Transcript heidrich_geriatrics

Caring for the Elderly:
A String of Geriatrics Pearls
Fred Heidrich, MD Family Medicine Residency Group Health
January 28, 2013
1. Set the Agenda
Geriatric visits are complex—
•Often chronic condition with acute illness superimposed
•Often multiple simultaneous conditions
•Atypical presentations are common
1. Set the agenda
Avoid the early dive:
“Before we get into that, I
want to be sure I know all the things you hope to discuss
today—are there any more?”
But there must be a limit:
after 5, may need to
add “assess for depression” on your own and postpone
any more.
Prioritize: “To be sure we use our time wisely, I’d like
to know which of those problems is the most important
for you today”
Agree on agenda:
“I want to be sure to deal with
that. Also, I feel … is very important to get to. We may
have to postpone the others to a future visit, depending
on how the time goes. Will that be all right?”
2. Meds, meds, meds
Need to balance risk and benefit
Even things they’ve been on for a long time can
cause trouble, from changing physiology, or
from other medications started in the
meantime.
http://www.americangeriatrics.org/health_care_professionals/cli
nical_practice/clinical_guidelines_recommendations/2012
Important 2012 New Additions to the Beers List:
For All
Megestrol (minimal effect on weight, increased risk of
thrombotic events)
Glyburide
(long duration, more hypoglycemia)
Sliding scale insulin (risk>benefit in glucose
control, even in nursing home setting)
Important 2012 New Additions to the Beers List:
For people with certain conditions
Thiazolidinediones (glitazones) in heart
failure
Acetylcholinesterase inhibitors (donepezil,
etc) in people prone to syncope
Sliding scale insulin (risk>benefit in glucose
control, even in nursing home setting)
Anticholinergics
TricyclicAntidepressants
Antiemetics/vertigo meds

Diphenhydramine, hydroxyzine, meclizine, promethazine, prochloperazine,
scopalamine
Antipsychotics

Olanzapine, quetiapine, thioridazine
Bronchodilators

Ipratropium, tiotropium
Mydriatic/cycloplegics

atropine
Bladder relaxers

Oxybutinin, tolterodine
Parkinson’s drugs

Benzotropine, trihexyphenidyl
Muscle relaxants

Cyclobenzaprine, orphenadrine
Anticholinergic side effects
Drowsiness/decreased cognitive function
Dry mouth
Blurred vision
Constipation
Urinary retention
Contraindicated:


