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Alliance for Geriatric Education in Specialties (AGES) Curriculum Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Curriculum Contents Introduction Module 1: The Physiology of Aging Module 2: Dementia Module 3: Delirium Module 4: Transitions of Care Module 5: Basics of Geriatric Assessment & Levels of Care Module 6: Iatrogenic Injury Module 7: Palliative Care Communications Module 8: Polypharmacy 2 Introduction AGES Curriculum The Alliance for Geriatrics Education in Specialties (AGES) consists of 8 interactive core curriculum modules: iatrogenic injury, delirium, dementia, polypharmacy, transitions of care, basics of geriatrics assessment and levels of care, physiology of aging, palliative care communication and medications. These 8 modules have been designed to teach specialty faculty, at all levels of their career, how to increase effectiveness and quality of care for their older adult patients. In 2009, the University of North Carolina School of Medicine at Chapel Hill conducted a needs assessment to evaluate the potential for improvement of UNC Healthcare System specialty/subspecialty faculty regarding geriatrics care through training. Based on the assessment results, the AGES curriculum was developed, implemented, evaluated, and now available for use through POGOe. The AGES curriculum can be taught as an entire course or each module can be taught as a separate training session. The UNC Healthcare System is currently using all 8 modules for training its non-geriatrician specialty faculty. Each of the 8 module PowerPoint presentations will take approximately 60 minutes per training session. *This curriculum may also be applicable to internists and family medicine practitioners. 3 AGES Module 1: The Physiology of Aging 4 Physiology of Aging Christine M. Khandelwal, DO Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Learning Objectives • Learners will be able to describe the normal changes that occur with aging. • Learners will be able to identify the common age-related changes that occur in the following systems: cardiovascular, respiratory, renal, hematology/immune, gastrointestinal, endocrine, neurologic, musculoskeletal, and reproductive. 6 Aging • Chronologic age is not an accurate predictor of physical condition or behavior • Poor health in later life is not inevitable • The rate of physiologic decline can be modified • Much of the illness and disability associated with aging is related to modifiable lifestyle factors that are present in middle age: » disparate factors predispose individuals to functional losses later in life » many conditions have suspected either genetic and/or environmental etiologies 7 Aging and Disease • It may not always be possible to differentiate normal aging from disease • Normal changes with aging reduce your reserve capacity • Aging results in a diminished ability to maintain homeostasis and regulate body systems • Aging is accompanied by heterogeneity 8 Cardiovascular System • The changes that normally occur in the cardiovascular system with aging do not significantly limit the normal work capacity of the heart • Advancing age increases the risk for hypertension and coronary artery disease 9 Cardiovascular System • The prevalence of coronary artery disease at autopsy may reach 75 percent after the sixth decade in men, two decades later in women* • The Baltimore Longitudinal study studied highly screened older individuals and found only a minimal impact of aging on resting cardiovascular function such as left ventricular ejection fraction** *(Van de Veire NR, De Backer J. Ascoop AK, Middemacht B. Veighe A. Sutter JD. Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals. Int. J. Cardiovasc Imaging. 2006;22(5):633). **Fleg JL, O’Connnor F. Gerstenblith G. Becker LC, Clulow J. Schulman SP, Lakatta EG. Impact of age on the cardiovascular response to dynamic upright exercise in health men and women. J Appl Physiol. 1995;78(3):890). 10 Cardiovascular System • A study found that aging was accompanied by an increase in LV mass and LA dimensions and an increase in relaxation abnormalities in normotensive individuals* • Ageing was associated with increased mean LV wall thickness, chamber diameter, mass, concentric remodelling, and a decline in LV diastolic function ** *(Van de Veire NR, De Backer J, Ascoop AK, Middernacht B, Velghe A, Sutter JD. Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals. Int J Cardiovasc Imaging. 2006;22(5):633). **(Gates PE, Tanaka H, Graves J, Seals DR. Left ventricular structure and diastolic function with human ageing. Relation to habitual exercise and arterial stiffness. Eur Heart J. 2003;24(24):2213). 11 Age-associated Change Common Clinical Consequence (s) Valves calcium deposits Cardiac conduction problems Pacemaker cell loss (SA node) Fibrous tissue/fat deposits Dysrhythmias Baroreceptors Orthostatic hypotension Arteries thicken/stiffen Ventricular cardiomyocytes hypertrophy Moderate increase in SBP Not normally aging: Atherosclerotic plaques or HTN 12 Respiratory System • Most of the normal respiratory changes with age are of little functional significance in healthy older adults • However, the normal anatomical changes do reduce reserve capacity and increase vulnerability to respiratory disease 13 Respiratory System • Aging chest wall changes include increased stiffness of the chest wall predominates over an increase in compliance of the lung parenchyma* • A decrease in PaO2 and increase in alevolararterial oxygen gradient is found in normal aging lungs • Carbon dioxide excretion is not impaired with age and any changes in PaCO2 are due to disease and should not be attributed to age alone *(Estenne M, Yernault JC, De Troyer A. Rib cage and diaphragm-abdomen compliance in humans: effects of age and posture.J Appl Physiol. 1985;59(6):1842). 14 Age-associated Change Clinical Consequence (s) Vital capacity reduced FEV reduced Chest wall compliance reduced Alveolar PO2 does not change with age, but age increases the alveolar-arterial (A-a) oxygen gradient. Reduced alveolar elasticity and reduced number of functional alveoli Decrease surface area for gas exchange Reduced exercise capacity and reduced reserve capacity Cilia activity reduced Increased risk of respiratory infections Glandular cells reduced Lung macrophages less effective Cough less forceful 15 Renal System • Most changes do not cause clinically significant disease or disability, but they do leave the kidney vulnerable to illness or medications that can depress renal function and lead to acute or chronic renal failure. • Normal aging is associated with diffuse sclerosis of glomeruli such that 30 percent of glomeruli are destroyed by age 75 * *(Nyengaard JR, Bendtsen TF. Glomerular number and size in relation to age, kidney weight, and body surface in normal man. Anat Rec. 1992;232(2):194). 16 Age-associated Change Clinical Consequence (s) Renal mass and size reduced Reduced the rate of blood flow Average Creatinine clearance is reduced 10ml/decade Decrease in excretion of drugs/toxins Renal tubular cells reduced, thickened tubular walls Decreased ability to concentrate urine Thirst is blunted Volume depletion ↓ serum renin and aldosterone (30-50%) Increased prostaglandins Dehydration Reduction of urine acidification and impairment in excreting Vulnerable to ischemic insult Prone to nephrotoxicity 17 Hematopoietic System • Maintains adequate function with aging • Overall, cell counts and parameters in the peripheral blood are not significantly different from in young adult life » Red cell life span, iron turnover, and blood volume are unchanged with age • EPO response to anemia in older subjects is similar to that of younger subjects* *(Powers JS, Krantz SB, Collins JC, Meurer K, Failinger A, Buchholz T, Blank M, Spivak JL, Hochberg M, Baer A. Erythropoietin response to anemia as a function of age. J Am Geriatr Soc. 1991;39(1):30.) 18 Hematopoietic System • Functional reserves are reduced with age due to a decreased bone marrow mass and an increase in fat* • Total circulating white cells counts do not change with age in healthy older people, but the function of several cell types is reduced *(Kirkland JL, Tchkonia T, Pirtskhalava T, Han J, Karagiannides I. Adipogenesis and aging: does aging make fat go MAD? Exp Gerontol. 2002;37(6):757). 19 Hematopoietic System • The compensatory hematopoietic response to phlebotomy, hypoxia, and other stressors is delayed and less vigorous in the healthy older person • Observational studies have shown increasing hypercoagulabailty state with aging » Higher risk of DVTs* *(Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol. 2006;60(2):144). 20 Immunologic System • Immunosenescence - aging changes in immune function: » Diminished cell mediated immunity » Increased incidence of anergy » Reduced helper, cytotoxic and effector T cells » Increased cytokine antagonists » Changes in neutrophil and macrophage function 21 Immunologic System • Immunosenescence contributes to increased frequency of infections, malignancies, and decreased changes of developing adequate immunity* *(Agarwal S, Busse P. Innate and adaptive immunosenescence. J Ann Allergy Asthma Immunol. 2010;104(3):183). 22 Gastrointestinal System • The physiologic changes of an aging GI system are minor • Aging itself does not cause malnourishment • Normal aging changes: » The amplitude of esophageal contractions during peristalsis decreases, but the movement of food is not impaired » the prevalence of H.Pylori increases with advancing age » Transaminases and alkaline phosphatase are minimally affected by age 23 Age-associated Change Clinical Consequence (s) Gastric cells reduced Gastritis Increased post prandial gastric pH Less effective mastication Decreased food clearance Increased risk of aspiration Muscle tone reduced, peristalsis reduced Constipation Hepatic size reduced, blood flow reduced Less efficient in metabolizing drugs/toxins 24 Endocrine System • Because the endocrine system is so complex & interrelated it is difficult to discern the effects of aging on specific glands • In most glands there is some atrophy & decreased secretion with age, but the clinical implications of this are not known • What may be different is hormonal action 25 The Endocrine System • Hormonal alterations are variable & genderdependent: • Most apparent in: » glucose homeostasis » reproductive function » calcium metabolism • Subtle in: » adrenal function » thyroid function 26 Genitourinary System • Aging changes in the genitourinary system increase the older person's risk of: » » » » urinary incontinence urinary tract infection erectile dysfunction dyspareunia • The prevalence of urinary incontinence increases with age due to: » » » » decrease in detrusor muscle contractility decrease in maximum bladder capacity decrease ability to withhold voiding an increase in postvoid residual 27 The Reproductive System Men • Testes become softer & smaller • Prostate enlarges; fewer viable sperm are produced & their motility decreases • May not experience orgasms every time they have sex • Erections are less firm & often require direct stimulation to retain rigidity 28 The Reproductive System Women • The “climacteric” occurs (defined as the period during which reproductive capacity decreases (ie, ovarian failure) then finally stops = loss of estrogen & progesterone; FSH & LH ↑↑) • This is also described as the transition from perimenopause (~age 40s) to menopause • Atrophy of vaginal tissues, hot flashes, sweats, irritability, depression, headaches, myalgias, sexual desire is variable 29 The Neurological System • Increased: • Reduced: » Abnormal proteins » Neurons » Cerebral atrophy » Neurotransmitter levels » Changes in sleep patterns » Lipid turnover rate » Stroke risk 30 Neurologic System • The weight of your brain peaks around age 20 and then a modest decline occurs with age that is limited to the gray matter (outer surface of the brain) in healthy older people • Cardiovascular disease and hypertension are predictors for cognitive impairment* *(Newman AB, Arnold AM, Sachs MC, Ives DG, Cushman M, Strotmeyer ES, Ding J, Kritchevsky SB, Chaves PH, Fried LP, Robbins J. . Long-term function in an older cohort--the cardiovascular health study all stars study. J Am Geriatr Soc. 2009;57(3):432) 31 Sensory Changes • As you age, your senses (vision, hearing, taste, smell, touch) may become less acute • The most dramatic sensory changes with age affects vision and hearing • Many of the changes can be compensated for with assistive devices (e.g., glasses, hearing aids, etc.) or by changes in lifestyle 32 Neurologic System • As people age, they usually experience such memory changes as slowing in information processing, but these changes are benign • Short-term and remote memories aren't usually affected by aging; recent memory may be affected • Not progressive and does not interfere with daily function or independence 33 Age-associated Change Clinical Consequence (s) Middle ear membranes and bones less flexible Decreased hearing sensitivity Pupil size reduced Lens becomes rigid Decreased ability to focus at near range, less tolerance to glare Ability to produce tears reduced Functional smell receptors reduced Dry eyes Diminished sense of smell Taste buds reduced in size and numbers Diminished taste Touch receptors reduced, response to painful stimuli reduced Diminished sense of touch 34 The Musculoskeletal System • Sarcopenia: age-related loss of muscle mass and strength » Loss of muscle is greater and faster from the legs than from the arms » Activity may decrease rate of decline » The loss of muscle contributes to age-related changes in body composition, and distribution for water soluble drugs* • Type 1 slow-twitch fibers are less affected by age than fast-twitch fibers » Older muscle easily fatigues *(Degens H. Age-related skeletal muscle dysfunction: causes and mechanisms. Musculoskelet Neuronal Interact. 