Transcript Goeke_CAPA Presentation 2016 - CAPA

Dr. Fred Goeke
MD, CCFP (EM, COE),FCFP
Assistant Professor, Department of Emergency
Medicine;
Critical Care Course Director, MPAS;
University of Manitoba
Surfing Lessons
Staying on Top of the Baby Boomer
Wave in ER
Demographics
• “Baby boomers accelerate Canada's population aging” (StatsCan 2015)
• In 2014/2015, the growth rate of the population aged 65 years and older
was 3.5%, approximately four times the growth rate of the total
population.
• The annual growth rate of this age group has accelerated since 2011,
when the first members of the baby boom generation (persons born
between 1946 and 1965) turned 65.
• Canadian Geriatric Journal Dec 2014, 17(4); 118-125
– 22% of ER visits (>65 years old)
– 50% had diagnostic imaging / 62% had lab work / 30% had
consultation
– 20% admission
Seniors Have Longer LOS in ER
Objectives
Discuss management of 3 common geriatric
syndromes to minimize LOS and maximize safety:
1. Opiate associated constipation and nausea.
2. The delirium susceptible senior in the ER.
3. The frail falling senior.
Opiate Associated Constipation (OAC)
Common
• 20-74% of elderly consider themselves
constipated
• 40-86% if they are using opioids
Investigation?
• History
–
–
–
–
Have you had any fever or blood your stool?
Do you have a lot of abdominal pain?
Are you vomiting?
Are you still passing gas?
• Abdominal exam and DRE
• No other tests are necessary if the history and
exam are negative.
What do you use?
• Softeners - Docusate
• Stimulants - Senna / Bisacodyl
• Electrolyte based Osmotic
– Sodium Phosphate (Fleet Enema / Oral Fleet),
– Magnesium citrate (Citromag),
– Sodium picosulfate (Picolax)
• Nonelectrolyte Based Osmotic
– Lactulose / PEG 3350
• ?Naloxone
Docusate?
• Docusate creates a soft stool.
• Alone it’s like a fast car propped up on
cinderblocks.
• Narcotic + docusate alone = All mush no push.
Fleet Enema?
• There are multiple case reports of
complications secondary to sodium phosphate
enemas including dehydration, hypotension,
hyperphosphatemia, hypocalcemia,
hypernatremia, hypokalemia, mucosal
ulceration and bowel perforation.
• FDA Black box warning about these effects.
Citromag?
• Magnesium salt is poorly absorbed in the intestine and acts
as an osmotic laxative.
• Because it contains magnesium, hypermagnesemia
(hypotension/resp depression/paralytic ileus) is a possible
complication.
• As an osmotic diuretic, other electrolyte abnormalities
could develop.
• UpToDate “avoid in patients with renal insufficiency, heart
failure and baseline electrolyte abnormalities.” Sounds like
every elderly patient I see.
Naloxone?
• Naloxone blocks opioid intestinal opioid receptors and has
low systemic bioavailability (2 % ) due to a marked hepatic
first-pass effect.
• Drawbacks
– Acts quickly but its effects usually last less than one hour.
– The therapeutic index of naloxone is very narrow, and doses
that reverse gut symptoms can cause reversal of analgesia.
– Naloxone crosses the blood brain barrier and therefore enters
the central nervous system causing opioid withdrawal
Naloxone
• Naloxone reverses opioid-associated constipation.
Meissner W1, Schmidt U, Hartmann M, Kath R, Reinhart K.
Pain. 2000 Jan;84(1):105-9.
– Oral naloxone was started and titrated individually between 3x3 mg/day
to 3x12 mg/day depending on laxation and withdrawal symptoms.
– This controlled study demonstrates that orally administered
naloxone improves symptoms of opioid associated constipation and
reduces laxative use.
– To prevent systemic withdrawal signs, therapy should be started with low
doses and patients carefully monitored during titration.
Naloxone
• ALiEM (Academic Life in Emergency Medicine)
• TRICK OF THE TRADE
• Oral naloxone
• “There are minimal systemic effects with oral naloxone. So,
constipation can be directly targeted without causing systemic
opioid withdrawal. Published case series reports show a variable
range of therapeutic doses, ranging from 0.1-20 mg of oral
naloxone. One series quoted no effectiveness under 1.5 mg.
