Geriatric Dilemmas

Educational Objectives

The goal of this program is to prevent falls and improve caregiving and medication compliance in the aging popula­tion. After hearing and assimilating this program, the clinician will be better able to:

1.   List risk factors for falls in the elderly.

2.   Outline an effective fall-prevention program.

3.   Counsel adult children with aging parents about developing a caregiving plan.

4.   Address concerns of caregiving, such as personal needs, housing, and financing.

5.   Define polypharmacy and assess medication compliance.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. McGonigal and Pereira spoke in Minneapolis, MN, at Family Medicine Update 2009: Striking the Balance, presented May 13-15, 2009, by the University of Minnesota Medical School. Ms. Goetschius was recorded in Burlington, VT, on June 9, 2009, at the 35th Annual Vermont Family Medicine Review Course, presented by the University of Vermont, College of Medicine. The Audio-Digest Foundation thanks the speakers and the spon­sors for their cooperation in the production of this program.

Prevention of Falls

Michael D. McGonigal, MD, Assistant Professor of Surgery, University of Minnesota Medical School, Minne­apolis, and Director of Trauma Services, Regions Hospital, St. Paul, MN

Introduction: risk for falls higher in elderly women than in men; falls usually recur; decreased bone density and poor exercise habits that result in decreased muscle tone and strength contribute to falls; several environmental hazards in home (eg, furniture placement, clutter) also contribute

Risk factors: difficult to address >2 risk factors at a time; chance for independence-threatening falls increases with number of risk factors; most risk factors can be addressed and fixed; osteoporosis  —  related to changes in intrinsic and extrinsic hormones; nutrition depends on financial status, and poor nutrition can accelerate bone loss; lack of physical activity leads to poor muscle tone, loss of muscle mass, decreased strength, and accelerated osteoporotic changes; vision problems  —  acuity changes with age; cataracts common and can be problematic; glaucoma can re­duce peripheral vision; medications  —  many patients take multiple agents; consider drug interactions; ask about nu­tritional supplements; consider alcohol use; medical conditions  —arrhythmias; atherosclerotic disease; dementia; perform echocardiography and electrocardiography (ECG) as indicated

Fall prevention program: treat falls as serious, sentinel event; begin investigation and management before patient discharged from hospital; program involves team of people and well-defined system

Multidisciplinary team: coordinator  —  handles paperwork, collects data, and monitors process; consider threshold (level for entering patients into system); interventions must be available; reporting and data analysis; emergency medical services (EMS) and police  —  act as first responders; can activate evaluation system; can perform initial home safety assessment; lead clinician  —  eg, nurse practitioner; acts as patient advocate and identifies essential risk factors; performs advanced studies and evaluation (eg, identifying cardiac factors) as needed; coordinates clinical team; performs patient history and physical examination; performs vision screening (refers to ophthal­mologist if indicated), basic nutrition screening, and osteoporosis screening; questionnaire to identify risk fac­tors; performs other medical screening tests; physical and occupational therapists  —  for patients with mobility problems; can provide more formal evaluation of motor strength and cognition, and initial screening test for de­mentia; exercise and nutrition programs  —community clubs (eg, YMCA, YWCA); resources for evaluation of overall nutritional state; social programs available to improve quality of food received; pharmacist  —  expertise in pharmacy databases essential; reviews medications and checks for interactions; has meaningful conversations with prescribing physicians to determine which medications necessary; addresses drugs that have specific indica­tions and may increase risk for falls (eg, warfarin [eg, Coumadin] and clopidogrel [Plavix]); social worker  —  connects patient to appropriate community resources; evaluates social and family situations; identifies possibil­ity of abuse and neglect; performs chemical dependency evaluation

Community ownership of program: present program to community; involve local businesses; data registry and research  —  assess efficacy of program; help reduce recurrences of falls; after completion of evaluations and inter­ventions, final recommendations made to primary physician and other members of team; follow-up mandatory to assess recurrence, progress, and efficacy of prevention

