Objectives Objectives 1. Define vulnerabilities prevalent among 1. - PowerPoint PPT Presentation

2/25/2017 What Can Geriatrics Teach Us About the Care of Vulnerable Patients? I have nothing to disclose Anna Chodos MD Assistant Professor Director, ZSFG Geriatrics Consult Clinics These slides heavily adapted from Helen UCSF February 25, 2017 Kao, MD. (CME Talk 2016) Objectives Objectives 1. Define vulnerabilities prevalent among 1. Define vulnerabilities prevalent among older adults older adults 2. Describe the role of geriatrics in the care 2. Describe the role of geriatrics in the care of complex and vulnerable patients of complex and vulnerable patients 3. Identify lessons from geriatrics which 3. Identify lessons from geriatrics which improve health outcomes for vulnerable improve health outcomes for vulnerable patients patients 1

2/25/2017 Snapshot: Older adults in U.S. Snapshot: Health of Older Adults • Older adult population is rapidly growing • Among people age 75+: 20% had 10/more visits to a health care professional in past • Adults who reach age 65 now have a life 12 mo (13% for 45-64 yo) expectancy of ~19 more years • Most have at least 1 chronic condition • 48% of older adults are economically vulnerable (income <2x supplemental • 39% take >5 meds poverty level) • Older Americans spent 13.4% of their total • Thin social networks: 46% of women 75+ expenditures on health, as compared with live alone 8% among all consumers. US Administration on Aging 2014 data US Administration on Aging 2014 data Vulnerabilities among older adults What care do they need? This image cannot currently be displayed. • High degree of chronic • At risk for abuse, neglect, and being taken • Most adults are unprepared for disability advantage of conditions and caregiving needs as they age • Physical disability increases with age • Greater proportion of • Many assume that Medicare will take care • Cognitive disability as high as 50% in adults physical disabilities and of their social care needs should they lose >85 cognitive impairment their independence– wrong! • Need caregiving • Require significant • Medical-Legal movement to encourage • Carry large burden of informal caregiving (incr caregiving comprehensive advance care planning- mortality risk) e.g. inclusion of financial and long-term Freedman V et al., "Trends in Late-Life Activity Limitations in care planning (prepare for incapacity ) the United States: An Update From Five National Surveys," Demography 49, no. 4 (2012) Acierno, Am J Public Health, 2010 100(2), 292-297. King DE et al. JAMA Internal Medicine , online Feb. 4, 2013 Wiglesworth, Journal of the American Geriatrics Society, 2010; 58 (3), 493-500 Schulz, JAMA. 1999;282(23):2215-9. http://www.geripal.org/2013/01/the-need-for-medical-legal-dialogue-in.html 2

2/25/2017 Vulnerable Elders Survey (VES-13) What is important to older adults? • Physical Health Survey developed by RAND (2001) to identify vulnerable older adults • Cognitive Abilities, “Memory” • Maintaining Mental Health Vulnerable for what? • Independence • Score of 4+ => 4X the risk of death or • Function functional decline in next 2 years • Quality of Life 2015 United States of Aging Survey Saliba, S, Elliott M, Rubenstein LA, Solomon DH, et al. Journal of the American Geriatric Society 2001; 49:1691-9 Geriatrics and Care of Vulnerable Objectives Older Adults 1. Define vulnerabilities prevalent among older adults Social 2. Describe the role of geriatrics in the care of complex and vulnerable patients 3. Identify lessons from geriatrics which Legal Medical improve health outcomes for vulnerable patients 3

2/25/2017 EXTRA CASE EXTRA CASE • Mr. O is a 76 yo M who • In talking to friend separately, he says he presents with a friend who has concerns: says he’s his main caregiver. – Thinks his son has taken ownership of his home and is neglecting him. • He has no complaints. – Every time they see each other. Mr. O asks to • Takes his medicines (“you get food right away. have the list”). • Lives with his son • Evaluation: undiagnosed cognitive impairment • Clothes are somewhat dirty. • Elder abuse- had already had an attorney • Adult Protective Services report Objectives Medical care is half of the work. . . Much like for other vulnerable populations: 1. Define vulnerabilities prevalent among older adults • Quality-metrics and evidence-based care are competent, not excellent 2. Describe the role of geriatrics in the care of complex and vulnerable patients For patients with the most complexity 3. Identify lessons from geriatrics which • The best care is, at most, 50% medical. . . improve health outcomes for and 50% everything else vulnerable patients • Lessons to be learned from caregivers, nurses, social workers, psychotherapists, pharmacists, rehab specialists, and others 4