Generally 2 mg PO is a good starting point. Then titrate up slowly to
achieve the laxative effect to minimize any systemic absorption.”
• “use the IV preparation, because no PO formulation
exits.”
Try This?
• Efficacy of Auriculotherapy for Constipation in Adults: A Systematic
Review and Meta-Analysis of Randomized Controlled Trials
Li-Hua Yang, RN,1 Pei-Bei Duan, RN, 2 Shi-Zheng Du, RN, MA,1 Jin-Fang Sun,
PhD,3 Si-Juan Mei, RN, MA,4 Xiao-Qing Wang, RN, MA,4 and Yuan-Yuan Zhang, RN,
BSc5
BMC Gastroenterol. 2015; 15: 130.
– In conclusion, the 17 eligible RCTs used AT as a complementary strategy to
treat constipation. Meta-analysis illustrated that because AT is a relatively
safe strategy for treating disease, it is probably more beneficial than other
agents in managing constipation. However, all eligible studies were conducted
in China. No definitive conclusion can be made because of cultural and
geographic differences. Further rigorous RCTs are warranted worldwide to
confirm the effect and safety of AT for constipation.
ER Approach to OAC
• Step 1. Manually disimpact if needed (rectal exam)
• Step 2. Consider 2mg PO naloxone in ED
• Step 3. PEG (1 gm /kg/day or easy dosing of 4 glasses per
day). Take for 6 days or until soft stool passes, whichever
comes first
• Step4. Senna ii to iv tabs HS
• Step 5. Maintenance PEG. (0.3-0.8g/kg/day or easy
dosing of 1 glass per day). Take for 2 weeks and slowly
taper
Bottom Line
• Use nonelectrolytes based osmotic laxatives
with bowel stimulants.
• Avoid docusate and electrolyte based osmotic
laxatives
• ?Try naloxone with opioid induced
constipation.
Opiate Associated Nausea
Prophylactic Anti-emetics?
• empharmd.blogspot.com/2015/11/4-4-por-favorprophylactic-ondansetron.html
– Currently, the prophylactic use of IV ondansetron with IV
opiates is unproven.
– Previous literature has shown that prophylactic antiemetic
therapy with IV opiates is unnecessary, increases costs,
and adds potential for adverse drug reactions.
• BestBETs
– “Use of anti-emetics routinely with intravenous morphine
in the emergency department should not be done.”
Prophylactic Anti-emetics?
Study
Intervention
Bradshaw et al.5
IV Morphine + placebo (n = 136)
Outcome
RCT- double blinded
IV Morphine + metoclopramide
10 mg (n = 123)
Performed in United
Kingdom
Bhowmik et al. 8
RCT- double blinded
N/V between the two groups was not
statistically significant (p = 0.3).
Overall incidence of N/V was low in
both treatment groups (3.7% in
placebo and 1.6% metoclopramide)
IV Morphine + promethazine (n =
54)
Overall incidence of N/V was low in all
treatment groups (9.4% ramosetron,
18.5% metoclopramide, 10.2% in
promethazine and 6.2% in placebo)
IV Morphine + ramosetron
54)
Rate of N/V was not statistically
significant between any of the groups.
Overall N/V associated with IV
morphine was very low and
recommended using antiemetics
for patients who develop N/V
Incidence of N/V in patients was
low in all treatment groups. Trial
concluded that patients should
receive antiemetic therapy only if
experience N/V and not as a
prophylactic agent with IV
opiates.
Investigated 2574 patients that
received IV opiates and
randomized 520 patients that
developed N/V associated with
IV opiates.
Resolution of N/V was statistically more
significant (p < 0.001) when comparing
ondansetron therapy with
placebo.
Per results patients that received
placebo + morphine had less N/V
compared to other treatment
groups; however, NOT statistically
significant.
Concluded the best practice
would be to treat patients’ N/V
after development in patients
that receive IV opiates.
Group 1: placebo
Group 1: 45.7% N/V resolved
IV Morphine + placebo (n = 53)
Performed in India
(n =
IV Morphine + metoclopramide
(n=54)
Sussan et al 9
Randomized Double
masked multicenter
trial
Performed in 9
countries
Conclusion
Determined pre-treating patients
with metoclopramide was not
necessary.
