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Caring for the Elderly:A String of Geriatrics Pearls
Fred Heidrich, MD Family Medicine Residency Group Health
January 28, 2013
1. Set the Agenda
Geriatric visits are complex—
•Often chronic condition with acute illness superimposed
•Often multiple simultaneous conditions
•Atypical presentations are common
1. Set the agenda
Avoid the early dive: “Before we get into that, I want to be sure I know all the things you hope to discuss today—are there any more?”
But there must be a limit: after 5, may need to add “assess for depression” on your own and postpone any more.
Prioritize: “To be sure we use our time wisely, I’d like to know which of those problems is the most important for you today”
Agree on agenda: “I want to be sure to deal with that. Also, I feel … is very important to get to. We may have to postpone the others to a future visit, depending on how the time goes. Will that be all right?”
2. Meds, meds, meds
Need to balance risk and benefit
Even things they’ve been on for a long time can cause trouble, from changing physiology, or from other medications started in the meantime.
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012
Important 2012 New Additions to the Beers List:For All
Megestrol (minimal effect on weight, increased risk of thrombotic events)
Glyburide (long duration, more hypoglycemia)
Sliding scale insulin (risk>benefit in glucose control, even in nursing home setting)
Important 2012 New Additions to the Beers List:For people with certain conditions
Thiazolidinediones (glitazones) in heart failure
Acetylcholinesterase inhibitors (donepezil, etc) in people prone to syncope
Sliding scale insulin (risk>benefit in glucose control, even in nursing home setting)
Anticholinergics
TricyclicAntidepressantsAntiemetics/vertigo meds Diphenhydramine, hydroxyzine, meclizine, promethazine, prochloperazine, scopalamine
Antipsychotics Olanzapine, quetiapine, thioridazine
Bronchodilators Ipratropium, tiotropium
Mydriatic/cycloplegics atropine
Bladder relaxers Oxybutinin, tolterodine
Parkinson’s drugs Benzotropine, trihexyphenidyl
Muscle relaxants Cyclobenzaprine, orphenadrine
Anticholinergic side effects
Drowsiness/decreased cognitive functionDry mouthBlurred visionConstipationUrinary retention
Contraindicated: gastric or urinary retention angle closure glaucoma.
Avoid in patients on cholinesterase inhibitors
Some common drugs where you should adjust dose for GFR<50:
Renal function declines with age, even though creatinine may not
Antimicrobials: Cardiovascular:
Acyclovir & other-clovirs Most ACE inhibitors
Aminoglycosides Atenolol, Nadolol, Sotalol
Cephalosporins (many) Digoxin
Penicillins (most)
Quinolones (most) Others:
Sulfonamides Lithium
Tetracycline (but not doxy) Acetaminophen
H2 blockers
Albuterol
Glyburide/glipizide
Insulin
When in doubt, look it up! No one can remember all these.
Got Hyponatremia?
Consider:
DiureticsSSRIsVenlafaxineChlorpropamideCarbamazepine, oxcarbazapineNSAIDsBarbiturates
3. Prevention: Doing What Counts
Ref: W alter L, Covinsky K, Cancer Screening in Elderly Patients JAMA 2001; 285:2750 -2956
0
500
1000
1500
2000
2500
50 70 75 80 85 90
Age
NN
S 75%ile50%ile25%ile
Mammography: Number to Screen to prevent one breast cancer death. Shown by quartiles of life expectancy
USPSFT 2012 recommendations for people over 65 years
Aortic aneurysm Men who have smoked, once, age 65-75
Alcohol misuse screening Periodically
Aspirin to prevent CV event Adults at increased risk for CV events
Breast cancer screening Mammography every 1-2 years at least to age 74
BRCA testing/genetic counseling Women with concerning family history
Cervical cancer screening Stop at age 65 unless unusual risk
Colorectal cancer screening Screen to age 75
Depression screening Periodically, if provider prepared to deal with it
Diabetes screening People with BP>135/80
Hypertension screening Optimal internal unknown, at least every 2 yr
(Continued)
USPSFT 2006 recommendations for people over 65 years
HIV screening All at increased risk, optimal interval unknown
Lipid screening Repeated screening after age 65 less important as values unlikely to change
