Canadian Society of Internal Medicine Annual Meeting 2019 Halifax, - - PowerPoint PPT Presentation
Canadian Society of Internal Medicine Annual Meeting 2019 Halifax, NS Geriatrics 2019 Update: Pills and Falls Dr. Kim Babb MD FRCPC Memorial University of Newfoundland kimberly.babb@easternhealth.ca CSIM Annual Meeting 2019 The following
Canadian Society of Internal Medicine
Annual Meeting 2019
Halifax, NS
Geriatrics 2019 Update: Pills and Falls
Memorial University of Newfoundland kimberly.babb@easternhealth.ca
CSIM Annual Meeting 2019
The following presentation represents the views of the speaker at the time of the
Learning Objectives
in the older adult.
frailty.
deprescribing in the older adult.
CSIM Annual Meeting 2019
Conflict Disclosures
I have the following conflicts to declare:
Geriatric Experiences in Primary Care (NLMA Family Practice Renewal Program)
“Caring for our Elderly Patients: A Focus on OAB and AF”
Audience Participation
Website: PollEV.com/kimbabb743 Text: KIMBABB743 to 22333 once to join
The Case of Ed
The Case of Ed
1. Depression 2. Atrial fibrillation 3. TIIDM (HgA1c 6.2%) 4. HTN 5. DLP 6. OA 7. Urinary incontinence (indwelling foley for 1 month) 8. Recurrent UTIs 9. CKD (eGFR ~30%)
The Case of Ed
14u supper
**warfarin recently d/c by FP secondary to falls
Audience Poll
Q: Which statement is true?
medications seem reasonable, so no need to make adjustments.
burden.
The Case of Ed
– 8/10 orientation, 1/5 concentration, 2/3 recall, 2/3 command
The Case of Ed
14u supper
**warfarin recently d/c by FP secondary to falls
Polypharmacy
Definition: LOTSA + MEDS
events
useful medication
Polypharmacy
– Complex association
Frailty
A physiologic decline in later life characterized by marked vulnerability to adverse health outcomes.
Frailty
Frailty at SCMH
17 14 26 83 86 74 20 40 60 80 100 120 7 West 7 East 4 West
Percentage of Frail Elderly Acute Care Medicine Patients SCMH
% Screen negative ( 3 or less) % Screen positive (4 or more)
80% screened vulnerable to frail 562 IM inpatients
Frailty at SCMH
20 40 60 80 100 120 Very fit Well Managing well Vulnerable Mildly frail Moderately frail Severely frail Very severely frail Terminally ill
Clinical Frailty Scores
Total number of patients Percentage of patients
Polypharmacy
– Complex association
Polypharmacy can promote frailty
Polypharmacy
Polypharmacy outcomes
Polypharmacy
syndromes
– Urinary incontinence, confusion, falls – Often leads to prescribing cascade
Prescribing Cascade
NSAID
CCB
edema
Diuretic
Bladder antimuscarinic
http://www.slideshare.net/prashantshukla927/polypharmacy-57404596
Why Deprescribe?
Polypharmacy outcomes
Why Deprescribe?
– 40 - 75%
Why Deprescribe?
Adverse drug reactions
an adverse drug reaction
– About 2/3 of these will require medical attention
American Family Physician Dec 15th, 2007 Pham and Dickman
Deprescribing
– Mobile and functionally independent
– Less mobile, functionally dependent
Deprescribing
Deprescribing
Golden Rules:
Audience Poll
Q: Which medication class is often under-prescribed in older adults?
