 HR 80 No OH RR 14 95% O2sat • He is alert, oriented to person, time and city. His MMSE is 23/30. He has a slow, shuffling gait, no tremors, mild symmetric rigidity with extension in the upper extremities. No motor, sensory deficits. A clock drawing test is shown. • Lab: CBC, complete metabolic panel, TSH, B12 normal. MRI brain shows mild generalized atrophy, no infarcts, hemorrhage, mass, hydrocephalus.

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5. Case 1. • Does this patient have dementia? Why or why not? • 2 cognitive domains affected (AAAA+E): • Amnesia, apraxia, agnosia, aphasia, executive dysfunction • Impairs daily or social or occupational function • Is a change from baseline • Not delirium • What is this patient’s diagnosis? • Alzheimer’s disease • Lewy Body dementia • Mild Cognitive impairment • Frontotemporal dementia

6. Case 1. • Does this patient have dementia? Why or why not? • 2 cognitive domains affected (AAAA+E): • Amnesia, apraxia, agnosia, aphasia, executive dysfunction • Impairs daily or social or occupational function • Is a change from baseline • Not delirium • What is this patient’s diagnosis? • Alzheimer’s disease • Lewy Body dementia • Mild Cognitive impairment • Frontotemporal dementia

7. Lewy Body Dementia Criteria • Progressive cognitive decline, dementia (required) plus • Core features (2 required for Probable LBD) • Visual hallucinations, recurrent, detailed, early • Fluctuations (change in alertness, attention) • Parkinsonism early • Suggestive Features • REM Sleep Disorder (acting out dreams) • Severe neuroleptic sensitivity (motor, consciousness, NMS, autonomic dysfxn) • Low dopamine transporter uptake in BG • Supportive Features • Repeated Falls • Syncope, transient loss of consciousness • Low uptake with reduced occipital activity PET/ SPECT

8. Case 2 Mrs. D is a 78 YO woman who comes to clinic with her daughter. She is followed for DM and HTN. She has no new complaints. In reviewing her medications you note she is unsure of how she has been taking them. When asking her questions she often turns to her daughter to supply the answers. When the daughter is queried she reports that her mother seems a little forgetful, “like all people her age.”

9. Upon further questioning, the dtr endorses 1-2 yrs of Mrs. D repeating the same question, misplacing items she cannot find later, & having difficulty thinking of words and using the remote control. She left food burning on the stove soon after Mrs. D’s husband died. Her husband always managed their finances, but after he died, her daughter began helping her after Mrs. D failed to pay some bills and other bills she paid twice. Mrs. D denies that she is having any significant problems and says she is doing as well as other people her age.

10. Mrs. D’s examination reveals excellent physical function with normal alertness, attention, strength, and gait. She has difficulty comprehending simple instructions during the examination. During the hour visit she tells you three times that she takes her dog on a walk daily. She scores 20/30 on the MMSE and has difficulty drawing a clock.

11. What should you do next? • Begin donepezil 5 mg HS • Begin donepezil 10 mg HS • Provide information on caregiver support groups and local services for patients with dementia • Check TSH • Offer hospice

12. What should you do next? • Begin donepezil 5 mg HS • Begin donepezil 10 mg HS • Provide information on caregiver support groups and local services for patients with dementia • Check TSH • Offer hospice

13. Recommended for dementia evaluation • Medication review: e.g. narcotics, benzodiazepines, anticholinergics • TSH • Vitamin B12 • Electrolytes and liver panel, Ca, CBC • Uncontrasted CT/MRI brain - NPH, strokes, tumors • RPR – in patients with specific risk factor

