geriatric times - cleveland clinic...geriatric care can be difficult; as always, we are happy to...
TRANSCRIPT
Ensuring Effective Care for Older Adults with COPD Understanding cost and treatment limitations p 6
Geriatric TimesAn Update for Physicians from Cleveland Clinic’s Medicine Institute | Spring 2014
Evaluating Safety, Outlook in Patients with Dementia
p 3
Tailoring Treatment for Patients with Diabetes
p 8
Assessing and Treating Pressure Ulcers
p 11
Addressing Challenging
Hypertension
p 13
ALSO IN THIS ISSUE
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Dear Colleagues:In each issue of Geriatric Times, it is my distinct pleasure to highlight different Cleveland Clinic specialties that help our Center for Geriatric Medicine fulfill its mission to improve care for the oldest and frailest members of society.
Our center serves as a central resource for physicians, nurses, therapists, social workers and other providers across Cleveland Clinic’s eight hospitals and 16 family health centers, coordinating and participating in clinical, educational and research programs.
In this issue, we focus on the efforts of our specialists to keep older patients as healthy and active as possible in the face of chronic diseases such as:
• Diabetes: Dr. Vinni Makin explains that HbA1c targets should be adapted with age and function in mind, especially for those who are frail.
• COPD: Dr. Loutfi Aboussouan reviews options for preventing exacerbations and maintaining quality of life in older patients.
• Hypertension: Dr. Leslie Wong demystifies blood pressure treatment goals for elderly patients.
We also address two issues affecting many elderly patients:
• Dementia: Social worker Rosemary Truchanowicz offers insights on evaluating outlook on life and the support network for aging patients.
• Pressure ulcers: Dr. Stephen Schwartz, who (among other duties) guides the Connected Care wound team in managing post-acute patients, offers practical advice on assessment and care.
Finally, we profile an active 92-year-old man who, grateful for cardiac and pulmonary care at Cleveland Clinic, decided to “give back” by sharing his insights as a dementia caregiver with internal medicine residents.
These articles represent a small sample of the work we do every day to help make a difference in the quality of our patients’ lives.
We understand that deciding where to send patients requiring comprehensive geriatric care can be difficult; as always, we are happy to offer our input and to work in partnership with you.
Please don’t hesitate to contact me with any questions, concerns or suggestions on how we might improve our services to you and your patients at 216.444.6801 or [email protected].
Kind regards,
Barbara Messinger-Rapport, MD, PhD, FACP, CMD
Director, Center for Geriatric MedicineCleveland Clinic Medicine Institute
Medical Editor Barbara Messinger-Rapport, MD, PhD
Managing Editor Cora M. Liderbach
Art Director Anne Drago
Cover Photo Tom Merce
Illustrations Joe Pangrace
Geriatric Times is published by the Center for Geriatric Medicine in Cleveland Clinic’s Medicine Institute. The institute also encompasses Family Medicine, Internal Medicine, Infectious Disease, Primary Care Women’s Health, and one of the nation’s largest Hospital Medicine programs. Primary care providers within the institute use the patient-centered medical home model to coordinate basic, chronic and complex care for patients at the main campus and 16 family health centers.
The Medicine Institute is one of 27 institutes at Cleveland Clinic, a nonprofit academic medical center ranked among the nation’s top hospitals by U.S. News & World Report. More than 3,000 physicians and researchers in 120 specialties at Cleveland Clinic collabo-rate to give every patient the best possible outcome and experience.
Geriatric Times is written for physicians and should be relied on for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient.
© 2014 The Cleveland Clinic Foundation
Geriatric Times Spring 2014
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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
Evaluating Older Patients with Dementia Part 2: Assessing Outlook on Life and Support Network
By Rosemary Truchanowicz, MSW, LISW-S, C-SWHC
OUTLOOK ON LIFE
Sixty percent of older adults who take their own lives see
their primary care physician within a few months of their
death. Educating members of the patient’s social support
network about suicide prevention and warning signs is
imperative. Older adults may not have been at high risk for
suicide in the past, but aging, eroding health and deterio-
rating coping skills can change that.
Assess suicide risk. Although older adults attempt suicide
less often than younger adults, their completion rate is
higher (American Association of Suicidology, 2012). Non-
Hispanic white men 85 or older have the highest death
rate. According to the Substance Abuse and Mental Health
Services Administration (SAMHSA), older people who
attempt suicide are more frail, more isolated, more likely
to have a plan and more determined than younger adults.
(See box on suicide risk factors on page 4.)
Ask about weapons in the home. The most common means
of suicide in older adults involves firearms (followed by
poisoning and suffocation). Older adults are nearly twice
as likely as people under age 60 to commit suicide using
firearms. Guns should be locked separately from ammuni-
tion at all times, and patients with dementia should not
have access to either.
Assess homicide risk. Asking whether anyone is bothering
an older adult may reveal paranoid ideation not otherwise
evident. One older adult, complaining that an upstairs
tenant listened to her conversations through heating
ducts and made noise to annoy her, said she intended to
use her deceased husband’s gun to protect herself if he
came near her.
Screen for depression. Routine screening of all older
patients for depression is recommended because depres-
sion raises risks of suicide and homicide. A more thorough
evaluation, a safety plan and possible admission may be
required if older adults seem depressed, agitated or restless.
Ask patients with mild dementia if they are responsible for
other family members. Caring for an adult child with
a disability, for grandchildren or for great-grandchildren
can lead to increased agitation, guilt and despondency.
Consider caregivers’ outlook. Attending to both caregiv-
ers’ and older adults’ emotional well-being is crucial to
prevent homicide and suicide. Family members may vastly
underestimate the care an older adult requires. They may
suffer under the weight of responsibility, or feel guilty or
hopeless. Overwhelmed caregivers need to know what
to monitor and report so that practical interventions or
referrals to appropriate agencies can be implemented in a
timely way. During a crisis, they will need to be relieved of
caregiving responsibilities and will require support. Long
before a crisis occurs, have them develop an emergency
plan for contacting social service resources or respite care
facilities on short notice.
SUPPORT NETWORK
It’s important to review older adults’ family and support
systems in detail. A thorough understanding of who pro-
vides care, and the type and frequency provided, is critical.
