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Pre workshop Survey Please complete our short survey at: www.gerimedrisk.com/cgs2018 Forging collaboration and improving access to geriatrics with eConsult: A WORKSHOP FOR CLINICIANS WHO ARE ALL ALONE 2018 CGS ASM "ADVANCES IN CARE:
Please complete our short survey at:
www.gerimedrisk.com/cgs2018
A WORKSHOP FOR CLINICIANS WHO ARE “ALL ALONE” 2018 CGS ASM "ADVANCES IN CARE: FROM PATIENT TO TECHNOLOGY“ APRIL 19‐21, 2018, MONTREAL, QUEBEC
Chair: Joanne Ho List of Speakers:
Centre, Dept. of Family Medicine, University of Ottawa
and Geriatric psychiatry) ‐ McMaster University/Grand River Hospital
To demonstrate how eConsult can enhance capacity in geriatric clinical pharmacology and psychiatry, and interdisciplinary collaboration.
health care system
prescribing and prevent drug interactions among seniors
prescribing for complex cases of older adults with mental health and multimorbidity.
Link to results: https://www.surveymonkey.com/results/SM‐FXH5WBS8L/
Forging Collaboration and Improving Access to Geriatrics with eConsult: A Workshop for Clinicians who are “All Alone”
Associate Professor and Clinical Investigator, C.T. Lamont Primary Health Care Research Centre, Dept. of Family Medicine, University of Ottawa April 20, 2018
YOU ARE NOT ALONE!
Faculty: Joanne Ho, Sophiya Benjamin and Jennifer Tung Relationships with commercial interests:
This program has received no financial support. This program has received no in‐kind support.
Potential for conflict(s) of interest:
CFPC CoI Templates: Slide 2
n/a
CFPC CoI Templates: Slide 3
McMaster University Faculty: Joanne Ho, Sophiya Benjamin Schlegel Research Institute for Aging: Joanne Ho (Clinical Scientist) Grand River Hospital (Kitchener, ON): Joanne Ho, Sophiya Benjamin, Jennifer Tung Canadian Coalition for Seniors’ Mental Health Clinical Guideline Working Groups: Joanne Ho (Benzodiazepine), Jennifer Tung (Alcohol) : Joanne Ho, Sophiya Benjamin, Jennifer Tung, Clare Liddy GeriMedRisk‐an interdisciplinary telemedicine geriatric clinical pharmacology and psychiatry consultation service that uses eConsult (BASE and OTN).
GeriMedRisk is supported by non‐profit health care organizations
Aging, St. Joseph’s Health Centre Guelph, Ontario Telemedicine Network, Ontario Poison Centre, Regional Geriatric Program Central
Geriatric Program Central, Ontario Medical Association, Schlegel Centre for Learning Research and Innovation in LTC
Disney
Disney
Increased mortality Increased morbidity
Wu et al Drugs and Aging 2009 Budnitz NEJM 2011 Morgan CMAJ Open 2016
Old Once!” 1986
National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS–CADES) project Budnitz et al NEJM 2011
department visits/year 2007‐2009 among adults >=65 years.
years old
Top Offenders
agents
agents
inhibitors
agents Wu et al Drugs and Aging 2009 Budnitz NEJM 2011 Morgan CMAJ Open 2016
Inci Incidence dence and and Econom
Burden en of
Adverse Dr Drug ug Re Reactions among among Elderly Elderly Patien tients ts in in Onta ntario Emer Emergency ncy Depar Departmen ments
Wu et al 2012
The Senior with Multimorbidity
Patient
Pharmacy Primary Care
Gastroenterologist
Nephrologist Cardiologist
Psychiatrist
Who’s talking to Whom About Medications?
Patient
Pharmacy Primary Care Gastroenterologist Nephrologist Cardiologist Psychiatrist
What is the need for geriatric pharmacology expertise among clinicians caring for older adults in the Waterloo Wellington Region?
and homecare
pharmacotherapy
professions.
