The Future of Continuing Education in Diagnostic Imaging

Age Specific Care for Adults and Geriatric Patients

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Author: Shaina McQuilkie, D.C.

Abstract: Imaging techniques are commonly used to diagnose various pathologies in adult and geriatric patients. Frequently used procedures include X-rays, ultrasonography (US), computed tomography (CT), high-resolution CT (HRCT), magnetic resonance imaging (MRI) and positron emission tomography (PET). As technological advances are constantly being made, continual study regarding the proper utilization of such technologies is imperative. Further, specific precautions for certain patient populations should be studied in an effort to obtain optimal medical images while maintaining patient safety. This article provides a continuing education activity for the registered technologist (R.T.) with emphasis being placed on age specific care for adults and geriatric patients.

 

Objective

 

This article was designed as a continuing education (CE) activity with focus being placed on the topic of age specific care for adults and geriatric patients. The participants will be able to describe particular precautions that should be taken when working with adults and geriatric patients in the radiology department. Further, participants will be able to define several conditions that are seen in geriatric patients, including osteoporosis, dementia including Alzheimer’s disease, vascular dementia and dementia with Lewy bodies (abnormal aggregates of protein that develop with nerve cells). Participants will be able to identify common signs and symptoms that are associated with each of these conditions. Participants will also be able to identify standard precautions that should be taken for fall prevention in geriatric patients and will be able to identify proper lifting techniques to utilize with patients in the radiology department. A technologist may benefit from an improved understanding of age specific care for adult and geriatric patients as it may help to inform the choice of equipment, positioning, doses and technical settings that optimize patient safety.

 

Introduction

 

Medical imaging has led to significant improvements in the diagnosis and treatment of various medical conditions in the adult and geriatric patient populations [1]. There are numerous imaging modalities that are commonly used, including X-ray, computed tomography and fluoroscopy; all of which use ionizing radiation. Ionizing radiation is a form of radiation that can potentially damage DNA and may increase an individual’s lifetime risk of developing cancer [1]. As with any medical procedure, there are benefits and risks associated with medical imaging procedures and the benefits must be weighed against the risks before performing any type of medical imaging. While the benefit of clinically important medical imaging usually far outweighs the risks, efforts should be made to minimize the risks by reducing unnecessary exposure to ionizing radiation [1]. 

 

In addition to minimizing ionizing radiation exposure, technologists should make efforts to reduce the risk of spreading infectious diseases. When working with adult and geriatric patients,  technologists must be diligent in following certain infection control procedures, including routine departmental cleaning and personal hygiene, as well as following standard precautions and isolation procedures to help prevent the spread of infectious diseases in the hospital setting.

 

Certain patient populations, including adults with comorbidities, pregnant women and geriatric patients require special consideration in regard to medical imaging procedures.

When working with the geriatric population, fall prevention is of the utmost importance. Falls are a common occurrence in the geriatric population and they often have devastating consequences; they are the leading cause of injury and death by injury in adults over the age of 65 years [3]. While falls are an uncommon occurrence in the radiology department, when they do occur they often result in significant morbidity and mortality [4,5]. As the population ages, more geriatric patients will be seen for radiographic procedures; as such, radiology departments need to implement fall prevention strategies to improve patient safety.

 

In addition to ensuring the safe treatment of patients,  technologists need to be trained to prevent injuries caused by improper lifting techniques.  Technologists can experience musculoskeletal disorders from repetitive movements during imaging procedures [6]. Employers should assess the radiology department for ergonomic stressors and should train  technologists on proper lifting techniques for transferring patients and positioning patients during imaging procedures. By educating  technologists on proper lifting techniques, the risk of injury to workers and patients is reduced [6].

 

Standard Precautions and Information Regarding Adults

 

Minimizing Ionizing Radiation

 

The benefits of clinically appropriate imaging examinations generally far outweigh the risks associated with the procedure; however, care should still be taken to minimize the risks by reducing unnecessary exposure to ionizing radiation. All medical imaging exams that use ionizing radiation should only be utilized to answer a medical question, treat a disease or guide a medical procedure [1]. When choosing an imaging modality the “As Low as Reasonably Achievable” (ALARA) principle should be used to minimize the patient’s exposure to radiation [1].

 

The FDA’s Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging recommends that imaging professionals follow two principles of radiation protection of patients. These principles were developed by the International Commission on Radiological Protection and are defined as:

  1. Justification – the imaging procedure should be judged to do more good than harm to the patient. The clinical indication and medical history should be thoroughly considered before referring a patient for a procedure that utilizes ionizing radiation, such as X-ray [1].
  2. Optimization – x-ray exams should use techniques that are adjusted to administer the lowest radiation dose required to yield quality images to allow for accurate diagnosis or intervention (ALARA). The factors that affect the technique choice should include patient size and anatomical area to be imaged. Furthermore, the imaging equipment should be properly maintained and regularly tested [1].

Referring physicians have the primary responsibility for justification of the imaging procedure, while the imaging team (including the technologist) have the primary responsibility for exam optimization. Therefore, communication between the referring physician and imaging team can help to ensure that the patient receives the appropriate exam with the lowest radiation dose possible [1]. It is critical that facilities have quality assurance programs in place as well as personnel training regarding radiation safety to apply the principles of radiation protection [1].