(n = 94)
Group 2: ondansetron 8 mg (n =
214)
Group 2: 62.3% N/V resolved
Group 3: 68.7% N/V resolved
Group 3: ondansetron 16mg (n =
211)
Trial determined the prevalence
of N/V is minimal and exposing
patients to medication they do
not need puts them at risk for
additional adverse drug
reactions.
What’s my best option in elderly patients?
• Dimenhydrinate (Gravol); strong anticholinergic causing
delirium, urinary retention, etc.
• Metoclopramide (Maxeran); strong D2 receptor blockade
causing akathisia, acute dystonic reactions and worsening
Parkinsonism
• Prochlorperazine (Stemetil); strong D2 blocker and
anticholinergic. Combined badness.
• Ondansetron; 5HT3 antagonist (a serotonergic receptor) can
cause QT prolongation (received an FDA warning).
Risk of QT Prolongation?
• Intravenous Ondansetron and the QT Interval in Adult Emergency
Department Patients: An Observational Study.
Moffett PM1, Cartwright L2, Grossart EA3, O'Keefe D2, Kang CS4.
Acad Emerg Med. 2016 Jan;23(1):102-5. doi: 10.1111/acem.12836. Epub
2015 Dec 31.
– Twenty-two adult ED patients were enrolled. Ondansetron caused a
mean prolongation of the QTc by 20 ms (95% confidence interval
[CI] = 14 to 26 ms), with a mean proportion change from baseline of
5.2% (95% CI = 3.8% to 6.6%). There were zero (95% CI = 0 to 13%)
reported serious adverse cardiac electrical events.
– CONCLUSIONS:
The clinical impact is questionable.
Risk of QT Prolongation?
•
Cardiac safety concerns for ondansetron, an antiemetic commonly used for nausea linked
to cancer treatment and following anaesthesia.
Doggrell SA1, Hancox JC.
Expert Opin Drug Saf. 2013 May;12(3):421-31
– The authors undertook a review of the cardiac safety of ondansetron. Their primary
sources of information were PubMed (with downloading of full articles) and the
Internet.
– Conclusion:
The dose of ondansetron that the FDA has concerns about is 32 mg i.v. (or several doses
that are equivalent to this), which is only used in preventing nausea and vomiting
associated with cancer chemotherapy. This suggests that ondansetron may be safe in
lower doses used to prevent nausea and vomiting in radiation treatment or
postoperatively. However, as there is a report that a lower dose of
ondansetron prolonged the QT interval in healthy volunteers, this needs to be clarified
by the FDA. More research needs to be undertaken on the relationship
between QT prolongation and torsades in order that the FDA can produce clear-cut
evidence of pro-arrhythmic risk when introducing warnings for this.
Risk of QT Prolongation?
• Ondansetron and the risk of cardiac arrhythmias: a
systematic review and postmarketing analysis.
Freedman SB1, Uleryk E2, Rumantir M3, Finkelstein Y4
Ann Emerg Med. 2014 Jul;64(1):
– Current evidence does not support routine ECG and
electrolyte screening before ondansetron administration
to individuals without known risk factors.
– Screening should be targeted to high-risk patients and
those receiving high dose ondansetron intravenously.
Risk Factors: Medication-Induced
Torsade's de Pointes
•
•
•
•
•
•
•
•
•
•
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Female gender
Elderly
Hypokalemia
Hypocalcemia
Hypomagnesemia
Bradycardia
Recent atrial fibrillation conversion
Congestive Heart Failure
Myocardial infarction
Concurrent digoxin use
Multiple concurrent agents that prolong QT
Again just about every elderly patient we see
Bottom Line
• Don’t use anti-emetics unless the patient is
nauseated or vomiting.
• Avoid Ondansetron in the high risk patient
with prolonged QT on ECG. In this case use
Metoclopramide unless the patient has
Parkinson's.
• If using Ondansetron, use low doses (4-8 mg)
Delirium
It’s all downhill.
Delirium in ER
• The perfect storm.
