Tips on How to Live Long and Prosper: the Geriatrics 2016 Year in Review

Transcription

1 Tips on How to Live Long and Prosper: the Geriatrics 2016 Year in Review Rollin M. Wright, MD, MPH, MS Assistant Professor 14 February 2017

2 Disclosures No relevant financial disclosures to report. Partial salary support from: HRSA 1 U1QHP , Geriatric Workforce Enhancement Program

3 Learning Objectives 1. Assess each older adult patient for baseline cognitive and physical performance to estimate health status prior to setting patient-specific blood pressure targets and using antihypertensives. 2. Identify opportunities in your own practice to improve continuity of care and reduce caregiver burden in the care of cognitively and physically impaired adults older than Use knowledge of each older patient's functional status to guide medical decision making regarding initiation of surgical and non-surgical interventions.

4 Overview 1. Review a framework for interpreting the evidence-based literature as it applies to older patients. 2. Apply the framework to the geriatrics evidence-based literature. 3. Major themes in geriatric research in 2016 Optimal blood pressure control for 60+ Brain health (Mobility)

5 Theories of Aging Program Theory Aging, and death, is genetically programmed to occur with time Damage Theory External, internal forces damage cells and organs, leading to death

6 What s Wrong with the Disease Model of Aging? A. Does not allow for functional decline as a separate process B. The physiology of aging that causes the wear-and-tear degradation that leads to organ system disease. The Journal of Physiology 11 MAR 2015 DOI: /jphysiol

7 Figure 1. The Seven Pillars of Aging (Processes that promote aging) Kennedy, et al. Cell, Volume 159, Issue 4, 2014,

8 Advances in Geroscience Lifespan Healthspan AGE = # 1 risk factor for diseases and conditions that limit healthspan How? Why? Sicker longer with multiple comorbidities, and conditions Lifespan Healthspan* Disease-focused treatment may decrease mortality without reversing decline in health. *health life expectancy (Kennedy, et al. Cell. Nov 2014)

9 Optimal Longevity: to increase healthspan, must maintain or restore function, and independence The Journal of Physiology 11 MAR 2015 DOI: /jphysiol

10 Aging Phenotypes: Would You Treat Each of these People the Same? 81y 79y 80y 82y 80y Hugh Hefner, Theodore Parisienne/For New York Daily News, Burt Reynolds,

11 A New Treatment Paradigm From: Targeting Vascular Risk Factors in Older Adults: From Polypill to Personalized Prevention JAMA Intern Med. 2015;175(12): doi: /jamainternmed Figure Legend: Proposed Stratification of Antihypertensive and Antidiabetic Treatment in Type 2 Diabetes Mellitus According to Patient VulnerabilitySolid line with arrowhead indicates standard vascular risk control strategy. Dashed lines with arrowheads indicate possible vascular risk control strategies for robust and vulnerable patients, with question marks pointing out the need for a choice. Gray box presents the proposed approach for vulnerable individuals. HbA 1c indicates hemoglobin A 1c ; RCTs, randomized clinical trials; SBP, systolic blood pressure; and T2DM, Copyright type 2 diabetes 2016 mellitus. American To Medical convert HbA 1c to a proportion of total hemoglobin, Date multiply of download: by /25/2016 Association. All rights reserved.

12 2016 Update on BP Control and Aging: The Sequel From Airplane II: The Sequel (1982), photo available in public domain.

