The Aging Hemophilia Patient. Mindy Nolte, RN VCU Hemophilia Treatment Center
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1 The Aging Hemophilia Patient and the Role of the HTC Mindy Nolte, RN VCU Hemophilia Treatment Center
2 Statistics in Aging PWH In PWH age 65 years and older, 77% had two other coexisting diseases Most common comorbidities are hepatitis C, HIV, chronic arthropathy, hypertension, and obesity Most frequent causes of death in PWH are liver cirrhosis, ischemic heart disease, neoplastic disease, and stroke
3 What is our Role in keeping Aging PWH Healthy?
4 Questions What role does the HTC play in the care of patients with hemophilia and new health risks as they age? How do we interface with the patient s primary care physician and other specialists? This is a new arena!
5 Potential Role We Can Play Standardize ways to screen for known health risks in aging PWH Develop standard treatment protocols for common procedures/surgeries seen in aging PWH Develop research protocols related to aging health issues in this population
6 How can we best help to maintain good health in aging PWH and how far should our role extend? What is the extent of comprehensive care?
7 Health Issues in the Aging PWH Complications from HIV, HCV, Chronic Arthropathy Cardiovascular Disease and strokes Renal Disease Cancer Fall Risk Dementia
8 Present Role of HTC Related to present comorbidities (HIV, HCV, arthropathy) Each HTC has screening tools, treatment recommendations, and referrals in place for patients with HIV, HCV, and chronic arthropathies
9 Examples Serial PT joint evaluations to monitor status Referral relationship with Orthopedic surgery Treatment protocols for Orthopedic surgeries Monitoring of liver related labs, liver U/S Monitoring of HIV labs Referral relationship with ID and Hepatology Treatment protocols for liver bx, liver transplant, endoscopies
10 Expanding and Modifying This Role Potential for research to help standardize these screening tools and treatment protocols across HTCs. What we currently have in place may need to change as the PWH and these comorbidities age, because of other health issues that can occur.
11 Comorbidity Effects on Aging Health Issues Liver failure Increased need for orthopedic surgeries Increased risk of CVD and renal disease in patients with HIV, HCV Increased risk of some cancers Should screening measures be different in patient s with and without these comorbidities?
12 Future Role of HTC related to Aging Health Risks Cardiac disease Strokes Renal disease Cancer Fall risk Dementia
13 Cardiovascular Disease in PWH Hemophilia diagnosis not as protective against CVD as once thought, especially in aging. Potential risk associated with use of factor products and increased factor levels Hard to assess symptoms of CVD because of physical restrictions of some PWH Joint disease may mask symptoms of PAD Decreased physical exercise, obesity, comorbidities may increase risk
14 Potential Role of HTC in Managing CVD Risk in Aging PWH Develop screening tools for PAD, CVD that incorporate unique challenges in this population (role of PT) Increase education on risk factors of CVD and how to decrease these Establish referral relationships with cardiac specialists
15 Potential Role of HTC in PWH and Cardiovascular Disease Risk Standardize management of PWH on antiplatelet therapy Standardize treatment protocols for cardiac procedures: Examples: Prophylaxis for bare metal stents vs. drug eluding stents Radial vs. femoral approach in cardiac caths
16 Risk of Renal Disease in Aging PWH Increase risk associated with hypertension, diabetes that are more prevalent in advanced age Increase risk associated with HIV, HCV, and some antiretroviral medications Increased risk associated with repeated kidney bleeds? Increased risk associated with proteins in factor concentrate Increased risk with chronic hypertension
17 Potential Role of HTC and Renal Disease Risk in PWH Standardize treatment protocols for dialysis catheter placement and management with heparin Standardize treatment protocols for renal transplant Develop screening guidelines to monitor for kidney disease Establish recommendations about Peritoneal dialysis vs. hemodialysis pros and cons in PWH. Establish referral relationship with specialists
18 Potential Role in Managing Increased Cancer Risk in Aging PWH Order screening tools for cancer surveillance: Liver U/S and labs Colonoscopies Standardize treatment protocols for colonoscopies (clipping vs cautery of polyps) Standardize treatment plan for liver transplant
19 Managing Increased Fall Risk in Aging PWH Chronic Joint disease increases risk of falls Increase fall risk can relate to increase risk of ICH, fractures Need for tools to assess fall risks as PWH age: use of OT home evals, PT evals in clinic Consideration of prophy dosing if increased falls are an issue
20 Managing Risk of Dementia in Aging PWH Increase risk of dementia as one ages Need for ongoing assessment of ability to do home therapy Develop screening tools to assess cognitive function (taking into account impact of HIV, HCV)
21 Other Potential Health Risks in Aging PWH Increase risk of inhibitors reported In severe hemophilia A 30% at age 50, 36% at age 75 Increased risk of inhibitors in mild PWH after intensive replacement (surgery) If inhibitors develop, increase risk of thrombotic events with age compounded with risk related to bypassing agents (rvii, Feiba) and with CVAD
22 Questions to ask ourselves as HTC Providers How should our role as HTC providers change in dealing with the aging PWH Should we focus on developing new screening tools for these health risks related to aging? Should we focus on standardized treatment protocols for managing surgeries/procedures related to this aging population? Should we develop research protocols related to health risks in this aging population?
23 What is our role as HTC providers and how do we interface with Primary Care Providers and Specialists? What is our definition of comprehensive care?
24
25 Whatever we develop now to deal with the current aging population of PWH will change over time as a new generation of PWH begin aging!!
26 References Zawilska K, Podolak Dawidziak M. Therapeutic problems in elderly patients with hemophilia. Polskie Archiwum Medycyny Wewnetrznej, 2012; 122 (11) Esposito P, et al. Renal diseases in haemophilic patients: pathogenesis and clinical managemant. European Journal of Haematology, 91 ( Tom AK. Hemophilia and Aging. National Hemophilia Foundation Nursing Working Group Nurses Guide to Bleeding Disorders
27 References Coppola A, et al. Emerging Issues on Comprehensive Hemophilia Care: Preventing, Identifying, and Monitoring Age Related Cormorbidities. Seminars in Thrombosis and Hemostasis, Vol. 39, No. 7/2013
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Page 1 of 5 I. TO (Required) This Section is required to be completed by all patients who undergo kidney transplant surgery. I hereby consent to and authorize Dr. and his/her assistant(s), including supervised