• ER is a terrible environment for elderly frail, sick, and often
cognitively impaired people.
– We give them drugs (eg. benzodiazepines, opioids, Gravol) that cause
delirium. Then we give them drugs to control their delirium
(antipsychotics) which make them more prone to falling. Then we
make them stay in bed to avoid falling and they get more delirious.
– We don’t feed or water them (NPO).
– We keep them immobile on a hard stretcher.
– We don’t take them to the bathroom.
– We keep the lights on 24 hours a day.
– We keep the party going all night and day.
– We put their hearing aides in a sample container.
– We put there glasses in the bedside table.
Prophylactic Haldol Does Work
Haloperidol prophylaxis decreases delirium incidence in elderly
patients after non-cardiac surgery: a randomized controlled trial
Wang W1, Li HL, Wang DX, Zhu X, Li SL, Yao GQ, Chen KS, Gu
XE, Zhu SN.
Crit Care Med. 2012 Mar;40(3):731-9. doi:
10.1097/CCM.0b013e3182376e4f.
• For elderly patients admitted to intensive care unit after noncardiac surgery, short-term prophylactic administration of low-dose
intravenous haloperidol significantly decreased the incidence of
postoperative delirium. The therapy was well-tolerated.
Prophylactic Haldol Doesn’t Work
• Randomized ICU trials do not demonstrate an association
between interventions that reduce delirium duration and
short-term mortality: a systematic review and meta-analysis
Al-Qadheeb NS1, Balk EM, Fraser GL, Skrobik Y, Riker RR, Kress
JP, Whitehead S, Devlin JW.
Crit Care Med. 2014 Jun;42(6):1442-54. doi:
10.1097/CCM.0000000000000224.
– A review of current evidence fails to support that ICU
interventions that reduce delirium duration reduce shortterm mortality. Larger controlled studies are needed to
establish this relationship.
What Works?
• Interventions for preventing delirium in hospitalized nonICU patients
Cochrane Database Syst Rev. 2016 Mar 11;3:CD005563. doi:
10.1002/14651858.CD005563.pub3.
Siddiqi N1, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins
SA.
– There is strong evidence supporting multi-component
interventions to prevent delirium in hospitalized patients. There
is no clear evidence that cholinesterase inhibitors, antipsychotic
medication or melatonin reduce the incidence of delirium. The
role of drugs and other anesthetic techniques to
prevent delirium remains uncertain.
How to Avoid the Trap?
• Avoid drugs which cause delirium and have limited therapeutic gain
(benzodiazepines, Gravol)
• Don’t starve people.
• Assess their ambulatory function, get a gait aide if needed and let
them out of bed.
• Get them to the bathroom.
• Re-orient at every opportunity.
• Have family / familiar people present as much as possible.
(Daughters work better than drugs)
• Try to have a quiet area with reduced night lighting in your
department.
• Maximize their potential to see and hear their environment
(adequate light during the day, glasses, hearing aide).
• Identify delirium as soon as possible and look for the cause.
Bottom Line
• There are only 2 indications for
benzodiazepine use in the elderly; seizures or
Etoh/Benzo withdrawal
• There are no indications for Gravol in the
elderly
• Try to keep the ER environment as “normal” as
possible
Assessing the Falling/Frail Elderly
Patient
• Tools for assessment of risk after discharge
– ISAR (Identification of Seniors At Risk)
– A “timed up and go” (TUG) test
– Comprehensive Geriatric Assessment (CGA) which
is a comprehensive assessment of physical,
cognitive, social, affective, and environmental
factors affecting health.
ISAR
• Identification of Seniors At-Risk Tool
• Before the injury or illness, did you need someone to help you on a
regular basis?
• Since the injury or illness, have you needed more help than usual?
• Have you been hospitalized for one or more nights in the past six
months?
• In general, do you see well?
• In general, do you have serious problems with your memory?
• Do you take more than 3 medications daily?
• >1 positive response is considered high-risk
ISAR May Work
•
Instruments to identify elderly patients in the emergency department in need of
geriatric care
Thiem U1, Heppner HJ, Singler K.
