Approach to Geriatric Syndromes Geriatrics: Family Medicine Board - - PowerPoint PPT Presentation

3/16/2015 1

Geriatrics: Family Medicine Board Review 2015

Veronica Rivera, MD

Assistant Professor, Icahn School of Medicine at Mount Sinai Departments of Geriatrics and Palliative Medicine, Family Medicine and Community Health, and Medical Education Associate Director, Martha Stewart Center for Living

March 16, 2015

Approach to Geriatric Syndromes

Environment? Dependency? Frailty? Co-morbidities? Sensory Impairments? Cognitive Impairments?

Outline

• Physiologic Changes of Aging
• Polypharmacy
• Falls
• Osteoporosis
• Urinary Incontinence
• Dementia
• Delirium
• Pressure Ulcers
• Palliative Care: Pain Management
• Ethical Issues

Case #1: Physiologic Changes of Aging

An 82 y/o male complains of hearing loss worsening for 5 years. You send him for audiometry. The following audiogram was obtained.

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What kind of hearing loss is depicted?

• 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)
• Ototoxic drugs

Sensorineural Hearing Loss

Conductive Hearing Loss

Obstruction of external auditory canal

• Cerumen
• Foreign body
• Debris for otitis externa

Impairment of tympanic membrane function

• Perforated tympanic

membrane

• Tympanosclerosis

Middle ear conditions

• Otits media with effusion
• Otosclerosis
• Cholesteatoma

Hearing Loss in Older Adults, AAFP. 2012.

Conductive Hearing Loss

Air/bone gap on audiogram

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Physiologic Changes in Aging: Sensory Changes

• Hearing:

– Presbycusis (bilateral, high frequency, sensorineural) – Increase wax buildup – Stiffening of ossicles and drum

• Decreased taste buds, oral secretions, smell
• Vision:

– Difficulty with glare & dark adaptation – Decreased accommodation – Decreased acuity – Decreased tear production

Physiologic Changes in Aging:

• Cardiovascular

– Myocardial/vascular stiffness – Decrease heart rate and cardiac output – Conduction abnormalities

• Pulmonary

– Decrease vital capacity – Increase Residual Volume

Physiologic Changes in Aging:

• Skeletal System

– Decrease in Bone Density – Loss of muscle mass – Decrease tendon and ligament elasticity

• Renal

– Decrease blood flow and GFR – Decrease ability to concentrate urine

Physiologic Changes in Aging:

• Skin

– Thins – Loss of hair follicles, sweat glands, and melanocytes – Atrophy of subcutaneous fat – Loss of elasticity

• Other

– Decreased immunity (Primarily cell mediated) – Decreased physiologic reserve and homeostasis – Recovery takes longer

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Physiologic Changes in Aging:

• Sleep

– Decreased sleep efficiency – Decreased total sleep time – Less and earlier REM sleep – Less deep (stage 3 and 4) sleep; more Stage 1 and 2 – More napping, night time awakening, early morning awakening

Case #2: Polypharmacy

An 80 y.o. woman with CHF, Afib, depression and DM2 presents with several months of intermittent nausea and anorexia without vomiting. She takes – digoxin 0.25 mg daily – warfarin sodium 5 mg daily – furosemide 40 mg daily – lisinopril 20 mg daily – glipizide 6 mg daily – citalopram 20 mg daily – occasional acetaminophen. She has been on these doses for 5 years.

Case #2: Polypharmacy

• Denies other GI symptoms or recent illnesses, and

has not been taking other medications.

• Other than a 10 lb weight loss (110lbs to 100lbs), her

vital signs and exam are normal except for a heart 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.

