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

2/25/2017 1

What Can Geriatrics Teach Us About the Care of Vulnerable Patients?

Anna Chodos MD Assistant Professor Director, ZSFG Geriatrics Consult Clinics UCSF February 25, 2017

I have nothing to disclose These slides heavily adapted from Helen Kao, MD. (CME Talk 2016)

Objectives

• 1. Define vulnerabilities prevalent among
• lder adults
• 2. Describe the role of geriatrics in the care
• f complex and vulnerable patients
• 3. Identify lessons from geriatrics which

improve health outcomes for vulnerable patients

Objectives

• 1. Define vulnerabilities prevalent among
• lder adults
• 2. Describe the role of geriatrics in the care
• f complex and vulnerable patients
• 3. Identify lessons from geriatrics which

improve health outcomes for vulnerable patients

2/25/2017 2

Snapshot: Older adults in U.S.

• Older adult population is rapidly growing
• Adults who reach age 65 now have a life

expectancy of ~19 more years

• 48% of older adults are economically

vulnerable (income <2x supplemental poverty level)

• Thin social networks: 46% of women 75+

live alone

US Administration on Aging 2014 data

Snapshot: Health of Older Adults

• Among people age 75+: 20% had 10/more

visits to a health care professional in past 12 mo (13% for 45-64 yo)

• Most have at least 1 chronic condition
• 39% take >5 meds
• Older Americans spent 13.4% of their total

expenditures on health, as compared with 8% among all consumers.

US Administration on Aging 2014 data

• High degree of chronic

conditions

• Greater proportion of

physical disabilities and cognitive impairment

• Require significant

caregiving

Freedman V et al., "Trends in Late-Life Activity Limitations in the United States: An Update From Five National Surveys," Demography 49, no. 4 (2012) King DE et al. JAMA Internal Medicine, online Feb. 4, 2013

Vulnerabilities among older adults

• At risk for abuse, neglect, and being taken

advantage of

• Physical disability increases with age
• Cognitive disability as high as 50% in adults

>85

• Need caregiving
• Carry large burden of informal caregiving (incr

mortality risk)

Acierno, Am J Public Health, 2010 100(2), 292-297. Wiglesworth, Journal of the American Geriatrics Society, 2010; 58 (3), 493-500 Schulz, JAMA. 1999;282(23):2215-9.

What care do they need?

• Most adults are unprepared for disability

and caregiving needs as they age

• Many assume that Medicare will take care
• f their social care needs should they lose

their independence– wrong!

• Medical-Legal movement to encourage

comprehensive advance care planning- e.g. inclusion of financial and long-term care planning (prepare for incapacity)

http://www.geripal.org/2013/01/the-need-for-medical-legal-dialogue-in.html

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What is important to older adults?

• Physical Health
• Cognitive Abilities, “Memory”
• Maintaining Mental Health
• Independence
• Function
• Quality of Life

2015 United States of Aging Survey

Vulnerable Elders Survey (VES-13)

Survey developed by RAND (2001) to identify vulnerable older adults Vulnerable for what?

• Score of 4+ => 4X the risk of death or

functional decline in next 2 years

Saliba, S, Elliott M, Rubenstein LA, Solomon DH, et al. Journal of the American Geriatric Society 2001; 49:1691-9

Objectives

• 1. Define vulnerabilities prevalent among
• lder adults
• 2. Describe the role of geriatrics in the

care of complex and vulnerable patients

• 3. Identify lessons from geriatrics which

improve health outcomes for vulnerable patients

Geriatrics and Care of Vulnerable Older Adults

Social Medical Legal

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EXTRA CASE

• Mr. O is a 76 yo M who

presents with a friend who says he’s his main caregiver.

• He has no complaints.
• Takes his medicines (“you

have the list”).

• Lives with his son
• Clothes are somewhat dirty.

EXTRA CASE

• In talking to friend separately, he says he

has concerns:

– Thinks his son has taken ownership of his home and is neglecting him. – Every time they see each other. Mr. O asks to get food right away.

• Evaluation: undiagnosed cognitive impairment
• Elder abuse- had already had an attorney
• Adult Protective Services report

Medical care is half of the work. . .

Much like for other vulnerable populations:

• Quality-metrics and evidence-based care

are competent, not excellent For patients with the most complexity

• The best care is, at most, 50% medical. . .

and 50% everything else

• Lessons to be learned from caregivers,

nurses, social workers, psychotherapists, pharmacists, rehab specialists, and others

Objectives

• 1. Define vulnerabilities prevalent among
• lder adults
• 2. Describe the role of geriatrics in the care
• f complex and vulnerable patients
• 3. Identify lessons from geriatrics which

improve health outcomes for vulnerable patients

2/25/2017 5

EXTRA Case

• 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
• n arm and ear, rash on trunk, dry skin

Lesson 1: Medical care is not the same as health care

EXTRA Case

For Ms. C:

• Medical care -> creams, biopsies
• Health care -> caregiver assessment and

support, dementia-focused care plan, patient’s goals, interdisciplinary team

Lesson 2: Help families help patients

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EXTRA Case

• Ms. C: How is she doing in her

environment?

