375

Dupuytren’s Contracture

SPECIFIC ENTITIES

HYPERTROPHIC OSTEOARTHROPATHY clubbing
and periarticular pain and swelling, most often affect
ing the wrists, ankles, and knees. Associated with
bronchogenic cancer, chronic pulmonary infections,
cystic fibrosis, and cyanotic congenital heart disease

Related Topics
Celiac Disease (p. 124)
Inflammatory Bowel Disease (p. 120)
Lung Cancer (p. 185)

Dupuytren’s Contracture
DIFFERENTIAL DIAGNOSIS

DIABETIC CHEIROARTHROPATHY (usually all four
fingers)
INTRINSIC JOINT DISEASE
DUPUYTREN’S CONTRACTURE
VOLKMANN’S ISCHEMIC CONTRACTURE
TRAUMATIC SCARS
PALMAR
FASCIITIS malignancy
(usually
bilateral)
PATHOPHYSIOLOGY

RISK FACTORS alcoholism, smoking, diabetes,
repetitive hand motions/vibrations, reflex sympa
thetic dystrophy
4 STAGES progressive fibrosis of the palmar fascia
! nodules form on the palmar fascia ! flexion
deformity ! fibrosis of dermis leads to skin
thickening

CLINICAL FEATURES

HISTORY finger stiffness (duration, pain, function),
past medical history (alcohol, diabetes, smoking, HIV),
occupational history
PHYSICAL most commonly involves the fourth and
fifth digits. Triangular puckering of the dermal tissue
over the flexor tendon just proximal to the flexor crease
of the finger (earliest sign), skin blanching on active
finger extension, palpable and visible nodules along
flexor tendons, mild tenderness over nodules, fixed
flexion contractures, reduced range of motion, tender
knuckle pads over the dorsal aspect of the PIP joints
MANAGEMENT

SYMPTOM CONTROL padded gloves, stretching
exercises for mild disease. Triamcinolone or lidocaine
injection for moderate disease. Surgery or radiation
for severe disease



376

Notes

Notes


13
GERIATRICS
Section Editor: Dr. Fiona Lawson
Geriatric-Specific Issues
THE FRAIL ELDERLY

THE CONCEPT OF FRAILTY frailty is a ‘‘weakened’’
or ‘‘precarious’’ state resulting in heightened suscept
ibility to stressors. While no standard definition for
frailty exists, it is associated with (1) limited function,
(2) multiple medical conditions, and (3) one of the
geriatric syndromes (dementia, delirium, depression,
falls !1 per month, osteoporosis, failure to thrive, and
urinary incontinence). Frailty predisposes patients to
functional and cognitive decline, particularly in the
presence of precipitants/stressors. While age can be a
factor in choosing treatments due to altered pharma
cokinetics, frailty is a more important treatment mod
ifying factor. In general, less aggressive (and some
times more palliative) treatments are offered to frail
patients. Clinical outcomes for frail seniors can be
improved with various interventions, such as compre
hensive geriatric assessment and exercise programs

POTENTIAL PRECIPITANTS acute illness, infec
tions, infarction, medications, social stress, environ
mental changes, and surgical intervention. Patients
with frailty are at higher risk of complications, such as
increased mortality, morbidity, and rates of institutio
nalization when faced with these precipitants
COMPREHENSIVE GERIATRICS ASSESSMENT

In addition to a focused history and physical, special
attention should be paid to the following domains,
which provide important information for the geriatric
assessment:
FUNCTIONAL HISTORY activities of daily living (ADLs,
dressing, bathing, eating, hygiene, toileting, mobility),
instrumental activities of daily living (IADLs, transporta
tion, shopping, phoning, laundry, cooking, accounting,
housekeeping, medications), falls (number, causes, frac
tures), mobility prior to admission (how many steps)
GERIATRIC SYNDROMES/GIANTS presence/absence
and severity of dementia, delirium, depression, falls
(!1/month), osteoporosis with spontaneous fractures,
neglect and abuse, failure to thrive, incontinence
COMORBID CONDITIONS in addition to the geria
tric syndromes, inquire about the number and

COMPREHENSIVE GERIATRICS ASSESSMENT (CONT’D)

severity of co existing diseases that are either life
threatening or function limiting
POLYPHARMACY number of medications, poten

tial medications that can cause delirium and other
significant side effects, adherence, assistance with
medications, drug interactions (p. 385)
NUTRITION RISK dietary intake, calorie intake
SOCIAL HISTORY living situation, education, work,
family, caregivers at home, financial stability, access
to transportation, personal directives
COGNITIVE EXAMINATION mini mental status
exam, clock face drawing, dementia (apraxia; aphasia;
agnosia; abstraction similarities, proverb; executive
safety situational questions), CAM score (see DELIRIUM
p. 380), language (4 legged animals in 1 min. Abnormal
<12), frontal assessment battery (abnormal <13), EXIT,
cognistat
FUNCTIONAL EXAMINATION timed up and go test
(subjects asked to rise from chair, walk 10 ft, turn and
return to chair; <20 s correlates with independence in
ADLs, >20 s abnormal), Tinetti’s gait assessment (score
<20/28 predictive of recurrent falls)
COMPREHENSIVE GERIATRIC MANAGEMENT

