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Geriatric Medicine A VERY, VERY BRIEF UPDATE – WITH A BIT ABOUT INTERFACE ALI ALSAWAF – CONSULTANT GERIATRICIAN, IHT.

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Presentation on theme: "Geriatric Medicine A VERY, VERY BRIEF UPDATE – WITH A BIT ABOUT INTERFACE ALI ALSAWAF – CONSULTANT GERIATRICIAN, IHT."— Presentation transcript:

1 Geriatric Medicine A VERY, VERY BRIEF UPDATE – WITH A BIT ABOUT INTERFACE ALI ALSAWAF – CONSULTANT GERIATRICIAN, IHT

2 What to cover  Polypharmacy  AF in the elderly  Anticoagulation  Constipation  When to investigate  Interface Geriatrics  Hot clinic

3 POLYPHARMACY 1  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

4 Effects of Polypharmacy  Falls  Increased side effect profile (including biochemical imbalance)  Cognitive decline/delirium  Increased hospital admissions  Increased pill burden = increased care

5 Why?  Changes in pharmacokinetics and pharmacodynamics in old age, eg renal clearance, 1 st 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

6  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

7 When to stop?  Falls  Delirium  Cognitive impairment  End of Life  Extreme age/frailty

8 EVIDENCE 2  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)

9 Making it Safe and Sound  King’s fund report  Suggests “Rather than attending several disease- specific clinics, patients could have all their long- term 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.”

10  Develop even more guidelines for multimorbidity  Reduce pill burden  Patient involvement is key (but no mention of capacity-impaired patients)

11 Polypharmacy Guidance  NHS Scotland, 2012  Mentions “Geriatricians”  Overall better guidance  British Geriatric Society support  Clear advice

12 Cochrane Review  Interventions for preventing falls in older people living in the community  Medication review by primary care physician reduced risk of falls

13 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

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15 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

16 In Summary  Polypharmacy is not easy  Multiple co-morbidities  Multiple factors to consider  Please contact us for advice (more on how later)

17 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)

18  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 cardio- selective) if patient active (gardening, walking)  Use digoxin if less/not active (eg limited mobility, house or bed bound)

19  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

20 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)

21 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)

22  Renal function-dependent (unlike Warfarin)  Reversibility unknown yet, but shorter half-life  Rivaroxaban only one suited for MDS and can be crushed

23 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)

24 CONSTIPATION  Infrequent bowel emptying  Hard stools  Difficulty passing motion (straining)  Feeling of incomplete evacuation

25 Slow transit…  Reduced physical activity  Poor oral intake  Medications (opiates, anti-cholinergics, and many more)  Many secondary causes (neurological, obstruction, metabolic etc)

26 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

27  Common cause of medical admissions  Usually because of secondary effects:  Delirium  Falls  Urinary Retention  Abdominal pain/vomiting  Overflow diarrhoea

28  Vomiting + aspiration pneumonia  Perforation  Delirium  Falls  Fractures CAN BE FATAL!

29  Bowel / stool history  Urinary symptoms  Daily fluid intake  Caffeine intake  Diet / Fibre  Red flag symptoms HISTORY

30  Anaemia  Rectal bleeding  Positive faecal occult blood test  Family history of bowel cancer or IBD  Tenesmus  Weight loss RED FLAGS

31  Bloods: FBC, U&E, Bone Profile, TSH  Urine dipstick  Refer for endoscopy if red flag symptoms Investigations

32 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)

33 Stool consistency  If it’s hard – soften it  If it’s soft – stimulate it

34 TREATMENT  Treat cause if possible (polypharmacy?)  Initially: education, diet and lifestyle measures  Softeners: Movicol, Lactulose, Phosphate  Stimulants: Senna, Docusate, Bisacodyl, Glycerine

35 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)

36 Points to consider  General state of health (co-morbidities)  Frailty  Functional baseline  Mental baseline

37  Patient and family engagement essential  Both in decisions to actively investigate or not  Clear explanation of implications of decision  Can be revisited in future

38  If patient lacks capacity, best interest decision  Must involve next of kin  Difficult decisions  Please contact us for advice

39 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

40 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

41  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

42 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

43 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

44 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

45 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

46 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)

47 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)

48  Service started November 2013  Still running  No direct GP referrals received to date

49 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

50 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)

51 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

52  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

53 REFERENCES  Polypharmacy Guidance (1)  armacy%20full%20guidance%20v2.pdf armacy%20full%20guidance%20v2.pdf  AF   2 hich-drugs-to-stop-in-which-older-patients/ hich-drugs-to-stop-in-which-older-patients/  Safe and sound and-medicines-optimisation and-medicines-optimisation

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