American Academy of Family Physicians 2012 Annual Scientific Meeting

October 16-20, 2012; Philadelphia, PA
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EDUCATIONAL SESSIONS

Osteoporotic Fractures are Preventable With Patient Education and Clinical Vigilance

In the United States, the estimated cost of osteoporotic fractures is $20 billion. Approximately one in three women and one in five men over the age of 50 years experience osteoporotic fractures, the most common of which occur at the hip, spine, wrist, humerus, and pelvis. Older adults with osteoporosis are more susceptible to fracture because of low bone mass, microarchitecture deterioration, and bone fragility. When a fall results in an osteoporotic fracture, especially of the hip, the consequences can be severe. Hip fractures are known to increase the risks for dependence in activities of daily living, for becoming nonambulatory, and for requiring long-term care placement. It is also estimated that as many as 20% of patients admitted with an acute fracture die within 6 months. However, fragilty fractures are not necessarily unavoidable outcomes of aging. In a session at the AAFP scientific assembly, Rajwinder Deu, MD, clinical assistant professor, Thomas Jefferson University Hospitals, Philadelphia, PA, reviewed the measures that older adults can take to prevent osteoporosis, discussed the pharmacological and nonpharmacological approaches to reducing bone loss and falls, and emphasized the clinician’s role in patient care.

An awareness of the risk factors, as defined by the World Health Organization (WHO), and appropriate use of screening tools are vital in the primary goal of preventing bone loss. These risk factors include history of fragility fracture, use of glucocorticoids, parental history of fracture, comorbidities, smoking, excessive alcohol use, and low body weight (body mass index <19 kg/m²). In women aged 50 to 64 years and in men aged 50 to 69 years with these clinical risk factors, a bone mineral density (BMD) test is recommended. This test compares the patient’s BMD to an established norm. Introduced by the WHO in 2008, the Fracture Risk Assessment (FRAX) is a validated tool that uses femoral neck BMD and clinical risk factors to estimate the 10-year probability of hip fracture or major osteoporotic fractures combined for an untreated patient. Deu noted that easy administration of FRAX can be done online (www.shef.ac.uk/FRAX) or via an iPhone application. Deu advised that FRAX does not replace sound clinical judgment, as it may only be used in untreated patients and does not take into account dose-response relationships.

If bone loss has begun, the secondary and tertiary goals are to inhibit further bone loss, to treat patients who have existing fractures, and to prevent falls that may cause future fractures. Simple lifestyle changes can be made to aid in these goals. Calcium with vitamin D in older adults is correlated with risk reduction of falls and hip fracture. Most guidelines recommend 400 IU of vitamin D daily for adults aged 70 years and older, Deu explained, and older adults with existing
osteoporosis are advised to take higher doses (600 to 800 IU). When taken alone, calcium has not been shown to reduce hip fractures, but it may improve hip bone density. Patients should be advised that smoking and excessive consumption of alcohol (defined by the WHO as >2 units per day) is associated with significant increase in fracture risk. Fall risk can be reduced with regular weight-bearing exercise (defined as 30 minutes three times per week) to maintain bone density and improve muscle mass and balance. Removing environmental hazards that may cause falls is also advised, however, a Cochrane Review found that reducing home safety hazards was most likely to prevent falls in high-risk populations only (eg, adults with severe vision impairment).

Clinicians should be cautious of side effects when taking a pharmacological approach toward preventing or treating bone loss. Polypharmacy in older adults should be well documented, and medication lists should be reviewed with patients at each clinical visit. Bisphosphonates have been considered front-line therapy, as they have been shown to inhibit the loss of bone mass and reduce the risk of fracture at clinically important sites in persons with osteoporosis. Recently, however, bisphosphonates have been associated with increased risk of atypical femoral fractures. Thus, continued use of bisphosphonates beyond a treatment period of 3 to 5 years should be reevaluated annually, and radiographic imaging may be warranted in patients who have femoral pain. Estrogen therapy is recommended in postmenopausal women, as estrogen deficiency is associated with rapid loss of BMD and increased fracture risk. Raloxifene, a selective estrogen receptor modulator, may help prevent and treat osteoporosis in postmenopausal women, yet the drug has been associated with increased risk of deep venous thrombosis and pulmonary embolism. Venous thromboembolic events are also associated with hormone replacement therapy, which may reduce the risk of vertebral and nonvertebral fractures in older women.