Ask why the family is not involved. One-third to one-half of
all patients with dementia have no identifiable caregiver.
If the family is not involved in an older patient’s care, con-
sider whether a drug or alcohol problem or mental health
disorder may have caused the estrangement.
Educate the family. Family members may need education
about the best environment for older adults with cogni-
tive impairment. For example, playing loud, jarring music
may overstimulate older adults, who may prefer calming,
Older adults with dementia and their caregivers may face gradual or precipitous changes in personality, cognition and
functioning. To prevent adverse incidents, we recommend assessing function in three areas: Self-Care, Outlook on
Life and Support Network (SOS). In our last issue, we addressed self-care. In this issue, we explain how understanding the
patient’s outlook on life and support support can help prevent suicide, homicide, abuse and exploitation.
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G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
spiritual music. Watching a movie with scenes of war or
violence may frighten older adults with dementia because
they may think it is happening now.
Consider family abuse/neglect. Unfortunately, the most
likely perpetrators of abuse, exploitation and neglect of
older adults are in fact close family members. Unusual
answers from older adults questioned about abuse or
neglect may be real — or the result of paranoid thinking
not evident to others. Be sure to take time to assess the
feasibility of patients’ concerns.
Older adults are at risk of financial exploitation and
medication diversion. Ask patients if family members or
acquaintances ask them for money or gifts — or if they
give medications to family members who don’t have insur-
ance or can’t afford to buy them.
Consider exploitation by others. Older adults are also vul-
nerable to exploitation from paid caregivers, neighbors or
acquaintances who may seem charming. Deceitful caregiv-
ers may gradually increase older adults’ dependence on
them, take over their finances, isolate them and provide
self-serving information to family and healthcare providers.
Caregivers may portray the family in a negative light,
brainwashing older adults to bond with them. Even
when questioned privately, older patients may deny they
are being exploited. Discerning which family members
and friends visited or helped the older adult before the
caregiver became involved — and finding a plausible
explanation for their absence — is crucial.
If you find yourself questioning whether caregivers have
older adults’ best interests in mind, consider report-
ing the situation to Adult Protective Services for further
investigation. n
Ms. Truchanowicz, of Cleveland Clinic’s Ob/Gyn & Women’s Health Institute, can be reached at [email protected] or at 216.445.8701.
Evaluating Older Patients with Dementia continued
Risk Factors for Suicide
SAMHSA lists the following as risk factors for suicide in older adults:
• Depression
• Prior suicide attempts
• Marked feelings of hopelessness
• Comorbid general medical conditions that significantly limit functioning or life expectancy
• Pain and declining role function (e.g., loss of independence or sense of purpose)
• Social isolation
More specific risk factors for suicide in older adults include:
• Loss of a close relationship or a move from a long-standing residence
• Acute stressors such as a new diagnosis
• Misuse/abuse of alcohol or medication
• Sleeping more or less than usual
• Impulsivity in the context of cognitive impairment
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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
Monroe Messinger was in his 20s and part of the
U.S. Army Corps of Engineers when he was tapped
for The Manhattan Project. Today he’s the last surviving
member of J. Robert Oppenheimer’s team. The retired
chemical engineer continues to fascinate listeners with
stories of his years in Los Alamos, N.M., before and after
the atomic bomb.
After World War II, Mr. Messinger settled into civilian life. He became a successful analytical research director at Chesebrough-Ponds (now Unilever). He and his wife traveled extensively throughout Europe. He loved motorcycles and rode with a motorcycle club well into his 70s.
Now 92, Mr. Messinger still leads an extraordinary life. A pacemaker, cardiac stents, hip replacement, COPD and gastrointestinal issues haven’t sidelined him.
STAYING MOBILE AND INDEPENDENT
“Mr. Messinger is a highly intelligent, conscientious and motivated man,” says Cleveland Clinic geriatric specialist Ronan Factora, MD. “He is focused on maintaining his independence and on being a dedicated spouse.”
Despite an extensive cardiac history and underlying pulmonary problems, Mr. Messinger’s quality of life is excellent. One reason is his participation in the PARTNER (Placement of Aortic Transcatheter Valves) trial. Dr. Factora recommended him for the trial comparing minimally invasive to surgical aortic valve replacement.
Participation in pulmonary rehabilitation, which combines exercise training with counseling and education, has also made a difference. Mr. Messinger no longer gets as breathless as he used to, and has not developed any infections, or required hospitalizations or steroids.
“Mr. Messinger’s age could have been a barrier for him to receive these interventions,” notes Dr. Factora. “But considering how much his medical conditions affected his quality of life, how sharp his mind was and how preserving his independence was the primary goal, our
CASE STUDY:
Maintaining an Extraordinary Life
medical team devised a plan that made these outcomes possible. Mr. Messinger’s case is an example of how age shouldn’t be the only factor in treating geriatric patients.”
GOING STRONG
Although he requires portable oxygen, Mr. Messinger wants to keep moving. In his twice-a-week exercise class at the VA hospital, he walks on a treadmill, uses a recumbent cross-trainer and lifts weights — and he uses a cross-trainer at home.
The exercise keeps him as able-bodied as ever. Mr. Messinger continues to be a caregiver for his wife, who has dementia. He’s eager to talk about the condition from a caregiver’s perspective, and thinks it is important to do so.
He shared his experiences and insights in presentations to Cleveland Clinic internal medicine residents in 2013.
“Doctors should talk to patients and their caregivers separately,” Mr. Messinger advised the group. “Caregivers can’t always say things candidly in front of the patient, particularly about dressing, incontinence and other sensitive issues.”
Caring for a loved one with dementia does cause tension, says Mr. Messinger. But he takes it in stride — it’s real life, he says.
And for Mr. Messinger, real life is still going strong. n
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COPD in the Elderly: Diagnostic and Management Challenges Understanding cost and treatment limitations
By Loutfi S. Aboussouan, MD, and Barbara Messinger-Rapport, MD, PhD
After a decade of large, well-designed trials, it appears that current chronic obstructive pulmonary disease (COPD)
management strategies may improve outcomes such as dyspnea and quality of life, reduce exacerbations and
perhaps increase survival.
