Case Presentation

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Case Presentation

• OGUEJIOFOR, LILIAN, M.D.
• Beghe, Claudia, M.D.
• September 18, 2009

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C/C

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

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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

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HPI

• Recently more forgetful
• Visual hallucination
• No gait abnormality
• No urinary symptoms

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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

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PMH

• Decline in cognitive function x 3 years
• Confusion, difficulty recognizing family members
• Some assistance with ADLs
• H/o wandering

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PMH

• Hypothyroidism
• Hypertension
• Hyperlipidemia
• Arthritis

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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

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ROS

• Very mild residual knee pain
• Hearing impairment wears hearing aids
• Hand tremor
• No visual impairments
• No urinary/fecal incontinence
• No depression

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• Functional limitations requires prompting to
  perform some ADLs and take meds
• Mobility ambulates unassisted
• Nutrition recent weight loss after URI, now
  improved

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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

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• RESP CTAB
• ABD BS, soft, NT
• MMSK no joint swelling/pain, good ROM
• NEURO non focal, neg rhomberg, intact gait

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A/P

• Fall multifactorial
• Dementia ? Cognitive decline
• Hypothyroidism
• Anemia
• Health maintenance COLORECTAL CANCER SCREENING

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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

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• 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

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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

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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

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• ABD BS, soft, NT
• EXT no edema
• MMSK normal ROM, no joint swelling
• NEURO non focal, nml gait

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A/P

• HTN
• Hypothyroidism
• Hyperlipidemia
• Health maintenance

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• UTD with mammogram ( refused this years since
  has had gt 30 mammograms)
• Colonoscopy many years ago
• ?PAP

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• TO SCREEN OR NOT TO SCREEN
• FOR COLORECTAL CANCER?

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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

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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.

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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.

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COLORECTAL CANCER SCREENING

• Decisions should be made on an individual basis
• What effect will a diagnosis of cancer have on a
  persons quality of life and functional status?
• How acceptable is a positive screening test for a
  patient since it will lead to further evaluation?
  

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COLONOSCOPY AND DEMENTIA

• Dementia is an independent predictor of
  inadequate colonoscopy prep.
• The American Journal of Gastroenterology (2001)
  96, 17971802 doi10.1111/j.1572-0241.2001.03874.
  x

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• 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

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• 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
  )

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• 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.

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• ROBUST ELDERLY
• / FUNCTIONALLY INDEPENDENT
• / LIFE EXPECTANCY gt 5-10 YRS IF lt 85 YRS
• Colonoscopy probably recommended
• FRAIL/MODERATELY DEMENTED/END OF LIFE / gt85 YRS
• / LIFE EXPECTANCY lt 2-5 YRS
• Avoid colonoscopy

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

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FURTHER REFERENCES

• NEJM Volume 3611179-1187 Number 12 September
  17,2009
• Ann Intern Med.2009150849-857
• UpToDate
• Geriatric Review Syllabus, Sixth Edition
• ACP CLINICAL GUIDEPATH, Health Malintainance

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• THANK YOU