Transcript - Catalyst

Geriatrics session
• After the break, please organize yourself into
groups of 3-4
• Designate a reporter/recorder
• Make sure you have a packet for your group
(there are two different kinds, you only need
one packet)
Essentials of Geriatric Medicine
Susan Merel, MD
UW Internal Medicine Clerkship
2015-16 Academic Year
Objectives
• Describe three important principles of
geriatric care
• Practice applying these principles to inpatient
and outpatient cases
• Highlight “pearls” of geriatric care relevant to
future clinical care and your shelf exam
What’s different about
the older patient?
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Physiologic changes with age
80% with at least one chronic illness
Many with functional disability
More susceptible to iatrogenic and adverse
drug events
Physiologic changes

• Cardiac: ventricular compliance, fibrosis of
conduction system  hypertension, diastolic
heart failure, arrythmias
• Pulmonary: chest wall compliance, lung
elasticity, mucociliary clearance 
pneumonias
• Renal: sclerosis of nephrons, blood flow 
GFR falls 45% by age 80  AKI, drug toxicities
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Rosenthal and Kavic Crit Care Med 2004; 32:S92-105
“Cascade to dependency”
USUAL
AGING
acute illness
CHRONIC
ILLNESS
hospitalization
environmental
factors
Creditor MC Ann Intern Med 1993
FUNCTIONAL
DEPENDENCE
3
Susan Merel’s Ten Ways to
Improve the Care of Elderly Patients
1. Prevent geriatric syndromes
2. Assess and maintain functional status
3. Avoid polypharmacy
1. Geriatric Syndromes
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Multifactorial condition occuring in the elderly
Can result in damage across multiple systems
Significant effects on function, quality of life
Common, but NOT inevitable with aging!
Can improve with interventions targeting risk
factors
Important Geriatric Syndromes
• Falls
• Cognitive impairment/delirium
• Urinary incontinence
2. Functional Status
• Ability to care for self
• Essential to developing appropriate care plan
• Very predictive of prognosis
– ADL disability predictive of readmission
– Elders with disability 4 times more likely to die
within a year of an ICU stay
Greysen SR et al JAMA Int Med 2015;175: 559-65; Ferrante LE et al JAMA Int Med 2015; 175:523-529
Brief Geriatric Assessment
• Assessment of functional status:
– ADL’s: kindergarten (dressing, toileting . . .)
– IADL’s: college (money, transportation . . .)
• Complete social history
– Where do they live?
– Who lives with them/helps them?
• Brief cognitive assessment
• PT/OT assessment for inpatients
3. Avoid polypharmacy
• Use of more drugs than clinically indicated
• Risks:
– Increased risk of adverse drug events
– Increased risk of inappropriate medications
– Decreased adherence
– Increased risk of falls and cognitive impairment
Causes of polypharmacy
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Prevalence of chronic illness
Guidelines, guidelines, guidelines!
Fragmented care by multiple subspecialists
Patient requests for pharmacologic solutions
“Prescribing cascade”
Prescribing Cascade
Rochon and Gurwitz. BMJ. 1997;315:1096.
The Beers Criteria
• Evidence-based list
• Drugs which may be inappropriate in the
elderly or with certain conditions
• Just updated 2015
• Intended to be used as a guide
for risk-benefit discussions
2015 Beers Criteria Update Expert Panel JAGS
Case exercise (15 min)
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Group 1: inpatient case
Group 2: outpatient case
Designate a recorder/reporter
Resources at your table
We’ll review both cases at the end
Case 1: Mr. M
• 90 year old man with afib on warfarin
admitted for GI bleed, develops confusion
• PMH: CAD, COPD, afib, hx CVA, type 2 DM
• Meds: Torsemide, metoprolol, glipizide,
glargine, warfarin (held), paroxetine, ambien
Case 1 questions
1. You are called by the nurse for confusion.
What is in your differential and how are you
going to assess this?
2. How are you going to manage his acute
confusion?