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Case #2: Polypharmacy

What physiologic changes best explain her symptoms? Age related changes in body composition and renal function

Drugs - Physiologic Changes in Aging:

• Absorption: unchanged
• Volume of Distribution:
• Water soluble drugs -> more concentrated (digoxin)

– Decrease body masssmaller volume of distribution

• Fat soluble drugs -> longer half life (Benzodiazepenes)

– Increase in body fatlarger volume of distribution

• Metabolism/elimination:
• Liver: glucuronidation generally not affected, may have

reductions in cytochrome p450

• Renal function may be affected

Age related changes in body composition and physiology

DECREASES

• Total Body Mass
• Liver Mass
• Creatinine Clearance

INCREASES

• Total Body Fat

Drugs - Practical Considerations:

• Pharmacodynamics:

– Older adults may have increased sensitivity to medications at standard doses:

• Increased sedation with some benzodiazepines
• Increased sensitivity to opiates
• Urinary retention / delirium with anti-

cholinergic drugs (diphenhydramine, tricyclics)

• Psychosocial dynamics: adherence may be limited

by cognition, dependency, lack of resources

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Drugs - Practical Considerations:

• Polypharmacy: The risk of drug interactions increases linearly

with number of drugs prescribed – 43% of men and 57% of women use 5 or more prescription/Over the Counter drugs/week – Institutionalized patients are prescribed an average 5-8 drugs – 10-17% of geriatric admissions are for adverse drug events

– 2002 AMA CSA report

Beers List: Drugs to Avoid (except if…)

Organ System or TC or Drug Rationale Recommend Quality of Evidence Strength of Recommend. Nitrofurantoin Pulmonary tox Alternatives Lack of efficacy <60 mL/min Avoid long term suppression; avoid if CrCl <60 mL/min Moderate Strong Antipsychotics (conventional or atypical) Increase CVA and CV mortality in dementia Avoid unless danger to self/others and non pharm has failed Moderate Strong Insulin, sliding scale Hypoglycemia risk Avoid Moderate Strong Chlorpropamide Glyburide Hypoglycemia risk Avoid High Strong

Beers List: Drugs to Avoid (except if…)

Organ System or TC or Drug Rationale Recommend. Quality of Evidence Strength of Recommend. Benzodiazepines Short and long acting Risk cognitive effects and injury (fall/MVA); rare use appropriate eg benzo withdrawal Avoid for treatment of insomnia, agitation, or delirium High Strong Megestrol Minimal effect on weight; risk of thrombotic events and death Avoid Moderate Strong Metclopramide EPS and TD Avoid, unless gastroparesis Moderate Strong Non-COX NSAIDs,

• ral

GI bleeding; Protection w/ PPIs Avoid chronic use Moderate Strong

Beers List: Drugs to Avoid (except if…)

Organ System or TC or Drug Rationale Recommend. Quality

• f

Evidence Strength of Recommend . Non Benzodiazepines Hypnotics Risk cognitive effects and injury (fall/MVA); same ADE as benzo’s Avoid chronic use, >90 days Moderate Strong Estrogens with or w/o progestin Carcinogenic potential, lack of efficacy in dementia/CV dz prevention Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms High Strong Muscle Relaxants Ineffective at tolerated doses, antichol, falls Avoid Moderate Strong

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Drugs – Pearls for the Boards:

• Always put drug effect or drug interaction in the differential

diagnosis for an elderly patient

• Don’t automatically “treat” a new symptom with a new drug
• Often the answer requires dose adjustment or drug

discontinuation

• Older patients with a normal creatinine may have modestly

impaired renal function

Case #3: Falls

• Ms T is an 80 year old woman who lives alone. She

just came in to your office for follow up of a fall resulting in a Colles’fracture. She has had two other falls over the past year and a half. She is scared of falling again.

• She has a history of osteoarthritis and

anxiety/depressison.

• She is on naproxen sodium 500mg BID, sertraline

50mg daily and ativan 1mg BID as needed

Case #3: Falls

Which is the best way to prevent future FALLS in this patient?

