Geriatric Medicine Update
Dr Elena Mucci
ConsultantPhysician/Geriatrician
Leadership Tutor
October 2013
Is the approach to HTN in the elderly different?
HYVET trial
• HYVET: 3845 subjects, 80+ and functional
– SBP > 160; goal 150/80
– Indapamide and ACEi vs. Placebo
30% reduction in all cause mortality
• ABP Substudy (112 subjects at baseline)
– Mean CBP 172/90 mm Hg
– No orthostasis
– Mean daytime ABP: 136/78
– Mean 24 hr ABP: 133/77
Beckett NS, NEJM, 2008; 358: 1887‐1898
Bulpitt CJ, Hypertension, 2013; 61: 89‐94
Anticoagulation and Fall Risk
Should we be prescribing anticoagulants in
patients with fall risk?
• Prospective study
▫ 515 pts, median age 71, treated w/ vitamin K antagonists
▫ Fall risk associated with risk for major bleeding?
▫ High fall risk if: fall in past yr, gait/balance/mobility issue
▫ 60% were high risk
• Outcomes
▫ No difference in time to first major bleeding event including fatal or
intracranial within 12 months f/u.
▫ Risk for major bleed independently associated with polypharmacy.
• 12% increased risk for each additional drug taken.
Am J Med 2012. PMID: 22840664
Anticoagulation and Fall Risk
• Take Home Point:
▫ Patient > 65 yrs with CHADS2 score of 2-3
would have to fall 295 times yearly for risk of
fall-related SDH to outweigh benefits of stroke
prevention.
▫ Polypharmacy greater risk.
▫ Use this opportunity to stop unnecessary
medications.
Aspirin to prevent recurrent DVT
• Recurrence of unprovoked VTE after stopping
anticoagulants
▫ 5-15% at one year, 30-50% at 5-10 yrs
▫ Highest risk: male, mod-severe post-thrombotic
syndrome, proximal DVT, elevated D-dimer 3-4
weeks after stopping therapy.
• Extending anticoagulants associated with
increased risk of bleeding.
• Is the use of low dose aspirin an alternative?
Low Dose Aspirin for prevention of
recurrent DVT
• Double blind placebo controlled RCTs
• WARFASA (402 pts) and ASPIRE (822 pts) Trials
▫ Pts with first unprovoked VTE who stopped anticoagulation after 6-18
months of therapy.
▫ Randomized to ASA 100 mg daily vs. Placebo
• VTE recurrence
▫ Pooled data from both trials
▫ 32% reduction in rate of recurrent VTE
▫ 34% reduction in rate of major vascular events
▫ Low risk of bleeding
NEJM 2012.
PMID: 22621626, 23121403, 231 21404
Update on drugs commonly used in
the Elderly
• Omeprazole impairs absorption of calcium,
iron, and levothyroxine
• Omeprazole is a cause of acute interstitial
nephritis
• Omeprazole can cause B12 deficiency
• Omeprazole contributes to C Dif and delays recovery
• Fenofibrate and losartan significantly lower
serum uric acid levels
• Longterm use of metformin may result in
significant B12 deficiency
• Trimethoprim causes reversible elevation
of serum creatinine and potassium
AF and new anticoagulatnts
• Dabigatran, direct Thrombin inhibitor, 110mg BD;
150 mg BD, 75mg BD if eGFR 15-30, renal
excretion. Non inferior to warfarin.
• Rivaroxaban, 10a inhibitor, 20mg OD, 15mg OD in
renal disease, also licensed for PE/DVT, renal/liver
excretion. Non inferior to warfarin.
• Apixaban, 10a inhibitor, 5mg BD and 2.5 mg BD,
mainly liver excretion-safer in renal disease. The
only one which showed reduction in all cause
mortality, including reduction in major bleeding,
GI bleeding-no difference.
AF, rate control
• RACE II
• Goal heart rate <80bpm vs. <110bpm
• Permanent atrial fibrillation
• <80 years of age
• Resting atrial fibrillation rate >80bpm
• Primary outcome composite:
– Death from cardiovascular causes
– Hospitalization for heart failure
– Stroke or systemic embolism
– Major bleeding
– Arrhythmic events including syncope or VT
– Implantation of pacemaker or ICD
•
Van Gelder et al. NEJM 2010;362:1363-1373
2011 ACC/AHA Updates
• Treatment to a goal
resting heart rate
<80bpm is not beneficial
compared to
<110bpm in patients with
atrial fibrillation
who have LVEF >40% and
no or minimal
symptoms (Class III)
Treatment Options
• Beta-blockers-sympathetic pathway
– Carvedilol less effective than others
• Verapamil-Diltiazem
• Digoxin-As adjunct only-parasympathetic
pathway
– Use if heart failure also
• Amiodarone-Rarely for rate control
• AV node ablation and pacing
Diastolic Dysfunction
HFpEF
• Prevalence: increasing with the aging
population and increasing recognition
• Systolic HF: CAD, HTN, DM
• Diastolic HF: Age, Female, HTN, Obesity
• Precipitating factors: labile HTN, Med
noncompliance,Diet non-compliance,
• Iatrogenenic (NSAIDS, fluids), Infections
HFpEF
•
•
•
•
•
•
•
•
•
•
•
Treatment:
Class I:
Control of BP (<130/80)
Agents not specified
Control of tachycardia in Afib
Reduction of central blood volume-with diuretics
Class IIa: coronary revascularization if ischemic
Class IIb:
Restoration of NSR
Digitalis use not well established
ACE/ARB/BB/CCB
Medications Used to Treat Hallucinations,
Delusions and Agitation
• Antipsychotics (Black Box Warning!)