3. What agents might be safest to manage his
acute knee pain?
Altered Mental Status
Chronic
Acute
Dementia
Psychiatric disease
Structural Brain Disease
Trauma
Stroke
CNS infection
Brain Tumor
Brain abcess
Delirium
Delirium vs Dementia
Delirium
Dementia
Clinical course
Acute
Chronic,
progressive
Usually impaired Usually normal
Level of
consciousness
Psychomotor
disturbances
Prognosis
Usually present
Usually absent
Often reversible
Usually
irreversible
Adapted from Paauw et al Internal Medicine Clerkship Guide
Diagnosis of delirium
• “Confusion Assessment Method” (CAM)
– Acute onset and fluctuating course AND
– Inattention AND
– Disorganized thinking OR
– Altered level of consciousness
• Sensitivity 46-94%, specificity 83-98%, LR 10.3
Inouye SK et al, Annals of Internal Medicine 1990; McGee D “Evidence Based Physical
Diagnosis” second edition
Bedside evidence of inattention
• Direct observation
• Digit span
– Present random numbers, one per second
– Inability to repeat at least 5 digits suggests
inattention
Importance of diagnostic criteria
• We don’t do a good job without it
– Missing as many as 2/3 of cases
• Helps you recognize delirium earlier
• Helps you recognize hypoactive delirium
– Distinguish from depression, dementia or “just
tired”
• Preventative measures more effective earlier
Inouye SK et al JAMA IM 2001
Nonpharmacologic prevention and
treatment of delirium
• Always treat underlying cause when possible
• Remove any possibly deliriogenic medications
• Normalize sleep-wake cycle, hydration,
nutrition and mobility as much as possible
– Nursing protocol can be helpful
– Daytime stimulation very important
– Educate and involve family when possible
• Tincture of time
Inouye SK et al NEJM 1999; Ann Intern Med 1993
Pharmacologic treatment of delirium
• Only if patient is a danger to self or others
• LOW dose antipsychotics
– E.g haloperidol 0.5 mg po qhs, quetiapine 6.25 mg
- 12.5 mg po qhs
– Avoid PRN, reassess frequently
• Atypical agents probably not superior to
typical at low doses
• Stop when delirium is resolved
– Write end date if discharging patient on it to SNF
Pain management in the elderly
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Tylenol first line for mild-moderate pain
Avoid NSAIDS – GI and renal toxicities
Avoid muscle relaxants and tramadol
Opioids appropriate for moderate to severe
pain
– Start at 25 – 50% of usual dose in most cases
– Lowest possible dose with goal of function
Case 2: Mrs. G
• 81 yo F diabetes, htn, bipolar disorder, chronic
back pain, chronic diarrhea c/o a fall at home
• PMH: bipolar d/o, hypothyroid, DM w/ last
A1C 6, CAD, hypertension
• Meds: Atenolol 12.5 mg, atorvastatin 80,
Depakote, glipizide, metformin 850 po bid,
levothyroxine, loperamide, lorazepam 1 mg po
bid
Case 2 questions
1. Describe your approach to fall assessment in
this patient.
2. What interventions are most likely to reduce
her risk of falling again in the future?
3. Over the next few clinic visits, what other
geriatric assessment might be helpful in this
patient?
Falls Assessment
1. Screen for falls and fall risk
Three falls questions
2. Evaluate gait, strength and balance
Patients
who “pass”
steps one
and two
are low fall
risk, repeat
screen
yearly
Timed Up and Go and/or 30 Second Chair Stand
3. Conduct brief multifactorial risk assessment
4. Implement targeted interventions
5. Follow up
Fall screening questions
• Have you fallen in the past year?
– If so, how many times, and were they injured?
• Do you feel unsteady when standing or
walking?
• Do you worry about falling?