14. A 77-yr-old woman is brought to the office by her daughter because she has been seeing her dead husband and dead brother for the past 2 mo. She sometimes talks to them and they may respond to her. She has a 4-yr history of declining memory and impairment in shopping, paying bills, cooking. She now requires some assistance choosing appropriate clothing and is reminded of meals. She has a history of major depressive disorder but is neither sad nor apathetic on examination. There is no history of alcohol or substance abuse. • Exam is notable for increasing rigidity in her arms that worsens with distraction and a mild shuffling gait. She has no tremor or other neurologic abnormality. Her score is 18/30 on the Mini-Mental State Examination. Laboratory tests are normal. CT shows cortical atrophy. • Which of the following is the most likely explanation for her symptoms? • Lewybody dementia • B. Late-onset schizophrenia • C. Major depressive disorder with psychotic features • D. Parkinson's disease with dementia • E. Alzheimer's disease

15. A 77-yr-old woman is brought to the office by her daughter because she has been seeing her dead husband and dead brother for the past 2 mo. She sometimes talks to them and they may respond to her. She has a 4-yr history of declining memory and impairment in shopping, paying bills, cooking. She now requires some assistance choosing appropriate clothing and is reminded of meals. She has a history of major depressive disorder but is neither sad nor apathetic on examination. There is no history of alcohol or substance abuse. • Exam is notable for increasing rigidity in her arms that worsens with distraction and a mild shuffling gait. She has no tremor or other neurologic abnormality. Her score is 18/30 on the Mini-Mental State Examination. Laboratory tests are normal. CT shows cortical atrophy. • Which of the following is the most likely explanation for her symptoms? • Lewy body dementia • B. Late-onset schizophrenia • C. Major depressive disorder with psychotic features • D. Parkinson's disease with dementia • E. Alzheimer's disease

16. A 72yo retired elementary school teacher presents with complaint of “problems with my memory” for 5 years, worse x 3 months after car was stolen. She has been in a “low point” since. She has difficulty remembering where she put things, but finds them later, and difficulty recalling people’s names. • 5 years ago she was started on donepezil. She is not aware that her memory is worse or better on donepezil. • She lives alone and is independent in ADLs and IADLs; she says she forces herself to do them. • She attends church less than in the past. She reports poor sleep, energy, & endorses psychomotor slowing. • MMSE = 28/30. Her physical exam, TSH, B12, CBC, complete metabolic panel are normal.

17. What is the most likely diagnosis? • Pseudodementia • What else might you do to confirm your diagnosis? • Depression screen, e.g. PHQ, GDS • “low point” for 3 weeks, anhedonia-quit exercising & attends church less, sleep difficulty, slower movements, decreased concentration • Talk to daughter (collateral history)

18. 70yo man with 3-4 years falls, usually backwards. PT noted rigidity, bradykinesia & suspected Parkinson Dz. Was then dx as Parkinson Disease • Took Sinemet for a while but seemed to fall more • Dropped cups when placing them on countertops, described by family as “missing” the surface • PhD in English and Literature. He loved to tell stories & family noticed he stopped doing so, language became more sparse. Then he began coughing while eating, liquids leak from mouth, drools, lost 7 lbs, and is more forgetful. Lost interest in hobbies, appearance; crying spells • Stopped doing finances

19. ROS: per HPI • PE: No orthostasis. Few blinks, slow speech, bradykinesia, normal arm swing, no tremor, symmetric leadpipe rigidity, poor balance, falls backward. Impaired downward vertical gaze that is overcome with passive head movement. MMSE 20/30; abnormal clock drawing and cube copy.

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21. LAB: TSH, B12, CBC, complete metabolic panel, are normal. An MRI show age-appropriate atrophy, no infarcts, hemorrhage, mass, or hydrocephalus.