Osteoporosis screening (DXA) Women 65 and older (60 + with risks), periodically
Tobacco cessation counseling periodically
Influenza shot Annually
Pneumovax At age 65
Tetanus immunization Every 10 years
5. Prevention: How to Decide What Really Counts?
The 5-year Rule for Screening
Most screening takes about 5 years to accrue a benefit.
There is little to gain and much to lose from telling someone who will soon die that he may develop cancer.
But how do we know when a person has <5 years to go?
Ref: Walter L, Covinsky K, Cancer Screening in Elderly Patients JAMA 2001; 285:2750-2956
What else tells you they have 5-year or less life expectancy?
Heart failure
End stage renal disease
Oxygen-dependent COPD
Frailty: 3 or more of
>10 pounds weight loss
Grip strength lowest 20%ile
Walking speed (15 feet) lowest 20%ile
Activity level lowest 20%ile
4. Isolation is Bad
Isolation is a disease or at least a risk factor
Associated findings:
Self-neglect (nutrition, cleanliness)
Depression
Approach to Isolation
Look carefully for Depression, Dementia, Abuse/neglect
Consider home visit volunteers, adult day centers, volunteer work, adult communities, family conferences—but must be patient-centered to work
Geriatric care managers Full Life (ElderHealth) $60-100/hour, private ones can be $200 an hour
Resources for home visit volunteers:
National (some places): Little Brothers Friends of the Elderly, Dorot
King County: ElderFriends (from Full Life Northwest) http://www.fulllifecare.org/we-can-help/by-service/elderfriends/
Prevent Isolation by Keeping Caregivers Sane
http://www.agingkingcounty.org/
Prevent Isolation by Keeping Caregivers Sane
http://www.fulllifecare.org/
Nutrition ScreenI have an illness or condition that made me change the kind or amount of food I eat 2I eat fewer than two meals per day. 3
I eat few fruits, vegetables, or milk products. 2
I have three or more drinks of beer, liquor, or wine almost every day. 2
I have tooth or mouth problems that make it hard for me to eat.2
I don’t always have enough money to buy the food I need. 4
I eat alone most of the time. 1I take three or more different prescription or over-the-counter drugs per day. 1Without wanting to, I have lost or gained 10 lb in the past six months. 2
I am not always physically able to shop, cook, or feed myself. 2
3-5 moderate risk6+ high risk
5) Hospitalization
Associated
Disability
Assessing Function:Activities of Daily Living
Bathing
Dressing
Eating
Transfers
Toileting
Continence
Assessing Function:Instrumental Activities of Daily Living
Shopping
Meal preparation
Taking medications
Housekeeping
Laundry
Transportation
Telephone/communication
Managing finances
Hospitalization Associated Disability
Loss of one or more ADL at time of discharge, compared to before the acute illness
BathingDressingToiletingTransferringFecal and urinary continenceFeeding
Functional Patterns with Admissions
No H.A.D. H.A.D.
Hospitalization Associated Disability
Loss of one or more ADL
??% of patients over age 70 hospitalized for a medical illness are discharged having lost at least one ADL
JAMA 2011; 306: 1782-1793
Hospitalization Associated Disability
Loss of one or more ADL
>30% of patients over age 70 hospitalized for a medical illness are discharged having lost at least one ADL
One year later fewer than half are back to their pre-illness level of functioning
JAMA 2011; 306: 1782-1793
Risk Factors for H.A.D.