Geriatric Pharmacotherapy Needs Assessment
GeriMedRisk is an interdisciplinary telemedicine geriatric clinical pharmacology consultation service for clinicians
psychiatry, Clinical pharmacology, Pharmacogenomics (as needed)
Primary care 34% Long Term Care 47% Acute care 15% Outpatient Specialist Care 4%
Pilot Consult Origin
“Without the [GeriMedRisk] recommendation I would still be on too many medications … It’s a great service and I would recommend it highly to anybody”. Senior Feedback, Waterloo, ON It totally is an excellent example of collaborative care. GeriMedRisk is extremely valuable in my eyes ‐ totally helpful! Family were happy with the care and outcome. Thanks so much for your help! Family Physician, Waterloo, ON
Waterloo Wellington pilot‐ 8 months, 3 LTC, 10% primary care (n=144)
# Prevented Cost Savings to System Hospitalizations (acute and mental health) 6 $110,028.00 In‐person consultations 3 specialities geri pharm/psych/med/clin pharm 20 $12,816.00 2 specialities geri pharm + psych or med or clin pharm 78 $28,009.00 CIHI acute medical 2004‐2005 MOHLTC mental health 2015‐2016
3 additional consults generated as a result of GMR consults
500 1000 1500 2000 2500 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17
Cumulative # of Clinicians
Events
COMPLEX CASES‐MAKE YOUR TEAM
eConsult: I have a frail 91 yr old with depression and chronic renal failure (Creatinine is 195, eGFR 19) and I would like to start her on an anti‐depressant, but would like your opinion on which one to choose.
decreased kidney function.
PMHX Nonvalvular A. fib HTN CKD (Cr 195 eGFR 19) essential tremor
OA Spinal stenosis GI bleed MEDICATIONS
ASA 81 mg po daily Amiodarone 100 mg po daily Vit D 1000 IU po daily L‐thyroxine 0.0125 mg po daily Pantoprazole Mg 40 mg po daily Propanolol 20 mg po daily APAP 650 mg q6h prn Oxazepam 30 mg po qhs prn Metrogel 1% top prn Nifedipine XL 60 mg po daily Lactulose 15 cc po daily
Amitriptyline 2%, gabapentin 6%, ketamine 10%, baclofen 2%, lidocaine 5%, clonidine 0.2%, ketoprofen 5% topical TID to legs PRN (pharmacy)
PMHX
HTN CKD (Cr 195 eGFR 19) essential tremor
OA Spinal stenosis ED visits for falls MEDICATIONS
ASA 81 mg po daily Amiodarone 100 mg po daily Vit D 1000 IU po daily L‐thyroxine 0.0125 mg po daily Pantoprazole Mg 40 mg po daily Propanolol 20 mg po daily APAP 650 mg q6h prn Oxazepam 30 mg po qhs prn Metrogel 1% top prn Nifedipine XL 60 mg po daily Lactulose 15 cc po daily
Amitriptyline 2%, gabapentin 6%, ketamine 10%, baclofen 2%, lidocaine 5%, clonidine 0.2%, ketoprofen 5% topical TID to legs PRN
(pharmacy)
12 Distinct Meds Every day: 2 creams ~17 pills
Medication Intolerances/Allergies: (MD and pharmacy)
What would you do?
PMHX
HTN CKD (Cr 195 eGFR 19) essential tremor
OA Spinal stenosis ED visits for falls MEDICATIONS
ASA 81 mg po daily Amiodarone 100 mg po daily Vit D 1000 IU po daily L‐thyroxine 0.0125 mg po daily Pantoprazole Mg 40 mg po daily Propanolol 20 mg po daily APAP 650 mg q6h prn Oxazepam 30 mg po qhs prn Metrogel 1% top prn Nifedipine XL 60 mg po daily Lactulose 15 cc po daily
Amitriptyline 2%, gabapentin 6%, ketamine 10%, baclofen 2%, lidocaine 5%, clonidine 0.2%, ketoprofen 5% topical
TID to legs PRN (pharmacy)
12 Distinct Meds Every day: 2 creams ~17 pills
Primary Care
GeriMedRisk Pharmacist Called pharmacy to get medication records.
