Transcript Geriatric Medicine - Ipswich and East Suffolk CCG

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!
[email protected]
01473 704134 (secretary)