Epidemiology of Falls

• 30- 40% of community-dwelling people over

the age of 65 years fall each year

• Increases to about 50% for those 80 years and
• lder
• 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

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Falls Cause Morbidity and Mortality

• Injuries are common:

– 40% of falls result in minor injuries – 10% result in major injuries

• Fracture, soft tissue injury, traumatic brain

injury

• 2.2% of injurious falls result in death

Tinetti, ME, JAGS 1995 Nachreiner J Women’s Health 2007 Tinetti & Kumar JAMA 2010 MMWR Morb Mortal Wkly Rep 2008

Risk Factors

Intrinsic Factors Extrinsic Factors FALLS

Medical conditions Impaired vision and hearing Age related changes Medications Improper use of assistive devices Environment

Intrinsic Risk Factors

• Increasing Age
• History of Falls
• Female Gender
• Medical Illness
• Peripheral neuropathy
• Orthostasis
• Cognitive impairment
• Visual impairment
• Lower extremity

weakness

• Abnormality

gait/mobility

• Incontinence
• Depression
• Foot problems
• Hearing impairment

Colon-Emeric. JCOM. 2001

Extrinsic Risk Factors: Environment

• Indoor Hazards:

– Slippery floors, rugs/carpet, poor lighting, shoes, bathroom fixtures, height of chair/bed, unstable furniture, stairways, improper use of assistive devices

• Outdoor Hazards:

– Uneven pavement, steps, snow and ice

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Extrinsic Risk Factors: Medications

• Antipsychotics
• Sedatives
• Antidepressants
• Antiarrhythmics
• Anticonvulsants
• Anxiolytics
• Antihypertensives
• Diuretics
• Systemic glucocorticoids

Interventions

• Single interventions
• Multifactorial Assessment with targeted

interventions

– Most consistently studied with effectiveness

Interventions

General Risk

• Exercise program
• Daily supplement Vitamin D

Medications

• Avoid agents with increase risk of falls
• Review medication lists

Mobility-related

• Improve lighting
• Remove environmental risks
• Refer to PT/OT for gait training

Medical Factors

• Optimize medical therapy for Parkinsons,

cardiac issues, depression

• Treat visual impairments

Effective Interventions

• Professionally supervised strength and

balance training (14-27% risk reduction)

• Reduction in home hazards after

hospitalization (19% risk reduction)

• Discontinuation of psychotropic medications

(39% risk reduction)

• Multifactorial assessment with targeted

management (25-39% risk reduction)

Tinetti 2003. NEJM.

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Vitamin D Supplementation

• 700-800IU a day has been shown to decrease

in falls and fractures

• 2004 meta-analysis found higher doses of

vitamin D have been associated with 6.7% absolute reduction in risk in both community and institutionalized

• Theory: increases muscle strength and

decreasing body sway.

• Also helps with bone mineral density.

Exercise

• 2009 Cochrane review on falls
• 43 trials looked at efficacy of exercise.
• Exercise classes using more than 1 type of

exercise was effective in reducing the rate of falls.

• Tai Chi (combines both strengthening and

balance).

Treatment of Vision Impairment

• One trial of 306 patients shows first cataract

surgery results in decreased rate of falls.

• Second cataract surgery showed no benefit.

Geriatrics Review Syllabus, 7th edition

Hip Protectors & Home Hazards

• Hip Protectors

– No evidence for decrease in falls – Of question of their usefulness in fractures

• Non-specific advice about modification of home hazards

– No proven effectiveness

• Multi-Factorial/Disciplinary Strategies

– Best effectiveness

• JAMA. 2007;298:413-422, 454-455

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Case #4: Osteoporosis

• 75yo female with history of diabetes,

hypertension, presents for care and asks about screening for osteoporosis.

• You order a DEXA scan and her T score is -2.0.
• What is the appropriate management?

Definitions

• Osteoporosis:

– A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture – Per WHO: BMD -2.5 SD below that of younger normal individuals (T score)

• Osteopenia:

– T Scores between -1 and -2.5 SD

Epidemiology

• Approximately 8 million women and 2 million

men in US

• Hip fractures cause mortality of about 10-

30%, greatest risk in first 6 months after a fracture.

Cooper C. Am J Med. 1997;103(2A):12S-17S. Slide from Shoback, UCSF.