13 How Low Do We Go? SPRINT-SR Weiss J et al systematic review ACP guideline Antihypertensive use and cognition

14 Main Outcomes of the Systolic Blood Pressure Intervention Trial (SPRINT) in Patients Age 75 and Older Mark A. Supiano, M.D. Professor and Chief, Geriatrics Division Director, VA Salt Lake City GRECC Director, University of Utah Center on Aging Jeff D. Williamson, MD, MHS Professor and Interim Chair, Department of Internal Medicine Chief, Geriatric Medicine and Gerontology Clinical Director, J Paul Sticht Center on Aging Williamson JD et al, JAMA, May AGS 2016 Symposium 1

15 SPRINT-SR Overview Purpose: To evaluate the effects of intensive (<120 mmhg) compared with standard (<140 mm Hg) SBP targets in persons aged 75 years or older with HTN but without DMT2, at increased risk of CVD* Design: multicenter RCT, older SPRINT participants, randomized to SBP target (intensive, n=1317 v. standard tx, n=1319), Outcomes: CVD outcomes (nonfatal MI, ACS not MI, nonfatal CVA, nonfatal acute CHF, death from CVD cause) Serious Adverse Events: hypotension, syncope, injurious falls, electrolyte abn, bradycardia, AKI evaluated in an ED Exclusions: DMT2, h/o CVA, symptomatic CHF in last 6 mo, LVEF <35%, dx or tx for dementia, life expectancy<3y, unintentional wt loss >10%, SBP < 110 Hg after standing 1 min, living in a NH *CV risk: h/o clinical or subclinical CVD, CKD, 10-year Framingham CVD risk 15%, or age >=75

16 SPRINT Formulary

17 Baseline Characteristics: Participants 75 years or older

18 Baseline Characteristics: Participants 75 years or older (MoCA) Montreal Cognitive Assessment (VR-12) Veteran s RAND 12-item Health Survey Values are N (%), mean ± SD, or median IQR)

19 Comparison of SBP at Followup # classes of meds # of participants

20 Cumulative Hazards for SPRINT Outcomes in Participants 75 and older Primary Outcome All-Cause Mortality Primary outcome includes non-fatal myocardial infarction (MI), acute coronary syndrome not resulting in MI, non-fatal stroke, non-fatal acute decompensated heart failure, and CVD death. AGS 2016 Symposium 19

21 Outcomes/Conditions of Interest *looked at modification of treatment effect by frailty status and gait speed -higher event rate with increasing frailty, slow gait -absolute event rates lower in intensive tx group

22 SPRINT Sr Strengths Time to benefit: 3.14y NNT 27 to prevent CVD outcome NNT 41 to prevent 1 death Benefit maintained across health status (even in frail) Included cognitively impaired (high functioning) Limitations Not stratified by categories of age 75 not same as 85 Looked at 1 (healthiest) subset of those with CVD risk Did not enroll the frailest (NH residents) Excluded multimorbidity Intensive tx group did not reach target, <120 mmhg

23 Weiss J et al, Ann Intern Med, January 2017

24 Weiss J et al Overview Purpose: To systematically review the benefits and harms of more v. less intensive BP control in adults 60 In order to inform guideline development Study selection: 21 RCTs comparing BP targets or tx intensity and 3 observational studies assessing harms Quality assessment: Cochrane Collaborative scoring tool; summary score of low, high, unclear bias Effectiveness outcomes measured: (minimum 6 mos tx) Benefits: all cause mortality, CVA, cardiac events Harms: cognitive impairment, quality of life, falls, fractures, syncope, functional status, hypotension, AKI, medication burden, withdrawal due to adverse events Analyzed according to baseline BP to compare treatment effects Moderate-to-severe HTN (SBP 160 mmhg) Mild HTN (SBP < 160 mmhg)

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28 Weiss J et al Overview Results: 8 trials compared BP targets 13 trials randomly assigned people to more v. less intense therapy Analyzed 15 (3 high risk of bias; 3 minimal difference or BP not reported) Treatment of moderate-severe HTN (SBP 160 mmhg) (9 trials): All outcomes improved (Cardio-Sys, HOT, JATOS, SPS3, VALISH, EWPHE, HYVET, SCOPE, Sys-Eur, SHEP) Drugs: Diuretic + ACE/BB/CCB; felodipine; CCB; MD choice; ARB; HCTZ+triamterene±methyl dopa; indapamide + peridopril; ARB+choice; chlorthalidone ±atenolol or reserpine; CCB±ACEi±HCTZ Ages: 60-68, 70, 71.6, 72, 73.6, 76.1, 76.4, 83.5 High strength evidence: SBP target <150/90 mmhg in pt>60y reduces mortality, stroke, and cardiac events

