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467
C 1: R U S
N F
Subjective:
BN is a 70-year-old widowed Asian American man in the rehabilitation program after sustaining
a hip fracture of the femur neck followed by arthroplasty 2 weeks ago. His postsurgical pain is
much improved.
Past Medical History:
Hypothyroidism, incontinence.
Medications:
Levothyroxine 100 mcg daily, tolterodine LA 2 mg daily, fondaparinux 2.5 mg daily (for total of
35 days then switch to warfarin for 5 months), aspirin 81 mg daily, Tylenol #3 1–3 per day prn
(no longer using), and calcium chew with vitamin K1 twice a day prn.
Allergies:
NKDA.
Social History:
Quit smoking 10 years ago and has a beer a day; Meals on Wheels at home; diet low in dairy
products; minimal exercise. Prior to hip fracture he lived independently in his own home. Wife
died 3 years ago; two children with families residing nearby.
Family History:
Mother died age 68 years due to breast cancer; she had a hip fracture at 65 years old; father
died age 83 years from a myocardial infarct; he had OA and dyslipidemia. BN has two sisters
with osteoporosis.
Objective:
Ht 5´6˝ per stadiometer (past height 5´9˝), Wt 160 lb, BP 160/95 mmHg, P 80 BPM, T 98.6
o
F, RR
18 BPM.
Physical Examination:
ROM improving but still limited. Difficulties with gait and balance. All other aspects within normal
limits.
Labs:
TSH 0.6 mIU/L (nl 0.4–10 mIU/L), T4 12.8 mcg/dL (nl 4.6–12 mcg/dL), Scr 1.4 mg/dL, BUN
25 mg/dL, 25 (OH) vitamin D 22 ng/mL, albumin 3.1 g/dL (nl 3.4–5.4 g/dL); all other lab values
within normal limits.
Procedures: lunar DXA spine T-score –2.3, nonsurgical hip/femoral neck
T-score –2.8, total hip T-score –2.5.
Assessment:
BN is a 70-year-old man doing well in physical therapy for postfracture rehabilitation. A walker
is needed for mobility. He is at increased risk for a pressure ulcer due to poor nutrition prior to
fracture. He has previously undiagnosed osteoporosis and vitamin D insufficiency.
Plan:
1.
Begin alendronate 10 mg weekly; provide patient education using the teach-back method,
and recheck for understanding in a week and on discharge to home.
2. Until warfarin therapy is completed, switch the calcium chew to calcium carbonate
1,250 mg with vitamin D 400 units once daily with food. Increase dairy (after determining
no lactose intolerance) and other high calcium content food intake. Provide patient with
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| Fundamentals of Geriatric Pharmacotherapy
list of high calcium–containing foods. Educate patient on counting calcium intake from
foods to try to achieve a daily calcium intake of 1,000 mg in divided servings, preferably
from foods and beverages and, if needed, supplements.
3.
Begin ergocalciferol 50,000 units weekly for 6 weeks, then begin vitamin D supplement
1,000 units daily. Reassess 25 (OH) vitamin D level in 4 months and adjust daily
supplementation as needed.
4.
Decrease levothyroxine dose to 88 mcg daily and reassess TSH in 4–6 months with
additional decreases to achieve a TSH concentration in the middle of the normal
therapeutic range.
5.
Provide patient and caregiver with fall prevention guidelines and a checklist for home
safety. If patient or caregiver cannot do this assessment, schedule a home visit by an
occupational therapist.
6.
Assess patient’s skin for hot spots (i.e., red spots from pressure but without skin
breakdown) and pressure ulcers frequently.
