What Can Geriatrics Teach Us About the Care of Vulnerable Patients?

Transcription

1 What Can Geriatrics Teach Us About the Care of Vulnerable Patients? Helen Kao MD Associate Professor Medical Director, UCSF Geriatrics Clinical Programs UCSF March 11, 2016 Objectives 1. Define vulnerabilities prevalent among older adults 2. Describe the role of geriatrics in the care of complex and vulnerable patients 3. Identify lessons from geriatrics which improve health outcomes for vulnerable patients 1

2 Older adults in U.S. Older adult population is rapidly growing Adults who reach age 65 now have a life expectancy of ~19 more years 48% of older adults are economically vulnerable (income <2x supplemental poverty level) 46% of women 75+ live alone US Administration on Aging 2014 data Vulnerabilities among older adults High degree of chronic conditions Greater proportion of physical disabilities and cognitive impairment Require significant caregiving At risk for abuse, neglect, and being taken advantage of Carry large burden of informal caregiving Freedman V et al., "Trends in Late-Life Activity Limitations in the United States: An Update From Five National Surveys," Demography 49, no. 4 (2012) King DE et al. JAMA Internal Medicine, online Feb. 4, 2013 Acierno, R. et al. The national elder mistreatment study. Am J Public Health, (2), Wiglesworth, A. et al. Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 2010; 58 (3),

3 Need for care: a growing problem Most adults are unprepared for disability and caregiving needs as they age Many adults mistakenly assume that Medicare will take care of their social care needs should they lose their independence Medical-Legal movement to encourage inclusion of financial and long-term care planning in ACP counsel (prepare for incapacity, not just EOL) Hooper S, Kao H Moving ACP Upstream. 10/6/ % everything else For patients with the most complexity The best care is, at most, 50% medical... and 50% everything else Lessons to be learned from caregivers, nurses, social workers, psychotherapists, pharmacists, rehab specialists, and others 3

4 Lesson 1: Medical care is not the same as health care Families progressively or catastrophically thrown into caregiving role; need to know how to provide total bed care and wound care to a grown adult Contrast this to new parents flooded with information on how to care for their newborn Home Health can educate caregivers how to adapt environment and care to a dependent adult Geriatrics counsel can help families read signs and symptoms of changes in status which can be managed as outpatient and don t warrant 911 Lesson 2: Help families help patients Geriatrics focuses on how someone functions and identifying mismatch between a patient s functional impairments and what their home and caregivers can provide Understanding what environmental, device, and care adaptations can be made, and which interprofessional disciplines to call upon, can help families support vulnerable adults 4

5 Lesson 3: Med review is a window into a patient s entire situation Polypharmacy; potential interactions or adverse effects Potentially inappropriate medications Health literacy Cognitive impairment Financial struggles Manual/swallowing difficulties Vision trouble Disorganized/inadequate care oversight Uncoordinated care amongst clinicians Medication biopsy Amlodipine 2.5mg 4x/day Aspirin 325mg daily Gabapentin 100mg nightly Losartan 50mg daily Losartan-HCTZ 50/12.5mg daily Lupron injections every 3 months Meclizine 12.5mg as needed for dizziness Methyldopa 500mg 4x/day Rabeprazole (aciphex) 20mg daily Diazepam (valium)?? As needed for anxiety, dizziness 5

6 Lesson 4: Less is more It is easy to write prescriptions But can take months to safely taper patients off meds they have become dependent on physiologically or simply bc they ve taken something for decades and are afraid to stop Med regimens should not only address polypharmacy but match a patient s prognosis, goals, cognitive and manual dexterity function, swallowing ability, etc. Dementia care 1 in 9 adults age 65+, and ~1 in 3 age 85+ have dementia Prospective studies have found low SES associated with incidence of dementia Dementia is leading cause of institutionalization for vulnerable and lowincome older adults Alzheimers Association Facts and Figures 2015 Yaffe K et al. BMJ 2013;347:f7051 Van Rensbergen G, Nawrot T. BMC Geriatrics 2010; /

