Disclosures. Care of the Aging Pa/ent: Driving, Falls, Pain, & Cons1pa1on. Objectives 10/31/12. My funding

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1 Disclosures Care of the Aging Pa/ent: Driving, Falls, Pain, & Cons1pa1on Anna Chang, M.D. Associate Professor of Medicine Division of Geriatrics, Department of Medicine University of California, San Francisco My funding SCAN Foundation Bechtel Foundation UCSF School of Medicine UCSF Academy of Medical Educators SF Veterans Affairs Medical Center Industry relationships: none Other financial relationships: none 2012 Primary Care Medicine CME 2 Objectives Learners will be able to Identify resources in caring for older patients: JAMA Care of the Aging Patient Series 2. Implement assessment and treatment for the older adult driver with cognitive impairment 3. Implement an assessment and treatment strategy for the older adult patient with falls 4. Describe management for pain in older adults 5. List therapies for constipation in older adults A. 94 B. 98 C. 104 D

2 Peggy McAlpine: Worldʼs Oldest Paraglider Reclaimed Her Guinness World Record" Objective 1: Your Clinical Resource - JAMA Care of the Aging Patient Series Peggy wasn't happy when she lost her world record. The Scottish woman was 100 when she became the oldest person to paraglide. That title was taken away by an American woman. " So at age 104, McAlpine took the the skies and regained the record." Driving: Pa/ent Story Mr. W: 92 year old re/red college professor PMH: OSA, HTN, osteoporosis, prostate cancer Meds: Vitamin B12 Mini Mental State Exam: 29/30 Func/on: Independent in ADLs and IADLs ARTICLE #1 Driving Carr et al. JAMA 2010; 303(16): Problem: Forge7ulness and losing his way driving to a familiar museum 7 8 2

3 Driving: Epidemiology 4% of drivers > 75 years old have demen/a 20% of > 80 years old failed demen/a screen. Drivers with demen/a have 2x risk of crashes. Risk with driving dura/on a`er disease onset. Drivers with Alzheimer s demen/a more likely Drive off road, drive more slowly, apply less brake pressure, make slower le` turns, difficulty signaling and changing lanes or parking. Driving: Assessment - History Has driver been in motor vehicle crashes? Has driver been in any near misses? Has driver had any /ckets? Has driver been pulled over by the police? Does driver have difficulty staying in a lane? Do other drivers honk at this driver? Has the driver gohen lost in familiar areas? 9 10 Driving: Assessment - Physical Vision: cataracts, diabe/c re/nopathy, macular degenera/on, glaucoma Cogni/ve: sleep apnea, Parkinson s Motor: DJD, neuropathy Func/on: ADLs and IADLs Medica/ons: seda/ng agents An/histamines, an/psycho/cs, TCAs, benzodiazepines, muscle relaxants Driving: Assessment - Tests The MMSE was NOT designed to assess driving capacity Does not predict future crashes Cutoff scores are not defined Tests of visuospa/al skills and execu/ve func/on predict driving impairment

4 Driving: Guidelines 1. Screen for demen/a: Moderately severe demen/a should not drive 2. Evaluate for driving impairment 3. Impaired driving AND demen/a = no driving 4. Impaired driving and NO demen/a = con/nue driving, monitor every 6 months 5. Impaired driving and? demen/a = referral to driving specialist, neuropsychologist, etc. Driving: Pa/ent Cataract surgery Treat obstruc/ve sleep apnea Remove seda/ng medica/ons No drinking before driving, use seatbelts, avoid mul/tasking Allow /me for ven/la/on of anger We can agree to disagree Let s assess over /me and see how things go Driving: Family Hide, file down, or replace car keys with keys that will not start the vehicle Send vehicle for repairs and remove Remove the vehicle: loaning, selling, dona/ng Disable vehicle Use contract Discuss other reasons for driving cessa/on (e.g. vision) 15 Driving: Referrals Refer to Driving Rehabilita/on Specialist Occupa/onal therapists with addi/onal training in driver evalua/on, vehicle modifica/on, rehab $ , not covered by insurance Refer to the Department of Motor Vehicles Preferable with pa/ent s knowledge Mandatory vs. voluntary repor/ng by state Refer to social worker Community transporta/on op/ons 16 4

5 Driving: Summary Drivers with demen/a are at risk Take a driving history from pa/ent / family Evaluate ADL/IADLs, visuospa/al skills, execu/ve func/on, cogni/on Op/mize medica/ons Treat visual impairment Engage family, occ therapy, social work Mandatory repor/ng to DMV A. 115 B. 120 C. 125 D 'World's oldest woman' dies at after slipping in bathroom of new flat Kazakhstan gave her to celebrate her age Sakhan Dosova broke her hip in a fall and never recovered. 19 ARTICLE#2: Falls Tineo et al. JAMA 2010; 303 (3):

