Geriatrics Board Review Daniel Pound, MD Clinical Professor - - PowerPoint PPT Presentation

Geriatrics Board Review

Daniel Pound, MD Clinical Professor Family and Community Medicine, UCSF Medical Director, UCSF Center for Geriatric Care

Doe wat je t’liefste doet

Carolina Origins

Emma Zuletta Otersen 1886 - 1976

Outline

 Dementia, delirium, and depression  Falls, osteopenia, and osteoporosis  Hearing and functional impairment  Urinary incontinence  Age related changes in drug metabolism  Medication prescribing with CKD

Welcome to Medicare

• Mrs. Jones 65 yr old retired teacher

 Diabetes HTN CHF atrial fib GERD  Complains about husband’s hearing

• Mr. Jones 65 yr retired airplane mechanic

 BPH insomnia anxiety URI symptoms  Hard to hear women or to hear in crowds  Not bothered by hearing loss

Which do you expect?

Sensorineural loss Air = bone Conductive loss Air < bone

Types of hearing loss

Sensorineural

 Age related presbycusis  Gradual onset  Effect of noise exposure  High frequency (♀ voice)  Worse in crowds  Air = bone on audiogram  Prescribe hearing aid or

cochlear implant Conductive

 Obstructed canal  Perforated or scarred TM  Otitis media  Air < bone on audiogram  Treat underlying cause

Consonants or Vowels?

He has mixed hearing loss

 Sensorineural: curve

slopes down to the right (high frequency)

 Conductive: air (O)

worse than bone (X) conduction

 Treat conductive loss:

 Remove cerumen  Antibiotic for otitis

media

Hearing aids

 His sensorineural loss persists after abx  Hearing loss is socially isolating  Is patient is likely to use hearing aids?

 Yes: if patient is bothered by hearing loss  No: if only his wife is bothered by hearing loss

 Side effects: discomfort, feedback, stigma  No interventions proven to increase use

Cochrane Database Syst Rev. 2014;7:CD010342.

Why Hearing Aids Don’t Work

Incontinence

 Mr. Jones has recent onset urine leakage  Unpredictable leak day and night x 4 days  Lower abdominal pain, no dysuria or fever  Hydrocodone PRN back pain  Diphenhydramine/pseudoephedrine OTC  Guaifenesin with codeine PRN cough

What type incontinence?

 Urge  Stress  Mixed urge/stress  Obstructive overflow  Atonic overflow  Functional  Keys = dribbling, BPH, opioid, cold meds

PVR > 200 cc = Overflow

Overflow etiology: two types

Too little tone Too much tone Bladder tone

Neuropathy Opioid Anticholinergic

 atonic

Sphincter tone

BPH Alpha agonist

 obstructive

Overflow treatment

to tone to tone Bladder tone

Atonic 

Stop codeine Stop Benadryl Bethanechol?

Sphincter tone

Obstructive

Stop decongestant Alpha blocker Finasteride Foley TURP?

• Mrs. Jones

What Type Incontinence?

 Mrs. Jones has chronic incontinence  Leaks urine with cough or sneeze  “Can’t get to the bathroom in time”  G1P1 vaginal birth  PVR 15 cc (normal is < 100 cc)  Keys = parous, Valsalva, urgency

Mixed urge + stress etiology

Too little tone Too much tone Bladder tone

Overactive bladder Dementia, UTI? Bladder stone, tumor

 urge

Sphincter tone

Vaginal birth Prolapse TURP, alpha blocker

 stress

Mixed incontinence treatment

to tone to tone Bladder tone

Urge 

Anticholinergic (oxybutynin) Sympathomimetic (mirabegron $$$)

Sphincter tone

Stress 

Kegel exercises Pessary ♀ Urethral sling surgery

Anticholinergic Choices

 Oxybutynin (Ditropan) and tolterodine

(Detrol) best studied in elderly

 Sustained release or patch  less side effects

 Newer M3 selective rx still cause dry mouth

 Trospium (Sanctura)  Solifenacin (Vesicare)  Darifenacin (Enablex)