Yet physiological aging makes the accurate diagnosis of
COPD challenging, as does the increased rate of adverse
medication effects in older adults. Physical challenges and
the growing recognition of substantial cognitive impair-
ment among elders with COPD pose additional problems.
A SEVERE BURDEN ON THE ELDERLY
COPD affects more than 14 million Americans, and hos-
pitalizations related to COPD increase with age — from
40.2 per 10,000 for ages 55 to 64 to 131 per 10,000 for ages
75 and older.1 Further, mild cognitive impairment, in 36
percent of COPD patients vs. 12 percent of controls, is asso-
ciated with worse health status and a longer hospital stay.2
Diagnostic standards supporting a fixed FEV1/FVC <0.70
for COPD may lead to overdiagnosis in the elderly. The
FEV1/FVC for healthy never-smokers decreases with age;
35 percent of those over age 70 and 50 percent of those over
age 80 have an FEV1/FVC < 0.7.3 Thus, clinical context must
be considered along with spirometric results.
TWO VACCINES MAY HELP
Ninety-five percent of influenza deaths occur in patients
over age 60.4 In elderly patients with chronic lung disease,
influenza vaccination reduces hospitalizations due to
exacerbations 52 percent and risk of death 70 percent.5
High-dose vaccines are associated with a higher antibody
response, although local reactions may be more frequent.
(Preliminary results of a Phase 3 trial show that in older
adults, high-dose vaccines may reduce influenza risk 24
percent more than the usual dose, but 200 patients must be
treated in order to prevent one case.) More data is needed on
the best candidates for the new vaccines.
Pneumococcal vaccination does not reduce hospitaliza-
tions or mortality, but when combined with influenza
vaccination may reduce infectious acute exacerbations,
hospitalization and risk of death in the first years after
administration.6 Vaccination is recommended for patients
65 and older or who have COPD; revaccination is not
needed.
MEDICATION COST MATTERS
The medical management of COPD relies heavily on
inhaled medications, with generic alternatives available
only for a few nebulized treatments. The expense can
be substantial; common medication combinations cost
several thousand dollars per year. Elderly COPD patients
whose out-of-pocket inhaler costs exceed $20 per month
are at higher risk of medication non-adherence.7
There are no easy solutions for physicians, except to:
• Ask patients whether medication expense may be the
cause of non-adherence
G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
COVER
STORY
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COPD in the Elderly: Diagnostic and Management Challenges Understanding cost and treatment limitations
By Loutfi S. Aboussouan, MD, and Barbara Messinger-Rapport, MD, PhD
• Consolidate medications when possible
• Direct patients to assistance programs as needed
• Consider generic nebulized alternatives, which are
80 percent reimbursed under Medicare Part B
EASE OF USE A KEY FACTOR
The success of inhaled devices depends largely on
ease of preparation, simple instructions and lung deposi-
tion rates. Pressurized metered-dose inhalers are easy
to prepare but hard to inhale correctly, whereas hard-to-
prepare nebulizers are easy to inhale correctly.
Lung deposition rates may also vary by device and are gener-
ally lower in nebulizers. Sixty percent of patients 65 and older
use dry powder inhalers correctly, compared with 25 percent
who are 80 and older.8 Newer devices requiring fewer steps
prior to inhalation and no coordination between inspiration
and actuation may be easier to use correctly.
Devices should be chosen based on patient age, capabil-
ity and preference; third-party payer coverage; physician
comfort with teaching inhalation techniques; convenience;
and portability.
SIDE EFFECTS HIGHER IN ELDERLY
Pharmacodynamic and pharmacokinetic changes, comor-
bidities and the potential systemic effects of inhaled
medications help to contribute to increased side effects
for elderly patients using respiratory medications.
The adverse effects of beta-adrenergic agonists include
arrhythmias, ischemia, tremors and osteoporosis. (An
increased risk of arrhythmia with new use of a long-acting
beta agonist reported in a large case-control study of COPD
patients 67 or older was found to be insignificant after
patients with a history of arrhythmia or heart failure
were excluded.) 9
The potential adverse effects of anticholinergic agents
such as ipratropium and tiotropium include dry mouth,
confusion and urinary retention. Inadvertent eye contact
(especially with nebulizers) may cause pupillary dilatation
and precipitate acute glaucoma. Despite initial cardio-
vascular concerns, the large UPLIFT (Understanding
Potential Long-term Impacts on Function with
Tiotropium) trial found no increase in strokes, heart
attacks or cardiovascular deaths.10
ADDITIONAL CONSIDERATIONS IN FRAIL ELDERS
Beta blockade: Uncertainty about using beta blockers in
COPD patients continues, mainly due to concerns that
the drugs might induce bronchospasm and worsen lung
function. Yet emerging evidence suggests that beta block-
ers may be associated with reduced mortality in COPD.
Cardioselective beta blockade need not be withheld from
patients with COPD who have cardiovascular disease if
they are monitored for adverse effects.
Cognitive impairment: Older adults may underuse inhal-
ers and cause recurrent COPD exacerbations or overuse
inhalers and increase risks of adverse effects. Prescribing
a simple regimen and recruiting a family member to
supervise medication may be the keys to compliance.
Osteopenia and osteoporosis: Older adults are more likely
to have these conditions, which can be accelerated by
inhaled beta agonists and/or steroids. Compliance with
bone-density screening recommendations and treatment of
osteoporosis using current standards should be encouraged.
COMBINATION REGIMEN, REHAB EFFECTIVE
Inhaled corticosteroids should be prescribed in com-
bination with long-acting beta agonists for COPD. The
potential survival benefit of this combination in the
TORCH (Towards a Revolution in COPD Health) trial was
attributed to the long-acting beta agonist.11 While several
studies have linked inhaled corticosteroid use by COPD
patients with a potentially increased risk of pneumonia,
overall risk remained low.
