Top 10 Ways to Help Geriatric Patients'

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Top 10Ways to Help Geriatric Patients.

• CDR Carol L. Blackwood
• MC, USN

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10Immunizations

• Routine Immunizations
• Flu shot annual
• Td q 10yrs
• Pneumovax once, repeat in 5yrs if first shot at
  lt65yrs age, immuno-suppressed, asplenic or
  chronic renal failure.
• New ImmunizationZoster
• Recently recommended by the CDCs, committee,
  The Advisory Committee on Immunization Practices
  (ACIP), for age gt60yrs.
• (Must be kept frozen, and thawed immediately
  prior to injection.)

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9CAD Primary Prevention / HTN

• Routinely screen males gt34yrs and women gt44yrs
  for lipids and tx disorders USPSTF (A)
• Howeverlooking closer at the evidence,
• There is no evidence that primary tx of lipids is
  of benefit to geriatric patients.

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9CAD Primary Prevention

• West of Scotland Coronary Prevention Study Group
  (WOSCOPS), excluded pts gt65yr at enrollment.
• Air Force/Texas Coronary Atherosclerosis
  Prevention Study had median age men57 and
  women62.
• Anglo-Scandinavian Cardiac Outcomes Trial-Lipid
  Lowering Arm, cut off age 60yrs.

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9CAD Primary Prevention

• Only large preventative study that included
  geriatric participants is PROspective Study of
  Pravastatin in the Elderly at Risk (PROSPER).
• Participants 70-82yrs, 3,239 in primary
  prevention group (56).
• No statistical significance in non-fatal MI,
  CHD-related death or stroke.

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9CAD Primary Prevention / HTN

• Fair evidence exists to measure routine BP in
  patients 65 - 84 yrs. CTFPHC (B)
• Insufficient evidence exists to include or
  exclude pharmacologic treatment of hypertension
  in patients gt84 yrs (sys or diastolic). CTFPHC
  (C) . A cautious, individualized approach is
  recommended.
• Insufficient evidence exists to include or
  exclude pharmacologic treatment of hypertension
  in patients aged 65 - 84 yrs with systolic BPs of
  140 to 160 and diastolic BPs lt90 mmHg or in
  patients gt70 years of age with diastolic BPs lt 90
  and systolic BPs lt160 mmHg CTFPHC (C).

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9HTN

• gt84yrs No evidence to support tx BP
• 65-84yrs Treat if above 160 and 90. /-
  140-160 and lt90
• Less than 65yrs, treat HTN
• Canadian Task Force for Preventive Health Care (C)

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8Vitamin B12 Deficency

• Pts often can be symptomatic even though their
  cyanocobalamin level is normal via lab criteria.
• Methylmalonic Acid is more sensitive, but also an
  expensive test.
• If a pt has neurologic/hematologic symptoms,
  recommended to start tx if B12 level is below
  500.
• Oral tx with is at least as effective as IM.
  (Cochrane) Limited evidence may indicate achieves
  replacement faster than IM B12.

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7Cognitive Impairment

• Dementia is defined as when cognitive impairment
  is significant enough to have social impairment.
• Routine screening for dementia is not recommended
  USPSTF (I) and CTFPHC (C) .
• However, When caregivers or informants describe
  cognitive decline in an individual, these
  observations should be taken very seriously
  cognitive assessment and careful follow-up are
  indicated USPSTF (A).
• Common family complaints are related to
  medication compliance issues, difficulty with
  finances, getting lost driving, forgetfullness,
  etc.

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7Cognitive Impairment

• MMSE is good screening test for people who speak
  English and have at least 12 grade education.
• Alternatively- clock drawing, or fact test (name
  as many flowers, cities, or animals as possible
  in a minute (normal is 10 or more without
  repeating).

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Clock Test 1110
Not so good!
Pretty good
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6Vitamin D

• Vitamin D cutaneous production affected by
• time of day
• season
• latitude
• skin tone (6 fold difference)
• Geriatric patients often have little sun exposure
  and low consumption/ absorption of Vit D
  fortified foods.
• 25-hydroxyvitamin D (gt30ng/ml optimal) is most
  accurate lab test to assess reserves.

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6 Vitamin D

• Vitamin D is vital for
• Muscle strength (loss of grip strength and
  increased body sway occur with deficency).
• Bone metabolism
• Supplementation in range of 800 units day reduces
  falls, and fractures. (Cochrane recommends
  supplementation to reduce falls)
• Adequate levels decrease risk of DM and metabolic
  syndrome.

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6 Vitamin D

• Vitamin D is also associated with
• Decreased risk of Multiple Sclerosis
• Decreased incidence of breast, colon and prostate
  CA!!
• Decreased incidence of MI
• Improved BP
• Better psoriasis control (when topically applied)

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6Vitamin D

• 12 women and 13 men over age 60 will have
  osteoporotic fx. High morbidity.
• Supplementation with approx 800 units a day
  reduces hip fx by 26 and non-vertebral fx 23 in
  elderly gt60yrs.
• NOTE No reductions seen in group taking 400
  units/day.