Falls screening tests
• “Timed up and go” (TUG)
– Stand up from chair, walk 10 feet, turn around, sit
– Usual assistive device
– More than 12 sec suggests increased risk
• “30 second chair stand”
– Number of stands w/o armrest, arms crossed
– Helpful for monitoring the effect of interventions
Focused physical exam
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Orthostatic vital signs
Visual acuity
Cardiac exam (rate, rhythm, murmurs)
Musculoskeletal exam of back and lower
extremities
• Neurologic exam including cognitive screen
Interventions to reduce fall risk
• Evidence-based exercise program
• Medication review, reduction of psychotropics
• Vitamin D supplementation
– Evidence not definitive but risk of harm low
– AGS recommends 800 IU/day
• Environmental assessment by OT
Exercise
• Strength and balance exercise is most effective
single intervention for reducing falls
– At least 50 hours total; progressive
– Tai chi may be particularly effective
• Walking alone does not reduce falls
CDC “STEADI” toolkit
Mrs. G: screening to consider
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Urinary incontinence
Cognitive screening
Vision and hearing screening
“Brown bag” medication review
Goals of care/advance directives
Mini-Cog™
• Ask patient to repeat and remember 3 words
• Ask patient to draw a clock:
– Direct them to draw the circle, then put in all the
numbers and set the time to 11:10.
• Ask them to recall the 3 words
• Scoring: 1 point for each word, 2 points for clock;
3 or greater suggests no impairment
Mini-Cog™ Copyright 2000, 2006, 2007. All rights reserved. Licensed for reprint distribution
by S. Borson, M.D., solely for use as a clinical aid. Any other use is strictly prohibited. To
obtain information on the Mini-Cog™ contact Dr. Borson at [email protected].
Mini-Cog
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Takes 2-4 min to administer
Easy to memorize; not copyrighted
Similar sensitivity and specificity to MMSE
Validated in multiethnic community sample
Less affected by education than MMSE
Reasonable to use w/ interpreter
Borson et al JAGS 2003
“Brown bag” medication review
Rational Prescribing in the Elderly
• Complete, accurate list of meds
– “Brown bag review”
• Meds contributing to presenting complaint?
• Look for drug-drug, drug-disease interactions
• Is new medication indicated?
– Non-pharmacologic options?
– Benefits > risks?
– Is this a prescribing cascade?
• “Start low and go slow”
Summary
1. Prevent geriatric syndromes
2. Assess and maintain functional status
3. Avoid polypharmacy
Resources
1. Eacker A and Wright J, MKSAP for students 5, chapter
40 “Comprehensive Geriatric Assessment.”
2. Labella AM et al, “Ten Ways to Improve the Care of
Elderly Patients in the Hospital,” Journal of Hospital
Medicine 2011;6:351-7
3. American Geriatrics Society 2015 Updated Beers
Criteria for Potentially Inappropriate Medication Use
in Older Adults, J Am Geriatr Soc 2015; 63:2227-2246
4. CDC “STEADI” toolkit, http://www.cdc.gov/steadi/
Additional reference material
MOCA
• Paper-and-pencil test
• 10 minute+ administration time
• Intended purpose is distinguishing MCI from
dementia
• Not copyrighted for clinical use
• Available at mocatest.org
Urinary incontinence screening
• Simple screen: “Have you had urinary
incontinence/do you “lose” your urine? Is this
bothersome to you?
• “3IQ tool” self-administered questionaire
– Distinguishes between stress and urge
incontinence.
• Further eval to rule out reversible causes
(meds, infection) and distinguish between
urge, stress, overflow and functional.
Targeted history for UI
• Onset and duration
• Types of symptoms
– Frequency, volume, timing and precipitants
• Fluid, alcohol and caffeine intake
• Access to toilet, mobility issues, falls
• Presence of constipation or fecal incontinence
– Constipation is risk factor for both acute and chronic UI;
present in up to 1/3 of elderly
• Thorough medication review
Advance Directives
• “Five Wishes” advance directive
– Agingwithdignity.org
– $5 (available in many systems free)
• theconversationproject.org
– Decision aid
• Simple free forms available at hospitals or
from caringinfo.org
• POLST form for those with limited life
expectancy