Referring older adults to pulmonary rehabilitation —
providing upper body conditioning, respiratory training
and aerobic training in a monitored environment — is
too often dismissed because of concerns about frailty or
deconditioning. Yet for motivated older adults with trans-
portation support, pulmonary rehabilitation can improve
exercise capacity, physical function and quality of life, and
is even beneficial beyond age 80.12
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DRUG INHALED NEBULIZED
Inhaler strength* (μg/actuation)
U.S. Monthly Costs† Nebulized strength* /vial
U.S. Monthly Costs†
Short-acting beta 2-agonists
Albuterol 90 pMDI $50-$60 2.5-5 mg in 3 mL ‡ $10
Levalbuterol 45 pMDI $60 0.63-1.25 mg in 3 mL ‡
$150-$350
Pirbuterol 200 BA pMDI $490 — —
Long-acting beta 2-agonists
Salmeterol 50 DPI $135 — —
Formoterol 12 DPI $200 20 mcg in 2 mL $535
Arformoterol — — 15 mcg in 2 mL $490
Indacaterol 75 DPI $200 — —
Short-acting anticholinergic
Ipratropium 17 pMDI $260 500 mcg in 2.5 mL ‡ $10-$20
Long-acting anticholinergics
Aclidinium 400 DPI $260 — —
Tiotropium 18 DPI $310 — —
Combination beta-2 agonist and anticholinergic
Albuterol/ipratropium 100/20 SMI $290 2.5 mg/0.5 mg in 3 mL ‡
$45-$120
Combinations of inhaled corticosteroids and beta-2 agonists
Budesonide/formoterol 80-160/4.5 pMDI $220-$260 — —
Fluticasone/salmeterol 100-250-500/50 DPI
45-115-230/21 pMDI
$230-$290-$370 — —
Mometasone/formoterol 100-200/5 pMDI $240 — —
Fluticasone/Vilanterol 100/25 DPI $290 — —
pMDI = pressurized metered-dose inhaler; BA pMDI = breath actuated pMDI; SMI = soft mist inhaler; DPI = Dry powder inhaler. * Base dose reported. † Rounded prices reported based on data from Medi-Span and www.goodrx.com. Monthly cost for as needed nebulized medications assumes 60 vials per month.‡Generic available
c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
Available Inhaled and Nebulized Medications for COPD with Cost Estimates
COPD in the Elderly continued
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Other interventions to consider for older adults
include smoking cessation strategies, ventilatory
muscle training, airway clearance techniques, medica-
tion management and psychological support. n
Dr. Aboussouan (left), of the departments of Pulmonary and Critical Care Medicine and the Sleep Disorders Center, can be reached at [email protected] or at
216.444.0420. Dr. Messinger-Rapport (right), Director of the Center for Geriatric Medicine, can be reached at [email protected] or at 216.444.6801.
REFERENCES
1. Ford ES, Croft JB, Mannino DM, et al. COPD surveillance—United States, 1999-2011. Chest 2013;144(1):284-305.
2. Villeneuve S, Pepin V, Rahayel S., et al. Mild cognitive impair-ment in moderate to severe COPD: a preliminary study. Chest 2012;142(6):1516-23.
3. Hardie JA, Buist AS, Vollmer WM, et al. Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J 2002;20(5):1117-22.
4. Sprenger MJ, Mulder PG, Beyer WE, et al. Impact of influenza on mortality in relation to age and underlying disease, 1967-1989. Int J Epidemiol 1993;22(2):334-40.
5. Nichol KL, Baken L, Nelson A. Relation between influenza vaccination and outpatient visits, hospitalization, and mortal-ity in elderly persons with chronic lung disease. Ann Intern Med 1999;130(5):397-403.
6. Nichol KL. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine 1999;17 Suppl 1:S91-S93.
7. Castaldi PJ, Rogers WH, Safran DG, et al. Inhaler costs and medica-tion nonadherence among seniors with chronic pulmonary disease. Chest 2010;138(3):614-20.
8 Quinet P, Young CA, Heritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmo-nary disease. Ann Phys Rehabil Med 2010;53(2):69-76.
9. Wilchesky M, Ernst P, Brophy JM, et al. Bronchodilator use and the risk of arrhythmia in COPD: part 2: reassessment in the larger Quebec cohort. Chest 2012;142(2):305-11.
10. Tashkin DP, Celli B, Senn S., et al. A 4-year trial of tiotro-pium in chronic obstructive pulmonary disease. N Engl J Med 2008;359(15):1543-54.
11. Suissa S, Ernst P, Vandeemheen KL, et al. Methodological issues in therapeutic trials of COPD. Eur Respir J 2008;31(5):927-33.
12. Baltzan MA, Kamel H, Alter A., et al. Pulmonary rehabilitation improves functional capacity in patients 80 years of age or older. Can Respir J 2004;11(6):407-13.
For Your Information
c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
The Cleveland Clinic WayBy Toby Cosgrove, MD,
CEO and President of Cleveland Clinic
Great things happen when a medical center puts
patients first. For details or to order a copy, visit
clevelandclinic.org/ClevelandClinicWay.
A Leader in Geriatric CareCleveland Clinic’s Center for Geriatric Medicine is
ranked the No. 7 geriatrics program in the country
by U.S. News & World Report. For details, visit
clevelandclinic.org/geriatricmedicine.
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Diabetes in the Elderly: Management Challenges Tailoring treatment for a vulnerable age group
By Vinni Makin, MD
Diabetes affects more than a quarter of 65-year-olds in the United States. Older adults with diabetes face an increased
risk of mortality and institutionalization, and age-related physiological changes, depression, polypharmacy, impaired
cognition, reduced functional status and cognitive decline are prevalent. Management presents unique challenges given the
comorbidities in this population.
INDIVIDUALIZING GOALS FOR ELDERLY
Intensive glycemic management has been controversial,
especially after data from the VADT (Glucose Control
and Vascular Complications in Veterans with Type 2
Diabetes), ACCORD (Action to Control Cardiovascular
Risk in Diabetes) and ADVANCE (Action in Diabetes and
Vascular Disease: Preterax and Diamicron MR Controlled
Evaluation) trials was made public.
Evidence suggests that glycemic targets should be individ-
ualized, considering life expectancy, duration of diabetes,
presence of micro- and macrovascular complications,
and comorbidities.
Most practitioners agree that adhering to guidelines
emphasizing an HbA1c greater than 7 percent is reason-
able for physically active, robust older adults with early
type 2 diabetes when this target can be achieved without
hypoglycemia, falls or confusion.
