Transcript Case 1 - UNC School of Medicine - The University of North Carolina

Alliance for Geriatric
Education in Specialties
(AGES) Curriculum
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Curriculum Contents
Introduction
Module 1:
The Physiology of Aging
Module 2:
Dementia
Module 3:
Delirium
Module 4:
Transitions of Care
Module 5:
Basics of Geriatric Assessment
& Levels of Care
Module 6:
Iatrogenic Injury
Module 7:
Palliative Care Communications
Module 8:
Polypharmacy
2
Introduction AGES Curriculum
The Alliance for Geriatrics Education in Specialties (AGES) consists of 8
interactive core curriculum modules: iatrogenic injury, delirium, dementia,
polypharmacy, transitions of care, basics of geriatrics assessment and levels of
care, physiology of aging, palliative care communication and medications. These 8
modules have been designed to teach specialty faculty, at all levels of their career,
how to increase effectiveness and quality of care for their older adult patients.
In 2009, the University of North Carolina School of Medicine at Chapel Hill
conducted a needs assessment to evaluate the potential for improvement of UNC
Healthcare System specialty/subspecialty faculty regarding geriatrics care through
training. Based on the assessment results, the AGES curriculum was developed,
implemented, evaluated, and now available for use through POGOe.
The AGES curriculum can be taught as an entire course or each module can be
taught as a separate training session. The UNC Healthcare System is currently
using all 8 modules for training its non-geriatrician specialty faculty. Each of the 8
module PowerPoint presentations will take approximately 60 minutes per training
session.
*This curriculum may also be applicable to internists and
family medicine practitioners.
3
AGES Module 1:
The Physiology of Aging
4
Physiology of Aging
Christine M. Khandelwal, DO
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Learning Objectives
• Learners will be able to describe the normal
changes that occur with aging.
• Learners will be able to identify the common
age-related changes that occur in the
following systems: cardiovascular,
respiratory, renal, hematology/immune,
gastrointestinal, endocrine, neurologic,
musculoskeletal, and reproductive.
6
Aging
• Chronologic age is not an accurate predictor
of physical condition or behavior
• Poor health in later life is not inevitable
• The rate of physiologic decline can be
modified
• Much of the illness and disability associated
with aging is related to modifiable lifestyle
factors that are present in middle age:
» disparate factors predispose individuals to
functional losses later in life
» many conditions have suspected either
genetic and/or environmental etiologies
7
Aging and Disease
• It may not always be possible to differentiate
normal aging from disease
• Normal changes with aging reduce your
reserve capacity
• Aging results in a diminished ability to
maintain homeostasis and regulate body
systems
• Aging is accompanied by heterogeneity
8
Cardiovascular System
• The changes that normally occur in the
cardiovascular system with aging do not
significantly limit the normal work capacity of
the heart
• Advancing age increases the risk for
hypertension and coronary artery disease
9
Cardiovascular System
• The prevalence of coronary artery disease
at autopsy may reach 75 percent after the
sixth decade in men, two decades later in
women*
• The Baltimore Longitudinal study studied
highly screened older individuals and
found only a minimal impact of aging on
resting cardiovascular function such as
left ventricular ejection fraction**
*(Van de Veire NR, De Backer J. Ascoop AK, Middemacht B. Veighe A. Sutter JD. Echocardiographically estimated
left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals. Int. J.
Cardiovasc Imaging. 2006;22(5):633).
**Fleg JL, O’Connnor F. Gerstenblith G. Becker LC, Clulow J. Schulman SP, Lakatta EG.
Impact of age on the cardiovascular response to dynamic upright exercise in health men
and women. J Appl Physiol. 1995;78(3):890).
10
Cardiovascular System
• A study found that aging was accompanied
by an increase in LV mass and LA
dimensions and an increase in relaxation
abnormalities in normotensive individuals*
• Ageing was associated with increased mean
LV wall thickness, chamber diameter, mass,
concentric remodelling, and a decline in LV
diastolic function **
*(Van de Veire NR, De Backer J, Ascoop AK, Middernacht B, Velghe A, Sutter JD. Echocardiographically estimated
left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals. Int J
Cardiovasc Imaging. 2006;22(5):633).
**(Gates PE, Tanaka H, Graves J, Seals DR. Left ventricular structure and diastolic function with
human ageing. Relation to habitual exercise and arterial stiffness. Eur Heart J. 2003;24(24):2213).
11
Age-associated
Change
Common Clinical Consequence (s)
Valves calcium
deposits
Cardiac conduction problems
Pacemaker cell loss
(SA node)
Fibrous tissue/fat
deposits
Dysrhythmias
Baroreceptors
Orthostatic hypotension
Arteries thicken/stiffen
Ventricular
cardiomyocytes
hypertrophy
Moderate increase in SBP
Not normally aging:
Atherosclerotic plaques or HTN
12
Respiratory System
• Most of the normal respiratory changes with
age are of little functional significance in
healthy older adults
• However, the normal anatomical changes do
reduce reserve capacity and increase
vulnerability to respiratory disease
13
Respiratory System
• Aging chest wall changes include increased
stiffness of the chest wall predominates over
an increase in compliance of the lung
parenchyma*
• A decrease in PaO2 and increase in alevolararterial oxygen gradient is found in normal
aging lungs
• Carbon dioxide excretion is not impaired with
age and any changes in PaCO2 are due to
disease and should not be attributed to age
alone
*(Estenne M, Yernault JC, De Troyer A. Rib cage and diaphragm-abdomen compliance in humans:
effects of age and posture.J Appl Physiol. 1985;59(6):1842).
14
Age-associated
Change
Clinical Consequence (s)
Vital capacity reduced
FEV reduced
Chest wall compliance
reduced
Alveolar PO2 does not change with age,
but age increases the alveolar-arterial
(A-a) oxygen gradient.
Reduced alveolar
elasticity and reduced
number of functional
alveoli
Decrease surface area for gas exchange
Reduced exercise capacity and reduced
reserve capacity
Cilia activity reduced
Increased risk of respiratory infections
Glandular cells reduced
Lung macrophages less
effective
Cough less forceful
15
Renal System
• Most changes do not cause clinically
significant disease or disability, but they do
leave the kidney vulnerable to illness or
medications that can depress renal function
and lead to acute or chronic renal failure.
• Normal aging is associated with diffuse
sclerosis of glomeruli such that 30 percent of
glomeruli are destroyed by age 75 *
*(Nyengaard JR, Bendtsen TF. Glomerular number and size in relation to age, kidney weight,
and body surface in normal man. Anat Rec. 1992;232(2):194).
16
Age-associated Change
Clinical Consequence (s)
Renal mass and size reduced
Reduced the rate of blood flow
Average Creatinine clearance is
reduced 10ml/decade
Decrease in excretion of
drugs/toxins
Renal tubular cells reduced,
thickened tubular walls
Decreased ability to
concentrate urine
Thirst is blunted
Volume depletion
↓ serum renin and aldosterone
(30-50%)
Increased prostaglandins
Dehydration
Reduction of urine acidification
and impairment in excreting
Vulnerable to ischemic insult
Prone to nephrotoxicity
17
Hematopoietic System
• Maintains adequate function with aging
• Overall, cell counts and parameters in the
peripheral blood are not significantly
different from in young adult life
» Red cell life span, iron turnover, and blood
volume are unchanged with age
• EPO response to anemia in older subjects is
similar to that of younger subjects*
*(Powers JS, Krantz SB, Collins JC, Meurer K, Failinger A, Buchholz T, Blank M, Spivak JL, Hochberg M,
Baer A. Erythropoietin response to anemia as a function of age. J Am Geriatr Soc. 1991;39(1):30.)
18
Hematopoietic System
• Functional reserves are reduced with age
due to a decreased bone marrow mass and
an increase in fat*
• Total circulating white cells counts do not
change with age in healthy older people, but
the function of several cell types is reduced
*(Kirkland JL, Tchkonia T, Pirtskhalava T, Han J, Karagiannides I. Adipogenesis and aging:
does aging make fat go MAD? Exp Gerontol. 2002;37(6):757).
19
Hematopoietic System
• The compensatory hematopoietic response
to phlebotomy, hypoxia, and other stressors
is delayed and less vigorous in the healthy
older person
• Observational studies have shown
increasing hypercoagulabailty state with
aging
» Higher risk of DVTs*
*(Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol. 2006;60(2):144).
20
Immunologic System
• Immunosenescence - aging changes in
immune function:
» Diminished cell mediated immunity
» Increased incidence of anergy
» Reduced helper, cytotoxic and effector T cells
» Increased cytokine antagonists
» Changes in neutrophil and macrophage
function
21
Immunologic System
• Immunosenescence contributes to increased
frequency of infections, malignancies, and
decreased changes of developing adequate
immunity*
*(Agarwal S, Busse P. Innate and adaptive immunosenescence. J Ann Allergy Asthma Immunol.
2010;104(3):183).
22
Gastrointestinal System
• The physiologic changes of an aging GI
system are minor
• Aging itself does not cause malnourishment
• Normal aging changes:
» The amplitude of esophageal contractions
during peristalsis decreases, but the
movement of food is not impaired
» the prevalence of H.Pylori increases with
advancing age
» Transaminases and alkaline phosphatase are
minimally affected by age
23
Age-associated Change
Clinical Consequence (s)
Gastric cells reduced
Gastritis
Increased post prandial gastric
pH
Less effective mastication
Decreased food clearance
Increased risk of aspiration
Muscle tone reduced,
peristalsis reduced
Constipation
Hepatic size reduced, blood
flow reduced
Less efficient in metabolizing
drugs/toxins
24
Endocrine System
• Because the endocrine system is so complex
& interrelated it is difficult to discern the
effects of aging on specific glands
• In most glands there is some atrophy &
decreased secretion with age, but the clinical
implications of this are not known
• What may be different is hormonal action
25
The Endocrine System
• Hormonal alterations are variable & genderdependent:
• Most apparent in:
» glucose homeostasis
» reproductive function
» calcium metabolism
• Subtle in:
» adrenal function
» thyroid function
26
Genitourinary System
• Aging changes in the genitourinary system
increase the older person's risk of:
»
»
»
»
urinary incontinence
urinary tract infection
erectile dysfunction
dyspareunia
• The prevalence of urinary incontinence
increases with age due to:
»
»
»
»
decrease in detrusor muscle contractility
decrease in maximum bladder capacity
decrease ability to withhold voiding
an increase in postvoid residual
27
The Reproductive System
Men
•
Testes become softer & smaller
•
Prostate enlarges; fewer viable sperm are
produced & their motility decreases
•
May not experience orgasms every time they
have sex
•
Erections are less firm & often require direct
stimulation to retain rigidity
28
The Reproductive System
Women
• The “climacteric” occurs (defined as the period
during which reproductive capacity decreases (ie,
ovarian failure) then finally stops = loss of
estrogen & progesterone; FSH & LH ↑↑)
• This is also described as the transition from
perimenopause (~age 40s) to menopause
• Atrophy of vaginal tissues, hot flashes, sweats,
irritability, depression, headaches, myalgias,
sexual desire is variable
29
The Neurological System
• Increased:
• Reduced:
» Abnormal proteins
» Neurons
» Cerebral atrophy
» Neurotransmitter
levels
» Changes in sleep
patterns
» Lipid turnover rate
» Stroke risk
30
Neurologic System
• The weight of your brain peaks around age
20 and then a modest decline occurs with
age that is limited to the gray matter (outer
surface of the brain) in healthy older people
• Cardiovascular disease and hypertension are
predictors for cognitive impairment*
*(Newman AB, Arnold AM, Sachs MC, Ives DG, Cushman M, Strotmeyer ES, Ding J, Kritchevsky SB,
Chaves PH, Fried LP, Robbins J. . Long-term function in an older cohort--the cardiovascular health study
all stars study. J Am Geriatr Soc. 2009;57(3):432)
31
Sensory Changes
• As you age, your senses (vision, hearing,
taste, smell, touch) may become less acute
• The most dramatic sensory changes with age
affects vision and hearing
• Many of the changes can be compensated
for with assistive devices (e.g., glasses,
hearing aids, etc.) or by changes in lifestyle
32
Neurologic System
• As people age, they usually experience such
memory changes as slowing in information
processing, but these changes are benign
• Short-term and remote memories aren't
usually affected by aging; recent memory
may be affected
• Not progressive and does not interfere with
daily function or independence
33
Age-associated Change
Clinical Consequence (s)
Middle ear membranes and
bones less flexible
Decreased hearing sensitivity
Pupil size reduced
Lens becomes rigid
Decreased ability to focus at
near range, less tolerance to
glare
Ability to produce tears
reduced
Functional smell receptors
reduced
Dry eyes
Diminished sense of smell
Taste buds reduced in size
and numbers
Diminished taste
Touch receptors reduced,
response to painful stimuli
reduced
Diminished sense of touch
34
The Musculoskeletal System
• Sarcopenia: age-related loss of muscle mass
and strength
» Loss of muscle is greater and faster from the
legs than from the arms
» Activity may decrease rate of decline
» The loss of muscle contributes to age-related
changes in body composition, and distribution
for water soluble drugs*
• Type 1 slow-twitch fibers are less affected by
age than fast-twitch fibers
» Older muscle easily fatigues
*(Degens H. Age-related skeletal muscle dysfunction: causes and mechanisms. Musculoskelet
Neuronal Interact. 2007;7(3):246)
35
The Musculoskeletal System
• The primary factors contributing to reduction in
height include compression of vertebrae, changes
in posture, and increased curvature of the hips and
knees
• The “wear-&-tear” theory regarding cartilage
destruction & activity doesn’t hold up as
osteoarthritis is also frequently seen in sedentary
elders
• Decrease H20 in the cartilage of the intervertebral
discs results in a ↓ in compressibility and flexibility
• Decrease H20 content of tendons & ligaments
contributing to ↓ mobility
36
The Musculoskeletal System
• Gradual loss of bone mass (bone resorption
> bone formation) starting around age 30s
• Aging in both men and women increases the
probability of fracture and once a fracture
occurs, the rate of repair is slowed
• Vitamin D deficiency further accelerates bone
loss
• Increasing weight bearing time or loading
forces may result increase bone mineral and
prevent age-related bone loss*
*(Schwab P, Klein R. Nonpharmacological approaches to improve bone health and reduce osteoporosis.
Curr Opin Rheumatol. 2008;20(2):213).