2007;7(3):246) 35 The Musculoskeletal System • The primary factors contributing to reduction in height include compression of vertebrae, changes in posture, and increased curvature of the hips and knees • The “wear-&-tear” theory regarding cartilage destruction & activity doesn’t hold up as osteoarthritis is also frequently seen in sedentary elders • Decrease H20 in the cartilage of the intervertebral discs results in a ↓ in compressibility and flexibility • Decrease H20 content of tendons & ligaments contributing to ↓ mobility 36 The Musculoskeletal System • Gradual loss of bone mass (bone resorption > bone formation) starting around age 30s • Aging in both men and women increases the probability of fracture and once a fracture occurs, the rate of repair is slowed • Vitamin D deficiency further accelerates bone loss • Increasing weight bearing time or loading forces may result increase bone mineral and prevent age-related bone loss* *(Schwab P, Klein R. Nonpharmacological approaches to improve bone health and reduce osteoporosis. Curr Opin Rheumatol. 2008;20(2):213). 37 Hair, Nails, and Skin • Epidermal cells decreases by 10% per decade and they divide more slowly making the skin less able to repair itself quickly » Epidermal cells become thinner making the skin look noticeably thinner » Thinning of the epidermis allows more fluid to escape the skin • Skin shears easy due to decrease in surface area • ↓ function of sebaceous & sweat glands » dry skin » reduced ability to cool the body » wrinkles, sagging of skin 38 Hair, Nails, and Skin • Mechanical protection altered • Tendency to hypothermia • Vulnerability to heat and cold • Decreased barrier function • Lax skin 39 Treatment Implications • Consider earlier and more aggressive treatment of infections BUT with attention to renal function • Pay closer attention to nutrition and bowel function • Pay close attention to CNS changes as harbingers of other pathologies • Screen carefully for metabolic disorders: thyroid, anemias, bone disease, vitamin deficiencies 40 Key Points: • It is not always possible to differentiate normal aging from disease • Many of the normal changes of aging do not cause clinically significant declines in function • Changes in the cardiovascular, respiratory, and gastrointestinal do not affect the ordinary activities of a healthy older adult 41 References • Rughwani, N. (2008). Physiology of Aging. POGOe - Portal of Geriatric Online Education. Retrieved February 21, 2011 from http://www.pogoe.org/productid/20284 • GRS 7th edition – American Geriatrics Society • Van de Veire NR, De Backer J, Ascoop AK, Middernacht B, Velghe A, Sutter JD. Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individualsInt J Cardiovasc Imaging. 2006;22(5):633). • Fleg JL, O'Connor F, Gerstenblith G, Becker LC, Clulow J, Schulman SP, Lakatta EG. Impact of age on the cardiovascular response to dynamic upright exercise in healthy men and women.J Appl Physiol. 1995;78(3):890). • Gates PE, Tanaka H, Graves J, Seals DR. Left ventricular structure and diastolic function with human ageing. Relation to habitual exercise and arterial stiffness. Eur Heart J. 2003;24(24):2213). • Estenne M, Yernault JC, De Troyer A. Rib cage and diaphragm-abdomen compliance in humans: effects of age and posture. J Appl Physiol. 1985;59(6):1842). • Glomerular number and size in relation to age, kidney weight, and body surface in normal man. Anat Rec. 1992;232(2):194). 42 References • Powers JS, Krantz SB, Collins JC, Meurer K, Failinger A, Buchholz T, Blank M, Spivak JL, Hochberg M, Baer A. Erythropoietin response to anemia as a function of age.J Am Geriatr Soc. 1991;39(1):30. • Kirkland JL, Tchkonia T, Pirtskhalava T, Han J, Karagiannides I. Adipogenesis and aging: does aging make fat go MAD? Exp Gerontol. 2002;37(6):757. • Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol. 2006;60(2):144. • Degens H. Age-related skeletal muscle dysfunction: causes and mechanisms. Musculoskelet Neuronal Interact. 2007;7(3):246. • Agarwal S, Busse P. Innate and adaptive immunosenescence. JAnn Allergy Asthma Immunol. 2010;104(3):183. • Newman AB, Arnold AM, Sachs MC, Ives DG, Cushman M, Strotmeyer ES, Ding J, Kritchevsky SB, Chaves PH, Fried LP, Robbins J. . Long-term function in an older cohort-the cardiovascular health study all stars study. J Am Geriatr Soc. 2009;57(3):432) • Schwab P, Klein R. Nonpharmacological approaches to improve bone health and reduce osteoporosis. Curr Opin Rheumatol. 2008;20(2):213. 43 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine and the Department of Family Medicine also provided support for this activity. 44 ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 45 AGES Module 2: Dementia 46 How to Teach about Dementia…. Debra Bynum, MD Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Does this Patient Have Dementia? • 78 year old man is seen in the clinic for routine follow-up. He is a retired physician and is worried about memory loss. His MMSE is 27. His son has started helping him with his bills and other financial activities. On exam, he has difficulty with word finding and difficulty with “no ifs, ands, or buts….” 48 Does this Patient Have Dementia? • 82 year old woman with a 6th grade education presents for follow up. Her eye sight is limited and the interview is challenging because of her severe hearing loss. Her MMSE is 20. 49 Does this Patient Have Dementia? • 91 year old man is admitted to the hospital with urosepsis. He is confused and upset. His MMSE is 23. 50 Outline • What is dementia? • Risk factors and prevention • Dementia, delirium, and depression: Red flags • Assessment tools and strategies • Types of dementia • Treatments • Teaching about dementia…. 51 Objectives The learner will be able to: •Define dementia •Name risk factors/causes for dementia •Discuss why delirium and depression are predictors/red flags for dementia •Discuss assessment tools/strategies for identifying dementia •Name at least 5 types of dementia •Discuss the treatment options for dementia 52 What is Dementia? • “I shall not today attempt further to define the kinds of material I understand to be embraced . . . but I know it when I see it . . .” » Justice Potter Stewart, 1964, attempting to define pornography…. 53 DSM IV Definition • Memory impairment associated with (at least 1): » Aphasia (disturbance in language) » Apraxia (impaired motor ability) » Agnosia (inability to identify objects) » Disturbance in executive functioning (ie, planning, organizing, sequencing, and abstracting) • Impacts social, functional, or occupational activities • Decline from a previous level of functioning • Does not occur solely in the setting of delirium Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) 54 Key: Impact on Functional Status/Life • Mild Cognitive Impairment: memory loss that does not significantly impact daily functional status • 55 Key Point • The score on the MMSE (or any other assessment or screening instrument) is not a component of the definition • You can have a low MMSE and NOT have dementia. You can have a nearly normal MMSE and HAVE dementia 56 Importance • Prevalence of dementia: » 3% to 11% in those aged ~65 years » 33% in those aged ~85 years • Over half of all skilled nursing home admissions in those aged >60 due to dementia 57 19th Century List of Causes of Dementia…. 58 2011: Risk Factors for Cognitive Decline • HTN (**) • Diabetes • Hyperlipidemia • Current smoking • HIV • ETOH abuse • Prior severe head trauma • Genetic factors 59 Primary Risk Factor • Age 60 Prevention? • No clear evidence to support preventing cognitive decline with Vitamin E, Gingko Biloba, leisure activities, fish oil, estrogen, NSAIDS….. • Observational studies looking at lifestyle changes, mental activity (crosswords, puzzles), etc all challenging because of potential selection bias • “Vitamin E is a drug looking for a disease….” » Dr. Zell Hoole 61 Prevention • Preventing/treating HTN (*), DM, hyperlipidemia, obesity, smoking in mid-life • Prevention of both vascular and Alzheimertype dementias 62 The 3 D’s: (table from Postgraduate Medicine, Volume 122, Issue 4, July 2010) Features Delirium Dementia Depression Onset Acute Insidious Subacute Course Fluctuating Progressive Related to specific events Duration Days to weeks Months to years Variable Consciousness Altered Clear Clear Attention Impaired Normal, except in severe dementia Normal Psychomotor changes Increased or decreased Often normal Decreased Reversibility Usually Rarely Usually 63 Reality… Features Delirium Dementia Depression Onset Acute Can seem acute Can be vascular and acute Course Fluctuating Function can fluctuate (LBD) Can fluctuate Duration Can be months or more Can progress quickly Can last years Consciousness Altered Can be altered Can be altered (psychotic) Attention Impaired Impaired when severe Can have psychoses Psychomotor changes Increased or decreased Can be altered (LBD) Reversibility Not always (post CABG) Rarely Can be difficult 64 Dementia, Delirium, and Depression • Much emphasis in past made on differentiation • Key points 1. Often tied together, can have overlap 2. Delirium and depression are markers for underlying cognitive impairment and the development of dementia 65 Late Life Depression: Predictor of Dementia • Women’s Health Initiative Study: Depressive disorder at baseline associated with double risk of incident MCI and dementia • HYVET: Patients with baseline depression had increased risk of mortality, CV mortality, stroke, and dementia (the higher the GDS score, the higher the risk)* • Late life depression may be early manifestation of cognitive impairment *Hypertension in the Very Elderly Trial, coordinated by scientists from Imperial College London, March 2008 66 Should We Screen? • Prevalence of dementia in primary care settings 6-15% in patients over age of 65 (increases with increasing age) • <20% of patients with confirmed dementia on screening had documentation of dementia 67 Assessment Tools for Dementia 68 If You Have 10 Minutes: • MMSE • GPCOG (General Practitioner Assessment of Cognition) 69 MMSE • Commonly used and standardized • Helpful when used repeatedly in same patient • 30 total points • Does not assess executive function, judgment, insight • Does not differentiate dementia, delirium, learning disabilities • Dependent upon age and education: Does NOT perform as well in the very educated/high functioning or the poorly educated/lower SES 70 GPCOG (General Practitioner Assessment of Cognition) • Brief cognitive screening for general practice • 9 item cognitive assessment (memory of recent events and orientation) • Plus 6 item informant questionnaire • 6 minute test • Sensitivity and specificity 85% 71 GPCOG: Patient Examination 1. Repeat name and address (John Brown, 42 West Street, Kensington): 0 points 2. What is the date?: 1 point 3/4. Clock Draw Test (CDT): Draw clock and show 10 minutes past eleven: 2 points 5. Can you tell me something that happened in the news this week?: 1 point 6. What was the name and address?: 5 points Score: x/9 (0-4 suggest cognitive impairment, 58?, 9= normal) 72 GPCOG: Informant Examination (If Patient Score 5-8) 1. Does the patient have more trouble remembering things that have happened recently? 2. Does the patient have trouble remembering conversation a few days later? 3. Does the patient have more difficulty finding the right word or tend to use the wrong words more often? 4. Is the patient less able to manage money and financial affairs? 5. Does the patient need more assistance with transport? Scores 0-3 suggest cognitive impairment 73 If You Have Only 3 Minutes… Mini-Cog 74 Mini-Cog • 3 minute test to screen for cognitive impairment in older adults in the primary care setting • 3 item recall plus scored Clock Drawing Test (CDT) » Normal clock » Hand placed on correct time (10 minutes after 11) » Untrained clinicians good at assessing normal vs abnormal • Faster and less affected by ethnicity, language, and education than MMSE • Can detect Mild Cognitive Impairment (MCI) 75 Mini-Cog: Scoring • 1 point for each recalled word • CDT: normal or abnormal • Score: » 0: positive for cognitive impairment » 1-2 abnormal CDT: positive for CI » 1-2 and normal CDT: negative for CI » 3: negative screen for dementia (no need to score CDT) 76 If You Have 15 Minutes… • MMSE or GPCOG plus » Trails testing » Categories and letters » Clock drawing 77 Trails B Testing • 1-A-2-B-3-C… • Score based upon total time to complete task correctly (seconds) • Mean times » 70-74: 111 seconds » 75-79: 119 seconds » 80-85: 152 seconds 78 Categories and Letter Naming • Score number of animals or letters named in 60 seconds • Mean scores: » 70-79: 16 animals » 80-89: 14 animals » 90-95: 13 animals • Animals: Alzheimer’s disease • F words: » Fronto-temporal dementias » May elicit F-bombs…. 