- Email: [email protected]
Geriatric Zebras
Geriatric Nursing xx (2015) 1e3
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Daniel Haimowitz
Geriatric Zebras Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, d, *, Daniel Haimowitz, MD, CMD, FACP e, f, g a
Thomas Jefferson University, College of Population Health, Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d AtlantiCare Health Solutions, Egg Harbor Township, NJ, USA e Private Practice, Levittown, PA, USA f Arden Courts of Yardley, PA, USA g Brunswick at Attleboro, Langhorne, PA, USA b c
Every provider has a few examples of rare cases that they have come across during their career; often we refer to these cases as ‘Zebras’ because of their rarity. Because common diseases are much more likely to present in an usual fashion in the elderly than an uncommon disease presenting in its typical manner, health care professionals are taught “When you hear hoof beats, think of horses, not zebras.” Occasionally though in a field of common everyday horses, these Zebras exist, failing to be recognized because we are so very focused on all of the horses that we normally encounter. The best clinician teams are able to identify these rare cases in a timely manner resulting in appropriate treatment and care. These providers are able to better do this by first being open to the very idea that Zebras exist. This seems easy enough but in today’s volume driven world we are often forced to play the odds. This means if you are seeing a patient for cognitive impairment one will diagnosis and treat as likely Alzheimer’s Dementia and if you see a patient with bruising on aspirin it is most likely due to an injury they forgot about. But several of these cases may be something else and in some instances could be a situation that would benefit from immediate action. Nurses involved in assisted care can truly provide assistance by picking up on subtle clues that might help the inter-professional team establish the correct diagnosis sooner, leading to earlier and * Corresponding author. Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA. E-mail addresses: [email protected], [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.11.007
more appropriate treatment. This should be communicated to providers through the use of the SBAR or a similar communication tool. The SBAR improves communication to the health care provider about your residents by describing the Situation of the issue going on, the Background of the issue, the Appearance of the resident (also referring to your Assessment in other settings), and finally your Recommendation. This should include your suggestion of some of the more common geriatric Zebras that may not occur to these physicians without your prompting. Beyond simply being open to the idea, any identification of Zebras requires the knowledge needed to identify these rare sightings. To this end there are actually several geriatric Zebras about which clinicians should be knowledgeable. These include conditions such as normal pressure hydrocephalus (NPH) which often presents as cognitive impairment and therefore can be easily mistaken for Alzheimer’s Disease. Another rare geriatric condition is Acquired Hemophilia A (AHA) which often starts as simple bruising and as such is often not initially diagnosed. A delay here could be life threating. Less rare is alcohol abuse, a condition that is usually not thought about in the elderly. There are some Zebras which come along silently such as Hepatitis C (HCV) and Human immunodeficiency virus (HIV). Early identification of these conditions could improve outcomes but testing and treatment need to be done in an efficient and effective manner requiring ‘balance.’ This is especially critical today as we all are forced to be mindful of our use of resources. Balance requires consideration about ordering expensive testing and referring to specialists when appropriate while holding back on the use of those
2
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing xx (2015) 1e3
resources when they are not needed or are not consistent with a resident’s goals of care. So let’s describe several geriatric Zebras so that you will be better armed with the knowledge to identify these conditions when they appear among your crowded schedule of plain horses.
