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Geriatrics

Geriatrics. What’s New In Medicine 2014 September 13, 2014 Jeffrey Wallace MD, MPH Professor, Internal Medicine & Geriatrics University of Colorado Health Sciences Center. Learning Objectives. Review health maintenance & dz prevention for older adults

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Geriatrics

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  1. Geriatrics What’s New In Medicine 2014 September 13, 2014 Jeffrey Wallace MD, MPH Professor, Internal Medicine & Geriatrics University of Colorado Health Sciences Center

  2. Learning Objectives • Review health maintenance & dz prevention for older adults • Preventive screeningprinciples (details in next talk) • Health promotion thru  physical activity • Health promotion thru improved nutrition - Vitamin D - Vitamin B12 • Consider Geriatric perspectives on DM & HTN • PCMH: Balancing guidelines and pt preferences

  3. Learning Objectives Review health maintenance/dzprevention for older pts • Preventive screening principles • What age is old? • Expected Survival? • Consider goals of screening and interventions • Quantity of life vs Quality of life

  4. Life Expectancy at Selected AgesU.S. Census Bureau, Statistical Abstract of U.S. 2012 Age Men Women 65 17.2 19.9 70 13.7 16.0 75 10.6 12.5 80 7.8 9.4 85 5.8 6.8 90 4.1 4.8 95 2.9 3.3 100 2.1 2.3

  5. Life Expectancy at Selected Ages by Gender and Health Status Age Men Women Robust Ave FrailRobust Ave Frail 7018.0 12.4 6.7 21.3 15.7 9.5 7514.2 9.3 4.9 17.0 11.9 6.8 8010.8 6.7 3.3 13.0 8.6 4.6 857.9 4.7 2.2 9.6 5.9 2.9 90 5.8 3.2 1.5 6.8 3.9 1.8 95 4.3 2.3 1.0 4.8 2.7 1.7 Adapted from JAMA 2001;285:2750

  6. How long is my pt going to live? ePrognosis.org Provides estimates of 1 and 4-10 yr survival Will pt survive to reap benefits of screen/intervention?

  7. Learning Objectives Review health maintenance/dzprevention for older pts • Preventive screening principles • What age is old? • Expected Survival? • Consider goals of screening and interventions • Quantity of life vs Quality of life • Pt preferences? Avoid disability/dysfunction?

  8. Life Expectancy and Years of Disabled LifeAmong Americans Aged 65 and Older Age 65 Age 75 Age 85 Life Disabled Life Disabled Life Disabled Expectancy Years Expectancy Years Expect Years Women Black 17.4 2.8 11.4 3.0 6.3 3.2 White 19.3 2.7 12.2 2.8 6.6 3.0 Men Black 13.5 1.4 8.9 1.6 5.1 1.7 White 15.5 1.4 9.6 1.6 5.3 1.5 _____________________________________________________________ National Center for Health Statistics 1996

  9. Compression of Morbidity/Mortality

  10. TO Prevent or Forestall Functional Decline & Frailty “All older adults should engage in regular physical activity and avoid an inactive lifestyle.” ACSM Position Stand, Exercise and Physical Activity for Older Adults, 2009

  11. Exercise to Enhance Capacity, Function & Quality of Life Physical Activity • Physical inactivity 2nd to tobacco as cause of morbidity and mortality • Regular physical activity (even for very old, frail) •  funx/ falls/ disability • Dz prevent/tx  DM, CV Dz, DJD, HTN, OP  •  Psychological health  sleep, depr, cognition J Gerontol 2002;57A:M262

  12. Exercise to Enhance Function & QL Physical Activity • Share the data: Clear benefits shown for reducing diabetes, cardiovascdz, falls, and cognition • Provide specific instruction • Rx for exercise • Modality: aerobic, strength, balance, flexibility • Dose: frequency, duration, intensity J Gerontol 2002;57A:M262

