CHOOSING WISELY TO IMPROVE CARE FOR GERIATRIC PATIENTS

CHOOSING WISELY TO IMPROVE CARE FOR GERIATRIC PATIENTS

About Choosing Wisely First conceived by the National Physicians Alliance Funded by an ABIM Foundation grant Created 3 lists of steps physicians could take to promote more effective use of healthcare resources As much as 30% of care delivered in the US may be duplicative or unnecessary 1 1 http://www.nap.edu/catalog.php?record_id=13444

An initiative of the ABIM Foundation Choosing Wisely aims to promote conversations between physicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary

The Choosing Wisely Campaign Leading specialty societies were asked to create a list of Things Physicians and Patients Should Question To date, 56 societies have released lists, some of them releasing a second or third list Consumer Reports has worked with the ABIM Foundation to maximize reach and impact of the Choosing Wisely campaign Engaged coalition of consumer organizations to disseminate content and messages about appropriate use to the communities they serve

AGS Final Five 1 Don t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer assisted oral feeding. 2 Don t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. 3 Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better. 4 Don t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. 5 Don t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

AGS Final Five List 2 6 7 Don t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. Don t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment. 8 Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance, and clarify patient goals and expectations. 9 Don t prescribe a medication without conducting a drug regimen review. 10 Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.

Choosing Wisely : Benzodiazepines 4 Don t use benzodiazepines or other sedativehypnotics in older adults as first choice for insomnia, agitation or delirium.

Sleep Disorders in long term care settings Sleep disorders are characterized by difficulty in initiating or maintaining sleep at night, difficulty in maintaining wakefulness during day or abnormal behavior associated with sleep. Sleep disturbance and its behavioral consequences in patients are common reason for admission to LTC. False and subsequent injury may be consequence of sleep disorders.

A common problem Chronic sleep problem: 57% of older adults Alprazolam and zolpidem among top 20 prescriptions in US Used by 12% of community-dwelling elderly, 13% of nursing home residents Foley Sleep 1995. http://www.imshealth.com. Aparasu J Am Geriatr Soc 2003. Stevenson Am J Geriatr Psychiatry 2010.

Observational data Motor vehicle accidents 1.6-fold increase (95% CI, 1.29 1.97) Crashes requiring hospitalization 5.3-fold increase (95% CI, 3.6 7.9) Comparable to a blood alcohol level at the legal limit Rapoport J Clin Psychiatry 2009. Meuleners J Amer Geriatr Soc 2011.

Observational data Falls leading to hospitalization and death 1.83-fold increase (95% CI, 1.10 3.06) Hip fractures 3.11-fold increase (95% CI, 1.96 4.91) Risk greater with zolpidem Stenbacka Alcohol 2002. Finkle J Amer Geriatr Soc 2011.

Sleep Changes with normal aging Increased nocturnal awakening. Sleep is less efficient. Earlier sleep onset and awakening increased time to fall asleep decreased deep sleep. Decreased REM sleep. Increased daytime napping.

Classification of sleep disorders Insomnia. Hypersomnia Parasomnias Twilight psychosis or sun-downing (Increased confusion or restlessness late in the day).

Risk factors for sleep disorders Delirium Dementia Depression Elderly Functional impairment Multiple comorbidities (Ex: COPD, CHF, Osteoarthritis) Multiple medication use Cont d

Risk factors for sleep disorders (Cont d.) Neurologic disease (Ex: Parkinsonism, restless legs syndrome) Newly admitted to LTC Pain Post Traumatic stress disorder (PTSD) Specific medications/ substances that interfere with sleep. Environmental factors Behavioral and Psychosocial factors

Benefits versus harms NNT: 13 (95% CI, 6.7 62.9) NNH: 6 (95% CI, 4.7 7.1) Adverse event more than twice as likely as improved sleep Glass BMJ 2005.

Randomized trials 24 RCTs, 2417 participants, mean age 60, sedatives for 5 nights Memory loss, confusion, disorientation 4.78-fold increase (95% CI, 1.47 15.5) Glass BMJ 2005.

