8/10/2018 Disclosures Clinical Issues in Geriatrics for Primary Care Physicians I have no financial disclosures to report. B R O O K C A L T O N , M D , M H S A S S I S T A N T P R O F E S S O R O F C L I N I C A L M E D I C I N E D I V I S I O N O F P A L L I A T I V E M E D I C I N E U N I V E R S I TY O F C A L I F O R N I A , S A N F R A N C I S C O During this hour, we’ll cover: P rognostication P reventive Care: Cancer Screening P rognostication P olypharmacy P EGS, Neuro p sychologic Symptoms, and P alliative Care in Patients with Advanced Dementia
8/10/2018 Prognostication – Why It’s Important Mrs. A Ms. A is a 79 yo woman presents to establish care since moving to Helps patients and providers to determine realistic, this area to live with her son and his wife. PMH notable for COPD, achievable goals of care and proceed with interventions with two hospitalizations in the past year. She has difficulty consistent with goals walking more than a block because of dyspnea. She lives with her son’s family who help with iADLs but she is independent in ADLs. She has a previous 50 pack year history of cigarette use but she “If your heart stops, do you want electrical shocks and hasn’t smoked in 10 years. chest compressions to try to get your heart beating again?” Based on this description, what is the likelihood Ms. A will be alive in 10 years: 61% 10% or less A. Helps patients with life planning 25% B. 37% Most older adults want to know! 50% C. D. 75% 2% 0% s % % % s e 5 0 5 l 2 5 7 o r % 0 1 Prognostication – Why It’s Hard Clinical Decisions Influenced by Life Expectancy Younger patients (often with cancer): Life Clinical Decision Expectancy Usually clearer trajectory <4-6 weeks Methylphenidate over SSRI for depression Older adults: <6 months Discontinue statins <6 months Refer to hospice Absence of a dominant terminal condition <1-2 years Nonoperative management of AAA Age + Functional + Cognitive + <2-3 years Tight BP control in diabetes unlikely to Multimorbidity prevent stroke, MI <5 years Bio-prosthetic heart valve over mechanical <9 years Discontinue tight blood sugar control in diabetes
8/10/2018 Multiple Domains Independently Heterogeneity in Aging Impact Prognosis Functional Status HEALTHY Comorbid Medical Life Expectancy > 10 yrs Independent Conditions Cognition MEDICALLY VULNERABLE Nutrition Life Expectancy: 5-10 yrs Polypharmacy Assisted in Living Psychological Status Social Support FRAIL Geriatric Syndromes Life Expectancy < 1-2 yrs Totally Dependent Great Variation in Life Expectancy How should we prognosticate? for People of Similar Ages 25 Life Expectancy for Women 20 Top 25th Percentile Clinical 50th Percentile Years 15 Judgement Years Lowest 25th Percentile 10 Life Tables 5 0 70 75 80 85 90 Age (Years) Walter LC. JAMA 2001; 285:2750-56
8/10/2018 How should we prognosticate? 14 eprognosis.ucsf.edu Clinical Judgement Life Tables Prognostic Indices 8/10/2018 Age Hospitalizations Sex ADLs/iADLS BMI Your Guess General Health Status PMH Cig Use
8/10/2018 Communication on Prognosis Ask for permission and preferences for how information is relayed 10 year mortality risk: Use ranges 87% “In other people in a similar situation to you….” Mrs. A (continued) Based on a combination of your own clinical judgement and using a prognostic index you decide you would be very surprised if Mrs. A lived longer than 10 years. P reventive Care: Cancer Screening Which of the following cancer screening strategies are appropriate for her? 79% A. Breast, colorectal and lung cancer screening B. Breast and colon cancer screening alone 14% 6% C. Lung Cancer screening alone 1% D. None of the above e e . . n v . . . o u o l r l b d e a a c g n n e a a n h c i t a l n t n e f c o e o e r o l c e o r s n c o l d r N o e c n c , a n t a s t a s C e a e g B r r n B u L
