Case Studies in Geriatric Medicine

In the united states, lower birth rates and increasing longevity has contributed to growing numbers of people 65 years old or older (Roberts, Ogunwole, Blakeslee, & Rabe, 2018). By 2050, it is predicted that at least ¼ of the united states population will be ≥ 65 years old (Roberts et al., 2018). Nearly all providers caring for adult populations will likely see increasing numbers of geriatric patients. This paper describes a case-based approach identifying and managing common geriatric syndromes and concerns that providers across all disciplines may encounter. The patients described have been assigned aliases and are part of Northwestern Medicine’s Home-Based Primary Care (HBPC) program. HBPC programs, targeting the highest need and highest-cost patients, have been shown to reduce Medicare costs and hospital admissions (Lindquist & Dresden, 2019). HBPC programs are different from traditional home care that typically focuses on acute problems. Rather, with HBPC, an interdisciplinary team of physicians, pharmacists, social workers, physical therapy and advanced practice providers collaborate to address a myriad of physiological, social and psychological elements for patients and caregivers to promote optimal well-being while allowing the patient to remain at home (Lindquist & Dresden, 2019)

Case Study #1

Providers may find themselves in a conundrum when trying to manage calls like these. Many providers would opt to bring the patient in for a visit or perhaps arrange for a home-care agency to send a nurse over. Either of these options may take some time before the patient is assisted. Fortunately, the APRN for the HBPC program was able to make a visit the following day. This patient did have a very confusing bag of medications that took the APRN sent for a home visit over 1 hour to straighten out.  For instance, she had an Advair Diskus as well as an Advair HFA, the same medication but two different preparations and appearances. Of the medications she had been sent home with, some were in pharmacy bottles and others in single-dose packages from the hospital. She also had multiple duplicates. She needed help to organize and understand her medications as well as placing all the like with like and fill her pillbox for the next 2 weeks. This patient had been holding on to several expired or discontinued medications. Emergency hospitalizations related to adverse drug events are a great health concern for the geriatric population and measures should be taken to assure that patients both understand and adhere to their medication regimens (Lindquist & Dresden, 2019).

Polypharmacy

Polypharmacy is defined as the use of multiple medications by a patient and is of concern for older adults who may have more chronic conditions being treated. Adverse drug reactions are suspected to account for 3-10% of all older adult hospitalizations (Saraf et al., 2016). The use of greater numbers of medications has been found to be an independent risk factor for adverse drug events (Saraf et al., 2016). Polypharmacy has been linked with falls and was an independent predictor of hip fractures (Jokanovic, Tan, Dooley, Kirkpatrick, & Bell, 2015). Patients may experience adverse drug events that are misinterpreted as a new medical condition leading to “prescribing cascade” of new medications to treat this condition (Rochon & Gurwitz, 2017). Multiple and complex medication regimens have been shown to increase medication nonadherence (Kucukdagli et al., 2019). Additionally, polypharmacy has been linked to functional decline, incontinence, cognitive impairment and poor nutrition (Jokanovic et al., 2015).

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The most widely used criteria for medication appropriateness in older adults is Beers criteria (Panel et al., 2015). Providers prescribing to the geriatric population should be considerate some of the special concerns for this population. Anticholinergic medications may lead to delirium, memory problems, confusion, hallucinations or anticholinergic symptoms of dry mouth, constipation, urinary retention, hypotension and tachycardia (Panel et al., 2015).  NSAIDs are likely the most widely used inappropriate agent and may worsen renal function or lead to GI bleeding (Panel et al., 2015). Benzodiazepines are an independent risk factor for delirium, may increase risks of falls and fractures and should be avoided, especially with concurrent use with opiates as this can lead to respiratory depression and death (Lindquist & Dresden, 2019; Zaal et al., 2015). Antipsychotics such as Haldol and Zyprexa should be avoided unless the patient poses a risk to self or others, but can be used short-term in the treatment of delirium (Lindquist & Dresden, 2019). Antipsychotic medication increases mortality in older adults and providers should focus on behavior modification prior to prescribing medications (Lindquist & Dresden, 2019). For acute pain control, avoid morphine due to buildup of active metabolites in the presence of decreased renal clearance (Lindquist & Dresden, 2019). Dilaudid in small doses may be more appropriate for hospitalized geriatric patients requiring acute pain control (Lindquist & Dresden, 2019).