79 Standard Workup…. • B12, HIV, RPR, TSH • If more acute, think of encephalitis or more atypical diseases • Most recommend imaging if never done before (unless longstanding dementia with slow, typical decline) » Rule out subdural » Rule out NPH 80 Types of Dementia • Alzheimer’s Disease • Vascular Dementia • Overlap (AD/Vascular) • Fronto-Temporal Dementia • Dementia with Lewy Body • Dementia due to Parkinson’s Disease • Other Parkinson Plus Processes • ETOH • HIV, Neurosyphilis, Prion Disease 81 Alzheimer’s Disease • Gradual short term memory loss • Personality changes • Visuospatial problems: difficulty with clock drawing • Apraxia • Medial temporal lobe atrophy on MRI • Difficulty with naming categories (animals, vegetables) 82 Vascular Dementia • Classic: Step wise decline 83 Overlap • Reality: Most cases of dementia in older patients are mixed AD and Vascular (largest risk factor for both is age) • Vascular risk factors increase risk for AD as well as vascular dementia • Cholinesterase inhibitors work just as well (or poorly) in patients with vascular dementia and AD 84 Frontotemporal Dementia (FTD) • Behavioral symptoms (disinhibition) • Executive function problems • Language dysfunction • Frontal release signs • Can occur in patients with motor neuron diseases (ALS) • Can have earlier onset and more often familial than AD 85 Dementia with Lewy Body (DLB) • 15-25% cases of dementia in patients >65 • Early visual (vivid) hallucinations • Prior sleep disorders (may precede dementia by years) • Parkinsonian features (not overt tremor, but some stiffness, cogwheeling) • More rapid decline • Decline with antipsychotics (especially typical agents) AVOID! • Fluctuating course (can resemble delirium with good days and bad days) 86 Dementia with Parkinson’s • 30 % or more of patients with Parkinson’s disease will develop cognitive decline and dementia 87 Parkinson Plus Syndromes • DLB • Multiple Systems Atrophy (Shy-Drager) • Progressive Supranuclear Palsy 88 ETOH Related Dementia • Can have associated cerebellar degeneration • ETOH abuse often unrecognized in older people 89 Impact of Dementia… • Driving, loss of autonomy • Loss of independence (IADLs, ADLs) • Caregiver stress • Wandering, behavioral problems, agitation, sleep disturbances • Risk for elder mistreatment • Risk of placement (falls, incontinence, behavioral) • Falls and fractures 90 Treatment Options 91 Cholinesterase Inhibitors • Benefits overall small: slowing of progression of disease • Similar benefits for AD and Vascular and overlap • No one agent better than another • No evidence to justify use with MCI 92 Cholinesterase Inhibitors • Donepezil 5 mg-10 mg • Rivastigmine pill: 1.5 mg BID – 6 mg BID • Rivastigmine patch: 4.6 mg/24 hrs – 9.5 mg/24 hrs • Galantamine: 4 mg BID or 8 mg ER QD – 12 mg BID or 24 mg ER QD 93 Cholinesterase Inhibitors: Side Effects • Nausea (11-47%) • Vomiting (10-31%) • Diarrhea (5-19%) • Anorexia (4-17%) • Lesser known: » hallucinations/odd dreams/nightmares » Bradycardia » Dizziness, tremor, leg cramps » Urinary Incontinence 94 Memantine (Namenda) • NMDA receptor antagonist/ neuroprotective • Starting dose: 5 mg/day; goal 20 mg (10 mg BID) • Used in combination with cholinesterase inhibitors for patients with moderate-severe dementia • Slowing of progression of disease, benefits limited • Costly, but few side effects or medication interactions 95 Beware Antipscyhotics…. • FDA Black Box warning: increased mortality and strokes • Bottom line: may help with symptoms of psychosis and aggression in selected patients, but use with caution and recognize risks • Similar risk and warning with both typical and atypical antipsychotics • Side effects: orthostasis, lethargy, confusion, QT prolongation, edema 96 Clinical Teaching • See one (sometimes), do one, teach one • Lectures • Role modeling • Clinical teaching 97 Role Modeling • Informal (hidden, unwritten) curriculum » Professionalism » Teamwork » Culture of the institution • You are being watched… 98 Strategies for Clinical Teaching • Canned 10 minute talks » Condense this talk and save • Thinking out loud/demonstrating » Use the tools discussed/practiced here in front of learners » Can be useful in acute or busy situations • One Minute Preceptor 99 One Minute Preceptor • Get a Commitment: What do you think is going on? • Probe for supporting evidence: Why? • Reinforce what was done well: You have a thorough differential… • Give guidance/correct errors: It is also important to consider…. • Teach a general principle: When you see this, you should always think of… • Conclusion: Let’s go see… 100 One Minute Preceptor • Assess the patient • Assess the learner • Focus teaching on one key point/pearl you want to get across • Give feedback 101 30 Second Preceptor…. • WHAT » What do you think is going on? • WHY » Why do you think that? • WHEN…. » When you see this, you need to think of …. » Feedback 102 Practice Teaching Cases • Pair up • Take turns role playing the resident/learner and the faculty/preceptor; Use one minute preceptor skills to teach key points about dementia • Spend 10 minutes working through the 3 cases • Wrap up discussion 103 Case 1 • 78 year old man is seen in the clinic for routine follow-up. He is a retired physician and is worried about memory loss. His MMSE is 27. His son has started helping him with his bills and other financial activities. On exam, he has difficulty with word finding and difficulty with “no ifs, ands, or buts….” • You are precepting in the clinic • The resident tells you that based on the MMSE, the patient has Mild Cognitive Impairment… • Does this patient have MCI? What teaching point do you make to the resident and how? 104 Case 2 • 82 year old woman with a 6th grade education presents for follow up. Her eye sight is limited and the interview is challenging because of her severe hearing loss. Her MMSE is 20. • Your resident is worried that the patient has dementia and can no longer live at home. • Does this patient have dementia? How would you assess this? What would you tell your resident? 105 Case 3 • 91 year old man is admitted to the hospital with urosepsis. He is confused and upset. His MMSE is 23. • Your resident is worried that the patient has dementia and will not be able to return home after discharge. • What do you tell your resident? What teaching points can be made in this case? 106 Group Discussion 107 Case 1: Teaching Strategies • “What do you think is going on? Why do you think the patient has MCI and not dementia?” • “What is the definition of dementia? Could this patient meet that definition?” • “When you see a high functioning, well educated patient, the MMSE may not work well. The diagnosis of dementia is not based upon a number on the MMSE, but an assessment that a patient’s memory loss and cognitive impairment are affecting his overall functional status”. 108 Case 2: Teaching Strategies • “What do you think is the cause of her low MMSE?” • “Why do you think she has dementia? Are there alternative reasons she may have done poorly on the MMSE?” • Feedback: You did a nice job in performing an MMSE on this patient, and recognizing that dementia may be a problem. But remember that MMSE scores may be low for other reasons…. • When you see a patient with a low MMSE, think about other factors such as vision, hearing, and educational status that may be playing a role. 109 Case 3: Teaching Strategies • “Why do you think this patient has dementia? What else could be going on?” • “What other diagnoses could account for his MMSE score? Does the MMSE perform well in this setting?” • Feedback: It is important to assess cognitive impairment in older patients who are acutely ill, but remember that acute delirium clouds the picture – you cannot diagnose dementia in the setting of delirium alone. But you are correct to be concerned because the presence of delirium is a red flag for an underlying dementia. • When you see cognitive problems in a patient who is acutely ill, think about delirium. When you see delirium, it is a red flag for possible underlying dementia as well. 110 Key Points: • Dementia is common and often missed • Vascular disease and dementia are intertwined • Red flags for dementia: Age, depression, delirium • Screening tools are quick and easy to use and teach • Think about the different types of dementias… • Dementia has incredible impact on functional status • Treatment options are still limited and do have side effects • Avoid antipsychotics if at all possible 111 Key Point • Take what you have learned and teach… in the clinic, in the ED, on the wards, by modeling, by showing, by talking out loud… 112 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health and the UNC Division of Geriatric Medicine also provided support for this activity. 113 ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 114 AGES Module 3: Delirium 115 Delirium Lindsay Wilson, MD Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Self-Test: 1. Delirium is associated with a _________-fold increase in mortality in the hospital. 2. _________ is the most common complication of hospital admission for older people. 3. Patients with delirium have an average increase of _________ days in the length of hospital stay. 4. If an appropriately trained person uses a brief cognitive assessment, they can diagnose delirium ________% of the time. 5. Up to ______% of cases in the hospital are unrecognized. 117 How Did You Do? 1. Delirium is associated with a 10-fold increase in mortality in the hospital. 2. Delirium is the most common complication of hospital admission for older people. 3. Patients with delirium have an average increase of 8 days in the length of hospital stay. 4. If an appropriately trained person uses a brief cognitive assessment, they can diagnose delirium approx 90% of the time. 5. Up to 70% of hospital cases are unrecognized. 118 Goals 1. Define delirium and describe its cardinal features and underlying pathophysiology 2. Recognize that delirium is common, underdiagnosed, and associated with significant morbidity and mortality 3. Regarding delirium, know ways to: » » » » prevent diagnose evaluate manage 4. Feel comfortable with teaching key concepts in < 1 minute 119 Goals 1. Define delirium and describe its cardinal features and underlying pathophysiology. 120 Delirium Definition Medical condition characterized by acute onset of: » Fluctuating course » Altered level of awareness » Inattention » Disorganized thinking » Increased or decreased psychomotor activity » Disturbance of sleep-wake cycle 121 Pathophysiology Image of black box or another image showing the multiple inputs to the brain that cause delirium 122 Predisposing Factors • Dementia • Functional impairment • Age • Immobility • Male sex • Alcohol abuse • Frailty • Sensory impairment • Malnutrition • High medical comorbidity • Depression • Polypharmacy • Terminal illness 123 Precipitating Factors • Medications • Severe illness • Neurologic disease • Low Hct • Surgery • Bed rest • Uncontrolled pain • Indwelling devices • Hypoxia • Restraints • Metabolic derangements • Sleep deprivation • Dehydration 124 Tipping the Scale... The greater the predisposing factors, the fewer precipitating factors required to initiate the delirium. Delirium is usually MULTIFACTORIAL. 125 Prediction Models: • Example by Inouye et al: • Assign 1 point for each of four risk factors: 1) Vision impairment 2) Severe illness 3) Cognitive impairment 4) BUN:Cr > 18 (signifying dehydration) • Those with 3-4 points have risk of delirium 32-83%. • Other predictive models specific for certain subsets of geriatric patients (ex. surgical patients). Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission characteristics. Ann Intern Med 1993: 119 (6); 474-481. 126 Goals 2. Recognize that delirium is common, underdiagnosed, and associated with significant morbidity and mortality 127 How many geriatric patients have delirium? • At presentation to the ED: 7-33%. • At hospital admission: 14-25%. • Postoperatively: 15-53%. • In the ICU: 70-87%. • In the community, ages 65-85: 1-10%, those >85: 14% . • At the end of life: Up to 83%. 128 Why under-diagnosed??? • 70% of cases go unrecognized! • #1 cause is neglecting to determine the acuity of change in mental status and dismissing presentation as dementia. • We ALL miss more of the hypoactive cases. • Diagnosis is delirium unless otherwise proven! Don’t be tempted to attribute the presentation to dementia or depression. 129 Prognosis • May persist weeks, months- 44% at 1 month, 33% at 3 months. • Has a waxing and waning course. • Has been associated with a » » » » 10-fold increased risk of death in the hospital 3-5 increased risk of nosocomial complications prolonged length of stay impaired physical and cognitive recovery at 6 and 12 months » need for post-acute nursing home placement • Has an associated one-year mortality rate of 35-40%! 130 Goals 3. Regarding delirium, know ways to: » » » » prevent diagnose evaluate manage 131 Prevention • Preventing delirium is the most effective strategy for reducing its frequency and complications. • At least 30-40% of cases may be preventable. • How do we prevent delirium??? 132 Picture of person sleeping Picture of hearing aids Picture of a walker Picture of a calendar Picture of eye glasses Picture of a beside toilet Picture of a glass of water Picture of earwax in ear Picture of a clock 133 Prevention: Yale Delirium Prevention Trial • Demonstrated the effectiveness of intervention protocol that included: » » » » » » Orientation and therapeutic activities Early mobilization Nonpharmacologic approaches Adaptive equipment Early intervention for volume depletion Sleep-enhancement protocol • Development of delirium reduced from 15% to 9.9% Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340(9): 669-676. 134 Diagnosis Picture of a patient or someone at the bedside 135 Diagnosis *****CAM: Confusion Assessment Method***** Based on the 4 cardinal elements of the DSM-3 criteria for delirium: 1. 2. 3. 4. Acute onset and fluctuating cource Inattention Disorganized thinking Altered level of consciousness Must have have 1 and 2 and either 3 or 4 Sensitivity 94%-100% Positive LR 9.6 Specificity 90-95% Negative LR 0.16 Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990: 113 (13): 941-948. 136 Feature 1. Acute Onset or Fluctuating Course: Must have this one! •This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: •Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? 137 Feature 2. Inattention: Must have this one! • This feature is shown by a positive response to the following question: • Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? 138 Feature 3. Disorganized thinking— May have this OR Feature 4 • This feature is shown by a positive response to the folllowing question: • Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 139 Feature 4. Altered Level of Consciousness—May have this OR Feature 3 • This feature is shown by any answer other than “alert” to the following question: • Overall, how would you rate this patient’s level of consciousness? » » » » » alert vigilant lethargic stupor coma 140 Practice Ms. G is a 73 year-old with mild Alzheimer's dementia. She is a new admit to rehab after surgery for a hip fracture. On morning rounds, she continuously sits up, then lies back in bed, picking at the bed sheets. Her family states that she did not sleep at all last night. This morning, she complained about "all the small children on her bed." Her family says she is not herself. You try to talk to the patient--she startles easily, then seems distracted and unable to pay attention to the conversation. What risk factors does this patient have for delirium? Is she CAM positive? 141 Diagnosis *****GAR: Global Attentiveness Rating***** Rate how easily patient can be engaged in a 2-minute conversation "How well did the patient keep his mind on interacting with you during the interview?" Supported by 1 study with geriatricians Sensitivity 94% Positive LR 65 Specificity 99% Negative LR 0.06 O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4): 470-473. 