  13. Mr./Ms. Couch. Potato 3/18/11 Walk 30 min (somewhat hard) 5 days per week for Sedentary Lifestyle

  14. NIA Website “to help you fit exercise and physical activity into your daily life” http://go4life.nia.nih/govCDC Website: Physical Activity Guideline for Adults“find out what you can do to be active” http://www.cdc.gov/physicalactivity/index.html  U.S. National Physical Activity Plan Info re: strategies to increase physical activityhttp://www.physicalactivityplan.org/theplan.php

  15. U.S. DHHS: For Important Health BenefitsOlder adults need at least: 2.5 hours (150 minutes) of moderate-intensity aerobic activity (i.e brisk walk) every week or- 1 hr 15 minutes (75 minutes) vigorous intensity aerobic activity (i.e., jogging or running)/wkand • muscle strengthening activity 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulder, & arms)

  16. U.S. DHHS 2008 Aerobic Activity Guidelines • Ten Minutes at a time is fine • 150 minutes a week sound like a lot of time --- • but it is not! • 2.5 hrs time you might spend watching a movie • can spread activity out during the day or the wk • its all about what works best for you as long as you are doing moderate or vigorous effort for at least 10 minutes at a time

  17. Resistance Training (RT) Exercise John at 79

  18. Muscle mass changes with aging (its not inevitable!) 20 yo W sedentary 65 yo W sedentary

  19. Functional Significance  muscle mass (& quality) strength  function

  20. Resistance Training Exercise Overview of RT benefits •  BP (no clear effect on lipids or glucose/DM) • Body composition:  muscle mass & quantity •  muscle mass   resting metabolic rate •  muscle mass   strength & function • Benefits may be greatest in frail elderly and those with CHD Circulation 2007;116:572

  21. Resistance Training Exercise Studies in frail and very old • Frail elderly (men and women) • RT   walking speed & endurance • RT   balance &  falls • Nursing home pts (mean age 87) • 10 wk RT   strength and gait velocity • RT   stair climbing power Circulation 2007;116:572

  22. Resistance Training Exercise: Good for the Brain Too? • 155 women age 65-75, 1 yr study • Wt training 1 or 2x/wkvs balance training 2x/wk • 60 minute sessions (10 warm-up&down, 40 min core) • Cognitive function testing • improved 11% with resistance training • no change with balance/tone Arch Intern Med 2010:170:170-8

  23. Resistance Training Exercise Prescribing RT for your older patients • Absolute contraindications • unstable CHD, decompensated CHF • pulm HTN > 55mmHg, uncontrolled HTN • Relative (consult MD and consider stress test) • major cardiac risk factors • Diabetes • stress test if low functional capacity (< 4 METS) • Musculoskeletal limitations Circulation 2007;116:572

  24. ACSM: Resistance Exercise for Older Adults • Closely supervise initial training sessions • Start w/light loads for musculotendinous adaptations • 1 set of 8 – 10 exercises; 10-15 reps per exercise • 2x/wk, nonconsecutive days • Progressive overload: increase reps then load • Moderate – high intensity (5-8 on 10-pt scale) • Maintain a normal breathing pattern (no breath hold)

  25. Resistance Training (RT) Exercise Grace at 91

  26. Nutrition: Vitamin Deficiencies 78yo pt requests bloodwork to test vitamin levels, states she feels fine but read somewhere that her PPI (proton pump inhibitor, eg Prilosec, Prevacid), could adversely affect some vitamin level. Which vitamin test should you order? 1. Vitamin C 2. Vitamin B6 3. Vitamin A 4. Vitamin B12 5. None

  27. Nutrition: Vitamin Deficiencies Vitamin B12 • PPI gastric acid Vit B12 absorption & levels Ann Intern Med 1994;120:211 • PPI  gastric acid can also impair: • Iron absorption (consider vit C or OJ with Fe rx) • CaCO3 absorption (consider calcium citrate)

  28. Vitamin B12 • Prevalence 5-15% • Etiology PA infreq, food-Cblmalab, achlorhydria • Signs/SxmsSubtle, non-specific, eg fatigue,  mood or memory,  balance Am J ClinNutr1997;66:741 N Engl J Med 2013; 368:149

