Doing Geriatrics in a Busy Practice

Transcription

1 Doing Geriatrics in a Busy Practice Clinical Pearls in Caring for Older Adults Anna Chodos, MD Assistant Professor Division of Geriatrics, UCSF 1. Assessing Function & Cognition in Primary Care 2. Prognosis and Advance Care Planning 3. De-prescribing tips Function & Cognition Mr. L Mr. L is 69yo, has afib, diabetes, neuropathy. New patient 1

2 You screen for cognitive impairment Mini-Cog 1. 3-item recall: Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The words are [e.g. banana, sunrise, chair ]. Please say them for me now. If the person is unable to repeat the words after three attempts, move on to Step 2 (clock drawing). You screen for cognitive impairment Mini-Cog 2. Clock drawing I want you to draw a clock for me. First, put in all of the numbers where they go. When that is completed, say: Now, set the hands to 10 past 11. Use preprinted circle (see next page) for this exercise. Repeat instructions as needed as this is not a memory test. Move on if clock is not complete in three minutes. You screen for cognitive impairment 3. Finish recall: What were the three words I asked you to remember? Mini-Cog Scoring Recall: 1 point for each word spontaneously recalled without cueing Clock: A normal clock has all numbers placed in the correct sequence and approximately correct position (e.g., 12, 3, 6 and 9 are in anchor positions) with no missing or duplicate numbers. Hands are pointing to the 11 and 2 (11:10). Hand length is not scored. Total score = Word Recall score + Clock Draw score. A cut point of <3 is validated for dementia screening. A more sensitive cut point for all types of cognitive impairment (including mild) is <4. 2

3 Mini-Cog results What MORE do you ask? Results: 1/3 words SCORE: 1 (1 word without cueing) + 1 (numbers ok) = 2 (POSITIVE SCREEN) What questions about cognition (See next slides for tips)? What questions about function? Discuss with a neighbor for 5 min. Pearls: Cognition Ask about more than 1 domain. Ask about trajectory. Get comfortable with a test. GP-Cog MOCA: use the instructions Cognitive Symptoms: Memory Problems with recent events Trouble remembering conversations, repeating things Remote events (generally remain intact until later in disease) Misplacing objects Repetitive Questions Missing appointments Objective findings: Repeats complaint stated earlier in visit, unable to do short-term recall exercise 3

4 Cognitive Symptoms: Executive Function Difficulty with planning or organization Multi-tasking Concentration/attention span Problem Solving Impulsivity (acting without thinking) Mental rigidity/inflexibility Objective findings: Difficulty following complex instructions, difficulty with clock draw or trails Cognitive Symptoms: Language Word finding trouble Poor articulation Impaired comprehension Impoverished speech (e.g. thingie instead of specific word) Impaired reading/writing/spelling Mutism/ Decreased speech output Objective findings: Can name <11 words in 1 minute, poor score on Boston Naming Test (doesn t know names of high frequency words) Cognitive Symptoms: Visuospatial Cognitive Symptoms: Behavioral Lost in familiar environments Difficulty recognizing faces Difficulty driving Difficulty parking Objective finding: Trouble drawing a cube Changes in emotional expression (blunting/labile) Changes in personality/behavior Apathy/decreased motivation Obsessive/compulsive behaviors Agitation/aggression Depression Delusions/Hallucinations Impaired Hygiene/eating Changes in sleep 4

5 Cognitive Symptoms: Motor Difficulty with walking or balance Trouble using utensils (apraxia) Change in handwriting Tremor Weakness Involuntary movements Trouble Swallowing Objective findings: Falls, cannot demonstrate how to brush teeth or hair (apraxia) You ask a bit more He has noticed that he loses his glasses and wallet often. He could not find his wallet the last time this happened. He is with his wife. She chimes in that he never remembers his appointments and now she has to put them on a calendar and remind him. He is not sleeping as well, he gets up several times a night. You have 5 min to do a test 5

6 GP-Cog: Score Part 1 Mr. L scores a 6 (misses 2 in the recall and gets the hands on the clock right). You go on to do Part 2 GP-Cog Part 2: Informant Yes No Don t N/A Know Do this part if score <9 on Part 1. 6