– Falls -> ordered home evaluation and home PT/OT for falls – Dep in Function -> gave caregiver resources for education, consider other caregivers – Poor appetite x months -> speech/swallow, medication review, taste, teeth

EXTRA Case

• Caregiver assessment

– Talked to DIL alone – Overwhelmed, no breaks, many other people relying on her (adult children, husband)

• Caregiver support

– Support groups, resources – Respite (day programs, SNF stays)

Lesson 3: Med review is a window into a patient’s entire situation

• Polypharmacy; potential interactions or adverse effects
• Potentially inappropriate medications
• Health literacy
• Cognitive impairment
• Financial struggles
• Manual/swallowing difficulties
• Vision trouble
• Disorganized/inadequate care oversight
• Uncoordinated care amongst clinicians

Medication biopsy

Aspirin 81mg daily Aricept 5mg daily Acyclovir 200mg 5x/day Acetaminophen 1gm TID Citalopram 10mg daily Metoprolol 50mg ½ tab daily Meclizine PRN Vitamin D 1000 units daily Clotrimizole topical Nystatin Travapost gtt Timolol gtt

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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 5: Screen for and Address Common Health and Social Vulnerabilities

For older adults, e.g.:

• Cognitive Screening
• Falls Screening
• Mobility Impairment
• Hearing and Vision Impairment
• Oral Health
• Inappropriate Medications
• Abuse
• Financial strain
• Caregiver burden

Lesson 6: Dementia, dementia, dementia = archetype

• Given its high prevalence, this should be

routinely assessed for and addressed

• Dementia “behaviors” occur in ~100% of

patients with dementia

– Nonpharmacologic approaches are first line – Educating caregivers (or helping them find education/training) is #1-10 of management

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Describe Dementia Behaviors

Agitated What is the behavior (describe it exactly):

• Easily upset
• Repetitive questions
• Arguing or complaining
• Hoarding
• Pacing
• Inappropriate screaming, crying, sounds
• Rejection of care
• Leaving home

Types of neuropsychiatric sx

• Apathy, depression, or dysphoria
• Anxiety, worry, shadowing
• Wandering, rummaging (repetitive activity)
• Night behaviors (waking/getting up)
• Irritability or lability
• Disinhibition (social/sexual behavior)
• Delusions (distressing beliefs)
• Hallucinations (visual, auditory, etc)
• Aggression/violent outbursts

Determine what underlies behavior

Could the behavior be a way to communicate about a basic need or emotion?

• Pain
• Hot or cold
• Hunger or thirst
• Toileting needs
• Depression or

anxiety

• Overstimulation
• Loneliness or social

isolation

Cohen-Mansfield and Werner 1999; Meares and Draper 1999; Hallberg et al 1993;

Determine if they are causing a problem

• What has been tried to modify the

behavior?

• Does the behavior result in a problem or

hazard for anyone?

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Address the behavior: trial & error

• Trying to work with the person with

dementia will require trial and error

• And SKILL (caregivers need training to

deal with this!)

Antipsychotic Epidemic

• 1 in 3 nursing home residents and 1 in 7

community-dwelling adults with dementia are prescribed antipsychotics

• 41% of nursing home veterans who were

given antipsychotics had no evidence- based indication

Gellad et al. Med Care 2012 GAO Antipsychotic Drugs and Older Adults 2012

CATIE-AD: antipsychotic v placebo

• CATIE-AD RCT study: 421 outpatients
• Risperdal, quetiapine, olanzapine, placebo*
• Ave tx length 7 wks (due to adverse effects)
• Risperdal (1mg) > olanz (5mg) > quet (50mg)

for paranoia/hostility/aggression/ mistrust, psychosis

• No change in function or care needs
• Olanz worse withdrawn depression, ADL

function

Sultzer DL et al. Am J Psych 2008

Risks of Antipsychotics

• 1.5-1.7x increased risk of mortality
• 2-3x increased stroke risk
• CV and metabolic effects (obesity, glucose)
• Extrapyramidal symptoms
• Worsening cognition
• Falls
• Hospitalizations

Schneider et al JAMA 2005; Trifiro et al Pharmacol Res 2009; Schneider et al. Am J Ger Psych 2006; Schneider et al NEJM 2006; Gurwitz et al. Am J Med 2005; Rochon et al. Arch Int Med 2008

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Translating risk

• NNH – risk of death occurs as early as <6mo

Maust et al. JAMA Psychiatry 2015; GAO Antipsychotic Drug Use, Jan 2015

Lesson 7: There are many ways in medicine to “save a life” EXTRA Case

2 years later, DIL brings Ms. C in and in tears describes how she regularly accuses her of inappropriate behavior

• > Referred to respite

asap, referred DIL to BH

Lesson 8: Change behavior to fix behavior

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EXTRA Case

• Ms. C’s behaviors continue to be very
• challenging. Accusing family, DIL of

strange behaviors, lashing out, refusing to

• eat. How do we improve their lives?

In summary

• Our population is aging
• With age comes increasing physical and

cognitive vulnerabilities

• Socioeconomic challenges from growing

care needs

• Dementia patients in particular are highly

vulnerable to medical misadventures and exhausting care resources

Lessons from Geriatrics

• 1. Medical care is not the same as health care
• 2. Help families help patients
• 3. Med review is a window into a patient’s

entire situation

• 4. Less is more
• 5. Screen for and Address Common Health and

Social Vulnerabilities

• 6. Dementia, dementia, dementia
• 7. There are many ways in medicine to “save a life”
• 8. Change behavior to fix behavior

Thank you Many thanks to Helen.kao@ucsf.edu