37
Hair, Nails, and Skin
• Epidermal cells decreases by 10% per
decade and they divide more slowly making
the skin less able to repair itself quickly
» Epidermal cells become thinner making the
skin look noticeably thinner
» Thinning of the epidermis allows more fluid to
escape the skin
• Skin shears easy due to decrease in surface
area
• ↓ function of sebaceous & sweat glands
» dry skin
» reduced ability to cool the body
» wrinkles, sagging of skin
38
Hair, Nails, and Skin
• Mechanical protection altered
• Tendency to hypothermia
• Vulnerability to heat and cold
• Decreased barrier function
• Lax skin
39
Treatment Implications
• Consider earlier and more aggressive
treatment of infections BUT with attention to
renal function
• Pay closer attention to nutrition and bowel
function
• Pay close attention to CNS changes as
harbingers of other pathologies
• Screen carefully for metabolic disorders:
thyroid, anemias, bone disease, vitamin
deficiencies
40
Key Points:
• It is not always possible to differentiate
normal aging from disease
• Many of the normal changes of aging do not
cause clinically significant declines in function
• Changes in the cardiovascular, respiratory,
and gastrointestinal do not affect the ordinary
activities of a healthy older adult
41
References
•
Rughwani, N. (2008). Physiology of Aging. POGOe - Portal of Geriatric Online Education.
Retrieved February 21, 2011 from http://www.pogoe.org/productid/20284
•
GRS 7th edition – American Geriatrics Society
•
Van de Veire NR, De Backer J, Ascoop AK, Middernacht B, Velghe A, Sutter JD.
Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic
pressure in normotensive healthy individualsInt J Cardiovasc Imaging. 2006;22(5):633).
•
Fleg JL, O'Connor F, Gerstenblith G, Becker LC, Clulow J, Schulman SP, Lakatta EG.
Impact of age on the cardiovascular response to dynamic upright exercise in healthy men
and women.J Appl Physiol. 1995;78(3):890).
•
Gates PE, Tanaka H, Graves J, Seals DR. Left ventricular structure and diastolic function
with human ageing. Relation to habitual exercise and arterial stiffness. Eur Heart J.
2003;24(24):2213).
•
Estenne M, Yernault JC, De Troyer A. Rib cage and diaphragm-abdomen compliance in
humans: effects of age and posture. J Appl Physiol. 1985;59(6):1842).
•
Glomerular number and size in relation to age, kidney weight, and body surface in normal
man. Anat Rec. 1992;232(2):194).
42
References
•
Powers JS, Krantz SB, Collins JC, Meurer K, Failinger A, Buchholz T, Blank M, Spivak JL,
Hochberg M, Baer A. Erythropoietin response to anemia as a function of age.J Am Geriatr
Soc. 1991;39(1):30.
•
Kirkland JL, Tchkonia T, Pirtskhalava T, Han J, Karagiannides I. Adipogenesis and aging:
does aging make fat go MAD? Exp Gerontol. 2002;37(6):757.
•
Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol. 2006;60(2):144.
•
Degens H. Age-related skeletal muscle dysfunction: causes and mechanisms.
Musculoskelet Neuronal Interact. 2007;7(3):246.
•
Agarwal S, Busse P. Innate and adaptive immunosenescence. JAnn Allergy Asthma
Immunol. 2010;104(3):183.
•
Newman AB, Arnold AM, Sachs MC, Ives DG, Cushman M, Strotmeyer ES, Ding J,
Kritchevsky SB, Chaves PH, Fried LP, Robbins J. . Long-term function in an older cohort-the cardiovascular health study all stars study. J Am Geriatr Soc. 2009;57(3):432)
•
Schwab P, Klein R. Nonpharmacological approaches to improve bone health and reduce
osteoporosis. Curr Opin Rheumatol. 2008;20(2):213.
43
Acknowledgements and Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation. This information or content
and conclusions are those of the author and should not
be construed as the official position or policy of, nor
should any endorsements be inferred by The Donald
W. Reynolds Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine and the Department of
Family Medicine also provided support for this activity.
44
©The University of North Carolina at Chapel
Hill, Center for Aging and Health.
All Rights Reserved.
45
AGES Module 2:
Dementia
46
How to Teach about Dementia….
Debra Bynum, MD
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Does this Patient Have Dementia?
• 78 year old man is seen in the clinic for
routine follow-up. He is a retired physician
and is worried about memory loss. His
MMSE is 27. His son has started helping him
with his bills and other financial activities. On
exam, he has difficulty with word finding and
difficulty with “no ifs, ands, or buts….”
48
Does this Patient Have Dementia?
• 82 year old woman with a 6th grade
education presents for follow up. Her eye
sight is limited and the interview is
challenging because of her severe hearing
loss. Her MMSE is 20.
49
Does this Patient Have Dementia?
• 91 year old man is admitted to the hospital
with urosepsis. He is confused and upset.
His MMSE is 23.
50
Outline
• What is dementia?
• Risk factors and prevention
• Dementia, delirium, and depression: Red
flags
• Assessment tools and strategies
• Types of dementia
• Treatments
• Teaching about dementia….
51
Objectives
The learner will be able to:
•Define dementia
•Name risk factors/causes for dementia
•Discuss why delirium and depression are
predictors/red flags for dementia
•Discuss assessment tools/strategies for
identifying dementia
•Name at least 5 types of dementia
•Discuss the treatment options for dementia
52
What is Dementia?
• “I shall not today attempt further to define the
kinds of material I understand to be embraced
. . . but I know it when I see it . . .”
» Justice Potter Stewart, 1964, attempting to
define pornography….
53
DSM IV Definition
• Memory impairment associated with (at least 1):
» Aphasia (disturbance in language)
» Apraxia (impaired motor ability)
» Agnosia (inability to identify objects)
» Disturbance in executive functioning (ie, planning,
organizing, sequencing, and abstracting)
•
Impacts social, functional, or occupational
activities
• Decline from a previous level of functioning
• Does not occur solely in the setting of delirium
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
54
Key: Impact on Functional
Status/Life
•
Mild Cognitive Impairment: memory loss that
does not significantly impact daily functional
status
•
55
Key Point
• The score on the MMSE (or any other
assessment or screening instrument) is not a
component of the definition
• You can have a low MMSE and NOT have
dementia. You can have a nearly normal
MMSE and HAVE dementia
56
Importance
• Prevalence of dementia:
» 3% to 11% in those aged ~65 years
» 33% in those aged ~85 years
• Over half of all skilled nursing home admissions
in those aged >60 due to dementia
57
19th Century List of Causes of
Dementia….
58
2011: Risk Factors for Cognitive
Decline
• HTN (**)
• Diabetes
• Hyperlipidemia
• Current smoking
• HIV
• ETOH abuse
• Prior severe head trauma
• Genetic factors
59
Primary Risk Factor
• Age
60
Prevention?
•
No clear evidence to support preventing
cognitive decline with Vitamin E, Gingko
Biloba, leisure activities, fish oil, estrogen,
NSAIDS…..
•
Observational studies looking at lifestyle
changes, mental activity (crosswords, puzzles),
etc all challenging because of potential
selection bias
•
“Vitamin E is a drug looking for a disease….”
»
Dr. Zell Hoole
61
Prevention
• Preventing/treating HTN (*), DM,
hyperlipidemia, obesity, smoking in mid-life
• Prevention of both vascular and Alzheimertype dementias
62
The 3 D’s: (table from Postgraduate
Medicine, Volume 122, Issue 4, July 2010)
Features
Delirium
Dementia
Depression
Onset
Acute
Insidious
Subacute
Course
Fluctuating
Progressive
Related to
specific events
Duration
Days to weeks
Months to
years
Variable
Consciousness
Altered
Clear
Clear
Attention
Impaired
Normal, except
in severe
dementia
Normal
Psychomotor
changes
Increased or
decreased
Often normal
Decreased
Reversibility
Usually
Rarely
Usually
63
Reality…
Features
Delirium
Dementia
Depression
Onset
Acute
Can seem acute Can be
vascular and
acute
Course
Fluctuating
Function can
fluctuate (LBD)
Can fluctuate
Duration
Can be
months or
more
Can progress
quickly
Can last years
Consciousness
Altered
Can be altered
Can be altered
(psychotic)
Attention
Impaired
Impaired when
severe
Can have
psychoses
Psychomotor
changes
Increased or
decreased
Can be altered
(LBD)
Reversibility
Not always
(post CABG)
Rarely
Can be difficult
64
Dementia, Delirium, and Depression
•
Much emphasis in past made on
differentiation
•
Key points
1. Often tied together, can have overlap
2. Delirium and depression are markers for
underlying cognitive impairment and the
development of dementia
65
Late Life Depression:
Predictor of Dementia
•
Women’s Health Initiative Study: Depressive
disorder at baseline associated with double
risk of incident MCI and dementia
•
HYVET: Patients with baseline depression
had increased risk of mortality, CV mortality,
stroke, and dementia (the higher the GDS
score, the higher the risk)*
•
Late life depression may be early
manifestation of cognitive impairment
*Hypertension in the Very Elderly Trial, coordinated by scientists from Imperial College London, March 2008
66
Should We Screen?
• Prevalence of dementia in primary care
settings 6-15% in patients over age of 65
(increases with increasing age)
• <20% of patients with confirmed dementia on
screening had documentation of dementia
67
Assessment Tools for Dementia
68
If You Have 10 Minutes:
•
MMSE
• GPCOG (General Practitioner Assessment of
Cognition)
69
MMSE
• Commonly used and standardized
• Helpful when used repeatedly in same patient
• 30 total points
• Does not assess executive function,
judgment, insight
• Does not differentiate dementia, delirium,
learning disabilities
• Dependent upon age and education: Does
NOT perform as well in the very
educated/high functioning or the poorly
educated/lower SES
70
GPCOG (General Practitioner
Assessment of Cognition)
• Brief cognitive screening for general practice
• 9 item cognitive assessment (memory of
recent events and orientation)
• Plus 6 item informant questionnaire
• 6 minute test
• Sensitivity and specificity 85%
71
GPCOG: Patient Examination
1. Repeat name and address (John Brown, 42
West Street, Kensington): 0 points
2. What is the date?: 1 point
3/4. Clock Draw Test (CDT): Draw clock and
show 10 minutes past eleven: 2 points
5. Can you tell me something that happened in
the news this week?: 1 point
6. What was the name and address?: 5 points
Score: x/9 (0-4 suggest cognitive impairment, 58?, 9= normal)
72
GPCOG: Informant Examination
(If Patient Score 5-8)
1. Does the patient have more trouble
remembering things that have happened
recently?
2. Does the patient have trouble remembering
conversation a few days later?
3. Does the patient have more difficulty finding
the right word or tend to use the wrong words
more often?
4. Is the patient less able to manage money and
financial affairs?
5. Does the patient need more assistance with
transport?
Scores 0-3 suggest cognitive impairment
73
If You Have Only 3 Minutes…
Mini-Cog
74
Mini-Cog
• 3 minute test to screen for cognitive impairment
in older adults in the primary care setting
• 3 item recall plus scored Clock Drawing Test
(CDT)
» Normal clock
» Hand placed on correct time (10 minutes after
11)
» Untrained clinicians good at assessing normal
vs abnormal
• Faster and less affected by ethnicity, language,
and education than MMSE
• Can detect Mild Cognitive Impairment
(MCI)
75
Mini-Cog: Scoring
• 1 point for each recalled word
• CDT: normal or abnormal
• Score:
» 0: positive for cognitive impairment
» 1-2 abnormal CDT: positive for CI
» 1-2 and normal CDT: negative for CI
» 3: negative screen for dementia (no need to
score CDT)
76
If You Have 15 Minutes…
• MMSE or GPCOG plus
» Trails testing
» Categories and letters
» Clock drawing
77
Trails B Testing
• 1-A-2-B-3-C…
• Score based upon total time to complete task
correctly (seconds)
• Mean times
» 70-74: 111 seconds
» 75-79: 119 seconds
» 80-85: 152 seconds
78
Categories and Letter Naming
• Score number of animals or letters named in
60 seconds
• Mean scores:
» 70-79: 16 animals
» 80-89: 14 animals
» 90-95: 13 animals
• Animals: Alzheimer’s disease
• F words:
» Fronto-temporal dementias
» May elicit F-bombs….
79
Standard Workup….
• B12, HIV, RPR, TSH
• If more acute, think of encephalitis or more
atypical diseases
• Most recommend imaging if never done
before (unless longstanding dementia with
slow, typical decline)
» Rule out subdural
» Rule out NPH
80
Types of Dementia
• Alzheimer’s Disease
• Vascular Dementia
• Overlap (AD/Vascular)
• Fronto-Temporal Dementia
• Dementia with Lewy Body
• Dementia due to Parkinson’s Disease
• Other Parkinson Plus Processes
• ETOH
• HIV, Neurosyphilis, Prion Disease
81
Alzheimer’s Disease
• Gradual short term memory loss
• Personality changes
• Visuospatial problems: difficulty with clock
drawing
• Apraxia
• Medial temporal lobe atrophy on MRI
• Difficulty with naming categories (animals,
vegetables)
82
Vascular Dementia
• Classic: Step wise decline
83
Overlap
• Reality: Most cases of dementia in older
patients are mixed AD and Vascular (largest
risk factor for both is age)
• Vascular risk factors increase risk for AD as
well as vascular dementia
• Cholinesterase inhibitors work just as well (or
poorly) in patients with vascular dementia
and AD
84
Frontotemporal Dementia (FTD)
• Behavioral symptoms (disinhibition)
• Executive function problems
• Language dysfunction
• Frontal release signs
• Can occur in patients with motor neuron
diseases (ALS)
• Can have earlier onset and more often
familial than AD
85
Dementia with Lewy Body (DLB)
• 15-25% cases of dementia in patients >65
• Early visual (vivid) hallucinations
• Prior sleep disorders (may precede dementia by
years)
• Parkinsonian features (not overt tremor, but
some stiffness, cogwheeling)
• More rapid decline
• Decline with antipsychotics (especially typical
agents) AVOID!
