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Primary Care of Older Adults: Pearls and Pitfalls
Colleen Christmas, MD, FACP
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Disclosures
• I have not received any payments from companies related to this talk.
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Objectives
• Describe a few general principles that can guide the primary care of older adults
• Describe an approach to choosing tests and treatments
• Describe an approach to medication review• Know when exercise is beneficial
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You’ve seen one 80 year old…
Thejournal.iewww.sunsetbeachclub.com
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DRUGS CAN BE DANGEROUS
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Patient #1
• 78 year-old man with dementia and behavior problems noted to have lost 9kg in past year (~10% of body weight)
• Also:– Chronic kidney disease– Hypertension– Edema– Atrial fibrillation
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What next?
• Medical evaluation normal• Psychiatrist and nursing home want to start
mirtazipine and nutritional supplements• You review his meds:
– Donepezil 23mg daily -omeprazole– Lisinopril -digoxin– Furosemide -citalopram– Aspirin– Amlodipine
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Drugs are Dangerous• Drugs should always be included in differential diagnosis• Resist temptation to treat all symptoms with drugs• Adverse drug reactions more frequent / severe in elderly• Starting any medication in older patients should be
viewed as a major intervention• “Start low, go slow”
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Geriatric Medication Review• Does every medication have a diagnosis?• Do diagnoses have matching high yield medications?
– Aspirin in coronary disease• Are medications working?
– Is mood improved with antidepressant?• For medications that need monitoring, is it up to date?
– Digoxin level, renal function for ACE inhibitors• Can anything be simplified?• Is one drug being used to treat side effects of another?
– Amlodipine -> edema -> furosemide• Is adherence and/or cost an issue?• Are the medications and treatments in line with the patient’s
goals of care? (longevity, function, comfort)
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Top Medications for Older Adults to Avoid
• Non-steroidal anti-inflammatory drugs• Digoxin in doses greater than 0.125 mg• Certain diabetes drugs
– Sulfonylureas, especially long acting• Muscle relaxants• Certain meds for anxiety/insomnia
– Benzodiazepines, sleeping pills• Anticholinergic drugs• Antipsychotics (unless patient has psychosis)• Estrogen pills and patches
www.americangeriatricssociety.org
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High Risk Drugs• Drugs associated with high rates of hospitalization
– Warfarin– Insulin– Oral hypoglycemics– Antiplatelet agents - aspirin and clopidogrel
– Digoxin
• 67% of hospitalizations for ADEs between 2007 and 2009 were due to top four medications listed above
• Two-thirds of hospitalizations for ADEs were due to unintentional overdoses Budnitz et al, NEJM 2011
Budnitz et al, Ann Int Med 2007
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Patient #1
• Needs careful medication review• Anorexia and weight loss
– Donepezil 23mg• Not more effective than 10mg (2 points on 100 point
scale)• Clinically significant increase side effects
– Digoxin• Amlodipine and furosemide?
Farlow. Clin Ther2010. Rathore NEJM 2002.
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Patient #2
• 89 year-old man reports fatigue and taking too many medications
• Accompanied by son and daughter• They are concerned about his safety and
ability to remain at home• Medications are expensive
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His Current Care PlanCondition Medical TreatmentProbable Alzheimer’s Disease donepezil, memantineSystolic Heart Failure furosemide, metoprolol,
lisinopril
Osteoarthritis acetaminophen, tramadolOsteoporosis calcium, D, alendronateInsomnia zolpidemType 2 Diabetes Mellitus metformin, glyburideBenign Prostatic Hyperplasia tamsulosin
Additional medications: aspirin, simvastatin
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His Current Care Plan
• Current data: – Mini Mental State exam 23/30– Sitting blood pressure: 110/70 pulse 54;
standing: 100/60 pulse 56– HemoglobinA1c 6.8% (3 months ago 7%)– Lipid panel: total 180, LDL 70, HDL 50,
triglycerides 300– Labs: Creatinine: 1.7
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Time Horizon to Benefit
• Length of time needed to accrue an observable and clinical meaningful risk reduction for a specific outcome
• Different than number needed to treat or harm
• May be different than the trial length
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Case: Evidence
• Osteoporosis– Bisphosphonates for osteoporosis effective, with a
modest absolute risk reduction
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Osteoporosis
TIME
% fr
act
ure
-fre
e
50% reduction in risk of fracture over a 3 year period
1.2% absolute risk reduction for fractures in 3 years
Median life expectancy: 2.7- 4.7 years
Time to benefit 9 to 18 months
bisphosphonate
National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis, 2009
placebo
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Reasons to Stop the Bisphosphonate
Black DM, Schwartz AV, Ensrud KE, et al. JAMA 2006;296:2927-38.
