geriatrics: objectives part ii8/11/16 3 polst (physician orders for life sustaining treatment ) o...
TRANSCRIPT
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Geriatrics:Part II
Joyce Danter, MSN, APRN-BCAdult/Geriatric Nurse Practitioner
OBJECTIVESO 1. Explain the end of life issues for geriatric
individuals and their families.O Analyze the common medication errors that
occur when caring for the elderly.O 3. Discuss the risks and needs of the older
individual in the aging process.
End of Life Issues
Case StudySylvia Smith, age 86
Sylvia Smith, Age 86, presents to your office. She has a history of CAD, Heart Failure, COPD, and Osteoporosis. She has a fever of 100, productive cough, and confusion. You suspect she has pneumonia and order labs and a CXR. Her CXR shows bilateral pneumonia and you end up admitting her to the hospital.
She has Living Will that says NO CPR or intubation. Her Advanced Directives list her daughter, Susie, who is her primary caregiver, as the decision maker.
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Susie knows her mother’s wishes and directs the care team to not intubate and to let “nature take it’s course”.
Cindy says “NO!”. She wants everything possible done for her mother and insists on intubation and “whatever else”may need to happen to keep her mother alive.
While in the hospital, she takes a turn for the worse and requires intubation. Her oldest daughter, Cindy, who lives in Montana, in in town on holiday. Susie is not currently available.
What do you do?
Unfortunately, there is no Durable Power Of Attorney on record.
What normally happens next?
End of LifeO Living WillO Advanced DirectivesO Durable Power of AttorneyO POLST
O Which one protects the patient the best?
Living Will - DefinitionO LIV-ING WILLO Noun
O a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.
O www.investopedia.com/terms/h/hcpa.asp
Advanced Directive -definition
O AD-VANCE DI-REC-TIVEO Noun
O a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.
O www.investopedia.com/terms/h/hcpa.asp
Durable Power Of Attorney -definition
O A legal form that allows an individual to empower another with decisions regarding his or her healthcare and medicaltreatment. Healthcare power of attorney becomes active when a person is unable to make decisions or consciously communicate intentions regarding treatments.
O www.investopedia.com/terms/h/hcpa.asp
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POLST(Physician Orders for Life Sustaining
Treatment )O Medical order completed by the health care
provider. The patient CANNOT complete this.O Patients with serious illness or frailty, with a life
expectancy of 1 year, should have a POLST Form.
O Similar to a DNRO The POLST form is actionable and prevents
initiation of unwanted, disproportionately burdensome extraordinary treatment.
POLSTO For persons with serious illness — at any ageO Provides medical orders for current
treatmentO Guides actions by Emergency Medical
Personnel when made availableO Guides inpatient treatment decisions when
made available
O Not yet in recognized in the State of Texas
Case StudyMelvin Warren, Age 88
Melvin Warren, age 88, presents to your office with a history of CAD, PVD, DM, and CVA. He is frail and has been losing weight. He has blood in his stool, and abdominal pain. He presents with his daughter, Jane, who is visiting from out of town. He has other children in town who visit him often but have not see the subtle changes in his health.
You check labs and see that he is severely anemic and needs a transfusion. He is then sent to the hospital to be admitted.
While in the hospital, Melvin receives 2 units of blood and reports “feeling better”. The day he was to be discharged, he suffered a severe stroke leaving him aphasic, ataxic, and paralyzed. Jane directs you to “do everything possible.” He would need a peg tube placed for nutrition and hydration immediately and needs to be placed in the ICU to stabilize him.
Melvin has a Living Will stating no extraordinary measures are to be taken. He does not want any tubes placed or CPR. He also has a Durable Power of Attorney for medical needs, naming his son, Martin, who is currently out of town. What do you do?
Do you place to tube despite his Living Will directives?
Do you talk with Jane or Martin to get consent of care?
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End Of LifeStart the conversation early.
Discuss the patient’s wishes annually and document it.
Get a copy of the legal documents for your chart and find out where they keep their legal document.
Case StudyTari Williams, Age 72
Tari Williams, age 72, with a history of lung cancer with metastasis to the brain. She also has chronic pain and severe arthritis in her back.
You see her in follow up and learn that she is is due to re-start radiation to the brain due to recurrent lesions, andshe has been having multiple falls. She can no longer drive and must rely on a daughter who lives 30 miles away for transportation. Her pain is severe and rated as a “12/10”. She has been “getting help” with pain management from a neighbor who has been supplying her with marijuana and Percocet. This does manage her symptoms well and keeps her out of pain.
Her Oncologist wants to continue treatments. She does not. She merely wants to control her pain and live out the rest of her life with some sort of quality. Her Ortho & Oncologists do not feel comfortable with her decision to use medical marijuana or opioids and do not want to write for the medications that has been working for her. They want to continue her treatments as planned.
She tells you she is “tired of the treatments” and knows that it is just palliative. She knows that the cancer is not curable & she cannot have the back surgery needed to “fix her pain” & improve her symptoms.