• Fluctuating course (can resemble delirium
with good days and bad days)
86
Dementia with Parkinson’s
• 30 % or more of patients with Parkinson’s
disease will develop cognitive decline and
dementia
87
Parkinson Plus Syndromes
• DLB
• Multiple Systems Atrophy (Shy-Drager)
• Progressive Supranuclear Palsy
88
ETOH Related Dementia
• Can have associated cerebellar degeneration
• ETOH abuse often unrecognized in older
people
89
Impact of Dementia…
• Driving, loss of autonomy
• Loss of independence (IADLs, ADLs)
• Caregiver stress
• Wandering, behavioral problems, agitation,
sleep disturbances
• Risk for elder mistreatment
• Risk of placement (falls, incontinence,
behavioral)
• Falls and fractures
90
Treatment Options
91
Cholinesterase Inhibitors
• Benefits overall small: slowing of progression
of disease
• Similar benefits for AD and Vascular and
overlap
• No one agent better than another
• No evidence to justify use with MCI
92
Cholinesterase Inhibitors
• Donepezil 5 mg-10 mg
• Rivastigmine pill: 1.5 mg BID – 6 mg BID
• Rivastigmine patch: 4.6 mg/24 hrs – 9.5
mg/24 hrs
• Galantamine: 4 mg BID or 8 mg ER QD – 12
mg BID or 24 mg ER QD
93
Cholinesterase Inhibitors: Side
Effects
• Nausea (11-47%)
• Vomiting (10-31%)
• Diarrhea (5-19%)
• Anorexia (4-17%)
• Lesser known:
» hallucinations/odd dreams/nightmares
» Bradycardia
» Dizziness, tremor, leg cramps
» Urinary Incontinence
94
Memantine (Namenda)
• NMDA receptor antagonist/ neuroprotective
• Starting dose: 5 mg/day; goal 20 mg (10 mg
BID)
• Used in combination with cholinesterase
inhibitors for patients with moderate-severe
dementia
• Slowing of progression of disease, benefits
limited
• Costly, but few side effects or medication
interactions
95
Beware Antipscyhotics….
• FDA Black Box warning: increased mortality
and strokes
• Bottom line: may help with symptoms of
psychosis and aggression in selected
patients, but use with caution and recognize
risks
• Similar risk and warning with both typical
and atypical antipsychotics
• Side effects: orthostasis, lethargy,
confusion, QT prolongation, edema
96
Clinical Teaching
• See one (sometimes), do one, teach one
• Lectures
• Role modeling
• Clinical teaching
97
Role Modeling
• Informal (hidden, unwritten) curriculum
» Professionalism
» Teamwork
» Culture of the institution
• You are being watched…
98
Strategies for Clinical Teaching
• Canned 10 minute talks
» Condense this talk and save
• Thinking out loud/demonstrating
» Use the tools discussed/practiced here in
front of learners
» Can be useful in acute or busy situations
• One Minute Preceptor
99
One Minute Preceptor
• Get a Commitment: What do you think is
going on?
• Probe for supporting evidence: Why?
• Reinforce what was done well: You have a
thorough differential…
• Give guidance/correct errors: It is also
important to consider….
• Teach a general principle: When you see
this, you should always think of…
• Conclusion: Let’s go see…
100
One Minute Preceptor
• Assess the patient
• Assess the learner
• Focus teaching on one key point/pearl you
want to get across
• Give feedback
101
30 Second Preceptor….
• WHAT
» What do you think is going on?
• WHY
» Why do you think that?
• WHEN….
» When you see this, you need to think of ….
» Feedback
102
Practice Teaching Cases
• Pair up
• Take turns role playing the resident/learner
and the faculty/preceptor; Use one minute
preceptor skills to teach key points about
dementia
• Spend 10 minutes working through the 3
cases
• Wrap up discussion
103
Case 1
• 78 year old man is seen in the clinic for routine
follow-up. He is a retired physician and is worried
about memory loss. His MMSE is 27. His son
has started helping him with his bills and other
financial activities. On exam, he has difficulty
with word finding and difficulty with “no ifs, ands,
or buts….”
• You are precepting in the clinic
• The resident tells you that based on the MMSE,
the patient has Mild Cognitive Impairment…
• Does this patient have MCI? What teaching
point do you make to the resident and how?
104
Case 2
• 82 year old woman with a 6th grade
education presents for follow up. Her eye
sight is limited and the interview is
challenging because of her severe hearing
loss. Her MMSE is 20.
• Your resident is worried that the patient has
dementia and can no longer live at home.
• Does this patient have dementia? How would
you assess this? What would you tell your
resident?
105
Case 3
• 91 year old man is admitted to the hospital
with urosepsis. He is confused and upset.
His MMSE is 23.
• Your resident is worried that the patient has
dementia and will not be able to return home
after discharge.
• What do you tell your resident? What
teaching points can be made in this case?
106
Group Discussion
107
Case 1: Teaching Strategies
• “What do you think is going on? Why do you
think the patient has MCI and not dementia?”
• “What is the definition of dementia? Could
this patient meet that definition?”
• “When you see a high functioning, well
educated patient, the MMSE may not work
well. The diagnosis of dementia is not based
upon a number on the MMSE, but an
assessment that a patient’s memory loss and
cognitive impairment are affecting his overall
functional status”.
108
Case 2: Teaching Strategies
• “What do you think is the cause of her low
MMSE?”
• “Why do you think she has dementia? Are there
alternative reasons she may have done poorly on
the MMSE?”
• Feedback: You did a nice job in performing an
MMSE on this patient, and recognizing that
dementia may be a problem. But remember that
MMSE scores may be low for other reasons….
• When you see a patient with a low MMSE, think
about other factors such as vision, hearing, and
educational status that may be playing a role.
109
Case 3: Teaching Strategies
• “Why do you think this patient has dementia? What
else could be going on?”
• “What other diagnoses could account for his MMSE
score? Does the MMSE perform well in this setting?”
• Feedback: It is important to assess cognitive
impairment in older patients who are acutely ill, but
remember that acute delirium clouds the picture – you
cannot diagnose dementia in the setting of delirium
alone. But you are correct to be concerned because
the presence of delirium is a red flag for an underlying
dementia.
• When you see cognitive problems in a patient who is
acutely ill, think about delirium. When you see
delirium, it is a red flag for possible underlying
dementia as well.
110
Key Points:
• Dementia is common and often missed
• Vascular disease and dementia are intertwined
• Red flags for dementia: Age, depression,
delirium
• Screening tools are quick and easy to use and
teach
• Think about the different types of dementias…
• Dementia has incredible impact on functional
status
• Treatment options are still limited and do have
side effects
• Avoid antipsychotics if at all possible
111
Key Point
• Take what you have learned and teach…
in the clinic, in the ED, on the wards, by
modeling, by showing, by talking out loud…
112
Acknowledgements and Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation. This information or content
and conclusions are those of the author and should not
be construed as the official position or policy of, nor
should any endorsements be inferred by The Donald
W. Reynolds Foundation.
The UNC Center for Aging and Health and the UNC
Division of Geriatric Medicine also provided support for
this activity.
113
©The University of North Carolina at Chapel
Hill, Center for Aging and Health. All
Rights Reserved.
114
AGES Module 3:
Delirium
115
Delirium
Lindsay Wilson, MD
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Self-Test:
1. Delirium is associated with a _________-fold
increase in mortality in the hospital.
2. _________ is the most common complication
of hospital admission for older people.
3. Patients with delirium have an average
increase of _________ days in the length of
hospital stay.
4. If an appropriately trained person uses a brief
cognitive assessment, they can diagnose
delirium ________% of the time.
5. Up to ______% of cases in the hospital
are unrecognized.
117
How Did You Do?
1. Delirium is associated with a 10-fold increase
in mortality in the hospital.
2. Delirium is the most common complication of
hospital admission for older people.
3. Patients with delirium have an average
increase of 8 days in the length of hospital stay.
4. If an appropriately trained person uses a brief
cognitive assessment, they can diagnose
delirium approx 90% of the time.
5. Up to 70% of hospital cases are
unrecognized.
118
Goals
1. Define delirium and describe its cardinal
features and underlying pathophysiology
2. Recognize that delirium is common, underdiagnosed, and associated with significant
morbidity and mortality
3. Regarding delirium, know ways to:
»
»
»
»
prevent
diagnose
evaluate
manage
4. Feel comfortable with teaching key concepts
in < 1 minute
119
Goals
1. Define delirium and describe its cardinal
features and underlying pathophysiology.
120
Delirium Definition
Medical condition characterized by acute onset
of:
» Fluctuating course
» Altered level of awareness
» Inattention
» Disorganized thinking
» Increased or decreased psychomotor activity
» Disturbance of sleep-wake cycle
121
Pathophysiology
Image of black box or another image showing the multiple inputs to the
brain that cause delirium
122
Predisposing Factors
• Dementia
• Functional impairment
• Age
• Immobility
• Male sex
• Alcohol abuse
• Frailty
• Sensory impairment
• Malnutrition
• High medical comorbidity
• Depression
• Polypharmacy
• Terminal
illness
123
Precipitating Factors
• Medications
• Severe illness
• Neurologic disease
• Low Hct
• Surgery
• Bed rest
• Uncontrolled pain
• Indwelling devices
• Hypoxia
• Restraints
• Metabolic
derangements
• Sleep deprivation
• Dehydration
124
Tipping the Scale...
The greater the predisposing factors, the fewer
precipitating factors required to initiate the
delirium. Delirium is usually
MULTIFACTORIAL.
125
Prediction Models:
• Example by Inouye et al:
• Assign 1 point for each of four risk factors:
1) Vision impairment
2) Severe illness
3) Cognitive impairment
4) BUN:Cr > 18 (signifying dehydration)
• Those with 3-4 points have risk of delirium
32-83%.
• Other predictive models specific for certain
subsets of geriatric patients (ex. surgical
patients).
Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission
characteristics. Ann Intern Med 1993: 119 (6); 474-481.
126
Goals
2. Recognize that delirium is common, underdiagnosed, and associated with significant
morbidity and mortality
127
How many geriatric patients have
delirium?
• At presentation to the ED: 7-33%.
• At hospital admission: 14-25%.
• Postoperatively: 15-53%.
• In the ICU: 70-87%.
• In the community, ages 65-85: 1-10%,
those >85: 14% .
• At the end of life: Up to 83%.
128
Why under-diagnosed???
• 70% of cases go unrecognized!
• #1 cause is neglecting to determine the
acuity of change in mental status and
dismissing presentation as dementia.
• We ALL miss more of the hypoactive cases.
• Diagnosis is delirium unless otherwise
proven! Don’t be tempted to attribute the
presentation to dementia or depression.
129
Prognosis
• May persist weeks, months- 44% at 1 month,
33% at 3 months.
• Has a waxing and waning course.
• Has been associated with a
»
»
»
»
10-fold increased risk of death in the hospital
3-5 increased risk of nosocomial complications
prolonged length of stay
impaired physical and cognitive recovery at 6
and 12 months
» need for post-acute nursing home placement
• Has an associated one-year mortality rate of
35-40%!
130
Goals
3. Regarding delirium, know ways to:
»
»
»
»
prevent
diagnose
evaluate
manage
131
Prevention
• Preventing delirium is the most effective
strategy for reducing its frequency and
complications.
• At least 30-40% of cases may be
preventable.
• How do we prevent delirium???
132
Picture of person sleeping
Picture of hearing aids
Picture of a walker
Picture of a calendar
Picture of eye glasses
Picture of a beside toilet
Picture of a glass of water
Picture of earwax in ear
Picture of a clock
133
Prevention: Yale Delirium
Prevention Trial
• Demonstrated the effectiveness of intervention
protocol that included:
»
»
»
»
»
»
Orientation and therapeutic activities
Early mobilization
Nonpharmacologic approaches
Adaptive equipment
Early intervention for volume depletion
Sleep-enhancement protocol
• Development of delirium reduced from 15% to
9.9%
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older
patients. NEJM 1999; 340(9): 669-676.
134
Diagnosis
Picture of a patient or someone at the bedside
135
Diagnosis
*****CAM: Confusion Assessment Method*****
Based on the 4 cardinal elements of the DSM-3 criteria for
delirium:
1.
2.
3.
4.
Acute onset and fluctuating cource
Inattention
Disorganized thinking
Altered level of consciousness
Must have have 1 and 2 and either 3 or 4
Sensitivity 94%-100%
Positive LR 9.6
Specificity 90-95%
Negative LR 0.16
Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method
for detection of delirium. Ann Intern Med 1990: 113 (13): 941-948.
136
Feature 1. Acute Onset or
Fluctuating Course:
Must have this one!
•This feature is usually obtained from a family
member or nurse and is shown by positive
responses to the following questions:
•Is there evidence of an acute change in mental
status from the patient’s baseline? Did the
(abnormal) behavior fluctuate during the day,
that is, tend to come and go, or increase and
decrease in severity?
137
Feature 2. Inattention:
Must have this one!
• This feature is shown by a positive response to
the following question:
• Did the patient have difficulty focusing
attention, for example, being easily
distractible, or having difficulty keeping track of
what was being said?
138
Feature 3. Disorganized thinking—
May have this OR Feature 4
• This feature is shown by a positive response to
the folllowing question:
• Was the patient's thinking disorganized or
incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas,
or unpredictable switching from subject to
subject?
139
Feature 4. Altered Level of
Consciousness—May have this OR
Feature 3
• This feature is shown by any answer other
than “alert” to the following question:
• Overall, how would you rate this patient’s
level of consciousness?
»
»
»
»
»
alert
vigilant
lethargic
stupor
coma
140
Practice
Ms. G is a 73 year-old with mild Alzheimer's
dementia. She is a new admit to rehab after
surgery for a hip fracture. On morning rounds,
she continuously sits up, then lies back in bed,
picking at the bed sheets. Her family states that
she did not sleep at all last night. This morning,
she complained about "all the small children on
her bed." Her family says she is not herself. You
try to talk to the patient--she startles easily, then
seems distracted and unable to pay attention to
the conversation.
What risk factors does this patient have for
delirium? Is she CAM positive?
141
Diagnosis
*****GAR: Global Attentiveness Rating*****
Rate how easily patient can be engaged in a 2-minute
conversation
"How well did the patient keep his mind on interacting with
you during the interview?"
Supported by 1 study with geriatricians
Sensitivity 94%
Positive LR 65
Specificity 99%
Negative LR 0.06
O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc.
1997; 45(4): 470-473.
142
Diagnosis: Differentiating delirium
from dementia and psychiatric
conditions
Talk with family/caregivers to establish baseline
Observe the patient:
An acute change in mental status is NOT dementia
Rapidly fluctuating course is NOT typical for dementia
Abnormal level of consciousness is NOT typical for
dementia
But, the lines are blurry and the diagnosis becomes
more difficult in patients with dementia.
143
Evaluation: D.E.L.I.R.I.U.M
Drugs!!
Electrolyte/endocrine disturbances (dehydration, sodium
imbalance, uremia, hypercalcemia, hypoglycemia,
thyrotoxicosis)
Lack of drugs (withdrawal from ETOH, benzos or poor pain
control, B12 deficiency)
Infection (sepsis, meningitis, encephalitis)
Reduced sensory input (can't see or can't hear)
Intracranial (infection, hemorrhage, stroke, tumor)
Urinary, fecal (urinary retention, fecal impaction--can be a
cause!)