40%

Unable to walk independently

30%

Permanent disability

20%

Death within

• ne year

80%

Unable to carry out at least one independent activity of daily living

Hip fractures are associated with increased morbidity & mortality *

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Screening

• National Osteoporosis Foundation

– Women >65 and Men >/= 70 – Postmenopausal Women (<65) and Men 50-70 if there is a concern based on risk factors

• USPSTF

– “Women >65 and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.” – “Insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men.”

Osteoporosis Risk Factors

• Current age
• Gender
• Personal history of fracture
• Femoral neck BMD
• Low body mass index (kg/m2)
• Use of oral glucocorticoids
• Secondary osteoporosis (e.g., rheumatoid arthritis)
• Parental history of hip fracture
• Current smoking
• Alcohol intake -- 3 or > drinks per day

Risk Assessment Tool

• FRAX= WHO Fracture Risk Assessment Tool
• Estimation of 10 year probability of hip fracture and

10 year probability of major osteoporotic fracture based on risk factor

FRAX: Calculating 10-Year Fracture Probability

FRAX web site at: http://www.shef.ac.uk/FRAX/

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Osteoporosis Treatment Guidelines

National Osteoporosis Foundation Treatment Guidelines

• Hip or Vertebral Fracture
• T-score ≤ -2.5 (at femoral neck, total hip, or spine) in absence
• f other risk factors
• Postmenopausal women and men age >50 with T-score

between -1.0 and -2.5 AND – 10 yr hip fracture probability > 3% or 10 yr major

• steoporosis-related fx probability of > 20% (per FRAX

calculator)

Osteoporosis Management

• Increase Calcium – 1200mg
• Increase Vitamin D – 800-1000 IU
• Weight-bearing exercise regimen
• Avoid tobacco
• Falls prevention
• Drug Therapies

Drug Therapies

• Bisphosphonates

– Example: Alendronate, Zoledronic Acid – Adverse class effect:

• Esophagitis
• Bone, joint, or muscle pain
• Osteonecrosis of jaw (0.01%-0.0001%)
• Atypical femural fractures (rare)

– Renal dosing required if CrCl <30mL/min – Consider discontinuing after 5 years

Drug Therapies

• Selective estrogen receptor modulators

– Example: Raloxifene – Increases bone mineral density and reduces risk of vertebral fractures. Not been shown to reduce hip fractures – Used more often for prevention because of reduced risk of breast cancer – Adverse effects: may cause hot flashes, increase risk of venous thromboemolism.

• Estrogen

– No longer first line approach because risk of breast cancer, stroke, VTE and coronary disease

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Drug Therapies

• Denosumab

– humanized monoclonal antibody against RANKL that reduces osteoclastogenesis – Alternative for those who do not tolerate bisphosphonate

• Calcitonin

– Subcutatenous or nasal spray – Relatively modest effect – May also be helpful for analgesic effect in patients with acute vertebral fracture.

Drug Therapies

• Parathyroid hormone

– Anabolic agent. Stimulates bone formation and activates bone remodeling. – Example: Teriparatide (Forteo). – Not good option given well-described deleterious effect on bone. – Consider for high-risk patients with multiple fractures who continue to fracture after 1 year on bisphosphonates or intolerate of bisphosphonates.

Case #5: Urinary Incontinence

• The wife of your 75 y.o. male moderately demented

patient asks you to prescribe incontinence supplies.

• He has been having abrupt urgency, frequency, and
• nocturia. He denies dysuria, hesitancy, thirst,

polyuria.

Case #5: Urinary Incontinence

• He has a history of hypertension, osteoarthritis,

vascular dementia, and hyperlipidemia. He had a TURP 8 years ago without complications.

• Medications include aspirin, hydrochlorothiazide

12.5 mg daily, simvastatin 20 mg daily, and donepezil 10 mg daily.

• His general physical exam, including prostate exam,

is normal. A post-void residual is 18 cc.

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Case #5: Urinary Incontinence

• What kind of urinary incontinence does he

have?

Urge Incontinence, Detrusor Overactivity

• What is the best initial treatment of his

urinary incontinence is?