Rationale:
1. BN has had a fragility fracture that warrants osteoporosis treatment, which has been
found to be cost effective. He has also lost 3 inches in height. Based on NOF guidelines,
the patient’s femoral neck DXA score prior to fracture would have warranted osteoporosis
prevention therapy. According to guidelines, alendronate, risedronate, zoledronic acid,
and denosumab are medications of choice. His estimated Cockcroft-Gault creatinine
clearance is above 35 mL/min. Because he has no underlying renal pathophysiology
besides aging, bisphosphonates are safe to use. Most Medicare Part D plans will require
generic bisphosphonate therapy first with zoledronic acid and denosumab requiring prior
authorization. More recent studies do not find a difference in adherence between weekly
and monthly therapies. He (and caregiver) will require alendronate education, making sure
directions are followed and the medication is not taken with other medications, especially
calcium. Repeated reinforcement and education can help ensure proper bisphosphonate
administration and medication safety, adherence, and persistence.
2. In this scenario, FRAX calculations are not necessary to determine osteoporosis
medication need but can be helpful with patient education and motivation to practitioners
to prescribe treatment and for BN to take his osteoporosis medications. His age, race,
height, and his mother’s and his own hip fracture are his risk factors.
3.
Patient has poor nutrition and osteoporosis; thus, he needs to improve his nutrition and
increase his daily calcium and vitamin D intake to prevent further bone loss and future
fractures. Improved nutrition will also help prevent pressure ulcers. If the calcium chew
contains vitamin K, it can be problematic with warfarin, especially if used erratically, but
is not a problem with injectable anticoagulants. A dietitian can determine BN’s nutritional
needs and suggest a balanced diet. His daily calcium intake needs to be determined to
make sure over calcium supplementation and risk of myocardial infarct do not occur.
Calcium foods are preferred but if insufficient to meet adequate intakes, a calcium
supplement can be used.
4. His vitamin D concentration is considered insufficient but not deficient. His replacement
schedule should replenish his stores and then the NOF vitamin D recommendations of
800–1,000 units daily can be implemented. Alternatively, a higher daily dose, for example
4,000 units per day, could be used. Because biologic feedback and equilibrium of vitamin
D takes some time, follow-up monitoring is usually done 3–6 months after replenishment
and stabilization with a maintenance dose. His follow-up vitamin D assessment should be
done at the same laboratory as the first assessment if the vitamin D assays have not been
standardized.
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5. Excessive levothyroxine replacement can increase bone metabolism. Currently BN’s TSH
concentration is at the lower end of the normal range and his T4 is slightly higher than the
upper limit of the normal range, suggesting excessive replacement and warranting a lower
levothyroxine dose. Because the new equilibrium can take time, follow-up TSH monitoring
is also done 3–6 months after a dosage change.
6. BN has osteoporosis and will benefit from a safe home environment, decreasing the
likelihood of falls, which can be achieved by completing the home safety ideas for falls
prevention as described in the above suggested websites.
7.
Male gender, decreased mobility, advanced age, poor nutrition, and surgical intervention
increase BN’s risk for a pressure ulcer, which can be prevented with modifications of risk
factors, good nutrition, and mobility.
Case Summary:
Osteoporosis is common in older adults, and a proactive approach to preventing bone loss and
preventing falls is required. Although men are at lower risk, as seen with BN, they still develop
osteoporosis and fractures. Men also have higher mortality after an osteoporotic fracture, so
close monitoring of BN is required. Nutrition is a common problem, especially for older adults
who live alone. Pharmacologic interventions exist to improve BN’s quality of life and potentially
extend life duration.
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C 2: I G C
Subjective:
SB is a 79-year-old African American woman living in an assisted living facility for the last 2
years since the death of her husband. For the past 4 weeks, she has experienced significant
increase in joint stiffness lasting about 1 hour every morning, weakness, and fatigue.
Past Medical History:
RA for past 22 years with acceptable control over the past few years, gout with last attack 3
years ago, and hypertension.
Medications:
Methotrexate 7.5 mg weekly, etanercept 50-mg injection weekly, celecoxib 100 mg twice daily,
and enalapril 10 mg daily. Occasional chewable calcium tablets. Previous treatments with
various combinations of DMARD medications. Past glucocorticoid therapy for RA flares has
been limited to 2–4 weeks of therapy with doses ranging from 5 to 10 mg per day.
Allergies:
NKDA.
Social History:
Negative for tobacco and alcohol use. SB has two children and five grandchildren living in other
states. She worked for 28 years in a hosiery textile mill.