Major organ system issues-- infarction, arrhythmia, shock,
COPD, hypoxia, hypercapnia, renal failure, liver failure,
hypertensive encephalopathy
144
Evaluation
Picture of pills
Basics:
History
Physical exam
Targeted labs
Careful medication history
Alcohol, illicit drug use
Vital signs
Multiple factors likely involved rather than a single
"cause" but delirium can be the sole manifestation
of serious underlying disease.
145
If still looking...
LP
Blood cultures
UA/Urine culture
Urine toxicology
Cardiac enzymes and EKG
Arterial blood gas
Blood alcohol
Head CT
EEG
146
Practice: Our 73-year old
You are concerned that Ms. G has delirium. What do
you do to evaluate her delirium?
147
Additional History
Ms. G does not drink any alcohol. She does have
hearing loss and vision loss and usually wears
hearing aids and glasses. She has not had either
since being in the hospital. She has had trouble
making it to the bathroom to urinate. A couple of
times she has been incontinent. Also per hospital
records, she has not had a bowel movement
since being admitted (5 days ago). She has not
reported any pain over the last 24 hours.
148
Physical Exam
Vitals
T 98.9
Heart rate 83
BP 110/70
RR 14
Physical exam
CTA bil, nl wob
RRR, no MRGs
No LE swelling
Abd full, decreased bowel sounds, no tenderness to
palpation
Surgical wound appears CDI, no erythema/drainage
Neuro exam unremarkable
CAM +
149
Ms. G's Medication List
Lisinopril 5 mg q day
Percocet 5/325 mg q 6 hours as needed for pain
Benadryl 25 mg qhs as needed for insomnia
Aricept 10 mg q day
Aspirin 81 mg q day
Calcium + D two tablets twice daily
HCTZ 25 mg q day
150
Ms. G's tests
Na 129 (baseline 135)
K 4.9
Cr 1.3 (baseline 1.2)
WBC 10 (baseline 5)
Hgb 10 (baseline 11)
UA 2+ LE, + nitrites, WBC clumps
CXR clear
Postvoid bladder scan <10
151
Management of Delirium
First, try to remove/treat precipitants of delirium.
Provide frequent orientation and therapeutic activities.
Provide glasses and hearing aids.
Avoid constipation/urinary retention/dehydration/electrolyte
imbalances.
Avoid complete bed rest.
Educate family and nursing support staff of ways to comfort
patient.
Try scheduled tylenol, ice/heat packs, warm milk in place of meds.
152
Medications to Reduce or Eliminate...
Anticholinergics
Diuretics
Antidepressants
Benzos
Opioids
Anticonvulsants
Antiparkinsonian agents
Nonbenzodiazepine
hypnotics
(zolpidem)
Fluroquinolones
(levaquin)
Muscle relaxants
Antiemetics
Steroids
153
What is your plan for Ms. G?
154
Your management plan for Ms. G...
1) Stop benadryl!!
2) Have family bring in glasses and hearing aids...
and have patient wear them!!
3) Start patient on an aggressive bowel regimen.
4) Stop her HCTZ and monitor her sodium
closely.
5) Obtain urine culture.
6) Start antibiotic to cover UTI.
7) Stop percocet. Start patient on tylenol 1000
mg TID and oxycodone 2.5 mg-5 mg q 6 prn pain
depending on how concerned you are that she
may have pain.
8) Get patient out of bed to the chair by the
window. Have the family provide frequent
orientation.
9) Try other measures for insomnia.
155
About Restraints...
We DO NOT recommend restraints as they can cause
bad outcomes (even death!).
Always, evaluate the patient first.
Always, try other interventions first:
--Have family stay with patient
--Use a sitter
--Demonstrate calming the patient to those involved in the
patient care.
If medically necessary to the patient, use restraints for the
least amount of time possible and always inform the family
about why they are needed.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4):
405-8.
156
Pharmacologic Therapy, ie Chemical
Restraints
Consider only if safety is in issue or if patient's symptoms are
very distressing to the patient
High-potency antipsychotics (haldol) usually first-line
Use low dose and go slow
ex. 0.25 mg IV haldol or 0.5 mg po haldol
Use for shortest duration possible
Can see akathisia, which can be
mistaken for worsening delirium
157
Goals
4. Feel comfortable with teaching key concepts in < 1
minute
158
If you have 30 seconds...Delegate!
Ask the family, RNs, or your trusty medical students to
1) Turn on the lights or open the blinds during the
daytime
2) Keep the calendar and clock right
3) Re-orient the patient frequently
4) Get the patient out of bed to chair as much as
possible
5) Use eyeglasses, hearing aids
7) Distract, reassure the patient as needed to avoid
restraints
8) Get rid of foley asap
9) Monitor closely for pain (nonverbal clues)
10) Evaluate the patient before ordering restraints
(chemical or physical) and use only as a last resort
11) Monitor closely for constipation
159
If you have one minute...
Be a good role model!
*Assess all hospitalized elderly
patient's for delirium on a daily basis
*Use the language (the word "delirium")
*Keep it on everyone's radar
because medical students,
nurses, etc won't think it is a big deal unless you
do
*Minimize use of restraints (including catheters
and chemical restraints)
160
If you have 2 to 5 minutes...
1) Have a conversation with the patient
to assess for delirium (GAR)
2) Use CAM to assess for delirium
3) Canned talks, examples:
• Ways to prevent delirium
• Ways to manage delirium
• Definition of delirium
4) Use/review DELIRIUM mneumonic
161
Hopefully we met these goals...
1. Define delirium and describe its cardinal features and
underlying pathophysiology
2. Recognize that delirium is common, under-diagnosed,
and associated with significant morbidity and mortality
3. Regarding delirium, know ways to:
•
•
•
•
prevent
diagnose
evaluate
manage
4. Feel comfortable with teaching key concepts in < 5
minutes
162
Take-home points
Delirium is common, under-recognized and serious!!
Cardinal features are acute onset, fluctuating awareness,
impairment of memory and attention, increased or
decreased psychomotor activity, disturbance of sleepwake cycle and disorganized thinking.
Preventing and managing delirium is key to minimizing poor
outcomes for our geriatric patients.
Use CAM to diagnose delirium.
Remember D.E.L.I.R.I.U.M. for differential diagnosis.
Drug treatment should be reserved for patients who pose a
risk to themselves or others or who seem to be very
distressed by their symptoms (ie hallucinations, delusions).
163
Works cited
Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): 2833.
Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion:
the confusion assessment method. Annals of Internal Medicine, 113(12), 941-948..
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older
patients. NEJM 1999; 340(9): 669-676.
Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission
characteristics. Ann Intern Med 1993: 119 (6); 474-481.
Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165.
O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4):
470-473.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4):
405-8
Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, 2010Vol 304.
164
Acknowledgments and Disclaimers
This project was supported by funds from The Donald W.
Reynolds Foundation. This information or content and
conclusions are those of the author and should not be
construed as the official position or policy of, nor should any
endorsements be inferred by The Donald W. Reynolds
Foundation.
The UNC Center for Aging and Health and The Division of
Geriatric Medicine also provided support for this activity.
This work was compiled and edited through the efforts of
Carol Julian.
165
©The University of North Carolina at Chapel
Hill, Center for Aging and Health. All
Rights Reserved.
166
AGES Module 4:
Transitions of Care
167
Transitional Care: Coordinating Care
for our Most Vulnerable Patients
Michael A. LaMantia, MD, MPH
Indiana University Center for Aging Research
Regenstrief Institute, Inc.
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Case One – Mr. S
• Mr. S: Friday, 7:30pm
» 85 yo with PMHx of moderate dementia from
ALF
» No paperwork or MAR
» Patient can’t give chief complaint
» Person on call from the facility who knows
patient has gone home
» Grandson states patient has been coughing
and that doctor at facility suspected PNA
169
Case One – Mr. S
• PMHx:
» CAD
» Htn
» Moderate dementia
• Allegies: NKDA
• Meds: (grandson believes he remembers
these)
»
»
»
»
Metoprolol
Aricept
Aspirin 81 mg
Simvastatin
170
Case One – Mr. S
» PE: 130/70 76 18 96%RA afebrile
• Patient slightly confused (this is change from
baseline according to grandson)
• NCAT, PERRL, MMM
• Reg S1S2, no m/r/g
• Some very mild crackles at right base otherwise
clear, normal work of breathing
• Rest of exam: unremarkable
» Labs: WBC 10.0 hgb 12.0 hct 36.0 plt 350, N
8.7, L 1.0, E 0.3
» Blood chemistry: WNL
» CXR: Possible developing right lower lobe
infiltrate vs. atelactasis. Clinical correlation
recommended
171
Case One – Mr. S
• PORT score: 105 points --- Risk Class IV –
approximately 8-9% mortality
• You recommend hospitalization ---- but
• Grandson states he is HCPOA and patient
would not wish to be hospitalized. He wishes
to take patient home and care for him there.
Patient is confused but agreeable
• You prescribe course of levofloxacin and ask
that they see their provider on Monday
172
Case One - Resolution
• Patient goes home and does well for 3 days
• He does so well, family does not follow-up
with PCP on Monday
• Tuesday evening: Patient returns with skin
bruising and blood in his urine
» Plt: WNL
» INR: 7.2
• When the patient’s pills are brought from
home, it is discovered he is taking warfarin
173
Case One – Breakdown
• What went well?
• What could have gone better?
174
Transitional Care
• Definition:
“A set of actions designed to ensure the
coordination and continuity of healthcare as
patients transfer between different locations or
different levels of care within the same
institution.”
–American Geriatrics Society (2003)*
*Coleman EA, Boult C. Improving the quality of transitional care for persons
with complex care needs. Journal of the American Geriatrics Society. Apr
2003;51(4):556-557.
175
Transitional Care
• During transitions, patients are at risk for:
•
•
•
•
Medical errors
Service duplication
Inappropriate care
Critical elements of care plan “falling though the
cracks”
-AGS (2003)*
*Coleman EA, Boult C. Improving the quality of transitional care for
persons with complex care needs. Journal of the American
Geriatrics Society. Apr 2003;51(4):556-557.
176
Transitional Care
• Conceptual model of effective transitional
care (Coleman 2003)*:
• Communication between sending and receiving
clinicians
• Preparation of the caregiver and patient for
transition
• Reconciliation of medication lists
• Arranging a plan for follow-up of outstanding
tests
• Arranging an appointment with receiving
physician
• Discussing warning signs that might
necessitate more emergent evaluation
*Coleman EA. Falling through the cracks: challenges and opportunities for
improving transitional care for persons with continuous complex care needs.
177
Journal of the American Geriatrics Society. Apr 2003;51(4):549-555.
How to Improve Transitional Care
• Suggestions:
» Changes to health care delivery systems (i.e.
use of nurses to follow patients or expanding PACE
programs)
» Adoption of information transfer technology
» Changes to health care policy (i.e. pay for
coordination of care or make providers responsible for
coordinating transitional care)
178
How to Improve Transitional Care
• Society for Academic Emergency Medicine
(SAEM) Geriatric Task Force:
» Developed at recommendation of SAEM and
American College of EM
» Identify and adopt quality measures to allow
assessment of care provided to elderly
patients
» Quality measures were vetted by:
• SAEM Geriatric Task Force
• SAEM annual meeting
• American Geriatrics Society (AGS) annual
meeting
179
How to Improve Transitional Care
• Quality Measures 1-4:*
» If nursing home (NH) patient goes to ED, then
paperwork should state:
•
•
•
•
Reason for transfer
Code status
Medication allergies
Contact information for:
» NH
» Primary care or on-call MD
» Resident’s HCPOA or closest family
member
*Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic
Emergency Medicine 2009; 16:441-449.
180
How to Improve Transitional Care
• Quality Measures 5-6:
» If NH patient goes to ED, then paperwork
should include:
• Patient’s Medication Administration Record
» If NH patient goes to ED for requested
studies, then:
• Document the performance of requested tests
or the reason why such tests were not
performed
181
How to Improve Transitional Care
• Quality Measures 7-9:
» If NH patient goes to ED and then will be
released from the ED, then:
• ED provider should speak with the NH provider,
primary care or on-call MD for the NH prior to
discharge from the ED
» If NH patient goes to ED and then will be
released from the ED, then written paperwork
should state:
• ED diagnosis
• Tests performed with results (and tests with
pending results)
182
How to Improve Transitional Care
• Quality Measures 10-11
» If NH patient goes to ED and then is released
back to the NH, then:
• The patient should receive the recommended
follow-up
• The recommended changes to the patient’s
medications or plan of care should be followed
(or the reason why not followed documented)
183
Case 2 – Mrs. J
• Mrs. J: Thursday evening, 5:30pm
» 82 year old woman who presents from home
accompanied by home aide with complaint of
“fall” --- she was carrying packages in dept
store and tripped over a bed
» List of PMHx:
•
•
•
•
Early memory changes
Hx of atrial fibrillation
Hx of compression fractures
COPD
» Patient sees PCP at UNC --- records are up to
date
184
Case 2 – Mrs. J
• In speaking with patient, she complains of right
shoulder pain and is placed on backboard with C-collar
• CT of the neck shows acute comminuted fracture
involving the left articular pillar of C2
• Neurosurgery consultation obtained --- recommended
that patient stay in Miami J collar . (No f/u plan given)
• Patient released from the ED at 1:10am with nursing
aide –
• given prescription for vicodin
• advised to take ibuprofen also
• told to wear Miami J collar until released
• asked to follow-up with PCP – “call for next
available appointment”
185
Case 2 – Mrs. J
• Next day (~4pm), PCP receives call from the
patient’s granddaughter , asking about why
patient went to ED --- she heard her grandma
broke her neck and is surprised she is at
home
• Patient’s son (primary caregiver) is in
Bahamas
• Call to house reveals aide at home isn’t
familiar with brace
• Neighbor who is retired nurse finds collar up
around patient’s nose and the patient with
uncontrolled pain
• Patient instructed to return to ED for further
evaluation
186
Resolution
• PCP meets pt in ED and admits pt to
geriatrics service
• CXR shows Pthx developed in interim
• Patient hospitalized for several days
• Seen by neurosurgery in hospital and plan for
f/u developed
• Evaluated by PT/OT during hospitalization
• D/C’d home with additional help (son flew
home from Bahamas) and with close followup with PCP
187
Case Two– Breakdown
• What went well?
• What could have gone better?
188
Questions for Group
• What would it mean to provide truly great
transitional care to your patients?
• What are the barriers to providing improved
transitional care to the patients in your care
setting?
• What would it take to address these issues?
189
Thank You!
• Questions/Comments?
• My contact information:
Michael LaMantia, MD, MPH
Assistant Professor of Medicine
Indiana University Center for Aging Research
Regenstrief Institute, Inc.