22. Most likely diagnosis? • Progressive supranuclear palsy • Gaze paresis + early falls*; often misdiagnosed as PD • Many develop pseudobulbar palsy (dysarthria, dysphagia) • Typically poor response to levodopa or more falls • Symmetric parkinsonism, axial stiffness (neck stiff flex/ext), falls backwards, usually no rest tremor • Cognitive impairment: early slowness of thought, difficulty synthesizing multiple ideas together moreso than forgetful and language d/o

23. 65yo woman is brought to clinic July 2009 by daughters. • January 2009: Lived alone/independent in IADLs, walking for exercise in Jxn Med Mall • Feb: began stumbling during walks • Feb-April: Falls & balance problems, “lilting to the right”, leaning on others for support, and a “shuffling” gait • April: admitted to OSH, diagnosed as Parkinson Disease, started on Sinemet, discharged to rehab • April-June: More rapid decline, withdrawn, not interacting/talking, visual hallucinations, confused, voice “low”, mumbles • Since June, lives in a nursing home, requiring full assistance with ADLs

24. Most likely diagnosis? • Creutzfeldt-Jakob • Cardinal: Rapidly progressive mental deterioration and myoclonus • Other: • EPS: hypokinesia, cerebellar (nystagmus, ataxia) • Corticospinal: hyperreflexia, Babinski, spasticity • ABIM Board ? -> CSF finding of 14-3-3 protein

25. What dementia syndrome best explains the following • Asymmetric rigidity, tremor, bradykinesia, narrow-based steps, stooped posture, and forward falls develop first, respond to levodopa and dopamine agonists, and are followed by cognitive problems and hallucinations >1 year later • Parkinson Disease with dementia • PD meds may worsen hallucinations • Quetiapine often used • Cholinesterase inhibitors

26. What dementia syndrome best explains the following • Difficulty initiating gait, moving/lifting feet, wide-based gait, followed by cognitive problems then urinary incontinence. Gait dyspraxia on exam • Normal Pressure Hydrocephalus (wobbly, wacky, wet; “magnetic gait”) • How is it diagnosed? • Clinical, MRI/CT, LP with nl pressure and 20-50 mL removal may improve gait dysfunction/cognitive (Fisher test); cisternography often used, low specificity

27. What is the usual treatment for NPH? • Large volume LP, shunt (acetazolamine/digoxin may reduce CSF production) • Rate of complications with shunt? • 30% (stroke, subdural hematomas, infection, shunt failure) • Response to shunt with long-term benefit? • 25-80%, best if: <2yrs, typical gait & urinary symptoms, no multi-infarcts on MRI brain. Fisher test poor negative predictive value.

28. What dementia syndrome best explains the following • A 64yo woman, described as “conscientious” and “prim and proper”, experiences increased appetite, weight gain, and is uncharacteristically flirtatious over the past year. She is aware of her actions but does not seem bothered by them. Her husband often reminds her to change her clothes and brush her teeth. Primitive reflexes, rigidity, and spasticity are present on exam. There are no significant cognitive abnormalities on initial screening but they develop later in her course. • Frontotemporal dementia • Behavioral • Progressive nonfluent aphasia • Semantic dementia

29. What dementia syndrome best explains the following • A 72yo man with PMH HTN, DM, hyperlipidemia begins having syncope and falls. He lives alone, and is independent in ADLs. His daughter notices his memory is worse since having these spells. He repeatedly asks the same question and is having trouble operating the microwave. No cardiac arrhythmias are identified on EKG or a 24-hour Holter. He has 4/5 strength of the right and 5/5 on left. MMSE 23/30, deficits clock and cube copy, recall, MRI shows a new thalamic infarct compared to MRI 2 years ago and diffuse moderate to severe white matter periventricular changes. • Vascular cognitive impairment (vascular dementia)

30. Vascular Cognitive Impairment • Details • Vascular dementia (multi-infarct) • Prevalence 11.3-20.1% of dementias • Two Types of Vascular Dementia • 1st type – Infarction of large arteries with clinical strokes with stepwise accrual of deficits. • 2nd type – Atherosclerotic small vessel disease • Subcortical pattern • Preservation of naming • May have mild Parkinsonism • Commonly have concomitant Alzheimer’s disease with disease correlating best with neurofibrillar tangles