American Diabetes Association (ADA) goals are not tai-
lored to age, but the European Diabetes Working Party for
Older People suggests a range of 7 to 7.5 percent for older
diabetic patients without comorbidities and of 7.6 to 8.5
percent for frail diabetic patients. The aim is to minimize
diabetes-related symptoms such as urinary incontinence,
falls, infections and cognitive decline while avoiding
hypoglycemia.
ADDRESSING HOME MONITORING AND NUTRITION
Home blood-sugar monitoring is often discussed with
older patients during office visits. A periodic review of
written blood sugar logs as well as meter downloads is
often recommended to obtain an accurate picture of
blood sugar control at home. Decreased fine-motor skills,
impaired vision and the cost of testing supplies are barri-
ers to home management. Low-cost test strips as well as
non-coding and talking meters can help elderly patients
monitor blood sugar levels.
Nutrition is a special consideration for older patients due
to functional limitations that often affect food prepara-
tion as well as dental difficulties, swallowing issues and
irregular eating patterns. Medical nutrition therapy (MNT)
involving care partners, adjusted for cultural differences
and personal ability, is helpful.
TAILORING MEDICATIONS
Factors to consider in medical management of the elderly
include an increased risk of drug-related events and
hypoglycemia, high costs and medication burden. Therapy
should account for comorbidities, social situation and
financial limitations.
• Metformin: This is considered first-line therapy when
MNT does not help patients meet their HbA1c target. It
has fewer potential cardiovascular outcomes compared
with sulfonylureas, as well as low cost. It is contraindi-
cated in advanced chronic kidney disease and in heart
failure with reduced ejection fraction, two common
comorbidities in older adults. Metformin is also not a
good choice for elderly patients with sarcopenia because
it may induce anorexia. In older adults with mobility
problems, loose stools induced by metformin may cause
fecal incontinence.
• Sulfonylureas: These have good efficacy for blood sugar
control and can increase appetite in elderly patients at
nutritional risk. However, hypoglycemia — especially in
those with irregular eating patterns — is a major concern.
G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
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• Dipeptide peptidase-IV inhibitors: These have a lower
risk of hypoglycemia, and postprandial blood sugar
control is good. DPP-IV inhibitors are often used in com-
bination with basal insulin to control both fasting and
postprandial hyperglycemia. However, their high cost
may be a limiting factor.
• Glucagon-like peptide-1 agonists: These can be very
beneficial for obese patients with type 2 diabetes.
However, their cost, the need for injection therapy
and gastrointestinal side effects restrict their use.
• Sodium glucose co-transporter inhibitors: These inhibit
glucose reabsorption in the proximal renal tubules,
providing an insulin-independent mechanism for
lowering blood glucose. (The only FDA-approved drug
in this class, dapagliflozin, has not yet been evaluated
in frail elders.)
• Insulin therapy: Insulin is considered when the HbA1c
target cannot be met using two oral drugs. Insulin pens
are easier to use than vials or syringes because they elimi-
nate the need to draw and measure insulin. However,
they are more costly. It’s also prudent for clinicians to
emphasize to patients the importance of managing
hypoglycemia to decrease the risk of falls. This includes
keeping glucose tablets on their persons at all times and
food on their nightstands. A 2 a.m. blood-sugar check
for one to two days after adjusting therapy is a suggested
precaution. The patient and family should be taught to
use a glucagon emergency kit.
• Insulin considerations for frail elders: Older diabetic
individuals are more likely than their non-diabetic
counterparts to have cognitive impairment, and dia-
betes is a risk factor for its progression to dementia.
Because uncontrolled hyperglycemia or hypoglycemia
can lead to falls that result in hospital admission, a
simple regimen that avoids hypoglycemia may be the
key to preventing institutionalization.
For appropriately selected elderly patients with type
2 diabetes, a daily basal injection and fasting blood
glucose measurement for safety facilitate home
glycemia management. Studies suggest that daily
dosing with a basal insulin such as detimir or glargine
attains glycemic control comparable to prandial
insulin dosing with less hypoglycemia. Also, treatment
regimens should not “require” an evening snack for
older patients who may eat irregularly.
A TEAM EFFORT
Diabetes management in the elderly is often a col-
laborative effort between the patient, geriatrician,
endocrinologist, diabetes educator, pharmacist, dietitian
and caregivers. Limited literature on diabetes studies
aimed at the elderly and frail populations makes manage-
ment of this group particularly challenging. Research
efforts should be targeted at evaluation of the benefits of
glycemic intervention in this vulnerable age group with
the highest prevalence rates. n
Dr. Makin is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism. She can be reached at [email protected] or at 216.444.0539.
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Managing Pressure Ulcers in the Elderly Patient By Steven Schwartz, MD, CWS
The physiologic changes associated with aging increase the risk of developing a pressure (decubitus) ulcer. In managing
pressure ulcers, it is important to not only implement appropriate topical care based on a proper assessment, but also to
address multiple risks that may contribute to skin breakdown.
AGING SKIN, AGING BODY
Risk factors for pressure ulcers include aging skin and
pressure, friction and shear.
• Skin changes: With aging, the skin becomes drier and
thinner. The basement membrane zone (which helps
anchor the epidermis to the dermis) flattens, making these
layers more likely to slide or separate. There is also less
subcutaneous fat between skin and bony prominences.
• Mechanical forces: Patients with chronic diseases such
as arthritis, heart disease and dementia may have dif-
ficulty maneuvering and shifting weight on their own.
Immobility contributes to pressure, friction and shear —
the three factors that combine to cause pressure ulcers.
OTHER CONTRIBUTING FACTORS
When evaluating elderly patients with pressure ulcers,
other key considerations include nutrition, continence
and medication use.
• Nutrition: Elderly patients may not consume sufficient
nutrition to heal. Protein supplements may be necessary
if patients are not getting 1.2 to 1.5 g/kg/day (depending
upon renal function and extent of the wound). Helpful
nutritional status markers that may change serially
include prealbumin, albumin and weight.
Diabetes patients with hyperglycemia may need better
control. The International Task Force of Experts in
Diabetes recommends a typical HbA1c target range
of 7 to 7.5 percent for older patients with uncontrolled
diabetes.1 Tighter control is usually unnecessary.