Deprescribing
Challenges:
– Rarely (if ever) focused on frailty
specialists medication prescribing
Deprescribing
– Important indications (ex: AF, osteoporosis) – Low tolerance for symptoms/cannot tolerate tapering
– Adverse drug reactions – No indication – Treating side effect of another medication (cascade)
Deprescribing Tools
(1) Beers Criteria
(2) STOPP/START
appropriate and stopping inappropriate meds
Anticholinergic Burden
acetylcholine
effects of anticholinergic medications
– Especially cognitive effects
Anticholinergic Burden
– None, low, medium, high
– Cumulative adverse effects of overall anticholinergic “load”
The Case of Ed
14u supper
The Case of Ed
14u supper
Deprescribing
My approach:
– Assess use of preventative medications in terminal/end stage disease
STOPP/START, etc)
The Case of Ed
DIAGNOSIS MEDICATION
supper
The Case of Ed
DIAGNOSIS MEDICATION
supper
The Case of Ed
DIAGNOSIS MEDICATION
No history CAD, MI, Stroke
No clear indication
Hx constipation, poorly treated
No clear indication, eats well
No clear indication, strongly anticholinergic
No hx GERD ?Prescribing cascade
?Prescribing cascade
The Case of Ed
DIAGNOSIS MEDICATION
No history CAD, MI, Stroke
No clear indication
Hx constipation, poorly treated
No clear indication, eats well
No clear indication
No hx GERD ?Prescribing cascade
?Prescribing cascade
The Case of Ed
14u supper
The Case of Ed
14u supper
The Case of Ed
The Case of Ed
Audience Poll
Q: Would you restart his warfarin?
Audience Poll
Q: How many times per year must an older adult fall for warfarin not to be the optimal therapy for stroke prevention in atrial fibrillation?
Clinical Pearl
The propensity to fall is NOT a contraindication to anticoagulation in older adults with atrial fibrillation.
The Case of Ed
Added:
The Case of Ed
14u supper
The Case of Ed
The Case of Ed
The Case of Ed
Falls
“Unintentionally coming to rest on the ground, floor, or other lower surface, with or without injury”.
Canadian Falls Prevention Curriculum, 2007
Falls
– Leading cause of injury in seniors
– Leading cause of injury during healthcare provision
– Leading cause of death due to injury
Falls
– $40 000
– $10 000
– $30 000
Falls Risk Factors
balance problem gait impairment muscle weakness joint problem ↓ leg sensation foot problem (any)
urinary urgency medications* age >80 female gender past hx falls cognitive impairment Parkinson’s prior stroke depression vision impairment
balance problem gait impairment muscle weakness joint problem ↓ leg sensation foot problem (any)
urinary urgency medications* age >80 female gender past hx falls cognitive impairment Parkinson’s prior stroke depression vision impairment
poor lighting inappropriate footwear/ clothing slippery/ uneven surfaces clutter wrong/misused assistive device pets
Dr. P. Feltmate
Risk Factors Chronic Falls Acute Falls medical illness
Falls
Practical approach for the internist: STEP 1: Case find! STEP 2: Assessment STEP 3: Management
Case Find
STEP 1: Case find! Ask the following (YEARLY)
Falls
STEP 2: Assessment
“Multifactorial risk factor model”
Falls: Assessment
Detailed history of falls themselves
– One fall = increased risk more falls2
– Dizziness, presyncope/syncope, palpitations
– If acute: health/med changes?
Falls: Assessment
Patient history
– Visual impairment, MSK, cardiac, neuro (cognitive impairment, movement disorders, sensory impairment)
– IADL & ADL (difficulty with ADLs = risk falls) – Gait/balance/mobility
– ETOH, other rec drugs
– Environmental hazards: rugs, bathroom equipment, lighting, rails, clutter, wet surfaces, gait aids
Falls: Assessment
Medication history
“Even if the meds are stable, the patient may not be.”
Woolcott et al (2009)
Falls: Assessment
Physical exam
– Lying to standing HR & BP
Falls: Assessment
Gait & balance exam
– Using patient’s own gait aid
– Timed Up and Go (TUG)
Falls: Assessment
Investigations
routinely recommended for falls assessment
– Choose investigations appropriately
Falls
Practical tips for the internist:
the consequences of the falls
– Vit D, calcium, bisphosphonate – PT, OT home assessment, exercise Rx
Multifactorial Risk Factor Model
Vision impairment ↓ Mobility/balance/strength Joint & foot problems Medications Orthostatic hypotension
Vision correction Cataract extraction Exercise, PT
balance, strength, gait
↓ psychoactive meds ↓ total # meds Behavioural strategies Compression stockings Foot care
Neurologic disease
Optimize medical management
Falls
What about single interventions?
What is the single intervention of choice?
Falls
exercise
(1) Home exercise 30min 3x weekly (2) Group exercise 1h, 1-2x weekly (3) Group exercise Tai Chi 1h 2x weekly
Audience Poll
Q: True or false? Use of physical restrains reduce fall injuries in hospital.
Falls
Helpful web resources
– “STEADI”