Geriatric Medicine A VERY, VERY BRIEF UPDATE – WITH A BIT ABOUT INTERFACE ALI ALSAWAF – CONSULTANT GERIATRICIAN, IHT What to cover Polypharmacy AF in the elderly Anticoagulation Constipation When to investigate Interface Geriatrics Hot clinic 1 POLYPHARMACY Medication is the commonest medical intervention 80% of over 75s are on prescription medication 36% of which are on four or more Patients on more medications suffer more side effects, regardless of age Most guidelines focus on starting treatment, not stopping it Medication review is part of primary care work Geriatricians review medication at every occasion Effects of Polypharmacy Falls Increased side effect profile (including biochemical imbalance) Cognitive decline/delirium Increased hospital admissions Increased pill burden = increased care Why? Changes in pharmacokinetics and pharmacodynamics in old age, eg renal clearance, 1st pass metabolism Change in normal physiology, eg autonomic dysfunction Absence of the initial indication for the prescription (eg bereavement and antidepressants/sedatives) Concomitant acute illness (eg D&V with CCF treatment) Risk of improper adherence and accidental drug errors At what point do we consider “Polypharmacy” Appropriate Polypharmacy vs Inappropriate Independent 80 year old with Diabetes (tablets and insulin), previous TIA x 2,CAS, IHD, and hypertension 85 year old RH resident with Parkinson’s Disease, CCF, hypertension and hypercholesterolaemia Frail 80 year old NH resident with Alzheimer’s Dementia, Diabetes (tablets and insulin), previous disabling stroke, CAS, MI, angina, and hypertension When to stop? Falls Delirium Cognitive impairment End of Life Extreme age/frailty 2 EVIDENCE Most research is around falls, with clear reduction of risk when medications rationalised Reducing polypharmacy improved cognition No research in extreme age/frail nor End of Life Could be controversial (eg Warfarin, insulin) Making it Safe and Sound King’s fund report Suggests “Rather than attending several diseasespecific clinics, patients could have all their longterm conditions reviewed in one visit by a clinical team responsible for coordinating their care. Patients with multi-morbidity admitted to hospital under one specialty may require access to a generalist clinician to co-ordinate their overall care.” “This may require training and development of more ‘generalists’ skilled in the complexity of multiple disease alongside training to manage polypharmacy.” Develop even more guidelines for multimorbidity Reduce pill burden Patient involvement is key (but no mention of capacity-impaired patients) Polypharmacy Guidance NHS Scotland, 2012 Mentions “Geriatricians” Overall better guidance British Geriatric Society support Clear advice Cochrane Review Interventions for preventing falls in older people living in the community Medication review by primary care physician reduced risk of falls What to stop Is there a valid indication, and is the dose correct? (e.g. long-term amitryptilline, PPIs, antidepressants, opiates) Secondary prevention (e.g. statins in extreme age, multiple antihypertensives) Consider side effects and interactions (difficult) Drug effectiveness in that patient group (e.g. bisphosphonates in extreme old age) High risk combinations, e.g. warfarin and duel antiplatelets, NSAIDS Always involve patient/family/carer with decision and its rationale What NOT to stop longterm (seek advice) Essential replacement drugs (eg Thyroxine) Drugs keeping symptoms under control (e.g. CCF treatment, COPD, long-term steroids) Parkinson’s Disease medications Antiepileptics (if used for epilepsy control) DMARDs Antipsychotics/depressants in severe mental illness. Amiodarone In Summary Polypharmacy is not easy Multiple co-morbidities Multiple factors to consider Please contact us for advice (more on how later) Atrial Fibrillation Prevalence increases with age Well-known increased risk of thromboembolic cerebrovascular disease Rate vs Rhythm Rate control acceptable for over 65s No increase in mortality (from cardiovascular complications) Investigate (FBC/U&E/LFT/TFT), CXR ECHO not required unless murmur clinically or CCF Rate control if HR > 100 Use betablockers (eg Bisoprolol as highly cardioselective) if patient active (gardening, walking) Use digoxin if less/not active (eg limited mobility, house or bed bound) Digoxin has much less side effect profile than betablockers But not good at controlling heart rate in activity Avoid Calcium-channel blockers (negative inotropics, reduce BP) Start low, go slow Anticoagulation All types of AF are at higher risk of stroke Anticoagulation should be considered in all patients Consider: falls risk (a fall a day!), pros vs cons (patient engagement with INR, bleeding history and risk, compliance and risk of mistakes) Remember NOACs are now available (second line) Aspirin is better than nothing (if not suitable for AC) NOACS Apibaxan, Dabigatran, Rivaroxaban Do not require INR monitoring All licensed for thromboembolic prevention in AF All non-inferior to Warfarin All have same bleeding risk as Wafarin, except Dabigatran (increased GI bleed) Renal function-dependent (unlike Warfarin) Reversibility unknown yet, but shorter half-life Rivaroxaban only one suited for MDS and can be crushed WHEN TO START? Warfarin remains first-line treatment Consider NOAC if Warfarin not tolerated (mostly INR monitoring, or dose compliance) Bleeding risk maybe less Follow local guidelines (checklists for GP