Geriatric Medicine Gary Winzelberg, MD MPH - PowerPoint Presentation

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Geriatric Medicine

Gary Winzelberg, MD MPH

Inpatient Medicine Clerkship

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Ms. IM

87

yo

woman, Holocaust survivor

“Positive” cardiac stress test, elective catheterization, no intervention

Pre-meds:

diphenhydramine

25 mg, diazepam 5 mg

Post-

cath

: somnolent, agitated, taking off clothes

Neurology consult

“Cause is atypical response to sedatives and benzodiazepines which is fairly normal in the elderly”

Slide3

IM (2)

Admitted to hospital (

vs

discharged home)

Next morning: somnolent, will not respond to commands, occasionally opens eyes and occasionally verbalizes

Neurology follow-up

Benadryl and valium should have been out of the patient's system at this point…In 24 hours if unchanged recommend lumbar puncture and MRI brain.

Slide4

IM (3)

Geriatrics: transition to health center at IM’s retirement community

Return to baseline mental status, cognitive function over 72 hours

Take Home points:

Preventable hospitalization

IM’s response was more typical than atypical

Pre-medicate 87 year old patients differently

Hospitals are dangerous places for older adults

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IM Follow-Up

Age 90

Fall,

subararchnoid

hemorrhage

Fall, right

humerus

& right hip

fractures

Age 91

Lives in assisted living

Ambulates independently with walker

Independent in activities

of daily living

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Objectives

To present medical student geriatric competencies

To discuss older adults’ diagnostic challenges

To identify potential hazards of hospitalization

To understand strategies re:

delirium

Diagnosis

Prevention

Evaluation

Management

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Who is a geriatric patient?

Age

Chronic diseases

Functional limitations (ADLs, IADLs)

Cognitive impairment

Frailty

Multidisciplinary assessment/service needs

Goals of care

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Minimum Geriatric Competencies

Medication management

Cognitive and Behavioral Disorders

Self-Care Capacity

Falls, Balance, Gait Disorders

Health Care Planning and Promotion

Atypical Presentation of Disease

Palliative Care

Hospital Care for Elders

Leipzig RM et al. Academic Medicine 2009

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Today’s Session

#17: identify at least 3 physiologic changes of aging for each organ system and their impact on the patient

#22: identify potential hazards of hospitalization

#5: formulate a ddx for patient with delirium

#6: in a patient with delirium, urgently initiate a diagnostic workup to determine the root cause

#8: develop an evaluation and nonpharmacologic management plan for agitated demented or delirious patients

#22: explain the risks, indications, alternatives and contraindications for Foley catheter use

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Diagnostic/Treatment

Challenges (& Opportunities)

Gradual decline in physiological reserve

Increased heterogeneity with aging

Genetic, lifestyle, environmental differences

Disease often presents at an earlier stage

Delirium with mild hypercalcemia

Urinary retention with mild BPH

Treatment may be simple

Drug side effects at lower doses

Resnick NM. Marcantonio ER. How should clinical care of the aged differ? Lancet 1997;350:1157-58

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Diagnostic/Treatment

Challenges (2)

Symptoms occur earlier, but patients delay care

Perceptions of “normal” aging

Disease presentation depends on most vulnerable organ system (weakest link)

How is UTI associated with delirium?

Abnormal findings in a younger person may be common (and not harmful) in older adults

Bacteriuria

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Diagnostic/Treatment

Challenges (3)

Symptoms from multiple cause (inverse Occum’s razor)

Syncope

Multiple homeostatic mechanisms compromised, multiple abnormalities amenable to treatment

Falls

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Hospitalization Hazards

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Hospitalization Risks

Delirium

Infection

UTI, pneumonia, C diff

Pressure ulcers

Malnutrition

Nursing home placement

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Nursing Homes

? live permanently: > 50% hospitalized older adults “very unwilling” or “rather die”

Mattimore TJ, JAGS 1997

Infrequent physician visits

Decreased likelihood of returning to community within 30 days if discharged from hospital with delirium

Marcantonio ER et al, JAGS 2005

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Mrs. W History

89 year old woman transferred from AL facility

CC: fever, lethargy (very quiet, not usual self)

HPI: Few days of diarrhea, cough, weakness, decreased PO intake, left hip pain

PMH: CRI, HTN, DM, CAD, h/o CVA

Meds: insulin, furosemide, atenolol, asa, plavix, amlodipine, doxazocin, isordil, nexium, calcium, nephrovite, fe, vitamin d, shohl’s

