End of Life Care: Talking About Hospice
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Geriatrics Board Review Daniel Pound, MD Clinical Professor Family and Community Medicine, UCSF Medical Director, UCSF Center for Geriatric Care Doe wat je t’liefste doet Carolina Origins Emma Zuletta Otersen 1886 - 1976 Outline Dementia, delirium, and depression Falls, osteopenia, and osteoporosis Hearing and functional impairment Urinary incontinence Age related changes in drug metabolism Medication prescribing with CKD Welcome to Medicare Mrs. Jones 65 yr old retired teacher Diabetes HTN CHF atrial fib GERD Complains about husband’s hearing Mr. Jones 65 yr retired airplane mechanic BPH insomnia anxiety URI symptoms Hard to hear women or to hear in crowds Not bothered by hearing loss Which do you expect? Sensorineural loss Conductive loss Air = bone Air < bone Types of hearing loss Sensorineural Conductive Age related presbycusis Obstructed canal Gradual onset Perforated or scarred TM Effect of noise exposure Otitis media High frequency (♀ voice) Worse in crowds Air = bone on audiogram Air < bone on audiogram Prescribe hearing aid or Treat underlying cause cochlear implant Consonants or Vowels? He has mixed hearing loss Sensorineural: curve slopes down to the right (high frequency) Conductive: air (O) worse than bone (X) conduction Treat conductive loss: Remove cerumen Antibiotic for otitis media Hearing aids His sensorineural loss persists after abx Hearing loss is socially isolating Is patient is likely to use hearing aids? Yes: if patient is bothered by hearing loss No: if only his wife is bothered by hearing loss Side effects: discomfort, feedback, stigma No interventions proven to increase use Cochrane Database Syst Rev. 2014;7:CD010342. Why Hearing Aids Don’t Work Incontinence Mr. Jones has recent onset urine leakage Unpredictable leak day and night x 4 days Lower abdominal pain, no dysuria or fever Hydrocodone PRN back pain Diphenhydramine/pseudoephedrine OTC Guaifenesin with codeine PRN cough What type incontinence? Urge Stress Mixed urge/stress Obstructive overflow Atonic overflow Functional Keys = dribbling, BPH, opioid, cold meds PVR > 200 cc = Overflow Overflow etiology: two types Too little tone Too much tone Neuropathy Opioid Bladder tone Anticholinergic atonic BPH Sphincter tone Alpha agonist obstructive Overflow treatment to tone to tone Atonic Bladder tone Stop codeine Stop Benadryl Bethanechol? Obstructive Stop decongestant Sphincter tone Alpha blocker Finasteride Foley TURP? Mrs. Jones What Type Incontinence? Mrs. Jones has chronic incontinence Leaks urine with cough or sneeze “Can’t get to the bathroom in time” G1P1 vaginal birth PVR 15 cc (normal is < 100 cc) Keys = parous, Valsalva, urgency Mixed urge + stress etiology Too little tone Too much tone Overactive bladder Dementia, UTI? Bladder tone Bladder stone, tumor urge Vaginal birth Prolapse Sphincter tone TURP, alpha blocker stress Mixed incontinence treatment to tone to tone Urge Anticholinergic Bladder tone (oxybutynin) Sympathomimetic (mirabegron $$$) Stress Sphincter tone Kegel exercises Pessary ♀ Urethral sling surgery Anticholinergic Choices Oxybutynin (Ditropan) and tolterodine (Detrol) best studied in elderly Sustained release or patch less side effects Newer M3 selective rx still cause dry mouth Trospium (Sanctura) Solifenacin (Vesicare) Darifenacin (Enablex) Tricyclic (nortriptyline, imipramine) side effects harder for elderly to tolerate Functional incontinence Too little to function Dementia Cognition functional functional Poor vision Prompted voiding Vision (timed voiding) functional Bedside commode Slow gait Urinal Poor dexterity External catheter ♂ Mobility Restraints Sweat pants functional No restraints Urinary Incontinence Too little Too much tone tone Atonic Neuropathy Overactive bladder Bladder Spinal cord disease Dementia Urge Anticholinergics Bladder stone Overflow Opioids Bladder tumor tone PVR < 100 cc PVR > 200 cc Mirabegron Bethanechol Childbirth BPH Sphincter- Prolapse Urethral stricture Obstructive Stress Prostate surgery Prostate cancer outlet Alpha blocker Alpha agonist Overflow PVR < 100 cc Finasteride Pessary PVR > 200 cc tone Foley catheter Bladder sling surgery Bedside commode Poor gait Urinal Poor vision Cognition- External catheter Functional Poor dexterity Sweat pants mobility Poor cognition Prompted voiding Bone Health Mrs. Jones asks about bone density test FH mother died in SNF after hip fracture Menopause age 48 (i.e., not early) DEXA at age 50 was low normal T - 0.9 No prior fractures, smoking, or steroids 3 drinks per day, Caucasian race 5’ 6” 135 lb. BMI 21 Who to screen National Osteoporosis Foundation Women > 65 and men > 70 Postmenopausal