Depression
Age
Mobility
Dementia
Minimal Functional Assessment of the Hospitalized Patient
1. ADLs—usually from nurse or PT/OT
2. Mobility: sit up, stand, walk a few steps
3. Cognitive function: mini-cog screen
JAMA, October 26, 2011—Vol 306, 1788
Mini-cog
Give patient 3 items to recall, check registrationClock drawRecall three items
If recall all 3, screen is negativeIf recall none, screen is positiveIf recall 1 or 2, then use clockdraw to decide if pos or negative
Clockdraw: need circle, numbers reasonably arranged, 2 hands more or less pointing to 11:10
Maintaining Function in the Hospital – Things Medical System Can Do
•Minimize bed rest—carpeted floors, grab rails
•Limit catheters and other tubes that limit mobility
•Pay attention to nutrition—avoid unneeded NPO or restricted diets
•Watch out for adverse meds effects—daily review MAR
•Pay attention to mental stimulation. Facilitate family visits, even overnight
•Try to let people get their rest at night!
•Easy access chairs and walking aids
•Avoid enforced dependence
•Planned transition to home
Maintaining Function in the Hospital – Things the patient can do
•Minimize bed rest—try to at least get into a chair if you can’t walk. Bed-based exercise sometimes the best option.
•Don’t let the tubes keep you down!
•Pay attention to nutrition. OK to ask for snacks
•Have your glasses/hearing aids
•Pay attention to mental stimulation—visitors help!
H.A.D. Prognosis
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
H.A.D. Prognosis
One year later:
41% dead
29% still disabled
30% returned to prehospital level of function
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
H.A.D. Prognosis
One year later:
41% dead
29% still disabled
30% returned to prehospital level of function
Boyd CM, et al. J Am Geriatr Soc.2008;56(12):2171-2179.
18% dead
15% alive with decline in ADLs
67% still at baseline
6. Prescribing the Fountain of Youth
EXERCISE: the miracle drugFree or low costNo interactions with pharmaceuticalsEssentially no side effects, except temporary muscle sorenessDuration of action days to weeksBenefits:
o Longer survivalo Reduced disabilityo Increased energy and moodo Improve/maintain cognitiono Improved sleepo Less restless leg syndrome
The Research in Chronic Disease
Increasing physical activity levels is the most important intervention for virtually ALL chronic disease management and prevention programs.
Tailored Advice
Chair bound – Sit and Be Fit (KBTC 9-9:30 AM)
PT-guided—especially if gait/balance issues
Senior Fitness Classes
Walking 5-10K steps by pedometer (JAMA 2007;298:2296)
Sports/fitness clubs/dancing, etc
7: Preventing falls
Fall Epidemiology
Annual rates of fallingCommunity-dwelling adults > 65: 30-40%
Adults>80 years: 50%
Adults in long term care: 50%
People with history of fall in prior year: 60%
Males and females equally likely to fall, but women more often injured in the fall.
Fall Epidemiology
5-10% of senior falls (but 10-30% in NH patients) results in major injury (fracture, head trauma, major lacerations)
50% of elderly who fall are unable to get up on their own
CONSEQUENCES OF FALLS
Long term admission to nursing home:
HR Adj HR
Single fall w/o injury
4.9 (3.2-7.5) 3.1 (1.9-4.9)
2 or more non-injury falls
8.5 (3.4-21.2) 5.5 (2.1-14.2)
One or more fall with
serious injury19.9 (12.2-32.6) 10.2 (5.8-17.9)
N Engl J Med 1997;337:1279-84
Why do elderly fall?(Physiology of aging)
Sensory system
Muscle changes
Hypotension/cerebral hypoperfusion
Why do elderly fall?(Physiology of aging)
Sensory system Visual declines
Loss of acuity Decreased depth perception Decreased dark adaptation
Decreased proprioception in legs Vestibular system decline
Why do elderly fall?(Physiology of aging)
Muscle changes Sarcopenia (fat replaces muscle fibers) Proximal muscles activated more quickly than distal Antagonistic muscle contraction
Why do elderly fall?(Physiology of aging)
Hypotension/cerebral hypoperfusion Decreased baroreflexes (heart rate, sympathetic tone) Postprandial diversion of blood flow Tendency to dehydration (decreased total body
water)
Why do elderly fall?(Burden of chronic disease)
Parkinson
Chronic musculoskeletal pain
Osteoarthritis
Dementia
COPD
Arrhythmia
Residua of CVA
Heart failureetc
Why do elderly fall?(Medications)
Neuroleptics
Benzodiazepines
Antidepressants__________________
Vasodilators
Problem drinking
Assessing Risk of Falls
History of prior falls most important
PE: Postural vitals, visual acuity, hearing, legs
Get up and Go
_________________
Functional Reach
Berg Balance Test
Tinetti Tool (POMA)
Divided attention tasks
Preventing Falls: Cochrane Analysis Community Dwelling Seniors
111 trials (55,303 participants).