Geriatrics/Clin Pharmacology Afib, hypertension, essential tremor, optic neuritis, OA, CRF, Spinal stenosis, falls
e‐consult
24‐48 hrs
Geriatric Psychiatry Depression Insomnia CRF
Patient
91 yr old with depression and chronic renal failure
Geriatric Psychiatry Geriatric Pharmacy/Clinical Pharmacology
and establish baseline ‐ PHQ9, GDS, MoCA (rule out cognitive impairment) ‐Labs (electrolytes, TSH, CBC, B12) ‐propanolol
contraindications, dosages, monitoring)
‐Amiodarone (CYP isoenzymes and PgP)
‐Amiodarone (thyroid, tremor, peripheral neuropathy,
‐Propanolol (cognition)
function
bleed (Amio + warfarin)
parkinsonism)
in pt with renal disease.
Amiodarone inhibits P‐glycoprotein aripiprazole CYP 1A2 (nifedipine‐minor) CYP 2D6 propanolol, sertraline, aripiprazole, active metabolite of trazodone (mCPP) CYP 3A4 oxazepam, sertraline, nifedipine, aripiprazole, trazodone (to active metabolite) CYP 2C9 sertraline, warfarin Stay tuned for the clinical tools section
Response within 5 business days Coordinated eConsult within 14 business days ‐geriatric pharmacy, geriatric psychiatry and geriatric clinical pharmacology Feedback Thank you very much for the in‐depth response. I have learned a lot. Much appreciated.
eConsult from LHIN 13 80 yr old lady with worsening hallucinations. Question: Can fentanyl cause her symptoms?
Primary care
GeriMedRisk Pharmacist
Geriatrics/Clin Pharmacology Fentanyl related psychosis? Falls, loss of function
OTN e‐consult 1‐2 Follow Ups
24‐48 hrs Geriatric Psychiatry Psychosis Change in behavior
Patient
OUR MODEL
2013 New onset hallucinations
hallucinations followed Progressed to hearing conversations verbatim
cameras that were watching her
becomes lethargic
symptoms
Fentanyl 50 mcg/hour Q 3 days Met Methot
rimepr mepraz azine 20 20 mg mg at at bedtim bedtime Venlafaxine 150 mg daily Atorvastatin 40 mg daily Hydromorphone 1 mg twice daily Lansoprazole 30 mg twice daily Sennosides 8.6 mg twice daily Lorazepam 0.5‐1 mg as needed Acetaminophen Up to 5g/day Diclofenac (Voltaren Emulgel) (slathering all
Fibromyalgia since 1995 Migraines; Insomnia Bilateral carotid artery stenosis 50‐70% 2015 Hypertension; Chronic kidney disease GERD; IBS; Diverticulitis Eczema; Psoriasis; Anemia (normocytic); MGUS ?Acetaminophen overuse Upwards of 10 ES/day according to daughter ?Diclofenac (voltaren) gel overuse Will slather
flare, as per daughter
What are some of the differential diagnoses applicable to this patient How might you manage this case if you are her family physician What might be some of the barriers for someone like this patient receiving care in your community
Unwillingness to see psychiatrist/ hospital due to poor insight Family physicians may not be familiar with or comfortable switching older antipsychotics and long acting injections May not be able to access care until significant deterioration, hospitalization and involuntary treatment Long Wait Times
Barua, B. (2015). Waiting your turn: 2015 Report. Fraser Institute
Early onset schizophrenia Late onset Schizophrenia 40‐60 Very late onset schizophrenia like psychosis (VLOSP) Delusional disorder
Feature Early‐onset schizophrenia Late‐onset schizophrenia VLOSP Female preponderance – + ++ Negative symptoms ++ + – Learning ++ + ?++ Retention – – ?++ Progressive cognitive deterioration – – ++ Brain abnormalities (strokes, tumors) – – ++ Family history of schizophrenia + + – Daily neuroleptic dose ++ + + Risk of tardive dyskinesia + + ++
Palmer BW, McClure FS, Jeste DV: Schizophrenia in late life: findings challenge traditional concepts. Harv Rev Psychiatry 9(2):51–58, 2001:Schizophrenia Spectrum and Other Psychotic Disorders Maglione Jeanne E., Vahia Ipsit V., and Jeste Dilip V. The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. March 2015
