Doreen Wan-Chow-Wah, MD, FRCPC Assistant Professor, Division of Geriatric Medicine, Department of Medicine McGill University Health Center Associate

Transcription

1 Doreen Wan-Chow-Wah, MD, FRCPC Assistant Professor, Division of Geriatric Medicine, Department of Medicine McGill University Health Center Associate member, Department of Oncology McGill University Medical Director, Geriatric Oncology Clinic, Segal Cancer Centre 68 th Annual refresher course for family physicians Hotel Bonaventure November 29, 2017

2 Disclosure I have no disclosure statements.

3 Objectives: 1. How to minimize pill burden and optimize prescribing? 2. What is the target HbA1C in the elderly? 3. Is my patient safe to drive? 4. Insomnia in older adults: Which sleeping pill? Can we choose the lesser of many evils

4 Mr. V 84 M came to clinic with his wife, using a cane PMH: Anxiety Vertigo DM2 HTN CAD, CABG x 3 in 2007 OA knees Independent in ADLs and IADLs, though wife supervises meds Wife s concerns: short-term memory loss, driving

5 Mr. V s meds Serc 8 mg TID Ativan 1 mg qhs Clonazepam 0.5 mg BID Metoprolol 25 mg BID Simvastatin 40 mg qhs Gabapentin 400 mg TID Metformin 500 mg BID Saxagliptin 5 mg qd Pantoloc 40 mg qd ECASA 80 mg qd

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7 Polypharmacy About 1/3 of community dwelling older adults take 5 prescription drugs (Qato et coll. JAMA 2008;300(24): ) Prevalence of inappropriate medications in elderly outpatients is 21% Aging has an impact on pharmacokinetics( GFR, changes in body composition, changes in hepaticmetabolism) Drug-drug, drug-disease, drug-geriatric syndrome interactions Inappropriate drug use in the elderly (Beers criteria, STOPP/START)

8 Discontinuing Medications: A Novel Approach for Revising the Prescribing Stage of the Medication Use Process Bain KT 1, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. J Am Geriatr Soc 2008 Oct;56(10): doi: /j x. Epub 2008 Sep 2.

9 Bain KT 1, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. J Am Geriatr Soc 2008 Oct;56(10): doi: /j x. Epub 2008 Sep 2.

10 Safely reducing or stopping medications is a team effort. Dr. Barbara Farrell and Dr. Cara Tannenbaum

11 ca/clinician-tools

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14 STEP-BY-STEP WEANING PROGRAM We recommend that you follow this program under the supervision of your doctor or pharmacist. EMPOWER Trial Tannenbaum C et al. JAMA 2014 Stopping benzodiazepines 17 Legend Full dose Half dose Quarter of a dose No dose 8 All rights reserved. Copyright 2014 by Cara Tannenbaum and Institut universitaire de Gériatrie de Montréal. Downloaded From: by a McGill University Libraries User on 07/11/

15 Mr. V s meds Serc 8 mg TID Ativan 1 mg qhs Clonazepam 0.5 mg BID Metoprolol 25 mg BID Simvastatin 40 mg qhs Gabapentin 400 mg TID Metformin 500 mg BID Saxagliptin 5 mg qd Pantoloc 40 mg qd ECASA 80 mg qd

16 2.What is the target HbA1C in the elderly?

17 HbA1C target in frail elderly Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.

18 Frail elderly Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.

19 How do I know my patient is frail? How can I predict life expectancy? Look at how fast they walk: 4 meter gait speed Any functional impairment? e-prognosis

20 Gait Speed and Survival in Older Adults. Studenskiet al. JAMA. 2011;305(1):50-58

21 Rockwood, Kenneth et al. A Global Clinical Measure of Fitness and Frailty in Elderly People. CMAJ : Canadian Medical Association Journal (2005): PMC. Web. 27 Nov

22 eprognosis Lee S. et al. Geriatric prognostic indices based on Prognostic indices for older adults: A systematic review. Yourman et al. JAMA 2012;307(2): Designed for older adults without a dominant terminal illness Rough guide for clinicians about possible mortality outcomes

23 eprognosis Lee S. et al.