410 West 10th Street, Suite 2000
Indianapolis, IN 46202-3012
Tel: 317-423-5621
Fax: 317-423-5653
190
Acknowledgements and
Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation/The John A. Hartford
Foundation Geriatrics for Specialists Grant. This
information or content and conclusions are those of the
author and should not be construed as the official
position or policy of, nor should any endorsements be
inferred by The Donald W. Reynolds Foundation
and/or The John A. Hartford Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine, the UNC Department of
Emergency Medicine, and the American Geriatrics
Society also provided support for this activity. This
work was compiled and edited through the efforts of
Carol Julian.
191
© The University of North Carolina School at
Chapel Hill, Center for Aging and Health.
All Rights Reserved.
192
AGES Module 5:
Basics of Geriatric Assessment
&
Levels of Care
193
Geriatric Assessment
Anthony J. Caprio, MD
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Objectives
1) To illustrate the importance of physical,
cognitive, and psychosocial assessments
for older adults
2) To describe Activities of Daily Living
(ADLs) and Instrumental Activities of Daily
Living (IADLs)
3) To demonstrate gait assessment and falls
risk assessment with an older adult
4) To demonstrate cognitive and depression
screening with an older adult
195
Function, Function, Function
• In real estate it’s “location,” in geriatric assessment the
focus is on function
• Physical Functioning
•Gait and balance
•Ability to perform daily self-care activities
• Cognitive Functioning
•Memory, reasoning, and judgment
•Ability to perform “life-maintenance” activities
• Psychosocial Functioning
•Depression and mental health
•Adequate caregiver support
•Financial resources
196
What Does Every Practitioner Need
to Know?
• Overall functional assessment or impression: Big
Picture
• Ask questions, but..
• Don’t just tell me, show me. (performance-based
testing)
• Make careful observations!
• Trust your gut, if something doesn’t look right, it
probably isn’t
• Screen and know when to refer for further evaluation
197
Asking About Function
"Can you tell me what your typical day is like?”
•
•
•
•
•
•
•
•
•
When do you get up?
What do you do in the morning?
Do prepare your own meals?
How many meals do you usually eat?
Do you get out of the house? Shopping? Church?
How do you spend the rest of the day?
Do you watch TV? Read?
When do you go to bed?
Are you generally satisfied with how you spend your
days?
198
Activities of Daily Living (ADLs)
Dressing
• Transferring
Eating (feeding)
• Walking
Ambulating (transferring)
• Toileting
Toileting (continence)
• Bathing
• Dressing
Hygiene (bathing)
• Eating (feeding)
Independent
Partially Dependent
Dependent
• Continence
199
Instrumental Activities of
Daily Living (IADLs)
Shopping
Housekeeping
Accounting
Food preparation
Transportation
• Driving or using the bus
(transportation)
• Using the telephone
• Managing medications
• Buying groceries
• Preparing meals
• Housework, laundry
• Paying bills, managing
money
Independent
Partially Dependent
Dependent
200
Why are ADLs/IADLs Important?
• ADL impairment is a stronger predictor of hospital
outcomes than admitting diagnoses, Diagnosis
Related Group (DRG), or other physiologic indices of
illness burden
• Functional decline
• Length of stay
• Institutionalization (nursing home placement)
• Death
• Approximately 25% to 35% of older patients admitted
to the hospital for treatment of acute medical illness
lose independence in one or more ADLs
• Implications for discharge planning and post-acute
care
201
Best Test is a “Real World”
Performance Test
• Easy to perform in an office/clinic/hospital room
• Easy to evaluate (can do, can’t do, or time to completion)
• Can be integrated into what you do already
• Provide objective information about a person’s actual
function in daily living
• Assessment starts the minute you start observing the
patient.
202
Assessing Function
• Perform a task
• Walk over to the exam table
• Get on/off the exam table
• Unbutton sleeve, take shirt off
• Put shirt back on, button sleeve, tie shoes
• Standardized tests
203
Assessing Physical Functioning:
Gait and Risk for Falling
• 35-40% of community-dwelling older adults
fall each year
• 10 to 15% of falls result in a fracture or other
serious injury
• 72% of all fall-related deaths are in the age
65+ population
• Approximately 40-70% of fallers develop fear
of falling
Risk Factor
Relative Risk (RR) for Falls
Leg Weakness
4.4
Gait Deficit
2.9
Impaired ADL
2.3
Depression
2.2
Cognitive Impairment
1.8
204
Timed “Get Up and Go" Test
• Patient sits in a chair, rises and walks ten
feet (3 meters), turns, and returns to the chair
• Should be able to do this in <20 seconds, if
>30 seconds functionally dependent (higher risk for
falls)
• Identifying fallers: Sensitivity and Specificity = 87%
• Abnormalities in mobility should prompt referral for
physical therapy or a further diagnostic work-up
• Predicts ADL disability and nursing home admission
Phys Ther. 2000;80:896 –903.
J Am Geriatr Soc 2010;58:844–852.
J Am Geriatr Soc 2004;52:1343–1348.
205
To link the video
(POGOe Product #18920
http://www.pogoe.org/vi
deo/3454) in Microsoft
PowerPoint 2010,
download the video just
as you have this
curriculum and save to
the same folder.
Timed “Get Up and Go”
Select the image to the
left. Go up to your
insert tab and select
“add a hyperlink.”
Select the the video file
you downloaded from
POGOe. On the left,
select the first option,
for “existing file or web
page.” Then navigate to
way to the file that I
need. Select that file and
click ok.
Now test your link by
going up to the top
menu again and
choosing the slide show
tab, then starting from
the current slide.
Be sure to delete these
instructions before
presenting.
Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine.
206
Chair Rise
• Use a standard chair with arms
Picture of chair
• Ask the subject to rise from the chair
• If they are able to do that, then ask them to rise from the
chair without the assistance of pushing-off of the arms of
the chair with their hands
• It may be helpful to have the subject fold their arms
across their chest during the maneuver
• Proximal muscle weakness, including trunk and proximal
thighs, makes this maneuver difficult and is a risk factor
for falls
• Can be timed (should take <15 seconds for 5 repetitions)
207
To link the video
(POGOe Product #18920
http://www.pogoe.org/vi
deo/3455) in Microsoft
PowerPoint 2010,
download the video just
as you have this
curriculum and save to
the same folder.
Select the image to the
left. Go up to your
insert tab and select
“add a hyperlink.”
Select the the video file
you downloaded from
POGOe. On the left,
select the first option,
for “existing file or web
page.” Then navigate to
way to the file that I
need. Select that file and
click ok.
Now test your link by
going up to the top
menu again and
choosing the slide show
tab, then starting from
the current slide.
Be sure to delete these
instructions before
presenting.
208
Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine
.
Cognitive Evaluation
• Prevalence of cognitive impairment
• 3% among persons ≥65 years of age
• Doubles every 5 years
• 40-50% among persons ≥90 years of age
• Unrecognized cognitive impairment
• Adherence to medications or treatment plans
• Difficulty navigating the health care system
• Caregiver stress
• Most common causes of cognitive impairment
• Delirium
• Dementia
• Depression
209
Delirium: More Than “Confusion”
• Sudden and fluctuating change in cognition
• Altered way of perceiving the world
• Hallucinations or delusions
• Might be disoriented
• Agitated or excessively sleepy
• Conversations don’t make sense
210
Confusion Assessment Method
(CAM)
1) Acute onset and fluctuating course
and
2) Inability to focus (inattention)
3) Disorganized thinking
or
4) Change in the level of consciousness
211
Folstein Mini-Mental State Exam
(MMSE)
• Orientation
• Registration/Recall (3 objects)
• Attention and Calculation
(WORLD  DLROW, serial 7s)
• Language (naming, repetition, 3 stage command,
reading, writing)
• Visual-Spatial (Copy Design)
212
Interpretation of MMSE Scores
• Score < 24 considered abnormal
• Ranges: 20-25 Mild impairment
10-20 Moderate impairment
0-10 Severe impairment
• Depends on literacy and native language
• Adjustments have been made for:
• Age
• Educational level
213
Mini-Cog
• 3 item recall after clock drawing task (CDT)
• Easy to administer
• Sensitivity: 76-99%, Specificity: 89-93%
• Not as dependent on education and language
J Am Geriatr Soc 2003; 51:1451-1454
Ann Intern Med 1995; 122:422-429
214
Mini-Cog
3 Items
1-2 Items
Recalled
0 Items Recalled
POSITIVE
SCREEN
Normal Clock
Drawing
Abnormal Clock
Drawing
POSITIVE
SCREEN
215
Clock Drawing Test:
“10 Minutes After 11”
216
Clock Drawing Test:
Mild Impairment
217
Clock Drawing Test:
Right-Sided Neglect
218
Severely Impaired Clock Drawing
219
At the End of an Encounter…
Teach-back method:
“We discussed a lot of things today and I want
to make sure that I explained things well, can
you summarize what we talked about today?”
“So let’s review our plan. What will you do
when you get home today? What will you do
before our next visit? How will you take this
medication?”
220
Psychological Assessment
• Prevalence of major depression
• Outpatient primary care: 6% - 10%
•
•
Inpatient : 11% - 45%
Persons aged ≥65
•
•
<13% of the populations
25% of suicides
221
Screening for Depression
• Single Question: “Do you often feel sad or
depressed?”
• Sensitivity 69-85%
• Specificity 65-90%
• 2-Item Screening
• Depressed Mood:
"During the past month, have you often been bothered
by feeling down, depressed, or hopeless?"
• Anhedonia:
"During the past month, have you often been bothered
by little interest or pleasure in doing things?“
• Test is negative for patients who respond "no" to both
questions
222
Geriatric Depression Scale (GDS)
• Long (30-item) and short forms (15 or 5 items)
• GDS 15-Item Screen:
Score > 5 points suggests depression
• Sensitivity 97%
• Specificity 85%
223
Case 1
• 86 yo female presents to the emergency
department with a two-day history of nausea,
vomiting, and unsteadiness.
• She lives independently in the community.
• Her ECG shows atrial tachycardia (rate=150)
with AV block.
• Patient’s medication list includes digoxin
0.125mg po daily.
• Labs show normal renal function but a
critically high digoxin level.
224
Case 2
• 88 yo male is admitted for elective surgery.
• He had an unremarkable pre-op evaluation one week
prior to admission. He was considered low risk for the
planned surgical procedure.
• The surgery was uneventful, but in the PACU, the
patient is very agitated and confused. He is trying to
get out of bed to “catch a train”.
• His nurse calls the resident because she is concerned
that he may have had a stroke during the procedure.
A stat head CT is negative for an acute process.
225
Case 3
• 78 yo female sustained a mechanical fall at home with
a left foot fracture and right wrist fracture.
• She is given a walking boot for her foot and a splint for
her wrist. No surgical intervention is indicated.
• She lives alone and insists that she will be just fine at
home.
• Her daughter lives about an hour away but will check
on her on the weekends and help with grocery
shopping.
226
Basic Geriatric Assessment
1) Functional Impairments
 Activities of Daily Living (ADLs)
 Instrumental Activities of Daily Living (IADLs)
2) Gait and Fall Risk Assessment
 Timed “Get Up and Go” Test
 Chair Rise
3) Cognitive Assessment
 Confusion Assessment Method (CAM)
 Mini-Cog
 Teach-back method
4) Depression Screen
 One or Two-item questions
 Geriatric Depression Scale (GDS)
227
Acknowledgments and Disclaimers
This project was supported by funds from The
Donald W. Reynolds Foundation. This
information or content and conclusions are
those of the author and should not be construed
as the official position or policy of, nor should
any endorsements be inferred by The Donald W.
Reynolds Foundation.
The UNC Center for Aging and the UNC Division
of Geriatric Medicine also provided support for this
activity. This work was compiled and edited through
the efforts of Carol Julian.
228
© The University of North Carolina at Chapel Hill,
Center for Aging and Health. All Rights Reserved.
229
AGES Module 6:
Iatrogenic Injury
230
Latrogenic Injuries in Geriatrics
Christine M. Khandelwal, DO
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Learning Objectives
• Learners will be able to list the most common
types of iatrogenic injuries.
• Learners will be able to identify the most
common cause of nosocomial fever in the
hospital.
• Learners will be able to identify the reasons
for use of restraints and how to avoid using
them.
• Learners will be able to list the appropriate
use of urinary catheters.
232
The Case of Mrs. TW
Mrs. TW is a 79yo female with
history of HTN, MCI, and
urge incontinence, who
was admitted for a
pneumonia. She is stable
on admission and sent to
the floor with a foley
catheter in-place.
Mrs. TW has an uneventful 24
hours, clinically stable and
doing well with plans for
discharge the next
morning to home.
Copyright © 2011 Lighthouse
International All rights reserved.
233
BACKGROUND
• Cascade iatrogenesis is a series of adverse
events triggered by an initial medical or
nursing intervention initiating a cascade of
decline.
» Occurs most frequently among the oldest,
most functionally impaired patients and those
with a higher severity of illness upon
admission.
»
Creditor 1993, Hofer 2002, Thomas 2000
234
BACKGROUND
• Hospitalization for the elderly is often followed
by an irreversible decline in functional status
and a change in quality and style of life.
 Elders are at high risk for poor outcome
 High 1 year mortality
 Thirty percent (30%) functional decline
 High rates of skilled nursing facility placement
Creditor 1993, Hofer 2002, Thomas 2000
235
Iatrogenesis in Older Patients
• Age-related factors that predispose the older
patient to iatrogenesis
• More co-morbid, chronic medical conditions
that require more diagnostic procedures and
medications
• Increased severity of illness and complexity
of care
• Longer length of stay
Hofer 2002, Thomas 2000
236
Elderly Are the Most Likely to
Suffer…
Adverse Drug Events
Delirium
Nosocomial Infections
Falls
Procedural/Surgical Complications
237
Adverse Drug Events
• Most common type of iatrogenic injury
• Predictors
» > 4 meds
» LOS > 14 days
» > 4 active medical problems
• # of drugs is the strongest predictor;
potential for interaction: 2 drugs 6%, 5
drugs 50%, ≥ 8 drugs nearly 100%
• 70-80% of ADEs in the elderly are dose
related
• 30-50% preventable!
Carbonin P et al. 1991
238
Adverse Drug Events
• Other ADE Predictors:
Multiple medical problems
Multiple medications
New medications added
Low weight, female gender, impaired
creatinine clearance
Carbonin 1991;Thomas and Brennen BMJ 2000
239
Adverse Drug Events
Common Drugs
Common Effects
Anticholinergics
Mental Status
Psychotropics
Urinary Complications
Sleepers
Infections
Narcotics
Gastrointestinal
Digoxin
Falls
Anti-hypertensives
240
The Case of Mrs. TW
Twenty four hours after
admission, nursing staff call
to report that Mrs. TW is
“yelling out and trying to catch
the butterfly in the hall.” With
further report from the nurse,
the patient has a fever.
