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To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement

To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement. Daniel Bluestein, MD, MS, CMD Sabine M. von Preyss-Friedman, MD, CMD Ashkan Javaheri, MD, CMD Irene Hamrick, MD. Learning Objectives:. By the end of the session, participants will be able to:

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To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement

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  1. To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement Daniel Bluestein, MD, MS, CMD Sabine M. von Preyss-Friedman, MD, CMD Ashkan Javaheri, MD, CMD Irene Hamrick, MD

  2. Learning Objectives: By the end of the session, participants will be able to: • Articulate a framework for evaluation of weight loss, urinary tract infection, depression, & osteoporosis. • Summarize evidence for the pros and cons of double-sided therapeutic options regarding these entities. • Examine potential quality improvement opportunities in relation to these entities. • Discuss how the interdisciplinary team can be engaged in this process.

  3. QI Caveats • Understand variation: Example; My trip from EVMS to WC • Is variation in rates within statistical limits? • Or did the process change? • Techniques for doing this beyond scope of this talk • Recc workshop by Matt Wayne & Len Gelman at national meeting • Understand the process • Flow charts • Fishbone diagrams • Pareto charts • MOST IMPORTANT • Brainstorm w stakeholders • Don’t rush to judgment (or blame)

  4. Weight loss Daniel Bluestein, MD, MS, CMD, AGSF Professor & Director, Geriatrics Division Department of Family & Community Medicine Eastern Virginia Medical School

  5. Case • On day on rounds, The team leader on 1-A tells me Ms. X has lost 7 lb. over the past month (she’s 109 years old). • She shows you the dietician progress notes that Mirtazapine be considered • Or if not Mirtazapine, then Megace or Marinol

  6. My responses (a Parody of Kluber-Ross) • Denial- • Is this for real • Anger- • How could you all be so dumb • Bargaining- • If I put Ms. X on something, maybe they will shut up & leave me alone • Depression- • I need to go somewhere else • Adaptation- • Maybe I can make this better

  7. E/M: Like some relationships “It’s complicated” Rx-able

  8. E/M Overview • Identify & anticipate at-risk pts (“SNAQ”) • Are weights accurate? • Is this fluid loss? • Vomiting & diarrhea • Diuretics • Osmotic losses (hyperglycemia) • Inadequate access • Physiologic effects of aging • How much food is he/she taking in? • Consider interventional strategies • Condition specific • Generic • Dietary supplements • Ambience/Assistance/Appeal • Activity & exercise • Drugs

  9. Diseases- Hypermetabolic Thyroid Pheochromocytoma Diabetes Wasting Cancers Collagen/vascular infections COPD ESRD Chronic infections Pressure ulcers Depression Dementia Digestive Diarrhea Dysphagia Other GI Dysgeusia Dentition Drugs etoh Deficiency states Dysfunction Distasteful Diets Don’t know Contributors: “the Ds” Huffman. Am Fam Physician 2002;65:640-50

  10. The Ds in LTC • Depression • Drugs • Dysfunctions • Dependent on others to feed (staff turnover, understaffed) • Isolation/poor ambience • Dysmobility • Dysphasia • Dental/Oral • Dementia/agitation/sedation • Diseases-wounds, COPD, CHF… • Distasteful Diets • Deficiencies • Don’t know Tamura et al. JAMDA 2013; 14(9):649-55 Aoyama et al. JAMDA 2005; 6:566-72

  11. Common Sense Treatment • Treat underlying disease. • Endocrine, drug, GI disorder, depression most amenable. • Functional • Dental care/dentures-oral hygiene • OT/PT/Speech/swallowing eval’ns • Hearing aides & glasses • Facilitate Bowel function • Exercise even in frail elders • Dietary • Ambience • Assistance • Small, frequent meals • Taste facilitators

  12. Supplements-conflicting evidence • Some studies show 1-2 kg gains in supplement group vs. 1 kg loss in controls • Small sample sizes • 60 day f/u • No real changes in functional status • Others: supplements substitute for meals, caloric intake the same • Should use between meals, not with • Cochrane (2009): • Small increase wt • Small mortality reduction • Morley et al. JAMDA 2010; 11: 391–6, varied JAMDA editorials • More sanguine about leucine-containing supplements in concert with exercise