7 Agitation? Describing someone with dementia as agitated does not help identify or solve the neuropsychiatric symptom (NPS) agitated is as non-specific to a geriatrician as rash is to a dermatologist Describe the NPS, determine if there are triggers, and whether it is tolerable behavior or at risk of causing harm Describing behaviors Examples: Easily upset Repetitive questions Agitated Arguing or complaining Hoarding Pacing Inappropriate screaming, crying, sounds Rejection of care Leaving home 7

8 Types of neuropsychiatric sx Apathy, depression, or dysphoria Delusions (distressing beliefs) Hallucinations (visual, auditory, tactile) Aggression/violent outbursts Anxiety, worry, shadowing Wandering, rummaging (repetitive activity) Disinhibition (social or sexual behavior) Night behaviors (waking and getting up) Irritability or lability Lesson 5: Sometimes what needs treatment isn t the patient Though we always try to keep someone in their own home, sometimes this isn t the best option (whether due to inadequate care, abuse/neglect, triggering risky behaviors) Adult day programs, changing caregivers, or changing the environment and moving to a different family home or facility, can minimize or extinguish NPS 8

9 Examples of modifications For 84yo hispanic woman with dementia and violent aggression (throwing knifes) Take her for walks to calm her Provide her a plant she can take care of Provide her own dishes to do housework to help her feel at home Change her roommate (to one who was minimally verbal to avoid irritating her) Provide Spanish-language magazines Be in her reality Antipsychotic Epidemic 1 in 3 nursing home residents and 1 in 7 community-dwelling adults with dementia are prescribed antipsychotics 41% of nursing home veterans who were given antipsychotics had NO evidencebased indication Gellad et al. Med Care 2012 GAO Antipsychotic Drugs and Older Adults

10 CATIE-AD: antipsychotic v placebo CATIE-AD RCT study: 421 outpatients Risperdal, quetiapine, olanzapine, placebo* Ave tx length 7 wks (due to adverse effects) Risperdal (1mg) > olanz (5mg) > quet (mg50) for paranoia/hostility/aggression/ mistrust, psychosis No change in function or care needs Olanz worse withdrawn depression, ADL function Sultzer DL et al. Am J Psych 2008 Risks of Antipsychotics x increased risk of mortality 2-3x increased stroke risk CV and metabolic effects (obesity, glucose) Extrapyramidal symptoms Worsening cognition Falls Hospitalizations Schneider et al JAMA 2005; Trifiro et al Pharmacol Res 2009; Schneider et al. Am J Ger Psych 2006; Schneider et al NEJM 2006; Gurwitz et al. Am J Med 2005; Rochon et al. Arch Int Med

11 Translating risk NNH risk of death occurs as early as <6mo Maust et al. JAMA Psychiatry 2015; GAO Antipsychotic Drug Use, Jan 2015 Determine what underlies behavior We wouldn t medicate a colicky child, so don t medicate an adult w dementia without first identifying whether there is discomfort or a need they are unable to communicate: Pain Depression / Anxiety Hot or cold Hunger or thirst Toileting needs Overstimulation Loneliness / isolation Feeling threatened Cohen-Mansfield and Werner 1999; Meares and Draper 1999; Hallberg et al 1993; 11

12 Lesson 6: There are many ways in medicine to save a life There is saving life and there is saving quality of life Dementia patients are susceptible to iatrogenic harm from polypharmacy Medication adverse effects can lead to inappropriate/premature hospice referrals Larson C, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA IM 2015:175(11):1750. Lesson 7: Change behavior to fix behavior Labs, xrays, tests are rarely useful in managing dementia neuropsychiatric behaviors Identifying ways in which a caregiver interacts/communicates with a dementia patient suboptimally can help you intervene/counsel/educate to improve a problem behavior more than prescriptions 12

13 Lessons from Geriatrics 1. Medical care is not the same as health care 2. Help families help patients 3. Med review is a window into a patient s entire situation 4. Less is more 5. Sometimes what needs treatment isn t the patient 6. There are many ways in medicine to save a life 7. Change behavior to fix behavior Helen.kao@ucsf.edu 13