Week 4 - Musculoskeletal and Skin Disorders

Question 1

Functional assessment

Answer 1

evaluation of ongoing medical comorbidities, premorbid functional status, current function, living situation and equipment, caregiver support, and patient functional goals

Question 2

Lawton IADL scale

Answer 2

The Lawton IADL scale was developed by Lawton and Brody in 1969 to assess the more complex ADLs necessary for living in the community
- shopping
- cooking
- finances
- driving

Question 3

Domains of geriatric care

Answer 3

mental, physical, functional, socio-economic

Question 4

Nutritional assessment should be triggered if a patient has how much weight loss?

Answer 4

more than 5% in 6 months

Question 5

Geriatric screening tools

Answer 5

• International Prostate Symptoms Score – for diagnosing urinary obstruction
• Patient Health Questionnaire–2 – screening for depression (all patients)
• If + use Patient Health Questionnaire–9 or the 15-item Geriatric Depression Scale
• Katz index for ADLs10 and the Lawton scale for IADLs.11
• Clinician’s Guide to Assessing and Counseling Older Drivers1
• AD-8 – changes in behavior which may indicate cognitive problems
• Neuropsychiatric Inventory Questionnaire (NPI-Q)
• Montreal Cognitive Assessment (MoCA
• Snellen chart 20/40 is visual impairment
• o Timed Up and Go (TUG) test18 is an assessment of gait and lower leg function – if more than 12 seconds, high fall risk
• Cognitive screening tools
• mini-cog (3-item recall and clock drawing1
• if mini cog is +  MoCA, Mini Mental State Exam (MMSE) – requires training
• Short Form-36 Health Survey22 (SF-36), - quality of life tool
• Mini nutritional assessment

Question 6

Gout

Answer 6

Iinflammatory reaction to monosodium urate (MSU) crystals deposited in the joint, is associated with hyperuricemia

Question 7

Gout s/s

Answer 7

Pain, heat and swelling in one or more joints. Usually big toe, non-symmetrical.

First metatarsal phalangeal join- more likely to involve small joints and develop tophi more rapidly and in unusual locations

Question 8

Gout treatments

Answer 8

NSAIDs, colchicine allopurinol, steroids or intraarticular injection. Diet low in red meats and seafood (purines).

Question 9

Diagnostic criteria for gout

Answer 9

1. an SU level >7 mg/dL in men or >6 mg/dL in women
2. the presence of tophi;
3. the presence of MSU crystals in SF or tissues;
4. a history of painful joint swelling with abrupt onset and remission

Question 10

S/S of Osteoporosis

Answer 10

• height loss >4 cm,
• rib-pelvis distance <2 finger-breadths
• inability to touch the occiput to the wall when standing with heels to the wall.

Question 11

Risk factors for Osteoporosis

Answer 11

• DM
• Corticosteroid use
• Radiation
• smoking

Question 12

DXA results for osteoporosis

Answer 12

T-score of ≤2.5 standard deviations below the mean of a young reference group is positive for osteoporosis

Question 13

DXA results for osteopenia

Answer 13

T-score between 1.0 and 2.5

Question 14

Non pharmacological treatment for osteoporosis

Answer 14

• Supplementation with Ca and Vit D
• Exercise
• Fall prevention
• Adequate caloric intake
• 1000mg of Calcium to age 50 (women) or 70 (men), 1200mg daily over those ages

Question 15

Osteoporosis management is recommended for which patients?

Answer 15

• Pts with hip or vertebral fracture
• BMD T-scores ≤−2.5,
• BMD T-scores between −1.0 and −2.5 and a 10-year probability of hip fracture >3% or 10-year probability of major osteoporotic fracture >20%

Question 16

Pharmacological treatments for Osteoporosis

Answer 16

Antiresorptive agents AKA bisphosphonates – slow the remodelling process to increase bone density –> continue treatment for 5 years
* (alendronate, risedronate, ibandronate)
* Zolendronic acid- once yearly dose
 Anabolic agents (teriparatide, abaloparatide)
 Other (raloxifene, estrogen,)

Question 17

How to monitor patients with osteoporosis

Answer 17

• Regular height measurements
• DXA scans 1-3 years
• Fracture risk assessment
• assessment for treatment compliance and side effects.

