Geriatric Medicine

1. Geriatric Medicine A very, very brief update – With a bit about interface ALI Alsawaf – Consultant Geriatrician, IHT

2. What to cover • Polypharmacy • AF in the elderly • Anticoagulation • Constipation • When to investigate • Interface Geriatrics • Hot clinic

3. POLYPHARMACY1 • Medication is the commonest medical intervention • 80% of over 75s are on prescription medication • 36% of which are on four or more • Patients on more medications suffer more side effects, regardless of age • Most guidelines focus on starting treatment, not stopping it • Medication review is part of primary care work • Geriatricians review medication at every occasion

4. Effects of Polypharmacy • Falls • Increased side effect profile (including biochemical imbalance) • Cognitive decline/delirium • Increased hospital admissions • Increased pill burden = increased care

5. Why? • Changes in pharmacokinetics and pharmacodynamics in old age, eg renal clearance, 1st pass metabolism • Change in normal physiology, eg autonomic dysfunction • Absence of the initial indication for the prescription (eg bereavement and antidepressants/sedatives) • Concomitant acute illness (eg D&V with CCF treatment) • Risk of improper adherence and accidental drug errors

6. At what point do we consider “Polypharmacy” • Appropriate Polypharmacy vs Inappropriate • Independent 80 year old with Diabetes (tablets and insulin), previous TIA x 2,CAS, IHD, and hypertension • 85 year old RH resident with Parkinson’s Disease, CCF, hypertension and hypercholesterolaemia • Frail 80 year old NH resident with Alzheimer’s Dementia, Diabetes (tablets and insulin), previous disabling stroke, CAS, MI, angina, and hypertension

7. When to stop? • Falls • Delirium • Cognitive impairment • End of Life • Extreme age/frailty

8. EVIDENCE2 • Most research is around falls, with clear reduction of risk when medications rationalised • Reducing polypharmacy improved cognition • No research in extreme age/frail nor End of Life • Could be controversial (eg Warfarin, insulin)

9. Making it Safe and Sound • King’s fund report • Suggests“Rather than attending several disease-specific clinics, patients could have all their long-term conditions reviewed in one visit by a clinical team responsible for coordinating their care. Patients with multi-morbidity admitted to hospital under one specialty may require access to a generalist clinician to co-ordinate their overall care.” “This may require training and development of more ‘generalists’ skilled in the complexity of multiple disease alongside training to manage polypharmacy.”

10. Develop even more guidelines for multimorbidity • Reduce pill burden • Patient involvement is key (but no mention of capacity-impaired patients)

11. Polypharmacy Guidance • NHS Scotland, 2012 • Mentions “Geriatricians” • Overall better guidance • British Geriatric Society support • Clear advice

12. Cochrane Review • Interventions for preventing falls in older people living in the community • Medication review by primary care physician reduced risk of falls

13. What to stop • Is there a valid indication, and is the dose correct?(e.g. long-term amitryptilline, PPIs, antidepressants, opiates) • Secondary prevention (e.g. statins in extreme age, multiple antihypertensives) • Consider side effects and interactions (difficult) • Drug effectiveness in that patient group (e.g. bisphosphonates in extreme old age) • High risk combinations, e.g. warfarin and duel antiplatelets, NSAIDS • Always involve patient/family/carer with decision and its rationale

15. What NOT to stop longterm(seek advice) • Essential replacement drugs (egThyroxine) • Drugs keeping symptoms under control (e.g. CCF treatment, COPD, long-term steroids) • Parkinson’s Disease medications • Antiepileptics (if used for epilepsy control) • DMARDs • Antipsychotics/depressants in severe mental illness. • Amiodarone

16. In Summary • Polypharmacy is not easy • Multiple co-morbidities • Multiple factors to consider • Please contact us for advice (more on how later)

17. Atrial Fibrillation • Prevalence increases with age • Well-known increased risk of thromboembolic cerebrovascular disease • Rate vs Rhythm • Rate control acceptable for over 65s • No increase in mortality (from cardiovascular complications)

18. Investigate (FBC/U&E/LFT/TFT), CXR • ECHO not required unless murmur clinically or CCF • Rate control if HR > 100 • Use betablockers (egBisoprololas highly cardio-selective) if patient active (gardening, walking) • Use digoxin if less/not active (eg limited mobility, house or bed bound)

19. Digoxin has much less side effect profile than betablockers • But not good at controlling heart rate in activity • Avoid Calcium-channel blockers (negative inotropics, reduce BP) • Start low, go slow

20. Anticoagulation • All types of AF are at higher risk of stroke • Anticoagulation should be considered in all patients • Consider: falls risk (a fall a day!), pros vs cons (patient engagement with INR, bleeding history and risk, compliance and risk of mistakes) • Remember NOACs are now available (second line) • Aspirin is better than nothing (if not suitable for AC)

21. NOACS • Apibaxan, Dabigatran, Rivaroxaban • Do not require INR monitoring • All licensed for thromboembolic prevention in AF • All non-inferior to Warfarin • All have same bleeding risk as Wafarin, except Dabigatran (increased GI bleed)