– Haloperidol
– Risperidone
– Olanzapine
– Quetiapine
• Anticonvulsants
– Carbamazepine
• Antidepressants
– Sertraline
• Β-adrenergic receptor antagonists
– Propanolol
• Antianxiety agents
– Clonazepam, lorazepam
Statin induced Myopathy
• Myalgia
 Normal CK, reduce the dose, try different drug, stop
the drug, restart at lower dose or different one.
• Myositis
 Elevated CK, stop the drug till CK/symptoms
normalised, restart with a statin with high half life, like
Rosuvastatin+/- Co-Enzyme Q10.
• Rhabdomyalisis
 CK 10 times the normal level, myoglobinuria, AKI,
death. Stop statin and never use again.
Continuation of donepezil in patients with moderate-to‐severe
Alzheimer’s disease may improve cognition at 52 weeks.
• RCT
• 295 community-dwelling patients, mean age 77.1; 65%
females; 95% white, mean MMSE 9; taking Donepezil
for at least 3 months.
• 4 groups:
 Continue donepezil with placebo memantine
 Continue donepezil and starting memantine
 Discontinue donepezil with placebo memantine
 Discontinue Donepezil an starting Memantine
Follow up period 52 weeks
Outcome measures: Cognition (SMMSE) and functional status (BADLS)
Howard R, McShane R, Lindesay J, Ritchie C et al. Donepezil and Memantine for
Moderate-Severe Alzheimer’s Disease. N Engl J Med. 2012 Mar 8;366(10):893-903.
Continuation of donepezil in patients with moderateto‐severe Alzheimer’s disease may improve cognition
at 52 weeks.
• Clinically important difference
 SMMSE of 1.4 points or more
 BADL score of 8 points or more
• Donepezil v no Donepezil: 1.9 points
difference on SMMSE and 3.0 points
difference on BADLS.
• Memantine v no Memantine: 1.2 points and
1.5 points difference respectively
• No difference Donepezil+Memantine
Clinical Bottom Lines
• NICE 2011: treatment should be continued only when
it is considered to be having a worthwhile effect on
cognitive, global, functional or behavioural symptoms.
• This study suggests that cognitive outcomes can be
improved with continuing Donepezil treatment.
• What do I do:
 If patient is on Donepezil I continue
 If not on any treatment I start on Memantine
 If on Donepezil and developed severe behavioural
problems I stop Donepezil and start Memantine
 I stop everything in the EoLC
Medications to treat mood
disorders in dementia
• Selection of antidepressant usually based on
previous response to the drug:
– trazodone (50mg at bedtime) – sedating and
useful with agitated depression and insomnia –
also consider nortriptyline 10mg at bedtime
– Sertraline 25-50mg per day (proven effective in
clinical trials, may especially be useful with
agitated depression)
• May see improvement in sleep and agitation soon
after instituting therapy but full relief of
depression delayed by 4-6 weeks
Medications to treat sleep
disturbances
• Trazodone 50-100mg po bedtime
• Quetiapine begin with 12.5mg bedtime but
can work up the dose. Use only if sleep
disturbance is severe and associated with
agitation.
• Avoid usual sleep medications such as
zopiclone
Medications to treat apathy
• May try a low dose of methylphenidate (5–
10mg early morning but never after 2pm)
• If depressed, may try a more stimulating
antidepressant such as fluoxetine (10mg to
begin with)
Tight control of DM in NH eligible older adults
may be associated with poor outcomes
• Cohort study
• 367 NH patients with DM, mean age 80 (+/-9)
• 67% female. Almost one-third on oral and 50% on
insulin, 79% cognitive impairment , mean ADLs 8,
follow up 2 years
• Outcome measures: functional decline and death at 2
years
• 4 groups: less than 7%, 7-8%, 8-9% and over 9%
Yau, C. Glycosylated Hb and Functional Decline in Community-Dwelling NHEligible Elderly Adults with DM. J Am Geriatr Soc. 2012 Jul;60(7):1215-21
Clinical bottom lines
• HbA1c level of 8-9% appears to be associated with less
functional decline or death at 2 years
• Current AGS recommends AbA1c target of 8.0% or less for
frail elderly adults with limited life expectancy may be
lower than necessary to maintain function and delay death
for this vulnerable population.
• ADA Position Statement suggests a patient-centred
approach in the management of type 2 DM and
recommends less stringent HbA1c goals.
• Although this study was conducted in NH patients, it
suggests that clinicians should consider less aggressive
glycaemic targets when managing vulnerable older adults.