In an effort to reduce unnecessary radiation exposure to patients, the FDA makes the following recommendations for health care professionals and hospital administrators:

Referring Physician – should be educated on radiation safety principles and how to effectively communicate them to patients. They should discuss rationale of the examination with the patient so that the patient understands the benefits and risks associated with the procedure. Lastly, they should reduce the number of inappropriate referrals for imaging by determining that the exam is clinically relevant, considering alternative examinations with lower or no radiation exposure and by checking the patient’s file to eliminate duplicate exams [1].

Imaging Teams – should receive training on radiation safety issues for specific equipment used in their facility, in addition to regular continuing education on this topic. They should develop protocol and technique charts that optimize exposure for each clinical task and patient group, using dose reduction tools when available. If questions arise, they should ask the manufacturer for assistance on appropriate and safe use of the device. They should regularly perform quality control tests of the equipment to ensure that it is functioning properly. Lastly, as part of a quality assurance program, they should monitor patient radiation doses at their facility and should compare them against diagnostic reference levels when available [1].

Hospital Administrators – should ask about the availability of dose reduction features and design features when making equipment purchases. They should ensure proper training and credentials for medical personnel using medical imaging equipment in their facility. They should ensure that the principles of radiation protection are incorporated into the facilities quality assurance program. Lastly, they should enroll their facility in an accreditation program for specific imaging modalities when available [1].

Of importance to imaging teams is that patient radiation dose is considered to be optimized when adequate image quality for the procedure is achieved with the lowest amount of radiation considered to be reasonably necessary [1]. Facilities can use their quality assurance program to optimize the radiation dose for each x-ray imaging exam, procedure and medical imaging task that it performs. Generally, larger patients require higher radiation doses than smaller patients to generate images of the same quality [1]. It should be noted that there may be a range of optimized radiation exposure settings depending on the machine’s capabilities and image quality requirements of the physician. Therefore, radiation exposure settings for the same procedure may differ among facilities [1].

An important aspect of the quality assurance program involves routine and systematic monitoring of radiation dose and the implementation of follow-up actions when the doses recorded are considered to be abnormally high (or low) [1]. The rudiments of dose monitoring and follow-up, according to the FDA are as follows:

  1. Recording of modality specific dose indices, associated equipment settings, and patient habitus. This information can be obtained from data of the DICOM radiation dose structured report. For examples, CT dose indices are standardized as CTDIvol and dose-length product (DLP), and are based on measurements in standardized dosimetry phantoms. In regards to fluoroscopy, typical dose indices include reference air kerma and air kerma-area product [1].
  2. Identification and analysis of dose-index values and conditions that consistently deviate from the corresponding norms [1].
  3. Investigative follow-up of circumstances associated with recorded deviations [1].
  4. Adjustments to clinical practice and/or protocols to reduce (or possibly increase) dose, if needed, while maintaining images of adequate quality for diagnosis, monitoring, or interventional guidance [1].
  5. Periodic reviews for updating current norms or adopting new norms. These reviews can be based on practice trends over time, equipment operator or medical practitioner performance or authoritatively established dose-index values associated with the most common exams and procedures [1].

Norms are referred to as “diagnostic reference levels” (DRSs) for interventional fluoroscopy exams and are determined by national, state, regional or local authorities and professional organizations [1]. DRL’s are typically set at the 75th percentile of the distribution of dose-index values associated within clinical practice [1]. DRLs serve as a guide to good practice, without the guarantee of optimal performance. Radiation doses that are higher than expected are not the only concern for imaging teams; radiation doses that are significantly lower than expected may result in poor image quality or inadequate diagnostic information [1]. This can result in the need for additional procedures, thereby increasing the patient’s exposure to radiation. Health care facilities can develop their own radiation dose practices in terms of local reference levels. Local levels should be compared to regional and/or national diagnostic reference levels when they are available as part of a thorough quality assurance program. Even when regional and national levels are unavailable, monitoring dose indices within a health care facility can help to identify procedures that have doses that fall significantly outside of their usual ranges [1].

One program that has been implemented to raise awareness in eliminating unnecessary radiation exposure is the Image Wisely Campaign, which is explained in detail below.

 

 

 

Image Wisely Campaign

 

The benefits of medical imaging procedures are well known; however, there are increasing concerns regarding the radiation dose associated with various imaging procedures, including computed tomography (CT), nuclear medicine procedures, fluoroscopy, and radiography. These concerns have captured the attention of imaging professionals, referring practitioners, patients, the public and the media [1,8]. In 2009, the American College of Radiology (ACR) and the Radiological Society of North America (RSNA) established the Joint Task Force on Adult Radiation Protection to address the safe and effective use of medical imaging and to incorporate dose optimization into all imaging practices [8]. The mission of the task force is to raise awareness of opportunities to eliminate imaging procedures that are unnecessary, and to lower the radiation dose in necessary imaging examinations to the minimum dose needed to acquire appropriate images [1,8].

 

Oversight for special precautions regarding radiation dose in adults is not clearly defined and must take into account other risk factors including sex and comorbidities when physicians are weighing the benefits versus the risks of performing a medical imaging study [8].