Effective (% reduction in falls) :
Tai Chi 37%
Individually prescribed home-based exercise 34%
Assessment and multifactorial intervention 25%
Multiple-component group exercise 22%
Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009
Preventing Falls: Cochrane Analysis Community Dwelling Seniors
The second tier -- Helpful in some groups Vitamin D in people with lower vitamin D levels. Home safety interventions with severe visual impairment, and in others at higher risk of fallingAnti-slip shoe device for icy conditions Gradual withdrawal of psychotropic medication Prescribing modification program for primary care physiciansPacemakers in people with carotid sinus hypersensitivity Cataract surgery
Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009
Preventing Falls: USPSTF Analysis Community Dwelling Seniors
54 studies judged to be relatively high quality
Percent reduction in falls:
Vitamin D supplementation 17%
Exercise or physical therapy 13%
Multifactorial assessment and management 6%?
(risk ratio, 0.94 [CI, 0.87 to 1.02])
Ann Intern Med. 2010;153(12):815 -- USPSTF=US Preventive Services Task Force
Preventing falls: exercise
When prescribing exercise for fall prevention, it seems important to include multiple categories:
Gait and balanceStrengthFlexibilityEnduranceGeneral physical activity (e.g. gardening)Movement exercise (tai chi, dancing)
Ask all patients ≥75 years old about falls and balance or gait difficulties. Get-up-and-go testing for all.
No falls and no balance or gait difficulties
Recommend general exercise program that includes balance and strength training
Two or more falls or balance or gait difficulties
One fall and no balance or gait difficulties
Formal assessment – See next page
Tinetti, NEJM 2003; 348 (1): 42-9
Fall Prevention in primary care
Summary—Assessment of a Faller
Gait, balance, mobility (neurologic or musculoskeletal impairments? Often get PT help with this.)
Fall historyMedicationsVisual acuityHeart rate and rhythmPostural vitalsReview environmental hazards
Modified from JAGS 2011; 59 (1) 148-157
Assist Devices
Adults>65—10% use canes, 5% use walkers Often poorly fit, improperly used, poorly maintained.
Top of cane/walker handle should be at wrist crease when patient stands up with arm relaxed at side.
Picking device depends on current state of strength, endurance, balance, cognitive function, home needs. Walkers a big hazard on stairs!
American Family Physician August 15, 2011
Assist Devices: Maybe good…or not
Increases confidence and feeling of safety
That increases activity, with its multitude of benefits
But…not enough data to say if they actually prevent falls
American Family Physician August 15, 2011
8. Geriatrics is all about Team
Core Team:Physician, PA-C, ARNPOffice nurse/home care nurseSocial workerFamily
Other key members depending on situation:HospiceDieticianPharmacistRehab therapistsMental health workersSpiritual counselorAudiologistDental care giversEye care specialistsSenior advocacy groups/Community agencies
Geriatrics is all about Team
1. Set the Agenda
2. Meds, meds, meds
3. Prevention—Do what Really Counts
4. Isolation is Bad
5. Avoid Hospitalization Associated Disability
6. Rx the Fountain of Youth
7. Prevent falls
8. Geriatrics is all about Team
The Eight Pearls