29 Weiss J et al Overview Treatment of mild HTN (SBP<160mmHg) (4 trials): ACCORD: diuretic + ACEI or BB; mean age 62; diabetics; goal SBP<120mmHg; no change in CVD outcome SPRINT: thiazide + ACEI or ARB; mean age 68; no diabetics; goal SBP<120 mmhg; improved CVD outcome FEVER: felodipine + other; mean age 61.5; goal SBP < 160/95mmHg; all 3 outcomes signif reduced ADVANCE: perindopril + indapamide +/- other; mean age 66; no goal SBP; achieved SBP 121/66-134/74; only reduced mortality Moderate strength evidence: tight control reduces CVA risk Low strength evidence: tight control reduces cardiac events Low strength evidence: tight control reduces mortality (NS)

30 Weiss J et al Conclusions Table 3. Strength of evidence by Cochrane standards for more (6 RCTs) v. less (9 RCTs) intensive treatment. Outcome (#RCT) Intense Control (SBP<140mmHg) Standard Control (SBP<150 mmhg) Reduced Mortality Low (6) High (9) Reduced Stroke Moderate (6) High (9) Reduced Cardiac Events Low (6) High (9) Increased Adverse Events (19) Mixed Mixed Worse Renal Function (13) Low No effect Low No effect Cognitive Decline (7) Moderate No Effect Moderate No Effect Falls/Fracture (3/3) Moderate No effect Moderate No Effect Quality of Life (1) (SBP mmHg Moderate evidence no effect) Functional Status (3) Low no effect Low no effect Effects of Comorbidity burden (0) Effects in frail older adults (2) No evidence Insufficient evidence Reduced risk of CVA with + hx (2) Moderate --

31 Qaseem A, Ann Intern Med, January 2017.

32 ACP Guideline Recommendations (and the Clinical Bottom Line) 1. Treat adults>60y for SBP>150 mmhg to target SBP<150 mmhg (strong, high quality evidence). 2. Initiate or intensify tx in pt>60y with h/o CVA or TIA to target SBP<140 mmhg (weak, moderate quality evidence). 3. Consider initiating or intensifying tx in some pt>60y with high CV risk, based on individualized assessment, to achieve SBP<140 mmhg (weak, low quality evidence).

33 Framework for Evaluating the Literature and any Intervention as It Relates to People > Does the study pertain to my patient (phenotype)? What are the trade-offs? Is it worth it to me to experience SE that has a 100% chance of happening in order to avoid an outcome that occurs times per 1000 patients over 5 years? This is patient-centered decision-making. 2. Do the results translate into improved healthspan for my patient?* *Translatable geroscience study design incorporates outcome measures relevant to healthspan and compression of morbidity.

34 Final Thoughts on Tight or ANY BP Control and the Frail Older Adult Are the frail in SPRINT really frail? Are all frail people the same (i.e. spectrum of BP targets according to spectrum of frailty)? It may help avoid CV outcomes in frail people. It doesn t seem to harm the more frail. Does it otherwise benefit the frail (i.e. make them less frail)? Is it better to live longer frail OR is it better to simply be less susceptible to CV outcomes but not less susceptible to other medical outcomes like pneumonia? Achievement of optimal BP goals that involves a non-pharma exercise component may well benefit the mildly-moderately frail 2 ways: reverse some degree of frailty and decrease risk of cardiac outcomes

35 2016 Update on Brain Health Dementia: Diagnosis, treatment, prevention, and care Delirium: Antipsychotics for prevention and management