Anticholinergic such as oxybutynin or tolterodine

Urinary Incontinence: First Things to Rule Out - DIAPPERS

• D elirium
• I nfection
• A trophy
• P harmeceuticals
• P sychologic
• E ndocrine or excess urine output
• R estricted mobility
• S tool impaction

Incontinence: Anatomy and Physiology

• Voiding is mediated by:
• 1. Detrusor contraction
• parasympathetic nervous system (S2-S4)
• 2. Sphincter relaxation
• somatic (S2-S4) and sympathetic nervous

systems (T11-L2)

• Storage of urine is mediated by:
• 1. Detrusor relaxation
• CNS inhibition of parasympathetic tone (S2-S4),
• 2. Sphincter closure
• Reflex increase in alpha adrenergic (T11-L2) and

somatic activity (S2-S4).

Types of Incontinence

• Stress Incontinence
• Urge Incontinence
• Mixed Incontinence
• Overflow Incontinence
• Functional Incontinence

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Stress Incontinence

• Loss of urine on effort or exertion, or on sneezing
• r coughing
• Cause: Impaired urethral sphincter mechanism
• Childbirth, pelvic floor laxity, radical

prostatectomy, alpha antagonists

• Signs/Symptoms: Leakage with cough/sneeze,

low PVR (post void residual)

• Treatment:
• Pelvic floor exercises (Kegels)
• Role of estrogen less clear
• Surgery

Urge Incontinence

• Urge Incontinence: Detrusor Overactivity

– Loss of urine with sensation of urgency – Risks: Age, local bladder irritation (UTI, stones, tumors), stroke, cervical stenosis – Symptoms/Signs: Urgency, Low PVR

Urge Incontinence: Treatment

– Behavioral Therapy

• Cognitively Intact: Bladder Training
• Cognitively Impaired: Scheduled Voiding

– Pharmacotherapy

• Anticholinergics - oxybutinin, tolterodine
• Efficacy: 60 -70% reduction in urge UI (30 -50%

placebo effect)

• Adverse events: Dry mouth in 20-25% (5%

“severe”)

Mixed Urinary Incontinence

• Most common type of incontinence in older

women, accounting for approximately one- half of all cases – Mix of urge and stress

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Overflow Incontinence

• Urine loss associated with bladder
• verdistention
• Symptoms are often nonspecific

– Reduced urinary stream – Incomplete voiding – Frequent or continuous dribbling – Leakage without warning

Overflow Incontinence

– Bladder Outlet Obstruction

• Benign Prostatic Hyperplasia
• Small volume leakage, high PVR
• Treatment: alpha antagonists (prazosin,

terazosin, tamsulosin, doxazosin) +/- finasteride, surgery

• Saw palmetto - no better than placebo

– Impaired Detrusor Contractility

• “Neurogenic”, high PVR
• Supportive treatment, Intermittent

catheterization

Functional Incontinence

• When an individual is unable or unwilling to reach

the toilet on time.

• Associated factors

– Mental function (ex: dementia) – Mobility, Dexterity (ex: arthritis, neuro disorders) – Environment (ex: inaccessible toilets) – Motivation (patients, caregivers)

Case #6: Dementia

• Mr. D, a 70 year old man with coronary artery disease,

chronic obstructive pulmonary disease, and dementia, is brought in by his family because of increased difficulty walking x 1 year. They are also concerned by his report that family members, long deceased, have been “visiting” him in the evenings for the last 6 months. Mr. D’s caregivers are worried about his “visitors” and his tendency to roam around the house at night. Exam is significant for tremor & rigidity in upper extremities, MMSE of 20/30, and normal labs including a normal TSH and B12.