• Incontinence: Urinary or fecal incontinence may
create an environment that impairs wound healing.
More frequent changing of undergarments and linens,
scheduled toileting, application of barrier creams and
less permeable secondary dressings can protect skin on
these areas. A time-limited bladder catheter trial should
be a last resort for a more advanced non-healing wound.
G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
Pressure Ulcer Stage I: Non-blanchable erythema Pressure Ulcer Stage II: Partial thickness
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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
• Medications: Oral and topical steroids as well as
immunosuppressive agents may delay wound-healing.
In addition, warfarin, NSAIDs and ACE inhibitors may
interfere with the healing process.
FIRST STEP: REPOSITIONING
If an ulcer has developed, pressure must be kept off the
area by repositioning the patient using wedges or towel
rolls, and redistributing pressure via an air mattress or
wheelchair cushion. Heels, if affected, should “float”
using a pillow and /or foam or, more reliably, a heel-
offloading boot.
ASSESSING THE WOUND
When examining high-risk elderly patients, it’s impor-
tant to focus on areas at greatest risk of breakdown: the
sacrum/coccyx, ischial tuberosities, maleoli and heels.
To properly assess the wound, document the following:
• Location
• Size (length, width and depth)
• Presence/extent of undermining (tissue destruction
beneath intact skin along the periphery of the wound)
or tunneling
• Wound-bed tissue type(s): Granulation, necrosis, slough
or epithelialization
• Amount and type of exudate (inspect the dressing)
• Periwound area change(s): Maceration, erythema, indu-
ration or fluctuance
• Pain and/or odor
The National Pressure Ulcer Advisory Panel (NPUAP)
provides wound-staging guidelines based on the depth of
tissue involved.2,3 These guidelines apply only to pressure
ulcers. Once documented, the stage does not change even
as a wound heals; pressure ulcers are never reverse-staged.
DEBRIDING THE WOUND
Wounds generally heal faster when necrotic tissue such
as slough, scab or eschar is removed. Methods of debride-
ment include:
• Autolytic: Moisture-retentive dressings that allow
endogenous enzymes to soften and remove necrotic
tissue.
• Enzymatic: Topical enzymes that degrade and remove
necrotic tissue.
Pressure Ulcer Stage III: Full-thickness skin loss Pressure Ulcer Stage IV: Full-thickness tissue loss
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• Mechanical: Soft abrasion with gauze and irrigation
using saline and other methods. In general, avoid anti-
septics such as Dakin’s, Betadine or peroxide to clean or
treat wounds; they are toxic to healthy tissue. Wet-to-dry
dressings are also not recommended, as they are nonse-
lective and may cause pain and trauma to healthy tissue.
• Surgical/sharp: A scalpel, forceps, curette or scissors —
avoid using on overanticoagulated patients and on limbs
with significant ischemia.
DRESSING THE WOUND
Moisture balance and bacterial control are important
considerations when choosing a dressing.
Moisture balance
Wounds heal faster when they are moist because
tissue that is too dry can desiccate and die. Yet exces-
sive moisture can cause maceration of surrounding
skin or excessive exudate, which can interfere with
healing. Options include:
• Hydrogels: These donate moisture.
• Hydrocolloid films, petrolatum and Adaptic®:
These maintain moisture.
• Alginates and foam: These absorb moisture.
• Collagen dressings: These absorb moisture and
stimulate non-healing wounds.
• Loose packing: This is best for deep wounds; typi-
cally, alginate rope, iodoform gauze, collagen or
wet-to-moist gauze are used.
• Composite dressings: These dressings combine two
or more products in one.
Antibacterials
No wound — not even a clean one — is sterile.
Antimicrobial dressings should not be used in clean
wounds due to the risk of bacterial resistance. However,
dressings with antibacterial properties are indicated
when there are signs of infection. These include:
• Topical antimicrobials: Mupirocin and other antibi-
otic products (containing iodine or silver, bacitracin
plus polymyxin B, and acetic acid) should be used for a
defined period of time — typically one to two weeks.
• PO or IV antibiotics: These may be needed when
a wound shows signs of deep or surrounding
infection. Systemic antibiotics should target gram-
positive organisms. Gram-negative or anaerobic
Managing Pressure Ulcers in the Elderly Patient continued
G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
Unstageable/Unclassified: Full-thickness skin or tissue loss — depth unknown
Suspected Deep Tissue Injury: Depth unknown
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1. BE CAUTIOUS WITH SILVER: Avoid combining dressings containing silver with enzymatic debriders; the silver can inactivate enzymes. Limit the duration of topical silver sulfadiazene to two weeks or less, and avoid topical silver products in those allergic to sulfa.
2. DON’T LOSE PACKING: Use a long continuous rope of gauze in deep tunnels or undermined areas instead of multiple pieces so that packing is not “lost.” Leave a small “wick” outside the wound for easy removal.
3. CONSIDER NPWT: Negative pressure wound therapy (NPWT) can help decrease edema, remove excessive exudate, increase blood flow, reduce bioburden and facilitate wound retraction in stage 3 and 4 ulcers. (Contraindications include necrotic tissue with eschar, untreated osteomyelitis, untreated coagulopathy, nonenteric and unexplored fistulas, a malignancy in the wound and an exposed vasculature, nerves, anastomosis or organ.)
4. TAKE SLOUGH SERIOUSLY: If slough is present, the ulcer is at least stage 3.
5. PRESERVE HEEL ESCHAR: Dry/stable eschar on the heel is considered to be protective and should not be debrided.
6. CONSIDER CHRONIC WOUND CAUSES: When wounds are not improving, consider inadequate nutrition, ongoing pressure, infection, excessive exudate or underlying osteomyelitis as causes.
7. AVOID HEEL ‘PAD’ PROTECTORS: Protectors that simply pad the heels are not recommended.
8. PRE-TREAT FOR PAIN: Schedule pain medication prior to wound treatment/manipulation if necessary.
9. AVOID DONUT CUSHIONS: These seat cushions are contraindicated, as they may cause pressure ulcers.
10. KEEP HEAD ELEVATION SLIGHT: Keeping the head of the bed at the lowest possible elevation will protect the sacrum/coccyx.