36 Dementia 2016 Copyright 2017 Express Newspapers. "Daily Express" is a registered trademark. All rights reserved.

37 Drugs and Dementia: A Call to Arms

38 Blood Pressure and Cognitive Function Purpose: To assess whether BP, ambulatory BP monitoring (ABPM), or use of antihypertensives predict progression of cognitive decline in pts with AD or MCI. Study design: longitudinal cohort study, Cohort: 2 outpatient memory clinics in Italy Inclusion: 65+, DSM4 dx of dementia or MCI, MMSE 0-27 Exclusion: permanent Afib, refusal to wear ABPM, refusal to f/u Outcome Variable: change/decline in MMSE score from baseline to follow-up Determinants/Measures: at T 0 and T 5, vascular comorbidity score (0-7), ongoing anti-hypertensive use, office SBP, cognitive assessment, BADL/IADL disability; at T 0 ABPM variables (mean daytime and nighttime SBP/DBP, BP variability, nighttime BP drop) Mosello E et al, J Intern Med, April 2015.

39 *same MMSE as SPRINT Mosello E et al, J Intern Med, April 2015.

40 Cognitively impaired older adults who take antihypertensive medications and maintain SBP 128 mm Hg experience greater progression of cognitive decline over 9 months (does not apply to pt with SBP 128 NOT on AHDs) Independent of age, vascular comorbidity, baseline cognition Mosello E et al, J Intern Med, April 2015.

41 Bottom Line: Drugs and Brain Change Use of anti-hypertensive meds in cognitively impaired older adults to achieve SBP < 130 mm Hg may accelerate cognitive decline Substantial observational data supports impact of AC meds on cognition Unclear whether AC med use disproportionately used in people with brain change does not look like it

42 2016: Year of Caregiving in Dementia Pittsburgh Post-Gazette, Sept 2016.

43 The Disconnect that Leads to Dependence on Caregivers LIFESPAN HEALTHSPAN NEED FOR CAREGIVERS After discharge from hospital Oldest old, gray tsunami Physical limitations Cognitive limitations Functional limitations

44 Free Informal Caregiving Costs A Lot Kelley AS et al, Ann Intern Med, November 2015.

45 Free Informal Caregiving Costs A Lot Older Less educated Poorer Less independent Kelley AS et al, Ann Intern Med, November More total cost Less Medicare cost ~2x greater out-of-pocket ~2x greater informal care cost

46 Group Total HC$ Medicaid and Medicare$ Out-of Pocket$ Informal Care$ Ratio of out-of pocket spending to household / financial wealth Dementia 287, ,776 61,522 83,022 32% / 242% + Black 296, ,992 23, ,496 84% / CAD 175,136 96,514 35,294 32,254 Cancer 173, ,468 28,818 39,230 Other 197, ,813 36,073 43,988 Other dz group + Black Caregiving Exposes Households to Substantial Financial Risk 219, ,002 17,790 65,569 11% / 81% 30% / OUT OF POCKET: median of ratio of real out-of-pocket spending 5y before death / household wealth measured closest to fifth year INFORMAL CARE: estimated hours unpaid caregiving/month x $20/h x 5y

47 Older Adults Who Need Caregivers

48 High Cost of Poorly Coordinated (Dementia) Care

49 Effect of Poorly Coordinated Care Purpose: To examine how caregivers involvement in older adults hc activities relates to caregiving responsibilities, support services use, caregiving-related effects. Study design: observational, retrospective study Cohort: 2011 National Health and Aging Trends Study (NHATS) and National Study on Caregiving (NSOC) participants family and unpaid caregivers community-dwelling older adults with disabilities Determinant: health care activities for older adults Outcome: Caregiving-related effects (emotional, physical, financial), participation restrictions in valued activities, work productivity loss Measures: sociodemographic and health characteristics, nature and intensity of care provided, use of support services, caregiving- related effects Wolff JL et al, JAMA Intern Med, February 2016.

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51 14.7 million Caregivers and Amount of Help Provided for Health Care Activities 26.1% 29.8% 44.1% -female -adult children -older -live with care recipient -lower self-rated health Substantial Help Some Help No Help Wolff JL et al, JAMA Intern Med, February 2016.