142 Diagnosis: Differentiating delirium from dementia and psychiatric conditions Talk with family/caregivers to establish baseline Observe the patient: An acute change in mental status is NOT dementia Rapidly fluctuating course is NOT typical for dementia Abnormal level of consciousness is NOT typical for dementia But, the lines are blurry and the diagnosis becomes more difficult in patients with dementia. 143 Evaluation: D.E.L.I.R.I.U.M Drugs!! Electrolyte/endocrine disturbances (dehydration, sodium imbalance, uremia, hypercalcemia, hypoglycemia, thyrotoxicosis) Lack of drugs (withdrawal from ETOH, benzos or poor pain control, B12 deficiency) Infection (sepsis, meningitis, encephalitis) Reduced sensory input (can't see or can't hear) Intracranial (infection, hemorrhage, stroke, tumor) Urinary, fecal (urinary retention, fecal impaction--can be a cause!) Major organ system issues-- infarction, arrhythmia, shock, COPD, hypoxia, hypercapnia, renal failure, liver failure, hypertensive encephalopathy 144 Evaluation Picture of pills Basics: History Physical exam Targeted labs Careful medication history Alcohol, illicit drug use Vital signs Multiple factors likely involved rather than a single "cause" but delirium can be the sole manifestation of serious underlying disease. 145 If still looking... LP Blood cultures UA/Urine culture Urine toxicology Cardiac enzymes and EKG Arterial blood gas Blood alcohol Head CT EEG 146 Practice: Our 73-year old You are concerned that Ms. G has delirium. What do you do to evaluate her delirium? 147 Additional History Ms. G does not drink any alcohol. She does have hearing loss and vision loss and usually wears hearing aids and glasses. She has not had either since being in the hospital. She has had trouble making it to the bathroom to urinate. A couple of times she has been incontinent. Also per hospital records, she has not had a bowel movement since being admitted (5 days ago). She has not reported any pain over the last 24 hours. 148 Physical Exam Vitals T 98.9 Heart rate 83 BP 110/70 RR 14 Physical exam CTA bil, nl wob RRR, no MRGs No LE swelling Abd full, decreased bowel sounds, no tenderness to palpation Surgical wound appears CDI, no erythema/drainage Neuro exam unremarkable CAM + 149 Ms. G's Medication List Lisinopril 5 mg q day Percocet 5/325 mg q 6 hours as needed for pain Benadryl 25 mg qhs as needed for insomnia Aricept 10 mg q day Aspirin 81 mg q day Calcium + D two tablets twice daily HCTZ 25 mg q day 150 Ms. G's tests Na 129 (baseline 135) K 4.9 Cr 1.3 (baseline 1.2) WBC 10 (baseline 5) Hgb 10 (baseline 11) UA 2+ LE, + nitrites, WBC clumps CXR clear Postvoid bladder scan <10 151 Management of Delirium First, try to remove/treat precipitants of delirium. Provide frequent orientation and therapeutic activities. Provide glasses and hearing aids. Avoid constipation/urinary retention/dehydration/electrolyte imbalances. Avoid complete bed rest. Educate family and nursing support staff of ways to comfort patient. Try scheduled tylenol, ice/heat packs, warm milk in place of meds. 152 Medications to Reduce or Eliminate... Anticholinergics Diuretics Antidepressants Benzos Opioids Anticonvulsants Antiparkinsonian agents Nonbenzodiazepine hypnotics (zolpidem) Fluroquinolones (levaquin) Muscle relaxants Antiemetics Steroids 153 What is your plan for Ms. G? 154 Your management plan for Ms. G... 1) Stop benadryl!! 2) Have family bring in glasses and hearing aids... and have patient wear them!! 3) Start patient on an aggressive bowel regimen. 4) Stop her HCTZ and monitor her sodium closely. 5) Obtain urine culture. 6) Start antibiotic to cover UTI. 7) Stop percocet. Start patient on tylenol 1000 mg TID and oxycodone 2.5 mg-5 mg q 6 prn pain depending on how concerned you are that she may have pain. 8) Get patient out of bed to the chair by the window. Have the family provide frequent orientation. 9) Try other measures for insomnia. 155 About Restraints... We DO NOT recommend restraints as they can cause bad outcomes (even death!). Always, evaluate the patient first. Always, try other interventions first: --Have family stay with patient --Use a sitter --Demonstrate calming the patient to those involved in the patient care. If medically necessary to the patient, use restraints for the least amount of time possible and always inform the family about why they are needed. Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8. 156 Pharmacologic Therapy, ie Chemical Restraints Consider only if safety is in issue or if patient's symptoms are very distressing to the patient High-potency antipsychotics (haldol) usually first-line Use low dose and go slow ex. 0.25 mg IV haldol or 0.5 mg po haldol Use for shortest duration possible Can see akathisia, which can be mistaken for worsening delirium 157 Goals 4. Feel comfortable with teaching key concepts in < 1 minute 158 If you have 30 seconds...Delegate! Ask the family, RNs, or your trusty medical students to 1) Turn on the lights or open the blinds during the daytime 2) Keep the calendar and clock right 3) Re-orient the patient frequently 4) Get the patient out of bed to chair as much as possible 5) Use eyeglasses, hearing aids 7) Distract, reassure the patient as needed to avoid restraints 8) Get rid of foley asap 9) Monitor closely for pain (nonverbal clues) 10) Evaluate the patient before ordering restraints (chemical or physical) and use only as a last resort 11) Monitor closely for constipation 159 If you have one minute... Be a good role model! *Assess all hospitalized elderly patient's for delirium on a daily basis *Use the language (the word "delirium") *Keep it on everyone's radar because medical students, nurses, etc won't think it is a big deal unless you do *Minimize use of restraints (including catheters and chemical restraints) 160 If you have 2 to 5 minutes... 1) Have a conversation with the patient to assess for delirium (GAR) 2) Use CAM to assess for delirium 3) Canned talks, examples: • Ways to prevent delirium • Ways to manage delirium • Definition of delirium 4) Use/review DELIRIUM mneumonic 161 Hopefully we met these goals... 1. Define delirium and describe its cardinal features and underlying pathophysiology 2. Recognize that delirium is common, under-diagnosed, and associated with significant morbidity and mortality 3. Regarding delirium, know ways to: • • • • prevent diagnose evaluate manage 4. Feel comfortable with teaching key concepts in < 5 minutes 162 Take-home points Delirium is common, under-recognized and serious!! Cardinal features are acute onset, fluctuating awareness, impairment of memory and attention, increased or decreased psychomotor activity, disturbance of sleepwake cycle and disorganized thinking. Preventing and managing delirium is key to minimizing poor outcomes for our geriatric patients. Use CAM to diagnose delirium. Remember D.E.L.I.R.I.U.M. for differential diagnosis. Drug treatment should be reserved for patients who pose a risk to themselves or others or who seem to be very distressed by their symptoms (ie hallucinations, delusions). 163 Works cited Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): 2833. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.. Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340(9): 669-676. Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission characteristics. Ann Intern Med 1993: 119 (6); 474-481. Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165. O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4): 470-473. Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8 Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, 2010Vol 304. 164 Acknowledgments and Disclaimers This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health and The Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 165 ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 166 AGES Module 4: Transitions of Care 167 Transitional Care: Coordinating Care for our Most Vulnerable Patients Michael A. LaMantia, MD, MPH Indiana University Center for Aging Research Regenstrief Institute, Inc. Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Case One – Mr. S • Mr. S: Friday, 7:30pm » 85 yo with PMHx of moderate dementia from ALF » No paperwork or MAR » Patient can’t give chief complaint » Person on call from the facility who knows patient has gone home » Grandson states patient has been coughing and that doctor at facility suspected PNA 169 Case One – Mr. S • PMHx: » CAD » Htn » Moderate dementia • Allegies: NKDA • Meds: (grandson believes he remembers these) » » » » Metoprolol Aricept Aspirin 81 mg Simvastatin 170 Case One – Mr. S » PE: 130/70 76 18 96%RA afebrile • Patient slightly confused (this is change from baseline according to grandson) • NCAT, PERRL, MMM • Reg S1S2, no m/r/g • Some very mild crackles at right base otherwise clear, normal work of breathing • Rest of exam: unremarkable » Labs: WBC 10.0 hgb 12.0 hct 36.0 plt 350, N 8.7, L 1.0, E 0.3 » Blood chemistry: WNL » CXR: Possible developing right lower lobe infiltrate vs. atelactasis. Clinical correlation recommended 171 Case One – Mr. S • PORT score: 105 points --- Risk Class IV – approximately 8-9% mortality • You recommend hospitalization ---- but • Grandson states he is HCPOA and patient would not wish to be hospitalized. He wishes to take patient home and care for him there. Patient is confused but agreeable • You prescribe course of levofloxacin and ask that they see their provider on Monday 172 Case One - Resolution • Patient goes home and does well for 3 days • He does so well, family does not follow-up with PCP on Monday • Tuesday evening: Patient returns with skin bruising and blood in his urine » Plt: WNL » INR: 7.2 • When the patient’s pills are brought from home, it is discovered he is taking warfarin 173 Case One – Breakdown • What went well? • What could have gone better? 174 Transitional Care • Definition: “A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same institution.” –American Geriatrics Society (2003)* *Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. Apr 2003;51(4):556-557. 175 Transitional Care • During transitions, patients are at risk for: • • • • Medical errors Service duplication Inappropriate care Critical elements of care plan “falling though the cracks” -AGS (2003)* *Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. Apr 2003;51(4):556-557. 176 Transitional Care • Conceptual model of effective transitional care (Coleman 2003)*: • Communication between sending and receiving clinicians • Preparation of the caregiver and patient for transition • Reconciliation of medication lists • Arranging a plan for follow-up of outstanding tests • Arranging an appointment with receiving physician • Discussing warning signs that might necessitate more emergent evaluation *Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. 177 Journal of the American Geriatrics Society. Apr 2003;51(4):549-555. How to Improve Transitional Care • Suggestions: » Changes to health care delivery systems (i.e. use of nurses to follow patients or expanding PACE programs) » Adoption of information transfer technology » Changes to health care policy (i.e. pay for coordination of care or make providers responsible for coordinating transitional care) 178 How to Improve Transitional Care • Society for Academic Emergency Medicine (SAEM) Geriatric Task Force: » Developed at recommendation of SAEM and American College of EM » Identify and adopt quality measures to allow assessment of care provided to elderly patients » Quality measures were vetted by: • SAEM Geriatric Task Force • SAEM annual meeting • American Geriatrics Society (AGS) annual meeting 179 How to Improve Transitional Care • Quality Measures 1-4:* » If nursing home (NH) patient goes to ED, then paperwork should state: • • • • Reason for transfer Code status Medication allergies Contact information for: » NH » Primary care or on-call MD » Resident’s HCPOA or closest family member *Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic Emergency Medicine 2009; 16:441-449. 180 How to Improve Transitional Care • Quality Measures 5-6: » If NH patient goes to ED, then paperwork should include: • Patient’s Medication Administration Record » If NH patient goes to ED for requested studies, then: • Document the performance of requested tests or the reason why such tests were not performed 181 How to Improve Transitional Care • Quality Measures 7-9: » If NH patient goes to ED and then will be released from the ED, then: • ED provider should speak with the NH provider, primary care or on-call MD for the NH prior to discharge from the ED » If NH patient goes to ED and then will be released from the ED, then written paperwork should state: • ED diagnosis • Tests performed with results (and tests with pending results) 182 How to Improve Transitional Care • Quality Measures 10-11 » If NH patient goes to ED and then is released back to the NH, then: • The patient should receive the recommended follow-up • The recommended changes to the patient’s medications or plan of care should be followed (or the reason why not followed documented) 183 Case 2 – Mrs. J • Mrs. J: Thursday evening, 5:30pm » 82 year old woman who presents from home accompanied by home aide with complaint of “fall” --- she was carrying packages in dept store and tripped over a bed » List of PMHx: • • • • Early memory changes Hx of atrial fibrillation Hx of compression fractures COPD » Patient sees PCP at UNC --- records are up to date 184 Case 2 – Mrs. J • In speaking with patient, she complains of right shoulder pain and is placed on backboard with C-collar • CT of the neck shows acute comminuted fracture involving the left articular pillar of C2 • Neurosurgery consultation obtained --- recommended that patient stay in Miami J collar . (No f/u plan given) • Patient released from the ED at 1:10am with nursing aide – • given prescription for vicodin • advised to take ibuprofen also • told to wear Miami J collar until released • asked to follow-up with PCP – “call for next available appointment” 185 Case 2 – Mrs. J • Next day (~4pm), PCP receives call from the patient’s granddaughter , asking about why patient went to ED --- she heard her grandma broke her neck and is surprised she is at home • Patient’s son (primary caregiver) is in Bahamas • Call to house reveals aide at home isn’t familiar with brace • Neighbor who is retired nurse finds collar up around patient’s nose and the patient with uncontrolled pain • Patient instructed to return to ED for further evaluation 186 Resolution • PCP meets pt in ED and admits pt to geriatrics service • CXR shows Pthx developed in interim • Patient hospitalized for several days • Seen by neurosurgery in hospital and plan for f/u developed • Evaluated by PT/OT during hospitalization • D/C’d home with additional help (son flew home from Bahamas) and with close followup with PCP 187 Case Two– Breakdown • What went well? • What could have gone better? 