Transcript Geriatric Syndromes and Assessment Neurodegenerative Disease

Age Related Conditions and
Geriatric Assessment
Alaa Mira, MD, CMD
Chief of Geriatrics
St. Luke’s University Health Network
Disclosure Statement of Financial Interest
I do not have financial relationships with
commercial interests to disclose
Learning Objectives
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Review common Geriatric syndromes
Principles of Geriatric assessment
Hazards of hospitalization of older adults
Geriatric care models
Older Adults are Hospitals’ CORE
Consumers
• Older adults 13% of the population:
- But comprise 37% of hospital discharges and 43%
of hospital days
- Have longer lengths of stay (7.8 days vs. 5.4 days)
- Higher rates of 30 day hospital re-admissions
- Higher rates of functional decline and medical
errors
Risk Ratios for Activities of Daily Living
Dependency
8
7
6
Risk Ratios
5
4
chronic diseases
3
2
1
0
1
2
>3
Number of chronic diseases
Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164
Risk Ratios for Activities of Daily Living
Dependency
8
7
6
Risk Ratios
5
geriatric condtions
4
3
chronic diseases
2
1
0
1
2
>3
Number of conditions/diseases
Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164
Geriatric Syndromes
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Dementia
Depression
Delirium
Falls
Sensory impairment
Polypharmacy
Incontinence
Sleep disorders
Weight loss
Dementia: A Growing Epidemic
Understanding Dementia
• Dementia is a general term used to describe a
decline in cognitive function
• Progressive irreversible brain disease
• No medication can cure dementia
• Alzheimer’s disease is the most common form of
dementia
• Caregiver burnout
Diagnostic Challenges
• Is this “normal aging”? Is it a change?
How Is Memory Affected By Aging
• As we age, the brain loses some of its abilities
that can lead to forgetfulness
– This is normal, and begins after the age of 40
– Not progressive
– No decline in activities of daily living
– Productive and satisfying life
Diagnostic Challenges
• Is this “normal aging”? Is it a change?
• Clinical presentations can be similar
Conditions that Mimic Dementia
Toxic/Metabolic
• B12 deficiency
• Hypothyroidism
• Medications
Systemic
Illnesses
• Infections
• Cardiovascular disease
• Pulmonary
Other
• Depression
• Psychosocial stressors
• Drugs
Diagnostic Challenges
• Is this “normal aging”? Is it a change?
• Clinical presentations can be similar
• Changes can begin up to 20 years before
noticeable by self & others
Stages of Dementia
Normal
Cognition
Very Mild
Cognitive
Impairment
Mild
Cognitive
Impairment
Moderate
Cognitive
Impairment
Severe
Cognitive
Impairment
Stages of Dementia
Normal
Cognition
Very Mild
Cognitive
Impairment
Mild
Cognitive
Impairment
Moderate
Cognitive
Impairment
Severe
Cognitive
Impairment
Is it worth screening for
Alzheimer’s disease or MCI?
“If there was treatment for AD, I'd recommend screening,
but there is no disease-modifying therapy."
“All older adults benefit from memory screening because
it detects cognitive problems before memory loss is noticeable.”
Healthy Aging, 2008; repost, 2010
“Memory Screening: Is it Worth It?”
Reasons to Screen and Diagnosis
Dementia Early
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Autonomy (right to know)
Patient can participate in planning and decision making
Lifestyle modification
Advance directives
Patient/caregiver education
Access to information, programs, support, and other
resources
• Symptomatic and disease modifying therapies are
more efficacious with early disease intervention
• Medications
Screening Tools For
Dementia
Name
Mini-Cog
Items/
Scoring
2 items
Score = 5
Domains assessed
Visuospatial, executive
function, recall
Web link (accessed Oct 2012)
http://geriatrics.uthscsa.edu/tools
/MINICog.pdf
SLUMS
11 items
Score = 30
Orientation, recall,
calculation, naming,
attention, executive
function
http://medschool.slu.edu/agingsuc
cessfully/pdfsurveys/slumsexam_0
5.pdf
MoCA
12 items
Score = 30
www.mocatest.org
Folstein
MMSE
19 items
Score = 30
Orientation, recall,
attention, naming,
repetition, verbal fluency,
abstraction, executive
function, visuospatial
Orientation, registration,
attention, recall, naming,
repetition, 3-step
command, language,
visuospatial
For purchase:
www.minimental.com
Clock Test
Treatment
• Non-pharmacologic treatment
• Lifestyle modifications
• Physical therapy and exercise
• Socializing
• Pharmacologic treatment
• No medication can CURE dementia
• Medication may slow down the dementia
• Treatment should be individualized
Delirium
• Also known as
– Acute mental status change
– Acute confusional state
– Altered mental status
– Toxic or metabolic encephalopathy
– Organic brain syndrome