 Tricyclic (nortriptyline, imipramine) side

effects harder for elderly to tolerate

Functional incontinence

Too little to function Cognition

Dementia

 functional functional 

Prompted voiding (timed voiding) Bedside commode Urinal External catheter ♂ Sweat pants No restraints

Vision

Poor vision

 functional Mobility

Slow gait Poor dexterity Restraints

 functional

Urinary Incontinence

Too little tone Too much tone

Bladder tone

Atonic

Overflow

PVR > 200 cc

Neuropathy Spinal cord disease Anticholinergics Opioids Mirabegron Overactive bladder Dementia Bladder stone Bladder tumor Bethanechol

Urge

PVR < 100 cc

Sphincter-

• utlet

tone

Stress

PVR < 100 cc

Childbirth Prolapse Prostate surgery Alpha blocker Finasteride Foley catheter BPH Urethral stricture Prostate cancer Alpha agonist Pessary Bladder sling surgery

Obstructive

Overflow

PVR > 200 cc

Cognition- mobility Functional

Poor gait Poor vision Poor dexterity Poor cognition Bedside commode Urinal External catheter Sweat pants Prompted voiding

Bone Health

 Mrs. Jones asks about bone density test  FH mother died in SNF after hip fracture  Menopause age 48 (i.e., not early)  DEXA at age 50 was low normal T - 0.9  No prior fractures, smoking, or steroids  3 drinks per day, Caucasian race  5’ 6”

135 lb. BMI 21

Who to screen

 National Osteoporosis Foundation

 Women > 65 and men > 70  Postmenopausal women <65 or men 50-70:

• nly if concern based on risk factors

 USPSTF (for board exams)

 Women >65 (younger women whose risk >=

65 yr. old white woman w/o other risk factors)

 Insufficient evidence to recommend for men

Medicare DEXA coverage >65

 Postmenopausal women  Men only if:

 Osteopenia or vertebral fracture on X-ray  Taking or starting steroids  Primary hyperparathyroidism  Already taking osteoporosis drugs

 Not covered by Medicare for men just

based on prostate cancer therapy

Osteoporosis Risk Factors

 Age  Gender  Low BMI  Current smoking  Alcohol 3 or more

drinks per day

 Low femoral neck

BMD

 Oral steroid use  Personal history of

fracture

 Parental history of hip

fracture

 Secondary

• steoporosis :

 Rheumatoid arthritis  Hyperparathyroidism

Her femur neck results

 Age 50

T -1.0

 Age 65

T -1.5

 Age 70

T -1.9

 Age 75

T -2.5 Normal Osteopenia Osteopenia Osteoporosis

Who to treat

 Osteoporosis

 Clinical diagnosis (hip or vertebral fracture)  DEXA diagnosis (T ≤ - 2.5)

 Osteopenia (-1 > T > - 2.5) if other risk

factors that predict 10-year risk of either:

 ≥3 % risk of hip fracture, or  ≥20 % risk of major osteoporotic fracture  These risk rates = cost effective to treat

FRAX for osteopenia

Age 65 @ 135 lb. 66 inch Age 70 @ 130 lb. 65 inch

Her FRAX results

 Age 50 T -1.0  Age 65 T -1.5  Age 70 T -1.9  Age 75 T -2.5

FRAX N/A (normal DEXA) 1.5% hip 19% major 6.5% hip 21% major FRAX N/A (osteoporosis)

Osteoporosis Treatment

 Calcium 1200 mg elemental total (incl diet)

 Ca carbonate inexpensive  Ca citrate better absorbed if high gastric pH

 Vitamin D3 800 – 1000 IU  Weight bearing exercise  Avoid tobacco and alcohol  Fall prevention  Osteoporosis drug therapy

Bisphosphonate

 Alendronate (po) or zoledronic acid (IV)  Prevent hip + spine fractures  Contraindicated if GFR < 30 (po) or 35 (IV)  Side effects:

 Esophagitis (sit up after taking)  Musculoskeletal pain  Osteonecrosis of jaw (rare)  Atypical femur fractures (rare)