188 Questions for Group • What would it mean to provide truly great transitional care to your patients? • What are the barriers to providing improved transitional care to the patients in your care setting? • What would it take to address these issues? 189 Thank You! • Questions/Comments? • My contact information: Michael LaMantia, MD, MPH Assistant Professor of Medicine Indiana University Center for Aging Research Regenstrief Institute, Inc. 410 West 10th Street, Suite 2000 Indianapolis, IN 46202-3012 Tel: 317-423-5621 Fax: 317-423-5653 190 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation/The John A. Hartford Foundation Geriatrics for Specialists Grant. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation and/or The John A. Hartford Foundation. The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine, the UNC Department of Emergency Medicine, and the American Geriatrics Society also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 191 © The University of North Carolina School at Chapel Hill, Center for Aging and Health. All Rights Reserved. 192 AGES Module 5: Basics of Geriatric Assessment & Levels of Care 193 Geriatric Assessment Anthony J. Caprio, MD Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Objectives 1) To illustrate the importance of physical, cognitive, and psychosocial assessments for older adults 2) To describe Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) 3) To demonstrate gait assessment and falls risk assessment with an older adult 4) To demonstrate cognitive and depression screening with an older adult 195 Function, Function, Function • In real estate it’s “location,” in geriatric assessment the focus is on function • Physical Functioning •Gait and balance •Ability to perform daily self-care activities • Cognitive Functioning •Memory, reasoning, and judgment •Ability to perform “life-maintenance” activities • Psychosocial Functioning •Depression and mental health •Adequate caregiver support •Financial resources 196 What Does Every Practitioner Need to Know? • Overall functional assessment or impression: Big Picture • Ask questions, but.. • Don’t just tell me, show me. (performance-based testing) • Make careful observations! • Trust your gut, if something doesn’t look right, it probably isn’t • Screen and know when to refer for further evaluation 197 Asking About Function "Can you tell me what your typical day is like?” • • • • • • • • • When do you get up? What do you do in the morning? Do prepare your own meals? How many meals do you usually eat? Do you get out of the house? Shopping? Church? How do you spend the rest of the day? Do you watch TV? Read? When do you go to bed? Are you generally satisfied with how you spend your days? 198 Activities of Daily Living (ADLs) Dressing • Transferring Eating (feeding) • Walking Ambulating (transferring) • Toileting Toileting (continence) • Bathing • Dressing Hygiene (bathing) • Eating (feeding) Independent Partially Dependent Dependent • Continence 199 Instrumental Activities of Daily Living (IADLs) Shopping Housekeeping Accounting Food preparation Transportation • Driving or using the bus (transportation) • Using the telephone • Managing medications • Buying groceries • Preparing meals • Housework, laundry • Paying bills, managing money Independent Partially Dependent Dependent 200 Why are ADLs/IADLs Important? • ADL impairment is a stronger predictor of hospital outcomes than admitting diagnoses, Diagnosis Related Group (DRG), or other physiologic indices of illness burden • Functional decline • Length of stay • Institutionalization (nursing home placement) • Death • Approximately 25% to 35% of older patients admitted to the hospital for treatment of acute medical illness lose independence in one or more ADLs • Implications for discharge planning and post-acute care 201 Best Test is a “Real World” Performance Test • Easy to perform in an office/clinic/hospital room • Easy to evaluate (can do, can’t do, or time to completion) • Can be integrated into what you do already • Provide objective information about a person’s actual function in daily living • Assessment starts the minute you start observing the patient. 202 Assessing Function • Perform a task • Walk over to the exam table • Get on/off the exam table • Unbutton sleeve, take shirt off • Put shirt back on, button sleeve, tie shoes • Standardized tests 203 Assessing Physical Functioning: Gait and Risk for Falling • 35-40% of community-dwelling older adults fall each year • 10 to 15% of falls result in a fracture or other serious injury • 72% of all fall-related deaths are in the age 65+ population • Approximately 40-70% of fallers develop fear of falling Risk Factor Relative Risk (RR) for Falls Leg Weakness 4.4 Gait Deficit 2.9 Impaired ADL 2.3 Depression 2.2 Cognitive Impairment 1.8 204 Timed “Get Up and Go" Test • Patient sits in a chair, rises and walks ten feet (3 meters), turns, and returns to the chair • Should be able to do this in <20 seconds, if >30 seconds functionally dependent (higher risk for falls) • Identifying fallers: Sensitivity and Specificity = 87% • Abnormalities in mobility should prompt referral for physical therapy or a further diagnostic work-up • Predicts ADL disability and nursing home admission Phys Ther. 2000;80:896 –903. J Am Geriatr Soc 2010;58:844–852. J Am Geriatr Soc 2004;52:1343–1348. 205 To link the video (POGOe Product #18920 http://www.pogoe.org/vi deo/3454) in Microsoft PowerPoint 2010, download the video just as you have this curriculum and save to the same folder. Timed “Get Up and Go” Select the image to the left. Go up to your insert tab and select “add a hyperlink.” Select the the video file you downloaded from POGOe. On the left, select the first option, for “existing file or web page.” Then navigate to way to the file that I need. Select that file and click ok. Now test your link by going up to the top menu again and choosing the slide show tab, then starting from the current slide. Be sure to delete these instructions before presenting. Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine. 206 Chair Rise • Use a standard chair with arms Picture of chair • Ask the subject to rise from the chair • If they are able to do that, then ask them to rise from the chair without the assistance of pushing-off of the arms of the chair with their hands • It may be helpful to have the subject fold their arms across their chest during the maneuver • Proximal muscle weakness, including trunk and proximal thighs, makes this maneuver difficult and is a risk factor for falls • Can be timed (should take <15 seconds for 5 repetitions) 207 To link the video (POGOe Product #18920 http://www.pogoe.org/vi deo/3455) in Microsoft PowerPoint 2010, download the video just as you have this curriculum and save to the same folder. Select the image to the left. Go up to your insert tab and select “add a hyperlink.” Select the the video file you downloaded from POGOe. On the left, select the first option, for “existing file or web page.” Then navigate to way to the file that I need. Select that file and click ok. Now test your link by going up to the top menu again and choosing the slide show tab, then starting from the current slide. Be sure to delete these instructions before presenting. 208 Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine . Cognitive Evaluation • Prevalence of cognitive impairment • 3% among persons ≥65 years of age • Doubles every 5 years • 40-50% among persons ≥90 years of age • Unrecognized cognitive impairment • Adherence to medications or treatment plans • Difficulty navigating the health care system • Caregiver stress • Most common causes of cognitive impairment • Delirium • Dementia • Depression 209 Delirium: More Than “Confusion” • Sudden and fluctuating change in cognition • Altered way of perceiving the world • Hallucinations or delusions • Might be disoriented • Agitated or excessively sleepy • Conversations don’t make sense 210 Confusion Assessment Method (CAM) 1) Acute onset and fluctuating course and 2) Inability to focus (inattention) 3) Disorganized thinking or 4) Change in the level of consciousness 211 Folstein Mini-Mental State Exam (MMSE) • Orientation • Registration/Recall (3 objects) • Attention and Calculation (WORLD DLROW, serial 7s) • Language (naming, repetition, 3 stage command, reading, writing) • Visual-Spatial (Copy Design) 212 Interpretation of MMSE Scores • Score < 24 considered abnormal • Ranges: 20-25 Mild impairment 10-20 Moderate impairment 0-10 Severe impairment • Depends on literacy and native language • Adjustments have been made for: • Age • Educational level 213 Mini-Cog • 3 item recall after clock drawing task (CDT) • Easy to administer • Sensitivity: 76-99%, Specificity: 89-93% • Not as dependent on education and language J Am Geriatr Soc 2003; 51:1451-1454 Ann Intern Med 1995; 122:422-429 214 Mini-Cog 3 Items 1-2 Items Recalled 0 Items Recalled POSITIVE SCREEN Normal Clock Drawing Abnormal Clock Drawing POSITIVE SCREEN 215 Clock Drawing Test: “10 Minutes After 11” 216 Clock Drawing Test: Mild Impairment 217 Clock Drawing Test: Right-Sided Neglect 218 Severely Impaired Clock Drawing 219 At the End of an Encounter… Teach-back method: “We discussed a lot of things today and I want to make sure that I explained things well, can you summarize what we talked about today?” “So let’s review our plan. What will you do when you get home today? What will you do before our next visit? How will you take this medication?” 220 Psychological Assessment • Prevalence of major depression • Outpatient primary care: 6% - 10% • • Inpatient : 11% - 45% Persons aged ≥65 • • <13% of the populations 25% of suicides 221 Screening for Depression • Single Question: “Do you often feel sad or depressed?” • Sensitivity 69-85% • Specificity 65-90% • 2-Item Screening • Depressed Mood: "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" • Anhedonia: "During the past month, have you often been bothered by little interest or pleasure in doing things?“ • Test is negative for patients who respond "no" to both questions 222 Geriatric Depression Scale (GDS) • Long (30-item) and short forms (15 or 5 items) • GDS 15-Item Screen: Score > 5 points suggests depression • Sensitivity 97% • Specificity 85% 223 Case 1 • 86 yo female presents to the emergency department with a two-day history of nausea, vomiting, and unsteadiness. • She lives independently in the community. • Her ECG shows atrial tachycardia (rate=150) with AV block. • Patient’s medication list includes digoxin 0.125mg po daily. • Labs show normal renal function but a critically high digoxin level. 224 Case 2 • 88 yo male is admitted for elective surgery. • He had an unremarkable pre-op evaluation one week prior to admission. He was considered low risk for the planned surgical procedure. • The surgery was uneventful, but in the PACU, the patient is very agitated and confused. He is trying to get out of bed to “catch a train”. • His nurse calls the resident because she is concerned that he may have had a stroke during the procedure. A stat head CT is negative for an acute process. 225 Case 3 • 78 yo female sustained a mechanical fall at home with a left foot fracture and right wrist fracture. • She is given a walking boot for her foot and a splint for her wrist. No surgical intervention is indicated. • She lives alone and insists that she will be just fine at home. • Her daughter lives about an hour away but will check on her on the weekends and help with grocery shopping. 226 Basic Geriatric Assessment 1) Functional Impairments Activities of Daily Living (ADLs) Instrumental Activities of Daily Living (IADLs) 2) Gait and Fall Risk Assessment Timed “Get Up and Go” Test Chair Rise 3) Cognitive Assessment Confusion Assessment Method (CAM) Mini-Cog Teach-back method 4) Depression Screen One or Two-item questions Geriatric Depression Scale (GDS) 227 Acknowledgments and Disclaimers This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and the UNC Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 228 © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 229 AGES Module 6: Iatrogenic Injury 230 Latrogenic Injuries in Geriatrics Christine M. Khandelwal, DO Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Learning Objectives • Learners will be able to list the most common types of iatrogenic injuries. • Learners will be able to identify the most common cause of nosocomial fever in the hospital. • Learners will be able to identify the reasons for use of restraints and how to avoid using them. • Learners will be able to list the appropriate use of urinary catheters. 232 The Case of Mrs. TW Mrs. TW is a 79yo female with history of HTN, MCI, and urge incontinence, who was admitted for a pneumonia. She is stable on admission and sent to the floor with a foley catheter in-place. Mrs. TW has an uneventful 24 hours, clinically stable and doing well with plans for discharge the next morning to home. Copyright © 2011 Lighthouse International All rights reserved. 