Staff is requesting to keep Mrs.
TW “quiet tonight” as they are
short-staffed and will not be
able to control her tonight.
What is the source of her
fever? Could this have been
prevented?
Copyright © 2011 Lighthouse
International All rights reserved.
241
Delirium
• Delirium is one of the most common
iatrogenic complications in hospitalized
elders affecting 50% or more post-operative
hip fracture and thoracic surgery patients
over age 65.
• We don’t diagnose it!
Elie 1998, Ely 2004, Inouye 1996, Inouye 2006, Pompei 1994
242
Risk Factors for Delirium
•
•
•
•
•
•
•
•
•
•
Age ≥ 70 years
Existing cognitive impairment
Functional impairment
Alcohol abuse
Abnormal preoperative level of sodium,
potassium or glucose
Preoperative psychotropic drug use
Depression
Increased comorbidity
Living in a long-term care facility
Visual or hearing impairment
243
Preventing Delirium
• At least 3 clinical trials suggest that
minimizing risk factors in hospital can reduce
delirium
» Pain, sleep, hydration, orientation, minimizing
tubes and lines, minimizing problem drugs
Inouye 1999, Marcantonio 2001, Millsen 2001
244
Treatment for Delirium
• Almost no drug studies of established
delirium
• Most experts would use traditional or atypical
antipsychotic agents in low dose for agitated
delirium treatment
» What about anticholinesterase inhibitors?
(Donepezil use in the prevention and treatment of postsurgical delirium did not prevent delirium.)
Liptzin 2005, Sampson 2007
245
Nosocomial Infections
• Infections are usually related to a procedure
or treatment used to diagnose or treat the
patient’s initial illness or injury
• 36% of these are preventable!
UTIs
Pneumonia
Surgical wound infections
Clostridium difficile colitis
246
Urinary Catheters
• 25% of hospitalized pts have indwelling
catheter
• Associated with  LOS,  inpatient mortality
• Inappropriate for over 50% of inpatient days
• Uncomfortable / Restrictive
Jain 1995, Saint 1999
247
Urinary Catheters
• Catheter-associated urinary tract infections
(CAUTIs) represent the most common
nosocomial infection, accounting for 40% of
all hospital-acquired infections.
• Foley catheters are commonly placed without
a compelling indication, and are a
preventable cause of hospital-acquired
infections.
Saint 2000, Saint
2002
248
Indications for Urinary
Catheterization
• Output monitoring of unstable patients
• Complete urinary retention
• Urinary incontinence in patients with wounds
or skin defects
• Urinary incontinence in general is not an
indication for catheterization, but it may be
considered for patient comfort at the request
of the patient or family
• Terminally ill patients
• Perioperative use
249
If Not a Foley…What Instead?
• Prevention and Treatment –
» Plan may include reviewing medications
(opiates, anti-cholingerics, diuretics, alphaadrenergic agonists, calcium-channel blockers
are offenders)
» Treat UTI (contributes to urge incontinence)
» Treat constipation
» Seek any reversible causes of delirium
» Regular toileting schedule
250
The Case of Mrs. TW
Wrist restraints were placed
on Mrs. TW to help
maintain her delirium
tonight. Three hours later,
nursing staff calls you to
report a fall for Mrs. TW.
You order a stat hip x-ray
and an acute fracture is
found.
What was the cascade of
events? Could any of this
been prevented?
Copyright © 2011 Lighthouse
International All rights reserved.
251
Why are Restraints Used?
•
•
•
•
Prevent falls
Prevent injuries
Prevent treatment disruption
Manage confusion
AGS Positional statement 2008, Tzeng 2008, Antonelli 2008
252
AGS Positional Statement:
Restraints are acceptable to use:
• If there is no safer alternative
• If patient is at significant risk of self-harm or
injury to others
• At the patient's request
• Short-term use to enable emergent treatment
that may result in a less confused patient
American Geriatrics Society, AGS
Position statement: Restraint use.
2008
253
To Restrain or Not to Restrain…
• Restraints are associated with:




increased rates of pressure sores
increased incidence of nonsocomial infections
distress
falls
American Geriatrics Society, AGS
Position statement: Restraint use.
2008
254
If Not a Restraint…What Instead?
• Non-pharmacological
»
»
»
»
Cognitive
◦ Orientation (calendar, caregiver names)
◦ Activities (cognitively stimulating)
Sleep
• ◦ Regular routine
• ◦ Sleep aids (relaxing music, massage)
• ◦Environmental (eliminate noise, night-time
meds)
»
»
»
»
Mobility (range of motion, limit IV’s, etc)
Visual Aids (glasses, large dial phones)
Hearing Aids (check ear wax)
Volume repletion for dehydration
Inouye 1999
255
Pharmacologic Treatment
• No medication is FDA approved for the
treatment of delirium
• No published double-blind, randomized,
placebo controlled trials
» ◦ Few controlled trials
» ◦ Small numbers
» ◦ Various patient populations
cancer, AIDS, hip fractures
post-op, ICU,
Slide from Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San
Francisco and San Francisco, VA Medical Center
256
Reduce Falls
•
Reduce restraint use / lower bed rails
•
Prevent delirium
•
Sensor alarms
•
Lower the bed
•
Non-slip shoes
•
Remove obstacles
•
Commode / toilet schedule
Gillespie 1997, Myers 2003, Currie 2006
257
Falls
• Falls frequently occur in hospitals, and the
patients most likely to fall are older patients
• Approximately 2% to 12% of patients
experience at least one fall during their
hospital stay
• These complications often result in a longer
length of stay and lead to greater healthcare
costs
Chelly 2008, Bates 1995, Alexander 1992
258
Fall Risks
•
•
•
•
•
•
Visual impairment
Hypotension / anti-hypertensives
Anticholinergics / sedative-hypnotics
Obstacles / slick surfaces
Elevated bed height
Confinement ….restraints!
Gillespie 1997, Myers 2003
259
Fall Prevention Strategies
• Unfortunately, there are no specific
recommendations to reduce the risk for falls
in the acute care setting.
• However, some fall prevention strategies in
the literature appear to offer an overwhelming
reduction in the incidence of falls among
hospitalized elderly patients.
American Geriatrics Society, British Geriatrics Society, and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention 2011
260
Fall Prevention Strategies
• Frequent and varied staff education and reeducation to promote and sustain sensitivity
to the risk for falls among hospitalized elders.
• Tools to assess risk for falls. Because most
patients' fall risks are multifactorial and the
factors are intertwined, the most effective
strategies will be interdisciplinary.
• The use of "sitters" for confused patients.
American Geriatrics Society, British Geriatrics Society, and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention 2011
261
Conclusion
• Avoidance of unnecessary Foley catheter
placement is an important method to reduce
nosocomial infections.
• Immobilizing patients during hospitalization is
contrary to therapeutic goals of restoring
normal mobility and function as quickly as
possible.
• The number and severity of falls can be
reduced by adopting quality improvement
strategies, relevant and practical fall risk
assessment tools, and staff education.
262
Acknowledgements and Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation, the American Geriatrics
Society/The John A. Hartford Foundation Geriatrics for
Specialists Grant. This information or content and
conclusions are those of the author and should not be
construed as the official position or policy of, nor
should any endorsements be inferred by The Donald
W. Reynolds Foundation, the American Geriatrics
Society or The John A. Hartford Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine, the UNC Department of
Emergency Medicine, and the UNC Department of
Family Medicine also provided support for this activity.
This work was compiled and edited through the efforts
of Carol Julian.
263
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older
adults. Am J Public Health 1992;82:1020–1030.
American Geriatrics Society. AGS position statement: restraint use. 2008;
www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml.
American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons
Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc.
2011;49:664-672.
Antonelli MT. Restraint management: moving from outcome to process. J Nurs Care Qual. Jul-Sep
2008;23(3) 227-232.
Bates DW, Pruess K, Souney P et al. Serious falls in hospitalized patients: Correlates and resource
utilization. Am J Med 1995;99:137–143.
Carbonin P, Pahor M, Bernabei R, Sgadari A. Is age an independent risk factor of adverse drug reactions in
hospitalized medical patients? J Am Geriatr Soc 1991;39(11):1093-9.
Chelly, JE, Conroy L, Miller, Gregory E, Marc N, Horne JL, Hudson, ME. Risk Factors and Injury Associated
With Falls in Elderly Hospitalized Patients in a Community Hospital J Am Geriatr Soc 56:29–36, 2008.
Creditor, MJ. Hazards of hospitalization of the elderly. Annals of Internal Medicine. 1993;118:219-223.
Currie LM. Fall and injury prevention. Annu Rev Nurs Res. 2006;24:39-74.
Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a
systematic review. J Am Geriatr Soc. 2006;54:1578-89.
Elie, M., Cole, M. G., Primeau, F. J., & Bellavance, F. (1998). Delirium risk factors in elderly hospitalized
patients. Journal of General Internal Medicine, 13, 204–212. Evidence Level I: Systematic Review.
Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E., Jr., et al. (2004). Delirium as a
predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American
Medical Association, 291, 1753–1762.
Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing
falls in elderly people. Cochr Database Syst Rev. 1997;CD000340.
Hofer, TF, Hayward, RA. Are bad outcomes from questional clinical decisions preventable medical errors? A
case of cascade iatrogenesis. Part 1. Annals of Internal Medicine. 2002;137.
Inouye, SK (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157-1165. Evidence
Level VI: Expert Opinion.
Inouye, SK, Bogardus, SK, Charpentier PA, Leo-summers L, Acampora, D, Holford, TR, Cooney LM. A
Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patient. N Engl J Med 1999; 341369-370.
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Inouye, S. K., & Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons:
Predictive model and interrelationship with baseline vulnerability. Journal of AMA, 275, 852–857.
Jain P JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical
patients. Arch Int Med. 1995; 155:1425-1429.
JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med.
2000;109:476-480.
Liptzin B, Laki A, Garb JL, et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J
Geriatric Psychiatry 2005; 13:1100-6.
Marcantonio E.R., Flacker J.M., Wright R.J. & Resnick N.M. Reducing delirium after hip fracture: a
randomized trial. Jol of the Am Geriatrics Society 2001.49, 546-522.
Millisen K., Foreman M.D., Abraham I.L., De Geest S., Godderis J., Vandermeulen E., Fischier B., Delooz
H.H., Spessens B. & Broos P.L. A nurse-led interdisciplinary intervention program for delirium in elderly hipfracture patients. Jo of the Am Geriatrics Society 2001.49, 516-522.
Myers H, Nikoletti S. Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk
assessment tools in predicting patient falls. Int J Nurs Pract. 2003;9:158-16.
Pompei, P., Foreman, M., Rudberg, M. A., Inouye, S. K., Braund, V., & Cassel, C. K. (1994). Delirium in
hospitalized older persons: Outcomes and predictors. J of the Am Geriatrics Society, 42, 809–815.
Saint S LB, Goold SD. Urinary catheters: A one-point restraint? Ann Int Med. 2002;137:125-127.
Saint S LB. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Int Med.1999;159:800808.
Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary
catheters? Am J Med. 2000;109:476-480.
Sampson ELA randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for
reducing the incidence of postoperative delirium after elective total hip replacement. .Int J Geriatr Psychiatry.
2007;4:343-9.
Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk
among older adults in community, home-support, long-term and acute care settings. Age Ageing.
2007;36:130-139.
Thomas E, Brennen T. Incidence and types of preventable adverse events in elderly patients: Population
based review of medical records. British Medical Journal, 2000, 320, 741-744.
Tzeng HM, Yin CY, Grunawalt J. Effective assessment of use of sitters by nurses in inpatient care settings. J
Adv Nurs. Oct 2008;64(2):176-183.
Vassallo M, Poynter L, Sharma JC, Kwan J, Allen SC. Fall risk-assessment tools compared with clinical
judgment: an evaluation in a rehabilitation ward. Age Ageing. 2008;37:277-281
265
© The University of North Carolina at
Chapel Hill, Center for Aging and Health.
All Rights Reserved.
266
AGES Module 7:
Palliative Care Communications
267
Palliative Care:
Addressing Communication &
Symptom Needs
Gary Winzelberg, MD, MPH
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Objectives
•
•
•
•
•
Address Palliative Care misconceptions
Palliative Care: What, Why, Where, Who
Review outcomes of Palliative Care
Present general communication strategies
Discuss pain assessment and management
principles for older adults
269
Geriatrics-Palliative Care
G
PC
270
Palliative Care is not…
•
•
•
•
•
the same as Geriatrics
the same as hospice
the hospice referral service
end-of-life care
the “getting the DNR” service
271
What is Palliative Care?
• Interdisciplinary care focused on relief of
suffering
• Support for best-possible quality of life for
seriously ill individuals and their family
caregivers
» Based on patient and family needs and goals
» Independent of illness severity & prognosis
» Complements disease-based evaluation and
treatment
• Palliative care is about care catching up with
the technology -- daughter of a patient
• www.getpalliativecare.org
272
Palliative Care in the Illness Trajectory
Murray S A et al. BMJ 2005;330:1007-1011
273
Why do we need Palliative Care?
• Seriously ill patients and their families receive
poor-quality medical care
»
»
»
»
Untreated symptoms
Unmet psychosocial and personal care needs
Caregiver burden
Low patient and family satisfaction
• 27% of Medicare spending (133 billion) spent
on hospital services
• 10% Medicare beneficiaries account for > 50%
of total program spending
Meier DE. Milbank Quarterly 2011.
274
Palliative Care Components
• Symptom assessment & management
• Facilitate decision-making
» Treatment goals
» Treatment preferences
» Hospital transition preferences & options
• Patient & family support
»
»
»
»
Information
Coordinate physician communication
Emotional
Spiritual
275
Where is Palliative Care offered?
