Transcript Geriatric Medicine - UNC School of Medicine

Geriatric Medicine
Gary Winzelberg, MD MPH
Inpatient Medicine Clerkship
Ms. IM
• 87 yo woman, Holocaust survivor
• “Positive” cardiac stress test, elective
catheterization, no intervention
• Pre-meds: diphenhydramine 25 mg, diazepam 5 mg
• Post-cath: somnolent, agitated, taking off clothes
• Neurology consult
• “Cause is atypical response to sedatives and
benzodiazepines which is fairly normal in the
elderly”
IM (2)
• Admitted to hospital (vs discharged home)
• Next morning: somnolent, will not respond to
commands, occasionally opens eyes and
occasionally verbalizes
• Neurology follow-up
• Benadryl and valium should have been out of
the patient's system at this point…In 24 hours
if unchanged recommend lumbar puncture
and MRI brain.
IM (3)
• Geriatrics: transition to health center at IM’s
retirement community
• Return to baseline mental status, cognitive
function over 72 hours
• Take Home points:
– Preventable hospitalization
– IM’s response was more typical than atypical
– Pre-medicate 87 year old patients differently
– Hospitals are dangerous places for older adults
IM Follow-Up
• Age 90
– Fall, subararchnoid hemorrhage
– Fall, right humerus & right hip fractures
• Age 91
– Lives in assisted living
– Ambulates independently with walker
– Independent in activities of daily living
Objectives
• To present medical student geriatric
competencies
• To discuss older adults’ diagnostic challenges
• To identify potential hazards of hospitalization
• To understand strategies re: delirium
– Diagnosis
– Prevention
– Evaluation
– Management
Who is a geriatric patient?
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Age
Chronic diseases
Functional limitations (ADLs, IADLs)
Cognitive impairment
Frailty
Multidisciplinary assessment/service needs
Goals of care
Minimum Geriatric Competencies
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Medication management
Cognitive and Behavioral Disorders
Self-Care Capacity
Falls, Balance, Gait Disorders
Health Care Planning and Promotion
Atypical Presentation of Disease
Palliative Care
Hospital Care for Elders
Leipzig RM et al. Academic Medicine 2009
Today’s Session
#17: identify at least 3 physiologic changes of aging
for each organ system and their impact on the
patient
#22: identify potential hazards of hospitalization
#5: formulate a ddx for patient with delirium
#6: in a patient with delirium, urgently initiate a
diagnostic workup to determine the root cause
#8: develop an evaluation and nonpharmacologic
management plan for agitated demented or
delirious patients
#22: explain the risks, indications, alternatives and
contraindications for Foley catheter use
Diagnostic/Treatment
Challenges (& Opportunities)
• Gradual decline in physiological reserve
• Increased heterogeneity with aging
– Genetic, lifestyle, environmental differences
• Disease often presents at an earlier stage
– Delirium with mild hypercalcemia
– Urinary retention with mild BPH
– Treatment may be simple
– Drug side effects at lower doses
Resnick NM. Marcantonio ER. How should clinical care of the aged differ? Lancet
1997;350:1157-58
Diagnostic/Treatment
Challenges (2)
• Symptoms occur earlier, but patients delay care
– Perceptions of “normal” aging
• Disease presentation depends on most
vulnerable organ system (weakest link)
– How is UTI associated with delirium?