 

The task force developed the “Image Wisely” campaign, which provides an educational resource for optimizing radiation dose in adults. Additionally, this campaign has partnered with various imaging equipment vendors to provide the most current information on dose reduction techniques available on specific equipment. The program also requires participants to take a pledge, by pursuing accreditation and by participating in national dose registries [8]. To learn more about this program, please visit their website at http://www.imagewisely.org/ [9].

 

Infection Control

 

Nosocomial infections are a critical challenge for healthcare workers and patients [10,11]. Needle stick injuries, blood contacts, airborne infections and any kind of contamination pose a risk for the spread of infections in hospitals [11]. Most infections are acquired through contact, primarily with the hands of healthcare personnel; therefore, hand hygiene is the single most effective preventative measure for controlling the spread of infectious disease [10]. While the radiology department has traditionally been considered a low risk setting for the transmission of infections, departments are becoming increasingly busy and the exposure time between workers and patients is increasing; therefore, adherence to standard infection control precautions is critical to prevent the spread of infection [10,11].

 

Radiology department infection control procedures should include routine departmental cleaning, personal practices, standard precautions and transmission based precautions [2].

 

            Routine Departmental Cleaning

Counters and surfaces that are frequently contacted by personnel who handle patients should be cleaned with hospital-grade disinfectant-detergent, diluted bleach or with commercially prepared germicide-impregnated disposable clothes, at least twice a day [2]. Closed storage areas containing linen and nonsterile medical supplies should be wiped down weekly with disinfectant, diluted bleach or germicide clothes [2]. Storage areas containing sterile supplies should be dusted daily.  Further, the shelves should be emptied weekly and washed with a disinfectant [2]. Items should be replaced or resterilized as needed [2]. Lead aprons and gloves should be cleaned weekly with disinfectant, diluted bleach or germicide clothes; they should be cleaned immediately following contact with blood or body fluids [2]. Mobile x-ray machines should be disinfected after each use and should be cleaned thoroughly on a weekly basis [2]. Further, they should be wiped thoroughly before entering a surgical area or patient room designated for protective precautions [2].  X-ray machine tabletops and vertical buckys should be thoroughly washed with a disinfectant, diluted bleach or germicide cloth after each patient contact [2]. New linens, including pillowcases, should be used for each new patient. The overhead tube, spot film devices, image intensifiers and television monitors should be dusted daily and the overhead tracks for ceiling mounted devices should be dusted weekly with a vacuum cleaner [2]. The control stands, spot film devices and entire x-ray table should be disinfected weekly [2]. All wheelchairs and stretchers should be thoroughly cleaned with a disinfectant, diluted bleach or germicide cloth weekly, with patient contact areas being wiped down daily [2]. Wheelchairs and stretchers used for isolation patients and those that have come into contact with bodily secretions should be disinfected immediately after patient contact [2].

 

Hand Hygiene

Imaging staff should wash their hands with either a non-antimicrobial soap or antimicrobial soap and water in the following situations: when their hands are visibly dirty or contaminated with blood or bodily fluids, before eating and after using a restroom, after blowing or wiping their nose, and if they are exposed to serious pathogens that involve spores, such as Bacillus anthracis [2].

 

The CDC recommends the following five steps for proper hand washing with soap and water [12]:

  • Wet your hand with clean, running water and apply soap
  • Lather your hands by rubbing them together; make sure to lather the backs of the hands, between the fingers (include thumbs) and under the nails
  • Scrub hands for a minimum of 20 seconds
  • Rinse hands under clean, running water
  • Dry hands with a paper towel and turn the tap off with the paper towel

 

 

An alcohol based hand rub or hand washing may be used in the following situations: upon reporting for duty, between patient encounters, before putting on sterile gloves, before inserting indwelling urinary catheters, after contact with a patient’s intact skin, after contact with contaminated equipment, after removing gloves, upon entering and exiting isolation area, after handling dressings, sputum containers, etc., if moving from a contaminated body site to a clean site during patient care and on completing duty [2].

 

The CDC recommends the following three steps for proper hand washing with an alcohol based rub [12]:

  • Apply the alcohol rub to the palm of one hand
  • Rub hands together
  • Rub the product over all hand surfaces, including between the fingers, until the hands are dry

 

Standard Precautions

All personnel, including  technologists, should utilize standard precautions whenever contact with blood or body fluids is possible [2,13]. Further, isolation guidelines require that all personnel utilize standard precautions with all patients potentially infected or colonized with an infectious agent [2].

