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ENDOCRINE DISORDERS in the ELDERLY - PAGETS DISEASE and ADRENAL DISEASES PowerPoint Presentation

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Slide 1-

ENDOCRINE DISORDERS in the ELDERLY Module #2 PAGETS DISEASE & ADRENAL DISEASES Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu Updated 11-18-06
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PROCESS A series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break
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OBJECTIVES: Upon completion, the learner will be able to: Describe the evaluation and treatment of hypoadrenocorticalism in the elderly 2) Describe the evaluation and treatment of hyperadrenocorticalism in the elderly 3) List the evaluation and treatment of Pagets’ disease
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AGING and the ADRENAL No significant change with aging Delay testing for 48 hrs after stress. When in doubt consult
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HYPOADRENOCORTICALISM Common Causes: Chronic glucocorticoid administration…………..Most common Pituitary tumors Tuberculosis Autoimmune Less common: Adrenal hemorrhage (in anticoagulated) Adrenal metastases
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SYMPTOMS SYMPTOMS (for all types) Anorexia Weight loss Nausea Fatigue Impaired functional status Hyponatremia Orthostatic hypotension Primary adrenal failure only Hyperkalemia Hyperpigmentation
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PREVENTION PREVENTION Taper off chronic corticosteroid therapy SLOWLY In chronic steroid patients Stress dose coverage -major surgery -acute physiologic stresses
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Evaluation (1) One of the following criteria: Basal plasma cortisol >15 μg/dL excludes adrenal insufficiency “Short” Cortrosyn stimulation test: -Cosyntropin 250 mcg IV/IM -Plasma cortisol 30 minutes after Cortrosyn Normal: if plasma cortisol > 20 mcg/dl
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Management of adrenal insufficiency Stress doses of corticosteroids Emergency situations do not wait for test results. Give hydrocortisone 100 mg IV q 8 h. For less severe stress -Double or triple usual oral replacement or -Prednisone 20 mg a day -Then taper back to baseline as quickly as possible.
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HYPERADRENOCORTICALISM
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HYPERADRENOCORTICALISM CAUSES Exogenous glucocorticoids. ……...most common ACTH secreting pituitary microadenoma Adrenal tumors Ectopic ACTH secreting tumors Photos used with permission Images.MD, accessed 2-18-06
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SYMPTOMS Cushionoid symptoms -truncal obesity -hypertension -hirsutism Psychiatric ( depression or mania) Cognitive symptoms Osteoporosis Myopathy Glucose intolerance Hypokalemia Photos used with permission Images.MD, accessed 2-18-06
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EVALUATION Screen with Dexamethasone suppression test -1 mg dexamethsone at 11 pm - plasma cortisol 8 am next day Normal: if plasma cortisol < 2 mcg/dl If positive: refer for evaluation
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CHRONIC GLUCOCORTICOID THERAPY BMD: -baseline and follow-up bone densitometry Calcium and vitamin D supplement Antiresorptive treatments (bisphosphonates)
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PAGET’s DISEASE Pathology: localized areas of increased bone remodeling Symptoms: pain Where: Pelvis, spine, femur, and skull Problems: deformity and fracture Prevalence: 2-5% over age 50 Discovery: - incidental on Xray -elevated alkaline phosphatase Photos used with permission Images.MD, accessed 2-18-06
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TREATMENT Asymptomatic disease----no treatment Treatment for -hearing loss from skull involvement, -nerve root or spinal cord compression -hip fracture Therapy Bisphosphonates During treatment monitor: -bone pain, joint function, and neurologic status,
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The End of Module three on Endocrine disorders in the ELDERLY PAGETS DISEASE & ADRENAL DISEASES
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Post-test A 67-year-old woman with Paget’s disease of bone involving her entire pelvis and the right proximal femur presents to clinic complaining of new, severe pain in her right hip. Six months ago she was treated with pamidronate 90 mg intravenously. Two months after she received the pamidronate, her serum alkaline phosphatase level fell from 297 U/L to 168 U/L, and her right hip pain improved. On physical examination, her right ilium is found to be more tender than it was on examination 4 months ago, and her gait is antalgic. Laboratory studies now show a serum alkaline phosphatase level of 197 U/L. On the basis of this history, what is the most appropriate next step?
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On the basis of this history, what is the most appropriate next step? A. Administer another 90-mg course of intravenous pamidronate. B. Prescribe alendronate 40 mg orally daily for 6 months. C. Order radiographs of the pelvis and right femur. D. Prescribe salmon calcitonin 100 IU subcutaneously daily for 6 months. E. Order serum alkaline phosphatase test. Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
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Answer; C. Order radiographs of the pelvis and right femur. The differential diagnosis of a substantial increase in pain in an area where a patient has Paget’s disease of bone may be a fracture or development of a sarcoma. In the case of sarcoma, the aggressive neoplasm may metastasize to the lungs and cause death quickly. Patients with Paget’s disease of bone in weight-bearing bones who develop new significant pain should have a fracture or a sarcoma ruled out with radiographs. Some studies suggest that there will be an elevation of serum alkaline phosphatase level as much as fivefold above baseline, but no change in serum alkaline phosphatase may also be seen.
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Therapy of Paget’s with pamidronate, calcitonin, or alendronate can control pain and normalize the serum alkaline phosphatase level; however, such therapy should not be administered until radiographs have been made to show that there is not a fracture or a neoplasm. Treatment with either bisphosphonates or calcitonin does not prevent the development of sarcomas in patients with Paget’s disease of bone. Fortunately, this complication occurs in less than 0.1% of affected persons. Aspirin should not be prescribed for pain without determining the cause of pain in the right hip. End
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Readings and resources Recommended readings and resources; Gruenewald DA, Matsumoto AM,Kenny AM. . Endocrine and metabolic disorders . Geriatric Review Syllabus. Sixth edition 2006 pp 368-381 Rueben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TD. Endocrine Disorders, Geriatrics at Your Fingertips. 8th edition pps. 62-65 Resources; (1) Clutter WE. Endocrine diseases. Washington Manual of Medical Therapeutics 30th Edition Chapter 23, pp473-482