ROS: headache, nausea & emesis x1, dizziness x 1 month

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Mrs. W Exam

General: lethargic, difficult to engage

VS: T 38, 142/90, HR 92, O2 sat 94% ra

Lungs: bibasilar crackles

Heart: RRR, S1/S2, II/VI SEM at USB

Ext: pain with external rotation left leg

Neuro: difficulty following commands

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Mrs. W Evaluation

WBC 18.5, H/H 12.7/36.3, Na 138, K 4.3, CO2 22, BUN 103 (95), Creat 5.6 (4.3), glucose 117

UA: LE 2+, WBC 25, occ bacteria, many WBC clumps

Fecal PMN negative

Hip xray negative for fracture

CXR: moderate pulmonary edema

CT head negative for bleed

Slide19

DDX

Impression:

89 year old woman with CRI, DM, CAD admitted with fever, lethargy and associated delirium. Most likely etiologies include…

DDX:

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Infectious Disease Consult

89 year old woman with DM, CRI, CAD presents with mental status change, headache, fever, chills, n/v, diarrhea. Labs showed leukocytosis, worsening renal function. DDX concerning for bacterial/viral meningoencephalitis, tick-born illness. Also include gastroenteritis, pneumonia, UTI, ? uremia

Recommend: LP, start vancomycin, ceftriaxone, ampicillin (listeria), acyclovir (HSV), doxycycline (tick-borne) until LP results available.

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Management & Outcome

No LP

Antibiotics – empiric treatment of UTI

Hydration – concern for dehydration

Urine culture – pansensitive Ecoli

Mental status (attention) improved

Physical weakness, nausea persisted

WBC 8.2 (18.5), BUN/Creat 115/6.7 (103/5.6)

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Delirium

Spectrum: hypoactive – agitated

Common

Costly

Morbidity & mortality

Preventable

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Delirium Diagnosis

Inouye SK et al. Ann Intern Med 1990

Confusion Assessment Method

Sensitivity 94-100%, Specificity 89-95%, high inter-rater reliability

Feature 1

: acute onset or fluctuating course

Feature 2

: inattention

Feature 3

: disorganized thinking

Feature 4

: altered level of consciousness

Diagnosis

: 1 & 2,

either

3 or 4

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Delirium Prevention

Inouye SK et al. NEJM 1999

Clinical trial: hospitalized gen med patients

>

70

Risk Factor

Intervention Protocols

1. Cognitive Impairment

Orientation & Activities

2. Sleep deprivation

Nonpharmacologic

& Sleep-enhancement

3. Immobility

Early mobilization; minimize catheters

4. Visual & Hearing impairment

Visual/Hearing aids and adaptive equipment; earwax

disimpaction

5. Dehydration

Early recognition, encouragement of oral intake of fluids

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Delirium Prevention Trial Outcomes

Intervention group: 10%

Usual-care group: 15%

OR 0.60 (0.39-0.92)

Intervention group: fewer total number of days with delirium & total number of episodes

No significant differences in delirium severity

87%: overall rate of intervention adherence

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Prevention Trial Dissemination

http://elderlife.med.yale.edu

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Delirium Management

Treat the underlying contributing conditions

Address risk factors

Foley, telemetry, nasal cannula

Involve family

Consider sitter

Does the patient need to remain in bed?

How important/urgent is the evaluation/tx?

Medication options

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Delirium Medications

No medications with FDA approval, evaluated in randomized trials

Geriatrics prescribing principle: start low, go slow

Benefits/side effect profile of atypical antipsychotics similar to first generation agents

Haloperidol (advantage PO/IM/IV): 0.25-0.5 mg, max 1 mg/day, prolonged QT interval

Risperidone: 0.25-0.5 mg BID, prolonged QT, increased mortality risk in dementia

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Indwelling Urinary Catheters

Risks

: infection, bladder weakness, hematuria, discomfort, immobility (1 point restraint

Saint S et al. Ann Intern Med 2002

Indications

: retention (+/-), comfort, I/O monitoring (+/-), pressure ulcer management )+/-)

Alternatives

: timed voiding with assistance, incontinence care, condom catheters,

Nonpayment for catheter associated UTI

Wald HL. Kramer AM. JAMA 2007.

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Other Topics

Tube feeding in dementia

Finucane TE et al. JAMA 1999

Pressure ulcer recognition and prevention

Syncope

Mendu ML. Arch Intern Med 2009

Goals of care communication

Winzelberg GS et al. JAGS 2005

Family communication

End of life care

Symptom management

Care options

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Remember the Social History

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