 

TABLE 1: Centers for Disease Control and Prevention Guidelines for Standard Precautions [13]

Precaution

Scenario

Hand hygiene

After contact with blood, body fluids, secretions, excretions, contaminated items; after removing gloves; between patient contacts

Personal Protective Equipment

 

Gloves

When contacting blood, body fluids, secretions, excretions, contaminated items, mucus membranes and non-intact skin

Gown

When skin or clothing contact with blood, body fluids, secretions, excretions or contaminated items is anticipated

Mask, eye protection, face shield

When there is a risk of splash or spray of blood, body fluids, secretions or excretions (e.g. suctioning and endotracheal intubation); if aerosol generating procedure, need N95 mask

Soiled patient care equipment, textiles, and laundry

Handle in a manner that minimizes the transfer of microorganisms; wear gloves if equipment is visibly contaminated; use hand hygiene

Environmental control

Routine care, cleaning, and disinfection of surfaces, especially frequently touched or proximity surfaces

Needles and sharp objects

Do not recap, bend, break or hand-manipulate used needles; dispose of sharps in a puncture-resistant receptacle

Patient resuscitation

Use mouthpiece, resuscitation bag or other ventilation devices to prevent contact with mucous membranes and oral secretions

Respiratory hygiene

Instruct symptomatic individuals to cover mouth or nose when sneezing or coughing; use tissues and dispose of them in no-touch receptacles; use hand hygiene if contact with respiratory secretions; wear surgical mask, if tolerated or maintain spatial separation (> 3 feet if possible)

 

Transmission Based Precautions

Airborne, droplet and contact precautions should be utilized in addition to standard precautions for patients that are suspected to be infected or colonized with highly transmissible pathogens [2].

 

Pregnancy

 

The increasing use of radiology procedures in the population will inevitably result in an increase in imaging requests for pregnant patients [14]. With regard to imaging in pregnancy, a pregnant woman is no more sensitive to radiation than a non-pregnant woman [15]. However, women of a reproductive age that are referred for computed tomography, nuclear medicine, angiography and/or x-rays should inform the  technologist of their pregnancy status. This may affect the decision about what tests to perform and which to delay until after the mother has given birth [15]. Almost all imaging tests expose the fetus to such low levels of radiation that they are not a concern; however, it is generally an accepted practice to avoid tests and procedures that directly expose the uterus or abdomen to radiation in women that may be pregnant [15].

 

The risk to the unborn fetus from ionizing radiation is dependent on a number of factors, including: the anatomical site being imaged, the stage of pregnancy and the radiation dose received [15]. Organogenesis (internal organ development) in the fetus occurs predominantly between 2 and 15 weeks gestation, which is the period when the fetus is most susceptible to the teratogenic effects (disruption of the normal development of a fetus) of ionizing radiation [14]. These effects can include microcephaly (abnormally small head), microphthalmia (abnormally small eye(s) with anatomic malformations), mental retardation, growth retardation, behavioral defects and cataracts [14,15]. The threshold radiation dose below which no teratogenic effects occur is unknown; however, it is estimated to range from 5 to 15 rad [15].

 

It is good practice to implement the following guidelines in all radiology facilities to protect an unborn fetus [14]:

  • Signs should be prominently displayed throughout the radiology department telling patients to notify the technologist if she is, or thinks she may be, pregnant.
  • All technologists  should ask women of childbearing age if they may be pregnant before performing a radiologic procedure.
  • Radiology requisition forms should have a section for the medical doctor to complete regarding the possibility of pregnancy.
  • No radiological procedure that utilizes ionizing radiation to the pelvis should be performed on a patient that declares she may be pregnant before consulting with the radiologist. Further, the radiologist should discuss benefits and risks of the procedure with the patient and determine if they will go ahead with the procedure, opt for an alternative procedure or delay the test.
  • If the test is deemed to be medically necessary, proper shielding of the fetus, increasing the kVp, removing the antiscatter grid and taking fewer films can help to lower the fetus’ exposure to radiation [16]

 

Imaging of traumatic injuries in pregnant patients poses an important and challenging aspect for the radiology team [17]. To encourage the best outcome for the mother and fetus, maternal injuries need to be diagnosed rapidly. From a radiological standpoint, the workup of a pregnant trauma patient should utilize conventional radiography, CT and MRI on an as needed basis [17]. When ionizing forms of radiation are used in this patient population, the dose should be kept as low as reasonably possible [17].

 

Standard Precautions and Information for Geriatric Patients

 

As the population in the United States ages, the prevalence of chronic disease and complex medical conditions will have significant implications for the future health care system [18]. Geriatric care has become a complicated, multidisciplinary effort and the role of radiology has expanded rapidly in geriatric medicine. As the geriatric patient population expands, and radiology continues to evolve, the complicated relationship between geriatric care and radiology will continue to be redefined [19].

 

Precautions that were described in “Standard Precautions and Information for Adults”, including minimizing radiation and infection control, cross over into radiographic imaging for geriatric patients. However, geriatric patients often present with additional health concerns that  technologists  need to be aware of. Diseases, including osteoporosis, dementia and Alzheimer’s disease are more prevalent in the geriatric population. Further, falls are more commonplace in the geriatric population, presenting an additional issue that  technologists need to be aware of. Lastly, the geriatric patient population may require additional assistance during radiographic procedures; therefore the risk of injury to the  technologist is increased.

 

Osteoporosis

 

Osteoporosis is the most common metabolic bone disorder, affecting millions of Americans. Osteoporosis is a progressive metabolic bone disease that involves decreased bone density, with deterioration of bone structure [20-26]. Bone weakness can lead to fractures with minor trauma, particularly in the thoracic and lumbar spine, wrist and hip (fragility fractures) [22,26]. In the United States, the lifetime risk of osteoporotic fracture is 40% in white women and 13% in white men [26]. Osteoporosis can affect both men and women; however, it most commonly affects older women [21]. Because of the aging population, the number of individuals affected by osteoporosis is expected to rise over the coming years [25].