2/25/2017 Lesson 1: Medical care is not the same EXTRA Case as health care • Ms. C is a 91yo woman with late stage dementia • DIL is her main caregiver • She is pleasant but very impaired • Active issues: herpes outbreak, skin lesion on arm and ear, rash on trunk, dry skin Lesson 2: Help families help patients EXTRA Case For Ms. C: • Medical care -> creams, biopsies • Health care -> caregiver assessment and support, dementia-focused care plan, patient’s goals, interdisciplinary team 5

2/25/2017 EXTRA Case EXTRA Case • Ms. C: How is she doing in her • Caregiver assessment environment? – Talked to DIL alone – Falls -> ordered home evaluation and home – Overwhelmed, no breaks, many other people PT/OT for falls relying on her (adult children, husband) – Dep in Function -> gave caregiver resources for education, consider other caregivers • Caregiver support – Poor appetite x months -> speech/swallow, – Support groups, resources medication review, taste, teeth – Respite (day programs, SNF stays) Lesson 3: Med review is a window into Medication biopsy a patient’s entire situation Aspirin 81mg daily • Polypharmacy; potential interactions or adverse effects Aricept 5mg daily Clotrimizole topical • Potentially inappropriate medications Acyclovir 200mg 5x/day Nystatin • Health literacy Acetaminophen 1gm TID • Cognitive impairment Citalopram 10mg daily Travapost gtt • Financial struggles Metoprolol 50mg ½ tab daily Timolol gtt • Manual/swallowing difficulties Meclizine PRN • Vision trouble Vitamin D 1000 units daily • Disorganized/inadequate care oversight • Uncoordinated care amongst clinicians 6

2/25/2017 Lesson 4: Less is more EXTRA Case • Up at night- should I prescribe a sleeping pill? – Why is she getting up? – How important is it that she sleep all night? • Poor appetite- should I prescribe an appetite stimulant? – Is she losing weight? • What is the least harmful approach I can take? Lesson 6: Dementia, dementia, Lesson 5: Screen for and Address Common Health and Social Vulnerabilities dementia = archetype • Given its high prevalence, this should be For older adults, e.g.: routinely assessed for and addressed • Cognitive Screening • Falls Screening • Mobility Impairment • Dementia “behaviors” occur in ~100% of • Hearing and Vision Impairment patients with dementia • Oral Health – Nonpharmacologic approaches are first line • Inappropriate Medications – Educating caregivers (or helping them find • Abuse education/training) is #1-10 of management • Financial strain • Caregiver burden 7

2/25/2017 Describe Dementia Behaviors Types of neuropsychiatric sx • Apathy, depression, or dysphoria What is the behavior (describe it exactly): • Anxiety, worry, shadowing • Easily upset • Wandering, rummaging (repetitive activity) • Repetitive questions Agitated • Night behaviors (waking/getting up) • Arguing or complaining • Irritability or lability • Hoarding • Disinhibition (social/sexual behavior) • Pacing • Delusions (distressing beliefs) • Inappropriate screaming, crying, sounds • Hallucinations (visual, auditory, etc) • Rejection of care • Aggression/violent outbursts • Leaving home Determine if they are causing a Determine what underlies behavior problem Could the behavior be • Toileting needs a way to • Depression or • What has been tried to modify the communicate about a anxiety behavior? basic need or • Overstimulation emotion? • Loneliness or social • Does the behavior result in a problem or • Pain isolation hazard for anyone? • Hot or cold • Hunger or thirst Cohen-Mansfield and Werner 1999; Meares and Draper 1999; Hallberg et al 1993; 8