31. 68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses. He is currently writing a textbook and continues to teach courses without difficulty. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 29/30. TSH, B12, CMP, CBC, and CT head are normal. What should you do next? • Reassure him • Order an MRI brain • Send for neuropsychological testing • Obtain neurology consult

32. 68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses. He is currently writing a textbook and continues to teach courses without difficulty. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 29/30. TSH, B12, CMP, CBC, and CT head are normal. What should you do next? • Reassure him • Order an MRI brain • Send for neuropsychological testing • Obtain neurology consult

33. 68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses, and thinks he depends more on lists as reminders than in past. He has cut back on the number of courses he teaches but continues to perform well at work. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head are normal. What is his diagnosis? • Early Alzheimer’s disease • Pseudodementia • Mild cognitive impairment • Generalized anxiety disorder

34. 68yo college professor is evaluated for memory loss. He forgets students’ names more than in past, misplaces keys and glasses, and thinks he depends more on lists as reminders than in past. He has cut back on the number of courses he teaches but continues to perform well at work. He is independent in ADLs and IADLs. His wife concurs with the history. His exam is normal. Depression screen is normal. MMSE 26/30. TSH, B12, CMP, CBC, and CT head are normal. What is his diagnosis? • Early Alzheimer’s disease • Pseudodementia • Mild cognitive impairment • Generalized anxiety disorder -MMSE 24-26 range -No effect on function (social, work, ADL/IADLs) -No drug treatment -10-15% progress to dementia annually -Cognitive behavioral therapy may help

35. Behavioral problems in dementia1st line treatment for behavioral problems:Environmental: 1. LOOK FOR TRIGGERS – pt may be uncomfortable due to cold bathroom, lack of modesty, aggressive caregiver2. Other - redirection, distraction, remain calm, use soft calming voice, reassurance, avoid arguing, use simple single 1-step commandsPharmacologic treatment for behavioral decline (all off label):-Psychosis (more common in Lewy Body dementia)- Atypical antipsychotics have fewer extra pyramidal side effects than haloperidol. Quetiapine (seroquel), has least and if need one for Lewy Body or PD patients, choose this one. Black box for 1.6 increased risk of mortality. Avoid with increased QT intervals. -Depression (also for non-demented) -Avoid trycyclics -SSRIs preferred but may cause REM-sleep disorder (body-limb movements in REM sleep) in patients with Lewy-Body disorder-Anxiety (also for non-demented) -Buspirone, SSRI or low dose atypical antipsychotics

36. 70yo Hispanic (or AA) woman has had increasing difficulty reading newspaper print for past 4-6 weeks. She has trouble following text & finding the next line. She rarely leaves her home. She has HTN, PVD, CVA 7yr ago, open-angle glaucoma 20 yr ago. She has had no follow-up care. What is the most likely cause of reading difficulty? • New stroke • Macular degeneration • Retinal hemorrhage • Open-angle glaucoma • Retinal detachment

37. 70yo Hispanic (or AA) woman has had increasing difficulty reading newspaper print for past 4-6 weeks. She has trouble following text & finding the next line. She rarely leaves her home. She has HTN, PVD, CVA 7yr ago, open-angle glaucoma 20 yr ago. She has had no follow-up care. What is the most likely cause of reading difficulty? • New stroke • Macular degeneration • Retinal hemorrhage • Open-angle glaucoma • Retinal detachment -OAG: leading cause blindness in Hispanics, AA -early peripheral visual field (VF) loss, encroaches centrally in advanced disease -Remains at home – familiar to her, may not notice earlier peripheral VF loss -RH – acute, new large floater -CVA- wrong VF loss pattern -RD – sudden vision loss; can be missed if pt doesn’t notice due to compensation by good eye