  29. Vitamin B12 • ScreenAge > 65, neuro/heme, gastric surg, thyroid dz • Lab DxB12 150-350pg/ml unreliable (as is  MCV) • B12 level 200 pg/ml sens/spec 50% •  Methylmalonic acid better but very expensive • Best to treat all low or borderline low levels? • Early dx/tx- neurologic recovery time depnt J Am GeriatrSoc1995;43:1290 N Engl J Med 2013; 368:149

  30. Vitamin B12: Treating Deficiency • Tx 1000g IM/mo or oral 1000g daily • Oral repletion • B12 diffusion  1% intake absorbed • Physiologic requirements 1-2 g/d • 1000g/d  clinical, heme, serum response • Caveats compliance, initial tx, clinical dz N Engl J Med 2013; 368:149

  31. Calcium & Vitamin D 78 y.o. F, on PPI for GERD, seeks counseling re: vitamins. She eats little dairy foods and asks your advice re: calcium and Vit D. Following National guidelines you recommend she takes the following supplements: 1. Calcium 500mg + Vitamin D 200IU 2. Calcium 1,000mg + Vitamin D 400IU 3. Calcium 1,200mg + Vitamin D 800IU 4. Calcium 1,200mg + Vitamin D 600IU

  32. Calcium & Vitamin D 1. Calcium 500mg + Vitamin D 200IU 2. Calcium 1,000mg + Vitamin D 400IU 3. Calcium 1,200mg + Vitamin D 800IU  but is 800 IU Vit D enough??? 4. Calcium 1,200mg + Vitamin D 200IU

  33. Vitamin D: Old RDA 200 IU/d too low • Inst Med (1997) • age 50-70 400IU, age 71+ 600IU • Inst Med (2010) • age 50-70 600 IU, age 71+ 800 IU • Is 800 IU enough? • US Dept Agriculture rec 1000IU/d • UL safety 4000 IU/d • 25-OH Vitamin D level goal > 20 vs 30ng/ml

  34. Vitamin D Dose and Fracture Prevention • Meta-analysis, 12 RCTs, age 60+, 19,000 subjects • Cholecalciferol (D3) used in all trials • 700-800 IU  RR 0.74 hip fx RR 0.77 any nonvertebralfx • 400IU  RR 1.15 hip fx, 1.03 any nonvertebralfx JAMA 2005;293:2257

  35. Vitamin D Dose and Fracture Prevention Higher dose VitD Lower dose VitD JAMA 2005;293:2257

  36. Effects of Vitamin D on Risk of Falling • Meta-analysis RCTs, n 1237, OR0.78 (0.64-.92) • NNT 15 to prevent one fall • MOA • Vit D defic assoc w/proximal muscle weakness • Muscle has Vit D receptors that  w/age • Muscle Vit D receptor   protein synthesis • Vit D levels assoc with  muscle strength/LE funx JAMA 2004;291:1999

  37. Vitamin D Dose and Fall Prevention 17ng/ml 38ng/mL BMJ 2009; 339:b3692

  38. Treating Vitamin D Deficiency • Replete with 50,000 IU Vitamin D2 q wk x 8wks • Check level, repeat 8wk tx if 25-Vit D < 30ng/ml • 25-Vit D level goal: 30-60ng/ml • Maintenance – starting points • 50,000 IU D2 q2wk or q month • 1000 IU daily NEJM 2007;357:266

  39. Learning Objectives • Review health maintenance & dz prevention for older adults • Preventive screeningprinciples (details in next talk) • Health promotion thru  physical activity • Health promotion thru improved nutrition - Vitamin B12 - Vitamin D • Consider Geriatric perspectives on DM & HTN • PCMH: Balancing guidelines and pt preferences

  40. Emergency Hospitalizations for Adverse Drug Events (ADEs) in Older Americans • National electronic ADE surveillance 2007-09 • Hospitalization rates after ED visits for ADEs • Pts age 65+ had 100,000 admits/yr d/t ADEs • Four meds/classes causes 2/3 of the mayhem - Warfarin 33% - oral antiplatelet drugs 13% - insulins14% - oral hypoglycemics 11% • 25% related to DM rx, 1oly d/t hypoglycemia from insulin and sulfonylurea agents NEJM 2011;365:2002-12