Delirium is most frequent complication of hospitalized
elderly Yet it is underdiagnosed
Prevalence
• Hospitalized medically ill
10-30%
• Hospitalized elderly
10-40%
• Postoperative patients
up to 50%
• Near-death terminal patients up to 80%
Risk Factors
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Age
Preexisting dementia
Recent surgery
Infections
Visual/hearing impairment
Polypharmacy
Substance Abuse
Types of Delirium
• Hyperactive
-Better recognized
-More attention to treatment
-Associated with improved outcome
• Hypoactive
-Little recognized
-Depression is primary differential
-Associated with poor outcomes
• Mixed
Clinical features
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Prodrome
Fluctuating course
Attentional deficits
Impaired cognition
Sleep-wake disturbance
Altered perceptions
Affective disturbances
Diagnosis of Delirium
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Delirium is a clinical diagnosis
History and physical examination
Mental Status Exam
Confusion Assessment Method (CAM)
• Standardized assessment tool
• CAM ICU-non-verbal, ventilated patients
• Identifies 4 features of the disorder
-Acute onset or fluctuating
-Inattention
-Disorganized thinking
-Altered level of consciousness
Delirium: Management
• Behavioral/Environmental Strategies
– Reorientation, calendars, clocks
– Room near nursing station
– Lights on/off during day/night
– Windows
– Family/familiarity
– Hearing aids, glasses
– Avoid restraints
Pharmacological Therapy
• Nothing FDA-approved
• Antipsychotics are treatment of choice for
agitation compromising care or safety
• Haloperidol best studied, widely used
• Atypical Antipsychotics: Risperidone, Olanzapine,
Quetiapine
• Black box warning
- Increased risk of death/CVA in patients with dementia
Complications
• Increased morbidity
• Increased risk of cognitive decline
• Increased risk of mortality
• Nursing home placement
Falls
Aging and Falls
• 30-40% of older adults fall every year
• 20-30% of people who fall suffer moderate to severe injuries
• 50% of fallers will report recurrent falls
• 50-60% of falls happens in or around the home
• Incidence of falling increases with age
Central Processing
Learning
Experience
Balance
Sensory Input
Visual
Vestibular
Somatosensation
Motor Output
Neural activation
Muscle strength
Range of motion
Reflexes
Falls are Multifactorial
Intrinsic Factors
Extrinsic Factors
Age related
changes
Medications
FALLS
Medical
conditions
Environment
Medication and Falls Risk
Group
Sedatives and
hypnotics
Antipsychotics
Antidepressants
Drugs with
anticholinergic
side effects
Drugs for
Parkinson’s
disease
Common Drug Names
Contributing Factors
Possible Actions for
Prescribers
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Tricyclics - amitriptyline,
dosulepin (Dothiepin),
imipramine, lofepramine
Other sedating – trazadone,
mirtazepine
Orthostatic hypotension,
sedation which can last into the
next day, lightheadedness, slow
reactions, impaired balance,
confusion
orthostatic hypotension,
confusion, drowsiness, slow
reflexes, loss balance. Long
term use - Parkinsonian
symptoms.
Double risk of falls
Drowsiness, blurred vision,
dizziness, orthostatic
hypotension, constipation,
urinary retention
SnRI – venlafaxine and MAOI
Orthostatic hypotension (OH)
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Dizziness, blurred vision,
retention of urine,
confusion, drowsiness,
hallucinations.
Sudden daytime
sleepiness, dizziness,
insomnia, confusion, low
blood pressure, orthostatic
hypotension, blurred vision.
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Temazepam, diazepam, lorazepam,
nitrazepam
Zopiclone, Zolpidem,
chlordiazepoxide, chloral betaine
(Welldorm), clomethiazole
Chlorpromazine, haloperidol,
lithium, promazine,
trifluoperazine, quetiapine,
olanzapine, risperidone
SSRI – citalopram, fluoxetine
Procyclidine, trihexyphenidyl
(Benzhexol), prochlorperazine,
oxybutynin, tolterodine
Co-beneldopa, co-careldopa,
rotigotine, amantadine,
entacapone, selegiline,
rivastigmine.
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Movement disorder with long
term use
Sedating, orthostatic
hypotension
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ACE inhibitors/Angiotensin-II
antagonists
Ramipril, lisinopril, captopril,
irbesartan, candesartan
Vasodilators - Hydralazine
Diuretics - bendroflumethiazide,
bumetanide, indapamide,
furosemide, amiloride,
spironolactone, metolazone.
Beta-blockers - Atenolol,
bisoprolol, carvedilol,
propranolol, sotalol
Alpha-blockers - doxazosin,
alfuzosin, terazosin, tamsulosin
Low blood pressure,
orthostatic hypotension,
dizziness, tiredness,
sleepiness, confusion,
hyponatraemia,
hypokalaemia
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Codeine, tramadol.
