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Geriatrics 101
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Geriatrics 101
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Upload Date:
2022-09-15T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DR. SMITH: Welcome back to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only, and should not be understood as medical advice under any circumstances. [intro music] [intro music] [intro music]
DR. REDD: Welcome back to Run the List. I'm your host, Walker Redd and I'm thrilled to be here with Dr. Andrea Schwartz today to discuss how we can provide the best possible care to older adults. Dr. Schwartz is a geriatrician with expertise in frailty and geriatrics education. In addition to working as the medical director of the Geriatrics Consult Clinic at the Boston VA and the associate fellowship director of the Harvard Geriatrics Fellowship, she serves in a number of different roles at the Harvard Medical School and School of Public Health.
DR. REDD: She is an absolutely phenomenal educator, her innovative and simple approach to teaching geriatric medicine certainly shaped the way I understand caring for elderly adults. So I'm really happy that we'll be able to have the chance to share her teaching with our audience. Okay, Dr. Schwartz, are you ready to Run the List? [Dr. Schwartz] Thanks Walker, let's do it.
DR. REDD: Perfect. So as usual, we will be starting with a case prop today, but today's case we're going to keep more general as the specifics here are less important than the overall approach. So our patient is Miss G. She is an 82-year-old retired elementary school teacher with hypertension, hyperlipidemia, atrial fibrillation, GERD, diabetes, osteoporosis, and a more recent concern for potential cognitive impairment.
DR. REDD: We can imagine two scenarios in which we would meet a patient like this. In the first scenario, we are in our outpatient primary care clinic and her former PCP has just retired. So her son's bringing her into the office today to establish care with you as her new PCP. And a second scenario, she's being admitted to the inpatient general medicine service at one in the morning after her son found her walking around the house confused and brought her into the emergency department.
DR. REDD: Regardless of what specialty we are working in, Miss G's case is similar to so many of the patients that we care for. While we all frequently care for older adults, the complexity of even routine care can be overwhelming, which is why I found this systematic approach of the Geriatric 5Ms so helpful. So, Dr. Schwartz, before we get started, could you just share a little bit of the background of how the creators of the 5Ms were motivated to do this and sort of what purpose this approach can serve?
DR. REDD: [Dr. Schwartz] Absolutely, thanks, Walker. So the Geriatric 5Ms was developed by doctors Mary Tinetti, Frank Molnar and Allen Huang at Yale and the University of Ottawa. And they initially came up with it as a way to explain what we do in geriatrics. And in recent years, the 5Ms has joined forces with the Age-Friendly Health Systems Initiative of the Institute for Healthcare Improvement.
DR. REDD: The M domains that we ought to be thinking about when we care for a patient like the one you've described here are mobility, mind, medications, multi-complexity, and what matters most. And the idea behind these 5M domains is to take a step back from the individual medical problems and think about how this older person is managing in each of the M domains and really what matters to them and what their goals are.
DR. REDD: So this systematic approach can help us make sure we're not missing the forest for the trees, and that in addition to caring for the individual problems that a person is facing, we're actually looking at this patient, Miss G's overall function by using the 5Ms to approach her care. Now, this does not mean that we're necessarily approaching all 5Ms in every encounter, but we ought to be thinking about how mentation and mobility and medications and what matters intersect with the particular symptom or medical condition that we're caring for.
DR. REDD: Thank you. So before stepping through the individual 5Ms, I just want to pause quickly and mention that it's important we recognize some assumptions we make, and some of the biases of ageism that may actually sort of arise when we hear about a patient we're caring for who may have cognitive decline and is elderly. It can be really complex to help these patients out, but it's really important to practice humanistic medicine and I know that one way Dr. Schwartz you've taught me before is to remember how you would want to be cared for when you're older or how you would want your family members cared for, and so just building on those comments you just shared with us, could you just speak a little bit to like some of the broader themes we can keep in mind while we go through these?
