Primary Care of Older Adults - Internal Medicine | ACP

Primary Care of Older Adults - Internal Medicine | ACP

Primary Care of Older Adults: Pearls and Pitfalls Colleen Christmas, MD, FACP Disclosures I have not received any payments from companies related to this talk. Objectives Describe a few general principles that can guide the primary care of older adults Describe an approach to choosing tests and treatments

Describe an approach to medication review Know when exercise is beneficial Youve seen one 80 year old DRUGS CAN BE DANGEROUS Patient #1 78 year-old man with dementia and behavior problems noted to have lost 9kg in past year

(~10% of body weight) Also: Chronic kidney disease Hypertension Edema Atrial fibrillation What next? Medical evaluation normal Psychiatrist and nursing home want to start mirtazipine and nutritional supplements You review his meds: Donepezil 23mg daily -omeprazole

Lisinopril -digoxin Furosemide -citalopram Aspirin Amlodipine Drugs are Dangerous Drugs should always be included in differential diagnosis Resist temptation to treat all symptoms with drugs

Adverse drug reactions more frequent / severe in elderly Starting any medication in older patients should be viewed as a major intervention Start low, go slow Geriatric Medication Review Does every medication have a diagnosis? Do diagnoses have matching high yield medications? Aspirin in coronary disease Are medications working? Is mood improved with antidepressant?

For medications that need monitoring, is it up to date? Digoxin level, renal function for ACE inhibitors Can anything be simplified? Is one drug being used to treat side effects of another? Amlodipine -> edema -> furosemide Is adherence and/or cost an issue? Are the medications and treatments in line with the patients goals of care? (longevity, function, comfort) Top Medications for Older Adults to Avoid Non-steroidal anti-inflammatory drugs

Digoxin in doses greater than 0.125 mg Certain diabetes drugs Sulfonylureas, especially long acting Muscle relaxants Certain meds for anxiety/insomnia Benzodiazepines, sleeping pills Anticholinergic drugs Antipsychotics (unless patient has psychosis) Estrogen pills and patches

High Risk Drugs Drugs associated with high rates of hospitalization Warfarin Insulin Oral hypoglycemics Antiplatelet agents - aspirin and clopidogrel Digoxin

67% of hospitalizations for ADEs between 2007 and 2009 were due to top four medications listed above Two-thirds of hospitalizations for ADEs were due to unintentional overdoses Budnitz et al, NEJM 2011 Budnitz et al, Ann Int Med 2007 Patient #1 Needs careful medication review Anorexia and weight loss Donepezil 23mg Not more effective than 10mg (2 points on 100 point

scale) Clinically significant increase side effects Digoxin Amlodipine and furosemide? Farlow. Clin Ther2010. Rathore NEJM 2002. Patient #2 89 year-old man reports fatigue and taking too many medications Accompanied by son and daughter They are concerned about his safety and

ability to remain at home Medications are expensive His Current Care Plan Condition Medical Treatment Probable Alzheimers Disease donepezil, memantine Systolic Heart Failure furosemide, metoprolol, lisinopril Osteoarthritis acetaminophen, tramadol Osteoporosis

calcium, D, alendronate Insomnia zolpidem Type 2 Diabetes Mellitus metformin, glyburide Benign Prostatic Hyperplasia tamsulosin Additional medications: aspirin, simvastatin His Current Care Plan Current data: Mini Mental State exam 23/30 Sitting blood pressure: 110/70 pulse 54;

standing: 100/60 pulse 56 HemoglobinA1c 6.8% (3 months ago 7%) Lipid panel: total 180, LDL 70, HDL 50, triglycerides 300 Labs: Creatinine: 1.7 Time Horizon to Benefit Length of time needed to accrue an observable and clinical meaningful risk reduction for a specific outcome Different than number needed to treat or harm May be different than the trial length

Case: Evidence Osteoporosis Bisphosphonates for osteoporosis effective, with a modest absolute risk reduction Osteoporosis % fracture-free bisphosphonate 50% reduction in risk of fracture over

a 3 year period 1.2% absolute risk reduction for fractures in 3 years placebo Time to benefit 9 to 18 months Median life expectancy: 2.7- 4.7 years