6 Falls: Pa/ent Story Falls: The Pa/ent s Words Mr. Y: 89 year old re/red salesman HPI: le` hip pain a`er fall, unsteady gait, confusion, weight loss, cogni/ve impairment PMH: hip fracture, CAD, CABG, HTN, gout Meds: oxycodone, aspirin, metoprolol, lisinopril, HCTZ, simvasta/n, omeprazole Func/on: Independent ADLs, dependent IADLs Cogni/on: MMSE 28/30 Mr. Y Mr. Y s daughter Falls: Prevalence Falls: Tests > 1/3 of community living adults > 65 years old fall each year 10% of falls result in major injury Women: more fractures Men & African Americans: trauma/c brain injury Half of fallers cannot rise without help Dehydra/on, pressure ulcers, rhabdomyolysis Increase skilled nursing facility placement Get Up and Go Test Pa/ent rise from chair Walk 10 feet Turn Return to chair and sit Takes 1 minute Performance Oriented Mobility Assessment Pa/ent rise from chair Stand (side by side, 1- leg, and tandem) Turn in circle Walk 10 feet, sit Takes 5-10 minutes

7 A. Previous falls B. Balance / gait impairment C. Decreased muscle strength D. Visual impairment E. > 4 medica/ons F. All of the above All were risk factors for falls, and here are more: Depression Dizziness or orthostasis Func/onal limita/on and ADL disabili/es Age > 80 Female Low body mass index Urinary incon/nence Cogni/ve impairment Arthri/s Diabetes Pain Falls: Risk The risk of falling increases with the number of risk factors The 1 year risk of falling is: 8% with 0 risk factors 19% with 1 risk factor 32% with 2 risk factors 60% with 3 risk factors 78% with 4 risk factors Falls: Screening Persons > 65 years who present with a fall, report at least 1 injurious fall, or 2 or more noninjurious falls, or report / display unsteady gait or balance should undergo fall risk factor assessment and management. The American Geriatrics Society recommends screening yearly

8 Falls: Assessment Falls: Interven/ons Predisposing Factors Cardiovascular Postural hypotension Vision Medica/ons Func/onal disabili/es Home hazards Feet Screening / Assessment Blood pressure, heart rate, caro/d sinus s/mula/on Blood pressure & pulse supine / standing Visual acuity, cataract screening Seda/ves, anxioly/cs, an/depressants, an/psycho/cs, an/hypertensives, opiates, an/histamines, digitalis, alcohol. ADLs and IADLs Home visit, PT / OT evalua/on Foot pain, bunions, toe deformi/es, ulcers, deformed nails, peripheral neuropathy. IntervenKon RelaKve Risk 95% Confidence Interval Cardiac pacing (for caro/d sinus hypersensi/vity) First cataract surgery Home safety modifica/ons (in those with previous falls or risk factors for falls) Withdrawing psychoac/ve medica/ons Exercise (Tai Chi, balance training) Variable Variable Falls: Management (1) Reduce or eliminate medica/ons Refer for cataract extrac/on Refer to low vision clinic Refer to ortho/st or podiatrist Refer to physical therapy for strength, balance, and gait training 31 Falls: Management (2) Refer to occupa/onal therapy for assis/ve devices Cane, walker, reaching device, sock aid, long shoe horn, grab bars, shower chairs, raised toilet seats Advise well- fiong shoes with low heel and high surface contact area Avoid mul/focal lenses while walking, especially on stairs Advise alcohol counseling / treatment if appropriate 32 8

9 Falls: Management (3) Falls: Summary Home safety measures Remove tripping hazards Ensure adequate ligh/ng Keep a telephone at floor level or a cell phone in pocket at all /mes Enroll in personal emergency response system like Lifeline Falls are common in community elders Screen for falls yearly or more frequently Assess for and modify fall risk factors Evaluate vision, gait, balance, and feet Reduce or eliminate medica/ons Refer for balance exercise training Consider adap/ve devices Implement home safety measures Pain Treatment WHO Ladder 2 More Brief Topic Reviews: WHO Analgesia Ladder: Level 1: Non- opioid for mild pain e.g. acetaminophen, NSAID Level 2: Opioid for mild to moderate pain e.g. fixed combina/on opioid + acetaminophen/nsaid Level 3: Opioid for moderate to severe pain e.g. morphine, hydromorphone, oxycodone, fentanyl 1. Trea/ng Pain in Older Adults 2. Cons/pa/on in Older Adults