Concerns of Caregivers for Older Adults

Suzanne K. Goetschius, APRN-BC, MSN, Director of Nursing Education and Research, Fletcher Allen Health Care Center, Burlington, VT

Introduction: many caregivers of older adults feel health care providers should have “all this information at their fin­gertips and be able to help me at a moment’s notice”; many not prepared for caregiving; important to help older adults find what makes them feel successful despite aging (eg, not getting sick, maintaining function); challenges to caregiving include keeping older adults engaged, and determining and communicating about important issues

Caregiving and planning: adults with aging parents should consider caregiving plan; attitude of older adult affects caregiver; reinforce good habits of older adult; consider goals of older adult; advise adult children to “never say never” (eg, “I will never put you in a nursing home”); adult children often consult health care providers to identify and meet needs of older adults (helpful to obtain information about older adult and caregiver); caregivers often ex­pect health care providers to intervene; difficult for older adults to ask adult children for help; older adults tend to overestimate their ability to function independently, and often refuse help from adult children

Deciding when to begin caregiving: consider changes in habits (eg, missing appointments), appetite, and food (eg, inedible food found in refrigerator); mishandled medications and prescription errors; diminished driving skills; older adults often self-regulate driving (eg, drive during day and not at night); reluctance to socialize

“My mother won’t do what I tell her to do”: “older adults have right to make stupid decisions just like you did when you were a teenager”; health care provider often asked to intervene; occasionally, strong, supportive physi­cian-patient relationship may positively influence outcome; avoid involvement in power struggle between dysfunc­tional individuals; decision-making patterns  —important to know primary people who help make decisions; helpful to reinforce idea that, “she still sees you as the child”; promote autonomy and independence; help older adult feel as though they are in control during decision-making process

Relocation: moving older adult from one location to another; weigh options; “dysfunction is not tempered by need” (families that did not do well before often do not pull together in crisis situations); adult child’s desire to relocate older adult may not benefit older adult; consider consulting geriatric care manager; consider coping mechanisms and nature of older adult (eg, quiet, subdued older adult may not do well in senior housing facility); reasons to con­sider relocation  —  safety issues; wandering; need for protective presence; unsound judgment

Health problems in older adults: distinguish normal aging from disease; confusion presenting symptom for multi­ple problems (eg, urinary tract infection, pneumonia, delirium); important to manage sudden changes in cognitive function; be precise with language (eg, “Alzheimer’s disease” vs “dementia”); make caregiver aware that some con­ditions (eg, depression) can be treated, while others cannot; sharing health care information  —  discuss having open honest dialogues between older adults, caregivers, and health care providers

Housing and financing care: be familiar with state regulations; eg, definitions of “assisted living” and “residential care” may differ by state; financing  —  many programs (eg, Medicare, Medicaid) available; caregivers often ask for information about coverage for various types of care, eg, hospitalization, observation stays, and nursing home care

Driving: reporting regulations vary by state; research about driving and effects of visual ability, cognitive and physi­cal function, and how far one can turn neck under way; automakers researching car designs that may be more sup­portive of older drivers (eg, addition of mirrors and cameras); occupational therapy programs for driving rehabilitation and support; car insurance discounts for seniors for safe driving; ask family members about accidents and damage (to, eg, car, mailbox, or fence); techniques for stopping older adults from driving  —  obtain prescription that advises against driving; remove parts of car to prevent operation; use community resources

Prioritizing planning: many people lack time to research nursing and rest home facilities; explore effects of deci­sions; caregiving stressful and affects quality of life, morbidity, and mortality; discuss capabilities and other stress­ors; understand family support structure; be familiar with community resources

Personal care and safety: consider Meals On Wheels, restaurant plans, and congregate dining places; consider hired help for, eg, helping older adult in and out of bathtub; personal safety emergency response systems (eg, Lifeline) recommended