7 GP-Cog: Scoring Part 2 Mr. L s score: 1 all were YES except for difficulty speaking. ADL Function Do you any help, direction or total assistance with. (yes = 1, no = 0) Bathing Dressing Toileting (Continence) Transferring Feeding Katz ADL Score IADL Function Do you any help managing: (yes = 1, no = 0) Transportation Using the phone Shopping Cooking Laundry Cleaning Doing your finances Managing medications Lawton IADLs ADLs His and his wife s answers IADLs Bathing No Transportation Yes Dressing No Using the phone No Toileting No Shopping Yes Transferring No Cooking Yes (no change) Feeding No Laundry Yes (no change) Cleaning Yes (no change) Doing your finances Yes Managing medications Yes 7

8 Pearls: Function Ask about baseline = 2 weeks ago and before. Ask about now. Change = decline Monitor over time, especially after hospitalizations or other sentinel events, e.g. a fall. You test Mr. L, again: MOCA Your next patient didn t show and you have more time, so you decide to do a MOCA. The MOCA: Bring the instructions with you in clinic. Let s get some pearls! Trails = executive function Cube= visuospatial function Clock= BOTH, visuospatial >executive function 8

9 Sustained attention/tapping = attention, concentration, working memory Serial subtraction Digits forward and backward Naming/confrontation= language Learning 5 nouns and 5- minute recall = Shortterm memory Repetition= language Phonemic fluency task = executive and language Two-item verbal abstraction task = executive Mr. L Learning 5 nouns and 5- minute recall = Shortterm memory Orientation = Orientation Score <26: MCI or dementia Adjust for education: 2 points added for 4-9 years of education 1 point added for years of education MOCA is 19/30. Mr. L went to college (no correction for education). He was a small business owner until retirement at age 63. His decline started around that time. 9

10 Does he have dementia? You do not have a prior cognitive test to compare to. But you have a history of progressive and gradual decline in cognition and function. Evidence of impaired domains on testing. You should inform them of your findings and concern, but do the next stages of the exam and workup. Disclosing the diagnosis Let s say you have normal labs, no concerning findings on neuro exam. No head imaging needed. Majority of patients and caregivers report they would want to know. You can now encourage advance care planning, family and caregiver education. If you don t feel sure, you can also say that time is a helpful diagnostic. Then follow-up, reassess, send to specialists, etc, and ultimately diagnose. Do I need to report? California: dementia is a reportable condition to your local health department. Disorders Characterized by Lapses of Consciousness ( ) There is no penalty for NOT reporting. ents/reportable_diseases_conditions.pdf They report to DMV. Do I need to report? Nevada: not a reportable condition, no requirement for DMV reporting. seasenvrept.pdf There is a confidential physician DMV report you can do within 30 days of exam. 10

11 Prognosis & Advance Care Planning Mr. L You think he likely has early dementia. Prognosis is ~8 years. Should you prioritize advance care planning? WHY? WHAT do you do? What is Prognostication? Two parts: 1. Estimating the probability of an individual developing a particular outcome over a specific period of time (prognosis). 2. Communicating the prognosis with the patient and/or family. Prognostication can change treatment Intervention should be targeted to patients whose life expectancy > time to benefit. Will this person survive to benefit from those interventions that have delayed benefits? What risks are they exposed to? 11

12 Why prognosticate? Life Expectancy Clinical Decision <4-6 weeks Methylphenidate over SSRI for depression >3 months Surgery for spinal cord compression due to metastatic cancer superior to radiation therapy <6 months Discontinue statins <6 months??? No need to measure QTc prior to starting methadone <1-2 years Nonoperative management of AAA <2-3 years Tight BP control in diabetes unlikely to prevent stroke, MI <5 years Bio-prosthetic heart valve over mechanical <8 years Discontinue tight blood sugar control in diabetes <10 years Discontinue breast and colon cancer screening Pearl: How can we prognosticate? 1. Clinical judgement Physicians are better in the short term > long term 2. Life expectancy (population averages) Age is not the best predictor (things like function, mobility can help stratify a little) 3. Use a prognostic index eprognosis.org spend a few minutes exploring this website Advance Care Planning What is the point? Paperwork? DNR/DNI documentation? Comply with an EHR quality measure? We want to: Elicit and document values Document surrogate decision makers Is that it? Pearl: ACP = Planning for incapacity We are preparing patients and families for the possibility (and in dementia, nearly certain eventuality) of incapacity. This means Preparing (not just documenting) a surrogate. Documenting any clear values and preferences. Planning for more than just medical decision making incapacity. ALSO LEGAL. 12

