Alycia Cleinman MD

Assistant Professor

Geriatric Medicine

77 yo man with few months of anorexia, weight loss (10-15 #), nausea and diarrhea, malaise, fatigue, and falls.PMHx: paroxysmal Afib, HTN, glaucomaMeds: Digoxin, lasix, lopressor, quinidine, ASA

VS stable except pulse 42, regular. Otherwise unremarkable exam.

What could be cause of anorexia, wt loss, GI upset?

Adverse drug reactions are increased 2-3x in elderlystrongly correlates with polypharmacy increased comorbidity

drug-disease interactionaltered pharmacokinetics related to body

composition changes and hepatic/renal alterations

Adverse drug effects may be subtleFallsAnorexiaCognitive ImpairmentFatigue Urinary IncontinenceConstipation

Body composition changes↑ body fat↓ body water↓ serum albumin

Changes in body composition can alter drug distributionLarger volume for distribution

Lipophilic eg Diazepam, trazodone Longer half life & duration action

Smaller volume for distribution Hydrophilic

Eg PCN Shorter half life & duration action

Physiological changesDelayed gastric emptyingSlowed GI motility

Drug Absorption Slowed rate of absorptionLower peak concentrationsVariable transdermal absorption

CNSAge related changes

↓ blood flow & O2 ↑ BBB permeability

Increased sensitivity Anti-cholinergics & sedating medications

Hyponatremiathiazide diureticsSSRI’shigh-dose narcotics

HyperkalemiaPotassium- sparing diuretics

eg spironolactoneACE inhibitors, ARBsNSAIDs

86 yo female with Alzheimer disease, GERD, and arthritis is admitted to hospital after a fall resulted in a hip fracture. She is very lethargic on your exam and her family reports this is a change from her normal mental statusMedications: donepezil, memantine, pantoprazole,

tylenol Plus inpatient meds – morphine, promethazine,

diphenhydramine, cyclobenzaprine

Which medications could be resulting in altered mental status?

What is best option for her pain?

Potential Side effects confusion, gait instability, dry mouth, constipation,

urinary retentionMedications with anti-cholinergic properties

Anti-depressants (amitriptyline) Anti-spasmodics (oxybutynin, dicyclomine) Anti-histamines (diphenhydramine, hydroxyzine) Anti-emetics (phenergan)

Anticholinergic drugsNarcoticsBenzodiazepinesL-dopa, bromocriptineprednisoneNSAIDscimetidine

WarfarinAntibiotics (FQs), herbals, and other meds

may increase bleeding risk and increase INR

SSRIs, SNRIs, tramadol, zyvoxCombination can increase risk for serotonin

syndrome

86 yo man with CHF, AFib, and Parkinson Disease is under your care in a NH. The nursing staff asks you to write an order for a physical restraint while he is in a wheelchair. They report that over the last 2 weeks he has become more confused at night with restlessness and that his gait is more unsteady. When he tries to walk, he needs the assistance of a nurse’s aide.

Medications: Furosemide, Digoxin, Levodopa-Carbidopa, Bromocriptine, Nitrate Patch, Diazepam

What could be contributing to his gait instability?

PUD NSAIDsBPH anticholinergicsCKD NSAIDs Syncope or falls Benzos, antidepressants,

neuroleptics, BP meds, oral hypoglycemicsProlonged QTc fluoroquinolones,

azithromycin, SSRIs, antipsychotics

ScreeningHearing handicap inventory for the elderly

10 item questionnaire - Impact of loss on daily activities

Handheld otoscope with tone generatorPresentation

Tinnitus – can be early symptomCognitive impairment

Examine ear canals for impactionHo TM sx or perforation – refer to ENT for

removalCerumenolytics – 40% effectives

Medication reviewLasix, salicylates, aminoglycosides, vancomycin

Asymmetrical lossmore concerning for a tumor

Comprehensive audiologic assessment

Personal amplifier/Adaptive equipmentHearing aids Bone anchored hearing aids

Use if:Unilateral hearing lossUnable to tolerate hearing aid in canalConductive/mixed hearing loss

Cochlear implantsSevere to profound hearing loss

with little/no benefit from aidPossible complication

Meningitis

A 78-year-old F with PMH HTN is seen in clinic for her medicare wellness visit reports falling once in past year. She tripped over her cat while going to the toilet at night in poor lighting. She denied injuries, LOC, preceding symptoms.