DR. REDD: [Dr. Schwartz] Absolutely, thanks for that question, Walker. I think the most important thing is, as you said, to think about how we would want our loved ones or our family members to be treated and imagine how scary it would be, if we or one of our family members was all of a sudden confused and we brought them to the hospital.
DR. REDD: We would want the doctor caring for them to ask, "Well, what are they usually like?" And we would want them to understand that this is a change and we are concerned. When we think about the care of older people, we need to be thinking about the person-centered dignified care that every single person deserves when they encounter the healthcare system, and one of the ways we can do that is by asking who is this person?
DR. REDD: What matters most to them? What is their life like? And what is their baseline? Knowing when there's a change from baseline can help us avoid ageist assumptions. Most older people do not have cognitive impairment at baseline, though most people with cognitive impairment are old. Most older people in the United States live independently, though most nursing home residents are old.
DR. REDD: And so by checking our assumptions and asking what this person's baseline is, who this person is and what matters to them can help us make sure that we're treating each patient as an individual, young or old, and making sure they get the person-centered care that they deserve. Something else to keep in mind when you're meeting an older person for the first time is the concept of frailty.
DR. REDD: Frailty refers to decreased physiologic reserve or resilience and the risk of badness as you age. And so, for example, if you think about a person who's having multiple falls in the same way that you might think about multiple NSTEMIs in a person with coronary artery disease, the person with frailty is at much higher risk for bad outcomes with those falls.
DR. REDD: And so thinking about someone's frailty and someone's risk level could also be a helpful framework to think about what kind of older adult are we encountering, a fit person, pre-frail or severely frail and that might affect how we deliver care. And it helps you shift your thinking from disease-focused assessment to a broader view of the patient as an entire person rather than a list of medical problems.
DR. REDD: Thanks, that is just such helpful context. While we're not going to dive into all the details within each of the 5Ms because that would be a much longer episode, we're just going to step through the 5Ms approach and highlight some teaching points. So let's imagine we're meeting Miss G, Dr. Schwartz just tell me how you would approach and assess sort of treating mobility, which is the first of the 5Ms we're going to talk about.
DR. REDD: [Dr. Schwartz] Absolutely. So one of the principles of age-friendly care is that for each M domain, you've got to assess and act on the information you find. So for mobility in a patient like Miss G, the first step is to assess her baseline mobility. What is her functional status like? Can she do her activities of daily living, like bathing and dressing at baseline, or her instrumental activities of daily living, her IADLs, like medication management or grocery shopping?
DR. REDD: And has there been a recent change in her mobility that we need to know about? Other things to consider in mobility are falls and whether falls or near falls have been an issue because falls are a major cause of morbidity and mortality in older adults. And like that patient with an NSTEMI, where you've got to do risk factor reduction on multiple risk factors to prevent the next NSTEMI, in a patient who's having falls, there are multiple risk factors that are modifiable and can be addressed to head that off in the future.
DR. REDD: So for someone like Miss G, I might ask about her living situation and what her day to day is like, and then I might do a quick falls risk assessment and if it's positive, go deeper, asking about extrinsic fall risk factors such as high risk medications or environmental hazards, and intrinsic fall risk factors like cognitive impairment, sensory deficits, urinary incontinence, strength, foot problems.
DR. REDD: And so you can do a quick test at the bedside, such as the chair stand, where if you're listening you can try this at home, put your feet flat on the floor, cross your arms over your chest, and try to stand up without using your arms. And an older person who can't complete a chair stand or has difficulty with it, may have sarcopenia, loss of muscle mass and may benefit from physical therapy and exercise and therapeutic chair stands to get stronger and lower their fall risk.
DR. REDD: You can also look at gait speed as a really important marker both of frailty and overall health and timing how your patient walks can be a really helpful indicator of how they're doing overall. Finally, under the mobility category, orthostatic hypotension is a really common fall risk factor in older people as the cardiovascular system ages, so checking blood pressure sitting and then after a minute standing, or in some cases lying to standing can be a really helpful clinical tool to make sure you're not missing a modifiable cause of falls or decreased mobility.