Feature Psychosis of AD Schizophrenia Prevalence 35%–50% of AD patients < 1% of population Bizarre or complex delusions Rare Frequent Misidentification of caregivers Frequent Rare Common form of hallucinations Visual Auditory Schneiderian first‐rank symptoms Rare Frequent Active suicidal ideation Rare Frequent Past history of psychosis Rare Very common Eventual remission of psychosis Frequent Uncommon Need for maintenance of antipsychotic Uncommon Very common
Schizophrenia Spectrum and Other Psychotic Disorders Maglione Jeanne E., Vahia Ipsit V., and Jeste Dilip V. The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. March 2015
Di Diagnosis: agnosis: Ve Very La Late Onset Onset Schi hizophr phreni nia Lik Like Psyc Psychosis (V (VLOSP) Trea eatm tmen ent: t: An Antip tipsychotics, tics, usual usually at atypical due due to to lo lower risk risk of
tard rdive dy dysk skin inesia ia Doses Doses usual usually muc much lo lower than than used used in in young ung onse
t, chr chronic schiz schizophr phrenia nia (25 (25‐ 50%) 50%)
commendat ations:
Cross
taper fr from Met Methotr
meprazi azine to to Aripip Aripiprazole le
Aim fo for dose dose ar around 10 10‐15 15 mg mg
Warned about about ak akathisia sia and and other
pertinen inent si side de eff effects
Other issues ssues addr addressed: essed: Sleep, eep, pai pain and and opi
s, Ty Tylenol and and NS NSAID AID to toxici city
Similar to Chlorpromazine (phenothiazines), low potency antipsychotic Affinity for binding to alpha 1, 5HT‐2 receptors, alpha 2 and antagonistic at dopaminergic‐receptors (subtypes D1,D2, D3 and D4), serotonergic‐receptors (5‐HT1 and 5‐HT2),histaminergic‐receptors, α1/α2‐receptors and muscarinic M1/M2‐receptors. More hypotension and more dizziness compared to other antipsychotics. Can be given subcutaneously. Used in palliative care. No the most appropriate first line medication for VLOSP.
Sivaraman P, Rattehalli RD, Jayaram MB. Levomepromazine for schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD007779
Opportunity to provide clear audit trail Consent – implied but good to inform Who is the MRP ? PCP
Continues to hold care and responsibility for decision making Closing consult and moving documents to medical record
Liability considerations for specialist
eConsult (just like phonecall, email) can create duty of care Penny vs Crawford https://www.ontariomd.ca/documents/econsult/cmpa%20assessment%20of%20econsult%20v4.pdf
Duty of care
Primarily with PCP Can extend to specialist
Standards of care
PCP must be able to give relevant details Specialists should decline if there is insufficient information or if you need to perform a physical exam.
Privacy Licensing
CMPA publication: Is that eConsultation or eReferral service right for your medical practice? (September 2017)
Encouraged me to learn with every consult Increased my capacity to think about medical issues for my own patients Helped me understand the kinds of questions that can be answered via e consults and those that can’t
DRUGBANK.CA / PHARMGKB CREDIBLEMEDS.ORG / ANTICHOLINERGIC BURDEN CALCULATOR THROMBOSIS CANADA / DIABETES CANADA
Online database of detailed drug data and drug target information 11,000 + drug entries Information including:
Online tool with 10 different anticholinergic burden scales Currently under development and validation
Pharmacogenomic knowledge resource Clinically actionable gene‐drug associations and genotype‐phenotype relationships Tools
& TdP risk
Formerly, Thrombosis Interest Group of Canada Tools
Tools
system
interactions among seniors
team members from CGS!