Geriatric Zebras. Sign/Symptom
Geriatric Zebra
Acute bleeding Cognitive impairment Frequent falls Asymptomatic viral infections
Acquired Hemophilia A (AHA) Normal pressure hydrocephalus (NPH) Alcohol abuse Human immunodeficiency virus (HIV) & Hepatitis C Virus (HCV)
More than a simple bruise Imagine Mr. Johnson an elderly resident of your assisted living community (ALC) on blood thinners asking you about a large bruise he just noticed on his side. Like many times before you would assume this was the result of the combination of his anticoagulant and traumatic fall. But what if instead this bruise was the result of acquired factor VIII inhibitors (acquired hemophilia)?1 Acquired Hemophilia A or AHA is a potentially life threatening cause of acute bleeding in older adults. Because of its rarity, AHA is often not considered in the differential diagnosis. As is the cause with other geriatric Zebras, the failure to recognize AHA can result in delayed initiation of appropriate treatment, and misdiagnosis, with initiation of potentially harmful procedures and/or treatments, can negatively affect patient outcome. AHA is an autoimmune condition characterized by acute bleeding that arises from the development of autoantibodies directed against clotting factors, most commonly factor VIII. This disorder is rare affecting an estimated 0.2e1.0 cases per 1 million persons per year. As a result of its rarity, AHA often goes unrecognized; as a result, the true incidence of acquired hemophilia is likely higher. Older adults are particularly susceptible to AHA as reflected in the higher reported incidence in this age group (14.7/million/year in the older adult population, 85 years of age or older). A typical patient with AHA is an older adult (median age, 77 years) with recent-onset or acute bleeding. Underlying conditions such as autoimmune disorders, respiratory diseases, drug reactions, and malignancy are commonly present, identified in approximately half (or more) of cases of AHA. Testing of the PTT with a noted isolated prolonged activated partial thromboplastin time (PTT) should raise the suspicion of AHA hemophilia because the condition is characterized by a prolonged PTT in the absence of prothrombin time and platelet function abnormalities. But of course if one is not looking for AHA this test may never be ordered. The critical step as with all geriatric Zebras is to consider these rare geriatric diagnoses.
Not always Alzheimer’s disease Just as all bleeding is not the result of poor anticoagulation and a slight fall the same is true that not all memory loss is due to Alzheimer’s disease. Picture an AL resident who has symptoms of increasingly worse gait disorder, incontinence and worst of all memory issues e of course the first thought is that of Alzheimer’s dementia. But it could also be a case of normal pressure hydrocephalus.
The reported incidence of normal pressure hydrocephalus (NPH) has varied in different studies from 2 to 20 per million persons per year so again it is a rare disease. Idiopathic NPH is most common in adults over the age of 60 years and equally common in both sexes. NPH is an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles, or cavities.2 It occurs if the normal flow of CSF throughout the brain and spinal cord is blocked in some way. This causes the ventricles to enlarge, putting pressure on the brain. NPH can occur in people of any age, but it is most common in the elderly. NPH may result from many medical conditions common in older adults such as subarachnoid hemorrhage, head trauma, infection, tumor, or complications of surgery. However, many people develop NPH even when none of these factors are present. In these cases the cause of the disorder is unknown, therefore termed “idiopathic.” Symptoms of NPH include progressive mental impairment and dementia, problems with walking, and impaired bladder control. The person also may have a general slowing of movements or may complain that his or her feet feel “stuck.” Because these symptoms are similar to those of other disorders such as Alzheimer’s disease and the rarity of NPH, the disorder is often misdiagnosed. When considered in the diagnosis, NPH can be correctly identified with simple brain scans (CT and/or MRI). Treatment for NPH involves relatively uncomplicated surgical placement of a shunt in the brain to drain excess CSF into the abdomen where it can be absorbed as part of the normal circulatory process. This allows the brain ventricles to return to their normal size and symptoms to resolve. As a reversible cause of cognitive impairment it is important that NPH not be missed.