DR. REDD: Well, so many excellent pearls there. Thank you so much for sharing. So after we gather some more history about Miss G's functional status, perform some of those tests at the bedside, now we turn towards what often is the family's and her son's sort of primary concern, which is this potential cognitive change. That brings us to the second of the 5Ms, the mind. So can you just share what tools you can use to help understand a patient's cognitive status?
DR. REDD: [Dr. Schwartz] Absolutely. So when it comes to mentation, it's all about the baseline. And so in Miss G's case, asking her and asking her son about perceived changes in memory and thinking can be really helpful to understand the acuity of the problem. If someone has an acute change in their mental status, like they were running their own finances last week and now they're disoriented, then I'm really worried about the first of the three Ds, delirium.
DR. REDD: Delirium is an acute change in mental status. We call it acute brain failure, and there's usually an underlying cause, an infection, an illness, medication, dehydration, something that has triggered the delirium. In Miss G's case, in the inpatient setting where there's been a sudden change, I'm very worried about delirium. Especially if you were to meet someone in the hospital who is delirious, you might want to think about the three Ps of pain, pee or poop, very common, an older adult who's hospitalized, and maybe has had a hip fracture or has been given new medications and is in pain or has urinary or fecal retention, and so there're often underlying reversible causes of delirium.
DR. REDD: But so in that first D, I would use a tool like the UB-2 to do your initial screen. The UB-2 is the ultra-brief delirium screen and it's the days of the week or months of the year backwards, which is a test of attention, and orientation to today. Can you tell me what day it is? And if a person can't do the UB-2, which was developed by Dr. Donna Fick and others, then they should be assessed using the CAM, the Confusion Assessment Method developed by Dr. Sharon Inouye and others.
DR. REDD: And these are tests of delirium that help you really treat this as the emergency that it is and figure out why there's been a change in mental status and how you can reverse it. But in Miss G's case, if it's not an acute change in mental status, then we're worried about the second D which is dementia. Dementia is the umbrella term for cognitive impairment, Alzheimer's being the most common type, followed by vascular dementia.
DR. REDD: And in the office setting, we'll often do a very quick screening tool such as the Mini-Cog developed by Dr. Soo Borson to help get a sense of whether there is objective evidence of cognitive impairment. The Mini-Cog is just a three-word recall and a clock draw. And if you're listening in, you can try drawing the face of a clock, putting in all the numbers, setting the time as 11:10, and you'll see it's a very complex task that requires executive function and visual spacial input.
DR. REDD: So a person who can't pass the Mini-Cog, definitely needs a longer cognitive screening test, such as the MOCA or Montreal Cognitive Assessment, and may even need longer, more in-depth cognitive testing to determine where their deficits are and help figure out what might be underlying their change in cognitive status. Now in older people, not all cognitive impairment is dementia.
DR. REDD: I can definitely tell you about cases where there was a new medication or sleep apnea or hypoglycemia that was contributing to cognitive impairment, as well as hearing impairment or vision impairment, which are often modifiable risk factors. So if you're concerned about dementia, one of the other things to think about is staging it because dementia is a wide spectrum, one of the most common staging skills is the FAST Scale.
DR. REDD: And the FAST Scale takes you from 1 to 7, 7 being severe or end-stage dementia, where a person is suffering from the neurodegeneration leading to not only loss of cognitive function, but loss of mobility and verbal ability. We often get asked to evaluate people when they're around FAST stage 3 or 4, and they're having difficulties with complex tasks like finances or medication management.
DR. REDD: And in any of these cases, delirium or dementia, we need an interprofessional team to help assess why the person is having cognitive changes and to help keep them safe and figure out the next steps in evaluation and management. The third D I'll mention is depression, because in older adults depression is often overlooked. It's not considered a normal part of aging, and so assessing mood is critically important using a tool like the PHQ-2, to assess if there's been a change in mood and things like anxiety or PTSD can often be missed in older adults and are eminently treatable.
