Download Primary Care of Older Adults: Pearls and Pitfalls

Primary Care of Older Adults:
Pearls and Pitfalls
Colleen Christmas, MD, FACP
Disclosures
• I have not received any payments from
companies related to this talk.
Objectives
• Describe a few general principles that can
guide the primary care of older adults
• Describe an approach to choosing tests and
treatments
• Describe an approach to medication review
• Know when exercise is beneficial
You’ve seen one 80 year old…
Thejournal.ie
www.sunsetbeachclub.com
DRUGS CAN BE DANGEROUS
Patient #1
• 78 year-old man with dementia and behavior
problems noted to have lost 9kg in past year
(~10% of body weight)
• Also:
– Chronic kidney disease
– Hypertension
– Edema
– Atrial fibrillation
What next?
• Medical evaluation normal
• Psychiatrist and nursing home want to start
mirtazipine and nutritional supplements
• You review his meds:
– Donepezil 23mg daily -omeprazole
– Lisinopril
-digoxin
– Furosemide
-citalopram
– Aspirin
– Amlodipine
Drugs are Dangerous
•
•
•
•
Drugs should always be included in differential diagnosis
Resist temptation to treat all symptoms with drugs
Adverse drug reactions more frequent / severe in elderly
Starting any medication in older patients should be
viewed as a major intervention
• “Start low, go slow”
Geriatric Medication Review
• Does every medication have a diagnosis?
• Do diagnoses have matching high yield medications?
– Aspirin in coronary disease
• Are medications working?
– Is mood improved with antidepressant?
• For medications that need monitoring, is it up to date?
– Digoxin level, renal function for ACE inhibitors
• Can anything be simplified?
• Is one drug being used to treat side effects of another?
– Amlodipine -> edema -> furosemide
• Is adherence and/or cost an issue?
• Are the medications and treatments in line with the
patient’s goals of care? (longevity, function, comfort)
Top Medications for Older Adults to
Avoid
• Non-steroidal anti-inflammatory drugs
• Digoxin in doses greater than 0.125 mg
• Certain diabetes drugs
– Sulfonylureas, especially long acting
• Muscle relaxants
• Certain meds for anxiety/insomnia
– Benzodiazepines, sleeping pills
• Anticholinergic drugs
• Antipsychotics (unless patient has psychosis)
• Estrogen pills and patches
www.americangeriatricssociety.org
High Risk Drugs
• Drugs associated with high rates of hospitalization
–
–
–
–
Warfarin
Insulin
Oral hypoglycemics
Antiplatelet agents - aspirin and clopidogrel
– Digoxin
• 67% of hospitalizations for ADEs between 2007 and 2009
were due to top four medications listed above
• Two-thirds of hospitalizations for ADEs were due to
unintentional overdoses
Budnitz et al, NEJM 2011
Budnitz et al, Ann Int Med 2007
Patient #1
• Needs careful medication review
• Anorexia and weight loss
– Donepezil 23mg
• Not more effective than 10mg (2 points on 100 point
scale)
• Clinically significant increase side effects
– Digoxin
• Amlodipine and furosemide?
Farlow. Clin Ther2010. Rathore NEJM 2002.
Patient #2
• 89 year-old man reports fatigue and taking too
many medications
• Accompanied by son and daughter
• They are concerned about his safety and
ability to remain at home
• Medications are expensive
His Current Care Plan
Condition
Medical Treatment
Probable Alzheimer’s Disease donepezil, memantine
Systolic Heart Failure
furosemide, metoprolol,
lisinopril
Osteoarthritis
acetaminophen, tramadol
Osteoporosis
calcium, D, alendronate
Insomnia
zolpidem
Type 2 Diabetes Mellitus
metformin, glyburide
Benign Prostatic Hyperplasia tamsulosin
Additional medications: aspirin, simvastatin
His Current Care Plan
• Current data:
– Mini Mental State exam 23/30
– Sitting blood pressure: 110/70 pulse 54;
standing: 100/60 pulse 56
– HemoglobinA1c 6.8% (3 months ago 7%)
– Lipid panel: total 180, LDL 70, HDL 50,
triglycerides 300
– Labs: Creatinine: 1.7
Time Horizon to Benefit
• Length of time needed to accrue an
observable and clinical meaningful risk
reduction for a specific outcome
• Different than number needed to treat or
harm
• May be different than the trial length
Case: Evidence
• Osteoporosis
– Bisphosphonates for osteoporosis effective, with a
modest absolute risk reduction
Osteoporosis
% fracture-free
bisphosphonate
50% reduction in
risk of fracture over
a 3 year period
1.2% absolute risk
reduction for
fractures in 3 years
placebo
Time to benefit
9 to 18 months
Median life expectancy:
2.7- 4.7 years
TIME
National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis, 2009
Reasons to Stop the Bisphosphonate
Black DM, Schwartz AV, Ensrud KE, et al. JAMA 2006;296:2927-38.