10 Tips for Treating Pressure Ulcers
Steven Schwartz, MD, is a geriatrician in the Center for Geriatric Medicine. He can be reached at [email protected] or at 216.445.2178.
REFERENCES
1. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. Sinclair A, Morley JE, et al. J Am Med Dir Assoc 2012 Jul;13(6):497-502. doi:10.1016/j.jamda.2012.04.012
2. National Pressure Ulcer Advisory Panel: NPUAP Pressure Ulcer Stages/Categories, available at: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/.
3. National Pressure Ulcer Advisory Panel: Pressure Ulcer Category/Staging Illustrations, available at http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/.
coverage may be added for chronic wounds and
immunocompromised patients.
• Cultures: Surface wound cultures are NOT rec-
ommended, but correctly obtaining deep wound
cultures or tissue samples from complicated wounds
may guide the antibiotic choice. Sulfamethoxazole/
trimethoprim, doxycycline and clindamycin are
good oral choices if MRSA is suspected.
LAST WORD ON WOUNDS
Despite our best efforts, not all wounds can be healed.
In debilitated elders who are unable to mobilize or replen-
ish their nutritional stores, appropriate wound-care
goals include pain reduction and infection prevention.
It is important to clarify the goals of care, to re-evaluate
the wound on a regular basis and to constantly reassess
treatment. n
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Addressing Challenging Hypertension in the Elderly Tailoring treatment for a vulnerable age group
By Leslie P. Wong, MD, and George Thomas, MD
Expert consensus suggests that most patients 65 and older benefit from treatment of hypertension1. Older hyper-
tensive patients are more likely to develop stroke, heart failure with preserved ejection fraction (HfpEF), atrial
fibrillation and dementia.
The randomized, controlled Hypertension in the Very
Elderly Trial (HYVET) supports the use of anti-hyper-
tensive agents — particularly diuretics — after age 80 to
reduce the risk of all-cause mortality, cardiovascular and
cerebrovascular death, and heart failure.2,3 There is some
evidence of a reduced risk of dementia as well. In addition,
HYVET did not demonstrate an increased fracture risk
in treated patients; in fact, their risk of fracture appeared
to be lower than that of the placebo cohort.
The strongest evidence supports keeping blood pressure
in older adults below 150/90 mmHg, and the Eighth Joint
National Committee recommends a goal blood pressure
of < 150/90 for patients 60 and older, and of < 140/90 for
those with diabetes or chronic kidney disease.4 However,
for the “young old,” a target of < 150/90 may increase risks
of stroke and heart failure. Because of concerns about
their longevity and vascular risks, other recent guidelines
recommend a goal of < 140/90 until age 80, after which
the goal is < 150/90.5
INCREASED ARTERIAL STIFFNESS: CAUSE AND EFFECT
With aging, collagen deposition and degradation of elastic
tissue in the aorta and arterial beds reduce elasticity and
increase vascular resistance. Changes in endothelial
function and loss of vascular reactivity to endogenous
vasodilators also contribute to stiffness.
While systolic blood pressure (SBP) increases due to
greater resistance, diastolic blood pressure (DBP) often
decreases due to loss of arterial compliance. This mani-
fests as isolated systolic hypertension and, by extension,
wide-pulse pressure hypertension.
The proportion of hypertensive patients with isolated
systolic hypertension increases with age; 65 percent of
patients over 60 are affected, compared with 90 percent
of patients over 70.2
A wide pulse pressure — the difference between SBP and
DBP — directly reflects aortic stiffness and is also more
prevalent with age. DBP is key in maintaining coronary
and cerebral perfusion, so as DBP decreases, cardiovas-
cular risk increases.2 Thus, pulse pressure is a critical
determinant of hypertensive risk in older individuals.
Unfortunately, antihypertensive medications do not selec-
tively reduce SBP. Trying to reduce SBP without excessively
lowering DBP often creates a therapeutic dilemma.
AUTONOMIC DYSREGULATION: CAUSE AND EFFECT
Significant autonomic nervous system abnormalities can
cause inappropriate vasoconstriction and/or vasodilation
in elderly hypertensive patients. Orthostatic hypotension
and its opposite, orthostatic hypertension, are common
in the elderly due to loss of baroreflex function and venous
insufficiency.2
Orthostatic hypertension may be associated with abnor-
mally increased alpha adrenergic activity; responsiveness
to beta adrenergic stimulation may decline, impairing
peripheral vasodilation.2 Orthostatic hypotension has a
much higher prevalence in patients with dementia than
in age-matched controls (hypotension may not manifest
until they have been upright for two to 10 minutes).
For elderly patients with significant orthostasis (a more
than 20-point drop in SBP with standing), titrating SBP
to < 160 sitting and > 120 standing is a reasonable target.
Although there is no evidence that it reduces stroke, this
algorithm — used in HYVET — may reduce risks of ortho-
static falls and fall-related injuries.
CHRONIC KIDNEY DISEASE: CAUSE AND EFFECT
Hypertension is a leading cause of chronic kidney disease
(CKD). Diminished functional renal mass, related to
cumulative damage from hypertension and age-related
G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
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nephron loss, reduces the ability to excrete sodium and
regulate extracellular fluid volume.
A high-sodium diet is clearly linked to elevated BP in
elderly hypertensive patients.2 Salt sensitivity in elders is
often coupled with decreased activity of the renin-angio-
tensin-aldosterone (RAAS) axis, in part due to sclerosis
of the juxtaglomerular apparatus.1
Efforts to manage hypertension in the setting of CKD
are often complicated by the side effects of common
medications:
• Diuretics: These have the strongest evidence basis
for reducing stroke and heart failure in older adults
with hypertension. However, diuretics may exacerbate
electrolyte disturbances such as hypokalemia and
hyperuricemia, leading to volume depletion and
worsening kidney function.
c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e
• ACE inhibitors, angiotensin receptor blockers and
aldosterone antagonists: These counter the RAAS axis,
and so may exacerbate hyperkalemia; they must be used
cautiously in the setting of CKD.