Home Medications: lisinopril.

On physical examination, BP 138/85 mm Hg, negative orthostatics.

Which of the following is the next step in the management of this patient?

A Assess gait and mobility

B Discontinue lisinopril

C Prescribe an exercise program

D Provide a standard walker

E Order Hip protectors

Consequences

Functional decline

Fracture (10-15%)

Head trauma/serious soft tissue injury (5%)

MCC of injury-related death

Increased use of medical services & NH

placement

Inquire about falls annuallyTake detailed history

Circumstances, frequencyAssess risk factors

Home hazard, sensory impairment, dz, meds, etoh, pets

Perform physicalGait assessment, orthostatics, visionStrength, ROM, sensation, proprioception, reflexes

Focused Labs/ImagingVitamin D, TFTs, Chemistry, B12MRI (Cervical, lumbar spine); Head CT Nerve conduction studies/EMG

Timed Get-Up-and-Go testGet up from chair, walk 10ft, turn around & sit

Less than 10 sec normal10-20 sec moderate fall risk>20 sec high fall risk

Balance assessmentPull testSemi-Tandem stanceTandem (heel-to-toe) walk

POMA (Tinetti)Balance + Gait

Antalgic gaitFestinationFoot dropFreezing of gait

PropulsionRetropulsionSteppage gaitTurn en bloc

Medication reviewAppropriate footwearAssistive devicesTreat vision impairment Life Alert systemsHome safety evaluation (OT)

Exercise Balance & resistance training

Tai chi - ~50% reductionVitamin D replacement/supplementationOsteoporosis evaluation and treatment if

necessary

A 76 yo man with PMH mild dementia, macular degeneration is seen in clinic for follow-up. His daughter reports she has concerns over his driving, as he confuses the gas & the brake sometimes and has hit the mailbox. The patient reports he is a good driver and denies these events. He has not had any recent traffic tickets or accidents with other vehicles. He scores 22/30 on the Mini–Mental State Examination. He lives in an area with nearby stores and his family is able to drive him to places he needs to go.

Which of the following is the most appropriate recommendation regarding driving for this patient?

A Limit driving to daytime and local roadsB Allow patient to continue driving without restriction C Instruct patient to immediately stop drivingD Recommend a driving evaluation

Vision impairmentRestricted mobility

Arthritis, foot drop, cervical dzCognition (ie judgement)NeuropathyParkinsonian diseases

RigidityMedication side effects

Sedation (decreased reaction time), dizziness

Office assessmentVision

Fields & acuityCognition

Visuospatial, Executive functionMusculoskeletal exam

Strength; ROM of neck, trunk, & extremitiesSensation & proprioception

Driving assessmentDriving rehabilitation specialistDMV

65 y/o F with PMH HTN c/o being more forgetful over the past 6 mo. She is losing items and forgetting names of distant friends, which is new for her. She no longer is interested in attending church or lunch with her girlfriends. She reports only sleeping 4 hours a night and has lost 10lb over this time period. She denies depressed mood, hallucinations, or gait changes.

Her physical exam is unremarkable; Mini-Mental State Examination (MMSE) score 23/30; Geriatric depression screen (GDS) 15/30

Results from basic blood work, including thyroid function studies, are normal. An MRI of the brain shows no abnormalities.