DR. REDD: And so in thinking about these three Ds, the most important message I leave you with is to use an objective screening tool. You really can't make an accurate diagnosis just based on gestalt because there can be overlaps in the presentations of dementia, delirium, and depression, so get a sense of the baseline and the time course and use one of these objective screening tools to help you figure out what is going on and how to help someone like Miss G when it comes to mentation.
DR. REDD: Thank you for sharing such a high yield overview there. So in both scenarios, the patient, Miss G and her son find your sort of taking her cognition seriously very helpful, because it really validates that concern like you mentioned earlier. And so now we turn to her list of medications. And so Dr. Schwartz, what are the most important things about medications?
DR. REDD: And I know this is a huge topic in and of itself, but just give me kind of your main takeaways for our listeners. [Dr. Schwartz] So the most important thing to remember when it comes to medications in older adults, is that any new symptom in an older person should be considered a possible medication side effect. And this geriatrics adage has been attributed to Dr. Gurwitz and others, is the idea that as we age, our physiology changes and so medications that we tolerated when we were in our 50s may make us confused or fall when we're in our 80s or 90s.
DR. REDD: And so reviewing an older person's medication list with an eye towards high risk or potentially inappropriate medications is critical in any setting in which you encounter them. So remember, the physiology of aging means that we should always start low and go slow when starting new medications and assessing whether there could be side effects because of decreased renal and hepatic clearance of meds as we age, we've got decreased muscle mass and increased body fat and body water, so fat-absorbed meds hang around longer as we age and the blood-brain barrier has increased permeability with age and so medications have a higher risk of causing confusion.
DR. REDD: And then there's the fact that older adults are more likely to be on multiple medications, greater than five is considered potential polypharmacy. And so they're at high risk for medication side effects and in fact, some of the top causes of ER visits in older adults are for medications commonly prescribed like anticoagulants or diabetes medications that land people in the emergency room.
DR. REDD: And so when possible, make sure that every medication has an indication and that medications aren't just treating a side effect of another med, what we call a prescribing cascade. And ask how the medications are being taken, if they're being taken. Don't increase a blood pressure medication until you've actually clarified that the patient is taking what's prescribed.
DR. REDD: And whenever possible, avoid high risk medications. You can use the American Geriatric Society Beers list of potentially inappropriate medications, to zero in on safer alternatives when it comes to things like pain medications or antidepressants. And in so doing, you can make sure that medications are delivering more benefit than harm to older adults and patients like Miss G who's cognitive impairment could very well be related to Benadryl or Ambien that could be affecting her cognition.
DR. REDD: So, so important to ask, assess and act on medications in older adults.
DR. REDD: So after carefully reviewing her medication list, we do get to sort of make her nurse unhappy and feels gratifying to us to do a little bit of deprescribing. It's not always the easiest thing to do, but certainly with the sort of expertise of looking through those different resources we can turn to, it's really great to be able to do that for our patients. So now let's turn to the fourth of the 5Ms, multi-complexity.
DR. REDD: I was grateful to learn about this topic from you as a resident. So can you just share a little bit of your wisdom in that area? [Dr. Schwartz] Absolutely. So multi-complexity is an umbrella that includes things like the social determinants of health that we know so clearly, things like structural racism impact how somebody ages and what kind of care and healthy environments they've had access to over their life course.
DR. REDD: And multi-complexity includes things like caregiver stress and the family environment in which an older adult lives, what kind of financial resources they have access to, which predicts so much the kind of help they're able to get should they need it as they age. One of my favorite examples of multi-complexity is looking at a patient's feet. And I love asking the question of how someone trims their toenails.