women <65 or men 50-70: only if concern based on risk factors USPSTF (for board exams) Women >65 (younger women whose risk >= 65 yr. old white woman w/o other risk factors) Insufficient evidence to recommend for men Medicare DEXA coverage >65 Postmenopausal women Men only if: Osteopenia or vertebral fracture on X-ray Taking or starting steroids Primary hyperparathyroidism Already taking osteoporosis drugs Not covered by Medicare for men just based on prostate cancer therapy Osteoporosis Risk Factors Age Personal history of Gender fracture Low BMI Parental history of hip fracture Current smoking Secondary Alcohol 3 or more drinks per day osteoporosis : Rheumatoid arthritis Low femoral neck Hyperparathyroidism BMD Oral steroid use Her femur neck results Age 50 T -1.0 Normal Age 65 T -1.5 Osteopenia Age 70 T -1.9 Osteopenia Age 75 T -2.5 Osteoporosis Who to treat Osteoporosis Clinical diagnosis (hip or vertebral fracture) DEXA diagnosis (T ≤ - 2.5) Osteopenia (-1 > T > - 2.5) if other risk factors that predict 10-year risk of either: ≥3 % risk of hip fracture, or ≥20 % risk of major osteoporotic fracture These risk rates = cost effective to treat FRAX for osteopenia Age 65 @ 135 lb. 66 inch Age 70 @ 130 lb. 65 inch Her FRAX results Age 50 T -1.0 FRAX N/A (normal DEXA) Age 65 T -1.5 1.5% hip 19% major Age 70 T -1.9 6.5% hip 21% major Age 75 T -2.5 FRAX N/A (osteoporosis) Osteoporosis Treatment Calcium 1200 mg elemental total (incl diet) Ca carbonate inexpensive Ca citrate better absorbed if high gastric pH Vitamin D3 800 – 1000 IU Weight bearing exercise Avoid tobacco and alcohol Fall prevention Osteoporosis drug therapy Bisphosphonate Alendronate (po) or zoledronic acid (IV) Prevent hip + spine fractures Contraindicated if GFR < 30 (po) or 35 (IV) Side effects: Esophagitis (sit up after taking) Musculoskeletal pain Osteonecrosis of jaw (rare) Atypical femur fractures (rare) More expensive therapies Used if intolerant of, contraindication to, or continued fractures with bisphosphonates Denosumab (Prolia) anti-RANKL antibody Prevents hip + spine fractures Subcu Q6mo, caution if GFR < 30 (hypoCa) Teriparatide (Forteo) anabolic PTH Prevents spine + non-spine fractures Not specifically proven to prevent hip fracture Subcu daily x2 years ($72,000 total for 2 yrs) Less attractive therapies Nasal calcitonin Prevents spine fractures, not proven for hip Causes small increased risk for cancer Short term use as analgesic for spine fracture Raloxifene (Evista) SERM Prevents spine fractures, not proven for hip Prevents breast cancer Not used in elderly due to risk for thrombi Her treatment T -1.0 Normal GFR 70 calcium D exercise T -1.5 FRAX 1.5% / 19% GFR 55 same T -1.9 FRAX 6.5% / 21% GFR 40 add bisphosphonate for % risk T -2.5 Osteoporosis GFR 25 stop bisphosphonate for GFR Mr. Jones falls Falls getting up from bed to toilet at night Minor injuries Diazepam, hydrocodone, or Flexeril (cyclobenzaprine) PRN back pain Zolpidem PRN insomnia Terazosin at bed time Multifactorial and Serious Intrinsic causes Extrinsic causes Abnl gait/balance Environment hazards Weakness Medications Neuropathy Vestibular Precipitating factors Orthostatic ↓BP Syncope Vision loss Acute illness 10% risk major injury 2% risk death Medicines That Cause Falls Sedation Orthostatic hypotension Opioids Antihypertensives Benzodiazepines Alpha blockers for BPH Other sleeping pills Nitrates Antipsychotics Antipsychotics Antidepressants Tricyclics Antiemetics Trazodone Antihistamines Anticholinergics Muscle relaxers Antiparkinsonian Fall Interventions PT for strength + balance Tai Chi (strength + balance) Stop psychotropic rx Address home hazards Multifactorial assessment Cataract surgery x1 for poor vision Vitamin D 800 IU/day per USPSTF Emergency Response Alert Texting For Seniors BFF = Best Friend Fell FWIW = Forgot Where I Was TTML = Talk To Me Louder ROFLACGU = Rolling On Floor Laughing And Can’t Get Up His Fall Prevention Plan Refer PT Change terazosin to tamsulosin Vision 20/50 eye exam for cataracts Reduce or stop sedating medications Avoid diazepam (Valium) in elderly Fat soluble half-life 4-5 days Avoid muscle relaxers (SOMA or Flexeril) Excess sedation >> minimal pain relief Mrs. Jones falls Falls going up step from garage to kitchen Painful buttock hematoma, no head bleed Daughter flies in from LA, reports she is unsteady, confused, has urine odor 80 yr 115 lb. 64 inches 19.7 BMI 108/55 Meds glyburide, oxybutynin, famotidine, clonidine, digoxin 0.25mg, apixaban, alendronate creatinine 1.9 A1C 6.8 Precipitating causes of fall Rx acute illness (UTI ↓ functional reserve) Check for orthostatic hypotension Supine vs standing up x3 minutes Systolic ↓ 20 or diastolic ↓10 = abnormal Elderly