233 BACKGROUND • Cascade iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline. » Occurs most frequently among the oldest, most functionally impaired patients and those with a higher severity of illness upon admission. » Creditor 1993, Hofer 2002, Thomas 2000 234 BACKGROUND • Hospitalization for the elderly is often followed by an irreversible decline in functional status and a change in quality and style of life. Elders are at high risk for poor outcome High 1 year mortality Thirty percent (30%) functional decline High rates of skilled nursing facility placement Creditor 1993, Hofer 2002, Thomas 2000 235 Iatrogenesis in Older Patients • Age-related factors that predispose the older patient to iatrogenesis • More co-morbid, chronic medical conditions that require more diagnostic procedures and medications • Increased severity of illness and complexity of care • Longer length of stay Hofer 2002, Thomas 2000 236 Elderly Are the Most Likely to Suffer… Adverse Drug Events Delirium Nosocomial Infections Falls Procedural/Surgical Complications 237 Adverse Drug Events • Most common type of iatrogenic injury • Predictors » > 4 meds » LOS > 14 days » > 4 active medical problems • # of drugs is the strongest predictor; potential for interaction: 2 drugs 6%, 5 drugs 50%, ≥ 8 drugs nearly 100% • 70-80% of ADEs in the elderly are dose related • 30-50% preventable! Carbonin P et al. 1991 238 Adverse Drug Events • Other ADE Predictors: Multiple medical problems Multiple medications New medications added Low weight, female gender, impaired creatinine clearance Carbonin 1991;Thomas and Brennen BMJ 2000 239 Adverse Drug Events Common Drugs Common Effects Anticholinergics Mental Status Psychotropics Urinary Complications Sleepers Infections Narcotics Gastrointestinal Digoxin Falls Anti-hypertensives 240 The Case of Mrs. TW Twenty four hours after admission, nursing staff call to report that Mrs. TW is “yelling out and trying to catch the butterfly in the hall.” With further report from the nurse, the patient has a fever. Staff is requesting to keep Mrs. TW “quiet tonight” as they are short-staffed and will not be able to control her tonight. What is the source of her fever? Could this have been prevented? Copyright © 2011 Lighthouse International All rights reserved. 241 Delirium • Delirium is one of the most common iatrogenic complications in hospitalized elders affecting 50% or more post-operative hip fracture and thoracic surgery patients over age 65. • We don’t diagnose it! Elie 1998, Ely 2004, Inouye 1996, Inouye 2006, Pompei 1994 242 Risk Factors for Delirium • • • • • • • • • • Age ≥ 70 years Existing cognitive impairment Functional impairment Alcohol abuse Abnormal preoperative level of sodium, potassium or glucose Preoperative psychotropic drug use Depression Increased comorbidity Living in a long-term care facility Visual or hearing impairment 243 Preventing Delirium • At least 3 clinical trials suggest that minimizing risk factors in hospital can reduce delirium » Pain, sleep, hydration, orientation, minimizing tubes and lines, minimizing problem drugs Inouye 1999, Marcantonio 2001, Millsen 2001 244 Treatment for Delirium • Almost no drug studies of established delirium • Most experts would use traditional or atypical antipsychotic agents in low dose for agitated delirium treatment » What about anticholinesterase inhibitors? (Donepezil use in the prevention and treatment of postsurgical delirium did not prevent delirium.) Liptzin 2005, Sampson 2007 245 Nosocomial Infections • Infections are usually related to a procedure or treatment used to diagnose or treat the patient’s initial illness or injury • 36% of these are preventable! UTIs Pneumonia Surgical wound infections Clostridium difficile colitis 246 Urinary Catheters • 25% of hospitalized pts have indwelling catheter • Associated with LOS, inpatient mortality • Inappropriate for over 50% of inpatient days • Uncomfortable / Restrictive Jain 1995, Saint 1999 247 Urinary Catheters • Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection, accounting for 40% of all hospital-acquired infections. • Foley catheters are commonly placed without a compelling indication, and are a preventable cause of hospital-acquired infections. Saint 2000, Saint 2002 248 Indications for Urinary Catheterization • Output monitoring of unstable patients • Complete urinary retention • Urinary incontinence in patients with wounds or skin defects • Urinary incontinence in general is not an indication for catheterization, but it may be considered for patient comfort at the request of the patient or family • Terminally ill patients • Perioperative use 249 If Not a Foley…What Instead? • Prevention and Treatment – » Plan may include reviewing medications (opiates, anti-cholingerics, diuretics, alphaadrenergic agonists, calcium-channel blockers are offenders) » Treat UTI (contributes to urge incontinence) » Treat constipation » Seek any reversible causes of delirium » Regular toileting schedule 250 The Case of Mrs. TW Wrist restraints were placed on Mrs. TW to help maintain her delirium tonight. Three hours later, nursing staff calls you to report a fall for Mrs. TW. You order a stat hip x-ray and an acute fracture is found. What was the cascade of events? Could any of this been prevented? Copyright © 2011 Lighthouse International All rights reserved. 251 Why are Restraints Used? • • • • Prevent falls Prevent injuries Prevent treatment disruption Manage confusion AGS Positional statement 2008, Tzeng 2008, Antonelli 2008 252 AGS Positional Statement: Restraints are acceptable to use: • If there is no safer alternative • If patient is at significant risk of self-harm or injury to others • At the patient's request • Short-term use to enable emergent treatment that may result in a less confused patient American Geriatrics Society, AGS Position statement: Restraint use. 2008 253 To Restrain or Not to Restrain… • Restraints are associated with: increased rates of pressure sores increased incidence of nonsocomial infections distress falls American Geriatrics Society, AGS Position statement: Restraint use. 2008 254 If Not a Restraint…What Instead? • Non-pharmacological » » » » Cognitive ◦ Orientation (calendar, caregiver names) ◦ Activities (cognitively stimulating) Sleep • ◦ Regular routine • ◦ Sleep aids (relaxing music, massage) • ◦Environmental (eliminate noise, night-time meds) » » » » Mobility (range of motion, limit IV’s, etc) Visual Aids (glasses, large dial phones) Hearing Aids (check ear wax) Volume repletion for dehydration Inouye 1999 255 Pharmacologic Treatment • No medication is FDA approved for the treatment of delirium • No published double-blind, randomized, placebo controlled trials » ◦ Few controlled trials » ◦ Small numbers » ◦ Various patient populations cancer, AIDS, hip fractures post-op, ICU, Slide from Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and San Francisco, VA Medical Center 256 Reduce Falls • Reduce restraint use / lower bed rails • Prevent delirium • Sensor alarms • Lower the bed • Non-slip shoes • Remove obstacles • Commode / toilet schedule Gillespie 1997, Myers 2003, Currie 2006 257 Falls • Falls frequently occur in hospitals, and the patients most likely to fall are older patients • Approximately 2% to 12% of patients experience at least one fall during their hospital stay • These complications often result in a longer length of stay and lead to greater healthcare costs Chelly 2008, Bates 1995, Alexander 1992 258 Fall Risks • • • • • • Visual impairment Hypotension / anti-hypertensives Anticholinergics / sedative-hypnotics Obstacles / slick surfaces Elevated bed height Confinement ….restraints! Gillespie 1997, Myers 2003 259 Fall Prevention Strategies • Unfortunately, there are no specific recommendations to reduce the risk for falls in the acute care setting. • However, some fall prevention strategies in the literature appear to offer an overwhelming reduction in the incidence of falls among hospitalized elderly patients. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011 260 Fall Prevention Strategies • Frequent and varied staff education and reeducation to promote and sustain sensitivity to the risk for falls among hospitalized elders. • Tools to assess risk for falls. Because most patients' fall risks are multifactorial and the factors are intertwined, the most effective strategies will be interdisciplinary. • The use of "sitters" for confused patients. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011 261 Conclusion • Avoidance of unnecessary Foley catheter placement is an important method to reduce nosocomial infections. • Immobilizing patients during hospitalization is contrary to therapeutic goals of restoring normal mobility and function as quickly as possible. • The number and severity of falls can be reduced by adopting quality improvement strategies, relevant and practical fall risk assessment tools, and staff education. 262 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation, the American Geriatrics Society/The John A. Hartford Foundation Geriatrics for Specialists Grant. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation, the American Geriatrics Society or The John A. Hartford Foundation. The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine, the UNC Department of Emergency Medicine, and the UNC Department of Family Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 263 REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992;82:1020–1030. American Geriatrics Society. AGS position statement: restraint use. 2008; www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2011;49:664-672. Antonelli MT. Restraint management: moving from outcome to process. J Nurs Care Qual. Jul-Sep 2008;23(3) 227-232. Bates DW, Pruess K, Souney P et al. Serious falls in hospitalized patients: Correlates and resource utilization. Am J Med 1995;99:137–143. Carbonin P, Pahor M, Bernabei R, Sgadari A. Is age an independent risk factor of adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc 1991;39(11):1093-9. Chelly, JE, Conroy L, Miller, Gregory E, Marc N, Horne JL, Hudson, ME. Risk Factors and Injury Associated With Falls in Elderly Hospitalized Patients in a Community Hospital J Am Geriatr Soc 56:29–36, 2008. Creditor, MJ. Hazards of hospitalization of the elderly. Annals of Internal Medicine. 1993;118:219-223. Currie LM. Fall and injury prevention. Annu Rev Nurs Res. 2006;24:39-74. Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc. 2006;54:1578-89. Elie, M., Cole, M. G., Primeau, F. J., & Bellavance, F. (1998). Delirium risk factors in elderly hospitalized patients. Journal of General Internal Medicine, 13, 204–212. Evidence Level I: Systematic Review. Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E., Jr., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association, 291, 1753–1762. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochr Database Syst Rev. 1997;CD000340. Hofer, TF, Hayward, RA. Are bad outcomes from questional clinical decisions preventable medical errors? A case of cascade iatrogenesis. Part 1. Annals of Internal Medicine. 2002;137. Inouye, SK (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157-1165. Evidence Level VI: Expert Opinion. Inouye, SK, Bogardus, SK, Charpentier PA, Leo-summers L, Acampora, D, Holford, TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patient. N Engl J Med 1999; 341369-370. 264 REFERENCES 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 27. 28. Inouye, S. K., & Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Journal of AMA, 275, 852–857. Jain P JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Int Med. 1995; 155:1425-1429. JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480. Liptzin B, Laki A, Garb JL, et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatric Psychiatry 2005; 13:1100-6. Marcantonio E.R., Flacker J.M., Wright R.J. & Resnick N.M. Reducing delirium after hip fracture: a randomized trial. Jol of the Am Geriatrics Society 2001.49, 546-522. Millisen K., Foreman M.D., Abraham I.L., De Geest S., Godderis J., Vandermeulen E., Fischier B., Delooz H.H., Spessens B. & Broos P.L. A nurse-led interdisciplinary intervention program for delirium in elderly hipfracture patients. Jo of the Am Geriatrics Society 2001.49, 516-522. Myers H, Nikoletti S. Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls. Int J Nurs Pract. 2003;9:158-16. Pompei, P., Foreman, M., Rudberg, M. A., Inouye, S. K., Braund, V., & Cassel, C. K. (1994). Delirium in hospitalized older persons: Outcomes and predictors. J of the Am Geriatrics Society, 42, 809–815. Saint S LB, Goold SD. Urinary catheters: A one-point restraint? Ann Int Med. 2002;137:125-127. Saint S LB. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Int Med.1999;159:800808. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480. Sampson ELA randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. .Int J Geriatr Psychiatry. 2007;4:343-9. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing. 2007;36:130-139. Thomas E, Brennen T. Incidence and types of preventable adverse events in elderly patients: Population based review of medical records. British Medical Journal, 2000, 320, 741-744. Tzeng HM, Yin CY, Grunawalt J. Effective assessment of use of sitters by nurses in inpatient care settings. J Adv Nurs. Oct 2008;64(2):176-183. Vassallo M, Poynter L, Sharma JC, Kwan J, Allen SC. Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward. Age Ageing. 2008;37:277-281 265 © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 266 AGES Module 7: Palliative Care Communications 267 Palliative Care: Addressing Communication & Symptom Needs Gary Winzelberg, MD, MPH Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Objectives • • • • • Address Palliative Care misconceptions Palliative Care: What, Why, Where, Who Review outcomes of Palliative Care Present general communication strategies Discuss pain assessment and management principles for older adults 269 Geriatrics-Palliative Care G PC 270 Palliative Care is not… • • • • • the same as Geriatrics the same as hospice the hospice referral service end-of-life care the “getting the DNR” service 271 What is Palliative Care? • Interdisciplinary care focused on relief of suffering • Support for best-possible quality of life for seriously ill individuals and their family caregivers » Based on patient and family needs and goals » Independent of illness severity & prognosis » Complements disease-based evaluation and treatment • Palliative care is about care catching up with the technology -- daughter of a patient • www.getpalliativecare.org 272 Palliative Care in the Illness Trajectory Murray S A et al. BMJ 2005;330:1007-1011 273 Why do we need Palliative Care? • Seriously ill patients and their families receive poor-quality medical care » » » » Untreated symptoms Unmet psychosocial and personal care needs Caregiver burden Low patient and family satisfaction • 27% of Medicare spending (133 billion) spent on hospital services • 10% Medicare beneficiaries account for > 50% of total program spending Meier DE. Milbank Quarterly 2011. 