General Principles
• When thinking about starting or stopping a
drug, ordering a screening test, or prescribing
other therapy, need to consider:
– What is this person’s estimated life expectancy?
– Is that estimate long enough to get benefit from
the proposed action?
– Is the absolute benefit reasonable?
Patient #3
• 80 year old woman
• Type 2 diabetes,
hypertension
• Independent all activities
• Walks 1 mile every other
day
• Lives with sister, helps her
with shopping
• No family history of
cancer
• Should she have a
mammogram?
Life Expectancy for Women
25
21.3
20
Y
e 15
a
r 10
s
17
15.7
13
11.9
9.5
6.8
4.6
5
0
9.6
8.6
5.9
2.9
70
75
Top 25th Percentile
80
50th Percentile
Adapted from Walter. JAMA. 2001
85
6.8
4.8
3.9
2.7
1.8
90
95
Lowest 25th Percentile
1.1
eprognosis.ucsf.edu
Risk of Dying From Breast Cancer in
Remaining Lifetime
Age 70
Life
expectancy
Age 75
21.3 15.7 9.5 17
% risk 3.3
of
dying
2.2
Age 80
11.9 6.8
1.2 2.8 1.8
0.9
13
8.6
4.6
2.4
1.5
0.7
Risk of dying from breast cancer = Life expectancy x Age-specific breast cancer
mortality rate
Walter. JAMA. 2001.
Walter. Ann Intern Med. 2004.
Patient #3
• Estimated life expectancy=13 years
• Risk of dying from screen-detectable breast
cancer=2.4%
• www.cancer.gov/bcrisktool
• Preference maintain health and independence
• Worries about stigma and mammograms
causing cancer
• No significant barriers
www.americangeriatrics.org
EXERCISE IS GOOD FOR WHAT AILS
YOU
Patient #4
• 75 year-old woman with major depression,
knee osteoarthritis, hypertension
– Knees hurt
– Tired
– Tired of taking pills
– Spends much of day sitting
– Needs help to do household chores
Aging resembles being sedentary
Aging
Illness
Disuse
Role of exercise
• Minimize physiologic changes associated with
typical aging
• Decrease risk of several common chronic
diseases
• Assist in prevention and treatment of
disability
• Serve as primary or adjunctive treatment for
some chronic diseases
Benefits
Condition
Effect
Osteoarthritis
Almost all studies show benefit
Interventions: many; quad strengthening
Moderate effect on pain (10-15%)
Some effect on function (~10%)
Low intensity may = high intensity
Depression
Response rates=31% to 88%
High intensity
Most significant effects in those with
comorbid illness
Osteopenia
Strength and weight-bearing
Overall treatment effect of exercise
training was a reversal or prevention of
bone loss of 0.9% per year
Hart, et al. Clin J Sport Med 2008; Fiatarone Singh MA Clin Geriatr Med 2004. Wolff I.
Osteoporos Int 1999
Benefits
More likely to:
Less likely to:
Disability
Increases chance of dying
without disability (RR 1.8)
Fracture a hip
Fall
rate=0.63-0.78
risk=0.65-0.83
Develop cognitive impairment
Develop
• Diabetes (RR 0.6-0.7)
• Colon cancer, breast cancer,
and death rate from cancer
(RR 0.3-0.6)
• Stroke (RR 0.3-0.76)
• Cardiovascular disease
Have a normal systolic BP
Be alive?
Nursing Res 2010;59:364-70; Weuve J. JAMA 2004;292:1454-61. Abbott RD. JAMA
2004;292:1447-53. Gillespie LD Cochrane Database of Systematic Reviews 2009; Young, JAGS 1999;47:277
Depression
Blumenthal JA, et al. Arch Intern Med. 1999.
Contraindications to exercise
• Almost all can safely engage in a program of
moderate activity, such as walking or lifestyle
modification, without screening
• Few conditions are true contraindications
(unstable cardiopulmonary disease)
• Start low, go slow, pace
• Warm up, cool down
• Supervision and structure best
• Fall risk, injury prevention
Patient #4: It’s never too late!
Summary
• A highly nuanced drug review is super high
yield for older patients
• Decisions about tests and treatments should
include consideration of time to benefit in
addition to degree of benefits and harms
• We use too many drugs and not enough
exercise in treating the elderly