 

Osteoporosis can develop as a primary disorder or can occur secondarily due to some other factor and is therefore categorized as either primary or secondary [21].

           

            Primary Osteoporosis

Primary osteoporosis can be further categorized into type I (post-menopausal) and type II (senile) [23]. More than 95% of cases of osteoporosis in women, and approximately 80% of cases of osteoporosis in men are primary in nature. Most cases of primary osteoporosis occur in postmenopausal women and older men [22].  Type I primarily affects women between the ages of 50 and 65 and is the result of estrogen deficiency resulting in accelerated trabecular bone resorption and typically involves the spine and wrist [22]. Conversely, type II affects both trabecular and cortical bone, which results in the characteristic hip, proximal humerus, tibia and pelvic fractures that are often seen in patients with osteoporosis [22].

 

Various factors can play a role in primary osteoporosis, including gonadal insufficiency, decreased calcium intake, low vitamin D levels and hyperparathyroidism [21].

 

Secondary Osteoporosis

Less than 5% of cases of osteoporosis in women are secondary in nature; this type of osteoporosis is more common in men [22]. The causes of secondary osteoporosis include cancer, chronic obstructive pulmonary disorder (COPD), chronic kidney disease, certain drugs, endocrine disease, hypercalciuria, hypervitaminosis A, hypophosphatasia, immobilization, liver disease, mal-absorption syndromes, prolonged weightlessness and rheumatoid arthritis [21].

 

Osteoporosis is often a silent disease unless a fracture occurs [22]. A patient with a symptomatic vertebral fracture presents with an acute onset of pain that does not usually radiate. The pain is usually aggravated by bearing weight and may be accompanied by point spinal tenderness. Symptoms tend to subside in one week; however, residual pain may persist for months [22]. When several thoracic compression fractures occur, dorsal kyphosis with an exaggerated cervical lordosis (dowager’s hump) eventually occurs. There may be a chronic, dull ache in the back and patients may have shortness of breath due to the reduced intra-thoracic volume as well as abdominal discomfort due to the compression of the abdominal cavity as the rib cage begins to approach the pelvis [22].

 

 

Compression fracture of the L3 vertebra

Figure 1 (above): Compression fracture of the L3 vertebra. Courtesy of Lucien Monfils (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

 

Dorsal kyphosis with an exaggerated cervical lordosis

Figure 2: Dorsal kyphosis with an exaggerated cervical lordosis (Dowager’s hump). Courtesy of Dr Roberto Schubert, Radiopaedia.org. From the case Dowager's hump.

 

  Major risk factors for osteoporosis include [20,21]:

  • Sex: females are more commonly affected
  • Age: older individuals are more commonly affected
  • Body size: small, thin individuals are more commonly affected
  • Ethnicity: Caucasian and Asian individuals are more commonly affected
  • Family history: osteoporosis tends to run in families

 

Other risk factors that have been identified include [20,21]:

  • Low estrogen levels in women and low testosterone in men
  • Anorexia
  • Low calcium and vitamin D intake
  • Medication use: certain medications increase the risk of osteoporosis
  • Low activity levels
  • Smoking
  • Drinking alcohol

 

Early diagnosis of osteoporosis is crucial as complications related to osteoporosis often result in social and economic burdens [25,26]. There are a wide variety of imaging techniques available; therefore, radiology plays a critical role in the diagnostic evaluation of patients with osteoporosis [27].

 

The dual energy X-ray absorptiometry (DXA, historically known as DEXA) is the only reference method accepted by the World Health Organization (WHO) and is the most widely used technique for identifying patients with osteoporosis [27-29]. DXA measures bone mineral density (g/cm2) and can be used to suggest osteoporosis, predict fracture risk and can also be used to follow response to treatment [22]. Bone density of the lumbar spine, hip, distal radius or entire body can be measured with DXA and it is ideally measured at three sites, including the lumbar spine and both hips [22].  DXA should be performed on all women over the age of 65 and on women between menopause and 65 who have risk factors [22].

 

Dual-energy X-ray absorptiometry

Figure 3: A Dual-energy X-ray absorptiometry (DXA) scan being administered. Courtesy of Nick Smith photography (ALSPAC web site) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

 

DXA results are reported as T-scores and Z-scores. The T-score corresponds to the number of standard deviations that the patient’s bone density differs from the peak bone mass of a healthy, young patient of the same sex and ethnicity [22]. A T-score -2.5 defines osteopenia, while as score of ≤ -2.5 is suggestive of osteoporosis [22]. The Z-score corresponds to the number of standard deviations that the patient’s bone mineral density differs from that of a person of the same age and sex. The Z-score should be used for children, premenopausal women, or men less than 50; therefore, the Z-score is essentially irrelevant in the geriatric population [22].

 

Dual-energy X-ray absorptiometry scan

Figure 4: DEXA assessment of bone mineral density of the femoral neck (A) and the lumbar spine (B): T scores of - 4.2 and - 4.3 were found at the hip (A) and lumbar spine (B), respectively in a 53 year-old male patient affected with Fabry disease. Courtesy of Dr Caroline LEBRETON, CHU Raymond Poincaré, Garches, France. [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons.

