Disclosures JAMA Care of the Aging Patient 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 Advances in Internal Medicine 2 Objectives Learners will be able to... 1.Identify a peer-reviewed resource for clinicians in caring for older patients: the JAMA Care of the Aging Patient Series 2.Implement an assessment and treatment strategy for the older adult driver with cognitive impairment 3.Implement an assessment and treatment strategy for the older adult patient with falls A. 94 B. 98 C. 104 D. 108 10% A. B. C. D. 3 4 21% 55% 15% 1
Peggy McAlpine: World s Oldest Paraglider Reclaimed Her Guinness World Record 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. www.npr.org 5 ARTICLE #1 Driving Carr et al. JAMA 2010; 303(16):1632-1641 6 Driving: Patient Story Driving: Epidemiology Mr. W: 92 year old retired college professor PMH: OSA, HTN, osteoporosis, prostate cancer Meds: Vitamin B12 Mini Mental State Exam: 29/30 Function: Independent in ADLs and IADLs Problem: Forgetfulness and losing his way driving to a familiar museum 4% of drivers > 75 years old have dementia 20% of > 80 years old failed dementia screen. Drivers with dementia have 2x risk of crashes. Risk with driving duration after disease onset. Drivers with Alzheimer s dementia more likely Drive off road, drive more slowly, apply less brake pressure, make slower left turns, difficulty signaling and changing lanes or parking. 7 8 2
Driving: Assessment - History Has driver been in motor vehicle crashes? Has driver been in any near misses? Has driver had any tickets? 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 gotten lost in familiar areas? Driving: Assessment - Physical Vision: cataracts, diabetic retinopathy, macular degeneration, glaucoma Cognitive: sleep apnea, Parkinson s Motor: DJD, neuropathy Function: ADLs and IADLs Medications: sedating agents Antihistamines, antipsychotics, TCAs, benzodiazepines, muscle relaxants 9 10 Driving: Assessment - Tests The MMSE was NOT designed to assess driving capacity Does not predict future crashes Cutoff scores are not defined Tests of visuospatial skills and executive function predict driving impairment Driving: Guidelines 1. Screen for dementia: Moderately severe dementia should not drive 2. Evaluate for driving impairment 3. Impaired driving AND dementia = no driving 4. Impaired driving and NO dementia = continue driving, monitor every 6 months 5. Impaired driving and? dementia = referral to driving specialist, neuropsychologist, etc. 11 12 3
Cataract surgery Driving: Patient Treat obstructive sleep apnea Remove sedating medications No drinking before driving, use seatbelts, avoid multitasking Allow time for ventilation of anger We can agree to disagree Let s assess over time 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, donating Disable vehicle Use contract Discuss other reasons for driving cessation (e.g. vision) 13 14 Driving: Referrals Refer to Driving Rehabilitation Specialist Occupational therapists with additional training in driver evaluation, vehicle modification, rehab $350-500, not covered by insurance Refer to the Department of Motor Vehicles Preferable with patient s knowledge Mandatory vs. voluntary reporting by state Refer to social worker Community transportation options Driving: Summary Drivers with dementia are at risk Take a driving history from patient / family Evaluate ADL/IADLs, visuospatial skills, executive function, cognition Optimize medications Treat visual impairment Engage family, occ therapy, social work Mandatory reporting to DMV 15 16 4
What was the age of the world s OLDEST person when she died in 2009 of a fall? 'World's oldest woman' dies at 130... A. 115 B. 120 C. 125 D. 130 28% 17% 10% 45% after slipping in bathroom of new flat Kazakhstan gave her to celebrate her age A. B. C. D. Sakhan Dosova broke her hip in a fall and never recovered. 17 18 Falls: Patient Story ARTICLE#2: Falls Tinetti et al. JAMA 2010; 303 (3): 258-266 Mr. Y: 89 year old retired salesman HPI: left hip pain after fall, unsteady gait, confusion, weight loss, cognitive impairment PMH: hip fracture, CAD, CABG, HTN, gout Meds: oxycodone, aspirin, metoprolol, lisinopril, HCTZ, simvastatin, omeprazole Function: Independent ADLs, dependent IADLs Cognition: MMSE 28/30 19 20 5
Falls: The Patient s Words Falls: Prevalence Mr. Y Mr. Y s daughter > 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: traumatic brain injury Half of fallers cannot rise without help Dehydration, pressure ulcers, rhabdomyolysis Increase skilled nursing facility placement 21 22 Falls: Tests Get Up and Go Test Performance Oriented Mobility Assessment Patient rise from chair Walk 10 feet Turn Return to chair and sit Takes 1 minute Patient rise from chair Stand (side by side, 1- leg, and tandem) Turn in circle Walk 10 feet, sit Takes 5-10 minutes A. Previous falls B. Balance / gait impairment C. Decreased muscle strength D. Visual impairment E. > 4 medications F. All of the above 95% 0% 2% 0% 0% 3% 23 24 A. B. C. D. E. F. 6
Falls: Risk All were risk factors for falls, and here are more: Depression Dizziness or orthostasis Functional limitation and ADL disabilities Age > 80 Female Low body mass index Urinary incontinence Cognitive impairment Arthritis Diabetes Pain 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 25 26 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 Predisposing Factors Cardiovascular Postural hypotension Vision Medications Functional disabilities Home hazards Feet Falls: Assessment Screening / Assessment Blood pressure, heart rate, carotid sinus stimulation Blood pressure & pulse supine / standing Visual acuity, cataract screening Sedatives, anxiolytics, antidepressants, antipsychotics, antihypertensives, opiates, antihistamines, digitalis, alcohol. ADLs and IADLs Home visit, PT / OT evaluation Foot pain, bunions, toe deformities, ulcers, deformed nails, peripheral neuropathy. 27 28 7
Falls: Interventions Falls: Management (1) Intervention Relative Risk 95% Confidence Interval Cardiac pacing (for carotid sinus hypersensitivity) 0.42 0.23-0.75 First cataract surgery 0.60 0.36-0.98 Home safety modifications (in those with previous falls or risk factors for falls) Withdrawing psychoactive medications 0.56 0.42-0.76 0.34 0.16-0.73 Reduce or eliminate medications Refer for cataract extraction Refer to low vision clinic Refer to orthotist or podiatrist Refer to physical therapy for strength, balance, and gait training Exercise (Tai Chi, balance training) Variable Variable 29 30 Falls: Management (2) Refer to occupational therapy for assistive devices Cane, walker, reaching device, sock aid, long shoe horn, grab bars, shower chairs, raised toilet seats Advise well-fitting shoes with low heel and high surface contact area Avoid multifocal lenses while walking, especially on stairs Advise alcohol counseling / treatment if appropriate Falls: Management (3) Home safety measures Remove tripping hazards Ensure adequate lighting Keep a telephone at floor level or a cell phone in pocket at all times Enroll in personal emergency response system like Lifeline 31 32 8
Falls: Summary 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 medications Refer for balance exercise training Consider adaptive devices Implement home safety measures 33 JAMA Care of the Aging Patient Team The Scan Foundation The UCSF Division of Geriatrics The Program for the Aging Century C. Seth Landefeld, M.D. Amy J. Markowitz. J.D. Louise Aronson, M.D. M.F.A Anna Chang, M.D. Stephen J. McPhee, M.D. Louise C. Walter, M.D. Phil Tiso B.A. We invite you to share your patient stories... http://jama.ama-assn.org/cgi/collection/care_of_aging http://geriatrics.medicine.ucsf.edu/agingpatient/ 35 36 9
Thank you! Questions? Anna.chang@ucsf.edu 10