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General Principles
• When thinking about starting or stopping a drug, ordering a screening test, or prescribing other therapy, need to consider:– What is this person’s estimated life expectancy?– Is that estimate long enough to get benefit from
the proposed action?– Is the absolute benefit reasonable?
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Patient #3• 80 year old woman• Type 2 diabetes,
hypertension• Independent all activities• Walks 1 mile every other
day• Lives with sister, helps her
with shopping• No family history of
cancer• Should she have a
mammogram?
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Life Expectancy for Women
Adapted from Walter. JAMA. 2001
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eprognosis.ucsf.edu
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Risk of Dying From Breast Cancer in Remaining Lifetime
Life expectancy
21.3 15.7 9.5 17 11.9 6.8 13 8.6 4.6
% risk of dying
3.3 2.2 1.2 2.8 1.8 0.9 2.4 1.5 0.7
Age 70 Age 75 Age 80
Walter. JAMA. 2001.Walter. Ann Intern Med. 2004.
Risk of dying from breast cancer = Life expectancy x Age-specific breast cancer mortality rate
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Patient #3
• Estimated life expectancy=13 years• Risk of dying from screen-detectable breast
cancer=2.4%• www.cancer.gov/bcrisktool• Preference maintain health and independence• Worries about stigma and mammograms
causing cancer• No significant barriers
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www.americangeriatrics.org
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EXERCISE IS GOOD FOR WHAT AILS YOU
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Patient #4
• 75 year-old woman with major depression, knee osteoarthritis, hypertension– Knees hurt– Tired– Tired of taking pills– Spends much of day sitting– Needs help to do household chores
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Aging
DisuseIllness
Aging resembles being sedentary
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Role of exercise
• Minimize physiologic changes associated with typical aging
• Decrease risk of several common chronic diseases
• Assist in prevention and treatment of disability• Serve as primary or adjunctive treatment for
some chronic diseases
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BenefitsCondition Effect
Osteoarthritis Almost all studies show benefitInterventions: many; quad strengtheningModerate effect on pain (10-15%)Some effect on function (~10%)Low intensity may = high intensity
Depression Response rates=31% to 88% High intensityMost significant effects in those with comorbid illness
Osteopenia Strength and weight-bearingOverall treatment effect of exercise training was a reversal or prevention of bone loss of 0.9% per year
Hart, et al. Clin J Sport Med 2008; Fiatarone Singh MA Clin Geriatr Med 2004. Wolff I. Osteoporos Int 1999
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BenefitsMore likely to: Less likely to:
DisabilityIncreases chance of dying without disability (RR 1.8)
Have a normal systolic BP
Be alive?
Fracture a hipFall rate=0.63-0.78 risk=0.65-0.83Develop cognitive impairmentDevelop
• Diabetes (RR 0.6-0.7)• Colon cancer, breast cancer,
and death rate from cancer (RR 0.3-0.6)
• Stroke (RR 0.3-0.76)• Cardiovascular disease
Nursing Res 2010;59:364-70; Weuve J. JAMA 2004;292:1454-61. Abbott RD. JAMA 2004;292:1447-53. Gillespie LD Cochrane Database of Systematic Reviews 2009; Young, JAGS 1999;47:277
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Depression
Blumenthal JA, et al. Arch Intern Med. 1999.
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Contraindications to exercise
• Almost all can safely engage in a program of moderate activity, such as walking or lifestyle modification, without screening
• Few conditions are true contraindications (unstable cardiopulmonary disease)
• Start low, go slow, pace• Warm up, cool down• Supervision and structure best• Fall risk, injury prevention
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Patient #4: It’s never too late!
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Summary
• A highly nuanced drug review is super high yield for older patients
• Decisions about tests and treatments should include consideration of time to benefit in addition to degree of benefits and harms
• We use too many drugs and not enough exercise in treating the elderly