Hypercalcemia in Elderly - Introduction to Geriatrics - Lecture Slides, Slides of Geriatrics

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Hypercalcemia

in the Elderly

Case Presentation

• ID: 83yo F from home, history of breast cancer
• RFA: cognitive decline x8months + constipation
• Assessed in Geriatrics clinic:
  • MMSE= 20/
  • Independent in ADLs, dependent for IADLs
  • Decreased interest in usual activities
  • Increased forgetfulness
  • Decreased orientation
  • Ca = 2.93 (Normal: 2.12-2.55)
  • P/E, CXR, EKG normal
  • Suggested repeat Ca and albumin

What is causing the

hypercalcemia?

Can the hypercalcemia

explain the symptoms?

What do I do now????

Hypercalcemia in the Elderly

Epidemiology

• Severe hypercalcemia accounts for 3-5% of hospital admissions
• More common in frail and elderly
• Hyperparathyroidism is the most common cause of mild- moderate hyperCa - 4/100,000/yr - Age: 56. - 2F:1M
• Malignancy is the most common cause of severe hyperCa
• Medications
  • Thiazides 8/100,000/yr

Symptoms

• Confusion
• Dizziness
• Drowsiness
• Lethargy, stupor, coma
• Fatigue
• Depression
• Anxiety
• Blunted affect
• Slowed speech

Symptoms

• Polyuria
• Polydypsia
• Dehydration
• Nephrolithiasis
• Acute or chronic

renal failure

• Nephrogenic DI
• RTA Type 1

Symptoms

• Shortened QT
• Arrhythmias
• ST elevation
• Hypertension
• Cardiomyopathy

Differential Diagnosis

Hyperparathyroidism: 1º, 2º, 3º Malignancy^ Drugs

Immobility Hyperthyroidism GranulomatousDiseases

Pancreatitis Familial HypocalciuricHypercalcemia

Hyperparathyroidism

Types

• Benign (96.5%)
  • Single gland adenoma: 85%
  • Multiple adenomas: 5%
  • Diffuse hyperplasia: 10%
• Malignant (4.5%)

Etiology

• Radiation
• MEN
• Familial hyperparathyroidism
• Idiopathic

Medications

• Vitamin D
• Calcium
  • Milk Alkali syndrome
• Thiazides
• Lithium

Milk alkali syndrome

Acute renal failure

Metabolic Alkalosis

Hypercalcemia

Granulomatous Diseases

• Sarcoidosis
• TB
• Leprosy
• Coccidiomycosis
• Histoplasmosis

Treatment

• Goals of Treatment:
  • Alleviate symptoms
  • Treat the underlying cause
  • Prevent sequelae
• Mechanisms of Treatment:
  • Decrease bone resporption
  • Decrease intestinal absorption
  • Increase urinary excretion

Treatment for All?

• Not necessarily
• Treatment depends on:
  • Symptoms
  • Degree of hypercalcemia
  • First time or repeat offender
• Always treat:
  • Symptomatic regardless of Ca
  • Ca >3.5 regardless of symptoms