8/10/2018 Cancer General Consensus Approach to Cancer Screening Breast Mammogram q2 years Should be individualized Stop if life exp < 10 years Consider lag-time to benefit Prostate Do not perform vs shared decision-making ~10 years for breast, colorectal, lung cancer screening Stop if life exp < 10 years ~15 years for prostate cancer screening Cervical Stop at age 65 in women who have had 3 consecutive neg Cervical cancer screening different—risk of cancer cytology or 2 consecutive neg cotests in pasts 10 years remote in women 65+ with normal Paps regardless of life expectancy Colorectal Start at age 50, age “cutoffs” vary by society Stop if life exp < 10 years Lung Start at age 55 with 30 pack year history and currently smoke or quit in last 15 years; Medicare covers to age 77 D/c if limited life expectancy Lee SJ. BMJ 2013;346:e8441 Lee SJ. JAMA 2013; 310(24): 2609–2610. To Screen or Not to Screen… To Screen or Not to Screen (cont)… Proposed Framework: Estimate Life Expectancy Determine possible benefits/harms Weigh benefits and harms alongside patient preferences Resources: USPSTF Preventive Services Selector Tool (http://epss.ahrq.gov/PDA/index.jsp) Eprognosis (http://eprognosis.ucsf.edu/) Salzman R. Am Fam Phys 2016; 93(8): 659-67
8/10/2018 Stopping Screening - Communication Trusting relationship crucial Personalized recommendations Cancer Poor health status or functional Screening is status are good reasons to not inadvisable screen for Mrs. A Antagonism to avoiding screening based on limited life expectancy “That’s like hitting you over the head with a hammer. Its too harsh” Schoenborn. JAMA Intern Med. 2017
8/10/2018 P olypharmacy What To Say… DO NOT SAY: “You will not live long enough to benefit from this test” INSTEAD, SAY: “This test will not help you live longer” Patients wanted to discuss health care that could help them live longer or better “When patients have medical conditions like yours and need help for day to day activities, this test can cause more harm than benefit” “It sounds like the doctor has considered my personal issues and decided I should not have the test” Ms. P Harms of Polypharmacy 8 months ago: Started HCTZ for BP . ~50% Medicare beneficiaries take 5+ meds Associated with bad outcomes: 7 months ago: Started oxybutynin for urinary incontinence. Mortality 5 months ago: Forgetful, confused at times, Hospitalization MMSE 20/30, loss of function. Started donepezil for Falls dementia. She takes tylenol PM (diphenhydramine) Not taking medications correctly for sleep problems. Adverse drug events and DDI 4 months ago: Loss of appetite, started PPI then megace. Developed DVT, started coumadin . Now: Admitted with fall and SDH. Steinman M. JAMA 2010; 304(14): 1592–1601 Fried TR. JAGS 2014: 2261–2272
8/10/2018 DE-Prescribing Principles Ms. P (continued) 8 months ago: HCTZ caused incontinence Stop before you start 7 months ago: oxybutynin caused confusion Symptom ≠ Medication 5 months ago: donepezil , tylenol PM All medicines should have: (diphenhydramine) donepezil caused low appetite, diphenhydramine risk of confusion A clear indication 4 months ago: PPI, megace, coumadin . PPI can Be evaluated for side effects cause drug-drug interactions, megace caused clot, Be at the lowest dose/frequency coumadin increased risk of SDH Be substituted with a safer alternative Now: Admitted with fall and SDH. >5 meds & centrally-acting meds (oxybutynin, donepezil, Be renally-dosed diphenhydramine) all increase risk of falls DE-Prescribing Principles Approach to De-Prescribing Condition Drug for Pot’l Notes In older adults, harm reduction is 1. D/c meds that that Problems don’t link to a critical. Condition condition If not benefiting someone, it is only potentially Dementia Memantine Potentially Withdrawl 2. D/c drugs that 10 mg BID ineffective/ trial and have limited or causing harm unnecessary reassess no benefit given Look for potentially inappropriate medications patients current condition “Beers List” (http://geriatricscareonline.org/) 3. D/c or sub out meds that are Anemia Ferrous Constipation No current high risk sulfate 325 indication, mg BID d/c Steinman. JAMA. 2010; 304(14): 1592–1601
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