  41. DM Management in Older Adults • AGS Choosing Wisely recs: • A1c target 7-7.5% if healthy & life expect > 10yr • A1c 7.5%-8% w/mod comorbidity & life exp < 10 yr • A1c 8%-9% w/multiple comorbidities/limited life-expectancy • Avoid meds other than metformin to  A1c < 7.5% J Am GeriatrSoc 2013;61:2020 http://www.choosingwisely.org

  42. DM Management in Older Adults ADA recommends • Healthy: HbA1c target of < 7.5% • or slightly higher (8% target) in pts • With limited life expectancy (< 10 yrs?) • Extensive comorbid conditions • At  risk for serious hypoglycemia (eg age,  renal function, cognitive impairment) Diabetes Care 2012; 35:2650 Diabetes Care 2013;36(S1):S11

  43. DM Management in Older Adults • Hypoglycemia risks  w/age & w/tighter control • 20 severe events/1000 pts age 80+ w/DM 10+ yrs • Hypoglyassoc w/ dementia, CV events, falls, etc • Yet recent VA study found 50% pts w/age 75+, Cr > 2, or cog impairment/dementia had A1C < 7% • Appears we are over-treating DM in older adults! Diabetes Care 2013;36:3535 JAMA Intern Med 2014;174:259

  44. HTN Management in Older Adults New Guidelines (& new controversies) • Age 60+: tx SBP > 150mmHg or DBP > 90mmHg - Goal: below these values • DM any age 18+, initiate/tx goal SBP < 140mmHg • CKD and age 18+ • eGFR < 60ml/min & age < 70, SBP goal<140mmHg • albuminuria at any age or eGFR, SBP goal<140mmHg JAMA 2014;311(5):507

  45. Applying Guidelines to Older Adults • Managing HTN in Very Old • Benefits of tx HTN among most consistent, enduring, robust findings in medicine • Historical concerns: Tx HTN at very advanced age may have  benefit/ risk • HYVET 2008 study laid these concerns to rest? • RCT nearly 4000 pts age 80+ • BP 173/91 → 143/78 tx (vs 158/84 placebo) •  CVA, CHF, cardiac & all-cause mortality

  46. Use of Guidelines in ElderlyCaveats and Cautions: Details Matter! • HYVET often cited: HTN tx pts 80+ y.o. beneficial • Details of study matter • inclusion: SBP seated 160+ (JNC recs seated BP) • exclusion: SBP standing < 140 (ie, if OH), Cr>1.7 • Target BP < 150/80 • Generally healthy community-dwelling elderly, most age 80-85, mostly eastern European • Comorbid dz, frail, age 90+  how best to proceed? • Tx BP in hospital?: supine or seated?, OH  , Cr? NEJM 2008;358:1887 JAMA 2003;289:2560

  47. Use of Guidelines in ElderlyApply with caution! • Almost all existing guidelines have single dz focus • Application of CPGs to hypothetical 79yo pt w/COPD, DM, HTN, OP, OA • 12 medications, complicated regimen • $406 monthly cost • Studies rarely include frail elderly, mult comorbid dz • Risks (drug-drug, drug-dz interactions) likely are  • Do CPGs address short & long term goals? • Pt preferences? JAMA 2005;294:716

  48. Apply clinical practice guidelines with caution! • CHF Guidelines: based on excellent RCT data • Issue: Older Adults w/CHF often w/comorbid dz • Characteristics 2.5 million Medicare Beneficiaries Hospitalized for Heart Failure, 2001-2005 • mean age 80 years old, nearly 60% women • 2/3 of pts w/chronic atherosclerosis • 67% HTN • 42% COPD • 42% diabetes mellitus each of these w/CPGs • 30% renal failure • 14% dementia Arch Intern Med 2008;168(22):2481

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