Providers should utilize guidelines for prescribing to the geriatric population (Lindquist & Dresden, 2019). Be sure to ask patients to bring ALL their medications in for visits as some may be on dangerous Over The Counter (OTC) medications or holding on to expired or discontinued medications (Lindquist & Dresden, 2019). A pharmacy consult may be helpful if polypharmacy is identified or for complex or concerning regimens (Lindquist & Dresden, 2019). Utilization of pillboxes and blister packs may improve adherence (Conn et al., 2015). Blister packs are available at some pharmacies for no additional charge and may be more accurate than caregiver filled pill boxes (Conn et al., 2015).

This patient is exhibiting concerning findings for frailty and functional decline. Frailty is characterized by a variety of elements including slowness, shrinking, exhaustion, inactivity, weakness, disability, malnutrition, and changes in cognition and mood (Fried et al., 2001). Frail patients have diminished physiological reserve leading to a higher incidence of disability, morbidity, institutionalization, falls and all-cause mortality (Fried et al., 2001).

Providers may have some concerns about sending Mr. Williams home. This patient would benefit from a multidisciplinary approach to address his needs. A social worker could assist with eligibility and costs of home assistance (Lindquist & Dresden, 2019). Physical and occupational therapy would be beneficial for home gait, balance, strength and function, while a dietitian could provide nutritional assessment and intervention (Lindquist & Dresden, 2019). He may benefit from home visits or perhaps placement in assisted living would be more appropriate. Since your time may be limited, referral to geriatrics for a geriatric assessment may be beneficial (Lindquist & Dresden, 2019). Geriatric appointments at Northwestern Medicine are over 1 hour and include consultation with our geriatric social worker. It may be a good idea to consider discussing goals of care with patient/ complete POLST form (Torke et al., 2019).

Northwestern Medicine also offers resources for additional evaluation. Some providers may consider admitting this patient for a social admission or for failure to thrive. Another, and possibly better choice, would be to send the patient to the Emergency Department (ED) at Northwestern Memorial for a geriatric assessment (Hwang et al., 2018; Lindquist & Dresden, 2019) The skilled geriatric nurses will administer a number of validated tests to assess for common geriatric conditions by evaluating cognitive function, delirium, functional status, falls risk and caregiver strain (Hwang et al., 2018). The comprehensive geriatric ED at Northwestern Memorial also includes access to 24-hour social work coverage and a Monday-Friday physical therapist. The interdisciplinary team evaluates the patient for safety in returning home arranges additional home services such as meals and household assistance. This program has been shown to reduce the need for hospitalization (Hwang et al., 2018; Lindquist & Dresden, 2019).

Case Study #3

Many providers may feel the best approach to this patient would be to send him into the ED for evaluation and treatment. This would likely cause increased burden and costs to his caregiver as he would need to travel by ambulance, an out-of-pocket cost for patients, other than those receiving Medicaid. It is also likely that this patient would subsequently be admitted from the ED, generating additional costs from inpatient admission and depleting scarce healthcare resources. This is a patient that benefited from the HBPC program and received a home evaluation by an APRN the following day. The APRN performed an exam and collected a CBC, BMP and UA and culture. On exam, the patient was not showing concerning signs of sepsis or other acute findings that would warrant admission. The patient was started on Cephalexin 500 mg by mouth every 8 hours while the labs were pending. The BMP and CBC were unremarkable. The urine culture was positive for Proteus mirabilis and susceptible to the antibiotic chosen. The patient was seen the following week for follow up by the HBPC APRN and found to be in stable condition with mentation and behaviors at his baseline.

Delirium

Mr. Edmond may be experiencing delirium in addition to his dementia. The Presence of delirium on admission is a strong indicator of increased functional decline during hospitalization (D’onofrio, Büla, Rubli, Butrogno, & Morin, 2018). Distinguishing delirium from dementia may be difficult and a patient may present with both. Delirium frequently occurs in people with dementia; however, having episodes of delirium does not always mean a person has dementia (Lindquist & Dresden, 2019).  The DSM-5 diagnostic criteria for delirium includes an acute and fluctuating disturbance in attention with a change in cognition (Lindquist & Dresden, 2019). The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time (Lindquist & Dresden, 2019). The patient may have a significantly impaired ability to maintain focus and attention (Lindquist & Dresden, 2019). Delirium can often be linked to one or more physiological factors such as acute or chronic illness, metabolic disturbances such as low sodium, infections, surgery, and drug or alcohol-related problems (Lindquist & Dresden, 2019). Delirium may manifest in several clinical presentations.  Hyperactive delirium, perhaps the most easily identified type, this may include restlessness, agitation, mood changes or hallucinations, uncooperative behaviors (Lindquist & Dresden, 2019). Hypoactive delirium manifests as inactivity or reduced motor activity, drowsiness, sluggishness and dazed appearance (Lindquist & Dresden, 2019). Patients may have a mixed delirium, with manifestations of both hyperactive and hypoactive delirium (Lindquist & Dresden, 2019).