Unexpected reason for falling Falls are a common problem in the elderly, with a host of potential causes including poor vision, balance issues, impaired judgment, and effects of medications among many others. It may not be recognized that the real reason in an AL resident might be alcohol abuse. The typical person with alcohol abuse is thought to be younger, but elderly patients may either have already had problems that persist or may develop alcoholism when they are older. As many of the other Zebras, alcohol abuse is under-recognized and underreported. One study reports the incidence in patients older than 65 years as about 2% in men and 0.4% in women.3 The elderly may be particularly prone to the effects of alcohol as aging lowers the body’s tolerance, and there can be interactions from prescription and over-the-counter medications. Alcohol abuse in older persons can show itself in many ways other than falling. This disease can cause cognitive impairment, patients can have nonadherence with doctor’s appointments and with tests and procedures, and there might be difficulties with control of common conditions such as high blood pressure and diabetes. The presence of alcohol abuse can also be detected when a patient develops delirium and withdrawal symptoms (“D.T’s”) during or after a hospitalization. It may be difficult to suspect alcohol abuse in the elderly in AL, since many of the screening questionnaires focus on topics no longer relevant (such as missing work). Often patients aren’t even asked if they drink, and if asked they will downplay the severity of their abuse. Sometimes the issue is discovered when bottles of alcohol are found in a resident’s room coincidentally. Lab work abnormalities may also tip off health care providers about this problem. While treatment can be very difficult, alcohol abuse needs to be identified if there is any chance for AL staff to help residents in the struggle against this challenging illness.
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing xx (2015) 1e3
Silent Zebras There are also silent or stealth geriatric Zebras e these are conditions that not only do we not often consider but what makes these even more difficult is that often there is no outward appearance that they even exist. As a result it is only through screening that these less common conditions can be recognized early and treated. These include such conditions as HIV and HCV. Years ago these may not have been considered geriatric conditions because individuals typically passed away prior to reaching an older age. Today, however, HIV and HCV have become chronic conditions due to improvements in treatments and increasing longevity of older adults making them increasingly common in the spectrum of long-term care. A growing number of people aged 50 and older in the United States are living with HIV infection. People aged 55 and older accounted for about one-quarter (24%, 288,700) of the estimated 1.2 million people living with HIV infection in the United States yet this population is often not thought of and as a result may be living with the disease without their or other’s knowledge.4 As a result older Americans are more likely than younger Americans to be diagnosed with HIV infection late in the course of their disease, meaning a late start to treatment and possibly more damage to their immune system. This can lead to poorer prognoses and shorter survival after an HIV diagnosis. For instance, 98% of people aged 25e29 who were diagnosed with HIV infection during 2004e2009 survived more than 12 months after diagnosis, compared with an estimated 86% of people aged 50e59, 82% of people aged 60e64, and 73% of people aged 65 and older. Late diagnoses can occur because health care providers may not always test older people for HIV infection, and older people may mistake HIV symptoms for those of normal aging and don’t consider HIV as a cause. Late diagnosis in the case of HIV can also have significant negative effects on others. Given that many older Americans are
3
sexually active including those living in ALCs, transmission can occur to partners without anyone’s knowledge. In an effort to improve early diagnosis the CDC is pursuing a High Impact Prevention approach to advance the goals of the National HIV/AIDS Strategy, maximize the effectiveness of current HIV prevention methods, and improve surveillance among older Americans. ALCs can do their part through community based education and screening programs. Another viral infection not often considered is Hepatitis C. Currently the CDC recommends routine HCV screening for all adults between the ages of 50 and 70, even without any risk factors. In addition, HCV testing should be performed on older adults of any age that have ever injected drugs, including those who injected only once many years ago, patients who were ever on long-term hemodialysis, patients with persistently elevated ALT levels and those infected with HIV. Today there are treatments for HCV that while expensive can cure the disease. Left untreated HCV can lead to liver cirrhosis and/or liver cancer which may require a liver transplant. For these reasons, the CDC recommends screening in an effort to lead to early diagnosis and treatment. In the end, while much of what we see every day in our geriatric practices are horses such as Alzheimer’s dementia, hypertension, diabetes, and COPD increasingly we come into contact with Zebras. It is important in our attempts to assist our patients that we recognize these Geriatric Zebras so that they can be guided to appropriate and timely treatment.
