Care of the Older Adults- 5Ms of Geriatrics
Ria Paul MD
Confidential – For Discussion Purposes Only Objectives
To understand Geriatric Principles in Primary Care
To increase understanding of 5 Ms of Geriatrics
Confidential – For Discussion Purposes Only What are the Geriatrics 5Ms?
Mobility Mind Medications Multicomplexity Matters Most
Created by: Sarah C. Phillips, MD; Chelsea Hawley, PharmD; Laura Triantafylidis, PharmD; Andrea Wershof Schwartz, MD MPH Modifications by: Ria Paul MD Tinetti et al, JAGS 2017 Module 1: Mobility
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017 Fall Prevalence
CDC, 2017; Hafner, 2014
Confidential – For Discussion Purposes Only Objectives
Differenti
Differentiate between intrinsic and extrinsic fall risk factors
Become familiar with Timed Up and Go (TUG) Test
Confidential – For Discussion Purposes Only Fall Risk Factor Modification Intrinsic Fall Risk Factors Extrinsic Fall Risk Factors Advanced age Footwear or foot problems Cardiovascular abnormalities Home hazards Chronic conditions Improper use of assistive device Cognitive impairment Multifocal eyeglasses Functional limitations New glasses prescription Gait and balance problems Substance use Medications Orthostatic hypotension Vision problems
M. E. Tinetti & Kumar, 2010; STEADI, CDC 2017.
Confidential – For Discussion Purposes Only Toe to Head Approach Socks, shoes, toenail Musculoskeletal
Bowel Cardiovascular Bladder Extrinsic Factors
Medications, Sensory
Cognition
Confidential – For Discussion Purposes Only Timed up and go test
Confidential – For Discussion Purposes Only CDC Home Safety Checklist
STEADI, CDC 2017.
Confidential – For Discussion Purposes Only Module 2: Medications
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017 Objectives −Identify when a patient is experiencing polypharmacy
−Utilize evidence-based tools for deprescribing
−Review the Beers Criteria
Confidential – For Discussion Purposes Only POLYPHARMACY
PROBLEM• Disability • Frailty • Drug-drug interactions • Impaired cognition • Slowed gait speed
How many meds? > 5
Adverse drug events: 5th leading cause of Gnjidic D et al. J Clin Epidemiol 2012 death Doan J et al. Ann Pharmacother 2013 Langeard et al. Frontiers in Pharmacology 2016
Confidential – For Discussion Purposes Only Deprescribing
Planned or supervised process of dose reduction or stopping medication(s) that may be causing harm or no longer providing benefit
Scott IA et al. JAMA. 2015; 175(5):827-834.
Confidential – For Discussion Purposes Only Deprescribing Protocol
1. Reconcile 2. Consider 5. Implement 3. Assess all risks/benefits 4. Prioritize and monitor eligibility medications of use deprescribing
Scott IA et al. JAMA. 2015; 175(5):827-834.
Confidential – For Discussion Purposes Only Use Medication Assessment Tools!
• American Geriatrics Society Beers Criteria • Medication Appropriateness Index • Anticholinergic Risk Scale AGS Beers Criteria 2015 Hanlon JT et al. J Clin Epidemiol.1992 • STOPP and START Gallagher P Int J Clin Pharmacol Ther 2008 Ruldolph et al. Arch Intern Med 2008 Phung E et al. Journal of Palliative Medicine 2018
Confidential – For Discussion Purposes Only Module 3: Mind
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017 Objectives
Apply the Mini-Cog as a screening tool for dementia
Formulate the initial diagnostic evaluation for dementia
Confidential – For Discussion Purposes Only Some Dementia Warning Signs
Trouble remembering • Defers to family • Problems with self-care “Poor historian” • Unexplained weight Appointment mix-ups loss • Vague symptoms Can’t follow instructions
Alzheimer’s Association and National Chronic Care Consortium, Getting lost 2003.
Confidential – For Discussion Purposes Only Normal Aging vs Dementia
Preclinical Mild Cognitive? Impairment Decline Cognitive Dementia
Time (years)
Confidential – For Discussion Purposes Only Primary Care Evaluation of Cognitive Impairment
Screen Evaluate Manage
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only Mini-Cog Test
Confidential – For Discussion Purposes Only Screen Evaluate Manage
Labs and History Imaging Function Mood
Cognition
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only Screen Evaluate Manage
Neuropsychology (if available) - Can provide comprehensive, objective information about which cognitive functions are affected and establish a baseline for future re-evaluations - Most helpful for MOCA 19-27, SLUMS 18-27, MMSE 18-28
Specialty physicians
− Geriatrics
Resource referral
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only Screen Evaluate Manage
Medications for dementia − Acetylcholinesterase Inhibitors (AChI) − NMDA Antagonists
Early/mild Middle/moderate Late/severe Start AChI Start ± AChI NMDA antagonist
Confidential – For Discussion Purposes Only Module 4: Multicomplexity and Matters Most
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017
Multicomplexity
Challenges in caring for older adults Multiple chronic diseases Limitations of current clinical guidelines Limited or no data on older adults Multifactorial nature of geriatric problems and syndromes Range of patient preferences
JAGS 2012 patient-centered care for older ad
Confidential – For Discussion Purposes Only
Multicomplexity
American Geriatrics Society Approach to Older Adults with Multimorbidity
Patient Look at the Estimate What is Communicate preferences evidence prognosis feasible a plan
American Geriatrics Society, 2012.
Confidential – For Discussion Purposes Only What Matters Most?
Tinetti et al, JAGS 2017 What Matters Most?
Confidential – For Discussion Purposes Only What Matters Most?
• Resources for patients • www.prepareforyourcare.org • www.theconversationproject.org • Resources for providers • www.vitaltalk.org • https://eprognosis.ucsf.edu/communication/
Confidential – For Discussion Purposes Only
Multicomplexity
http://cancerscreening.eprognosis.org/
Confidential – For Discussion Purposes Only Questions?
Confidential – For Discussion Purposes Only 33