Primary Care of Older Adults: Pearls and Pitfalls

Colleen Christmas, MD, FACP

Disclosures

• I have not received any payments from companies related to this talk.

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

You’ve seen one 80 year old…

Thejournal.iewww.sunsetbeachclub.com

DRUGS CAN BE DANGEROUS

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

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

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”

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)

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

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

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.

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

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

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

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

Case: Evidence

• Osteoporosis– Bisphosphonates for osteoporosis effective, with a

modest absolute risk reduction

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

Reasons to Stop the Bisphosphonate

Black DM, Schwartz AV, Ensrud KE, et al. JAMA 2006;296:2927-38.

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?

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?

Life Expectancy for Women

Adapted from Walter. JAMA. 2001

eprognosis.ucsf.edu

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

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

www.americangeriatrics.org

EXERCISE IS GOOD FOR WHAT AILS YOU

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

Aging

DisuseIllness

Aging resembles being sedentary

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

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

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

Depression

Blumenthal JA, et al. Arch Intern Med. 1999.

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

Patient #4: It’s never too late!

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