Alternative therapies include strontium ranelate, which has been shown to reduce the risk of nonvertebral fracture risk by 16%, and subcutaneous injections of human parathyroid hormone (PTH). PTH has been shown to exert anabolic effects, leading to an increased number of osteoblasts and increased bone formation, yet no significant effect on the risk of nonvertebral fractures has been observed.—Allison Musante
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Diagnosing and Managing Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is considered to be a preventable and treatable lung disease that is characterized by persistent limitation in airflow that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to gases or noxious particles. According to the World Health Organization, COPD is currently the fifth leading cause of death worldwide, but it projects that this disease will become the third leading cause of death by 2030. This is because of continued exposure to COPD risk factors and the aging of the world’s population, said Barbara Yawn, MD, adjunct professor, Department of Family and Community Health, University of Minnesota, Rochester, MN, at the AAFP scientific assembly. Yawn’s session provided attendees with an overview of the diagnosis and management of COPD, a debilitating condition that poses a significant economic burden.

There are numerous risk factors that predispose patients to COPD, said Yawn, including age (most patients are aged ≥40 years), exposure to cigarette smoke (including secondhand smoke), occupational exposure to dust and chemicals, exposure to indoor and outdoor pollutants, and genetic factors (particularly alpha-1-antitrypsin deficiency). Diagnosis requires physicians to consider patients’ exposure to risk factors and their symptoms, which typically include persistent shortness of breath that is worse with exercise, chronic cough that may be intermittent and nonproductive, and chronic sputum production that is often coughed up. If the risk factors and symptoms point to COPD, spirometry should be undertaken to confirm the diagnosis, advised Yawn.

Spirometry is a commonly performed pulmonary function test that assesses how much air enters and exits the lungs. To minimize variability in the test, Yawn noted that spirometry should be undertaken after the administration of an adequate dose of a short-acting inhaled bronchodilator. A post-bronchodilator FEV₁ (forced expiratory volume in 1 second)/FVC (forced vital capacity) below 0.70 confirms airflow limitation, she said, but noted that patients’ values should be compared with age-related normal values to prevent the condition from being over diagnosed, particularly among elders. Once a diagnosis of COPD is established, spirometry is useful for monitoring disease progression. Yawn noted that changes are often seen earlier in spirometry than through the use of many other respiratory parameters, including arterial blood gas measurements and chest radiographs.

There are multiple therapeutic options for patients with COPD, including lifestyle changes, pharmacotherapies, immunizations, oxygen therapy, and ventilatory support. Patients with COPD who are smokers should be strongly encouraged to quit, as “smoking cessation has the greatest capacity to influence the natural history of COPD,” said Yawn. All COPD patients should be advised to minimize their exposure to pollutants and to engage in regular physical activity, making sure to monitor public announcements regarding air quality to avoid exercising outdoors or spending long stints outside during pollution episodes. Air pollutants inside the home should also be minimized, which can be achieved by ensuring proper ventilation. Immunizations are another key protective measure, said Yawn, as they can help protect against respiratory infections, which exacerbate symptoms and can be difficult to recover from. Pneumococcal polysaccharide vaccine is recommended for COPD patients who are aged 65 years and older and for those with an FEV₁ below 40% of the predicted value.

Pharmaceutical treatments for COPD include beta2-agonists, anticholinergics, methylxanthines, inhaled corticosteroids, systemic corticosteroids, phosphodiesterase-4 inhibitors, and combination inhalers (eg, beta2-agonists combined with an anticholinergic or a corticosteroid). When considering a bronchodilator, Yawn noted that long-acting formulations are convenient and more effective for symptom relief than short-acting formulations, but that combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared with increasing the dose of a single bronchodilator. Patients with an FEV₁ below 60% of the predicted value may benefit from the use of inhaled corticosteroids, but this therapy has been associated with an increase risk of pneumonia and withdrawal from treatment has caused exacerbations in some patients. The phosphodiesterase-4 inhibitor, roflumilast, can be considered for individuals with severe and very severe COPD and a history of exacerbations and chronic bronchitis, said Yawn. She noted that this agent has been shown to reduce exacerbations treated with oral glucocorticosteroids. 