Family History:
Mother died age 61 years after 30 years with RA; father died age 82 years from a motor
vehicle accident.
Objective:
Ht 5´3˝, Tt 173 lb, BP 156/76 mmHg, P 82 BPM, T 98.6 °F, RR 16 BPM. Pain today 8/10;
average 1 month ago 4/10.
Physical Examination:
Joint and muscle aches in neck, shoulders, and hips significantly worse in the past 2 days.
Patient also describes weakness and lethargy. Negative for synovitis.
Labs:
ESR 89 mm/hr (nl 0–30 mm/hr).
Assessment:
SB is a 79-year-old woman with suspected PMR in addition to longstanding RA.
Plan:
1.
Initiate glucocorticoid therapy with prednisone 20 mg daily for 2 weeks then return to
clinic. After 2 weeks, if symptoms are eliminated and the ESR has returned to normal,
the prednisone can be tapered by 2.5 mg every 2–4 weeks. If symptoms persist, wait a
month and then re-evaluate, and if symptoms decreased can try tapering again. If pain
returns while tapering, return to previous dose that controlled symptoms, wait 2–4 weeks,
then slow the taper schedule. Once the dose is at 10 mg, maintain for a week and try
decreasing dose by 1 mg every month. Patient might require low-dose long-term (i.e., 1–2
years) prednisone therapy to eliminate pain and prevent symptom reoccurrence. Assess
bone density to determine baseline before using long-term (>3 months) prednisone. As an
African American woman, SB’s FRAX 10-year osteoporosis fracture risk score is 11% prior
to glucocorticoids and 17% on glucocorticoids, giving her medium risk for glucocorticoid-
induced osteoporosis, which warrants treatment. Her FRAX might underestimate her risk
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because it does not account for fracture risk from falls, which she experiences. She can
be started on alendronate, risedronate, or zoledronic acid. Her daily calcium intake needs
to be determined, or use the average for her age, approximately 600–640 mg of elemental
calcium daily. Because glucocorticoids decrease calcium absorption, adequate intakes
are higher (1,200–1,500 mg). She should be educated to increase the calcium in her diet
but if not, supplements can be used. If she will be on a PPI, calcium citrate, which has
acid independent absorption, can be used, or she should take the calcium carbonate with
the evening meal. She should take 800–1,000 units of vitamin D daily from a vitamin D
supplement or multivitamin.
2.
Monitor blood pressure during glucocorticoid therapy and adjust enalapril if blood
pressure exceeds 150/90 mmHg or if any symptoms of end-stage organ impact (e.g.,
extreme headache, chest pain, altered urine output).
3.
Obtain patient’s tolerable pain level and use this as therapeutic goal until PMR controlled.
4.
Monitor GI symptoms. Another option would be to start a PPI in conjunction with the
glucocorticoid regimen, especially because the patient is also on a COX-2 inhibitor.
Rationale:
1. Glucocorticoids are the gold standard treatment for PMR. They have the additional benefit
of assisting in confirmation of diagnosis. If a patient’s symptoms, and ESR and anemia,
if present, respond to the therapy, then it is likely the patient has PMR. If this patient also
had headache, jaw pain, and inflamed arteries in the temples, neck, and arms then GCA
could also be considered. Higher glucocorticoid doses are used to treat GCA.
2. Symptom relief is the primary goal of therapy, but the long-term effects of glucocorticoid
therapy will have to be managed. Glucocorticoids can decrease bone density and increase
blood pressure, so it is important to evaluate this patient for osteoporosis and the need
for antiresorptive therapy, monitor blood pressure, and adjust hypertensive medication
as needed. Other problems should be monitored, such as increase in blood glucose and
infections.
3. Sometimes older adults cannot describe their pain or have different means of expressing
pain, such as decreased eating and sleeping and increased aggression. In addition,
increased function and quality of life are important goals. SB is already on celecoxib, so
a change in NSAID is unlikely to control the PMR pain. The glucocorticoid therapy should
help control pain and joint inflammation.