INTERPROFESSIONAL TEAMS often require inter
disciplinary teams consisting of geriatricians, nurses,
social workers, physiotherapists, occupational
therapists, pharmacists, registered dieticians,
speech language therapists, recreational therapists,
psychologists, and family

Discipline
Dieticians

Nurses
Occupational
therapists
Pharmacists
Physiotherapists

D. Hui, Approach to Internal Medicine, DOI 10.1007/978 1 4419 6505 9 13,
Ó Springer ScienceỵBusiness Media, LLC 2006, 2007, 2011

Task
Nutrition and diet
Education and assistance with
ADLs, IADLs
Cognitive and functional
assessments, ADL training
Medication use
Training to " ROM, strength,
endurance, coordination,
mobility

377


378

Dementia and Cognitive Impairment

COMPREHENSIVE GERIATRIC MANAGEMENT (CONT’D)

Discipline

Recreational
therapists
Social workers

Speech
language
therapists

Task
Maintenance of social roles
Counseling, evaluation, and
disposition within
community
Training in communication and
therapy for swallowing
disorders

HEALTH CARE AND FINANCIAL PROXY

ADVANCE DIRECTIVE (living will) a document that
is created when patient is competent. Allows direc
tion of their care in future (e.g. regarding tube feed
ing, resuscitation status) when they are no longer
capable of expressing their own wishes
PERSONAL DIRECTIVE agent assigned when
patient competent so that if they become incompe
tent, agent can act on patient’s behalf regarding
decisions for personal care and accommodation
POWER OF ATTORNEY agent assigned when
patient competent so that if they become incom


HEALTH CARE AND FINANCIAL PROXY (CONT’D)

petent, agent can act on patient’s behalf regarding
finances
GUARDIANSHIP created when patient is incompe
tent and personal directive not available. Guardian
assists with decisions regarding personal care and
accommodation
TRUSTEESHIP created when patient is incompe
tent and power of attorney not available. Trustee
assists with finances
COMPETENCY ASSESSMENT

ENSURE IT IS NECESSARY suspect incapacity, risk,
undue influence
DIAGNOSED PHYSICAL/MENTAL ILLNESS chronic
vs. acute
OBTAIN RELEVANT COLLATERAL INFORMATION
reliable? Ask what concerns them (ADLs, financial)
PERFORM FORMAL TESTING ask patient details
about ADLs, finances, medical condition, living will. Are
they consistent in their choices? Do they understand and
appreciate the consequences of their actions?
INFORM AND ACT

Dementia and Cognitive Impairment
DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS (CONT’D)


PRIMARY PROGRESSIVE DEMENTIA
 ALZHEIMER’S slow insidious cognitive decline
but otherwise no physical findings, mini mental
status examination globally low, CT may show
white matter change, mostly a diagnosis of
exclusion, but accounting for 60% of dementias
 VASCULAR acute stepwise or slow progressive
decline, focal neurological deficits, mini mental
status examination patchy, CT may show white
matter change, pure vascular dementia uncom
mon, more frequently occurs with Alzheimer’s
like dementia (mixed vascular)
 PARKINSON’S Parkinsonian symptoms for a
long time, slow decline, Parkinson’s patients
have 6Â increased risk for dementia
 LEWY BODY Parkinsonism, persistent visual hal
lucinations, progressive decline, fluctuating cog
nition especially attention/alertness, marked
adverse hypersensitivity to typical antipsychotic
medications, supportive features include syn
cope, delusions, and sleep disturbance
 FRONTOTEMPORAL prominent impairment in exe
cutive function, disinhibited or passive presenta
tion, impaired judgment, significant social indif
ference, declining hygiene, prominent language

deficits but amnesia less noticeable early on, early
primitive reflexes/incontinence, late akinesia/
rigidity/tremor, MMSE may be normal, abnormal

clock drawing, CT frontal temporal atrophy
 PRION DISEASE Creutzfeldt Jakob disease
POTENTIALLY REVERSIBLE DEMENTIA (<1%)
 METABOLIC alcoholism, vitamin B12, hypo
thyroidism
 STRUCTURAL NPH, subdural hemorrhage, neo
plastic, vascular
 INFECTIONS chronic meningitis, HIV, neurosy
philis, Whipple’s
 INFLAMMATORY vasculitis, Hashimoto encepha
litis, multiple sclerosis
DEMENTIA MIMICS depression, delirium, develop
mental disorder, age associated memory impairment
PATHOPHYSIOLOGY