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• Mr. D’s clinical presentation is

most consistent with which of the following? Dementia with Lewy bodies

Case #6: Dementia Dementia Diagnosis

Short-term memory impairment PLUS At least one other impaired cognitive domain:

• Language (Aphasia)
• Motor (Apraxia, impairment in learned

movements)

• Visuo-spatial
• Behavioral
• Executive function

PLUS Functional Impairment

• Deficits limit social or occupational function
• Deficits represent change from prior level of

functioning

Assessing Function

• ADLs: Impacted late

– Bathing – Dressing – Toileting – Continence – Transferring – Feeding

• IADLs: Impacted early

– Driving/transportation – Working/managing phone – Shopping for food – Finances – Taking meds – Cooking – Housework

Dementia:

• Mild cognitive impairment (MCI)

– MCI causes memory deficits generally without functional impairment. – Risk of progression to Alzheimer’s disease was 16% over 3 years in one study

• R. Petersen, NEJM 2005

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Delirium vs Dementia:

DELIRIUM DEMENTIA Acute onset Insidious onset Changes with time (wax and wane) Slowly progressive over years Attention severely affected Memory mainly affected Often reversible Not reversible Needs urgent attention Better to diagnose after hospitalization

Dementia – DDx Pearls:

• 60-70%: Alzheimer’

’ ’ ’s Disease – Gradual decline. Memory impairment. Language

• 15-30%: Other progressive disorders

– Vascular dementia: “step-wise progression” – Dementia with Lewy bodies:

• Dementia & Parkinsonian symptoms,

fluctuation in cognition, hallucinations, sensitivity to neuroleptics. – Parkinson’s Disease: Dementia late in Disease. Executive dysfunction – Frontotemporal dementia: Younger onset.

• Disinhibition. Executive dysfunction.

Dementia – DDx Pearls:

• 2-5% Reversible dementias

– Normal pressure hydrocephalus

• “wet/wacky/wobbly”

– Subdural hematoma – Thyroid, B12, Syphilis, Depression (pseudodementia) – Other: HIV, drug or toxin related

Dementia - Diagnostic Workup:

• History and Physical: look for reversible causes
• Cognitive testing

– Mini-Cog:

• 3 item recall and clock draw test. Easier for non-English

speakers – Mini Mental State Exam (MMSE):

• good screening test, not sufficient to establish

diagnosis. – Montreal Cognitive Assessment (MoCA) – Neuropsychological testing:

• not required for diagnosis, but may help

3/16/2015 20 Mini-Cog: 3 item recall/clock draw

**Can be used in multiethnic and multilingual populations

Sensitivity 76-97% Specificity 89-95%

Borson S. Int J Geriatr Psychiatry 2000; 15(11):1021. Borson S et al. JAGS 2003; 51: 1451-54. Scanlon J and Borson S. Int J Geriatr Psychiatry 2001; 16: 216-222

Mini-Cog Recall=0 Recall=3 Recall=1-2 Clock Abnormal Clock Normal Cognitive impairment No Cognitive Impairment Cognitive impairment No Cognitive Impairment

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Dementia - Diagnostic Workup:

• Neuroimaging: either CT or MRI

– Controversial, but recommended by the American Academy of Neurology

• Laboratory testing:

– CBC, Calcium, Renal/lytes, B12, TSH – RPR and HIV not routinely recommended: evaluate pt’s risk – Heavy metal testing if supported by history

Dementia - Treatment Options:

• Acetylcholinesterase inhibitors

– Example: Donepezil, rivastigmine, galantamine – Some benefit in mild-moderate dementia (MMSE 18-24): AD2000 1 point increase in MMSE at 2 yr – Controversies: ?severe dementia, MCI – Main side effects are GI: nausea, vomiting, diarrhea, anorexia; ?incontinence

• NMDA receptor blockers

– Example: Memantine – For moderate to severe AD – Main SE are CNS: confusion, dizziness

Dementia - Treatment Options:

• Treat the environment

– Change environment rather than patient (e.g. disable stove, make all clothes pull-on sweats in matching colors, circular corridors) – Reminiscent therapy – Break down complex activities into simple tasks – Structured activities and routines – Simple words and sentences

• Treat the caregiver

– Alzheimer’s Association, support groups, respite

Dementia - Pearls:

• Alzheimer’s disease -> most common
• Dementia may predispose to delirium and may
• verlap with both depression
• Dementia with Lewy bodies: unlike the dementia

from Parkinson’s disease, the cognitive impairment

• ccurs earlier in the illness

– May have dangerous reactions to neuroleptics particularly those with D2 dopamine receptor effects (typical antipsychotics).