22. Renal function-dependent (unlike Warfarin) • Reversibility unknown yet, but shorter half-life • Rivaroxaban only one suited for MDS and can be crushed

23. WHEN TO START? • Warfarin remains first-line treatment • Consider NOAC if Warfarin not tolerated (mostly INR monitoring, or dose compliance) • Bleeding risk maybe less • Follow local guidelines (checklists for GP available)

24. CONSTIPATION • Infrequent bowel emptying • Hard stools • Difficulty passing motion (straining) • Feeling of incomplete evacuation

25. Slow transit… • Reduced physical activity • Poor oral intake • Medications (opiates, anti-cholinergics, and many more) • Many secondary causes (neurological, obstruction, metabolic etc)

26. In the elderly • 40% of older people in the community • 60-80% of those in long-term care • More than 50% of nursing home residents are on regular laxatives

27. Common cause of medical admissions • Usually because of secondary effects: • Delirium Falls • Urinary Retention • Abdominal pain/vomiting • Overflow diarrhoea

28. CAN BE FATAL! • Vomiting + aspiration pneumonia • Perforation • Delirium  Falls  Fractures

29. HISTORY • Bowel / stool history • Urinary symptoms • Daily fluid intake • Caffeine intake • Diet / Fibre • Red flag symptoms

30. RED FLAGS • Anaemia • Rectal bleeding • Positive faecal occult blood test • Family history of bowel cancer or IBD • Tenesmus • Weight loss

31. Investigations • Bloods: FBC, U&E, Bone Profile, TSH • Urine dipstick • Refer for endoscopy if red flag symptoms

32. Digital Rectal Examination • MUST be done if possible • Both constipation and diarrhoea/incontinence • Looking for: • Fistulas • Resting and active tone • Mass • Faecal loading and its consistency (hard/soft)

33. Stool consistency • If it’s hard – soften it • If it’s soft – stimulate it

34. TREATMENT • Treat cause if possible (polypharmacy?) • Initially: education, diet and lifestyle measures • Softeners: Movicol, Lactulose, Phosphate • Stimulants: Senna, Docusate, Bisacodyl, Glycerine

35. INVESTIGATIONS IN THE ELDERLY • Common question to department • Main principles: • Can the patient tolerate the proposed investigation? • Will it make a difference to their management? • Will it make a difference to their wellbeing? • OR • Will it help with prognostication/future planning • Any other benefit (eg financial, insurance)

36. Points to consider • General state of health (co-morbidities) • Frailty • Functional baseline • Mental baseline

37. Patient and family engagement essential • Both in decisions to actively investigate or not • Clear explanation of implications of decision • Can be revisited in future

38. If patient lacks capacity, best interest decision • Must involve next of kin • Difficult decisions • Please contact us for advice

39. INTERFACE GERIATRICS • Many definitions, BGS “Harmonious combination of hospital and community geriatric care” • Core idea: break down the barrier between Hospital and the rest of the community

40. Older person in crisis • Various “rescue” plans: crisis teams (self-referral, GP), community matrons, GPs, emergency placement, community “step-up” hospitals, IHT. • A patient can move between a number of this during one episode

41. Lots of assessments (mainly therapy) • Duplication of work • Delayed (or no) specialist medical assessment which can delay correct diagnosis and management • Potential crisis avoidance ideally, or at least anticipation

42. CGA • Ideally, a Comprehensive Geriatric Assessment should be performed as soon as possible • Geriatrician involved throughout, not just when too late • Requires full team, not just a doctor

43. Borders • Lots of imaginary borders exist • Example: Hospital and GP. GP and community team. Hospital and community team. Acute and Rehab hospitals • Paperwork is varied, doesn’t capture everything • Patient at the centre of all this

44. Aims • Interface Geriatricians aim to smooth this process • Break down borders • Improve patient’s care and journey from primary to secondary careand back • Assess promptly, utilising available community and hospital services/expertise • Admission avoidance

45. What we currently provide • MDT leadership across all three community hospitals • Comprehensive Geriatric Assessment of in-patients. Both “step up” and “step down” • Liaison with IHT to improve patient care and “solve problems” • Access to IHT IT system (eVolve, Pathlab) to improve patient’s care

46. Community Team Reviews • Working with community and crisis teams • Discussing patients, identifying those that may benefit from a CGA • Reviewing patients in a community setting (clinic, domiciliary or care home visit)

47. HOT CLINIC • 2 hours a day of instant access to Consultant Geriatrician and diagnostics • Set up as part of first Interface Geriatrician appointment • GP can refer patients directly via EAU consultant (bleep 620)

48. Service started November 2013 • Still running • No direct GP referrals received to date

49. REINVETING THE HOT CLINIC • We will provide 9-5 access to Consultant Geriatrician directly • Mobile phone • Available to all GPs, Community Matrons, Community Therapy Teams

50. TO PROVIDE… • Verbal advice and support • Urgent review of patients (same or next day), i.e. Hot Clinic • Less urgent review at all the locations we visit: • Ipswich • Aldeburgh • Stowmarket • Hadleigh • Hartismere (Eye)