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P OSTER
A BSTRACTS
erly men, index of suspicion for MTS was low in our patient. His striking
initial presentation and worsening symptoms after anticoagulation
prompted further evaluation, leading to the diagnosis of MTS.
Although CDT is associated with a higher risk of bleeding compared
to anticoagulation alone, its benefits outweigh risks in highly active
patients.
Conclusion
In acute proximal lower extremity DVT with severe symptoms,
diagnostic work-up with CT venogram and aggressive catheter-based
intervention should be pursued if indicated. Although DVT due to
MTS is very rare in older adults, failure to recognize can result in serious
vascular sequelae, particularly PTS, and thus appropriate clinical
suspicion should be maintained.
A19
The Importance of Goals of Care in Elders with Mild Dementia.
S. Arora, S. Khosla, M. J. Brennan. Internal Medicine, Baystate
Medical Center/Tufts Univ. School of Medicine, Springfield, MA.
Background:
Existing literature regarding goals of care for dementia patients
focuses on those with advanced disease facing end of life decisions
due to aspiration, infections and debility. Little attention has been
paid to those with early impairment. The authors present a case of an
elderly man with mild dementia for whom a lack of clarity around
goals prevented optimal care.
Case Report:
Mr. S. was an 88 year old with DM and CKD. A geriatrician diagnosed
a mild dementia while he was admitted for an RCA STEMI
with shock requiring vasopressors and intubation. Six weeks later he
was readmitted with syncope and bradycardia secondary to hypovolemia.
An echo documented an EF of 30-35%. AICD or pacer placement
for sinus node dysfunction was discussed; an EP consultant
opted for conservative treatment noting that Mr. S. had dementia.
There was no discussion with the patient or family about possible device
therapies. Within a week, Mr. S. returned to the ER unresponsive,
hyperkalemic and bradycardic with a heart rate in the 20s. He improved
with atropine but bradycardia recurred and attempts to place
a pacer failed. Mr. S. required prolonged CPR for PEA, asystole and
VT but was resuscitated and reintubated. At that point, his family
chose a DNR order. After a lengthy CCU stay and placement of a
dual chamber pacemaker, he was discharged for rehabilitation with
cognitive abilities near his baseline.
Discussion and Conclusions:
Would earlier pacemaker placement have saved Mr. S. suffering
and a long hospital stay? Was the decision not to place a pacemaker
influenced by his diagnosis of dementia? Potentially life-sustaining
therapies should not be foregone due to mild, cognitive deficits especially
if prognosis and goals of care have not been discussed. To avoid
unconscious paternalism, providers must not make judgments about
a patient’s quality of life without input from the patient and family. It
is best to clarify understanding and goals in the outpatient setting
when families are not overwhelmed and patients can participate. This
case was medically complex; elders like Mr. S. have largely been excluded
from the clinical trials of post MI devices. Improved communication
among primary care MDs, geriatricians, cardiologists and patients/families
is essential. Research on communication strategies to
enhance advanced care planning and to clarify clinical outcomes for
vulnerable geriatric cardiology patients are both sorely needed.
A20
Femoral Spontaneous fracture Associated with Bisphosphonate
Therapy.
S. Rahgoshay, S. M. Friedman, S. V. Bukata, T. V. Caprio. Division of
Geriatrics and Aging, University of Rochester, Rochester, NY.
BACKGROUND: Hip fractures are important because they are
associated with an increased rate of morbidity, substantial costs, and
overwhelming effects on quality of life. Bisphosphonates(BPPs) are
widely used for treatment of postmenopausal osteoporosis. BPPs
have proven efficacy in reducing the incidence of vertebral and nonvertebral
fractures. Although short term efficacy, safety and tolerability
of these drugs have been documented, an increasing number of recent
case reports suggest that some subtrochanteric hip fractures
might occur in patients who have been treated on a long-term with
BPPs due to suppressed bone turn over.
CASE SUMMARY: A 58 year old female with known osteoporosis
presented to the hospital after hearing an “audible creak”
while going up stairs, followed by a spontaneous right-sided subtrochanteric
hip fracture. Two weeks before the fracture she had prodromal
pain in the right thigh with walking difficulty and came to the
emergency department. Xrays of the right leg and hip did not show
any sign of fracture at that time and she was therefore treated with
analgesics. Five years previously, the patient had started taking alendronate
and after 2 years was switched to zoledronic acid with calcium
and vitamin D. At presentation again to the emergency department
she had severe pain, acute tenderness in the right thigh, and her
lower extremity was shortened with external rotation. The subthrochanteric
fracture was treated with an intramedullary gamma
nail and the patient recovered from surgery successfully. Routine
blood tests; including bone profile, viamin D, thyroid function tests
were normal. She was taken off her BPPs, and was discharged on calcium,
and vitamin D. Outpatient arrangements were made to repeat
her DEXA and to consider an alternative like teraparatide treatment
for osteoporosis.
CONCLUSION:
Bisphosphonates have proven efficacy in reducing the incidence
of vertebral and non-vertebral fractures. The literature suggests the
existence of BPP-related atypical fractures, with unique clinical and
radiographic features in patients on long-term BPP therapy as observed
in this case study. Continued use of BPPs beyond a treatment
period of 3 to 5 years should be reevaluated annually.
A21
A Doggone Cough-an unusual complication of pet ownership-a case
report. Nathan S, Gorbien M, Olson J, Leiding M, Bednarzcyk M.
S. N. Nathan. Department of Geriatric Medicine, Rush University
Medical Center, Chicago, IL.
Purpose: Discuss an unusual health consequence of pet ownership.
Background: Kennel Cough is an infectious tracheobronchitis. It
is a canine respiratory syndrome, often contagious in high density
areas-pet shops, kennels, etc. The most frequent bacterial isolate is
Bordetella bronchiseptica (B.b.)[i]. B.b. is a recognized respiratory
tract pathogen of mammals since 1910. Evidence suggests that it colonizes
human respiratory tract and causes infection in compromised
hosts[ii]. Old age is an immunocompromised state[iii]. Snakes are
also prone to pneumonia, which is contagious between species.This is
an 82 year old woman with Herpes Zoster, URI & systemic symptoms
after her dog was diagnosed with Kennel Cough, after exposure to
the neighbor’s dog. The neighbors illegally bred dogs, snakes & mice.
Method: Case report.
Case Report: Ms. C is an 82 year old woman with Herpes Zoster
seen in clinic for 2-3 days of URI & systemic complaints. The whole
family had been ill for weeks, they think from their dog. The dog was
diagnosed with Kennel Cough. The neighbor would sneak over & try
to get the family’s dog to impregnate his dog. The neighbor had 2 pitbulls
who died 4 weeks prior, whose bodies were dumped in the family’s
garbage. The neighbors also had an illegal snake farm, with 200 of
the snakes dying shortly before this visit.
Discussion: There is benefit to pet ownership in the elderly
[iv][v]. However, pets can transmit illness. This case shows an unusual
situation that put the patient, family & dog at risk for an unexpected
illness.
i J Vet Med Sci Vol 70: 563-569.(2008). “Etiologic Study of
Upper Respiratory Infections of Household Dogs”. Mochizuki M,
Yachi A, Ohshima T, Ohuchi A, Ishida T.
AGS 2012 ANNUAL MEETING
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