4. Because glucocorticoids and celecoxib can cause GI ulcers, a PPI might prevent GI
adverse effects instead of treating them after the fact.
Case Summary:
The sudden increase in pain and stiffness with concomitant fatigue and weakness could
indicate PMR. This patient’s RA has been fairly well controlled with her current regimen for
over 2 years making a flare up less likely. The location of the specific pain is not indicative of
a gout flare. PMR is usually responsive to glucocorticoid treatment, and a good response to
therapy helps to confirm the diagnosis. Glucocorticoids have many side effects that should be
monitored, such as blood pressure changes, antihypertensive medication doses, and bone loss,
which is highly likely in older adults, especially those with RA.
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C S
Musculoskeletal conditions have increased
prevalence with increased age. Such condi-
tions have a direct negative impact on function
and increase fall potential. Through risk factor
modification, exercise, healthy nutrition, and
good medical care, some of these conditions
can be prevented or onset delayed. The care of
patients with these conditions requires a patient-
specific approach taking into consideration all
risk factors, concomitant medical conditions
and medications, and patient preferences, toler-
ances, and longevity. The cornerstone of therapy
for the musculoskeletal conditions covered is
nonpharmacologic therapies. Pharmacologic
therapy is one aspect of this care but carries
associated risks and generally does not eradi-
cate the disease. The medications commonly
used to treat these conditions have adverse
effect profiles that can further negatively impact
function and comorbidities as well as increase
morbidity. Some of these therapies require age-
related adjustments. To maximize effectiveness
and minimize risk, a healthcare professional with
expertise in pharmacologic therapy is an impor-
tant part of the healthcare team. Achieving and
maintaining control of these conditions are keys
for patient function, quality of life, and safety.
S-A Q
1. What risk factors for musculoskeletal
disease can be modified to prevent disease
development?
Clinical Pearls
• Although concern exists about using warfarin in older adults with a history of falls,
the risk of stroke is greater than uncommon negative fall consequences.
142
Thus,
older adults with intermediate to high risk of stroke risk (CHADs score of 2 or more
or CHA
2
DS
2
-VASc score of 1 or more) should receive oral anticoagulation. Based on
a Markov decision analysis, quality of life was better for those with fall history taking
oral anticoagulants than those not taking the medication. Most falls do not result in
intracranial hemorrhages or fall-related subdural hematomas, but the effects of stroke
can greatly alter function. Provider education might be needed to overcome prescribing
fears. Minimizing fall risk and closely monitoring warfarin therapy could help decrease
major bleeding risks.
•
Obtaining accurate data about height can be difficult, but this measurement is recom-
mended, especially when doing FRAX estimations. Optimally, an older adult needs to
stand totally erect (i.e., no bent knees or poor posture) against the wall on a flat floor
(i.e., no carpeting) or stadiometer with shoes off, feet together, arms at side, shoul-
ders level, head and eyes focused straight ahead parallel to floor, and heels, buttock,
shoulders, and head against the wall (as much as possible).
143
A straight edge or the
headpiece of the stadiometer is placed flatly and firmly at a 90° angle to the wall on the
older adult’s head (not the top of his or her hair). This method can be difficult or impos-
sible in older adults with significant spine curvature or inability to stand. An alternative
is to measure the individual in a supine position on a flat surface, using a similar 90°
angle straightedge to mark the distance between the bottom of the feet and the top of
the head.
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2. What aspects of daily life could be modified
to decrease the development or progres-
sion of musculoskeletal diseases?
3. How can you prevent falls, especially related
to medication therapies?
4.
What information is needed to calculate
osteoporotic fracture risks for the FRAX esti-
mation for an older adult?
5. Which medications for musculoskeletal
disorders require dose adjustments due to
age-induced decreases in renal or hepatic
function?
6.
Which medications for musculoskeletal
disorders require attention to product selec-
tion based on comorbidities?
7.
What are the risks of NSAIDs and COX-2
inhibitors in older adults, and how can you
minimize these?
8. What patient comorbidities can be wors-
ened with glucocorticoid therapy?
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