Bishchoff-Ferrari HA, et al. 2004 JAMA
2911999-2006
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6 Vitamin D

• Vit D Supplementation dosing 600-1,000 units
  daily.
• Available in small doses in MVI, Fosamax plus
  D, mixed with calcium, etc.
• Vit D Deficency dosing 5-10,000 units po daily
  50,000 units po/IM for 1-5 months

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5- Medications

• BEERS list. Medications that can have severe
  adverse outcomes in the elderly patients.
• 1997, updated 2002.
• http//www.dcri.duke.edu/ccge/curtis/beers.html
• (Nice summary with links for patient education
  on individual drugs)
• http//archinte.ama-assn.org/cgi/content/full/163/
  22/2716SEC2
• (Actual article with lists)

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5BEERS List
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5BEERS List-by diagnosis
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5Medications Highlights

• Use of H2 blockers although cheap, have high
  potential for negative effects Sedative effects
  predispose patients to falls and fractures! Use
  Proton Pump Inhibitors.
• Anti-cholingergic meds (Ditropan, etc.), may make
  dementia worse, and cancel effects of Aricept,
  Excelon, etc.

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5Medications Highlights

• Difficult to diagnose pain with severe dementia
  (may express as aggitation). Tx with scheduled
  meds.
• Scheduled acetaminophen 1000mg tid -first line.
• Ultram, Celebrex, morphine and oxycodone, 2nd and
  3rd line.
• No Ds (Darvocet, Demerol, Darvon).
• Start bowel regime with initiation of narcotics
  (stool softener and stimulant (MOM or senna).

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4Falls

• More than one third of adults 65 and older fall
  each year (Hornbrook et al. 1994 Hausdorff et
  al. 2001).
• Of those who fall, 20 to 30 suffer moderate to
  severe injuries that make it hard to get around
  or live alone and increase the chance of early
  death (Alexander et al. 1992).
• Older adults are hospitalized for fall-related
  injuries five times more often than they are for
  injuries from other causes (Alexander et al.
  1992).

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4Falls

• Fractures were both the most common and most
  costly type of nonfatal injuries. Just over one
  third of nonfatal injuries were fractures, but
  they made up 61 of costsor 12 billion (Stevens
  et al. 2006).
• Fall Complications
• 50 result in no injury
• 30 associated with mild-mod soft tissue injury
• 20 require prompt medical attention
• 5 result in fractures (hip, wrist, humerus, rib)
• 50 of hip fx patients, never fully recover
• 10-20 lead to nursing home placement

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4 Falls Multi-factorial Causes

• Balance
• Gait
• Vision
• Orthostasis
• Depression
• Cognitive Impairment

• Psychoactive Meds
• Use of 4 or more Rx meds
• Arthritis
• Muscle strength

Multi-factoral intervention for elderly can be
effective to reduce falls. USPSTF (B) AGS
recommends multi-factoral assessment of patients
with hx of more than 1 fall in previous year.
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3Anemia

• Very common in elderly. Approx 1/3 due to
  deficiency (iron, B12 and rarely folate), 1/3 due
  to chronic dx, and 1/3 unidentified cause.
• Although common, anemia is not normal and it is
  an independent risk factor of future harm.
• All cause mortality increases when Hct is lt30.
• Falls are twice as common with anemia
• Heart failure worsens with anemia

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3Anemia

• Minimum evaluation CBC, ferritin, TIBC, iron,
  B12
• Tx deficiencies if present.
• Do not use more than 325mg ferrous sulfate daily.
  
• Consider erythropoieten (with iron supplement) if
  chronic disease cause.
• Short term 1-3mo trial of po iron if not sure if
  anemia of iron deficency, chronic dz or mixed.
• Long term iron can have multiple side effects
  in geriatric patients.

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2 Saints Triad and Hickams Dictum

• Osler-popularized concept of parsimony in
  diagnosis. Works well in patients limited number
  of underlying diseases.
• Both Saint and Hickam believed a patient can
  have as many diagnoses as he darn well pleases
• In geriatrics, there are often many diseases
  which act synergistically to cause common
  syndromes.

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2 Common Geriatric SyndromesUniversity of
South Carolina-2006

• Dementia
• Delirium
• Urinary Incontinence
• Osteoporosis

• Falls/Gait Disorders
• Decubitus Ulcers
• Sleep Disorders
• Failure to Thrive

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2 Common Geriatric Syndromes

• Orthostatic HTN
• Cataracts
• Diabetes
• Dementia
• Arthritis

• Falls
• Incontinence
• Medications
• Compliance/side effects
• Failure to thrive

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1Do No Harm

• In the elderly, the combination of a high burden
  of competing risks and high rates of
  treatment-related complications conspires to
  reduce the net benefit of numerous interventions.

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1Do No Harm

• In other words
• More than any other patient population, geriatric
  patients are more prone to suffer negative
  effects from our well meaning interventions (both
  screening and treatments).
• Potential gain in life span/quality of life from
  intervention, must clearly exceed potential harm.

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1Estimating Male Physiologic Age
Self Reported Health Status
Excellent
Good
Fair
Poor
Chronologic Age
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Many thanks to the faculty and staff of the

• East Carolina University
• Brody School of Medicine
• Geriatrics Division

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References

• Agency for Healthcare Research and Quality
  Clinical Guidelines and Evidence Reports (AHRQ)
• Center for Disease Control (CDC)
• Osteoporosis Australia Foundation
• Canadian Task Force on Preventive Health Care
  (CTFPHC)
• Cochrane Reviews

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References

• Alexander BH, Rivara FP, Wolf ME. The cost and
  frequency of hospitalization for fall-related
  injuries in older adults. American Journal of
  Public Health 199282(7)10203.Hausdorff JM,
  Rios DA, Edelber HK. Gait variability and fall
  risk in community-living older adults a 1-year
  prospective study. Archives of Physical Medicine
  and Rehabilitation 200182(8)10506.Stevens
  JA, Corso PS, Finkelstein EA, Miller TR. The
  costs of fatal and nonfatal falls among older
  adults. Injury Prevention 2006122905.