Top 10 Ways to Help Geriatric Patients.

1. Top 10Ways to Help Geriatric Patients. CDR Carol L. Blackwood MC, USN

2. #10Immunizations Routine Immunizations Flu shot annual Td q 10yrs Pneumovax once, repeat in 5yrs if first shot at <65yrs age, immuno-suppressed, asplenic or chronic renal failure. New Immunization�Zoster Recently recommended by the CDC�s, committee, The Advisory Committee on Immunization Practices (ACIP), for age >60yrs. (Must be kept frozen, and thawed immediately prior to injection.)

3. #9CAD Primary Prevention / HTN Routinely screen males >34yrs and women >44yrs for lipids and tx disorders USPSTF (A) However�looking closer at the evidence, There is no evidence that primary tx of lipids is of benefit to geriatric patients.

4. #9CAD Primary Prevention West of Scotland Coronary Prevention Study Group (WOSCOPS), excluded pt�s >65yr at enrollment. Air Force/Texas Coronary Atherosclerosis Prevention Study had median age men=57 and women=62. Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm, cut off age = 60yrs.

5. #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.

6. #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 >84 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 <90 mmHg or in patients >70 years of age with diastolic BPs < 90 and systolic BPs <160 mmHg CTFPHC (C).

7. #9HTN >84yrs No evidence to support tx BP 65-84yrs Treat if above 160 and 90. +/- 140-160 and <90 Less than 65yrs, treat HTN Canadian Task Force for Preventive Health Care (C)

8. #8Vitamin B12 Deficency Pt�s 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.

9. #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.

10. #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).

12. #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 (>30ng/ml optimal) is most accurate lab test to assess reserves.

13. #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.

14. #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)

15. #6Vitamin D 1:2 women and 1:3 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 >60yrs. NOTE: No reductions seen in group taking 400 units/day.

16. #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

17. #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/163/22/2716#SEC2 (Actual article with lists)

19. #5BEERS List

20. #5BEERS List-by diagnosis

21. #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.

22. #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 �D�s� (Darvocet, Demerol, Darvon). Start bowel regime with initiation of narcotics (stool softener and stimulant (MOM or senna).

23. #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).

24. #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 costs�or $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

25. #4 Falls Multi-factorial Causes Balance Gait Vision Orthostasis Depression Cognitive Impairment Psychoactive Meds Use of 4 or more Rx meds Arthritis Muscle strength

26. #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 <30. Falls are twice as common with anemia Heart failure worsens with anemia

27. #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.

28. #2 Saint�s Triad and Hickam�s 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.

29. #2 Common Geriatric SyndromesUniversity of South Carolina-2006 Dementia Delirium Urinary Incontinence Osteoporosis Falls/Gait Disorders Decubitus Ulcers Sleep Disorders Failure to Thrive

30. #2 Common Geriatric Syndromes Orthostatic HTN Cataracts Diabetes Dementia Arthritis Falls Incontinence Medications Compliance/side effects Failure to thrive

31. # 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.�

32. #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.

33. #1Estimating Male Physiologic Age

34. Many thanks to the faculty and staff of the East Carolina University Brody School of Medicine Geriatrics Division

35. 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

36. 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 1992;82(7):1020�3.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 2001;82(8):1050�6.Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290�5.