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Case #7: Delirium

82yo male with h/o Alzheimer’s dementia (MMSE 25/30), hearing impairment, visual impairment, CHF, admitted with a CHF exacerbation. On hospital day #3 was found to have decreased level

• f consciousness.

Labs are unremarkable. What is cause of his change in level of consciousness?

86

How common is delirium?

Delirium Rates

• 10-50% of hospitalized older patients
• 15-53% in postoperative patients
• 70-87% in the ICU
• 20-60% in the Nursing home or post-acute

care

Inouye, NEJM. 2006.

87

Things that make you vulnerable to delirium

Older age Male gender Dementia History of delirium Depression Functional

dependence /Immobility

Sensory Impairment Dehydration Malnutrition Many Drugs Psychoactive drugs Alcohol abuse Many Medical

Problems

Inouye SK. NEJM 2006;354:1157-65

88

What do we see in delirium?

Confusion Assessment Method (CAM)

• Acute and fluctuating clouding of consciousness
• Difficulty paying attention or maintaining focus
• AND-
• Disorganized or jumbled thoughts
• or-
• A change in the level of consciousness.
• Wilber. Emerg Med Clin N Am. 2006

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89

How to Work-Up & Treat Delirium

• A directed medical workup

– CBC, chemistries, LFT’s, CXR, U/A, EKG – Assure adequate hydration and oxygenation. – CT’s are rarely helpful if non-specific neuro exam. – evaluate for urinary retention, constipation

• Medications are related to 40% of case of delirium
• Sitters are preferable to restraints.
• When all else fails:

– Haldol starting at 0.5mg – Sedation and QT prolongation may occur. (so avoid IV if possible.)

90

Medications!!!

• Sleeping Meds

– Diphenhydramine – Zolpidem

• Anxiety Meds

– Lorazepam, Diazepam

• Pain Meds

– Meperidine

• Antiparkinsons Meds
• Anti-inflammatory (ex:

prednisone)

• Lithium
• Anti-cholinergic

– Oxybutynin, Diphenhydramine

• Anti-nausea Meds

– Promethazine – Metoclopramide

• Anti-depressants
• Muscle Relaxants

– Cyclobenzaprine

• CV: digitalis, anti-HTN

Prevention of Delirium

• Orientation
• Sleep
• Early mobilization
• Visual aids
• Hearing aids
• Treatment of dehydration and medical conditions

like infection, pain.

Case #8: Pressure Ulcers

The nursing home calls to report that your new admission, a frail 92 year old man who is recovering from pneumonia, has a 2.5 cm stage 2 ulcer on his sacrum with mild surrounding erythema and a 1 cm eschar on his left heel. He is bed bound and has been in the hospital for 10 days.

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Case #8: Pressure Ulcers

In addition to improving his nutritional status and frequent turning, the most appropriate management for his skin issues would be: Hydrocolloid dressing to sacrum and elevate heels

Pressure Ulcers - Risk Factors:

• Mechanical/local environmental factors

– Pressure – Friction/shear – Moisture: urinary/fecal incontinence

• Host factors

– Malnutrition, decreased albumin – Excessively dry skin – Immobility and debility – Sensory impairment

Pressure Ulcers - Friction and Shear

Shear: bone against tissues Friction: Skin/tissue against surface

From: www.ahrq.gov

Pressure Ulcers - Classification:

• Stage I

– Non-blanchable erythema of intact skin

• Stage II

– Partial thickness loss of dermis presenting as a shallow open ulcer

• Stage III

– Full thickness tissue loss. SQ fat may be visible but bone, tendon or muscle are not

• Stage IV

– Damage down to the muscle, tendon, bone

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Pressure Ulcers - Classification:

• Unstageable

– Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar

• Deep Tissue Injury

– Localized area of purple or maroon discoloration

• f intact skin or blood-filled blister indicating soft-

tissue injury due to pressure and/or shear – Often evolves rapidly to stage III or IV.