Z Gerontol Geriatr. 2015 Jan;48(1):4-9. doi: 10.1007/s00391-014-0852-1. Epub
2015 Jan 16.
– The instrument best studied in various settings and countries is the
Identification of Seniors At Risk (ISAR) screening tool which contains six simple
questions that are easy to administer and can be assessed even in urgent
situations. In recent years, several studies have examined the validity
of ISAR in different European countries. Most of these studies, including one
German study and a recent systematic review, confirmed the validity of ISAR.
Unfortunately, evidence is conflicting, as some studies found only weak or
even no association between ISAR and negative health outcomes. Other
instruments have been investigated to a lesser extent and do not indicate
obvious advantages over ISAR. Despite growing evidence in the field, there are
still many uncertainties. Further research is needed
ISAR May Not Work
• Predicting older adults who return to the hospital or die
within 30 days of emergency department care using
the ISAR tool: subjective versus objective risk factors
Suffoletto B1, Miller T2, Shah R2, Callaway C1, Yealy DM1
Emerg Med J. 2016 Jan;33(1):4-9. doi: 10.1136/emermed-2014203936. Epub 2015 May 18.
• The self-reported ISAR tool did not discriminate well
between older adults with or without 30-day hospital
revisit or death. An optimum score of ≥2 would identify
many older adults at no apparent increased risk of poor
outcomes at 30 days. Using objective ISAR-related risk
factors did not improve overall discrimination.
TUG
• A timed test to assess ones ability to rise from a chair,
walk 3 meters using your usual gait aide, turn, and return
to sit in the chair.
• Cut-off for normal is unclear (12-20 seconds is quoted as
normal). More than 30 seconds is very predictive of fall
risk.
• Endorsed by the British Geriatrics Society and American
Geriatrics Society as a screening tool for fall risk.
Maybe Nothing Works
•
Risk factors and screening instruments to predict adverse outcomes for
undifferentiated older emergency department patients: a systematic review and
meta-analysis
Carpenter CR1, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman
RE, Hogan TM
Acad Emerg Med. 2015 Jan;22(1):1-21. doi: 10.1111/acem.12569.
– Risk stratification of geriatric adults following ED care is limited by the lack of
pragmatic, accurate, and reliable instruments. Although absence of
dependency reduces the risk of 1-year mortality, no individual risk factor,
frailty construct, or risk assessment instrument accurately predicts risk of
adverse outcomes in older ED patients. Existing instruments designed to risk
stratify older ED patients do not accurately distinguish high- or low-risk
subsets. Clinicians, educators, and policy-makers should not use these
instruments as valid predictors of post-ED adverse outcomes. Future research
to derive and validate feasible ED instruments to distinguish vulnerable elders
should employ published decision instrument methods and examine the
contributions of alternative variables, such as health literacy and dementia,
which often remain clinically occult.
CGA Lite?
• Enlist Team Members (geriatric nurses, physio, OT, pharmacy)
• Risk Factors for Further Falls
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–
–
–
–
–
A history of previous falls (especially falls leading to injuries)
Medical issues which increase risk of falls
Medications (BEERs criteria)
Assess for impaired hearing and eyesight
Assess home/social situation
Assess cognitive function in at least a very basic way. Are they
oriented? Do they have insight into their situation?
– Assess global function particularly basic ADLs (mobility, dressing,
toileting) and IADLs (shopping, cooking, laundry)
• Do a basic “Road test” of mobility and balance, which can predict
future falls. A “timed up and go” test.
• Discharge Plan with family and community services (PCP, HC,
Geriatric Day Hospital).
Bottom Line
• Who knows what works
• Best bet may be a very simplified CGA
• Scan for high fall risk medications and sensory
impairments because these are easy to fix
• Use all your resources (Nursing, OT, PT, Family,
SW, Geriatrics, Outpatient resources)
Resources
• Geriatric Emergency Department Guidelines
– www.acep.org/geriedguidelines
• Dr. Don Melady
– www.Geri-EM.com
• 6 modules which are very useful and give high quality
CME credits
– Senior Friendly ED
• Course which runs at various locations in Canada
• BEERs criteria
– http://pharmacistsletter.therapeuticresearch.com/pl/Articl
eDD.aspx?nidchk=1&cs=&s=PL&pt=2&segment=4413&dd=
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