Obtaining a history from a confused or uncooperative patient may be difficult. Relatives or caregivers, if available, may be able to provide valuable information about potential causes such as recent infection, organ failure, drug or alcohol abuse, or depression (Lindquist & Dresden, 2019). A focused exam concentrating on vital signs, hydration, skin and potential infectious etiologies should be performed (Lindquist & Dresden, 2019). Simple tests like asking the patient to spell “lunch” or “world” backward may be useful in identifying inattention (Lindquist & Dresden, 2019). Delirium can be confirmed using either the Confusion Assessment Method (CAM) or the Brief Confusion Assessment Method (bCAM) (Lindquist & Dresden, 2019). Both assess the four elements of delirium, which include acute altered mental status, disorganized thinking, inattention, and altered consciousness (Lindquist & Dresden, 2019). Medications should be assessed, and drug levels evaluated for toxicity when possible (Lindquist & Dresden, 2019). A finger stick blood sugar, CBC, CMP, lactate, blood gas, liver function tests, ammonia level urine analysis and culture, chest x-ray, CT brain, EEG, lumbar puncture, EKG may be ordered indicated by history and exam (Lindquist & Dresden, 2019).

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Interventions that may help reduce delirium include orientation to environment, clocks, calendars, windows with outdoor views and reorientation (Lindquist & Dresden, 2019). Visits from family and friends and provision of visual and hearing aids if needed, will aid in cognitive stimulation for patients, yet overstimulation should be avoided (Lindquist & Dresden, 2019). If possible, it is best to avoid procedures and medication administration during sleep hours. Early mobilization with PT and OT, limiting the use of restraints and sedatives have been shown to be useful for mitigating delirium (Lindquist & Dresden, 2019). Medications should be reviewed for potential culprits. Benzodiazepines, opioids, antihistamines and should all be used with caution or avoided. Medical complications such as dehydration, dihydropyridines (nifedipine, amlodipine), hypoxemia and infections may contribute to development of delirium and must be identified and treated (Lindquist & Dresden, 2019). Untreated pain may be an important contributor for delirium (Lindquist & Dresden, 2019).  Non-opioid and nonpharmacological pain control interventions should be used when possible and appropriate as these have least risk of potentiating delirium (Lindquist & Dresden, 2019).

Dementia

While delirium is often acute with a reversible cause, dementia is chronic, progressive and irreversible (Lindquist & Dresden, 2019). Dementia is a progressive loss of memory and other thinking capabilities due to reduction or damage of brain cells (Smits et al., 2015).  Dementia is not a specific disease but rather a set of symptoms associated with loss of mental capacity and social skills severe enough to affect daily living (Smits et al., 2015). There are several different types of dementia with varying etiologies. Alzheimer’s disease is the most common type of dementia in people 65 and older (Raz, Knoefel, & Bhaskar, 2016). While the exact cause is poorly understood, clumps of plaques and tangles of fibers composed of protein are found in the brains of Alzheimer’s patients on autopsy (Raz et al., 2016). Vascular dementia is the 2nd most common type of dementia and occurs secondary to damage to the blood vessels supplying the brain from vascular problems such as stroke (Raz et al., 2016). Lewy body dementia is a progressive dementia that occurs in Parkinson’s and Alzheimer’s disease and is characterized by the presence of abnormal clumps of protein found in the brain called Lewy bodies (Raz et al., 2016). Many patients with dementia have mixed dementia, or a combination of Alzheimer’s, Lewy body and vascular dementia (Raz et al., 2016).

Patients with dementia experience a myriad of psychological and cognitive changes such as personality changes, depression, anxiety, inappropriate behavior, paranoia, agitation, hallucinations, memory loss, trouble communication, reasoning, problem solving, completing tasks, planning, organizing and with coordination and motor functions (Smits et al., 2015).  Previously patients with dementia were often grouped together and identified as having “senile dementia.” It is now better understood that accurate diagnosis of the type of dementia is important for accurate treatment and prognosis (Bredesen et al., 2018).