 

Central DXA systems that are currently used can also assess vertebral deformities in the lower thoracic and lumbar spine. This procedure is called vertebral fracture analysis (VFA) [22]. Vertebral deformities, even when asymptomatic, are diagnostic of osteoporosis and predict an increased risk of future fractures [22]. This procedure is more likely to be useful in patients with a height loss ≥3cm [22].

 

Monitoring of on-going bone loss and the response to treatment using serial DXA scans should be done using the same DXA machine and the comparison should be made to the actual bone mineral density (g/cm2), not the T-score [22]. Patients being treated for osteoporosis should have DXA repeated every 2 years; although some patients may get tested more frequently, especially if they are taking glucocorticoids. There is a lower fracture risk when a stable or improved bone mineral density is found on repeat exams [22].

 

While DXA is the gold standard for the diagnosis of osteoporosis, other imaging techniques are also used. Conventional radiography allows for qualitative and semi-quantitative evaluation, while other imaging techniques allow for quantification of bone loss. These techniques include quantitative computed tomography, morphometry, and ultrasonography. Further, in recent years, new imaging modalities including micro-CT and high-resolution magnetic resonance imaging have been developed in an effort to diagnosis osteoporosis in the early phases of the condition [25,29].

 

Radiographic features of osteoporosis include decreased cortical thickness and loss of bony trabecula. Usually, bones such as the vertebrae, long bones, calcaneus and tubular bones are visualized to look for evidence of osteoporosis [30]. Plain film radiography is not a sensitive modality because more than 30% to 50% of bone loss is needed to visualize decreased bone loss on radiography. Vertebral osteoporosis shows as pencilling of vertebrae, loss of cortical bone (picture frame vertebra) and trabecular bone (ghost vertebra) as well as compression fractures and vertebra plana [23, 30]. Loss of trabeculae may be seen in the proximal femur and calcaneus [30]. Thinning of the cortex in tubular bones, especially in the metacarpals, may be seen in patients with osteoporosis [30].

 

Loss of cortical bone

Figure 5 (above): Loss of cortical bone (picture frame vertebra).  Published with permission from LearningRadiology.com.

 

 

Loss of trabecular bone

Figure 6: Loss of trabecular bone (ghost vertebra). Published with permission from LearningRadiology.com.

 

In the geriatric population, treatment of osteoporosis needs to focus on a combination of non-pharmacological and pharmacological interventions [31]. The goals of treatment should be to strengthen bone, optimize function, and reduce morbidity and mortality associated with the first fracture and to prevent subsequent fractures [31, 32]. Successful non-pharmacological options include falls risk assessment and management, participation in an exercise program and the use of hip protectors [31]. Pharmacological options including calcium, vitamin D, alendronate (Fosamax), risedronate (Actonel, Ateliva), zoledronic acid (Zometa, Zomera, Aclasta and Reclast), teriparatide (Forteo) and strontium ranelate (Protelos) are safe in the geriatric population and significantly reduce fractures, especially vertebral fractures [31].

 

Dementia

 

Dementia is a term that is used for the loss of memory and other mental abilities that is severe enough to interfere with daily life that is the result of physical changes in the brain [33]. Dementia is not a specific disease; rather, it is a term that is used to describe a wide range of symptoms that are associated with diminished memory and thinking skills [33].  The three most common forms of dementia are Alzheimer’s disease (AD), Vascular dementia and Lewy body dementia (LBD) [35].

 

Alzheimer’s Disease

 

Alzheimer’s disease is the most common type of dementia, accounting for 60% to 80% of dementia cases [32]. The prevalence of Alzheimer’s disease is strongly linked to increasing age. Symptoms of Alzheimer’s disease usually develop slowly and progressively worsen, eventually interfering with an individual’s ability to carry out normal activities of daily living [33]. Early symptoms of Alzheimer’s disease include difficulty remembering recent conversations, name and/or events, as well as apathy and depression. Later symptoms of the disease include impaired communication, poor judgement, disorientation, confusion, behavior changes, as well as difficulty speaking, swallowing and walking [33]. Risk factors have been identified, including: advanced age, female gender, apolipoprotein (APOE) ε4 allele carrier status, smoking and having a family history of dementia [35]. Socioeconomic risk factors have also been identified, including: lower education level, lower income level, lower occupational status and smaller social network [36].

 

Physicians can usually determine if an individual has dementia, but it may be difficult to determine the exact cause. Diagnosis of the underlying cause of dementia requires a thorough medical history and physical examination, including mental status testing and neurological testing as well as additional testing including blood work and radiologic procedures [32].

 

Alzheimer’s disease is characterized by the accumulation of senile plaques, neurofibrillary tangles and progressive loss of neurons [36]. The progression of the disease initially involves the transentorhinal region and spreads to the hippocampal complex and mesial temporal lobe structures and eventually the temporal lobes and basal forebrain [36]. The primary role of MRI in the diagnosis of Alzheimer’s disease is the assessment of volume change in the brain locations that are commonly affected by the disease. The diagnosis should be made on the basis of two characteristic features: mesial temporal lobe atrophy and temporoparietal cortical atrophy [36]. Nuclear imaging procedures, including SPECT and PET can be used to detect regional hypoperfusion/hypometabolism in a bi-parietal and bi-temporal distribution [36].

