3/25/2013 Approach to Geriatric Syndromes Geriatrics: Family Medicine Board Cognitive Impairments? Review 2013 Dependency? Sensory Impairments? Veronica Rivera, MD Assistant Professor Environment? Icahn School of Medicine at Mount Sinai Brookdale Department of Geriatrics and Palliative Medicine Frailty? Co-morbidities? Department of Family Medicine and Community Health March 25, 2013 Outline Case #1: Physiologic Changes of • Physiologic Changes of Aging Aging • Polypharmacy • Falls An 82 y/o male complains of hearing • Osteoporosis loss worsening for 5 years. • Urinary Incontinence • Dementia You send him for audiometry. The • Delirium following audiogram was obtained. • Pressure Ulcers • Palliative Care: Pain Management 1
3/25/2013 Sensorineural Hearing Loss • Presbycusis – Age Related hearing loss – Symmetric, high frequency, gradual onset – Difficulty understanding speech in noisy places • Menière's Disease – Low frequency, sensorineural loss fluctuates and progresses. – Episodes of vertigo, aural fullness, tinnitus – Rx: avoidance of triggers; diuretics when diet fails • Excessive noise exposure • Acoustic neuroma (asymmetric) What kind of hearing loss is depicted? • Ototoxic drugs Conductive Hearing Loss Conductive Hearing Loss Obstruction of external •Cerumen auditory canal •Foreign body •Debris for otitis externa Impairment of tympanic •Perforated tympanic membrane function membrane Air/bone gap on •Tympanosclerosis audiogram Middle ear conditions •Otits media with effusion •Otosclerosis •Cholesteatoma Hearing Loss in Older Adults, AAFP. 2012. 2
3/25/2013 Physiologic Changes in Aging: Physiologic Changes in Aging: Sensory Changes • Hearing: • Cardiovascular – Presbycusis (bilateral, high frequency, – Myocardial/vascular stiffness sensorineural) – Increase wax buildup – Decrease heart rate and cardiac output – Stiffening of ossicles and drum – Conduction abnormalities • Vision: • Pulmonary – Difficulty with glare & dark adaptation – Decrease vital capacity – Decreased accommodation – Decreased acuity – Increase Residual Volume – Decreased tear production • Decreased taste buds, oral secretions, smell Physiologic Changes in Aging: Physiologic Changes in Aging: • Skin • Skeletal System – Thins – Decrease in Bone Density – Loss of hair follicles, sweat glands, and melanocytes – Loss of muscle mass – Atrophy of subcutaneous fat – Decrease tendon and ligament elasticity – Loss of elasticity • Renal • Other – Decrease blood flow and GFR – Decreased immunity (Primarily cell mediated) – Decrease ability to concentrate urine – Decreased physiologic reserve and homeostasis – Recovery takes longer 3
3/25/2013 Physiologic Changes in Aging: Case #2: Polypharmacy An 80 y.o. woman with CHF, Afib, depression and DM2 presents • Sleep with several months of intermittent nausea and anorexia – Decreased sleep efficiency without vomiting. She takes – digoxin 0.25 mg qd, – Decreased total sleep time – warfarin sodium 5 mg qd, – Less and earlier REM sleep – furosemide 40 mg qd, – Less deep (stage 3 and 4) sleep; more Stage 1 and 2 – lisinopril 20 mg qd, – glipizide 6 mg qd, – More napping, night time awakening, early morning – citalopram 20 mg qd, and awakening – occasional acetaminophen. She has been on these doses for 5 years. Case #2: Polypharmacy Case #2: Polypharmacy What physiologic changes best explain • Denies other GI symptoms or recent illnesses, and her symptoms? has not been taking other medications. • Other than a 10 lb weight loss (110lbs to 100lbs), her Age related changes in body composition vital signs and exam are normal except for a heart and renal function rate of 55. • Serum creatinine is 1.2 mg/dl (unchange in past 10 years), electrolytes normal, hemoglobin A1C is 7.2%, INR is 3.0, and hemoglobin 12.5 g/dl. 4
