GetMeOuttaThisMess Posted June 17, 2018 Share Posted June 17, 2018 You have a late 80's female in a hybrid ECF/residential home. Pt. PMH includes AF with RVR in past (hospitalized a year ago x 1 week for same secondary to renal lithiasis), hypothyroidism, hypercholesterolemia, and a muscular disorder which is classified as a variant of MD. This disorder not only affects proximal LE muscles and distal UE muscles but also smooth muscle. Pt. is moved from bed to wheelchair, or placed in a shower by using a Hoyer lift device. Pt. hasn't been ambulatory for about 5 years. Meds are a beta-blocker, PPI for suspected GERD, and levothyroxine. Staff from a separate company facility comes in and instead of using Hoyer says that they can lift the patient without being aware of patient's history. When attempting to do so by raising patient by lifting under the arms the patient screams loudly and complains of CWP on left side. Subsequent portable CXR shows a non-displaced 5th rib fx. on the left and the pt. is reasonably comfortable and is able to maneuver the wheelchair to get around. Pt.'s PCP at residence recommends placing the patient on a bisphosphonate orally since injectable won't be covered by Medicare B. Go get them cowboys! What comes to mind here on several fronts? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 18, 2018 Author Share Posted June 18, 2018 All you IM/FM/Gerontology folks, if you don't at least have some concerns here I'm really worried about you. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 18, 2018 Moderator Share Posted June 18, 2018 ugh inhumane care is what comes to mind overall med simplification is needed get rid of everything that is absolutely not essential honest discussion with she and the HCP about goals consider reporting the person whom broke her rib - might or might not have been high energy injury needs a provider that will slow down and listen and be their advocate As for the injection - ah no - especially en-light of the most recent data..... CMO is the rule Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 18, 2018 Author Share Posted June 18, 2018 Any issues with PMH and initiation of biphos? Link to comment Share on other sites More sharing options...
vb315 Posted June 18, 2018 Share Posted June 18, 2018 3 hours ago, GetMeOuttaThisMess said: Any issues with PMH and initiation of biphos? Well she has a variant of MD that affects smooth muscle, such as in the esophagus, so it's probably not a good idea for her to take bisphosphonates orally. Plus, she might not be able to sit/stand upright without help. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 18, 2018 Author Share Posted June 18, 2018 Good point. Esophagitis is a known complication of therapy so based on this alone risk/reward needs to be significantly pondered. Anything even bigger than esophagitis a concern in this patient which in my book is a deal breaker? Link to comment Share on other sites More sharing options...
vb315 Posted June 18, 2018 Share Posted June 18, 2018 12 minutes ago, GetMeOuttaThisMess said: Good point. Esophagitis is a known complication of therapy so based on this alone risk/reward needs to be significantly pondered. Anything even bigger than esophagitis a concern in this patient which in my book is a deal breaker? Her aFib? Would the decrease in serum calcium put her at higher risk for a serious arrythmia? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 18, 2018 Author Share Posted June 18, 2018 Bingo! A fib is a significant risk with therapy initiation in older individuals. Which is worse? Fx risk from moving location in a Hoyer or esophagitis/AF w/ RVR? Link to comment Share on other sites More sharing options...
kidpresentable Posted June 18, 2018 Share Posted June 18, 2018 Well, if she fractures them heart bones... Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 18, 2018 Moderator Share Posted June 18, 2018 tough call my informal rule of 50's for elderly hip fracture is 50% done leave hospital, of those 50% don't leave the nursing home... with 50% death rate Afib is the devil we know and can manage - and in it self is not fatal hip fx is the unknown - 50% occur in people with out osteoporosis - can can be fatal (and with a possible low energy bony fracture that might be real - what is her T score - more on that below) So I do not see this as an absolute contraindication, but instead one that takes talking to the patient. Good cardio look, risk benefit assessment and what is the patient afraid of? Sometimes that last question is the one that holds the answer - some patients are scared to death of a stroke and will do anything to avoid, others are afraid of bony fractures..... seems to be coordinated to what the have personally seen as a loved one's demise So yes a great point, and goes back to the point that overall patients need to be educated. Also goes to the providers (and legal professions) desire to do something to maybe help then to do nothing and let mother nature determine things.... As a final question what do people think about the new data showing Vit D and Ca might not be of benefit???? Course then we have a Hx of renal stones so what should the Ca++ recommendation be??? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 18, 2018 Author Share Posted June 18, 2018 Pt. took a hit to the noggin while hospitalized with RVR from Afib a year ago due to poor perfusion. Pt. has no recollection of hospital stay. While nothing is impossible, unless she falls out of bed it's going to be hard to fracture the hip. No dexa since transportation has been limited for years. At this stage, though mental faculties are appropriate, if not better than, what one would expect at age 88, she is at a comfort care state. Link to comment Share on other sites More sharing options...
cbrsmurf Posted June 19, 2018 Share Posted June 19, 2018 Why would you give an immobile 88 year old a biphos? She can't actually fall unless someone pushes her off the bed. Plus, life expectancy. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 19, 2018 Moderator Share Posted June 19, 2018 because we can..... not because we should... read some of the data coming out about polypharmacy in the elderly and the problems with hospitalists service starting to many meds and the simple picture is the PCP has lost the ability to advocate for their patients.... sad Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 19, 2018 Author Share Posted June 19, 2018 Lost some respect for this PCP. Either you don’t appreciate the risks or you don’t take into consideration the overall picture. Link to comment Share on other sites More sharing options...
Rondaben Posted June 19, 2018 Share Posted June 19, 2018 Still in didactic but the esophogeal issues screams pill esophagitis to me. Link to comment Share on other sites More sharing options...
karebear12892 Posted June 19, 2018 Share Posted June 19, 2018 Not my area of expertise but I do recall PPI's can cause and/or worsen osteoporosis with prolonged use due to interference with vitamin absorption. Perhaps consider evaluating whether the patient really needs to be on this medicine or if it can be replaced with H2 blocker and/or Carafate. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 19, 2018 Author Share Posted June 19, 2018 7 hours ago, karebear12892 said: Not my area of expertise but I do recall PPI's can cause and/or worsen osteoporosis with prolonged use due to interference with vitamin absorption. Perhaps consider evaluating whether the patient really needs to be on this medicine or if it can be replaced with H2 blocker and/or Carafate. I wonder about these things as well. Why use a PPI when one could just as easily use an H2 inhibitor and avoid the risk? No need to eat 30" afterward either. Link to comment Share on other sites More sharing options...
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