More expensive therapies

 Used if intolerant of, contraindication to, or

continued fractures with bisphosphonates

 Denosumab (Prolia) anti-RANKL antibody

 Prevents hip + spine fractures  Subcu Q6mo, caution if GFR < 30 (hypoCa)

 Teriparatide (Forteo) anabolic PTH

 Prevents spine + non-spine fractures  Not specifically proven to prevent hip fracture  Subcu daily x2 years ($72,000 total for 2 yrs)

Less attractive therapies

 Nasal calcitonin

 Prevents spine fractures, not proven for hip  Causes small increased risk for cancer  Short term use as analgesic for spine fracture

 Raloxifene (Evista) SERM

 Prevents spine fractures, not proven for hip  Prevents breast cancer  Not used in elderly due to risk for thrombi

Her treatment

 T -1.0 Normal

GFR 70  calcium D exercise

 T -1.5 FRAX 1.5% / 19% GFR 55

 same

 T -1.9 FRAX 6.5% / 21% GFR 40

 add bisphosphonate for % risk

 T -2.5 Osteoporosis

GFR 25  stop bisphosphonate for GFR

• Mr. Jones falls

 Falls getting up from bed to toilet at night  Minor injuries  Diazepam, hydrocodone, or Flexeril

(cyclobenzaprine) PRN back pain

 Zolpidem PRN insomnia  Terazosin at bed time

Multifactorial and Serious

Intrinsic causes

 Abnl gait/balance

 Weakness  Neuropathy  Vestibular

 Orthostatic ↓BP  Vision loss

10% risk major injury

Extrinsic causes

 Environment hazards  Medications

Precipitating factors

 Syncope  Acute illness

2% risk death

Medicines That Cause Falls

 Sedation

 Opioids  Benzodiazepines  Other sleeping pills  Antipsychotics  Antidepressants  Antiemetics  Antihistamines  Muscle relaxers

 Orthostatic hypotension

 Antihypertensives  Alpha blockers for BPH  Nitrates  Antipsychotics  Tricyclics  Trazodone  Anticholinergics  Antiparkinsonian

Fall Interventions

 PT for strength + balance  Tai Chi (strength + balance)  Stop psychotropic rx  Address home hazards  Multifactorial assessment  Cataract surgery x1 for poor vision  Vitamin D 800 IU/day per USPSTF

Emergency Response Alert

Texting For Seniors

 BFF  FWIW  TTML  ROFLACGU

= Best Friend Fell = Forgot Where I Was = Talk To Me Louder = Rolling On Floor

Laughing And Can’t Get Up

His Fall Prevention Plan

 Refer PT  Change terazosin to tamsulosin  Vision 20/50  eye exam for cataracts  Reduce or stop sedating medications  Avoid diazepam (Valium) in elderly

 Fat soluble  half-life 4-5 days

 Avoid muscle relaxers (SOMA or Flexeril)

 Excess sedation >> minimal pain relief

• Mrs. Jones falls

 Falls going up step from garage to kitchen  Painful buttock hematoma, no head bleed  Daughter flies in from LA, reports she is

unsteady, confused, has urine odor

 80 yr 115 lb. 64 inches 19.7 BMI 108/55  Meds glyburide, oxybutynin, famotidine,

clonidine, digoxin 0.25mg, apixaban, alendronate creatinine 1.9 A1C 6.8

Precipitating causes of fall

 Rx acute illness (UTI ↓ functional reserve)  Check for orthostatic hypotension

 Supine vs standing up x3 minutes  Systolic ↓ 20 or diastolic ↓10 = abnormal  Elderly have less ability to increase pulse rate

 Accept less strict targets (DM, HTN)  Adjust drugs based on weight loss  Adjust drugs based on GFR

Age related drug changes

 Body mass ↓ Body water ↓ Body fat ↑  GFR ↓ Serum albumin ↓  Gastric absorption unchanged  Liver metabolism +/- decreased  Water soluble drugs: ↑ potent (digoxin)  Protein bound drugs: ↑ potent (phenytoin)  Fat soluble drugs: ↑ half-life (diazepam)