Oxygen therapy and ventilatory support can be beneficial in more severe COPD cases. Oxygen therapy, which consists of the long-term administration of oxygen for more than 15 hours per day, has been shown to increase survival in patients with chronic respiratory failure and severe resting hypoxemia. It can also be a useful treatment option for an exacerbation. In such cases, oxygen can be titrated to improve the patient’s hypoxemia to achieve a target saturation of 88% to 92%, said Yawn. A small subset of patients, particularly those with pronounced daytime hypercapnia, may benefit from the addition of ventilatory support to their oxygen therapy regimen. In concluding the session, Yawn provided attendees with five must-haves for COPD: spirometry, smoking cessation, pulmonary rehabilitation, pharmacotherapy, and assessment and therapy of comorbidities.—Christina T. Loguidice
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Managing Eye Injuries and Conditions in Elders

According to a recent study by researchers at Boston University School of Medicine, elders represent a “unique, yet neglected ocular trauma population” (www.ncbi.nlm.nih.gov/pubmed/20709403). Because geriatric patients are more susceptible to ophthalmic problems due to the effects of aging and comorbidities, it is important for clinicians to be prepared when elders develop eye emergencies. In a scientific session at the AAFP scientific assembly, Daniel Freed, MD, family medicine practitioner, Lynchburg, VA, discussed the importance of timely physical examinations to determine the nature of eye emergencies when patients sustain such injuries and reviewed when clinicians should refer patients to an ophthalmologist or other subspecialist. Freed introduced the nature of eye emergencies as being especially “scary” to patients, caregivers, and physicians, yet these injuries are often preventable and only occasionally severe. Freed continued his presentation with a discussion of some common acute eye problems and their diagnostic and treatment approaches.

A globe rupture refers to a full-thickness corneal and/or scleral injury caused by a blunt or penetrating mechanism, such as a foreign body. Although this condition is most frequently seen in younger men, likely due to recreational and occupational hazards, it is also seen in older persons who experience blunt trauma as a result of falls (www.ncbi.nlm.nih.gov/pubmed/16096559). To diagnose globe rupture, Freed recommended performing a visual acuity test, examining the pupil for defects, and undertaking fluorescein angiography. Treatment options include shielding the eye, pain control, infection management, and ophthalmology referral to assess for further damage and arrange for surgical removal of a foreign body, if necessary.

Corneal abrasion is another common and painful condition seen among all ages and can result from a multitude of causes, including being poked in the eye, having foreign matter blow into the eye, aggressively rubbing the eye, and using dirty contact lenses. A visual acuity test, which may require the use of anesthesia, and fluorescein staining with a cobalt filter or a slit lamp may be used to diagnose corneal abrasion. In cases of minor corneal abrasions, which tend to heal on their own, analgesia, topical antibiotics, and follow-up vision checks are advised. Deep corneal injury should be referred to an ophthalmologist or subspecialtist.

Acute angle-closure glaucoma, a condition marked by elevated intraocular pressure due to a blocked anterior chamber angle, is frequently seen in older persons and has been associated with medications and diabetes. Patients may report severe eye pain, blurry vision, and nausea. Conjunctival infection, corneal edema, and nonreactive pupil may also be observed. Visual acuity, pachymetry, tonometry, and other tests are advised to determine the diagnosis. As with other forms of glaucoma, the goal of treatment is to lower intraocular pressure, which may require referral to an ophthalmologist for appropriate prescribing of medication, or for surgical intervention, if necessary.

Retinal artery occlusion is another condition more likely to present in older persons due to comorbidities (ie, carotid artery disease, diabetes, atrial fibrillation, hyperlipidemia, and hypertension). When a retinal artery is blocked, depriving it of oxygen and blood, sudden onset of blurry vision may occur. To diagnosis this condition, clinicians can administer a visual acuity or visual field test, conduct a pupil examination, perform ophthalmoscopy, and undertake an embolic work-up. Once a diagnosis is reached, immediate referral to an ophthalmologist is advised.

Freed concluded that eye injuries are often preventable if patients exercise caution in their daily activities and visit their primary care provider regularly to assess changes in vision. Most of the conditions can be managed in the primary care setting with diagnostic testing and referral to specialty consultation when needed.—Allison Musante