 

Normal brain compared to Alzheimer's Brain

Figure 7 (above): Normal brain (left) compared to Alzheimer’s disease brain (right). Courtesy of derivative work: Garrondo (talk) SEVERESLICE_HIGH.JPG: ADEAR: "Alzheimer's Disease Education and Referral Center, a service of the National Institute on Aging." PRECLINICALSLICE_HIGH.JPG: ADEAR: "Alzheimer's Disease Education and Referral Center, a service of the National Institute on Aging." (SEVERESLICE_HIGH.JPG PRECLINICALSLICE_HIGH.JPG) [Public domain], via Wikimedia Commons.

 

 

PET scan of an Alzheimer's patient

Figure 8: PET scan of an Alzheimer’s patient showing loss of function in the temporal lobe (arrow). By US National Institute on Aging, Alzheimer's Disease Education and Referral Center [Public domain], via Wikimedia Common.

 

 

Vascular Dementia

 

Vascular dementia is considered to be the second most common type of dementia according to many experts, accounting for 20% - 30% of cases [37]. Vascular dementia involves decreased thinking skills caused by conditions that block or reduce blood flow to the brain, which deprives brain cells of oxygen and nutrients [37]. In patients with vascular dementia, changes to thinking skills can occur suddenly after strokes due to the blockage of major brain blood vessels. However, changes to thinking skills may also develop slowly and gradually worsen over time as the result of multiple mini-strokes or other conditions that affect the smaller blood vessels [37]. The changes that are seen in vascular dementia can be linked to other forms of dementia, including Alzheimer’s disease and dementia with Lewy bodies.

 

Symptoms of vascular dementia range in severity depending on the blood vessel damage and the area of the brain that has been affected. Depending on the area of the brain affected, memory loss may or may not be a prominent symptom [37]. Sudden symptoms that occur following a stroke may include: disorientation, confusion, difficulty speaking and understanding speech, and vision loss. Gradual changes resulting from several mini strokes may cause widespread small vessel disease, resulting in symptoms including: impaired planning and judgement, uncontrolled laughing and crying, decreased attention span, decreased ability to interact in social situations and difficulty with word selection [37].

 

Diagnosis of vascular dementia may be difficult and the condition may go undiagnosed in many patients. It is recommended that high-risk patients be assessed with brief testing to assess memory, thinking and reasoning [37]. Depression screening is also recommended for high-risk patients as depression commonly coexists with brain vascular disease and can add to cognitive symptoms [37]. If these brief assessments suggest that the patient may be suffering from vascular dementia, a more thorough work up is necessary. This workup may include: a detailed medical history, including family history, evaluation of independent function and daily activities, neurological examination and laboratory testing including blood work and brain imaging. Typically a work up includes input from family members or close friends [37].

 

Both CT and MRI may be able to show evidence of ischemic damage; however, MRI is more sensitive, especially in patients with small vessel ischemic changes [38].

 

PCA infarction involving the medial temporal lobe

Figure 9: PCA infarction involving the medial temporal lobe.  Courtesy of Frederik Barkhof, Marieke Hazewinkel, Maja Binnewijzend and Robin Smithuis - Alzheimer Centre and Image Analysis Centre, Vrije Universiteit Medical Center, Amsterdam and the Rijnland Hospital, Leiderdorp, The Netherlands.

 

 

Lewy Body Dementia (LBD)

 

Lewy body dementia is considered to be the third most common type of dementia, accounting for 10% to 25% of cases. It is a progressive brain disease that leads to a decline in thinking, reasoning and independent function, resulting from abnormal microscopic deposits that cause brain cell damage [39].

 

The hallmark finding of LBD is Lewy bodies, which were named after Frederick H Lewy, M.D.[39]. Lewy bodies are also found in other types of dementia, including Alzheimer’s disease and Parkinson’s disease. Parkinson’s disease patients often develop thinking and reasoning problems and many patients with LBD experience movement symptoms including a hunched posture, rigid muscles, difficulty initiating movement and a shuffling gait. The overlap of symptoms suggests that LBD, Parkinson’s disease and Parkinson’s disease dementia may all be linked to the abnormalities in how the brain processes the protein alpha-synuclein (the main component of Lewy bodies) [39]. Many patients with LBD also have plaques and tangles. Plaques are abnormal clusters of sticky protein (beta-amyloid) that build up between nerve cells [38[. Tangles are twisted fibers of a protein (tau) that form inside of dying cells [38], Plaques and tangles are hallmark brain changes that are seen in Alzheimer’s disease patients [39].

 

Symptoms of LBD include changes in thinking and reasoning, confusion and alertness that vary significantly throughout the day, Parkinson-like symptoms, visual hallucinations, delusions, difficulty interpreting visual information, acting out dreams, malfunction of the autonomic nervous system and memory loss [39].

 

As with other forms of dementia, the diagnosis of Lewy body dementia is often a clinical diagnosis. This means that the physician uses their best professional judgement of the patient’s symptoms to diagnosis this condition. The only way to confirm a diagnosis of LBD is through a post-mortem autopsy [39].