Avoid with low GFR

 Glyburide (GFR <60: hypoglycemia)  NSAIDs (<60: fluid retention / CHF, AKI)  Chlorpropamide (Diabenese) (<50: ↓ BS)  Bisphosphonates (<30-35: adynamic bone)  Septra (<30: hyperkalemia, AKI)  Nitrofurantoin (<30: ineffective for UTI)  Newer anticoagulants (<25-30: ↑ bleeding)

↓ Dose To Avoid CKD toxicity

 Gabapentin (GFR <60: sedation)  Famotidine (<50: delirium)  Digoxin (<50: delirium, anorexia)

 > 0.125mg/day almost always toxic in elderly

 Metformin (30-45: lactic acidosis)  Allopurinol (<30: hypersensitivity rash)  Simvastatin (<30: myopathy)

Her CKD medication changes

 Creatinine 1.9 = GFR 25  Stop her glyburide, accept A1C < 8 - 8.5  Prefer glipizide if oral agent needed  Stop digoxin 0.25mg, beta block instead  Change apixaban to warfarin  Stop alendronate  Stop famotidine, prefer PPI (but PPI →↓Ca,

↓Mg, ↓B12, ↓Fe, fracture, C diff, pneumonia)

Her cognitive evaluation

 Patient denies memory problems  MMSE 24/30 (recall 1/3) college educated  Never drove, husband is driver  Patient handles bills without problems  Too much pain to cook or do housework  Daughter helping to bathe due to pain  No tremor or rigidity, EOMI, gait antalgic

Dementia vs MCI

Dementia

 Cognitive impairment

 Short term memory  At least one other area

 Language  Visual spatial  Executive  Apraxia

 Worse than prior  Impaired function

Mild cognitive impairment

 Cognitive impairment  Intact function  Risk to progress to

Alzheimer’s:

 16% over 3 years

Neurology 2004;63(1):115.

Assessing Function

 IADLs: lost early

 Finances  Medications  Transportation  Housework  Shopping  Cooking  Using telephone

 Things you did when

you went to college

 ADLs: lost late

 Bathing  Dressing  Transferring  Feeding  Toileting  Continence

 Things you did to get

ready to come today

Her evaluation = MCI

 MMSE 24 < median for years of education

Education years 0-4 5-8 9-12 >12

 Age 70-74

21 26 28 29

 Age 75-79

21 26 27 28

 Age 80-84

19 25 26 28

 Age >=85

20 24 26 28

 No missed bills (at least none we know of)  Resumes ADLs as pain resolves

Mild Cognitive Impairment

Medicines That Cause Confusion

 Sedation

 Antidepressants  Antipsychotics  Antiemetics  Antihistamines  Opioids  Muscle relaxers  Benzodiazepines  Other sleeping pills

 Other

 Prednisone, digoxin  Central antiHTN drugs

 Anticholinergic

 Tricyclics  Antipsychotics  Antiemetics  H1 antihistamines

(Benadryl)

 H2 antihistamines

(Cimetidine)

 Oxybutynin (Ditropan)  Loperamide (Imodium)  Dicyclomine (Bentyl)

Avoid Anticholinergic Drugs

 Anticholinergic

 Diphenhydramine

(Benadryl)

 Cimetidine (Tagamet)  Amitriptyline (Elavil)  Loperamide (Imodium)  Promethazine

(Phenergan)

 Not Anticholinergic

 Fluticasone (Flonase)

Melatonin

 Omeprazole (Prilosec)  Citalopram (Celexa)  Bismuth (Kaopectate)  Ondansetron (Zofran) $

Medicines she should stop

 Risk of confusion from

 Famotidine  Clonidine  Digoxin  Oxybutynin

Hip Fracture

 Her daughter returns to town after she is

hospitalized for hip + vertebral fractures

 Severe postoperative pain on POD #1  Husband visits POD #2 morning, she is

withdrawn and not complaining

 Daughter visits POD #2 evening, she has

pulled out her IV and is disoriented and restless

Hip Fracture

 1 year outcomes:

 20% die  40% unable to walk independently  80% need help with 1+ ADL

 You consider teriparatide injections since

she fractured after taking bisphosphonates

 Nasal calcitonin may help vertebral

fracture pain during next 2 months

Pain Rx With Stage 4 CKD

 Oral NSAIDs and COX-2 contraindicated  Topical NSAIDs, oral acetaminophen ok  Toxic metabolites accumulate from:

 Morphine, oxycodone, codeine, meperidine

 Less risk from

 Tramadol, fentanyl, methadone,

hydromorphone, buprenorphine

 Reduce doses of gabapentin, pregabalin

Delirium Is Common

 Up to 50% hospitalized older patients  Up to 50% postoperative patients  Up to 60% nursing home patients  Up to 90% in ICU  Hyperactive (agitated) delirium is obvious  Hypoactive (withdrawn) delirium is just as

serious but is often not recognized

Delirium Risk Factors

 Older age  Male  Dementia  Prior delirium  Depression  Many medications  Many medical

problems

 Sensory impairment  Psychoactive drugs  Alcohol  Dehydration  Malnutrition  Functional

dependence

 Immobility

Confusion Assessment Method (CAM)

 Diagnose delirium in hospital based on:

 Acute onset, fluctuating course

and

 Inattention (distractible)

and

 Either one of these two:

 Disorganized thinking (rambling, illogical)  Altered level of consciousness (hyperalert/vigilant

• r drowsy/lethargic)

Delirium Evaluation

 Look for underlying causes

 Medications implicated in 40% of cases  Check CBC, chemistries, LFT, CXR, UA, EKG  CT not usually needed unless focal findings  Look for constipation, urinary retention  Not all cases will have an obvious cause

Delirium Management

 Treat underlying causes  Address dehydration, pain, infection  Reorientation, early mobilization  Maintain regular sleep hours  Use hearing aids, glasses  Use sitter, not restraints  Haloperidol if agitation prevents medical

care and endangers patient or others

Watch out for QTc interval

 Antipsychotics prolong QTc interval  Check baseline EKG first  Caution if combining haloperidol with:

 Amiodarone, sotalol, quinidine, flecainide  Fluconazole, ketoconazole  Fluoroquinolones (ciprofloxacin etc.)  Macrolides (azithromycin etc.)  Tricyclic > citalopram, fluoxetine  Methadone

After Her Fracture

 IV fentanyl (no toxic metabolites in CKD)  Fentanyl patch (fat soluble) is not effective

since she is cachectic

 Family visit with her during day  No vital signs checked at night  Cancel standard PRN Benadryl order  She develops “blister” on right heel and

redness on sacrum

Decubitus Ulcer Risk Factors

 Intrinsic

 Immobility  Immobility  Immobility  Malnutrition  Poor skin perfusion  Sensory loss

 Extrinsic

 Friction (skin rubbing

• r sliding against bed

surface)

 Shear (bone pulling

against tissues when lying still at inclined angle in bed)

 Incontinence/moisture

Decubitus Ulcer Stages

 Assign stage only after full extent is known  Stage 1 intact red skin  Stage 2 partial skin loss

 Wound base is red or pink

 Stage 3 into subcutaneous tissue

 Wound base may be red, white, yellow

 Stage 4 down to bone, tendon, or muscle  Unstageable: brown/black eschar visible

What Color Is Wound Base?