DEMENTIA acquired, progressive, global decline in
cognition resulting in impairment in function. Learn
ing and memory impairment are present, plus !1 of
the following: aphasia, agnosia, apraxia, impairment
of executive function. Deficits result in impaired func
tion. Disorientation and impairment in regulation of
emotion and aggression may also be present


379

Dementia and Cognitive Impairment

PATHOPHYSIOLOGY (CONT’D)


PATHOPHYSIOLOGY (CONT’D)

MILD COGNITIVE IMPAIRMENT predominant
memory complaints with other cognitive domains
largely intact and preservation of functional

independence; 10 15% of patients progress to Alz
heimer’s annually

CLINICAL FEATURES

DISTINGUISHING FEATURES BETWEEN VARIOUS TYPES OF DEMENTIA
Vascular
Alzheimer’s
Physical findings
Relatively normal
Focal neurological deficits
MMSE

Globally low

CT

White matter changes

Patchy changes
Early executive loss
White matter changes

Frontal temporal atrophy


CLINICAL FEATURES (CONT’D)

Related Topics
Delirium (p. 380)
Parkinson’s disease (p. 320)
Stroke (p. 299)
Vitamin B12 deficiency (p. 405)

Cambridge Cognitive Examination, Modified Mini
Mental State Examination, Community Screening
Interview for Dementia, or the Montreal Cognitive
Assessment’’
JAMA 2007 297:21

CLINICAL FEATURES (CONT’D)

INVESTIGATIONS

RATIONAL CLINICAL EXAMINATION SERIES:
DOES THIS PATIENT HAVE DEMENTIA?
MINI MENTAL STATE EXAMINATION (MMSE)
orientation to place (5), time (5), immediate and
delayed recall (6), spell ‘WORLD’’ backward (5), 3
step commend (3), name 2 objects (2), close your
eyes (1), repeat sentence ‘No, if’s, and’s, or but’s’’
(1), write a sentence (1), intersecting pentagons (1).
Maximum score is 30, generally <24 is impaired
but varies with education and age
MEMORY IMPAIRMENT SCREEN recall four

objects (an animal, a city, a vegetable, and a musi
cal instrument). Two points for free recall of each
object and one point if prompting needed (‘‘Tell me
the name of the city.’’). Maximum score is 8. Takes
4 min

BASIC

SELECTED TOOLS
MMSE
Reports from an informant
that the patient has
memory loss
Memory impairment
screen
Clock drawings

Fronto temporal
Disinhibited or passive
Primitive reflexes
Early executive loss

LR+
6.3
6.5

LR
0.19

33


0.08

1.2 7.7

0.13 0.710

APPROACH ‘ to detect cognitive impairment of at
least moderate severity, consider the mini mental
state examination. The Hopkins Verbal Learning Test
or the Word List Acquisition Test may be used to
screen for mild impairment in highly educated
patient. If very little time is available, consider the
Memory Impairment Screen or the Clock Drawing
Test. If plenty of time is available, consider the

CBCD, lytes, creatinine, glucose, Ca, TSH,
vitamin B12
 IMAGING head CT
SPECIAL
 FURTHER DEMENTIA WORKUP AST, ALT, ALP, bilir
ubin, RBC folate, VDRL, HIV serology, urine collec
tion for heavy metals
 LABS

DIAGNOSTIC ISSUES

DSM IV CRITERIA FOR DEMENTIA
A. Short term memory loss
B. One of agnosia, aphasia, apraxia, executive dys

function (abstraction, planning)
C. Functional/social decline
D. Rule out depression or delirium
MINI MENTAL STATE EXAMINATION (MMSE)
adjusted based on age and education. An abnormal
test may indicate the presence of dementia, delirium,
or depression. Traditional threshold for MMSE 23
suggests dementia (LR+ 6 8) in the absence of delir
ium. Newer thresholds: 20 rules in dementia (LR+
14.5, sens 39 69%, spc 93 99%), !26 rules out
dementia (LR+ 0.1), 21 25 inconclusive (LR+ 2.2)
HACHINSKI ISCHEMIC SCORE
 SCORING abrupt onset (2), stepwise progression
(1), fluctuating course (2), nocturnal confusion (1),
relative preservation of personality (1), depression
(1), somatic complaints (1), emotional inconti
nence (1), history of hypertension (1), history of
strokes (2), evidence of associated atherosclerosis
(1), focal neurological symptoms (2), focal neuro
logical signs (2)