• Abnormal findings in a younger person may be
common (and not harmful) in older adults
– Bacteriuria
Diagnostic/Treatment
Challenges (3)
• Symptoms from multiple cause (inverse
Occum’s razor)
– Syncope
• Multiple homeostatic mechanisms
compromised, multiple abnormalities
amenable to treatment
– Falls
Hospitalization Hazards
Hospitalization Risks
• Delirium
• Infection
– UTI, pneumonia, C diff
• Pressure ulcers
• Malnutrition
• Nursing home placement
Nursing Homes
• ? live permanently: > 50% hospitalized older
adults “very unwilling” or “rather die” Mattimore TJ,
JAGS 1997
• Infrequent physician visits
• Decreased likelihood of returning to
community within 30 days if discharged from
hospital with delirium Marcantonio ER et al, JAGS 2005
Mrs. W History
• 89 year old woman transferred from AL facility
• CC: fever, lethargy (very quiet, not usual self)
• HPI: Few days of diarrhea, cough, weakness,
decreased PO intake, left hip pain
• PMH: CRI, HTN, DM, CAD, h/o CVA
• Meds: insulin, furosemide, atenolol, asa,
plavix, amlodipine, doxazocin, isordil, nexium,
calcium, nephrovite, fe, vitamin d, shohl’s
• ROS: headache, nausea & emesis x1, dizziness
x 1 month
Mrs. W Exam
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General: lethargic, difficult to engage
VS: T 38, 142/90, HR 92, O2 sat 94% ra
Lungs: bibasilar crackles
Heart: RRR, S1/S2, II/VI SEM at USB
Ext: pain with external rotation left leg
Neuro: difficulty following commands
Mrs. W Evaluation
• WBC 18.5, H/H 12.7/36.3, Na 138, K 4.3, CO2
22, BUN 103 (95), Creat 5.6 (4.3), glucose 117
• UA: LE 2+, WBC 25, occ bacteria, many WBC
clumps
• Fecal PMN negative
• Hip xray negative for fracture
• CXR: moderate pulmonary edema
• CT head negative for bleed
DDX
• Impression:
• 89 year old woman with CRI, DM, CAD
admitted with fever, lethargy and associated
delirium. Most likely etiologies include…
• DDX:
Infectious Disease Consult
• 89 year old woman with DM, CRI, CAD presents
with mental status change, headache, fever,
chills, n/v, diarrhea. Labs showed leukocytosis,
worsening renal function. DDX concerning for
bacterial/viral meningoencephalitis, tick-born
illness. Also include gastroenteritis, pneumonia,
UTI, ? uremia
• Recommend: LP, start vancomycin, ceftriaxone,
ampicillin (listeria), acyclovir (HSV), doxycycline
(tick-borne) until LP results available.
Management & Outcome
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No LP
Antibiotics – empiric treatment of UTI
Hydration – concern for dehydration
Urine culture – pansensitive Ecoli
Mental status (attention) improved
Physical weakness, nausea persisted
WBC 8.2 (18.5), BUN/Creat 115/6.7 (103/5.6)
Delirium
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Spectrum: hypoactive – agitated
Common
Costly
Morbidity & mortality
Preventable
Delirium Diagnosis Inouye SK et al. Ann Intern Med 1990
• Confusion Assessment Method
• Sensitivity 94-100%, Specificity 89-95%, high
inter-rater reliability
• Feature 1: acute onset or fluctuating course
• Feature 2: inattention
• Feature 3: disorganized thinking
• Feature 4: altered level of consciousness
• Diagnosis: 1 & 2, either 3 or 4
Delirium Prevention Inouye SK et al. NEJM 1999
Clinical trial: hospitalized gen med patients > 70
Risk Factor
Intervention Protocols
1. Cognitive Impairment
Orientation & Activities
2. Sleep deprivation
Nonpharmacologic & Sleepenhancement
3. Immobility
Early mobilization; minimize catheters
4. Visual & Hearing impairment
Visual/Hearing aids and adaptive
equipment; earwax disimpaction
5. Dehydration
Early recognition, encouragement of
oral intake of fluids
Delirium Prevention Trial Outcomes
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Intervention group: 10%
Usual-care group: 15%
OR 0.60 (0.39-0.92)
Intervention group: fewer total number of
days with delirium & total number of episodes
• No significant differences in delirium severity
• 87%: overall rate of intervention adherence
Prevention Trial Dissemination
http://elderlife.med.yale.edu
Delirium Management
• Treat the underlying contributing conditions
• Address risk factors
– Foley, telemetry, nasal cannula
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Involve family
Consider sitter
Does the patient need to remain in bed?
How important/urgent is the evaluation/tx?
Medication options
Delirium Medications
• No medications with FDA approval, evaluated in
randomized trials
• Geriatrics prescribing principle: start low, go
slow
• Benefits/side effect profile of atypical
antipsychotics similar to first generation agents
• Haloperidol (advantage PO/IM/IV): 0.25-0.5 mg,
max 1 mg/day, prolonged QT interval
• Risperidone: 0.25-0.5 mg BID, prolonged QT,
increased mortality risk in dementia
Indwelling Urinary Catheters
• Risks: infection, bladder weakness,
hematuria, discomfort, immobility (1 point
restraint Saint S et al. Ann Intern Med 2002
• Indications: retention (+/-), comfort, I/O
monitoring (+/-), pressure ulcer management
)+/-)
• Alternatives: timed voiding with assistance,
incontinence care, condom catheters,
• Nonpayment for catheter associated UTI Wald HL.
Kramer AM. JAMA 2007.
Other Topics
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Tube feeding in dementia Finucane TE et al. JAMA 1999
Pressure ulcer recognition and prevention
Syncope Mendu ML. Arch Intern Med 2009
Goals of care communication Winzelberg GS et al. JAGS 2005
Family communication
End of life care
– Symptom management
– Care options
Remember the Social History