10 Pain Treatment Principles Pain medications should be given By mouth, if possible Around the clock in most cases Make reakthrough doses Using the ladder as guide (do not have to climb ladder sequentially) With adjuvant drugs to enhance analgesia (e.g. antidepressants, anticonvulsants, anticholinergics) Why do I recommend that you do NOT prescribe meperidine (Demerol)? A. It is not effective B. It doesn t last C. Its toxic metabolite causes seizures and delirium D. All of the above Meperidine (Demerol) should not be used because... A. It is not effective B. It doesn t last C. Its toxic metabolite causes seizures and delirium D. All of the above

11 Pain Opioid Equivalents Question 5 Drug Oral/Rectal IV/SC Morphine 30 mg 10 mg Oxycodone 20 mg N/A Hydromorphone 7.5 mg 1.5 mg Codeine 200 mg 120 mg (IM only) Hydrocodone 30 mg N/A Fentanyl One oxycodone 5 mg / acetaminophen 325 mg tablet (Percocet) is roughly equivalent to: A. 3 mg oral morphine B. 7.5 mg oral morphine C. 15 mg oral morphine D. 4 mg oral hydromorphone (Dilaudid) Answer - B One oxycodone 5 mg / acetaminophen 325 mg tablet (Percocet) is roughly equivalent to: A. 3 mg oral morphine B. 7.5 mg oral morphine C. 15 mg oral morphine D. 4 mg oral hydromorphone (Dilaudid) Pain Starting Doses Start with a low dose of an immediate release oral product: 5 mg hydrocodone or morphine 3 mg of oxycodone 1 mg hydromorphone Slow release tablets or patches should not be used for rapid dosage titration

12 Pain Breakthrough pain The dose for a breakthrough pain medication (used prn / as needed in addition to around-the-clock dose): 10% of the 24-hour total dose The frequency of breakthrough dosages: Every hour if oral or rectal dosing Every 30 minutes if subcutaneous Every 6-15 minutes if iv Pain Side effects Constipation All patients receiving opioid therapy should be placed on preventive laxative regimens at the same time as the opioid prescription. Nausea and vomiting Sedation, drowsiness, and somnolence Confusion, hallucinations Myoclonus Pain - Summary Assess for causes of pain (e.g. physical, psychological, spiritual, etc) Use a systematic method to treat pain (e.g. WHO pain ladder) Reassess treatment effect, and titrate therapy accordingly Prevent or treat side effects of opioid therapy

13 Constipation - Causes Immobility Opioids Antacids with aluminum or calcium Diuretics Iron NSAIDS Anticholinergics Antidepressants Antihistamine Calcium channel blockers 49 Constipation Solid Waste The first of 4 components of stool Too much, or too little, causes constipation The intestine is most efficient pushing intermediate volumes In patients with minimal fluid intake or poor gut motility, adding fiber can worsen the situation, causing an impaction. Not usual treatment target 50 Constipation Water Content Determined by water intake, general hydration status, water absorption and secretion into the intestine, and speed that stool moves through the bowel. Treatment target: Polyethylene glycol, sorbitol, lactulose: adding non-absorbed sugars to retain water in gut Constipation - Motility Patients with low activity levels (e.g. bedbound, dying) and those with certain medications can decrease gut motility Treatment target: Senna: stimulate myenteric plexus Start with 1 tablet daily (qhs) Up to 4 tablets BID

14 Constipation Lubrication Lubrication eases passage and minimizes pain with excretion Treatment target: Docusate (Colace): decreases stool surface tension, like soap Never give liquid formulation by mouth taste Mineral oil enema Glycerin suppositories Constipation - Tips Do not use docusate (Colace) alone to treat constipation Use senna + docusate for opioid-induced constipation Do not use bulk forming agents (e.g. psyllium) in elderly and debilitated Mineral oil can be used as an enema but not by mouth pneumonitis if aspirated Constipation - Tips Before increasing motility (e.g. with senna), evacuate existing constipated stool with an enema or cramping can result Magnesium and phosphorus salts are contraindicated in renal failure Sweet sorbitol and lactulose may be difficult to for patients to tolerate Constipation Summary Assess for reversible causes Determine ideal treatment target(s) Always prescribe bowel regimen along with opiates Prevention is important Do not use docusate (Colace) alone Consider polyethylene glycol for moderate to severe constipation

15 Thank you! Ques1ons? 15