Patients with dementia will often lose decision-making capacity and should identify a Health Care Power of Attorney (HPOA) (Austrom, Boustani, & LaMantia, 2018). Behavioral disturbances are common in dementia and should be routinely screened for during visits. Caregivers should be asked about hallucinations, delusions, aggression, apathy, wandering and other behavior problems (Austrom et al., 2018).  Underlying causes of behavioral disturbances in dementia include delirium, medication side effects, pain, depression, anxiety, sleep disorders and sensory deficits (Austrom et al., 2018). Pain is an important and often under-identified or treated condition that may exacerbate dementia symptoms (Austrom et al., 2018). It is important to explore nonpharmacological interventions prior to drug therapy as polypharmacy may contribute to worsening dementia symptoms and sleep disturbances (Austrom et al., 2018). Many patients with dementia will experience sleep disturbances (Austrom et al., 2018). Some general recommendations to promote adequate sleep include keeping the environment dark at night and bright during the day, reducing night-time noise and unessential night-time wake-ups, sleep hygiene education, establishing consistent sleep-wake schedules and controlling stimuli (Austrom et al., 2018).

Strange or unfamiliar environments or changes in daily routines may exacerbate symptoms; therefore, it is important for dementia patients have routines and to participate in regular activities and chores (Austrom et al., 2018). Eating problems are very common in dementia patients (Nifli, 2018). Patients tend to have a diminished sense of smell; therefore, supplements, appetite stimulants, increasing spices, flavor content, and texture in foods and assisted feeding have been used with varying degrees of success (Perna et al., 2019). Safety concerns are prominent for patients with dementia. In addition to lack of decision-making capacity, dementia patients are often unaware of their deficits and may engage in risky behaviors such as driving and cooking (Brims & Oliver, 2019). Patients are prone to wandering and may become lost in remote areas (Brims & Oliver, 2019).

Caregiver Burden

Caregivers of persons with dementia often experience significant role strain and burden (Liu et al., 2017). Caregiver burden can be assessed by the Modified Caregiver Strain Index, a validated tool (Lindquist & Dresden, 2019). Psychotherapy, support groups, and respite care have all been shown to improve caregiver well-being, reduce burden or reduce the intent institutionalize the patient (Austrom et al., 2018; Rausch, Caljouw, & van der Ploeg, 2017; Vandepitte, Putman, Van Den Noortgate, Verhaeghe, & Annemans, 2019).

Information technology innovations are emerging as useful tools to help improve safety, independence and function (Osvath, Kovacs, Boda-Jorg, Tenyi, & Fekete, 2018). Security cameras, motion detectors, water temperature sensors have been used to help promote safety while allowing for patient independence (Osvath et al., 2018).  Computer and tablet games allow for pastimes and promotion of cognitive processes (Osvath et al., 2018). Telemedicine, online support groups and web applications can provide disease information and interpersonal connections (Osvath et al., 2018).  Calendar apps, such as google calendar, can be set up to deliver automatic reminders such as time for medications or doctor’s appointments (Rover, 2018). Video calling, such as Face Time and Skype, allow for direct visualization between dementia patients and caregivers and can help reduce feelings of isolation (Rover, 2018). Voice-activated assistants, such as Alexa, can be programmed to deliver reminders, play music, read books and even answer questions like “what day is it?” when asked repeatedly (Rover, 2018). Spark memories radio allows for creation of playlists of music dating back to the 1930s (Rover, 2018)

Implications for Practice

Geriatric patient populations are growing in the united states and will likely be seen at some point by all providers practicing adult medicine. Providers should assess for and understand appropriate interventions for common geriatric syndromes such as polypharmacy, frailty, dementia and delirium and caregiver burden in order to provide patient-centered, age-specific care. Providers may consider referral for specialist comprehensive geriatric assessment and should choose an accredited geriatric emergency department when referring to emergency care.

References

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• Bredesen, D., Sharlin, K., Jenkins, D., Okuno, M., Youngberg, W., & Cohen, S. (2018). Reversal of cognitive decline: 100 patients. J Alzheimers Dis Parkinsonism, 8(450), 2161-0460.1000450.
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