Which of the following is the most appropriate next step in management?A Start remeronB Start amitriptylineC Start paroxetineD Start donepezilE Start quetiapine

Prevalence – 6-10% primary care clinic12-20% NH residents

Presentation in Elderly -Less frequently report depressed mood “Pseudo-dementia”Overlap with chronic illness in somatic

symptoms

Clinic setting -Initial visit then annual

Nursing home -Within 2wk of admission then every 6 months

Screening Instruments – PHQ-9GDS

Evaluate for co-morbid conditionsHypothyroidism Substance abuse

1st line – SSRI Preferred – sertraline, citalopram, escitalopram

Paroxetine, fluoxetine (long half life) Beers criteria –

TCA – anticholinergic, sedating, OH Preferred TCAs – nortriptyline, desipramine

Weight loss or insomnia Mirtazapine QHS

Aggressive acute phase treatment to bring about remission Follow-up in 4 weeks to re-assess

Continuation tx to prevent relapse Additional 6mo after symptom remission

Maintenance tx to prevent recurrence 3 or more years for depression with psychosis,

suicidality, or recurrent episodesAddition of psychotherapy if psychosis or suicidal

A 65 y/o F with severe COPD is referred to palliative care clinic with persistent complaints of dyspnea. She wears her oxygen at all times . On exam – oxygen saturation 94%, clear lung fields bilaterally. An acceptable quality of life for her would be to spend time with her dogs and husband outside, without having constant dyspnea.

What should be done next in the management of this patient’s dyspnea?

a. Explain to her that oxygen saturation is in the mid 90’s and she does not need to worry

b. Recommend addition of spironolactonec. Recommend morphine immediate release elixir 2.5-5 mg

every 4 hours as neededd. Recommend she increase her oxygen from 2 to 4 liters

Palliative careGoals

Relieve physical/emotional suffering, optimize function, assist with MDM for pts with advanced dz

May be provided regardless of whether the patient is receiving curative or disease-modifying treatment

HospiceComprehensive care for pts with life

expectancy ≤6 months

Dyspnea Opioids*

Oral & parenteral effectiveNebulized morphine not shown to be helpful

Supplemental oxygen, cool air (fan)Benzo – if anxiousDiuretics - if volume overloaded

Increased respiratory secretionsAtropine drops, glycopyrrolate, scopolamine,

Hyoscyamine

Painopioidsalternative routes of delivery

suppositories, transmucosal formulations, SC

Bone pain NSAIDs*, steroids*Bisphosphonates, calcitonin, radiation (mets)

Nausea/vomitingHaldol*, ondansetron, steroidsReglan (dysmotility), PPI/H2 Blocker (gastritis)Anti-histamines, antivan, phenergan – with

cautionDiarrhea

Check for impactionCholestyramine, octreotide

ConstipationProphylactic bowel regimen if receiving opioids

fecal softener (eg, docusate) + bowel stimulant (eg, senna, bisacodyl)

Can addosmotic laxative (eg, sorbitol, lactulose, or

polyethylene glycol) Lubiprostone

If no bowel movement for ≥4 days – check for impaction/obstruction & consider enema

opioid-induced constipation Methylnaltrexone

A 94 y/o F with moderate dementia, vision/hearing impairment was hospitalized for CAP. She was started on Levaquin and 2 days into her admission began “talking out of her head” according to her family, which is a change from her baseline.

On exam - T 37.3C, BP 108/56 mmHg, HR 95/min, RR 16/min, O2 sat 94% on ambient air, thin, inattentive, lungs with rhonchi over posterior right base (unchanged from admit), no focal deficits. All home meds were continued on admission including: omeprazole, rivastigmine, lorazepam PRN.

LABS - normal serum electrolytes/glucose Cr 1.4 (up from 1.2 on admission)CBC with WBC 10 (down from 14 on admission) UA negative

Which of the following would be the best next step?

A Haloperidol, restrain for safety B Change antibiotics, bedside observerC Olanzapine, head CT D Risperidone, EEGE Short acting benzodiazepine, head

CT

~1/3 hospitalized elders have delirium50% present on admission

Prevalence increased in ICU & hospice settings

May persist for weeks to months in subsetOlder, dementia, functional impairment,

multiple co-morbidities; restraint use & delirium severity

Independently associated with poor patient outcomesIncreased risk of death, institutionalization, &

dementia

Confusion Assessment Method (CAM) Most useful bedside assessment tool Requires presence of 1 + 2 + (3 or 4)

1. Acute change in mental status & fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness

CAM - ICU Designed for non verbal/vent dependent pts Sensitivity lower than traditional CAM