  13. Drugs • Mirtazapine- • small wt gain –up to 7% at best • ? any better than other antidepressants • ? Effect in non-depressed • Hyponatremia, sedation, orthostasis, serotonin syndrome • Megestrol Acetate • Yeh et al RCT: 4 lbwt gain @ 25 wks; no mortality difference • DVT, CHF, Adrenal suppression, ↑mortality, large C/C study • Dronabinol • Mostly small studies: 5-10 ib gain at best • MI, delirium, death • http://www.uptodate.com/contents/geriatric-nutrition-nutritional-issues-in-older-adults?source=see_link&anchor=H20#H20

  14. What I did • Read up on Dx & Rx of wt loss • Went on “weight & wounds rounds” a few times • (Usually on a Tuesday AM when I can’t easily attend) • Some findings: • Lack of real knowledge • Good intentions • External pressure • Organizational culture; other priorities • NO PROCESS • They are really not used to a hands-on medical director

  15. My intervention • Educate & inform • Develop & implement a rational, step-wise policy, Elements: • Screen for nutrrisk -SNAQ or tool of your choice • When someone triggers on wt loss: • Med review for new meds • PHQ 2/9 • Note to provider to assess for other treatable causes as appropriate in keeping with prognosis & philosophy of care • Implement of non pharmacological interventions • Reassess & consider • Further evaluation on occasion • Risk/benefit ratio of drugs • In process: Goal: • 1o: documentation this process has been followed • 2o: stabilization/improvement

  16. It remains to be seen… Whether this (& other QI measures discussed today) improve care remains an open question at this time.

  17. To Treat Or Not To Treat: How Clinical Conundrums Become Opportunities For QIUrinary Tract Infection or Asymptomatic Bacteriuria? Sabine von Preyss-Friedman MD, CMD Associate Clinical Professor, Division of Gerontology and Geriatric Medicine, University of Washington

  18. Asymptomatic Bacteruria • Prevalence (without catheters) • 25-50% for women • 15-40% for men. • Prevalence (with Catheters)-100% • Treatment does not improve outcomes • Consequence: Frequent, unnecessary Abx • Cost • Resistance • C Diff • Adverse effects • Drug Interactions (cipro-coumadin) • Inadvertentnephrotoxic doses (flouroquinolones, nitrofurantion) • Missed the real problem Nicolle LE. Int J Antimicrob Agents. 1999

  19. On the other hand…. • Non specific presentation of serious infection • Dubious (or no) history in cognitive impairment • True UTI & Urosepsis are alive & well • Symptomatic UTI: 0.1-2.4 episodes/1000 resident days (variation due to differences in definitions). • Systemic infection: 0.49-1.04/10,000 noncatheterized-resident days.

  20. Problem, continued • Serious complications from infections • Death from potentially treatable cause • Transfers • Functional decline • LTC: • More limited diagnostic resources • Telephone medicine (e.g. “empirical” abx)

  21. Grey areas • The febrile patient with a positive U/A or culture & no other focus: • Only 10% of such patients show rise in serum antibodies to infecting urinary pathogens. • Corollaries: • Look hard for other reasons for fever • Consider other studies such as a CBC • Fever + hematuria does point more to UTI • The patient who is acting “differently” • Typically more advanced dementia, can’t give History • Lots of other reasons to consider • If UTI the cause, will have fever • Treatment? Guidelines would say no.

  22. How are Practitioners making decisions? • 19 MDs, 3 PAs, 41 nurses. • 5 most common triggers for suspect UTI, noncatheterized pts. • change in mental status (90%), • fever (76%), • change in voiding pattern (70%), • dysuria (65%), • Change in character of urine (59%) • MDs, PAs significantly less likely to know or apply diagnostic criteria. • 55% would treat asymptomatic bacteruria • Nurses more likely to urge treating asymptomatic bacteruria • See nonspecific changes in status as “symptoms” • Juthani-Mehta et al. JAGS, 2005.