References 1. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.02016.x/abstract. 2. http://www.ninds.nih.gov/disorders/normal_pressure_hydrocephalus/normal_ pressure_hydrocephalus.htm. 3. Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 20012002. Drug Alcohol Depend. 2004;74:223e234. 4. http://www.cdc.gov/hiv/group/age/olderamericans/index.html.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Daniel Haimowitz
Geriatric Zebras Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, d, *, Daniel Haimowitz, MD, CMD, FACP e, f, g a
Thomas Jefferson University, College of Population Health, Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d AtlantiCare Health Solutions, Egg Harbor Township, NJ, USA e Private Practice, Levittown, PA, USA f Arden Courts of Yardley, PA, USA g Brunswick at Attleboro, Langhorne, PA, USA b c
Every provider has a few examples of rare cases that they have come across during their career; often we refer to these cases as ‘Zebras’ because of their rarity. Because common diseases are much more likely to present in an usual fashion in the elderly than an uncommon disease presenting in its typical manner, health care professionals are taught “When you hear hoof beats, think of horses, not zebras.” Occasionally though in a field of common everyday horses, these Zebras exist, failing to be recognized because we are so very focused on all of the horses that we normally encounter. The best clinician teams are able to identify these rare cases in a timely manner resulting in appropriate treatment and care. These providers are able to better do this by first being open to the very idea that Zebras exist. This seems easy enough but in today’s volume driven world we are often forced to play the odds. This means if you are seeing a patient for cognitive impairment one will diagnosis and treat as likely Alzheimer’s Dementia and if you see a patient with bruising on aspirin it is most likely due to an injury they forgot about. But several of these cases may be something else and in some instances could be a situation that would benefit from immediate action. Nurses involved in assisted care can truly provide assistance by picking up on subtle clues that might help the inter-professional team establish the correct diagnosis sooner, leading to earlier and * Corresponding author. Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA. E-mail addresses: [email protected], [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.11.007
more appropriate treatment. This should be communicated to providers through the use of the SBAR or a similar communication tool. The SBAR improves communication to the health care provider about your residents by describing the Situation of the issue going on, the Background of the issue, the Appearance of the resident (also referring to your Assessment in other settings), and finally your Recommendation. This should include your suggestion of some of the more common geriatric Zebras that may not occur to these physicians without your prompting. Beyond simply being open to the idea, any identification of Zebras requires the knowledge needed to identify these rare sightings. To this end there are actually several geriatric Zebras about which clinicians should be knowledgeable. These include conditions such as normal pressure hydrocephalus (NPH) which often presents as cognitive impairment and therefore can be easily mistaken for Alzheimer’s Disease. Another rare geriatric condition is Acquired Hemophilia A (AHA) which often starts as simple bruising and as such is often not initially diagnosed. A delay here could be life threating. Less rare is alcohol abuse, a condition that is usually not thought about in the elderly. There are some Zebras which come along silently such as Hepatitis C (HCV) and Human immunodeficiency virus (HIV). Early identification of these conditions could improve outcomes but testing and treatment need to be done in an efficient and effective manner requiring ‘balance.’ This is especially critical today as we all are forced to be mindful of our use of resources. Balance requires consideration about ordering expensive testing and referring to specialists when appropriate while holding back on the use of those
2
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing xx (2015) 1e3
resources when they are not needed or are not consistent with a resident’s goals of care. So let’s describe several geriatric Zebras so that you will be better armed with the knowledge to identify these conditions when they appear among your crowded schedule of plain horses.