Pressure Ulcers - Treatment:

• REDUCE PRESSURE
• MOISTURE BALANCE

– Keep surface moist and covered – Absorb exudates

• CONTROL INFECTION/INFLAMMATION

– Topical antimicrobials – Systemic Antibiotics only if signs of infection: fever, purulence, markedly increased erythema, osteomyelitis. – As pressure ulcers are subject to polymicrobial colonization, routine wound cultures are generally not helpful.

Pressure Ulcers - Treatment:

• DEBRIDEMENT

– Sharp debridement – Autolytic debridement (hydrogels or moisture- retaining dressings) – Topical enzyme debridement (example: collagenase)

Case #9: Pain Management

A 75 year old woman with widely metastatic breast cancer has previously had good pain relief from sustained release morphine, 200 mg every 8 hours, but now she reports severe pain once every 3 days

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Case #9: Pain Management

Which of the following is the most appropriate therapy for her breakthrough pain? Morphine solution 60mg q2h prn

Pain Management - Opiate Basics:

• Determine total opiate requirement in 24 hours
• Use extended release formulas around the clock if

pain is continuous – fentanyl patch may take 12-24 hours to take effect, 72 hours to reach steady state

• Conversion of IV morphine to PO:

– 1 mg iv morphine = 3 mg po morphine

• If uncontrolled, increase doses by 25-50% for mild-

moderate pain, 50-100% for severe pain

Pain Management - Opiate Basics:

• Rescue or breakthrough analgesia is often needed
• Each rescue dose = 10% of total 24 hour dose

– Example:

• basal dose sustained release morphine 200 mg

q8h (600 mg/24 hours)

• then breakthrough is liquid morphine 60 mg

q2h prn

• For rapidly changing pain, offer q1h prn orally, q30

minutes prn SC/IM or q10 minutes prn IV.

Pain Management - Pearls

• Prevent constipation aggressively
• Opiate related nausea is mediated by D2 receptors

– Antidopaminergic antiemetics: prochlorperazine, haloperidol.

• NSAIDs may be helpful for bone pain
• Gabapentin and tricyclic antidepressants may be

helpful for neuropathic pain

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Case #10: Ethical Issues

• Mrs. X is an 87 y/o retired attorney with dementia who is

homebound due to severe arthritis

• Lost 20lbs in the last 12 months. Her home smells

strongly of urine and there is a significant amount of clutter.

• She endorses depressive symptoms, but no suicidal

ideation.

• She hasn’t refilled her medications in some time. She

says that she doesn’t want to take pills anymore and likes things the way they are: “I want to stay here until I die.”

Case #10 : Ethical Issues

• PMH: dementia, hypertension, urinary incontinence

and chronic obstructive pulmonary disease.

• Exam: Her BP is 170/100, HR 100. Thin elderly
• female. 6/15 on the Geriatric Depression Scale

(positive is > 5).

• Your plan is to start an anti-depressent but she

refuses

Case #10 : Ethical Issues

What is the most appropriate assessment of the current situation? The patient may be depressed but her capacity is unknown

Ethical Issues - Capacity vs Competence:

• Decision making capacity is not the same as

legal competence

• Capacity may be determined by the clinician
• Capacity is situational and specific to a

particular decision

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Ethical Issues - Capacity:

• Patients with decision making capacity:

– Able to make and communicate a choice – Able to appreciate the medical situation and prognosis – Able to appreciate the nature of recommended care – Able to appreciate risks, benefits, and consequences of options – Decisions are not the result of delusions and are not coerced

Ethical Issues - If the patient lacks capacity:

• Is there an advance directive and/or has a health

care proxy been identified? – If so, the DPOA for health care is legally able to make healthcare decisions.

• If there is no documented advance directive, is there

a surrogate? – Role is to use “substituted judgment”

• If not, what is in the patient’s best interest? May

require ethics consultation.

Questions?

• Contact: veronica.rivera@mssm.edu

Acknowledgements: Eric Widera, MD Ron Goldschmidt, MD Carla Perissinotto, MD Louise Aronson, MD Anna Chodos, MD