13 Pearl: Goals and Values Advance directives ask for choices to be made IN ADVANCE and often OUT OF CONTEXT. (I.e. not how people make decisions!) For example, what do you want for lunch next Saturday? Don t you need to know where you re eating, what s available, how hungry you are, etc? On the other hand, maybe you always have the same thing on Saturdays. Pearl: Goals and Values Ask patients about their prior experiences with health care for themselves or with family/friends. Give them options to understand what you are asking. What seems more like you? Which of the following statements is most true for you? You may choose one, or create your own: Try to live as long as possible, even with pain or disability? Try treatments for a period of time, but stop if you are suffering? Focus on quality of life and comfort, even if your life is shorter? Sudore R, Fried T. Redefining the Planning in Advance Care Planning: Preparing for End-of Life Talk with your surrogate! PREPARE Videos to help people and their surrogates talk about goals and values. (In English and Spanish) Use any other tools you like! (Five Wishes, etc.) Decision Making. Ann Intern Med. 2010;153:

14 Pearl: Triage ACP Steps 1. Prioritize poor prognosis patients. 2. Document a surrogate and ask your patient to communicate this choice to that person/s. 3. Continue a discussion about goals and values and complete paperwork, e.g. advance directives, POLST, as you can. 1. Priority to formalizing surrogate decision makers when there is no legal hierarchy (e.g. California) What about legal advance care planning? Legal matters = financial = benefits. Poor does not mean no need for planning. Find services for legal (legal=financial advance care planning) in your area that can help older adults, especially lowincome. Communicating prognosis De-prescribing Tips What do you say to him about overall prognosis? What do you say to him about limiting cancer screening from now on? Look at videos: ndex.php 14

15 You review Mr. L s medications Glyburide, 2.5 mg Digoxin, mg Warfarin (varying dose) Etodolac, 400 mg Docusate sodium, 100 mg Multivitamin and iron, each taken daily Metoprolol, 25 mg Gabapentin, 300 mg; twice daily Essential fatty acids, 3 times daily Acetaminophen, 650 mg every 6 hours PRN Lactulose, PRN 12 medications at 16 scheduled doses per day More medications = more risks Each new medication increases the risk of an adverse drug event (ADE) each year Taking six or more medications substantially increases the risk of an ADE Pearls: Medication management Minimize medication use A problem does not have to equal medication Medications in older adults should be carefully chosen and dosed appropriately Periodic review of all medications (you d be amazed what you don t know!) Decrease dose or frequency when possible Avoid inappropriate medications Inappropriate medications onlinelibrary.wiley.com/doi/ /jgs /pdf 15

16 Another resource STOPP/START criteria Step by-step 1. Get an accurate list (e.g.review medication bottles, call the pharmacy, ask about OTC) 2. Look for inappropriate medications, no matter what the indication. -> d/c or substitute Entire class is inappropriate Drug-drug interaction Drug-disease interaction 3. Look for medications without an indication -> d/c or substitute Step-by-step 4. Look at all medications for decrease in dose and/or frequency. Also review renal function. 5. Look at ALL medications for safer substitution. 6. Make notes for appropriate monitoring and follow-up. No, you don t need to do it all in one visit! Steinman, JAMA 2010;304(14): What do you think about Mr. L s meds? Glyburide, 2.5 mg Digoxin, mg Warfarin (varying dose) Etodolac, 400 mg Docusate sodium, 100 mg Multivitamin and iron, each taken daily Metoprolol, 25 mg Gabapentin, 300 mg; twice daily Essential fatty acids, 3 times daily Acetaminophen, 650 mg every 6 hours PRN Lactulose, PRN 12 medications at 16 scheduled doses per day 16

17 What else can help you decide? If you need to choose between medications to stop/start/prioritize, ask your patient what his/her goals are. What is causing the most potential or actual harm? What is easiest to d/c? Any questions? 17