• Hospital
» # of hospitals with PC team increased from 658
(25%) to 1,568 (63%) from 2000-09
» More likely in large (>300 bed) hospitals: 85%
» Joint Commission advanced certification (2011)
• Clinic
» UNC Supportive Care clinic for oncology
patients
• Nursing home
» Programs may be independent or exist within
hospice programs
• Barriers to growth: reimbursement, role
misconceptions
276
Complementary Services
•
•
•
•
Anesthesia Pain service
Comprehensive Cancer Support Program
Department of Pastoral Care
Hospice
277
Hospice & Palliative Medicine
• Established as medical subspecialty in 2006
• Co-sponsoring specialty boards:
Anesthesiology
Pediatrics
Emergency Medicine
Physical Medicine & Rehabilitation
Family Medicine
Psychiatry & Neurology
Internal Medicine
Radiology
Obstetrics & Gynecology
Surgery
• Fellowship training required after 2012
• 3,075 certified physicians
278
UNC Palliative Care Program
• Hospital-based consultation
• 386 new patients in 2010
• Requesting Service:
» 20% Oncology
» 19% Surgery
» 15% Gen Med
• Primary diagnosis
»
»
»
»
55% cancer
14% neurologic
8% cardiac
8% pulmonary
279
Patient Disposition Post-Consult
280
Patient “GW”
• 41 year old with metastatic colon cancer
• Diagnosed six months ago
• Six admissions over last three months for pain,
fever, anemia (Surgery, Hospitalist)
• Receives approx. 2x/month PRBC transfusions
• Uncontrolled pain despite fentanyl patch and
oxycodone at home
• Nausea & emesis
• Feels down, passive suicidal ideation
» Unable to play with six year old son
» Hospital bed in living room
281
Palliative Care Involvement
(6 day hospitalization)
• Hydromorphone PCA
» Concerns re: fentanyl absorption & cost
» Significant improvement in pain
» After two days, rec: switch to MS Contin
• Scheduled metoclopramide
• Discussed antidepressant with Psychiatry
• Home hospice initially considered
» Willingness to support transfusions
• Patient expressed fears of dying at home
• Pain worsened, concern for obstruction
• Transitioned to inpatient hospice
282
Palliative Care Improves Quality
RCT cancer care with palliative care comanagement from diagnosis vs standard cancer
care only for patients with metastatic NSCLC
•Improved quality of life
•Reduced major depression
•Reduced “aggressiveness” of care
» Chemotherapy < 14 days before death
» No hospice care
» Hospice < 3 days before death
•Improved survival (11.6 vs 8.9 months)
Temel et al. Early palliative care for patients with NSCLC. NEJM 2010;
363: 733-42
283
Palliative Care Improves
Quality & Value
• Improves family satisfaction with care
» Improved pain, dignity, communication, treatment
» Earlier consultations associated with higher
satisfaction
• Average per-patient per-admission net cost
saved by hospital consultation = $2,659
• Improves quality of communication,
documentation of treatment preferences
Casarett JPSM 2010; Gade JPM 2008; Zimmerman JAMA 2008;
Morrision Arch Intern Med 2008
284
Factors [Possibly] Associated with
Prolonged Survival
• Reduction in symptom burden, including
depression
• Avoidance of hospitalization & high-risk
interventions
• Improved support for family caregivers
» Permits patients to remain safely at home
Meier DE. Milbank Quarterly 2011
285
Symptom Assessment
“Review of Symptoms”
•
•
•
•
•
•
•
•
Pain
Dyspnea
Nausea
Constipation
Anorexia and cachexia
Anxiety
Depression
Delirium
286
Communication Needs
• Information
»
»
»
»
What’s happening next?
Breaking bad news
Prognosis
Care options
• Decision-making
»
»
»
»
Assessment of decision-making capacity
Advance care planning
Goals of Care
Treatment preferences (including code status)
• Support
» Responding to emotions
» Acknowledge caregiver burdens
287
Breaking Bad News
1. Getting started
»
»
Physical setting
Participants
2. Finding out how much the patient knows
3. Finding out how much the patient wants to know
4. Sharing the information
»
»
Warning shot
Give information in small chunks
5. Responding to the patient’s feelings
6. Planning and follow-through
»
Be explicit
Buckman R. How to Break Bad News. 1992
288
Prognosis
• Has anyone talked to you about what to
expect? What do you think is ahead?
• Are there reasons that you need to know?
» Unfinished business
» Upcoming life cycle events
• Do you have any sense of how much time is
left?
• Although every patient is different, in general,
patients with your condition live…give range
» Avoid point estimate
» Emphasize uncertainty
289
Goals of Care
• What are patient and family priorities?
• Longevity
• Function
»
»
»
»
Physical
Cognitive
Safety
Avoid nursing home placement
• Comfort
• What goals do you have for the time you
have left?
• What would be left undone if you were to die
this week?
290
Responding to Emotions
NURSE
1.Name the emotion
»
You sound frustrated
2.Understand
»
I can’t imagine what it’s like to be so sick
3.Respect
4.Support
5.Explore
»
ASK – TELL – ASK
291
Responding to Emotions
NURSE
1.Name the emotion
»
You sound frustrated
2.Understand
»
I can’t imagine what it’s like to be so sick
3.Respect
4.Support
5.Explore
»
ASK – TELL – ASK
http://depts.washington.edu/oncotalk/
292
“Wish” Statements
• Instead of stating “I’m sorry”
» Confused with pity or an apology
» Shortcuts deeper understanding
• Empathic statement
» Wish for different circumstance
» Acknowledge emotional impact of loss
» Aligns physician with patient and family
• Desired outcome unlikely to occur
• Doesn’t specify what can be done
• May initiate deeper level of conversation
• I wish we had treatments that could turn things around
• I wish I had better news to give you
Quill TE et al. Ann Intern Med 2001
293
Patient “PC”
• 85 year old male, PMH: Alzheimer’s disease,
CHF, HTN
• Hospitalized after hip fracture (4th in past year)
• Postoperative course: pneumonia, delirium,
pressure ulcers
• Losing weight, unable to participate in therapy
• 84 year old wife feels overwhelmed
• Primary physician frustrated by frequent
readmissions
Morrison RS. Meier DE. NEJM 2004
294
Distinct Palliative Care Needs
of Older Adults
•
•
•
•
Pain assessment and management
Prevalence of delirium
Impact of cognitive impairment
Role of family caregivers
» Direct care
» Surrogate decision-makers
295
Pain is common for older adults
• 40-80% of nursing home residents
» 15% have daily moderate-severe pain
• 29% of nursing home residents with
advanced cancer have daily pain
» 26% receive no pain medication
Ferrell BA. JAGS 38:409; Bernabei JAMA 279:1877
296
Patient & Family Barriers
•
•
•
•
Pain is normal when you’re old
Value stoicism, “being strong”
Fear of addiction
Communication problems
» Unable to talk
» Confusion, dementia
Ferrell BA JAGS 38:40; Bernabei JAMA 279:18
297
Health Professional Barriers
•
•
•
•
•
Pain is normal when you’re old
Older adults feel less pain
Don’t recognize chronic persistent pain
Older adults can’t tolerate pain medications
Legal risks of using opioids
» NC Boards all endorse right to effective pain
control
298
Pain Is Undertreated
• 18-24% bereaved family members believe
pain was undertreated
» 19% in hospital
• 41% of cancer patients undertreated
» Primary risk factor age > 70
Hanson JAGS 45:1339; Teno JAMA 291:88; Cleeland NEJM 330:592
299
Pain Assessment
• Patients with dementia may be capable of
reporting pain
»
»
»
»
Words easier than numbers
Ask in the present – Are you in pain now?
Ask several ways – pain, discomfort
Give time to respond
• Non-verbal
» Behavior change – more passive vs restless
» Ask about/observe behavior during care
300
Goals of Pain Treatment
• Complete elimination of pain may or may not
be the appropriate clinical goal
• Primary goals are:
» Reduce suffering
» Improve daily functioning
» Avoid additional harms
301
Non-Medication Treatments
• Use for every patient in pain
»
»
»
»
»
»
Music
Decreased noise OR added distractions
Massage
Warm or cold packs
Repositioning, exercise
Emotional and spiritual support
302
Medication Choice
• Medication based on cause, physiology,
severity, frequency, and toxicity
» Combining medications at low dose can
increase effect with fewer side effects
» PRN medication is for pain that is infrequent
» Scheduled medication is for pain that is
usually present
303
Before Medication
• Assess baseline mental status exam
• Know concurrent chronic illnesses
» Hepatic function: fentanyl appears safe, use
caution with other opioids
» Renal function: fentanyl & methadone appear
safe; use caution with other opioids
» Hydration status
304
Opioid Side Effects
• Side effects that improve on stable dose
» Sedation, confusion
» Nausea
» Respiratory depression
• Side effects that persist but are treatable
» Constipation
» REMEMBER BOWEL REGIMEN
• Side effect that requires opioid change
» Neurotoxicity
305
Opioid Dosing in Older Adults
• Consider using lower starting dose, increasing
dosing interval
» Example: Oxycodone 2.5 mg vs 5 mg
• Remember that every older adult is an
individual
• Both opioids and pain are associated with
delirium
306
Family Caregiver
Roles & Burdens
• Competing responsibilities
» Work
» Parent, spouse
•
•
•
•
•
Direct care (48 hour day)
Surrogate decision-maker
Financial hardship
Emotional impact -- depression
Increased mortality risk (Schulz R. JAMA 1999;282)
307
Surrogate Decision-Making
• Approx. 1/3 experience emotional burdens
» Stress, anxiety, depression
» Guilt over decisions made
» Doubt regarding whether right decisions made
• Negative effects may last months or years
• Potential for beneficial effects
» Supporting the patient
» Feeling a sense of satisfaction
• Knowing patient’s preferences lessened
negative effect
Wendler D. Rid A. Ann Intern Med 2011.
308
“PC”
• Pain management
» Scheduled acetaminophen, prn vs scheduled
oxycodone
» Reassess every 24-48 hours
• Communicate with wife, family regarding
PC’s condition and care goals
» Approx. 50% six-month mortality risk
» Trial of rehabilitation vs transition to comfortexclusive approach
» Anticipate complications – how to manage?
» Address feeding concerns
309
If you have 1-5 minutes…
• Address misconceptions about Palliative
Care on rounds
• Review medication list – PRN may mean
“patient receives nothing”
• Consider Palliative Care consultation for
patients with:
» Inadequate symptom control
» Complex decision-making
» Emotional needs (patient and/or family)
310
If you have 15 minutes…
• Perform symptom assessment
• Inquire about patient and family
communication needs
» Information
» Decision-making
» Support
311
If you have 15-30 minutes…
• Communicate with patient and family about
goals of care
• Observe learner’s communication and
provide feedback
312
Summary
• Patients and families have unmet
communication and symptom needs
• Palliative Care is an important resource for
seriously/chronically patients, families and
health professionals
• Cognitive impairment impacts pain
management and communication with older
adults
313
Acknowledgements and Disclaimer
This project was supported by funds from The
Donald W. Reynolds Foundation Grant. This
information or content and conclusions are those
of the author and should not be construed as the
official position or policy of, nor should any
endorsements be inferred by The Donald W.
Reynolds Foundation.
The UNC Center for Aging and Health and the
UND Division of Geriatric Medicine also provided
support for this activity. This work was compiled
and edited through the efforts of Carol Julian.
314
© The University of North Carolina School of
Medicine at Chapel Hill, Center for Aging
and Health. All Rights Reserved.
315
AGES Module 8:
Polypharmacy
316
Medication Use in the Older Patient
Anthony J. Caprio, MD
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Objectives
1) Identify risk factors for Adverse Drug Events
(ADEs) in older adults
2) Identify the physiologic changes associated with
normal aging that influence pharmacokinetics
and pharmacodynamics
3) Recognize ADEs when an older adult presents
with a new clinical condition or complaint
4) Avoid potentially harmful medications for older
adults
5) Utilize strategies for shortening medication lists
and carefully introducing new medications
318
Mrs. Anderson
• 87yo female from nursing home; fell last night with
complaint of left hip and back pain
• Unable to recall events, agitated; says “yes,” when
asked if she is in pain. Seems very confused
• Reportedly able to ambulate short distance with walker
at baseline, needs assistance with dressing, bathing,
toileting. Able to feed herself
• Note from nursing home about rectal bleeding 2 days
ago
• Electronic medical record indicates that she was in the
ED last month for a heavily bleeding laceration after a
fall and supratherapeutic INR of 5.6 (while on
antibiotics for a urinary tract infection)
319
Past Medical History
1)
Dementia (MMSE 20/30)
12) Osteoarthritis, especially
hips and knees
2)
Parkinson’s disease
3)
13) Macular degeneration
CVA with residual L-sided
weakness
14) Type 2 DM
4)
Osteoporosis
15) Peripheral neuropathy
5)
Urinary incontinence
16) Chronic renal insufficiency
6)
Recurrent UTIs
17) Anemia
7)
Hypertension
18) Hypothyroidism
8)
CAD s/p stent 2 years ago
19) COPD on oxygen
9)
CHF (EF 30%)
20) Diverticulosis
10) Atrial Fibrilation
11) Hyperlipidemia
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Medications
Picture of pills
1)
Donepezil (Aricept) 5mg po Daily
18)
Docusate sodium 100mg po BID
2)
Carbidopa/Levodopa 10/100 po TID
19)
PEG powder (Miralax) 17g po Daily
3)
Aspirin 325mg po Daily
20)
4)
Warfarin (Coumadin) 5mg po qHS
Tiotropium (Spiriva) 18mcg inhaled
Daily
5)
Tolterodine (Detrol) 2mg po BID
21)
Montelukast (Singulair) 10mg po Daily
6)
Atorvastatin (Lipitor) 40mg po qHS
22)
Fluticasone/Salmeterol (Advair) 100/50
inhaled BID
7)
Insulin (long-acting and sliding scale)
23)
8)
Gabapentin (Neurontin) 300mg po TID
Albuterol/Atrovent nebulizers prn
wheezing
9)
Iron sulfate 325mg po TID
24)
Multivitamin one po Daily
10)
Trazodone 50mg po qHS
25)
Vitamin E 400 IU po Daily
11)
Levothyroxine 50mcg po Daily
26)
Calcium Carbonate 500mg po TID
12)
Furosemide (Lasix) 60mg po BID
27)
Vitamin D 800 units po Daily
13)
Potassium Chloride 20meq po Daily
28)
Nitrofurantoin (Macrodantin) 100mg po
qHS
14)
Metoprolol 100mg po BID
15)
Lisinopril 20mg po Daily
16)
Amlodipine 10mg po Daily
17)
Acetaminophen 1000mg po TID
321
Challenges of Prescribing
for Older Adults
Multiple medical conditions
Multiple medications
Multiple prescribers
Different metabolisms and responses
Adherence and cost
Supplements, herbals, and over-the-counter
drugs
Lancet. 1995;346(8966):32–36.
322
Lots of Medications
and Little Evidence
• 2/3 of older adults are on regular medications
• Adults age >65 account for 1/3 of all
prescriptions, but only represent 15% of the
US population
• Older adults are frequently not included in
clinical trials, which makes it difficult to
predict drug metabolism or drug effects
Health Care Financ Rev. 1990;11:1-41.