Adverse events Daytime fatigue 3.82-fold increase (95% CI, 1.88 7.80) Dizziness, loss of balance, falls 2.61-fold increase (95% CI, 1.12 6.09) Glass BMJ 2005.

Common medical conditions affecting sleep CONDITION Congestive heart failure Delirium GERD Pain Syndromes Neurodegenerative disease Psychiatric disorders Anxiety Depression Mania EFFECT Orthopnea, daytime sleepiness, nocturia Sleep wake cycle fragmentation, hyper somnolence Nighttime reflux or aspiration Onset and maintenance insomnia Sleep wake cycle fragmentation, hyper somnolence Episodic sleeplessness, Nightmares, Daytime fatigue

Treatment of sleep disorders Integrate treatment of sleep disorders into patients interdisciplinary, individualized care plan. Key feature of patient care that may reduce incidents of sleep problems is offering patients choices to the extent possible, about when to go to bed, get up and have their meals. ALWAYS RECONSIDER THE NEED OF MEDICATION THAT MAY BE INTERFERING WITH SLEEP.

Principles of Drug Therapy for sleep disorders Use the lowest effective dose. Use intermittent dosing 2-4 times weekly. Prescribe medication for short term use (No more than 3-4 weeks) Discontinue medication gradually. Be alert for rebound insomnia following discontinuation of medication. NOTE: Adapted from Kupfer and Reynolds.

Wake up refreshed and recharged Patients who take insomnia drugs can experience impairment of mental alertness the morning after use, even if they feel fully awake. FDA 1/10/13

Effectiveness in older adults Improved sleep quality: 0.11 pts (7-point scale) Increased sleep time: 25 minutes (95% CI, 12.8 37.8) Decreased night-time awakenings: 0.63 (95% CI, 0.48 to 0.77) Glass BMJ 2005.

Two exceptions Sedative-hypnotics are indicated for: Alcohol withdrawal/delirium tremens Severe generalized anxiety disorder

Pharmacological Therapy - BENZODIAZEPINES Continuous use should be discouraged because of risk of side effects such as Agitation Ataxia Daytime Sleepiness Disorientation Headache Impair motor skills Falls Rebound insomnia Nocturnal confusion due to disinhibition Cognitive deficits

BENZODIAZEPINES In short term use abuse of BZD receptor agonist is not a major problem but problems associated with their long term use require further study. Likelihood of misuse is low when BZD are used in small uses. When taken for extended period of time withdrawal symptoms and tolerance to the drugs and hypnotic effects are common.

Pharmacological treatment of insomnia Consider moving evening drugs that may be stimulating to earlier in day Steroids, stimulants Dopaminergic drugs (Sinemet, requip, etc) Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) Move drugs that may be sedating to later in evening Gabapentin, memantine, SSRI, SNRI, mirtazapine Treat underlying pain: Tylenol arthritis or ES; gabapentin; pregabalin Avoid alcohol at night (fragmentation of sleep)

NON PHARMACOLOGIC INTERVENTIONS Greater long-term effectiveness: Comfortable bed. Cool, quiet, dark room (with night light for toileting). Avoid daytime naps longer than 30-60 minutes. Good sleep hygiene throughout LTC facility. Cognitive behavioral therapy such as relaxation therapy, sleep restriction therapy are very effective. Complementary therapies such as meditation, acupressure, massage therapy may be effective.

CONCLUSION Multifactorial approach Environmental Individual behavioral Cognitive therapy Identifying/treating underlying causes Reassessment of medication regimen

Sources Finkle WD, Der JS, Greenland S, Adams JL, Ridgeway G, Blaschke T, Wang Z, Dell RM, VanRiper KB. Risk of fractures requiring hospitalization after an initial prescription of zolpidem, alprazolam, lorazepam or diazepam in older adults. J Am Geriatr Soc. [Internet]. 2011 Oct;59(10):1883 1890. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. Kripke DF, Langer RD, Kline LE. Hypnotics association with mortality or cancer: a matched cohort study. BMJ Open. 2012 Feb 27;2(1):e000850. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005 Nov 19;331(7526):1169. Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, Nielsen GH, Nordhus IH. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006 Jun 28;295(24):2851-8.