52 Hours/wk Years of caregiving invisible work of caregiving Wolff JL et al, JAMA Intern Med, February 2016.

53 Wolff JL et al, JAMA Intern Med, February aor 1.79 aor 2.03 aor 2.21 aor 5.03 aor 3.14

54 Take-Away Few caregivers use support services Support services are not part of routine health care of caregivers, i.e. caregiver health is invisible to health care system. Family and informal caregivers provide 80% of long-term care (custodial) services to older adults. Family/informal caregivers also manage complex care needs, similar to nursing skills, but with little training. Caregivers are not routinely included in patients interdisciplinary care teams, even though they coordinate all health care services. Total spending for dementia care: $287,038

55 Effect of Poorly Coordinated Care, Part II Purpose: To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. Study design: observational, retrospective study Participants: 2012 national sample from fee-for-service Medicare claims; 1,416,369 community dwelling older adults with dementia and at least 4 ambulatory visits Determinant: continuity of care score on pt visits across physicians for 12 months (fewer clinicians=higher continuity) Outcomes measured: all cause hospitalization, observation (OP) adm, ED visits, imaging, lab testing (CT head, CXR, UA/Ucx), health care spending (overall, hospital, SNF, MD) Amjad H et al, JAMA Intern Med, Sept 2016

56 Sample Statistics Mean age 81 63% female 83% white Mean # OP visits/year: 13.6 Mean # unique OP providers seen: 4.8 Amjad H et al, JAMA Intern Med, Sept 2016

57 Continuity High continuity: 10.5 visits, 2.5 providers higher age more women and nonwhites lower household income Medium continuity: 14.8 visits, 4.8 providers Lower continuity: 15.6 visits, 7.1 unique providers More comorbidity, higher HCC score More CAD/CHF/COPD Higher health service utilization (CT scan, UA) Amjad H et al, JAMA Intern Med, Sept 2016

58 Rate of health care utilization among pts with dementia is high Does lack of continuity explain this? Amjad H et al, JAMA Intern Med, Sept 2016

59 Bottom Line Pts with most fragmented, lowest continuity care $567 million to $1.1 billion in hc spending Higher likelihood of hospitalization, ED visits, overused procedures More subspecialists (more burdensome for caregivers) Dementia=more hospital, ED use than CHF and COPD Care more reactive than proactive Higher risk of adverse event

60 Delirium 2016

61 Antipsychotics for Delirium Prevention and Treatment: Hospitals Purpose: To systematically review, conduct meta-analysis of the effectiveness of antipsychotic medications in preventing and treating delirium Study selection: 19 RCTs and cohort studies (12 perioperative delirium prevention and delirium tx in med/surg populations; 7 postoperative delirium prevention age 61-87); Drugs studied: risperidone (4), olanzepine (2), haloperidol PO/IV (13), quetiapine (3) Study quality: Cochrane Collaborative risk of bias scoring tool Inclusion: antipsychotic use to prevent/treat adult med/surg inpatients, including ICU and non-icu inpatient units Exclusion: non-english publications, pediatric, other substance withdrawal, schizophrenia, dementia, stroke, neurosurgery or trauma pts, non-hospital settings; delirium not diagnosed using validated tool Neufeld KJ et al, J Amer Geriatr, April 2016.

62 7 studies, 1970 pts OR 0.56, 95% CI ( ), I 2 =93% Heterogenous design, patients (few focused on older adults) 1 study showed preventive effect flawed Neufeld KJ et al, J Amer Geriatr, April 2016.

63 7 postoperative prevention, treatment studies; 581 individuals Similar results for other outcomes: Duration of delirium Severity of delirium Hospital LOS ICU LOS Neufeld KJ et al, J Amer Geriatr, April 2016.