  23. Why Antibiotic Overuse? • Lack of up to date Medical Education • Ingrained beliefs of Medical Providers, Nursing, patients, families • Geropsychiatry ”Due Diligence” • Fear of rapid deterioration and poor outcomes in frail elderly who have bacterial infection

  24. Prior Criteria less than helpful • 2013 study of Loeb criteria (data collected 2011) • Often disregarded • Even when taking into account, did not curb antibiotic use • Olsho et al. JAMDA 2013; 14(4):309 e1-e7.

  25. New McGeer Criteria, 2012 • Fever Definition • A single oral temperature greater than37.8°C (100°F) or • Repeated oral temperatures greater than37.2°C(99°F)or rectal temperaturesgreaterthan37.5°C (99.5°F)or • A single temperature greater than 1.1°C(2°F) over baseline from any site. • Acute functional decline in activities of daily living (ADLs) • A new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence) Bed mobility,   Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene, Eating • Use of CAM to define acute change in mental status • Re. UTI-reliance on cx w appropriate symptom combination (either alone is inconclusive)

  26. UTI (No Indwelling Foley), Criterion 1,Need Both: • At least one of the following s/s: • Acute dysuria or acute pain, swelling, or tenderness of testes, epididymis, or prostate in men • Fever or increased WBC and ONE of the following: • Acute costovertebral pain or tenderness • Suprapubic pain • Gross hematuria • New or increased incontinence • New or increased urgency • New or increased frequency • No fever or increased WBC and TWO from the above list!

  27. Criterion 2. One of the following microbiologic subcriteria: • At least 100,000 cfu/mL of no more than 2 species of microorganisms in a voided urine sample. • At least 100 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter

  28. UTI with foley For residents with an indwelling catheter (both criteria 1 and 2 must be present): Criteria1 (at least 1 of the following signs/symptoms): • Fever, rigors, or new-onset hypotension, with no alternate site of infection. • Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis. • New-onset suprapubic pain or costovertebral angle pain or tenderness. • Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate

  29. With foley, continued Criteria 2. Urinary catheter specimen culture with at least: • 100,000 cfu/mL of any organism(s). • Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are c/w UTI but are not necessary for diagnosis. • Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 d).

  30. interventions • Inservices about UTI vs. ASB to nursing staff • Medical Director provides attending physicians with literature and personal education and discussion • Medical Director inservices psychiatric consultants • “MD compare” • Protocols based on McGeer Criteria for when it is appropriate to order a U/A

  31. Alternatives to Rx for grey areas • Examples: • Isolated voiding symptoms, • increased incontinence, • change in urine odor, • change in behavior… • Watchful waiting for 24 hours • No u/a or c/s • Hydrate • Perineal hygiene • Address constipation • Attend to comfort • Q 8 VS • Evaluate for UTI if go on fulfill criteria • Look for alternatives if sx persist

  32. It remains to be seen… • We still lack a convincing marker for UTI vs. colonization in advanced dementia. • Sx to meet minimum criteria for UTI frequently absent in NH residents w advanced dementia. • Abx are prescribed for the majority of suspected UTIs that do not meet these minimum criteria • D’Agata et al. JAGS 2013; 61(1):62-6

  33. To treat or not to treat:How Clinical Conundrums become Opportunities for Quality Improvement Depression Ashkan Javaheri, MD, CMD Assistant Clinical Professor- UC Davis School of Medicine Geriatric Division and Senior Care Program Division Head Mercy Medical Group Sacramento, CA

  34. Overview • Prevalent • Treatable • Often under-recognized

  35. Chronic Medical Illness and Depression • Stroke 30 to 60 % • Coronary heart disease 8 to 44 % • Cancer up to to 40 % • Parkinson’s disease 40 % • Alzheimer’s disease 20 to 40 % • Boswell  EB, Stoudemire  A.  Major depression in the primary care setting.  Am J Med.  1996;101:3S–9S

  36. Consequences • Decreased quality of life • Decreased participation in activities • Falls • Malnutrition • Dehydration • Increased risk of intercurrent infections • Behavioral symptoms • Agitation • Rejection of care