323
Dangers of Multiple Medications:
“Polypharmacy”
• Adverse effects (side effects)
• Drug-drug interactions
• Duplication of drug therapy
• Poor adherence
» Cost
» Decreased quality of life
324
Adverse Drug Events (ADEs)
• Adverse symptoms
• Adverse clinical outcomes
»
»
»
»
»
Doctor visits or hospitalizations
Falls
Functional decline
Changes in cognition (delirium)
Death
• Poor adherence, poor quality of life
• Increased cost
325
Most Common Medications Causing
ADEs
•
•
•
•
•
•
•
•
Antibiotics
Analgesics
Anticoagulants
Antihistamines
Anticonvulsants
Antipsychotics
Cardiovascular meds
Diabetic meds
JAMA 2006; 296:1858–1866
JAGS 2004;52:1349–1354
NEJM 2003;348:1556–64
326
Prevalence of ADEs
•
•
•
•
35% of community-dwelling older adults
5-28% of inpatient geriatric admissions
2/3 of nursing home patients (over 4 years)
In the emergency department:
» 2.0 per 1000 for adults under 65
» 4.9 per 1000 for aged 65 years or older
» 6.8 per 1000 for aged 85 years or older
JAGS 1997;45:945-948
JAGS 1996;44:194-197
Am Pharm Assoc 2002;42:847-857
JAMA 2006; 296:1858–1866
327
Potential Risk Factors for
Adverse Drug Events (ADE)
>6 chronic disease
>12 doses/day
≥ 9 medications
Low BMI (<22kg/m2)
Age >85 years
Creatinine clearance < 50 mL/min
History of prior ADE
328
Consult Pharm 1997;12:1103–11.
Is Mrs. Anderson at Risk for an ADE?








6 chronic disease
>12 doses/day
≥ 9 medications
Low BMI (<22kg/m2) likely
Age >85 years
Creatinine clearance < 50 mL/min possibly
History of prior ADE
Nursing home resident
329
Why is Mrs. Anderson at Risk?
• Multiple drugs (high “exposure” )
» Risk of ADE is proportional to number of drugs
» Increased probability of drug-drug interactions
• Physiologic changes (increased susceptibility)
» Associated with disease states
» Associated with NORMAL AGING
330
Physiologic Changes
with Normal Aging
• Less water
• More fat
Picture of Jack LaLanne
• Less muscle mass
• Slowed hepatic metabolism
• Decreased renal excretion
• Decreased responsiveness and
sensitivity of the baroreceptor
reflex
331
Absorption
• Not affected by the normal aging process
• Can be altered by drug interactions
» Antacids
» Iron
• Can be effected by disease
» Lack of intrinsic factor (B12 absorption)
» Delayed gastric emptying
332
Distribution
• Less water = ↓ volume of distribution
Higher concentration of water soluble drugs
• More fat = ↑ volume of distribution
Prolonged action of fat-soluble drugs
(increased half-life)
• Lower serum proteins (like albumin) increases
the concentration of unbound (free or active)
form of drugs
333
Metabolism
• Slowed Phase I, cytochrome P450, reactions
» Oxidation, reduction, dealkylation
» Warfarin and phenytoin levels may be higher
because of altered metabolism
• Phase II reactions are essentially unchanged
» Conjugation, acetylation, methylation
• Drug-drug interactions
» Increased risk with increased number of drugs
334
Excretion
• Hepatic
• Renal
» Renal clearance may be reduced
» Serum creatinine may not be an accurate
reflection of renal clearance in elderly
patients.
(decreased lean body mass)
• Active drug metabolites may accumulate
» Prolonged therapeutic action
» Adverse effects
335
Physiologic Changes
Associated with Disease States
• Cardiac disease
» Impaired cardiac output (decreased
absorption, metabolism, clearance)
» Greater susceptibility to cardiac adverse
effects
• Kidney and liver disease
» Decreased drug clearance and altered
metabolism
• Neurological diseases
» Diminished neurotransmitter levels
» Greater susceptibility to neurological
effects
336
Why Did Mrs. Anderson Fall?
• Functional status
» Uses walker at baseline
» Dependent in other ADLs (like bathing)
• Sensory impairments
» Macular degeneration
» Peripheral neuropathy
• Neurological diseases
» Dementia
» Parkinson’s Disease
• Co-morbid diseases
» Cardiovascular (syncope)
» Diabetes mellitus (hypoglycemia)
» Anemia (hypotension)
337
Orthostatic Hypotension, Falls,
and Hip Fractures
• Baroreceptor sensitivity decreases with age
• Trazodone
» New medication according to nursing home med record
» Associated with orthostatic hypotension
• Diuretic use can cause volume depletion and orthostatic
hypotension
• Falls and hip fractures are associated with significant
morbidity and mortality in older adults
338
Why is Mrs. Anderson Confused?
• Head injury?
» Contusion on forehead
» Recent history of supratherapeutic INR
• Dementia
» Moderate dementia by history
» What is her baseline?
• Delirium
» Infection (history of UTIs)
» Drugs (Adverse Drug Event)
» Hospital (change in environment)
339
Delirium
• More than confusion
» Acute onset, fluctuating course
» Inattention
» Disorganized thinking or altered level of
consciousness
• Associated with low levels of acetylcholine
» Low levels in patients with dementia at
baseline
» Risk with use of anticholinergic medications
340
Anticholinergic Medications
• Drug classes
• Antihistamines
• Tricyclic antidepressants
• Antispasmodics and muscle
relaxants
Diagram of the parasympatheic nervous system.
• Adverse effects
•
•
•
•
Dry Mouth
Urinary retention
Constipation
Delirium
341
Pharmacologic Tug-of-War
•
Tolterodine (Detrol)
» Potent anticholinergic
» Relaxes detrusor muscle to treat urge incontinence
(detrusor hyperactivity; “overactive bladder”)
» Can worsen delirium, constipation
•
Donepezil (Aricept)
»
»
»
»
•
Acetylcholinesterase Inhibitor
Higher levels of acetylcholine may help improve cognition
Can cause detrusor hyperactivity and diarrhea
Could cause symptomatic bradycardia and syncope (also
on β-blocker)
Incontinence and falls
» Dementia is a risk factor for both incontinence and falls
» Incontinence may be an ADE related to Donepezil
» Diuretic use can worsen incontinence and cause orthostatic
hypotension
342
Principle 1: “Think Drugs”
Before Making a New Diagnosis
• Consider adverse drug effect as etiology of
new signs/symptoms
• Consider discontinuing or dose-reducing
medications
• Avoid prescribing a new medication to treat an
adverse drug effect (“Prescribing Cascade”)
• Remember that over-the-counter drugs,
supplements, and herbals can be the culprit
Picture of prescription pad
343
344
Slide courtesy of Anthony Caprio, MD
Common Conditions Could
Really Be Adverse Drug Effects
Constipation 
Calcium Channel Blockers; Iron
Incontinence 
α-blockers
Memory loss 
Antihistamines
Syncope
Tricyclics, α-blockers
Falls 
Benzodiazepines
Weight loss 
Fluoxetine (Prozac)
345
Mrs. Anderson: Acute Management
• Pain
» Morphine 2mg iv x 2 doses for pain
» More comfortable after the 2nd dose
• Nausea and vomiting
» Complains of “sick stomach”
» Vomits repeatedly
• Agitation
» Increasingly agitated, trying to climb out of bed
» Shouting “Veronica” repeatedly
346
What Do You Prescribe?
•Pain
•Nausea
•Agitation
347
Beers Criteria
• A consensus-based list of potentially
inappropriate medications for older adults
• The Beers criteria were published 1991 and
revised in 1997, 2002, and 2012
• Statistical association with adverse drug
events has been documented
• Does not account for the complexity of the
entire medication regimen
J Am Geriatrics Society, 2012
Online link to this article is: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
Pharmacotherapy 2005;25(6):831–838
348
Beers Criteria: Potentially Inappropriate
Medications for Older Adults
• Table 2: Organ System or Therapeutic
Category or Drug
» Describes concern for prescribing certain drugs or classes
of drugs for older adults
» Rationale, recommendation, quality of evidence, and
strength of recommendation
•
Table 3: Due to Drug-Disease or DrugSyndrome Interactions
» Describes drugs or classes of drugs that can cause or
worsen a particular disease or syndrome
» Rationale, recommendation, quality of evidence, and
strength of recommendation
J Am Geriatrics Society, 2012
Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
349
Pain Medications
• Caution with non-steroidal anti-inflammatory
drugs (NSAIDS)
» Indomethacin has significant CNS side effects
» Ketorolac (Toradol) can cause serious GI and renal
effects
• Meperidine (Demerol) has low oral efficacy,
active metabolites and CNS effects
• Morphine metabolites are renally cleared
Beers criteria: J Am Geriatrics Society, 2012
Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
350
Anti-Emetics
• Antihistamines: promethazine (Phenergan)
» Anticholinergic, may worsen delirium
(↓acetylcholine)
» Beers Criteria medication
• Dopamine antagonists: metoclopramide (Reglan)
» May worsen Parkinsonism (↓dopamine)
» Beers Criteria medication
• Serotonin (5-HT3) antagonists: odansetron
(Zofran)
» Expensive, but likely safest for this patient
Beers criteria: J Am Geriatrics Society, 2012
351
Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
Managing Agitated Delirium
• Treat pain
» Although opioids may cause confusion,
untreated pain may precipitate and perpetuate
delirium
• Assess for other sources of discomfort
» Hunger, thirst, cold
» Urinary retention, fecal impaction;
• Sensory
» Eye glasses and hearing aids
» Try to minimize sensory “overload”
» Reorientation
352
Antipsychotic Medications
• “Black Box” warning: increased risk stroke, death
• Typical (ie. haloperidol)
»
»
»
»
Potent antidopaminergic effects
Can severely worsen Parkinsonism
Beers Criteria medication
Intravenous haloperidol associated with arrhythmias
• Atypical (ie. risperidone, quetiapine, olanzepine)
» Olanzepine may be best choice in setting of
prolonged QTc
» Quetiapine safest for Parkinson’s Disease but may
not be as useful for acute management
353
Benzodiazepines
for Agitated Delirium
• Avoid if possible
» Appropriate if being used to treat alcohol
withdrawal
» If necessary, use lowest dose possible
» Beers Criteria medication
• May cause a paradoxical reaction in older adults
» Increased agitation and anxiety
» May lead to prescribing cascade (ie. antipsychotic)
• Avoid long-acting benzodiazepines
» Prolonged half-life in older adults (days)
» Sedation, aspiration, delirium
» Increased risk of falls and fractures
Beers criteria: J Am Geriatrics Society, 2012
Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
354
Conclusion: Mrs. Anderson
• Medicated with morphine for pain
• One dose of odansetron (Zofran) for nausea
• Evaluated by orthopedics and plan for
operative repair for pain control and since
patient ambulatory at baseline
• Fecal disimpaction
• Her family brings her eye glasses and
hearing aids to the hospital
Beers criteria: J Am Geriatrics Society, 2012
355
Clinical Case: Mr. Johnson
Mr. Johnson is 83 years old. He complains of a
“runny nose” during meals on a daily basis. He
asks if there is a medication to stop his runny
nose. Although inconvenient at mealtime, he is
not bothered by this symptom at other times
during the day.
Question: Does he need a prescription?
356
Vasomotor Rhinitis
• Likely diagnosis is vasomotor rhinitis
• May respond to ipratropium (Atrovent) nasal
spray.
• Disposable facial tissues are available
without a prescription and have few side
effects
• “Sedating” antihistamines can have
significant anticholinergic effects.
357
Am Fam Physician 2005;72:1057-62.
Principle 2: “Less is More”
(Keep the Medication List Short)
•
•
•
•
•
Question the need for new medications
Stop medications, whenever possible
Prioritize treatments
Weigh risks and benefits
But, avoid undertreating older patients
» Pain
» Systolic hypertension (stroke, renal failure,
heart disease)
» Anticoagulation and atrial fibrillation (stroke
prevention)
Drugs Aging 2003; 20: 23-57.
Lancet 2000; 355: 865–872.
Ann Intern Med 1999;131:492-501.
J Gen Intern Med 2005; 20:116–122.
358
Clinical Case: Mr. Jones
Mr. Jones is 82 years old with a history of
herpes zoster (shingles) 6 months ago. He
continues to experience severe daily pain in the
same dermatomal distribution as the original
rash.
•Question: What is the diagnosis?
•Question: What is the treatment?
359
Post-Herpetic Neuralgia
• Opioid medications
• Capsaicin
» OTC alternative
» Topical (better than systemic)
» May be poorly tolerated due to local effects
• Tricyclic antidepressants
» Effective, but have anticholinergic properties.
Amitriptyline > nortriptyline > desipramine
» Amitriptyline is a Beers Criteria medication
• Gabapentin (Neurontin)
» Clinical trials: 1800–3600mg/day divided doses.
» Dose-reduce with renal insufficiency.
Neurology 2002;59(7):1015–21.
Pain 1988;33(3):333–40.
Neurology 1998;51(4):1166–71.
JAMA 1998;280(21):1837–42.
360
Principle 3:
“Start Low and Go Slow…”
• Start one medication at a time
• Start with a low dose and increase gradually
• Monitor for response and adverse effects
• Once daily is usually best
• Assess adherence with regimen
361
“…But, Go All The Way!”
• Be conservative, but don’t miss the target!
• What is your goal? Are you achieving it?
• If you are not at goal, can the dose be
increased or are you limited by side effects?
• Are you observing a clinical benefit at lower
doses?
• Consider stopping if you can’t “go all the way”
and the benefits at lower doses are not clear.
362
Physiologic Changes Associated
with Normal Aging
• Absorption usually does not change
•
↑ concentrations of water soluble and free
(unbound) drugs
• Longer half-life for lipophilic drugs
• Slower phase I metabolism
• Impaired excretion
• Decreased responsiveness of the
baroreceptors
363
Prescribing for Older Adults
1) “Think drugs” before making a new
diagnosis
2) “Less is more” (keep the med list short)
3) Use caution with Beers Criteria medications
4) “Start low and go slow”…when starting a
new drug….“but go all the way.”
364
Acknowledgments and Disclaimers
This project was supported by funds from The Donald
W. Reynolds Foundation, the American Geriatrics
Society/The John A. Hartford Foundation Geriatrics for
Specialists Grant. This information or content and
conclusions are those of the author and should not be
construed as the official position or policy of, nor
should any endorsements be inferred by The Donald
W. Reynolds Foundation and/or The John A. Hartford
Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine, and the UNC
Department of Emergency Medicine also provided
support for this activity. This work was compiled and
edited through the efforts of Carol Julian.
365
© The University of North Carolina at Chapel
Hill, Center for Aging and Health. All
Rights Reserved.
366