Under-recognition is HUGE Standardized screening of ICU, post-op, very

elderly pts Daily; aids in recognition of hypoactive delirium

Baseline riskAdvanced ageDementiaImpairment with ADLsHigh medical comorbidityLab abnormalities

Dehydration, sodium, thyroidSome evidence

Males, sensory impairment (hearing, vision), depression, alcohol abuse

Acute riskMedications

sedating, anti-cholinergic

withdrawlSurgeryUncontrolled painAnemiaBed rest

Indwelling devices & restraints

InfectionStrokeMIUrinary retentionFecal impaction

FIRST STEPTake a history – patient, support staff, family

Includes chart reviewFull physical exam THEN Targeted labs, imaging, other

diagnosticsREMEMBER

Typically multiple contributing factors

MedicationsBEERS CriteriaEffect OR withdrawl

InfectionsFluid balance

Dehydration, heart failureElectrolyte Disturbances

Sensory deprivationEyeglasses, hearing aids/amplifiers

Elimination issuesFecal impaction, urinary retention

Impaired CNS oxygenationAnemia, hypoxia, hypotension

Severe pain

ALLCBC, chem8

ConsiderUA, UDS, LFTs, ABGCXR, EKG, cultures, troponinEEG if seizure activityLP if meningitis suspectedHead CT/Brain MRI

if head trauma suspected or focal findings on neuro exam

Behavioral InterventionsFamily visitationDaily reorientationSleep-wake schedule

Avoid unnecessary interventions at nightLimit tethers & ties

Pharmacologic InterventionLow dose, short term antipsychotics

Haldol, risperidone, olanzapine, seroquelRemember to check EKG to evaluate QT interval

What do I do if they have prolonged QT interval??Remember to taper off as soon as possibleAvoid 1st generation antipsychotics in LBD & PD

Opt for seroquel Ativan – IF benzo or ETOH withdrawl

Urinary incontinenceScheduled toileting program

Immobility/FallsPhysical therapy – MOBILIZE THAT PATIENTAvoid restraints – they are NOT your friend

Opt for 1:1 sitter

Pressure ulcersMobilization – can I hear it again?!Repositioning if immobileMonitor pressure points

Sleep disturbanceSleep hygiene is your best option

Feeding disordersAssist with mealsAspiration precautionsNutritional supplements at snacks

EnvironmentNoise reduction, lighting, familiar objects

Cognitive reconditioningReorientation TID

ADL performanceFamily education/supportTime for discharge

Providing support services at home or facility

Hospital Elder Life Program (HELP) Interventions/Risk factors

Cognitive impairmentSleep deprivationImmobilityVisual/Hearing impairmentDehydration

A 75-yo M is admitted to rehab after having a stroke 2 wk ago. He has residual right-sided paralysis, aphasia & urinary incontinence. He spends most of the day in bed or in a chair and needs assistance with all ADLs. The patient has a poor appetite, cannot use his right arm to feed himself, and is eating only half his meals. He also has intermittent urinary incontinence.

Which of the following is the most appropriate intervention for preventing pressure ulcers in this patient?

A An air-fluidized bed

B A doughnut cushion when seated

C A foam mattress overlay

D Bladder catheterization

E Massage of skin over pressure points

Any process rendering immobility for extended time period

Intrinsic risk factorsAge, poor nutritional status, decreased

arteriolar blood pressureExtrinsic risk factors

Friction, shear, moisture, urinary or fecal incontinence

Skin care (Limited evidence)Daily skin inspectionSkin cleaning with mild agent; MoisturizerDo NOT massage over bony prominencesAvoid skin exposure to wound drainage, urine,

feces, perspiration

Nutrition (inconsistent studies)Do NOT OVER-supplement pts with protein,

vitamin, mineral supplements evidence is lacking if no deficiency

Optimal nutrition is part of national pressure ulcer prevention guidelines

Mechanical off-loadingMinimize friction/shear Reposition q2HUse of bed positioning devicesDo NOT use seating cushions (ie doughnuts)