38. An 83-yr-old woman is brought to the office by her daughter because the mother has become confused and forgetful for the past 6 months. Other than urinary incontinence, she has no medical problems. Her only medication is extended-release oxybutynin 10 mg for urge urinary incontinence which was started about 6 moago with improved symptoms of incontinence. The mother, when asked, has no new complaints about memory or cognition. MMSE is 23 of 30. The patient is inattentive, repeats herself during the interview, but exam is otherwise normal. Which of the following is the most appropriate next step?A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QIDB. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeksC. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeksD. Discontinue oxybutynin 10mg ER; begin behavioral therapy for urinary incontinence

39. While most patients on anticholinergic bladder medications have no discernable cognitive effects, some will. Because the symptoms in this patient may be due to the medication – symptoms began after initiating this new medication – the drug should be discontinued. Cognitive adverse effects are related to peak med concentrations. IR agents with the same total dose as the ER drug could worsen this effect. Behavioral therapy is an effective therapy for urge incontinence. If the patient is not cognitively intact to fully participate in behavioral therapy, scheduled toileting may be of benefit. Behavioral therapy may include bladder training, prompted voiding, pelvic floor muscle exercises, biofeedback training. Which of the following is the most appropriate next step?A. Discontinue oxybutynin 10mg ER; begin oxybutynin IR 2.5mg QIDB. Begin memantine 5mg daily, titrating to 20mg/d over 4 weeksC. Begin donepezil 5mg daily, titrating to 10mg daily after 8-12 weeksD. Discontinue oxybutynin 10mg ER; begin behavioral therapy for urinary incontinence

40. An 86yo woman comes to the office for routine evaluation. She was the primary caregiver for her husband until his death 9 mo ago. She is somewhat fatigued and has a poor appetite but does not think that she is depressed. She has had some dizziness but no falls, and she has had occasional diarrhea with incontinence but no melena or hemato-chezia. PMH: atrial fibrillation, heart failure (EF 40%), and HTN. Medications include atenolol, digoxin, lisinopril, and warfarin. On examination, blood pressure is 118/66 mmHg. Ventricular heart rate is 56 beats per minute. She has lost 6.4 kg (14 lb; 9% of her body weight) over the last 6 mo. The remainder of the physical examination is not substantially changed from her last visit. Which of the following is most likely to identify the cause of weight lossA. Chest xrayB. Fecal occult blood testingC. Serum digoxin levelD. Home visitE. Depression Screening

41. Weight loss assessment in older adults should include medication review. Anorexia, diarrhea, and dizziness are common effects of digoxin toxicity. Bradycardia, ventricular arrhythmias, apathy, nausea, confusion, visual disturbances, depression are also seen and can lead to significant weight loss. There is some controversy regarding measuring digoxin levels: patients may have toxicity even with “normal” concentrations; nonetheless, higher concentrations correlate with greater adverse events. If subacute digoxin toxicity is suspected, a trial of tapering the dosage may be reasonable instead of measuring the serum concentration. Usual max daily dose is 0.125mg in older pts.FOBT is reasonable, but adverse effects of digoxin are more common and should be checked immediately. Depression screen may be positive, but depression should not be considered endogenous until digoxin toxicity is excluded; depression will likely be refractory until toxicity resolves. A home visit may determine if the patient is caring for herself and has quality nutrition available; however, poor living conditions could be due to depression and apathy caused by digoxin toxicity. Lung cancer can cause weight loss, but there is little else in this case to suggest lung pathologyWhich of the following is most likely to identify the cause of weight loss?A. Chest xrayB. Fecal occult blood testingC. Serum digoxin levelD. Home visitE. Depression Screening

42. An 88-yr-old woman with peripheral arterial disease is admitted to the hospital because she has gangrene in 2 toes and soft-tissue infection of her distal foot. She is a widow and lives alone; her daughter visits at least weekly. On admission, her blood pressure is 140/80 mmHg, respiratory rate is 16 breaths per minute, pulse is 90, and temperature is 38°C (100.4°F). She is acutely confused and inattentive. Her speech is rambling. Which of the following factors is most likely to increase her risk of in-hospital functional decline and nursing home placement? A. Marital statusB. RaceC. GenderD. Delirium