DR. REDD: Because if you think about it, for you Dr. Redd, if you or I couldn't trim our own toenails which- You try it right now, I mean, bending down, it takes a lot of mobility and dexterity and flexibility, and if we couldn't reach, maybe we'd be lucky enough to have someone in our lives we could ask to trim our toenails for us. Well, maybe we'd let them grow long for a little while, but after a while, they'd start to curl around the tip of our toes and we need to trim them so that our shoes would fit and we wouldn't fall.
DR. REDD: Maybe we'd go get a pedicure, we'd go to a podiatrist, but those cost money, you need transportation, you need the executive cognitive function to be able to plan that out. So when I look at the feet of every older adult and I do this, when I meet them inpatient or outpatient, or even on a telehealth visit, I ask to look at the feet because long toenails are this hidden sign of multi-complexity.
DR. REDD: Because if you can't trim your toenails, you may have issues in mobility, you may have issues in mentation because maybe you're depressed and you're self-neglecting or you're having cognitive impairment and you can't plan out how to get them trimmed. You may be having issues in medications where you get dizzy when you bend down or in multi-complexity where you don't have the financial resources or the caregiver support.
DR. REDD: And so by asking this question of how do you get your toenails trimmed and looking at the feet, you can identify an older person who may be at risk of bad outcomes, who may need that extra support because the toenails are often hidden and we don't see them, they're not an obvious sign that things are going in the wrong direction. And so my colleague, Dr. Orkaby and I describe the toenails as the A1C of physical function, that the same way that the A1C tells you how someone's sugars have been over the last few months, more so than a spot point-of-care glucose, long toenails tells you how an older adult has been doing over the last few months, if they're able to attend to their own needs or they have caregivers involved.
DR. REDD: So in Miss G's case, if she's got beautiful toenails and her son is doing them for her, that reassures me that there's someone paying attention to the details. And so that's a nice pearl in multi-complexity that you can use to get a sense of how an older person is managing. One other thing I'll mention in multi-complexity is assessing frailty, because again, that can help you think about what kind of risk an older person may have, and so a nice, quick bedside tool that you can use to assess frailty is the FRAIL scale, where you ask about fatigue, resistance, where you ask about fatigue, resistance, like whether you can walk up 10 steps, ambulation, how many illnesses the person has and the L in FRAIL stands for loss of weight.
DR. REDD: So this was developed by Dr. Morley and others, and the FRAIL scale is a nice history-based tool to get a sense of how high risk an older person may be in terms of the risk of hospitalization, falls or even institutionalization. And it can help you prioritize getting that interprofessional team in place to mitigate the frailty and help the person stay independent as long as they are able to.
DR. REDD: That's great. And so for Miss G that discussion uncovers a number of different ways in which our multidisciplinary team can help support her going forward. Now that we've established some rapport with Miss G and her son, we turn to the fifth of the 5Ms, matters most. We're actually covering end of life care and kind of goals of care discussions in another entire episode with one of your colleagues Dr. Schwartz, but would you mind just sharing from the geriatrics perspective, what is most important to remember?
DR. REDD: [Dr. Schwartz] Absolutely. So matters most in some way is the most important M because if we don't know what matters to our patients, we don't know that we're aligning care with their goals. And so asking what matters is critical for both current care planning and advanced care planning. So advanced care planning as you mentioned you're going to cover in another podcast, but the COVID era has really shown us the urgency of making sure that we've got on file a person's wishes when it comes to serious illness and end of life care.
DR. REDD: And I think every person of every age, but especially a frail older person ought to have that advanced care planning discussion focused on their goals of care at the end of life. In some ways more importantly, every older person and really people of all ages should have a current care planning discussion focused on their priorities and goals for their care right now.
DR. REDD: And one example of this is the Patient Priorities Care tool developed by Dr. Mary Tinetti and others. And Patient Priorities Care gets us to ask about what matters in terms of your care right now. So I could imagine Miss G telling us that the most important thing to her is her family and she values being able to interact and engage with her family. Well, that might help us engage with her and deprescribe meds that are clouding her cognition, but she might also say the most important thing for her is her independence and being able to get out and walk her dog.