Support surfaces (pressure redistribution device) Use with any pt at risk No one surface superior but all superior to standard

mattress Two types of devices

Static: foam, static air, gel/waterDynamic: alternating air, low air loss, air fluidized

Which to use?Static is less expensive so used in most Use dynamic IF:

“bottoming out” (surface compressed to <1 inch) Reactive hyperemia despite static support use

Dynamic airflow potential adverse effectsDehydration, sensory deprivation, difficulty with

mobilization

Suspected Deep Tissue Injury Purple with intact skin/blister

Stage I Non blanching erythema

Stage II Partial thickness loss of dermis

Stage III Full thickness tissue loss

Stage IV Exposed bone, tendon, or muscle

Suspected Deep Tissue Injury Purple with intact skin/blister

Stage I Non blanching erythema

Stage II Partial thickness loss of dermis

Stage III Full thickness tissue loss

Stage IV Exposed bone, tendon, or muscle

A 77-year-old F is transferred to SNF after a 2-wk hospital stay for hip fracture repair. Her hospital course was complicated initially by a lower gastrointestinal hemorrhage and subsequent bacteremia from an intravenous line.

Her vital signs are within normal limits. She is alert and oriented to person and date. She appears thin. She has a 4 x 5 cm pressure ulcer over her presacral area that extends through the skin, but no muscle or bone is exposed. The ulcer is debrided with little exudates. There is minimal surrounding erythema.

Which of the following is indicated for the pressure ulcer?

A Calcium Alginate dressing

B Hydrocolloid dressing

C Short course of systemic antibiotics

D Silver sulfadiazine cream

E Vacuum-assisted closure device

Location

Stage

Area

Depth

Drainage

Necrosis

Granulation

Cellulitis

Transparent filmi.e. tegadermStage I & IIc/i if draining or suspected infection

Foam islandi.e. allevyn, lyofoamStage II & III; with lo-mod exudatec/i if excessive exudate or dry/crusted

Hydrocolloids i.e. duo-derm, tegasorbStage II & III; with lo-mod drainageGood for autolytic debridementremains in place 3-5 daysc/i poor skin integrity, infection, packing

Alginatei.e. AlgiDERM, Sorbsan, AlgosterilStage III, IV; excessive drainagec/i dry/min drainage, superficial with

maceration

Hydrogel Gel or sheet – Intrasite, vigilon, restore Stage II, III, IV c/i macerated, excess exudate

Gauze packing (moistened with saline) Stage III/IV c/i deep wounds, tunneling

Silver dressings ie aquacel Ag, silvadene Malodorous wounds; hi exudate; suspected local infection;

slow healing c/i systemic infection, cellulitis, fungus, skin necrosis,

leukopenia, interstitial nephritis

RecommendationsWet-to-dry discouragedHydrocolloid preferred

Require fewer dressing changes; block bacteria; maintain moist environment

Pick a dressing based on stage, amount of wound exudate, suspected infection

Performed if necrotic, devitalized tissue present – as it prevents healing

Four types Mechanical: wet-to-dry, hydrotherapy

Can remove vitalized tissue; painful Enzymatic: topical agent

Use if no infection present; damage surrounding skin Autolytic: synthetic dressings allow self digestion

Use if no infection present & no other method tolerated; takes longer for effect

Sharp: scalpel, scissors, forceps, laser Quick, effective; use if infection present

Biosurgery: Maggot or larva therapy Good for those who cannot tolerate surgery

Surgical Repair Viable option for stage III & IV ulcers Types

Direct closure, skin grafting, skin flaps, musculocutaneous flaps, free flaps

Diet/Nutritional Supplements Controversial; limited evidence Dietary recommendations –

30-35 calories/kg/d1.25-1.5g of protein/kg/d

Amino acids may assist Argine, glutamine, cysteine

New problem – blame a drugFalling elders – give vitamin D, order

PT, home safety evaluation (OT)Preferred drugs

Anti-depressants Citalopram, escitalopram, remeron, sertraline

Pain medicationTylenol, tramadol

InsomniaZolpidem, trazodone, remeron