Elderly CKD patients have largely been excluded from
clinical trials, so evidence to guide treatment decisions is
limited. Due to the increased risk of complications in this
population, experts stress the need to avoid adverse treat-
ment effects and to individualize BP goals, rather than
adhere to a fixed BP target.1
MANAGING CHALLENGING HYPERTENSION
The large, multicenter NIH-sponsored Systolic Blood
Pressure Intervention Trial (SPRINT) should provide a
better understanding of optimal BP goals related to end-
organ changes in community-dwelling elderly patients
who are able to participate in trials.
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G E R I AT R I C T I M E S | S P R I N G 2 0 1 4
In the meantime, a target BP of < 140/90 is reasonable for
adults up to 80 years of age, and a target BP of < 150/90 is
reasonable for community-dwelling adults 80 and older.4
Referral to specialized hypertension centers such as
Cleveland Clinic’s Hypertension Clinic can assist in
individualized BP management for challenging cases.
For frail elders — those with severely impaired mobility
and/or cognition, and a limited life expectancy — consider
initiating and titrating antihypertensives to function-
oriented goals such as dyspnea, edema and orthostasis.
Referral to a geriatric clinic can help delineate goals of
treatment in these cases. n
Dr. Wong (left), of the Department of Nephrology and Hypertension, can be reached at [email protected] or at 216.445.0673. Dr. Thomas (right), who heads the Hypertension Clinic
in the Department of Nephrology and Hypertension, can be reached at [email protected] or at 216.636.5420.
REFERENCES
1. Taler SJ, Agarwal R, Bakris GL, et al: KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis 62(2):201-213, 2013.
2. Aronow WS, Fleg JL, Pepine CJ, et al, ACCF Task Force: ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation 123(21):2434-2506, 2011.
3. Beckett NS, Peters R, et al, HYVET Study Group: Treatment of hyperten-sion in patients 80 years of age or older. N Engl J Med 358(18):1887, 2008.
4. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
5. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens. 2014 Jan;32(1):3-15. doi: 10.
Take-Home Points: Measuring Hypertension in the Elderly
CHECKING BLOOD PRESSURE
Pressures on both arms should be measured on the first visit; for discrepancies > 10 mmHg, the arm with higher BP should guide therapy.
Look for orthostatic changes in BP after patients stand for 2 minutes (or longer, if there is a history of syncope or dementia).
Suspect pseudohypertension, a false elevation in SBP during inflation caused by incompressible sclerotic arteries, in elderly patients with “resistant” hypertension and signs/symptoms of overmedication.1
Fully automated oscillometric devices that take multiple consecutive BP readings in the office, with patients sitting and resting alone, can reduce the “white coat” response.
Addressing Challenging Hypertension in the Elderly continued
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Geriatric Medicine Staff
GERIATRICIANS AND GERIATRIC PSYCHIATRISTS IN THE CLEVELAND CLINIC HEALTH SYSTEM
MAIN CAMPUS
Ronan Factora, MD Do Gyun Kim, MD Amanda Lathia, MD Barbara Messinger-Rapport, MD, PhD Steven Schwartz, MD Quratulain Syed, MD Anne Vanderbilt, CNS, CNP
AVON LAKE FAMILY HEALTH CENTER
Ali Mirza, MD
BEACHWOOD FAMILY HEALTH AND SURGERY CENTER
Barbara Messinger-Rapport, MD, PhD Steven Schwartz, MD
EUCLID HOSPITAL
Geriatrics Ami Hall, DO
Geriatric Psychiatry Upma Dhingra, MD
FAIRVIEW FAMILY MEDICINE
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FAIRVIEW HOSPITAL
Geriatric Psychiatry John Sanitato, MD
INDEPENDENCE FAMILY HEALTH CENTER
Ronan Factora, MD
LAKEWOOD HOSPITAL/LUTHERAN HOSPITAL
Center for Brain Health Babak Tousi, MD Christine Nelson, MSN, CNP
Geriatric Psychiatry Mark Frankel, MD John Sanitato, MD
LORAIN INSTITUTE
Lynn (Chris) Chrismer, MD Itri Eren, MD Kashif Khan, MD Ali Mirza, MD Sathya Reddy, MD Pragati Singh, MD Rebecca Haney, CNP Renee Smith, CNP Wanda Williams, CNP
CLEVELAND CLINIC FLORIDA
Diana Galindo, MD Jesus Loquias, MD
JOINT APPOINTMENTS IN THE CENTER FOR GERIATRIC MEDICINE
CENTER FOR CONNECTED CARE
Michael Felver, MD Duane Kirksey, MD Renato Ramon Samala, MD Ethel Smith, MD Maidana Vacca, MD William Zafirau, MD Luanne Capon, GNP, MSN, CPHQ Carol Hall, CNP Sam Palmer, CNP
DIGESTIVE DISEASE INSTITUTE
Brooke Gurland, MD Tracy Hull, MD Matthew Kalady, MD Jamilee Wakim-Fleming, MD
EMERGENCY SERVICES INSTITUTE
Fredric Hustey, MD
ENDOCRINOLOGY & METABOLISM INSTITUTE
Angelo Licata, MD, PhD
GLICKMAN UROLOGICAL & KIDNEY INSTITUTE
Raymond Rackley, MD Sandip Vasavada, MD
HEAD & NECK INSTITUTE
Catherine Henry, MD
NEUROLOGICAL INSTITUTE
Charles Bae, MD Karen Broer, PhD Neil Cherian, MD Kathy Coffman, MD Kathleen Franco, MD Richard Lederman, MD, PhD Mark Luciano, MD, PhD Richard Naugle, PhD Leo Pozuelo, MD Babak Tousi, MD Brinder Vij, MD
Brain Tumor and Neuro-Oncology Gene Barnett, MD Glen Stevens, DO, PhD
Physical Medicine and Rehabilitation Frederick Frost, MD Vernon Lin, MD, PhD
OB/GYN & WOMEN’S HEALTH INSTITUTE
Matthew Barber, MD Marie Fidela Paraiso, MD Beri Ridgeway, MD
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TAUSSIG CANCER INSTITUTE
Mellar Davis, MD Mona Gupta, MD Terence Gutgsell, MD Abdo Haddad, MD Susan LeGrand, MD Armida Parala-Metz, MD Dale Shepard, MD, PhD
All physicians in Regional Geriatrics have joint appointments in the Center for Geriatric Medicine.
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