274 Palliative Care Components • Symptom assessment & management • Facilitate decision-making » Treatment goals » Treatment preferences » Hospital transition preferences & options • Patient & family support » » » » Information Coordinate physician communication Emotional Spiritual 275 Where is Palliative Care offered? • Hospital » # of hospitals with PC team increased from 658 (25%) to 1,568 (63%) from 2000-09 » More likely in large (>300 bed) hospitals: 85% » Joint Commission advanced certification (2011) • Clinic » UNC Supportive Care clinic for oncology patients • Nursing home » Programs may be independent or exist within hospice programs • Barriers to growth: reimbursement, role misconceptions 276 Complementary Services • • • • Anesthesia Pain service Comprehensive Cancer Support Program Department of Pastoral Care Hospice 277 Hospice & Palliative Medicine • Established as medical subspecialty in 2006 • Co-sponsoring specialty boards: Anesthesiology Pediatrics Emergency Medicine Physical Medicine & Rehabilitation Family Medicine Psychiatry & Neurology Internal Medicine Radiology Obstetrics & Gynecology Surgery • Fellowship training required after 2012 • 3,075 certified physicians 278 UNC Palliative Care Program • Hospital-based consultation • 386 new patients in 2010 • Requesting Service: » 20% Oncology » 19% Surgery » 15% Gen Med • Primary diagnosis » » » » 55% cancer 14% neurologic 8% cardiac 8% pulmonary 279 Patient Disposition Post-Consult 280 Patient “GW” • 41 year old with metastatic colon cancer • Diagnosed six months ago • Six admissions over last three months for pain, fever, anemia (Surgery, Hospitalist) • Receives approx. 2x/month PRBC transfusions • Uncontrolled pain despite fentanyl patch and oxycodone at home • Nausea & emesis • Feels down, passive suicidal ideation » Unable to play with six year old son » Hospital bed in living room 281 Palliative Care Involvement (6 day hospitalization) • Hydromorphone PCA » Concerns re: fentanyl absorption & cost » Significant improvement in pain » After two days, rec: switch to MS Contin • Scheduled metoclopramide • Discussed antidepressant with Psychiatry • Home hospice initially considered » Willingness to support transfusions • Patient expressed fears of dying at home • Pain worsened, concern for obstruction • Transitioned to inpatient hospice 282 Palliative Care Improves Quality RCT cancer care with palliative care comanagement from diagnosis vs standard cancer care only for patients with metastatic NSCLC •Improved quality of life •Reduced major depression •Reduced “aggressiveness” of care » Chemotherapy < 14 days before death » No hospice care » Hospice < 3 days before death •Improved survival (11.6 vs 8.9 months) Temel et al. Early palliative care for patients with NSCLC. NEJM 2010; 363: 733-42 283 Palliative Care Improves Quality & Value • Improves family satisfaction with care » Improved pain, dignity, communication, treatment » Earlier consultations associated with higher satisfaction • Average per-patient per-admission net cost saved by hospital consultation = $2,659 • Improves quality of communication, documentation of treatment preferences Casarett JPSM 2010; Gade JPM 2008; Zimmerman JAMA 2008; Morrision Arch Intern Med 2008 284 Factors [Possibly] Associated with Prolonged Survival • Reduction in symptom burden, including depression • Avoidance of hospitalization & high-risk interventions • Improved support for family caregivers » Permits patients to remain safely at home Meier DE. Milbank Quarterly 2011 285 Symptom Assessment “Review of Symptoms” • • • • • • • • Pain Dyspnea Nausea Constipation Anorexia and cachexia Anxiety Depression Delirium 286 Communication Needs • Information » » » » What’s happening next? Breaking bad news Prognosis Care options • Decision-making » » » » Assessment of decision-making capacity Advance care planning Goals of Care Treatment preferences (including code status) • Support » Responding to emotions » Acknowledge caregiver burdens 287 Breaking Bad News 1. Getting started » » Physical setting Participants 2. Finding out how much the patient knows 3. Finding out how much the patient wants to know 4. Sharing the information » » Warning shot Give information in small chunks 5. Responding to the patient’s feelings 6. Planning and follow-through » Be explicit Buckman R. How to Break Bad News. 1992 288 Prognosis • Has anyone talked to you about what to expect? What do you think is ahead? • Are there reasons that you need to know? » Unfinished business » Upcoming life cycle events • Do you have any sense of how much time is left? • Although every patient is different, in general, patients with your condition live…give range » Avoid point estimate » Emphasize uncertainty 289 Goals of Care • What are patient and family priorities? • Longevity • Function » » » » Physical Cognitive Safety Avoid nursing home placement • Comfort • What goals do you have for the time you have left? • What would be left undone if you were to die this week? 290 Responding to Emotions NURSE 1.Name the emotion » You sound frustrated 2.Understand » I can’t imagine what it’s like to be so sick 3.Respect 4.Support 5.Explore » ASK – TELL – ASK 291 Responding to Emotions NURSE 1.Name the emotion » You sound frustrated 2.Understand » I can’t imagine what it’s like to be so sick 3.Respect 4.Support 5.Explore » ASK – TELL – ASK http://depts.washington.edu/oncotalk/ 292 “Wish” Statements • Instead of stating “I’m sorry” » Confused with pity or an apology » Shortcuts deeper understanding • Empathic statement » Wish for different circumstance » Acknowledge emotional impact of loss » Aligns physician with patient and family • Desired outcome unlikely to occur • Doesn’t specify what can be done • May initiate deeper level of conversation • I wish we had treatments that could turn things around • I wish I had better news to give you Quill TE et al. Ann Intern Med 2001 293 Patient “PC” • 85 year old male, PMH: Alzheimer’s disease, CHF, HTN • Hospitalized after hip fracture (4th in past year) • Postoperative course: pneumonia, delirium, pressure ulcers • Losing weight, unable to participate in therapy • 84 year old wife feels overwhelmed • Primary physician frustrated by frequent readmissions Morrison RS. Meier DE. NEJM 2004 294 Distinct Palliative Care Needs of Older Adults • • • • Pain assessment and management Prevalence of delirium Impact of cognitive impairment Role of family caregivers » Direct care » Surrogate decision-makers 295 Pain is common for older adults • 40-80% of nursing home residents » 15% have daily moderate-severe pain • 29% of nursing home residents with advanced cancer have daily pain » 26% receive no pain medication Ferrell BA. JAGS 38:409; Bernabei JAMA 279:1877 296 Patient & Family Barriers • • • • Pain is normal when you’re old Value stoicism, “being strong” Fear of addiction Communication problems » Unable to talk » Confusion, dementia Ferrell BA JAGS 38:40; Bernabei JAMA 279:18 297 Health Professional Barriers • • • • • Pain is normal when you’re old Older adults feel less pain Don’t recognize chronic persistent pain Older adults can’t tolerate pain medications Legal risks of using opioids » NC Boards all endorse right to effective pain control 298 Pain Is Undertreated • 18-24% bereaved family members believe pain was undertreated » 19% in hospital • 41% of cancer patients undertreated » Primary risk factor age > 70 Hanson JAGS 45:1339; Teno JAMA 291:88; Cleeland NEJM 330:592 299 Pain Assessment • Patients with dementia may be capable of reporting pain » » » » Words easier than numbers Ask in the present – Are you in pain now? Ask several ways – pain, discomfort Give time to respond • Non-verbal » Behavior change – more passive vs restless » Ask about/observe behavior during care 300 Goals of Pain Treatment • Complete elimination of pain may or may not be the appropriate clinical goal • Primary goals are: » Reduce suffering » Improve daily functioning » Avoid additional harms 301 Non-Medication Treatments • Use for every patient in pain » » » » » » Music Decreased noise OR added distractions Massage Warm or cold packs Repositioning, exercise Emotional and spiritual support 302 Medication Choice • Medication based on cause, physiology, severity, frequency, and toxicity » Combining medications at low dose can increase effect with fewer side effects » PRN medication is for pain that is infrequent » Scheduled medication is for pain that is usually present 303 Before Medication • Assess baseline mental status exam • Know concurrent chronic illnesses » Hepatic function: fentanyl appears safe, use caution with other opioids » Renal function: fentanyl & methadone appear safe; use caution with other opioids » Hydration status 304 Opioid Side Effects • Side effects that improve on stable dose » Sedation, confusion » Nausea » Respiratory depression • Side effects that persist but are treatable » Constipation » REMEMBER BOWEL REGIMEN • Side effect that requires opioid change » Neurotoxicity 305 Opioid Dosing in Older Adults • Consider using lower starting dose, increasing dosing interval » Example: Oxycodone 2.5 mg vs 5 mg • Remember that every older adult is an individual • Both opioids and pain are associated with delirium 306 Family Caregiver Roles & Burdens • Competing responsibilities » Work » Parent, spouse • • • • • Direct care (48 hour day) Surrogate decision-maker Financial hardship Emotional impact -- depression Increased mortality risk (Schulz R. JAMA 1999;282) 307 Surrogate Decision-Making • Approx. 1/3 experience emotional burdens » Stress, anxiety, depression » Guilt over decisions made » Doubt regarding whether right decisions made • Negative effects may last months or years • Potential for beneficial effects » Supporting the patient » Feeling a sense of satisfaction • Knowing patient’s preferences lessened negative effect Wendler D. Rid A. Ann Intern Med 2011. 308 “PC” • Pain management » Scheduled acetaminophen, prn vs scheduled oxycodone » Reassess every 24-48 hours • Communicate with wife, family regarding PC’s condition and care goals » Approx. 50% six-month mortality risk » Trial of rehabilitation vs transition to comfortexclusive approach » Anticipate complications – how to manage? » Address feeding concerns 309 If you have 1-5 minutes… • Address misconceptions about Palliative Care on rounds • Review medication list – PRN may mean “patient receives nothing” • Consider Palliative Care consultation for patients with: » Inadequate symptom control » Complex decision-making » Emotional needs (patient and/or family) 310 If you have 15 minutes… • Perform symptom assessment • Inquire about patient and family communication needs » Information » Decision-making » Support 311 If you have 15-30 minutes… • Communicate with patient and family about goals of care • Observe learner’s communication and provide feedback 312 Summary • Patients and families have unmet communication and symptom needs • Palliative Care is an important resource for seriously/chronically patients, families and health professionals • Cognitive impairment impacts pain management and communication with older adults 313 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation Grant. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health and the UND Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 314 © The University of North Carolina School of Medicine at Chapel Hill, Center for Aging and Health. All Rights Reserved. 315 AGES Module 8: Polypharmacy 316 Medication Use in the Older Patient Anthony J. Caprio, MD Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Objectives 1) Identify risk factors for Adverse Drug Events (ADEs) in older adults 2) Identify the physiologic changes associated with normal aging that influence pharmacokinetics and pharmacodynamics 3) Recognize ADEs when an older adult presents with a new clinical condition or complaint 4) Avoid potentially harmful medications for older adults 5) Utilize strategies for shortening medication lists and carefully introducing new medications 318 Mrs. Anderson • 87yo female from nursing home; fell last night with complaint of left hip and back pain • Unable to recall events, agitated; says “yes,” when asked if she is in pain. Seems very confused • Reportedly able to ambulate short distance with walker at baseline, needs assistance with dressing, bathing, toileting. Able to feed herself • Note from nursing home about rectal bleeding 2 days ago • Electronic medical record indicates that she was in the ED last month for a heavily bleeding laceration after a fall and supratherapeutic INR of 5.6 (while on antibiotics for a urinary tract infection) 319 Past Medical History 1) Dementia (MMSE 20/30) 12) Osteoarthritis, especially hips and knees 2) Parkinson’s disease 3) 13) Macular degeneration CVA with residual L-sided weakness 14) Type 2 DM 4) Osteoporosis 15) Peripheral neuropathy 5) Urinary incontinence 16) Chronic renal insufficiency 6) Recurrent UTIs 17) Anemia 7) Hypertension 18) Hypothyroidism 8) CAD s/p stent 2 years ago 19) COPD on oxygen 9) CHF (EF 30%) 20) Diverticulosis 10) Atrial Fibrilation 11) Hyperlipidemia 320 Medications Picture of pills 1) Donepezil (Aricept) 5mg po Daily 18) Docusate sodium 100mg po BID 2) Carbidopa/Levodopa 10/100 po TID 19) PEG powder (Miralax) 17g po Daily 3) Aspirin 325mg po Daily 20) 4) Warfarin (Coumadin) 5mg po qHS Tiotropium (Spiriva) 18mcg inhaled Daily 5) Tolterodine (Detrol) 2mg po BID 21) Montelukast (Singulair) 10mg po Daily 6) Atorvastatin (Lipitor) 40mg po qHS 22) Fluticasone/Salmeterol (Advair) 100/50 inhaled BID 7) Insulin (long-acting and sliding scale) 23) 8) Gabapentin (Neurontin) 300mg po TID Albuterol/Atrovent nebulizers prn wheezing 9) Iron sulfate 325mg po TID 24) Multivitamin one po Daily 10) Trazodone 50mg po qHS 25) Vitamin E 400 IU po Daily 11) Levothyroxine 50mcg po Daily 26) Calcium Carbonate 500mg po TID 12) Furosemide (Lasix) 60mg po BID 27) Vitamin D 800 units po Daily 13) Potassium Chloride 20meq po Daily 28) Nitrofurantoin (Macrodantin) 100mg po qHS 14) Metoprolol 100mg po BID 15) Lisinopril 20mg po Daily 16) Amlodipine 10mg po Daily 17) Acetaminophen 1000mg po TID 321 Challenges of Prescribing for Older Adults Multiple medical conditions Multiple medications Multiple prescribers Different metabolisms and responses Adherence and cost Supplements, herbals, and over-the-counter drugs Lancet. 1995;346(8966):32–36. 