available) CONSTIPATION Infrequent bowel emptying Hard stools Difficulty passing motion (straining) Feeling of incomplete evacuation Slow transit… Reduced physical activity Poor oral intake Medications (opiates, anti-cholinergics, and many more) Many secondary causes (neurological, obstruction, metabolic etc) In the elderly 40% of older people in the community 60-80% of those in long-term care More than 50% of nursing home residents are on regular laxatives Common cause of medical admissions Usually because of secondary effects: Delirium Falls Urinary Retention Abdominal pain/vomiting Overflow diarrhoea CAN BE FATAL! Vomiting + aspiration pneumonia Perforation Delirium Falls Fractures HISTORY Bowel / stool history Urinary symptoms Daily fluid intake Caffeine intake Diet / Fibre Red flag symptoms RED FLAGS Anaemia Rectal bleeding Positive faecal occult blood test Family history of bowel cancer or IBD Tenesmus Weight loss Investigations Bloods: FBC, U&E, Bone Profile, TSH Urine dipstick Refer for endoscopy if red flag symptoms Digital Rectal Examination MUST be done if possible Both constipation and diarrhoea/incontinence Looking for: Fistulas Resting and active tone Mass Faecal loading and its consistency (hard/soft) Stool consistency If it’s hard – soften it If it’s soft – stimulate it TREATMENT Treat cause if possible (polypharmacy?) Initially: education, diet and lifestyle measures Softeners: Movicol, Lactulose, Phosphate Stimulants: Senna, Docusate, Bisacodyl, Glycerine INVESTIGATIONS IN THE ELDERLY Common question to department Main principles: Can the patient tolerate the proposed investigation? Will it make a difference to their management? Will it make a difference to their wellbeing? OR Will it help with prognostication/future planning Any other benefit (eg financial, insurance) Points to consider General state of health (co-morbidities) Frailty Functional baseline Mental baseline Patient and family engagement essential Both in decisions to actively investigate or not Clear explanation of implications of decision Can be revisited in future If patient lacks capacity, best interest decision Must involve next of kin Difficult decisions Please contact us for advice INTERFACE GERIATRICS Many definitions, BGS “Harmonious combination of hospital and community geriatric care” Core idea: break down the barrier between Hospital and the rest of the community Older person in crisis Various “rescue” plans: crisis teams (self-referral, GP), community matrons, GPs, emergency placement, community “step-up” hospitals, IHT. A patient can move between a number of this during one episode Lots of assessments (mainly therapy) Duplication of work Delayed (or no) specialist medical assessment which can delay correct diagnosis and management Potential crisis avoidance ideally, or at least anticipation CGA Ideally, a Comprehensive Geriatric Assessment should be performed as soon as possible Geriatrician involved throughout, not just when too late Requires full team, not just a doctor Borders Lots of imaginary borders exist Example: Hospital and GP. GP and community team. Hospital and community team. Acute and Rehab hospitals Paperwork is varied, doesn’t capture everything Patient at the centre of all this Aims Interface Geriatricians aim to smooth this process Break down borders Improve patient’s care and journey from primary to secondary care and back Assess promptly, utilising available community and hospital services/expertise Admission avoidance What we currently provide MDT leadership across all three community hospitals Comprehensive Geriatric Assessment of in-patients. Both “step up” and “step down” Liaison with IHT to improve patient care and “solve problems” Access to IHT IT system (eVolve, Pathlab) to improve patient’s care Community Team Reviews Working with community and crisis teams Discussing patients, identifying those that may benefit from a CGA Reviewing patients in a community setting (clinic, domiciliary or care home visit) HOT CLINIC 2 hours a day of instant access to Consultant Geriatrician and diagnostics Set up as part of first Interface Geriatrician appointment GP can refer patients directly via EAU consultant (bleep 620) Service started November 2013 Still running No direct GP referrals received to date REINVETING THE HOT CLINIC We will provide 9-5 access to Consultant Geriatrician directly Mobile phone Available to all GPs, Community Matrons, Community Therapy Teams TO PROVIDE… Verbal advice and support Urgent review of patients (same or next day), i.e. Hot Clinic Less urgent review at all the locations we visit: Ipswich Aldeburgh Stowmarket Hadleigh Hartismere (Eye) WHICH PATIENTS No age limit Not acutely unwell (requiring hospital admission), but need urgent advice that cannot wait for routine clinic Any patients with complex medical problems Including movement disorders Details currently being finalised GP Briefing will be sent out with details on how to refer Including clear guidance on the reverse for your office Aiming to start first of July REFERENCES Polypharmacy Guidance (1) http://www.central.knowledge.scot.nhs.uk/upload/Polyph armacy%20full%20guidance%20v2.pdf AF http://cks.nice.org.uk/atrial-fibrillation 2 http://britishgeriatricssociety.wordpress.com/2014/03/17/w hich-drugs-to-stop-in-which-older-patients/ Safe and sound http://www.kingsfund.org.uk/publications/polypharmacyand-medicines-optimisation THANK YOU! ali.alsawaf@ipswichhospital.nhs.uk 01473 704134 (secretary)