Geriatric Zebras. Sign/Symptom
Geriatric Zebra
Acute bleeding Cognitive impairment Frequent falls Asymptomatic viral infections
Acquired Hemophilia A (AHA) Normal pressure hydrocephalus (NPH) Alcohol abuse Human immunodeficiency virus (HIV) & Hepatitis C Virus (HCV)
More than a simple bruise Imagine Mr. Johnson an elderly resident of your assisted living community (ALC) on blood thinners asking you about a large bruise he just noticed on his side. Like many times before you would assume this was the result of the combination of his anticoagulant and traumatic fall. But what if instead this bruise was the result of acquired factor VIII inhibitors (acquired hemophilia)?1 Acquired Hemophilia A or AHA is a potentially life threatening cause of acute bleeding in older adults. Because of its rarity, AHA is often not considered in the differential diagnosis. As is the cause with other geriatric Zebras, the failure to recognize AHA can result in delayed initiation of appropriate treatment, and misdiagnosis, with initiation of potentially harmful procedures and/or treatments, can negatively affect patient outcome. AHA is an autoimmune condition characterized by acute bleeding that arises from the development of autoantibodies directed against clotting factors, most commonly factor VIII. This disorder is rare affecting an estimated 0.2e1.0 cases per 1 million persons per year. As a result of its rarity, AHA often goes unrecognized; as a result, the true incidence of acquired hemophilia is likely higher. Older adults are particularly susceptible to AHA as reflected in the higher reported incidence in this age group (14.7/million/year in the older adult population, 85 years of age or older). A typical patient with AHA is an older adult (median age, 77 years) with recent-onset or acute bleeding. Underlying conditions such as autoimmune disorders, respiratory diseases, drug reactions, and malignancy are commonly present, identified in approximately half (or more) of cases of AHA. Testing of the PTT with a noted isolated prolonged activated partial thromboplastin time (PTT) should raise the suspicion of AHA hemophilia because the condition is characterized by a prolonged PTT in the absence of prothrombin time and platelet function abnormalities. But of course if one is not looking for AHA this test may never be ordered. The critical step as with all geriatric Zebras is to consider these rare geriatric diagnoses.
Not always Alzheimer’s disease Just as all bleeding is not the result of poor anticoagulation and a slight fall the same is true that not all memory loss is due to Alzheimer’s disease. Picture an AL resident who has symptoms of increasingly worse gait disorder, incontinence and worst of all memory issues e of course the first thought is that of Alzheimer’s dementia. But it could also be a case of normal pressure hydrocephalus.
The reported incidence of normal pressure hydrocephalus (NPH) has varied in different studies from 2 to 20 per million persons per year so again it is a rare disease. Idiopathic NPH is most common in adults over the age of 60 years and equally common in both sexes. NPH is an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles, or cavities.2 It occurs if the normal flow of CSF throughout the brain and spinal cord is blocked in some way. This causes the ventricles to enlarge, putting pressure on the brain. NPH can occur in people of any age, but it is most common in the elderly. NPH may result from many medical conditions common in older adults such as subarachnoid hemorrhage, head trauma, infection, tumor, or complications of surgery. However, many people develop NPH even when none of these factors are present. In these cases the cause of the disorder is unknown, therefore termed “idiopathic.” Symptoms of NPH include progressive mental impairment and dementia, problems with walking, and impaired bladder control. The person also may have a general slowing of movements or may complain that his or her feet feel “stuck.” Because these symptoms are similar to those of other disorders such as Alzheimer’s disease and the rarity of NPH, the disorder is often misdiagnosed. When considered in the diagnosis, NPH can be correctly identified with simple brain scans (CT and/or MRI). Treatment for NPH involves relatively uncomplicated surgical placement of a shunt in the brain to drain excess CSF into the abdomen where it can be absorbed as part of the normal circulatory process. This allows the brain ventricles to return to their normal size and symptoms to resolve. As a reversible cause of cognitive impairment it is important that NPH not be missed.