TIME National Osteoporosis Foundation. Clinicians guide to prevention and treatment of osteoporosis, 2009 Reasons to Stop the Bisphosphonate Black DM, Schwartz AV, Ensrud KE, et al. JAMA 2006;296:2927-38. General Principles When thinking about starting or stopping a drug, ordering a screening test, or prescribing other therapy, need to consider: What is this persons estimated life expectancy? Is that estimate long enough to get benefit from

the proposed action? Is the absolute benefit reasonable? Patient #3 80 year old woman Type 2 diabetes, hypertension Independent all activities Walks 1 mile every other day Lives with sister, helps her with shopping No family history of

cancer Should she have a mammogram? Life Expectancy for Women 25 21.3 20 Y e 15 a

r 10 s 17 15.7 13 11.9 9.5 6.8 4.6 5 0

9.6 8.6 5.9 2.9 70 75 Top 25th Percentile

80 50th Percentile Adapted from Walter. JAMA. 2001 85 6.8 3.9 1.8 90

4.8 2.7 95 Lowest 25th Percentile 1.1 Risk of Dying From Breast Cancer in

Remaining Lifetime Age 70 Life expectancy 21.3 15.7 9.5 17 % risk 3.3 of dying 2.2

Age 75 Age 80 11.9 6.8 1.2 2.8 1.8 0.9 13 8.6

4.6 2.4 1.5 0.7 Risk of dying from breast cancer = Life expectancy x Age-specific breast cancer mortality rate Walter. JAMA. 2001. Walter. Ann Intern Med. 2004.

Patient #3 Estimated life expectancy=13 years Risk of dying from screen-detectable breast cancer=2.4% Preference maintain health and independence Worries about stigma and mammograms causing cancer No significant barriers

EXERCISE IS GOOD FOR WHAT AILS YOU Patient #4 75 year-old woman with major depression, knee osteoarthritis, hypertension Knees hurt Tired Tired of taking pills Spends much of day sitting Needs help to do household chores Aging resembles being sedentary

Aging Illness Disuse Role of exercise Minimize physiologic changes associated with typical aging Decrease risk of several common chronic diseases Assist in prevention and treatment of disability Serve as primary or adjunctive treatment for some chronic diseases

Benefits Condition Osteoarthritis Depression Osteopenia Effect Almost all studies show benefit Interventions: many; quad strengthening Moderate effect on pain (10-15%) Some effect on function (~10%)

Low intensity may = high intensity Response rates=31% to 88% High intensity Most significant effects in those with comorbid illness Strength and weight-bearing Overall treatment effect of exercise training was a reversal or prevention of bone loss of 0.9% per year Hart, et al. Clin J Sport Med 2008; Fiatarone Singh MA Clin Geriatr Med 2004. Wolff I. Osteoporos Int 1999

Benefits More likely to: Less likely to: Disability Increases chance of dying without disability (RR 1.8) Fracture a hip Fall rate=0.63-0.78 risk=0.65-0.83

Develop cognitive impairment Develop Diabetes (RR 0.6-0.7) Colon cancer, breast cancer, and death rate from cancer (RR 0.3-0.6) Stroke (RR 0.3-0.76) Cardiovascular disease Have a normal systolic BP Be alive? Nursing Res 2010;59:364-70; Weuve J. JAMA 2004;292:1454-61. Abbott RD. JAMA

2004;292:1447-53. Gillespie LD Cochrane Database of Systematic Reviews 2009; Young, JAGS 1999;47:277 Depression Blumenthal JA, et al. Arch Intern Med. 1999. Contraindications to exercise Almost all can safely engage in a program of moderate activity, such as walking or lifestyle modification, without screening Few conditions are true contraindications (unstable cardiopulmonary disease) Start low, go slow, pace

Warm up, cool down Supervision and structure best Fall risk, injury prevention Patient #4: Its never too late! Summary A highly nuanced drug review is super high yield for older patients Decisions about tests and treatments should include consideration of time to benefit in addition to degree of benefits and harms We use too many drugs and not enough

exercise in treating the elderly

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