gastric or urinary retention
angle closure glaucoma.
Avoid in patients on cholinesterase inhibitors
Renal function declines with age, even though creatinine may not
Some common drugs where you should adjust dose for GFR<50:
Antimicrobials:
Cardiovascular:
Acyclovir & other-clovirs
Most ACE inhibitors
Aminoglycosides
Atenolol, Nadolol, Sotalol
Cephalosporins (many)
Digoxin
Penicillins (most)
Quinolones (most)
Others:
Sulfonamides
Lithium
Tetracycline (but not doxy)
Acetaminophen
H2 blockers
Albuterol
Glyburide/glipizide
Insulin
When in doubt, look it up! No one can remember all these.
Got Hyponatremia?
Consider:
Diuretics
SSRIs
Venlafaxine
Chlorpropamide
Carbamazepine, oxcarbazapine
NSAIDs
Barbiturates
3. Prevention: Doing What Counts
Mammography: Number to Screen to prevent one breast
cancer death. Shown by quartiles of life expectancy
2500
NNS
2000
75%ile
50%ile
25%ile
1500
1000
500
0
50
70
75
80
85
90
Age
Ref: Walter L, Covinsky K, Cancer Screening in Elderly Patients JAMA 2001; 285:2750-2956
USPSFT 2012 recommendations for
people over 65 years
Aortic aneurysm
Men who have smoked, once, age 65-75
Alcohol misuse screening
Periodically
Aspirin to prevent CV event
Adults at increased risk for CV events
Breast cancer screening
Mammography every 1-2 years at least to age 74
BRCA testing/genetic counseling
Women with concerning family history
Cervical cancer screening
Stop at age 65 unless unusual risk
Colorectal cancer screening
Screen to age 75
Depression screening
Periodically, if provider prepared to deal with it
Diabetes screening
People with BP>135/80
Hypertension screening
Optimal internal unknown, at least every 2 yr
(Continued)
USPSFT 2006 recommendations for
people over 65 years
HIV screening
All at increased risk, optimal interval unknown
Lipid screening
Repeated screening after age 65 less important as values
unlikely to change
Osteoporosis screening (DXA)
Women 65 and older (60 + with risks), periodically
Tobacco cessation counseling
periodically
Influenza shot
Annually
Pneumovax
At age 65
Tetanus immunization
Every 10 years
5. Prevention: How to Decide What Really Counts?
The 5-year Rule for Screening
Most screening takes about 5 years to
accrue a benefit.
There is little to gain and much to lose from
telling someone who will soon die that he
may develop cancer.
But how do we know when a person has <5
years to go?
Ref: Walter L,
Covinsky K,
Cancer
Screening in
Elderly Patients
JAMA 2001;
285:2750-2956
What else tells you they have
5-year or less life expectancy?
Heart failure
End stage renal disease
Oxygen-dependent COPD
Frailty: 3 or more of
>10 pounds weight loss
Grip strength lowest 20%ile
Walking speed (15 feet) lowest 20%ile
Activity level lowest 20%ile
4. Isolation is Bad
Isolation is a disease or at least a risk factor
Associated findings:
Self-neglect (nutrition, cleanliness)
Depression
Approach to Isolation
Look carefully for Depression, Dementia, Abuse/neglect
Consider home visit volunteers, adult day centers, volunteer
work, adult communities, family conferences—but must be
patient-centered to work
Geriatric care managers Full Life (ElderHealth) $60100/hour, private ones can be $200 an hour
Resources for home visit volunteers:
National (some places): Little Brothers Friends of the Elderly,
Dorot
King County: ElderFriends (from Full Life Northwest)
http://www.fulllifecare.org/we-can-help/by-service/elderfriends/
Prevent Isolation by Keeping
Caregivers Sane
http://www.agingking
county.org/
Prevent Isolation by Keeping
Caregivers Sane
http://www.fulllifecare.org/
Nutrition Screen
I have an illness or condition that made me change the kind or amount of food I eat 2
I eat fewer than two meals per day.
3
I eat few fruits, vegetables, or milk products.
2
I have three or more drinks of beer, liquor, or wine almost every day.
2
I have tooth or mouth problems that make it hard for me to eat.
2
I don’t always have enough money to buy the food I need.
4
I eat alone most of the time.
1
I take three or more different prescription or over-the-counter drugs per day.
1
Without wanting to, I have lost or gained 10 lb in the past six months.
2
I am not always physically able to shop, cook, or feed myself.
2
3-5 moderate risk
6+ high risk
5) Hospitalization
Associated
Disability
Assessing Function:
Activities of Daily Living
Bathing
Dressing
Eating
Transfers
Toileting
Continence
Assessing Function:
Instrumental Activities of Daily Living