322 Lots of Medications and Little Evidence • 2/3 of older adults are on regular medications • Adults age >65 account for 1/3 of all prescriptions, but only represent 15% of the US population • Older adults are frequently not included in clinical trials, which makes it difficult to predict drug metabolism or drug effects Health Care Financ Rev. 1990;11:1-41. 323 Dangers of Multiple Medications: “Polypharmacy” • Adverse effects (side effects) • Drug-drug interactions • Duplication of drug therapy • Poor adherence » Cost » Decreased quality of life 324 Adverse Drug Events (ADEs) • Adverse symptoms • Adverse clinical outcomes » » » » » Doctor visits or hospitalizations Falls Functional decline Changes in cognition (delirium) Death • Poor adherence, poor quality of life • Increased cost 325 Most Common Medications Causing ADEs • • • • • • • • Antibiotics Analgesics Anticoagulants Antihistamines Anticonvulsants Antipsychotics Cardiovascular meds Diabetic meds JAMA 2006; 296:1858–1866 JAGS 2004;52:1349–1354 NEJM 2003;348:1556–64 326 Prevalence of ADEs • • • • 35% of community-dwelling older adults 5-28% of inpatient geriatric admissions 2/3 of nursing home patients (over 4 years) In the emergency department: » 2.0 per 1000 for adults under 65 » 4.9 per 1000 for aged 65 years or older » 6.8 per 1000 for aged 85 years or older JAGS 1997;45:945-948 JAGS 1996;44:194-197 Am Pharm Assoc 2002;42:847-857 JAMA 2006; 296:1858–1866 327 Potential Risk Factors for Adverse Drug Events (ADE) >6 chronic disease >12 doses/day ≥ 9 medications Low BMI (<22kg/m2) Age >85 years Creatinine clearance < 50 mL/min History of prior ADE 328 Consult Pharm 1997;12:1103–11. Is Mrs. Anderson at Risk for an ADE? 6 chronic disease >12 doses/day ≥ 9 medications Low BMI (<22kg/m2) likely Age >85 years Creatinine clearance < 50 mL/min possibly History of prior ADE Nursing home resident 329 Why is Mrs. Anderson at Risk? • Multiple drugs (high “exposure” ) » Risk of ADE is proportional to number of drugs » Increased probability of drug-drug interactions • Physiologic changes (increased susceptibility) » Associated with disease states » Associated with NORMAL AGING 330 Physiologic Changes with Normal Aging • Less water • More fat Picture of Jack LaLanne • Less muscle mass • Slowed hepatic metabolism • Decreased renal excretion • Decreased responsiveness and sensitivity of the baroreceptor reflex 331 Absorption • Not affected by the normal aging process • Can be altered by drug interactions » Antacids » Iron • Can be effected by disease » Lack of intrinsic factor (B12 absorption) » Delayed gastric emptying 332 Distribution • Less water = ↓ volume of distribution Higher concentration of water soluble drugs • More fat = ↑ volume of distribution Prolonged action of fat-soluble drugs (increased half-life) • Lower serum proteins (like albumin) increases the concentration of unbound (free or active) form of drugs 333 Metabolism • Slowed Phase I, cytochrome P450, reactions » Oxidation, reduction, dealkylation » Warfarin and phenytoin levels may be higher because of altered metabolism • Phase II reactions are essentially unchanged » Conjugation, acetylation, methylation • Drug-drug interactions » Increased risk with increased number of drugs 334 Excretion • Hepatic • Renal » Renal clearance may be reduced » Serum creatinine may not be an accurate reflection of renal clearance in elderly patients. (decreased lean body mass) • Active drug metabolites may accumulate » Prolonged therapeutic action » Adverse effects 335 Physiologic Changes Associated with Disease States • Cardiac disease » Impaired cardiac output (decreased absorption, metabolism, clearance) » Greater susceptibility to cardiac adverse effects • Kidney and liver disease » Decreased drug clearance and altered metabolism • Neurological diseases » Diminished neurotransmitter levels » Greater susceptibility to neurological effects 336 Why Did Mrs. Anderson Fall? • Functional status » Uses walker at baseline » Dependent in other ADLs (like bathing) • Sensory impairments » Macular degeneration » Peripheral neuropathy • Neurological diseases » Dementia » Parkinson’s Disease • Co-morbid diseases » Cardiovascular (syncope) » Diabetes mellitus (hypoglycemia) » Anemia (hypotension) 337 Orthostatic Hypotension, Falls, and Hip Fractures • Baroreceptor sensitivity decreases with age • Trazodone » New medication according to nursing home med record » Associated with orthostatic hypotension • Diuretic use can cause volume depletion and orthostatic hypotension • Falls and hip fractures are associated with significant morbidity and mortality in older adults 338 Why is Mrs. Anderson Confused? • Head injury? » Contusion on forehead » Recent history of supratherapeutic INR • Dementia » Moderate dementia by history » What is her baseline? • Delirium » Infection (history of UTIs) » Drugs (Adverse Drug Event) » Hospital (change in environment) 339 Delirium • More than confusion » Acute onset, fluctuating course » Inattention » Disorganized thinking or altered level of consciousness • Associated with low levels of acetylcholine » Low levels in patients with dementia at baseline » Risk with use of anticholinergic medications 340 Anticholinergic Medications • Drug classes • Antihistamines • Tricyclic antidepressants • Antispasmodics and muscle relaxants Diagram of the parasympatheic nervous system. • Adverse effects • • • • Dry Mouth Urinary retention Constipation Delirium 341 Pharmacologic Tug-of-War • Tolterodine (Detrol) » Potent anticholinergic » Relaxes detrusor muscle to treat urge incontinence (detrusor hyperactivity; “overactive bladder”) » Can worsen delirium, constipation • Donepezil (Aricept) » » » » • Acetylcholinesterase Inhibitor Higher levels of acetylcholine may help improve cognition Can cause detrusor hyperactivity and diarrhea Could cause symptomatic bradycardia and syncope (also on β-blocker) Incontinence and falls » Dementia is a risk factor for both incontinence and falls » Incontinence may be an ADE related to Donepezil » Diuretic use can worsen incontinence and cause orthostatic hypotension 342 Principle 1: “Think Drugs” Before Making a New Diagnosis • Consider adverse drug effect as etiology of new signs/symptoms • Consider discontinuing or dose-reducing medications • Avoid prescribing a new medication to treat an adverse drug effect (“Prescribing Cascade”) • Remember that over-the-counter drugs, supplements, and herbals can be the culprit Picture of prescription pad 343 344 Slide courtesy of Anthony Caprio, MD Common Conditions Could Really Be Adverse Drug Effects Constipation Calcium Channel Blockers; Iron Incontinence α-blockers Memory loss Antihistamines Syncope Tricyclics, α-blockers Falls Benzodiazepines Weight loss Fluoxetine (Prozac) 345 Mrs. Anderson: Acute Management • Pain » Morphine 2mg iv x 2 doses for pain » More comfortable after the 2nd dose • Nausea and vomiting » Complains of “sick stomach” » Vomits repeatedly • Agitation » Increasingly agitated, trying to climb out of bed » Shouting “Veronica” repeatedly 346 What Do You Prescribe? •Pain •Nausea •Agitation 347 Beers Criteria • A consensus-based list of potentially inappropriate medications for older adults • The Beers criteria were published 1991 and revised in 1997, 2002, and 2012 • Statistical association with adverse drug events has been documented • Does not account for the complexity of the entire medication regimen J Am Geriatrics Society, 2012 Online link to this article is: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf Pharmacotherapy 2005;25(6):831–838 348 Beers Criteria: Potentially Inappropriate Medications for Older Adults • Table 2: Organ System or Therapeutic Category or Drug » Describes concern for prescribing certain drugs or classes of drugs for older adults » Rationale, recommendation, quality of evidence, and strength of recommendation • Table 3: Due to Drug-Disease or DrugSyndrome Interactions » Describes drugs or classes of drugs that can cause or worsen a particular disease or syndrome » Rationale, recommendation, quality of evidence, and strength of recommendation J Am Geriatrics Society, 2012 Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf 349 Pain Medications • Caution with non-steroidal anti-inflammatory drugs (NSAIDS) » Indomethacin has significant CNS side effects » Ketorolac (Toradol) can cause serious GI and renal effects • Meperidine (Demerol) has low oral efficacy, active metabolites and CNS effects • Morphine metabolites are renally cleared Beers criteria: J Am Geriatrics Society, 2012 Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf 350 Anti-Emetics • Antihistamines: promethazine (Phenergan) » Anticholinergic, may worsen delirium (↓acetylcholine) » Beers Criteria medication • Dopamine antagonists: metoclopramide (Reglan) » May worsen Parkinsonism (↓dopamine) » Beers Criteria medication • Serotonin (5-HT3) antagonists: odansetron (Zofran) » Expensive, but likely safest for this patient Beers criteria: J Am Geriatrics Society, 2012 351 Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf Managing Agitated Delirium • Treat pain » Although opioids may cause confusion, untreated pain may precipitate and perpetuate delirium • Assess for other sources of discomfort » Hunger, thirst, cold » Urinary retention, fecal impaction; • Sensory » Eye glasses and hearing aids » Try to minimize sensory “overload” » Reorientation 352 Antipsychotic Medications • “Black Box” warning: increased risk stroke, death • Typical (ie. haloperidol) » » » » Potent antidopaminergic effects Can severely worsen Parkinsonism Beers Criteria medication Intravenous haloperidol associated with arrhythmias • Atypical (ie. risperidone, quetiapine, olanzepine) » Olanzepine may be best choice in setting of prolonged QTc » Quetiapine safest for Parkinson’s Disease but may not be as useful for acute management 353 Benzodiazepines for Agitated Delirium • Avoid if possible » Appropriate if being used to treat alcohol withdrawal » If necessary, use lowest dose possible » Beers Criteria medication • May cause a paradoxical reaction in older adults » Increased agitation and anxiety » May lead to prescribing cascade (ie. antipsychotic) • Avoid long-acting benzodiazepines » Prolonged half-life in older adults (days) » Sedation, aspiration, delirium » Increased risk of falls and fractures Beers criteria: J Am Geriatrics Society, 2012 Tables available online at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf 354 Conclusion: Mrs. Anderson • Medicated with morphine for pain • One dose of odansetron (Zofran) for nausea • Evaluated by orthopedics and plan for operative repair for pain control and since patient ambulatory at baseline • Fecal disimpaction • Her family brings her eye glasses and hearing aids to the hospital Beers criteria: J Am Geriatrics Society, 2012 355 Clinical Case: Mr. Johnson Mr. Johnson is 83 years old. He complains of a “runny nose” during meals on a daily basis. He asks if there is a medication to stop his runny nose. Although inconvenient at mealtime, he is not bothered by this symptom at other times during the day. Question: Does he need a prescription? 356 Vasomotor Rhinitis • Likely diagnosis is vasomotor rhinitis • May respond to ipratropium (Atrovent) nasal spray. • Disposable facial tissues are available without a prescription and have few side effects • “Sedating” antihistamines can have significant anticholinergic effects. 357 Am Fam Physician 2005;72:1057-62. Principle 2: “Less is More” (Keep the Medication List Short) • • • • • Question the need for new medications Stop medications, whenever possible Prioritize treatments Weigh risks and benefits But, avoid undertreating older patients » Pain » Systolic hypertension (stroke, renal failure, heart disease) » Anticoagulation and atrial fibrillation (stroke prevention) Drugs Aging 2003; 20: 23-57. Lancet 2000; 355: 865–872. Ann Intern Med 1999;131:492-501. J Gen Intern Med 2005; 20:116–122. 358 Clinical Case: Mr. Jones Mr. Jones is 82 years old with a history of herpes zoster (shingles) 6 months ago. He continues to experience severe daily pain in the same dermatomal distribution as the original rash. •Question: What is the diagnosis? •Question: What is the treatment? 359 Post-Herpetic Neuralgia • Opioid medications • Capsaicin » OTC alternative » Topical (better than systemic) » May be poorly tolerated due to local effects • Tricyclic antidepressants » Effective, but have anticholinergic properties. Amitriptyline > nortriptyline > desipramine » Amitriptyline is a Beers Criteria medication • Gabapentin (Neurontin) » Clinical trials: 1800–3600mg/day divided doses. » Dose-reduce with renal insufficiency. Neurology 2002;59(7):1015–21. Pain 1988;33(3):333–40. Neurology 1998;51(4):1166–71. JAMA 1998;280(21):1837–42. 360 Principle 3: “Start Low and Go Slow…” • Start one medication at a time • Start with a low dose and increase gradually • Monitor for response and adverse effects • Once daily is usually best • Assess adherence with regimen 361 “…But, Go All The Way!” • Be conservative, but don’t miss the target! • What is your goal? Are you achieving it? • If you are not at goal, can the dose be increased or are you limited by side effects? • Are you observing a clinical benefit at lower doses? • Consider stopping if you can’t “go all the way” and the benefits at lower doses are not clear. 362 Physiologic Changes Associated with Normal Aging • Absorption usually does not change • ↑ concentrations of water soluble and free (unbound) drugs • Longer half-life for lipophilic drugs • Slower phase I metabolism • Impaired excretion • Decreased responsiveness of the baroreceptors 363 Prescribing for Older Adults 1) “Think drugs” before making a new diagnosis 2) “Less is more” (keep the med list short) 3) Use caution with Beers Criteria medications 4) “Start low and go slow”…when starting a new drug….“but go all the way.” 364 Acknowledgments and Disclaimers This project was supported by funds from The Donald W. Reynolds Foundation, the American Geriatrics Society/The John A. Hartford Foundation Geriatrics for Specialists Grant. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation and/or The John A. Hartford Foundation. The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine, and the UNC Department of Emergency Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 365 © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. 366