Transcript Geriatric Interdisciplinary Noon Report

Taking Away the Keys
Geriatric Interdisciplinary Noon Report
Introduction
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Case
Geriatric Assessments
Statistics
Possible intervention
Evaluation
HPI
• CC: “confusion”
• HPI: 75 yo man admitted to subacute unit for
delirium
• Found to have R sided PNA
• Treated with abx, short term intubation, O2 therapy
• Demonstrated impulsivity, intermittent agitation,
confusion
PMH
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COPD on home O2
A fib
OA
CAD
Pulm Htn
RV dysfunction
PSH
• Popliteal bypass with
saphenous graft
(7/2006)
• Left eye cataract
extraction (3/2005)
Family History
• Mother died of “old
age”
• Father died of
pneumonia
Social History
• Smoked 3 PPD cigarettes
for 60+ years
• Drinks 1 small glass of
beer each day
• Lives in a studio
apartment alone,
patient reports being
able to perform all ADLs
and IADLs
Medications
• acetaminophen PRN
• albuterol/ipratropium inh QID
• budesonide/formoterol inh
BID
• divalproex
• folic acid
• furosemide 20 mg daily
• metoprolol 150 mg BID
• PPI
• warfarin
Allergies
• NKDA
Focused Exam
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T 98 F
P 81 RR 16 BP 125/77
Sat 92% on RA
General Appearance: NAD, A&O x2 (self, place)
Neck: supple, full ROM, no LAD
Chest: decreased breath sounds in bases, no wheezing
Cardiovascular: irreguarly irregular, no murmurs
Abdomen: non-distended, + BS. no HSM. no tenderness
Extremities: 2+ peripheral pulses BL, no edema
Neurologic: cranial nerves II-XII intact, moves
extremities, 5/5 strength x 4.
Other Testing
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Montreal Cognitive Assessment: 21/30
Barthel Index: 92/100
Geriatric Depression scale: 5/15
Trail Making Test A: moderately impaired
with no sequencing errors
• Trail Making Test B: unable to complete
due to inability to remember instructions
Mahoney FI, Barthel D. “Functional evaluation: the Barthel
Index.”Maryland State Medical Journal 1965;14:56-61.
Trails A
Trails B
Spreen, O., & Strauss, E. (1998). A compendium of neuropsychological tests: Administration, norms and
commentary (2nd ed.). New York: Oxford University Press.
Delirium vs Dementia?
• Neuropsych assessments performed once
patient’s delirium resolved
• Testing indicated underlying dementia
• POAHC was activated
• Recommended that he stop driving
• Consider more supportive living
environment
Who has discussed driving with
elderly patients?
Why is this important?
Traffic Safety Facts 2011 Data http://www-nrd.nhtsa.dot.gov
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Traffic Safety Facts 2011 Data http://www-nrd.nhtsa.dot.gov
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Why is this important?
• In 2011:
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5,401 people age 65 and older were killed
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185,000 were injured in motor vehicle traffic
crashes
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Older individuals made up 17 percent of all traffic
fatalities and 8 percent of all people injured
Public Health Perspective
• By 2030 one out of every five Americans will be
over 65 years of age
• Number of drivers over 65 will double to 60
million during the next three decades
• Compared to young and middle-age adults,
people over 70 are more likely to be involved in
a crash while driving and more likely to die in
that crash
What can we do?
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n engl j med 367;13 nejm.org september 27, 2012
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Physician Warnings
• Warnings to patients who are potentially
unfit to drive are a medical intervention
intended to prevent trauma from motor
vehicle crashes
• Goal was to assess the association between
medical warnings and the risk of
subsequent road crashes
Physician Warnings
• Identified patients who had received a medical
warning from a physician between April 2006
and December 2009 in Ontario Canada
• Collected data on:
• age
• sex
• place of residence
• hospitalizations, ED visits, outpatient visits
• diagnoses
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Physician Warnings
• Identified :
• road crashes that involved patient as
driver
• crashes resulted in ED visit
• Looked at all data available:
• Before physician warning and after
warning
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n engl j med 367;13 nejm.org september 27, 2012
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Physician Warnings
• Warning patients was associated with a
reduction in risk of crashes requiring ED
visits
• Be prepared to deal with consequences of
warning:
• may increase depression
• may reduce number of visits to the
responsible MD
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What do we do next?
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Driving Evaluation
At VA:
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Place consult for OT driving evaluation
Initial interview (driving habits, living arrangement, etc.)
Functional ROM/coordination testing
Vision testing (simulator)
Cognitive screening via the SLUMS, Trailmaking Tests
Basic road sign recognition test
Reaction time testing (simulator)
Road testing
At University Hospital:
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Place consult for OT eval
Depending on type of insurance, may not be covered
Wisconsin Law
• A driver license can only be immediately
cancelled when a medical professional
reports or supplies information to the DMV
that indicates a person is unsafe to drive
• A form completed in full and signed by a
provider and must be based on an
examination conducted within the past
three months
Other Resources
• AMA: Older Driver Safety
• Counseling
• State by State guide
• AARP: Driver Safety Program
• Online Courses
• Referrals to nearby courses
• Online quizzes
• Online seminar “Talking with Older Drivers”
Take Home Points
• Think of functioning in elderly patients
• Utilize further assessments to predict abilities
(Trails B)
• Talk to patients! Intervene!
• Be prepared for an emotional response
• Share concerns with DMV
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References
1. Redelmeier DA, et al. Physicians’ Warnings for Unfit
Drivers and the Risk of Trauma from Road Crashes.N
Engl J Med 2012;367:1228-36
2. Predictors of Automobile Crashes and Moving
Violations among Elderly Drivers. Ann Intern Med.
1994;121(11):842-846
3. Wisconsin Driver Data
http://www.dot.wisconsin.gov/safety/index.htm
4. Traffic Safety Facts 2011 Data. Older Population.
http://www-nrd.nhtsa.dot.gov/Pubs/811745.pdf