Recommendations: encourage companionship, recreation, and volunteering; understand respite care and respite care opportunities in community; help caregiver accept respite care services; be familiar with transportation programs; encourage obtaining financial information from safe resources; advise family members or caregivers to collect  rel­evant financial information (eg, account numbers, billing information) in binder; encourage wellness and preven­tion; identify family’s fears (eg, not being there when needed, insufficient finances); encourage family meetings or counseling; discuss permission to talk to caregiver when managing older adult; organize important numbers; know community resources to refer patients; consult geriatric care manager

Pharmacotherapy

Chrystian Pereira, PharmD, Assistant Professor and Clinical Specialist, University of Minnesota College of Pharmacy, Minneapolis

Multiple definitions of polypharmacy: use of more than 4 or 5 medications; use of more drugs than clinically indi­cated; use of ³2 drugs of same class; use of ³2 drugs for same disease; use of >1 pharmacy; polypharmacy causes uneasiness and concern for errors or harm to patient

Evaluation for drug therapy: indication (make sure medications appropriate); efficacy; safety (no risk for adverse effects or toxicity); compliance (involves how patient fits in with care plan; 33%-50% of patients do not take pre­scribed medications); convenience (involves how plan fits in with patient’s life); cost (consider affordability of medication)

Compliance Issues

Cost: 10% of hospital admissions and »27% of nursing home admissions thought to be result of poor compliance; $100 billion/year spent in United States due to noncompliance; affects health outcomes

Poor compliance: negative effects  —  potential for errors; reduces understanding of disease; erosion of patient-pro­vider relationship (eg, reduced trust); positive aspects  —patients making active decision about health care; patients more alert to side effects; better communication can reduce errors and erosion of relationship between patient and provider

Adherence vs compliance: “compliance” associated with judgmental tone and highlights power relationship between provider and patient; “adherence” highlights partnership between patient and provider (understates power distribu­tion); compliance  —defined as extent patient acts in accordance with prescribing intervals and dosing regimens of drug therapy; percentage of time patient takes medication between observation periods; persistence associated with amount of time patient actually takes medication; compliance not quantitative; categorizing compliance  —  generally agreed 50% compliance (or use of <50% of prescribed medications) thought to be poor compliance; pa­tients can be wholly compliant (ie, take all medications), completely noncompliant, or partially compliant (ie, amount of medications taken insufficient for therapeutic benefit)

Measuring compliance: electronic monitoring systems to count pills; pharmacy refill data; not shown to improve compliance

Risk factors for noncompliance: older age; polypharmacy; comorbidities; low education level; mental health issues; greater number of physicians; health care costs; living alone; HIV patients  —  too few or too many people at home; illicit drug use; depression; not believing medication effective

Suggested Reading

Berdot S et al: Inappropriate medication use and risk of falls--a prospective study in a large community-dwelling el­derly cohort. BMC Geriatr 9:30, 2009; Comans T et al: A break-even analysis of a community rehabilitation falls prevention service. Aust N Z J Public Health 33:240, 2009; Covinsky KE et al: Patient and caregiver characteristics associated with depression in caregivers of patients with dementia. J Gen Intern Med 18:1006, 2003; Cumming RG et al: Home visits by an occupational therapist for assessment and modification of environmental hazards: a random­ized trial of falls prevention. J Am Geriatr Soc 47:1397, 1999; Gillespie LD et al: WITHDRAWN: Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2:CD000340, 2009; Hanyok LA et al: Potential care­givers for homebound elderly: more numerous than supposed? J Fam Pract 58:E1, 2009; Maeda K: A systematic re­view of the effects of improvement of prescription to reduce the number of medications in the elderly with polypharmacy. Yakugaku Zasshi 129:631, 2009; Naditz A: Medication compliance--helping patients through tech­nology: modern "smart" pillboxes keep memory-short patients on their medical regimen. Telemed J E Health 14:875, 2008; Russell C et al: Dying with dementia: the views of family caregivers about quality of life. Australas J Ageing 27:89, 2008; Schulz R et al: Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA 282:2215, 1999.