3/25/2013 Drugs - Physiologic Changes in Age related changes in body Aging: composition and physiology • Absorption : unchanged DECREASES INCREASES • Volume of Distribution : • Total Body Mass • Total Body Fat • Water soluble drugs -> more concentrated ( digoxin ) • Liver Mass • Fat soluble drugs -> longer T1/2 (BDZ ’ s) – Decrease body mass � smaller volume of • Creatinine Clearance distribution – Increase in body fat � larger volume of distribution • Metabolism/elimination : • Liver: glucuronidation generally not affected, may have reductions in cytochrome p450 • Renal function may be affected Drugs - Practical Considerations: Drugs - Practical Considerations: • Pharmacodynamics : • Polypharmacy : The risk of drug interactions increases linearly – Older adults may have increased sensitivity to medications with number of drugs prescribed at standard doses: – 43% of men and 57% of women use 5 or more • Increased sedation with some benzodiazepines prescription/OTC drugs/week (benadryl, TCA ’ s) • Increased sensitivity to opiates – Institutionalized patients are prescribed an average 5-8 drugs • Urinary retention / delirium with anti-cholinergic drugs – 10-17% of geriatric admissions are for adverse drug events – 2002 AMA CSA report • Psychosocial dynamics : adherence may be limited by cognition, dependency, lack of resources 5
3/25/2013 Drugs – Pearls for the Boards: Case #3: Falls resulting in a Colles ’ fracture. She has had two other • Ms T is an 80 year old woman who lives alone. She • Don ’ t automatically “ treat ” a new symptom with a new drug • Always put drug effect or drug interaction in the differential just came in to your office for follow up of a fall diagnosis for an elderly patient falls over the past year and a half. She is scared of • Often the answer requires dose adjustment or drug falling again. discontinuation • Older patients with a normal creatinine may have modestly • She has a history of osteoarthritis and impaired renal function anxiety/depressison. • She is on naproxen sodium 500mg BID, sertraline 50mg daily and ativan 1mg BID as needed Epidemiology of Falls Case #3: Falls • 30- 40% of community-dwelling people over Which is the best way to prevent the age of 65 years fall each year future FALLS in this patient? • Increases to about 50% for those 80 years and older • Half are repeat fallers • Over half of those in nursing homes and hospitals will fall each year Tinetti, ME. N Engl J Med 2003 Rubenstein LZ Clin Ger Med 2002 Chang JT et al BMJ 2004 6
3/25/2013 Falls Cause Morbidity and Mortality Risk Factors • Injuries are common: – 40% of falls result in minor injuries Intrinsic Factors Extrinsic Factors – 10% result in major injuries Medical Medications •Fracture, soft tissue injury, traumatic brain conditions injury Impaired vision • 2.2% of injurious falls result in death Improper use of Nachreiner J Women ’ s Health 2007 and hearing FALLS Tinetti, ME, JAGS 1995 assistive devices Age related Tinetti & Kumar JAMA 2010 changes MMWR Morb Mortal Wkly Rep 2008 Environment Extrinsic Risk Factors: Intrinsic Risk Factors Environment • Increasing Age • Lower extremity • Indoor Hazards: weakness • History of Falls – Slippery floors, rugs/carpet, poor lighting, shoes, • Abnormality bathroom fixtures, height of chair/bed, unstable • Female Gender gait/mobility furniture, stairways, improper use of assistive • Medical Illness • Incontinence devices • Peripheral neuropathy • Depression • Outdoor Hazards: • Orthostasis • Foot problems – Uneven pavement, steps, snow and ice • Cognitive impairment • Hearing impairment • Visual impairment Colon-Emeric. JCOM. 2001 7
3/25/2013 Extrinsic Risk Factors: Interventions Medications • Antipsychotics • Single interventions • Sedatives • Multifactorial Assessment with targeted • Antidepressants interventions • Antiarrhythmics – Most consistently studied with effectiveness • Anticonvulsants • Anxiolytics • Antihypertensives • Diuretics • Systemic glucocorticoids Interventions Effective Interventions General Risk • Exercise program • Professionally supervised strength and • Daily supplement Vitamin D balance training (14-27% risk reduction) Medications • Avoid agents with increase risk of falls • Reduction in home hazards after • Review medication lists hospitalization (19% risk reduction) • Discontinuation of psychotropic medications Mobility-related • Improve lighting (39% risk reduction) • Remove environmental risks • Refer to PT/OT for gait training • Multifactorial assessment with targeted Medical Factors • Optimize medical therapy for Parkinsons, management (25-39% risk reduction) cardiac issues, depression Tinetti 2003. NEJM. • Treat visual impairments 8
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