Her daughter sides with the providers and directs them to continue with the radiation and to withhold the high doses of opioids as she feels her mother will recover with this treatment so she can get her “back surgery”.
What do you do?
She has no Living Will. She has no Advanced Directives. She has no Durable Power of Attorney.
Medication Issues
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Adverse Drug Reactions (ADR) &Adverse Drug Events (ADE)
O AgitationO AnorexiaO AnxietyO AtaxiaO Constipation
O DeliriumO DiarrheaO DizzinessO ForgetfulnessO Hallucinations
Common ADR/ADE in Elders
O LethargyO Memory impairmentO Nausea/vomitingO New onset of
confusion or cognitive decline
O Worsening of preexisting dementia
O Insomnia/sleep disturbances
O RestlessnessO SedationO Skin rashO SyncopeO Unexplained falls,
traumaO VertigoO Weight loss
ADR’sØ Common complication of hospitalization
Ø Significant factor in Delirium and Falls
Ø Often go unrecognized
Ø Symptoms may be mistaken for normal aging or worsening of chronic condition
ADEØ Responsible for 5-28% of acute geriatric
admissions to the hospital
Ø 36% of elders have an ADE
Ø NIH study – 51% of ADE’s are preventable
Risk Factors for ADR/ADEq 6 or more concurrent chronic diseases
q 12 or more doses of meds per day
q 8 or more medications
q Estimated creatinine clearance <50ml
q Low body weight or BMI
q > 85 YO
q History of a previous ADR
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REMEMBERq Serum creatinine clearance is not a reliable
indicator of renal function in the elderly.
q Decreased muscle mass affects creatinine production in older adults
q Need to calculate for accurate estimation renal function
Top 10 Drug Interactions in Long term Care Facilities
ü Warfarin — NSAIDsü Warfarin — Sulfa drugs ü Warfarin — Macrolides ü Warfarin — Quinolonesü Warfarin — Phenytoin ü ACE inhibitors — Potassium supplementsü ACE inhibitors — Spironolactone ü Digoxin — Amiodarone ü Digoxin — Verapamil ü Theophylline — Quinolones
* NSAID class does not include COX-2 inhibitors
Beers List
O Beers developed criteria to identify meds whose use was potentially inappropriate in the general elderly population and in the elderly with specific diagnoses
O This was last updated in 2015 and is now a 14 page list.
O Beers M.H., Archives of Internal Medicine, 1997, 157, 1531-1536
Partial List from Beers Update:Drugs to Avoid
O Limit use and dose of short acting benzodiazepines
O No long acting benzodiazepinesO Do not use: Dalmane, Elavil, Limbitrol, Triavil,
SinequanO Do not use a daily Prozac as it has a long half life&
can cause sleep problems and agitationO GI antispasmotics are highly anticholinergic
O When in doubt – consult the list.
Partial List from Beers Update:Drugs to Avoid
O Macrodantin may cause renal impairmentO Avoid all anticholinergics (benadryl, phenergan,
other antihistamines)O Includes over 600 drugs
O Do not use NSAIDs long term as they may cause GI bleed, CHF, renal failure
O Avoid DemerolO Avoid Pentazocine (Talwin)O Avoid Fentanyl as it has a prolonged affect after
being removed
“… Diazepam (increased sensitivity to benzodiazepines. Increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults)
Diclofenac (increases risk of GI bleeding and peptic ulcer disease in high-risk groups, including those aged >75 or taking corticosteroids or anticoagulants) …”
Excerpt from MPRClinical Charts September 2014
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Most Common Inappropriate Prescriptions for the Elderly
O BenadrylO Elavil
(amitriptyline) O Long acting
BenzodiazepinsO Persantine
(dipyridamole)
O Anticholinergics(used in 1/3 of Alzheimer’s medications, rendering those medications ineffective)
O Ticlid (ticlopidine)O Sinequan (doxepin)
Common Causes of Medication Errors
O PolypharmacyO Pill Burden O Multiple prescribersO Non-disclosed OTC medicationO Education
Polypharmacy
O The use of 4 or more medications.O This includes Rx and OTC’sO Effects up to 40% of the elderlyO Leads to ADR and ADE
O Which medications do you stop?
Case Study
Sam W. Age 72
Sam, a 72 year old with CAD, HTN, hyperlipidemia, asthma, OA, & GERD. He is taking the following medications:
For CAD: Metoprolol, Lasix, Baby AspirinFor HTN: Lisinopril, NorvascFor Hyperlipidemia: Lipitor & FenofibrateFor Asthma: Symbicort, MDI and ProAirFor OA: Voltaren GelFor GERD: Omeprazole
What do you stop?
Pill BurdenO The number of pills you take in a day.O Think of the frequency of a medication. O Daily dose versus BID, TID, or QID.