24 Lee S. et al.

25 eprognosis for Mr. V 84 M BMI 25 Ever had cancer No Diabetes - Yes COPD that limits activities at home No CHF No Currently smoking - No Difficulty bathing/showering without help No Difficulty managing finances on their own - No Difficulty walking several blocks - Yes Difficulty pulling/pushing large object - No

26 Lee index 4 and 10 year mortality Lee S. et al.

27 3. Is my patient safe to drive?

28 CMA Driver s Guide 9 th Edition Section 7: Aging Mandatory reporting of medically unfit drivers except in Nova Scotia, Quebec and Alberta (discretionary) Red flags the 3Rs RECORD: Family/caregiver history: concerns, unexplained damage to vehicle, speeding tickets, near crashes/crashes RECENT CRASHES: reported by patient RESTRICTION: of driving to less complex situations Mr. V

29 Approach to assessing fitness to drive in patients with cardiac and cognitive conditions Frank J. Molnar MSc MDCM Christopher S. Simpson MD. Canadian Family Physician Le Médecin de famille canadien Vol 56: November Novembre 2010 Mr. V: Cognition Neuromusculoskeletal disease Drugs

30 CMA Driver s Guide 9 th Edition Section 8: Dementia and Mild Cognitive Impairment Increasing number of older drivers with dementia Canadian Dementia Guidelines (Third Canadian Consensus Conference on Dementia: Hogan et al. 2008) Diagnosis of dementia is not sufficient to withdraw driving privileges Moderate to severe dementia is a contraindication to driving. Driving is contraindicated in people who, for cognitive reasons, can t perform multiple IADLs or any ADLs independently Abnormal MMSE, clock-drawing, Trail B should trigger further testing Mild dementia: need re-evaluation every 6-12 months

31 Montreal Cognitive Assessment test (MoCA): Screening tool for Mild Cognitive Impairment

32 Mr. V

33 4. Insomnia in older adults: Which sleeping pill? Can we choose the lesser of many evils

34 Insomnia in older adults Educate your patient about changing sleep patterns with age Sleep fewer hours Take longer to fall asleep Less time in deeper stages of sleep Bunka, D. Oct 2013

35 Insomnia non pharmacological Manage underlying comorbidities (CHF, GERD, OSA, RLS, pain..) Address drug/substance use that can worsen sleep Diuretics (stimulating) antidepressants (Venlafaxine, Citalopram) Acetylcholinesterase inhibitors, alcohol, steroids, levodopa, Non-pharmacological measures Sleep hygiene Sleep restriction Relaxation Cognitive behavioural therapy Bunka, D. Oct 2013

36 Insomnia pharmacological Use lowest effective dose, short-term 2 weeks Re-evaluate chronic use Melatonin: 1-3 mg qhs (max 5 mg), 2-3 hours before bed Look for Natural Product Number, better quality Non-benzo hypnotic! Zopiclone mg qhs Zolpidem 5 mg SL qhs (shorter acting) (! Inappropriate in elderly) Bunka, D. Oct 2013

37 Insomnia - pharmacological Other agents- depends on comorbidities Quetiapine mg qhs (BPSD)! Nortriptyline mg qhs (chronic pain)! Mirtazapine mg qhs (depression) Trazodone mg qhs (sundowning) Intermediate-acting benzo! Temazepam 15 mg qhs Lorazepam 0.5 mg qhs Oxazepam mg qhs (! Inappropriate in elderly) Bunka, D. Oct 2013

38 Geriatric Pearls: 4 take homes 1. Less is more Think about deprescribing at each patient encounter 2. Avoid tight glycemic control in frail elderly Target HbA1C 8.5% 3. Assessing fitness to drive Remember the 3Rs,CanDrive, clock drawing and Trail B 4. Improving sleep Favor non-pharmacological approach All drugs potentially harmful, use lowest dose, short-term