DR. REDD: And so then we might prioritize focusing on her mobility and her physical therapy so that she can get out and do that. The current care planning conversation helps us understand what an older person's goals are. And I don't mean process goals like their A1C or their blood pressure, I mean functional goals. What do they want to be able to do more of, if all this health care were actually working and helping you have a better quality of life, what would that look like?
DR. REDD: Maybe it's getting out into your garden and so we need to focus on your knee pain and your orthostasis so you can get down in the weeds. Maybe it's writing your next book and so we need to focus on your vision and on getting rid of medications that are making it hard for you to think. And so by asking what matters and what someone's goals are right now, in addition to advanced care planning, but right now that can help us really make sure that care is aligned with goals.
DR. REDD: And so that we're not just treating diseases, but we're actually helping older people live their best lives day by day.
DR. REDD: I mean, what you just summarized there to me is really what makes a doctor a good doctor. It's what brings us to medicine in the first place, it's that ability to care for the human themselves. And so, in addition to all the practical clinical pearls, I love ending with kind of some of those broader themes and this will help empower our listeners to do justice to the privilege of caring for our elderly patients. It's really a privilege, it's been one of the most gratifying parts of my young career, and I think that certainly learning some of these concepts from you changed my practice and so I hope if you're a student listening or a resident, this can help frame the way you approach things.
DR. REDD: Or if you're someone who's a little bit later in your career, this can also help change the way you approach things and how you help patients prioritize. So just to briefly return to our case, in the one scenario in which we met this patient in the outpatient setting, we applied the 5Ms over the course of a few visits, we made a referral to a geriatrics consultant for co-management and we were able to help prioritize efforts to improve Miss G's functional status, characterize her cognitive status, deprescribe some medications, arrange some support for caregivers and update those current as well as advanced goals of care.
DR. REDD: On the inpatient side, we use these principles and practices proactively. We were able to diagnose Miss G with delirium secondary to a UTI and treat that while avoiding the use of anti-psychotics and working with her family. She improved quickly and was able to return home and get back to life after a brief hospitalization. So every episode, Dr. Schwartz, and this is just filled with takeaways, we try to just say, if nothing else that our listeners walk away with, what are three sort of important concepts that you want to make sure students or new interns or attendings, anyone sort of gets out of this?
DR. REDD: [Dr. Schwartz] Thank you, Dr. Redd. The three main takeaways I would leave for our listeners are first, when you approach the care of an older adult, think about the Geriatric 5Ms as the principles of an Age-Friendly Health System and be an advocate for older adults, whether that's calling your Congress people to make sure that caregivers are adequately compensated in the home and in the nursing home setting, whether it's advocating for your patient on the wards to make sure that they're treated as an individual and that their needs are met.
DR. REDD: And the second takeaway I would say is, ask at your healthcare center if they're enrolled in the Age-Friendly Health Systems Initiative which integrates into existing models of care. And the third point I would leave you with is that you can't do this alone. To take good care of older adults, you need to partner with the patient to deliver person-centered care.
DR. REDD: You need to communicate with families, you need to work with an interprofessional team. You can't do this alone, and you can't do this all at once, but that doesn't mean that you can avoid it. You need to learn, deepen your own understanding and use the Geriatric 5Ms and the Age-Friendly Health Systems approach to deliver the kind of care that we all want for ourselves and our loved ones and that our patients deserve as we age.
DR. REDD: So thank you, Dr. Redd for the opportunity to talk with the Run the List listeners and for the incredible work you do through the podcast.
DR. REDD: Thanks for the kind words. And I'm leaving this recording super inspired, and I know our listeners will be too. As we all go forward and take better care of our older adults, we thank you for joining on Run the List, and we look forward to seeing you next time. [Dr. Schwartz] Thank you so much. [outro music] [outro music]