Pharmacists
Accessible through:
Primary care
GeriMedRisk Pharmacist
Geriatrics/Clin Pharmacology
OTN e‐consult 1‐2 Follow Ups
24‐48 hrs Geriatric Psychiatry
Patient
OUR MODEL
Primary care physician Poisoning concern
GeriMedRisk Pharmacist
Case review (Information from MD, Clinical connect, Clinician Portal, Caseworks CMHA) Geriatrics/Clin Pharmacology Issues identified: ?Poisoning, Tinnitus, Tachycardia, Schizoaffective disorder, Cognition
OTN e‐consult
1‐2 Follow Ups 24‐48 hrs
Geriatric Psychiatry Schizophrenia Cognition
Patient
POISONING
Setting Outpatient, Within LHIN Existing barriers to care Patient would not agree to see a psychiatrist Community Partners and intersecting systems including EMR GeriMedRisk, Clinical Connect, CMHA Resolution Supporting primary care physician in the care of complex patient with psychiatric and medical comorbidities
Primary Care (Thornhill)
GeriMedRisk Pharmacist Called pharmacy to get medication records.
Geriatrics/Clin Pharmacology Afib, hypertention, essential tremor, optic neuritis, OA, CRF, Spinal stenosis, falls
OTN e‐consult
24‐48 hrs
Geriatric Psychiatry Depression Insomnia CRF
Patient
Frail 91 yr old with depression and chronic renal failure
Setting Outpatient, Out of LHIN Existing barriers to care Frailty and difficulty attending multiple specialist appointments Community Partners and intersecting systems including EMR GeriMedRisk, CMHA, OTN eConsults Resolution Supporting primary care physician in the care of complex patient with psychiatric and medical comorbidities Feedback: Thank you very much for the in‐ depth response. I have learned a lot. Much appreciated.
Long Term Care
GeriMedRisk Pharmacist
Geriatrics/Clin Pharmacology Pain (on opiates) Constipation, Bone health RLS
Telephone/Fax consult
24‐48 hrs
Geriatric Psychiatry Schizophrenia Tardive Dyskinesia ?Restless Leg syndrome (on pramipexole)
Patient
One patient, many settings
Setting Long Term Care, recently discharged from St. Mary’s, Seen by S. Benjamin in COTT, seen by Dr. Ho at St. Mary’s Community Partners and intersecting systems including EMR GeriMedRisk, CMHA, Behavioral Services Ontario, Clinical connect, Poinclickcare Resolution Medication recommendations send to primary care physician who has implemented almost all recommendations.
COTT (Outpatient) Retirement home
Long Term Care
within 2‐5 business days
materials
Primary care 34% Long Term Care 47% Acute care 15% Outpatient Specialist Care 4%
Consult Origin
The Senior with Multimorbidity and Mental Illness
Patient
Pharmacy Primary Care
Gastroenterologist
Nephrologist Cardiologist
Psychiatrist
Who’s talking to Whom About Medications?
Patient
Pharmacy Primary Care Gastroenterologist Nephrologist Cardiologist Psychiatrist
Patient
Pharmacist
Primary Care
GastroenterologistNephrologist
Cardiologist
Psychiatrist
10 20 30 40
Clin Pharm Geri Psych Geri Pharm Both Clin Pharm & Geri Psych
Services Provided
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Dementia BPSD Delirium Mental health rug adverse effects Deprescribing Polypharmacy Bone health Other
Consult Topics
Patient
Acute
Primary Care
Community
200 400 600 800 1000 1200 1400 1600
Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17
Cumulative # of Clinicians
Date
Educational Rounds (Acute Hospital)
Invitation to Improve Perioperative Standardized Hospital Order Sets for Seniors with Hip Fractures (Impact 300 Seniors/year) “Without the [GeriMedRisk] recommendation I would still be on too many medications … It’s a great service and I would recommend it highly to anybody”. Senior Feedback, Waterloo, ON It totally is an excellent example of collaborative care. GeriMedRisk is extremely valuable in my eyes ‐ totally helpful! Family were happy with the care and outcome. Thanks so much for your help! Family Physician, Waterloo, ON