Shopping
Meal preparation
Taking medications
Housekeeping
Laundry
Transportation
Telephone/communication
Managing finances
Hospitalization Associated Disability
Loss of one or more ADL at time of discharge, compared to
before the acute illness
Bathing
Dressing
Toileting
Transferring
Fecal and urinary continence
Feeding
Functional Patterns with Admissions
No H.A.D.
H.A.D.
Hospitalization Associated Disability
Loss of one or more ADL
??% of patients over age 70
hospitalized for a medical illness are
discharged having lost at least one
ADL
JAMA 2011; 306: 1782-1793
Hospitalization Associated Disability
Loss of one or more ADL
>30% of patients over age 70
hospitalized for a medical illness are
discharged having lost at least one
ADL
One year later fewer than half are back to their pre-illness
level of functioning
JAMA 2011; 306: 1782-1793
Risk Factors for H.A.D.
Depression
Age
Mobility
Dementia
Minimal Functional Assessment of
the Hospitalized Patient
ADLs—usually from nurse or PT/OT
2. Mobility: sit up, stand, walk a few steps
3. Cognitive function: mini-cog screen
1.
JAMA, October 26, 2011—Vol 306, 1788
Mini-cog
Give patient 3 items to recall, check registration
Clock draw
Recall three items
If recall all 3, screen is negative
If recall none, screen is positive
If recall 1 or 2, then use clockdraw to decide if pos or
negative
Clockdraw: need circle, numbers reasonably arranged, 2
hands more or less pointing to 11:10
Maintaining Function in the Hospital –
Things Medical System Can Do
•Minimize bed rest—carpeted floors, grab rails
•Limit catheters and other tubes that limit mobility
•Pay attention to nutrition—avoid unneeded NPO or restricted diets
•Watch out for adverse meds effects—daily review MAR
•Pay attention to mental stimulation. Facilitate family visits, even
overnight
•Try to let people get their rest at night!
•Easy access chairs and walking aids
•Avoid enforced dependence
•Planned transition to home
Maintaining Function in the Hospital –
Things the patient can do
•Minimize bed rest—try to at least get into a chair
if you can’t walk. Bed-based exercise sometimes
the best option.
•Don’t let the tubes keep you down!
•Pay attention to nutrition. OK to ask for snacks
•Have your glasses/hearing aids
•Pay attention to mental stimulation—visitors help!
H.A.D. Prognosis
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
H.A.D. Prognosis
One year later:
41% dead
29% still disabled
30% returned to prehospital level of function
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
H.A.D. Prognosis
One year later:
41% dead
29% still disabled
30% returned to prehospital level of function
18% dead
15% alive with decline in ADLs
67% still at baseline
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
6. Prescribing the Fountain of Youth
EXERCISE: the miracle drug
Free or low cost
No interactions with pharmaceuticals
Essentially no side effects, except temporary muscle
soreness
Duration of action days to weeks
Benefits:
o
o
o
o
o
o
Longer survival
Reduced disability
Increased energy and mood
Improve/maintain cognition
Improved sleep
Less restless leg syndrome
The Research in Chronic Disease
Increasing physical
activity levels is the
most important
intervention for
virtually ALL
chronic disease
management and
prevention
programs.
Tailored Advice
Chair bound – Sit and Be Fit (KBTC 9-9:30 AM)
PT-guided—especially if gait/balance issues
Senior Fitness Classes
Walking 5-10K steps by pedometer
Sports/fitness clubs/dancing, etc
(JAMA 2007;298:2296)
7: Preventing falls
Fall Epidemiology
Annual rates of falling
Community-dwelling adults > 65: 30-40%
Adults>80 years: 50%
Adults in long term care: 50%
People with history of fall in prior year: 60%
Males and females equally likely to fall, but
women more often injured in the fall.
Fall Epidemiology
5-10% of senior falls (but 10-30% in NH
patients) results in major injury (fracture,
head trauma, major lacerations)
50% of elderly who fall are unable to get up
on their own
CONSEQUENCES OF FALLS
Long term admission to nursing home:
Single fall w/o
injury
2 or more noninjury falls
One or more
fall with
serious injury
HR
Adj HR
4.9 (3.2-7.5)
3.1 (1.9-4.9)
8.5 (3.4-21.2)
5.5 (2.1-14.2)
19.9 (12.2-32.6)
10.2 (5.8-17.9)
N Engl J Med 1997;337:1279-84
Why do elderly fall?
(Physiology of aging)
Sensory system
Muscle changes
Hypotension/cerebral hypoperfusion
Why do elderly fall?
(Physiology of aging)
Sensory system