Drowsiness, confusion,
hallucinations, orthostatic
hypotension, slow reactions
Unsteadiness & ataxia if levels
high
Phenytoin – permanent
cerebellar damage and
unsteadiness in long term use
Vestibular
Sedatives
Phenothiazines – prochlorperazine
Cardiovascular
drugs
Analgesics
Antihistamines- cinnarazine,
betahistine
Opiates – morphine, oxycodone.
Anti-epileptics
Carbamazepine*, phenytoin*,
phenobarbitone*, primidone*
sodium valproate*, gabapentin
lamotrigine, topiramate,
levatiracetam, pregabalin
Bradycardia, hypotension,
orthostatic hypotension,
syncope
Newer agents – insufficient data
regarding falls risk
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Stop if possible
Long term use will need
slow, supervised withdrawal
No new initiation
Review indication and stop if
possible (may need specialist
opinion/support)
Reduce dose/frequency if
unable to stop
Review indication (do not use
amitriptyline as night
sedation)
Stop if possible, may need
slow supervised withdrawal
Populations studies show
increased falls risk with SSRI
but mechanism unclear,
probably safest class to use
Review indication
Reduce dose or stop
Check L&S BP, drugs and
PD itself can cause OH
Poorly controlled PD can
cause falls
It may not be possible to
change the medication
Do not change treatment
without specialist advice
Do not use long term – no
evidence of benefit
Check L&S BP
Review indication, use
alternative if possible,
especially for alpha blocker
Reduce dose if possible
Symptomatic OH + LVF – if
systolic LVF then try to maintain
ACEi and β Blocker as survival
benefit clear. Stop nitrates, CCB,
other vasodilators and if no fluid
overload reduce or stop diuretics.
 Seek specialist advice if
needed
 Start low, go slow, review
dose and indication regularly
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Consider indication (many
used for pain or mood)
May need specialist review
*Consider Vitamin D
supplements for at risk
patients on long term
treatment with these drugs
Never stop or withhold medication without agreement from the medical team
Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright owner.
Medication and Falls Risk
All patients who present with a fall must have a medication review
with modification/withdrawal (NICE CG 161)
Whilst any medication changes will be finally decided by the doctor (GP or consultant) anyone
working in falls can help to make this review as useful as possible:
Take a comprehensive list of all medications currently taken (NB this should be what they
actually take, not what has been prescribed!). Anyone on FOUR or more medications are at
increased risk of falls.
Check the patient’s understanding of their medication and how they take them. Consider
concordance and compliance aids.
Check lying and standing BP (5 mins lying down, check BP, stand, check BP then every
minute for 3 minutes). A drop of 20 systolic or 10 diastolic is abnormal. Record any symptoms
experienced and send this in to the doctor who is doing the medication review.
Look for high or moderate risk drugs – see chart and highlight these for the doctor.
Medication review:
 Is it still the right drug? (eg methyl dopa should no longer be used for hypertension)
 Is it still necessary? (eg analgesia given for acute flare OA, now resolved)
 Is it a moderate or high risk drug (see chart)? If so what is the risk/balance ratio?
 Is there a safer alternative?
 Could the dose be reduced? (eg 5mg bendroflumethiazide no significant increase in
antihypertensive effects, but significant increase in side effects compared with 2.5mg)
 Should they be on calcium and vitamin D? – Ca and Vit D (800iu daily) reduce falls by up to
20% by improving muscle function and reducing body sway. Consider vitamin D level in patients
with falls over age 65 (see pathway for management of deficiency). Consider supplements in all
people who fall and are housebound or in residential or nursing homes. Don’t forget osteoporosis
risk assessment / treatment.
Stopping or reducing medication isn’t always easy and requires commitment and
understanding by the prescriber and patient. Advice on complex cases is always available from the
consultant geriatricians at Ipswich Hospital, in the community sessions or via the Rapid Assessment
Falls Clinic.
The attached table is provided as a guide to medication review in falls only. Each patient must
be assessed as an individual and the risk/benefit for each drug considered and discussed and a
decision made by the prescriber in consultation with the patient.
Higher risk drugs
Moderate risk drugs
Never stop or withhold medication without agreement from the medical team
Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright
owner.