Unexpected reason for falling Falls are a common problem in the elderly, with a host of potential causes including poor vision, balance issues, impaired judgment, and effects of medications among many others. It may not be recognized that the real reason in an AL resident might be alcohol abuse. The typical person with alcohol abuse is thought to be younger, but elderly patients may either have already had problems that persist or may develop alcoholism when they are older. As many of the other Zebras, alcohol abuse is under-recognized and underreported. One study reports the incidence in patients older than 65 years as about 2% in men and 0.4% in women.3 The elderly may be particularly prone to the effects of alcohol as aging lowers the body’s tolerance, and there can be interactions from prescription and over-the-counter medications. Alcohol abuse in older persons can show itself in many ways other than falling. This disease can cause cognitive impairment, patients can have nonadherence with doctor’s appointments and with tests and procedures, and there might be difficulties with control of common conditions such as high blood pressure and diabetes. The presence of alcohol abuse can also be detected when a patient develops delirium and withdrawal symptoms (“D.T’s”) during or after a hospitalization. It may be difficult to suspect alcohol abuse in the elderly in AL, since many of the screening questionnaires focus on topics no longer relevant (such as missing work). Often patients aren’t even asked if they drink, and if asked they will downplay the severity of their abuse. Sometimes the issue is discovered when bottles of alcohol are found in a resident’s room coincidentally. Lab work abnormalities may also tip off health care providers about this problem. While treatment can be very difficult, alcohol abuse needs to be identified if there is any chance for AL staff to help residents in the struggle against this challenging illness.
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing xx (2015) 1e3
Silent Zebras There are also silent or stealth geriatric Zebras e these are conditions that not only do we not often consider but what makes these even more difficult is that often there is no outward appearance that they even exist. As a result it is only through screening that these less common conditions can be recognized early and treated. These include such conditions as HIV and HCV. Years ago these may not have been considered geriatric conditions because individuals typically passed away prior to reaching an older age. Today, however, HIV and HCV have become chronic conditions due to improvements in treatments and increasing longevity of older adults making them increasingly common in the spectrum of long-term care. A growing number of people aged 50 and older in the United States are living with HIV infection. People aged 55 and older accounted for about one-quarter (24%, 288,700) of the estimated 1.2 million people living with HIV infection in the United States yet this population is often not thought of and as a result may be living with the disease without their or other’s knowledge.4 As a result older Americans are more likely than younger Americans to be diagnosed with HIV infection late in the course of their disease, meaning a late start to treatment and possibly more damage to their immune system. This can lead to poorer prognoses and shorter survival after an HIV diagnosis. For instance, 98% of people aged 25e29 who were diagnosed with HIV infection during 2004e2009 survived more than 12 months after diagnosis, compared with an estimated 86% of people aged 50e59, 82% of people aged 60e64, and 73% of people aged 65 and older. Late diagnoses can occur because health care providers may not always test older people for HIV infection, and older people may mistake HIV symptoms for those of normal aging and don’t consider HIV as a cause. Late diagnosis in the case of HIV can also have significant negative effects on others. Given that many older Americans are
3
sexually active including those living in ALCs, transmission can occur to partners without anyone’s knowledge. In an effort to improve early diagnosis the CDC is pursuing a High Impact Prevention approach to advance the goals of the National HIV/AIDS Strategy, maximize the effectiveness of current HIV prevention methods, and improve surveillance among older Americans. ALCs can do their part through community based education and screening programs. Another viral infection not often considered is Hepatitis C. Currently the CDC recommends routine HCV screening for all adults between the ages of 50 and 70, even without any risk factors. In addition, HCV testing should be performed on older adults of any age that have ever injected drugs, including those who injected only once many years ago, patients who were ever on long-term hemodialysis, patients with persistently elevated ALT levels and those infected with HIV. Today there are treatments for HCV that while expensive can cure the disease. Left untreated HCV can lead to liver cirrhosis and/or liver cancer which may require a liver transplant. For these reasons, the CDC recommends screening in an effort to lead to early diagnosis and treatment. In the end, while much of what we see every day in our geriatric practices are horses such as Alzheimer’s dementia, hypertension, diabetes, and COPD increasingly we come into contact with Zebras. It is important in our attempts to assist our patients that we recognize these Geriatric Zebras so that they can be guided to appropriate and timely treatment.
References 1. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.02016.x/abstract. 2. http://www.ninds.nih.gov/disorders/normal_pressure_hydrocephalus/normal_ pressure_hydrocephalus.htm. 3. Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 20012002. Drug Alcohol Depend. 2004;74:223e234. 4. http://www.cdc.gov/hiv/group/age/olderamericans/index.html.