The MKSAP Challenge
Clinical scenario
An 80-year-old, thin, white woman is hospitalized with a hip fracture that resulted from a fall. Her medical history is remarkable for isolated systolic hypertension, insomnia, osteoarthritis of the knee and a hysterectomy 20 years ago. Her medications are hydrochlorothiazide, 25 mg daily; zolpidem, 0.5 mg as needed at bedtime; conjugated estrogens, 0.625 mg daily; and a multivitamin daily. She has at least eight ounces of yogurt and two glasses of milk daily, in addition to a cheese sandwich. Her bone mineral density T-score is -2.8.
Which one of the following management options will most likely reduce her risk of a future fracture?
A. Stopping hydrochlorothiazide
B. Stopping conjugated estrogens and beginning nasal calcitonin
C. Stopping zolpidem
D. Starting calcium, 1,000 mg daily
Answer: C
Educational Objective: Recognize drugs that may predispose a frail elderly patient to falls.
Zolpidem, a hypnotic, has recently been shown to be associated with falls in frail older adults, similar to antidepressants, benzodiazepines and antipsychotics. The patient's daily calcium intake is about 1,100 mg a day just from her diet, close to the 1,500 mg a day recommended for a postmenopausal woman. Thiazide diuretics decrease calcuria, and have been associated with a 20% decrease in hip fractures. Although recent studies have clearly shown that conjugated estrogens do not prevent coronary artery disease, the same study by the Working Group for the Women's Health Initiative found that it reduced the risk of fractures. There is no evidence that nasal calcitonin is more effective at preventing fractures than conjugated estrogens.
References
1. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Zolpidem use and hip fractures in older people. Journal of the American Geriatrics Society. 2001;49:1685-90.
2. Jones G, Nguyen T, Sambrook PN, Eisman JA. Thiazide diuretics and fractures: Can meta-analysis help? Journal of Bone and Mineral Research. 1995;10:106-11.
3. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. Journal of the American Medical Association. 2002;288:321-33.
The above feature contains questions and answers excerpted from MKSAP 12 Update, an enhancement to the College's popular self-assessment program. For more information about MKSAP 12 Update, contact ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.
Internist Archives Quick Links
ACP Career Connection
Looking for a new internal medicine or subspecialty position?
ACP Career Connection can help you find your next job in internal medicine. Search internist and subspecialist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
Register Now For Your ACP Fall Chapter Meeting
Attend your fall chapter meeting, earn CME credit, and find out what your local ACP Chapter has to offer! See the Chapter calendar or find out more, including the answers to frequently asked questions about ACP Chapters and regions.
Test Your Medical Knowledge on Your Mobile Device with ACP’s Doctor's Dilemma™ Game!
This new online game is based on the popular ACP Doctor's Dilemma™ Competition from ACP’s annual Internal Medicine meetings. The game is simple to play but challenging to master. Start now!