Visual declines
Loss of acuity
 Decreased depth perception
 Decreased dark adaptation

Decreased proprioception in legs
 Vestibular system decline

Why do elderly fall?
(Physiology of aging)
Muscle changes
Sarcopenia (fat replaces muscle fibers)
 Proximal muscles activated more quickly than distal
 Antagonistic muscle contraction

Why do elderly fall?
(Physiology of aging)
Hypotension/cerebral hypoperfusion
Decreased baroreflexes (heart rate, sympathetic tone)
 Postprandial diversion of blood flow
 Tendency to dehydration (decreased total body
water)

Why do elderly fall?
(Burden of chronic disease)
Parkinson
Chronic musculoskeletal pain
Osteoarthritis
Dementia
COPD
Arrhythmia
Residua of CVA
Heart failure
etc
Why do elderly fall?
(Medications)
Neuroleptics
Benzodiazepines
Antidepressants
__________________
Vasodilators
Problem drinking
Assessing Risk of Falls
History of prior falls most important
PE: Postural vitals, visual acuity, hearing, legs
Get up and Go
_________________
Functional Reach
Berg Balance Test
Tinetti Tool (POMA)
Divided attention tasks
Preventing Falls: Cochrane Analysis
Community Dwelling Seniors
111 trials (55,303 participants).
Effective (% reduction in falls) :
Tai Chi 37%
Individually prescribed home-based exercise 34%
Assessment and multifactorial intervention 25%
Multiple-component group exercise 22%
Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2009
Preventing Falls:
Cochrane Analysis Community Dwelling Seniors
The second tier -- Helpful in some groups
Vitamin D in people with lower vitamin D levels.
Home safety interventions with severe visual impairment,
and in others at higher risk of falling
Anti-slip shoe device for icy conditions
Gradual withdrawal of psychotropic medication
Prescribing modification program for primary care
physicians
Pacemakers in people with carotid sinus hypersensitivity
Cataract surgery
Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2009
Preventing Falls: USPSTF Analysis
Community Dwelling Seniors
54 studies judged to be relatively high quality
Percent reduction in falls:
Vitamin D supplementation 17%
Exercise or physical therapy 13%
Multifactorial assessment and management
6%?
(risk ratio, 0.94 [CI, 0.87 to 1.02])
Ann Intern Med. 2010;153(12):815 -- USPSTF=US Preventive Services Task Force
Preventing falls: exercise
When prescribing exercise for fall prevention, it
seems important to include multiple categories:
Gait and balance
Strength
Flexibility
Endurance
General physical activity (e.g. gardening)
Movement exercise (tai chi, dancing)
Fall Prevention in primary care
Ask all patients ≥75 years old
about falls and balance or gait
difficulties. Get-up-and-go
testing for all.
Two or more
falls or balance
or gait
difficulties
One fall and no
balance or gait
difficulties
No falls and no
balance or gait
difficulties
Recommend
general exercise
program that
includes
balance and
strength training
Formal assessment –
See next page
Tinetti, NEJM 2003; 348 (1): 42-9
Summary—Assessment of a Faller
Gait, balance, mobility (neurologic or
musculoskeletal impairments? Often get PT help
with this.)
Fall history
Medications
Visual acuity
Heart rate and rhythm
Postural vitals
Review environmental hazards
Modified from JAGS 2011; 59 (1) 148-157
Assist Devices
Adults>65—10% use canes, 5% use walkers Often
poorly fit, improperly used, poorly maintained.
Top of cane/walker handle should be at wrist crease
when patient stands up with arm relaxed at side.
Picking device depends on current state of strength,
endurance, balance, cognitive function, home needs.
Walkers a big hazard on stairs!
American Family Physician August 15, 2011
Assist Devices:
Maybe good…or not
Increases confidence and feeling
of safety
That increases activity, with its
multitude of benefits
But…not enough data to say if
they actually prevent falls
American Family Physician August 15, 2011
8. Geriatrics is all about Team
Core Team:
Physician, PA-C, ARNP
Office nurse/home care nurse
Social worker
Family
Other key members depending on
situation:
Hospice
Dietician
Pharmacist
Rehab therapists
Mental health workers
Spiritual counselor
Audiologist
Dental care givers
Eye care specialists
Senior advocacy groups/Community agencies
Geriatrics is all about Team
The Eight Pearls
1. Set the Agenda
2. Meds, meds, meds
3. Prevention—Do what Really Counts
4. Isolation is Bad
5. Avoid Hospitalization Associated Disability
6. Rx the Fountain of Youth
7. Prevent falls
8. Geriatrics is all about Team