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Multiple Prescribers
O The PCP and the “-ologists”O Duplication of medicationsO Interactions from medications that
were prescribed
Over the Counters
O Interactions from prescriptions with herbals
O Interactions from prescriptions with the OTC’s that were once prescriptions
O Health Food store recommendationsO Pills from friends and family members
EducationO Patient does not know to continue a
routine medications as “there were no refills left”.
O Instructions to take with or without mealsO Instructions on when to takeO Side effect profilesO Possible interactions with other
medications
Other issues
O “The People’s Pharmacy”O TV AdsO TV personalities
Case StudyJohnny May, Age 68
Johnny May, age 68, was watching her favorite daytime TV talk show. They were discussing the latest weight loss medications she should take and how some medications cause you to gain weight.
Johnny May has a history of depression, obesity, RA, and, Inflammatory Arthritis. She has been on Paxil for “years” and prednisone daily for the past 2 months for the arthritis. She learned from the TV show that her weight issues may be due to the Paxil and Prednisone so she decides to stop these and buy the Foskolin they are talking about.
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She comes to see you due to having “flu-like symptoms” and body aches. She has some nausea and is generally feeling ill. She does not have any fever or signs of infection.
What do you do?
Strategies to Prevent Medication Errors
O Have the patient bring in ALL of the medications (RX and OTC) from all providers at each visit
O Review the medications they are taking with the patient at each visit
O Provide clear instructions for each medication including side effect profile –write them down!
RISKS AND NEEDS OF THE ELDERLY RISKS
O Internal risks:O Increasing age.O Female O Comorbidities.O Substance abuse.O Mental illness.O Cognitive
impairment.O Sensory impairment.O Impairment in ADL’s.O Malnutrition.
O External risks:O Lack of social network.O Dependence on a care
giverO Living alone.O Lack of community
resources.O Inadequate housing.O Unsanitary living
conditions.O High-crime
neighborhood.O Adverse life events.O Poverty.
Red FlagsO Repeated ER visits or
hospital admissions.O Neglect of medical
problems.O Lack of follow-up for
appointments.O NoncomplianceO Acute deterioration in
ADLs or cognition.O Unexplained weight loss
or failure to thrive.O Poor grooming or
hygiene.O Inappropriate or soiled
attire.
O Refusal of appropriate and needed assistance
O Threat of eviction.O Infestations O Motor vehicle accidents
or moving violations.O “Doctor shopping.”
O Decline in financial status.
O Victimization, exploitation.
O Sudden appearance of new “caregiver
RisksO Malnutrition/DehydrationO Lack of social networkO Adverse Life EventsO Cognitive impairmentO Noncompliance
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Case StudyDorrie Jones
Age 78
Dorrie is a 78 year old female living with her daughter &grandson. She has dementia, diabetes, & Hypothyroidism. Overall, she has been doing well.
You saw her 2 months ago and her weight was stable, she answered questions fairly well, and was responsive. Today, she presents today as her daughterhas questions about her thyroid medications.
She is carried in the office by her grandson, moaning, & her lips are parched. She sleeps while the visit isin progress but she is easily aroused.
You learn that she fell out of bed 1 week ago and her daughterbrought her to the ER 24hours later as she was moaning in painwhen her left leg was touched. Her work-up was negative for fractures or illness. You learn that she has been off of her thyroid medications and potassium supplements. She continuesto take her Namenda and Aricept. Her weight is stable.
On exam, her lips are dry and mucus membranes are dry. She hasa stage 1 pressure sore to her right hip and eroded skin to her buttock bilaterally. She moans in pain when her left hip is touched.
Her daughter states she has been “sleepy” but is still eating and drinking well. She has not gotten out of bed for about 3 weeks though as she has been “tired”.
What is her risk?
Case StudyLouise Jackson, age 66
Louise is a 65 year old school teacher with a history of HTN and DM.She comes in for her “routine quarterly visit”, however she is 4 months overdue for this. She states she cannot come in as requested as she is a “school teacher”.
She does not check her blood sugars but states she feels “OK”. She states she has not been taking her medications because they “cost too much”. She lets you know that her brother, who justdied of diabetes related complications, had a lot of NovologInsulin at home so she has been taking that … sometimes.
You check her labs and her HgbA1c is 12.5%, FBS 367, eGFR 58, and she has 3+ glucose in the urine.
You have a long discussion with this patient regarding the need for her to be complaint with her care. You find medications that are “free” with pharmaceutical discount cards for the next year. Shestarts on a GLP1 and a SLG2. Her next HgbA1c, 3 months later, comes back at 8.5%.
She comes in again 5 months later, for her routine 3 month followup. She ran out of her medication again. Her labs now her HgbA1c at 13.2%, FBS 312, urine microalbumin 6.2, and eGFR 22.
She now needs a referral to the Nephrologist.
What is her risk?
What do you do now?
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In ConclusionO Know your patient’s wishes regarding their
end of life plansO Review all medications at each visit to
decrease the risk of adverse eventsO Watch for risk factors to help with healthy
aging.