43. Factors that predict in-hospital functional decline (measured by ability to perform ADLs) and nursing-home placement include older age, IADL dependence , delirium and cognitive impairment, such as dementia. After a complete history that may necessitate calling caregivers or nursing homes for nursing home residents, the evaluation of acute mental status changes should include vitals including oxygen saturation, blood counts, electrolytes, evaluation for infection (pneumonia, UTI, sepsis) and review of medications and recent changes in medications. ROS and exam should assess presence of urinary or fecal impaction. Cardiac assessment (EKG or troponin) may be warranted. Which of the following factors is most likely to increase her risk of in-hospital functional decline and nursing home placement? A. Marital statusB. RaceC. GenderD. Delirium

44. A 90-yr-old man is brought to the emergency department by his family because he has had an abrupt change in behavior. The patient moved into his daughter and son-in-law's house a few months ago, because he was no longer able to manage living alone. A few days ago, he became aggressive and angry, and hit his son-in-law for no apparent reason. He has also become incontinent in the last few days. He has multiple bruises, which the family suspects are from falling. History includes moderate dementia and benign prostatic hyperplasia. On examination, he is inattentive, blood pressure is 160/90 mmHg; all other vital signs are normal. He is demanding to be released from "prison'' and is aggressive with the staff. The physical examination is unremarkable. Although he is uncooperative with the neurologic examination, he appears to be moving all extremities well. Which of the following is the most appropriate next step? A. Bladder scanB. Lumbar punctureC. ElectroencephalographyD. CT of the brainE. BMP, CBC, urinalysis/culture, pulse oximetry

45. A 90-yr-old man is brought to the emergency department by his family because he has had an abrupt change in behavior. The patient moved into his daughter and son-in-law's house a few months ago, because he was no longer able to manage living alone. A few days ago, he became aggressive and angry, and hit his son-in-law for no apparent reason. He has also become incontinent in the last few days. He has multiple bruises, which the family suspects are from falling. History includes moderate dementia and benign prostatic hyperplasia. On examination, he is inattentive, blood pressure is 160/90 mmHg; all other vital signs are normal. He is demanding to be released from "prison'' and is aggressive with the staff. The physical examination is unremarkable. Although he is uncooperative with the neurologic examination, he appears to be moving all extremities well. Which of the following is the most appropriate next step? A. Bladder scanB. Lumbar punctureC. ElectroencephalographyD. CT of the brainE. BMP, CBC, urinalysis/culture, pulse oximetry

46. This patient demonstrates an acute change in cognition and behavior from his baseline deficits. Increased confusion, new falls, and new incontinence all suggest a new underlying illness or medication adverse event. An acute change in mental status may be the only sign of a serious acute illness. Even when the examination is unremarkable, metabolic abnormalities should be pursued, including chemistries, renal function, glucose, and oxygen saturation. Urinalysis and review of prescribed and OTC medicationsare indicated. The most common causes of acute confusion are medical illness, metabolic disturbance, and medications. Stroke, hemorrhage, meningitis, and encephalitis are much less common, and should be considered after more likely causes are excluded. Thus, LP is not part of the routine evaluation for delirium. Many OTC medications with strong anticholinergic properties (eg, diphenhydramine) are easily accessible and often misperceived by patients as safe, yet can cause delirium. In an older man with BPH, urinary retention can manifest as a change in mental status. However, medical illness, metabolic abnormalities, and medications are more common causes of delirium. EEG can demonstrate a pattern consistent with delirium but will not provide a diagnostic rationale for its cause, unless seizures are strongly suspected. Brain imaging is not recommended in absence of an abnormal neurological exam, but may be indicated if the patient's laboratory and other tests are unremarkable.