Subjects in the Intervention and Control Groups
Who Had Multifactorial Intervention to Reduce the
Tinetti M et al. N Engl J Med 1994;331:821-827
Risk of FallingtagesO
Effect of Vitamin D on Falls
• Meta-analysis included 5 RCTs with 1237 elderly
individuals treated with different vit D analogues for
2 months to 3 years
• Vitamin D supplementation reduced the risk of falls
among the elderly by 22%
• Improved the body sway by 9% and musculoskeletal
function by 11%
• 400 IU of vit D may not be clinically effective
• Trials used 800 IU of vit D did find significant
reductions in observed fractures
Heike et al. JAMA 2004; 291;1999-2006
Comprehensive Geriatric Assessment
• Multi-disciplinary team approach
• Address the unique needs of older adults
• Work collaboratively with PCP and other
specialists
• Patient and family centered care
• Improve satisfaction and quality of life
St. Luke’s Senior Care Services
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Center for positive aging
Acute Care for the Elderly (ACE)
Geriatrics surgical program
Nurses Improving Care of Healthsystem Elders
(NICHE)
Center for Positive Aging
• Comprehensive Geriatric
assessment
• Multi-disciplinary approach
• Social worker
• Driving issues
• Pre-operative assessment
• Family care conference
• Recommendations to PCP
Acute Care for the Elderly
(ACE)
ACE Model Concepts
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Specialized model of care
Address the needs of hospitalized older adults
Evidence based best practice
Multi-disciplinary team approach
Prevent functional decline and NH placement
Reduce iatrogenic complications
Decrease hospital length of stay and costs
Improve outcomes and satisfaction
ACE Consult Criteria
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65 years or older
Acutely ill
Co-morbid conditions
At risk of functional decline
Identification seniors at risk (ISAR) tool
St. Luke’s ACE
Outcome Data 2014
• Ativan orders decreased by 33%
• Benadryl orders decreased by 13%
• LOS decreased by 10%
• Delirium rate decreased by 60%
Geriatrics Surgical Program
• Pre-operative geriatric
assessment
• Nurse navigator
• 65 years or older
• Elective surgery
• Geriatric assessment
• Update anesthesiologists
and surgeons
Nurses Improving Care for
Healthsystem Elders
(NICHE)
• NICHE is a program of the Hartford Institute
at the NYU College of Nursing
• NICHE is the only national geriatric nursing
program that addresses the needs of
hospitalized older adults
• There are approximately 680 hospitals in
more than 40 states as well as Canada with
NICHE designation
NICHE Program
• Goal
– Achieve systematic nursing change that will benefit
hospitalized older adults
• Vision
– Provide geriatric sensitive and exemplary care to all
hospitalized older adults
• Mission
– Import principles and tools to stimulate change in the
culture of healthcare facilities to achieve patientcentered care for older adults
Nurses are Positioned to Paly a
Central Role
• Nurses are the primary caregivers for older
patient in hospitals
• Nurses are generally not fully prepared to care
for older patients
• Nursing models can improve older patients’
care and decrease hospital complications
• Nursing can be the focal point for stimulating
interdisciplinary care
NICHE Resources
• Start-up tools
– NICHE planning and implementation guide
– Leadership training program
• Measurement
– Geriatric Institutional Assessment Profile (GIAP)
– Clinical outcomes
– Program self-evaluation
• Clinical management tools
– Organizational strategies and clinical
improvement models
• Training and education programs
– Care curricula: for nurses, patient care techs (CNA),
other disciplines and general staff
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Webinars and in-service materials
Educational resources for patients and families
Conferences
Geriatric Resource Nurse (GRN)
• National community
Geriatric Resource Nurse
(GRN)
• Certified GRN
• Assist staff in evaluating, planning and
implementing geriatric care
• Disseminate information about geriatric care
• GRN core screening tool (SPICES)
• Geriatric assessment rounding
NICHE Outcomes
• Enhance nursing knowledge and skills
regarding the treatment of common geriatric
syndromes
• Increase patient satisfaction
• Decrease length of stay
• Reduce readmission rates
• Reduce costs associated with elder care
St. Luke’s Network
and NICHE Program
• St. Luke’s became NICHE designated in Jan 2014
• RNs and Patient Care Assistants completed the
NICHE Geriatric Resource Education and St Luke’s
older adult sensitization
• Non-nursing staff received NICHE information and
sensitization experiences
• Network-wide Geriatric Institutional Assessment
70% completion rate
• St. Luke’s NICHE Program video viewed by over
1100 employees
St. Luke’s Network Performance
Improvement Activities
• Reducing polypharmacy in older adults
• Effective ambulation and reducing
deconditioning
• Reducing pressure ulcers
• Reducing delirium
Fall Rate Outcomes
4.5
Network Fall Rate/1000 pt days
4
3.5
3
2.5
2
1.5
1
0.5
0
2013
2014
Fasical Year
2015
Conclusions
• Multidisciplinary team approach is
recommended to coordinate the care of older
adults
• Geriatric syndromes are prevalent
• Geriatric assessment improves outcomes
• Geriatric care models (ACE/NICHE) decrease
functional decline, falls, polypharmacy, LOS
and increase satisfaction
“In the end, it’s not the years in your
life that count. It’s the life in your
years.”
Abraham Lincoln
“Thank You”