  37. Suicide • Elderly 13% of US population; 24% of completed suicides • Less often; more likely successful • Elderly men highest suicide rate: 28.9/ 100,000. • Yes it can happen in LTC

  38. Trends-LTC (1999-2007) • Diagnosis of depression and antidepressant therapy in residents diagnosed increased rapidly. • By 2007, 51.8% of residents diagnosed with depression, 82.8% of whom received an antidepressant. • Gaboda D et al. JAGS 2011; 59:673–680

  39. Underuse/ Overuse • 3692 LT residents in 133 VA facilities • 877 depressed • 25.4 % did not get treatment underuse • 57.5% potential inappropriate use • drug-drug and drug-disease interactions • 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants • Hanlon JT - J Am Geriatr Soc 2011

  40. Not as safe as we once thought • SSRI safer than older drugs, still first choice • SSRIs have side effects; • Falls, • hip fracture, • insomnia, • hyponatremia • GI bleeding, • worsen RLS, • serotonin syndrome

  41. Evidence Base • Available evidence offers weak support to the contention that antidepressants are an effective treatment for patients with depression and dementia and at best moderateevidence in non demented patients. • It is not that antidepressants are necessarily ineffective but there is not much evidence to support their efficacy either. • Given that they may produce serious side-effects clinicians should prescribe with due caution. • Cochrane Database Syst Rev.2002 • Hanlon et al, J Am Med DirAssoc 2012 • Boyce et al, J Am Med DirAssoc 2012

  42. Why-depression a mixed bag • Medical causes • Major Depression • Minor Depression (or Subsyndromal) • Dysthymia • Bereavement • Vascular Depression • Psychotic Depression • Depression in AD • Thakur M, Blazer D, J Am Med Dir Assoc 2008

  43. Medical conditions associated with depression symptoms • Uncontrolled pain • Medications • Alcohol and substance abuse • Thyroid disease • Anemia (B12) • Electrolyte abnormalities & organ failures • (Cancers)

  44. Major Depression DSM-IV Symptoms for > 2 weeks 5 or more symptoms At least one should be Depressed Mood Anhedonia (lack of interest or pleasure) Meds retain utility here Mild; 5% superior to placebo (46-41%) If major, severe, or prolonged depression, 27% superior (58%-31%) Nelson et al. Am J Psychiatry, 6-13 Other symptoms Significant weight loss or weight gain (more than 5%) Insomnia or hypersomnia Psychomotor retardation or agitation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness, nearly every day  Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide AND

  45. Subsyndromal Depression/Dysthymia • One of core symptoms (depressed mood / anhedonia) plus 1 to 3 (other) symptoms • Depression without sadness in elderly • Risk factor for Major Depression • For > 2 weeks => chronic • Associated with • Poorer health and social outcomes • Functional impairment • Higher health utilization and treatment costs • Not very responsive to drugs in younger populations • Role for non-pharmacological therapies

  46. Bereavement • Usually time-limited • Behavioral treatments, support groups treatments of choice • Now indications for meds if bereavement triggers major depression • Likewise for complex or protracted bereavement • Simon NM. JAMA 2013; 310(4):416-23.

  47. Psychotic Depression • Subtype of Major Depression • Depression with delusions (somatic and persecutory)/ hallucinations • Common in elderly • Especially inpatient and long-term setting • ECT

  48. Vascular Depression (subcortical ischemic depression) • Ischemic changes are detected with MRI • Higher prevalence in patients with vascular dementia • 20%- 50% of patients develop depression within 1st year after stroke • Left hemisphere more chance of depression • Associated with more cognitive impairment and disability, more psychomotor retardation, less agitation, less guilt, and less insight into their illness  • Some may have “silent stroke” • No consensus of diagnosis • Response to drugs?

  49. Apathy Ishii S et al. Apathy: A Common Psychiatric Syndrome in the Elderly. JAMDA 2009; 10: 381–93.

  50. Other considerations • Short vs. Long-term residents • Seasonal variation

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