47.  An 87yo woman comes to the office for a routine evaluation. She reports that she has fallen once or twice a month for past 4 months. The falls occur at various times of the day and immediately after standing or standing for some time. She does not experience dizziness, lightheadedness, vertigo, palpi-tations, chest pain or tightness, focal weakness, loss of consciousness, or injury. She lives alone. PMH includes HTN and DJD of both knees. Medications are acetaminophen and hydrochlorothiazide.PE: T 98.6, BP 135/85 mm Hg without postural change, HR 72/min, RR 16. Visual acuity with glasses is 20/40 OD & 20/60 OS. Cardiopulmonary exam is normal. Knees have bony enlargement w/o warmth or effusion. On balance & gait screening with the “get up and go” test, the patient must use her arms to rise from the chair. Neuro exam is normal. MMSE is 26/30 (nl≥24/30). Results of a complete blood count and blood chemistry studies are normal. Which of the following should be included as part of her management at this time?A. Begin risedronateB. Measure serum 25-hydroxyvitamin D levelC. Prescribe hip protectorsD. 24-hour electrocardiographic monitoring

48. Low Vitamin D associated with muscle weakness, functional impairment, falls, fractures. In RCT, replacement (goal >30ng/ml) may reduce risk of falling 20%. If the vitamin D level is low, this patient should take ergocalciferol or cholecalciferol, 50,000 units weekly for 6 to 8 weeks, followed by 800 to 1000 units of vitamin D daily along with calcium supplementation (at least 1200 mg of elemental calcium [diet plus supplementation]). Although vitamin D deficiency is common in the elderly, routine vitamin D level screening is not recommended. In the absence of clinical manifestations of osteoporosis (such as vertebral, hip, or wrist fracture) or a low bone mineral density measurement, use of medications such as risedronate to treat osteoporosis is not warranted. A Cochrane systematic review concluded that hip protectors are ineffective in preventing hip fractures in elderly persons who fall, partly as a result of limited patient acceptance and adherence because of discomfort. There is no proven value of performing routine 24-hour electrocardiographic monitoring in elderly persons who fall. A. Begin risedronateB. Measure serum 25-hydroxyvitamin D levelC. Prescribe hip protectorsD. 24-hour electrocardiographic monitoring

49. 77yo man comes to the office for a 12-mos history of pain over the posterior right calf after prolonged standing or walking. At first, the pain occurred only after walking 10-12 blocks, but it now occurs after <1 block. He has pain when he stands more than 10 minutes. The pain is relieved immediately with sitting. On exam, pulses are full in both legs. The skin is normal, with full skin hair throughout both legs. Bilateral straight leg raise tests are normal. There is good mobility of both hips without pain. There is mild weakness of the right great toe extensor, right hip abductor, & right hip extensor. Radiography of the lumbar spine shows diffuse degenerative changes of the lumbar disks & facet joints. There is evidence of mild to moderate osteoarthritis of the right hip.What is the most likely cause of this patient’s pain? A. Bone or joint disease of the hip B. Vascular insufficiency C. Lumbar spinal stenosis D. Ruptured popliteal cyst E. Metastatic cancer to the bone

50. 77yo man comes to the office for a 12-mos history of pain over the posterior right calf after prolonged standing or walking. At first, the pain occurred only after walking 10-12 blocks, but it now occurs after <1 block. He has pain when he stands more than 10 minutes. The pain is relieved immediately with sitting. On exam, pulses are full in both legs. The skin is normal, with full skin hair throughout both legs. Bilateral straight leg raise tests are normal. There is good mobility of both hips without pain. There is mild weakness of the right great toe extensor, right hip abductor, & right hip extensor. Radiography of the lumbar spine shows diffuse degenerative changes of the lumbar disks & facet joints. There is evidence of mild to moderate osteoarthritis of the right hip.What is the most likely cause of this patient’s pain? A. Bone or joint disease of the hip B. Vascular insufficiencyC. Lumbar spinal stenosis D. Ruptured popliteal cyst E. Metastatic cancer to the bone