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