64 10 studies reporting on mortality up to 30d post-hospital stay Antipsychotic use does not decrease mortality related to delirium

65 Neufeld KJ et al Strengths Similar to other metaanalyses on delirium prevention Consistent with studies of other delirium management outcomes Most comprehensive systematic review + metaanalysis Points to need for standardization of data collected, pts studied Limitations Heterogenous study design, pts, outcomes Limited homogenous data available led to merging Some studies show modest outcome improvement Few studies only age>60

66 Antipsychotics for Delirium Treatment: Palliative Care Purpose: To determine efficacy of risperidone or haloperidol relative to placebo in relieving symptoms of delirium associated with distress in patients receiving palliative care Study design: DB, parallel-arm, dose-titrated RCT; 11 Australian inpatient hospice services; ; pts with delirium and delirium symptom score of 1 or more Intervention: oral risperidone, haloperidol, or placebo q12h for 72h + supportive care +/- SQ midazolam for severe distress or safety Outcomes: improved delirium severity score (0-6) by day 3. Secondary outcomes: delirium severity, midazolam use, EPS, sedation, survival Inclusion: adults with terminal disease, DSM-IV delirium criteria, MDAS 7; other sx of delirium (distress on Nursing Delirium Screening Scale) Exclusion: delirium due to substance withdrawal, NMS, antipsychotics regularly used for another indication, AE with prior use, non-english speaking, inability to swallow, predicted survival < 7d Agar MR et al, JAMA Intern Med, January 2017.

67 249 participants randomized, 2 removed More conservative antipsychotic doses than in prior RCT

68 Primary intention-to-treat analysis Risperidone and haloperidol: significantly greater delirium sx scores than placebo Secondary MV mixed-model analysis Higher delirium sx scores: Risperidone and haloperidol Higher delirium severity score: Risperidone EPS sx: worse with Risperidone, haloperidol Agitation: no improvement with risperidone; worse with haloperidol; Midazolam use lower in placebo Death: 1.5 x more likely to die if receiving antipsychotic

69 Clinical Bottom Line: Antipsychotic Use in Delirium Does not prevent delirium Does not decrease severity or duration of delirium sx in acute or palliative care settings May increase duration of delirium

70 Determining the Right Intervention for the Right Patient

71 Honorable Mention Hippocampal Response to a 24-Month Physical Activity Intervention in Sedentary Older Adults (Rosano C et al, Am J Geriatr Psychiatry 2016) 2. Leisure-time Physical Activity Associates with Cognitive Decline (Willey JZ et al, Neurology, 2016) 3. Incidence of Dementia over Three Decades in the Framingham Heart Study (Satizabal CL et al, NEJM, 2016) 4. Etiology of Syncope and Unexplained Falls in Elderly Adults with Dementia: Syncope and Dementia (SYD) Study (Ungar A et al, J Amer Geriatr Soc, 2016) 5. Endothelial Progenitor Cell Levels Predict Future Physical Function: An exploratory Analysis from the VA Enhanced Fitness Study (Povic TJ et al, J Gerontol A Biol Sci Med, 2016) 6. Effect of Structured Physical Activity on Overall Burden and Transitions Between States of Major Mobility Disability in Older Persons (Gill TM et al, Ann Intern Med, 2016) 7. Patterns of Prescription Drug Use Before and After Fragility Fracture (Munson JC et al, JAMA Intern Med, 2016)

72 Summary Science and medicine of aging must move beyond the organsystem-based medical model in order to test, achieve outcomes that prioritize functional independence and healthspan. The most beneficial, least harmful blood pressure target for most people over 60 is SBP<150mm Hg. We as providers may be able to streamline and reduce the cost of dementia care through stronger, more supportive partnerships with family and unpaid caregivers and by improving continuity of care. Antipsychotics do not improve delirium symptoms or outcomes. For our patients to prosper through aging while living longer, our medical decision-making must prioritize prevention of functional decline including decisions to forgo interventions that will accelerate progression of frailty.

73 May you all live long and prosper! Thank you!!! Neil Resnick, MD David Pasquale, MD Leslie Scheunemann, MD Linda Eazor Photo by Wright