Question 18

Signs and symptoms of OA

Answer 18

• Asymmetrical joint swelling
• Hebreden and bouchards nodes
• joint pain and stiffness for 10-15 min after rest
• DIP, PIP, hips, knees, neck, back

Question 19

Treatment for OA

Answer 19

• Weight loss
• Exercise
• Brace/splinting
• Tai Chi/Qi Gong
• Acupunture
• Tyelnol
• NSAIDS – for hand, knee hip
• Steriod injections

Question 20

Labs for OA

Answer 20

• ANA - negative
• RF - negative
• ESR - normal
• CRP - normal

Question 21

Imaging for OA

Answer 21

Xrays show joint space narrowing, osteophytes, subchondral sclerosis, and cystic changes

Question 22

Signs and symptoms of RA

Answer 22

Joints affected symmetrically Warmth and swelling at joints
Joint pain and stiffness in the morning for 2-3 hours

Question 23

Labs for RA

Answer 23

ANA - positive RF - positive (32-89%) ESR - elevated at onset

Question 24

Treatment for RA

Answer 24

Disease modifying antirheumatic drugs (DMARDS) – can do triple therapy, requires lab testing every 8-12 weeks for monitoring
* Methotrexate
* Sulfasalazine
* Hydroxychloroquine (avoid in macular degeneration)

Biologicals (can reactivate hep B and C and TB)
* Humira (adalimumab)
* Enbrel (etanercept)

Question 25

Xray findings for RA

Answer 25

Loss of articular space, multiple erosions, juxtaarticular osteopenia, and ulnar deviation.

Question 26

Treatment of gout

Answer 26

Uric acid lowering therapy with 2-3 acute attacks, renal complications or presence of tophi  xanthine oxidase inhibitors – uric acid less thatn 6mg/dL

Lifestyle
* Avoid alcohol, avoid purines (shellfish and organ meats)

Pharmacological
* Allopurinol (safe to titrate up despite renal insufficiency) urate lowering
* Febuxostat if no response to allopurinol

Prophylaxis
o Colchicine 0.6mg daily
o Low dose steroids

Question 27

Pseudogout

Answer 27

calcium pyrophosphate dehydrate (CPPD) crystal deposition in joints

Question 28

Treatment for pseudogout

Answer 28

NSAIDs, intraarticular steroids

Question 29

Timed up and go test

Answer 29

Stand up from chair, walk 10 feet and return to chair.

An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.

Question 30

Onset of herpes zoster

Answer 30

Prodrome of unilateral pain or pruritus followed by corresponding dermatomal vesiculopustular eruption within days to a week

Question 31

Is someone with herpes zoster contagious?

Answer 31

The host is contagious during the prodrome (via respiratory route) and through direct contact until the lesions become dried and crusted

Question 32

Diagnosis for herpes zoster

Answer 32

Clinical presentation
- Polymerase chain reaction (PCR) is a rapid, sensitive, and specific assay

Question 33

Vaccines for herpes zoster

Answer 33

For patients over 50:
* Zostavax (attenuated live virus - not for immunocomprimised patients)
* Shingrix (recombinant, 2-doses)

Question 34

Treatment for herpes zoster

Answer 34

• Antiviral therapy within 72 hours of rash onset
• Caution with CKD
• IV therapy with ocular involvement, immunosuppression, suspected meningitis or sepsis
• Acyclovir, famciclovir, valcyclovir

Question 35

Post herpetic neuralgia

Answer 35

PHN is a debilitating chronic neuropathic pain condition that can persist for months to years after zoster rash resolution. PHN occurs most commonly in older patients with zoster, probably as a function of immunosenescence.

Treatment with gabapentin and lyrica.

Question 36

All treatments for OA

Answer 36

• acetaminophen
• Topical capsaicin
• Referral to physical therapy
• Referral to occupational therapy
• Referral to orthopedics
• Follow-up with NP in one month
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Low-impact exercises

Question 37

All treatment for RA

Answer 37

• Referral to rheumatology
• Low-dose oral corticosteroids
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Low-impact exercises