 

Neuroimaging and interventional radiology in particular require patients to strictly adhere to instructions in order to obtain adequate images. Dementia patients may be confused or combative when undergoing radiology procedures; however, this should not exclude the use of imaging or interventional techniques in patients that suffer from this debilitating condition [19].

 

Fall Precautions

 

Falls of hospitalized geriatric patients are a concern for patients, family members, third-party payers and caregivers. Falls are the most common safety incident reported among hospitalized patients, with falls rates reported between 2.9-13 per 1,000 patient days [40]. Of patients that fall in the radiology department, those that fall while ambulating, compared to those that fall when sitting or standing, are at an increased risk of suffering fall-related injuries [4]. Falls in the radiology department are more prevalent in the following patients [4]:

  • Older patients
  • Patients with altered mental status
  • Patients with a history of falls
  • Patients taking certain medications (i.e. CNS-acting medications, antihypertensive medications and non-narcotic analgesics)

 

Implementation of a fall reduction/prevention program in radiology departments will help to prevent falls in geriatric patients [4]. The steps in a successful falls prevention program include the following steps [4]:

  • Assess and reassess patient risk factors for falls
  • Identify patients at risk for falling
  • Communicate patient fall risks to staff in the radiology department
  • Educate patients, families and staff about how to prevent falls
  • Conduct analysis of why a fall occurs and making improvements

 

Specific aspects may need to be considered when developing a falls reduction program in a radiology department. These may include simple suggestions to patients such as adhering to assistance from staff, avoiding walking in socks, carefully observing surroundings, mobilizing at a slow and steady pace, the use of eyeglasses, and using extra caution when taking certain medications [4]. Further,  technologists should ensure that the radiology department floors are kept clean and dry, and ensure that the aisles and passageways are kept clear of obstructions [42].

 

Falls in the geriatric population can have devastating effects; therefore implementation of appropriate falls reduction/prevention programs in radiology departments should be implemented to reduce the risk of falls.  

 

Proper Lifting Techniques

 

 Technologists are stressed due to the high tension of their work; additionally, their muscles, blood vessels and the nerve tissue in their necks, shoulders, arms, hands, waists, legs and knees are often damaged by the physical work that they perform, including prolonged standing, repetitive movements, and repetitive lifting to help patients move [43]. While musculoskeletal disorders in  technologists can occur anywhere in the body, they primarily occur in the shoulders and lumbar region [43]. This may be due to the fact that  technologists are required to lift and maneuver patients during radiologic procedures and transfers on a daily basis [42,43]. Research has suggested that lower back pain experienced by  technologists is closely related to the frequency with which they assist in moving patients [43].

 

In order to minimize the risk of injury,  technologists should be trained on proper lifting techniques, including: lifting items as close to the body as possible, avoiding awkward postures, such as twisting, while performing a lift, and avoiding lifting or reaching above shoulder height [42].  Technologists should instruct the patient in ways that they can help to facilitate and help the lifting procedure [42]. In addition to educating  technologists on proper lifting protocols, health care facilities should use mechanical aids to reduce the need for  technologists to lift, when possible, and should provide a sufficient number of staff to perform required lifts [42].  Technologists should also be educated regarding exercises to prevent lower back pain [43].

 

Conclusion

 

Medical imaging for the diagnosis and treatment of numerous medical conditions has become increasingly popular over the past few decades due to advancement in imaging technology. While the benefits of medical imaging are undeniable, there are certain factors which cause concern for the healthcare community and patients alike. The damaging effects of ionizing radiation are of utmost concern and efforts are continually being made to reduce unnecessary exposure to ionizing radiation. Furthermore, as medical imaging becomes more popular, radiology departments become busier with more interactions between patients and staff.. This makes the radiology department a potential area for the spread of infectious disease. Radiology staff, especially  technologists, need to be diligent in following infectious disease prevention protocols, including routine department cleaning and personal hygiene as well as adhering to standard and isolation procedures to reduce the spread of disease in hospital settings. 

 

Certain precautions need to be taken when working with particular patient populations, including pregnant female patients and geriatric patients. When working with pregnant patients, the medical benefits of the imaging procedure must be weighed against the potential risk of exposing the unborn fetus to ionizing radiation. This will help the patient, physician, radiologist and  technologist make an informed decision about what is best for the patient and her unborn child. When it is determined that an imaging procedure is medically necessary, the  technologist must take certain precautions to protect the unborn fetus.

 

Geriatric patients often present to the radiology department with significant medical conditions which need to be addressed by R.Ts. Furthermore, as the population ages and the number of geriatric patient visits rise in the radiology department, fall prevention strategies need to be implemented as falls in this population can often have a detrimental impact, resulting in significant morbidity and mortality.

 

Occupational safety in regards to  technologists has focused on potential radiation exposure and defense against this exposure, while the issue of safety in relation to work-related musculoskeletal disorders has essentially been neglected. Further research and education is needed in health care settings regarding musculoskeletal injury prevention, through the use of correct working postures, including proper lifting techniques, as well as exercise methods for  technologists [44].

 


 

 

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