Stage 2 = Always red or pink Any other color = Stage 3 or worse

Her decubitus wounds

 Sacrum has Stage 1 intact red skin

 Change to air mattress  Turn every 2 hours to prevent tissue ischemia  Keep skin clean from urine or feces

 Heel has deep tissue injury

 Intact ecchymotic skin with boggy underlying

damaged tissue

 Heel tissue turns to black eschar later  Float heel so it does not touch the bed

Heel DTI  Unstageable 

Decubitus Ulcer Debridement

 Remove dead tissue to prevent infection

 Sharp debridement (with analgesia)  Enzymatic debridement with collagenase

• intment (Santyl)

 Autolytic debridement with hydrocolloid

(Duoderm) dressing in place for 3-7 days

 NOT wet to dry dressings (harmful / painful)

 Do not debride dry eschar on heel, or if

patient terminal not expected to survive

Further Cognitive Decline

 After 2 months in SNF her cognition has

declined further, MMSE 18/30

 She cannot remember PT exercises  Able to walk, dexterity good  Cannot coordinate dressing herself (ADL)  More confused and agitated later in day  Both dementia and delirium have impaired

recall and can have some fluctuations

Delirium vs. Dementia

Delirium Dementia Onset

Acute Insidious

Attention

Impaired Intact

Fluctuations

Prominent Less prominent

Prognosis

Transient Irreversible

Acuity

Emergency Chronic

Quote from Norman Wisdom

Dementia Differential Dx

 Rule out delirium or reversible causes

 Medication induced  Test labs for causes of delirium  Also check B12 and TSH  Test HIV, RPR only if other risk factors  CT imaging controversial but recommended

by American Academy of Neurology

 Other than medications and thyroid, most

“reversible” causes do not actually reverse

Dementia Causes

 Alzheimer’s most common: 70%

 Insidious ↓ language, memory, visualspatial

 Lewy Body second most common

 Parkinsonism, fluctuations, hallucinations

 Vascular dementia stepwise decline

 Often co-exists with Alzheimer’s

 Frontotemporal in younger patients

 Disinhibition, executive dysfunction

Dementia Progression

Early stage Late stage Alzheimer’s

Memory ↓ Gait ↓ Rigidity

Parkinson’s

Tremor Gait ↓ Rigidity Memory ↓

Lewy Body

Hallucinations Gait ↓ Rigidity Memory ↓

Dementia Care Plan

 Help with ADLs  Provide safe supervised environment  Simplify communication and instructions  Avoid sedatives and anticholinergics  Treat vascular risk factors  Caregiver support  Medications of only modest benefit

Dementia Medications

 Acetylcholinesterase inhibitors

 Donepezil (Aricept), rivastigmine, galantamine  Increase acetylcholine in synapses  Opposite of anticholinergic (ie, oxybutynin)  Side effects nausea, diarrhea, anorexia,

incontinence, bradycardia, syncope

 NMDA receptor blocker

 Memantine (Namenda) for moderate to

severe dementia

Agitation in Dementia

 Satisfy hunger, thirst  Treat constipation, bladder retention  Address overstimulation, understimulation  Assume presence of pain based on

pathology (i.e., if you would sense pain)

 Empiric analgesic trial (even opioids)  Antipsychotics (older and newer) increase

mortality in dementia J Amer Geriatr Soc 2002;50:S205-S240

Husband at home

 Daughter is worried that Mr. Jones is

developing dementia

 He quit driving to see wife at SNF  Complains of headache and fatigue  MMSE 24/30, some “don’t know” answers  Denies sad mood  No alcohol

Depression in Elderly

 More common when isolated, dependent,

with illness, pain, or cognitive impairment

 Anhedonia > sad mood in elderly  Somatic complaints common, may overlap

with symptoms of other diseases

 Minor (subsyndromal) depression has

similar consequences as major depression

 Older white men at highest risk for suicide

His Evaluation

 Endorses little interest or pleasure  Geriatric Depression Scale positive for

boredom, helplessness, worthlessness

 Encourage socialization (Senior Center)  Offer counseling  SSRI usually first choice (few side effects)  Mirtazapine good for insomnia/anorexia

Conclusions:

Keeping Up With Mr. & Mrs. Jones

 Functional status reflects changes in

medical conditions

 Impairments in mobility and cognition

require more coordination of care

 Older patients take more medications and

are often at risk for side effects

 Accommodating for chronic illness

improves QOL as primary goal for elderly

Geriatrics Board Review

daniel.pound@ucsf.edu

Dan is het altijd goed