care of the older patient: evidence to change practice · 2019-11-01 1 care of the older patient:...

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Care of the Older Patient: Evidence to Change Practice

November 1, 2019

FMF 2019 Session F221

Member Interest Groups Section

• Introducing the Member Interest Groups Section (MIGS) formerly Communities of Family Practice in Family Medicine

• The Member Interest Groups Section links CFPC members across Canada with similar practice interests. It fosters professional peer connections to explore and address issues impacting family medicine.

• The Member Interest Groups Section is designed to support the College of Family Physicians of Canada’s (CFPC’s) dedication to providing a professional home for family physicians across a diversity of clinical and non-clinical interests and practice types. Currently the Section is comprised of 19 different member interest groups.

• To join, simply indicate your interest(s) in your CFPC member profile or see the MIGS team at the Mainpro+ and Practice Support booth and they will make sure you’re kept up to date on any future developments!

MiGroupsPowered by Members, Connected by TimedRight

• MIGS members are invited to join MiGroups, a private, secure online community for family physicians

• MiGroups is used by members to share their experiences with peers, ask clinical questions, promote new practice tools, learn about upcoming events, and more!

• To join, visit http://cfpc.timedright.com or scan the QR code. Then, sign up with the email you use to receive CFPC emails

Questions? Contact us at [email protected]

Faculty/Presenter Disclosure

• Presenters:

• Sid Feldman

• Matthieu Lafontaine-Godbout

• Huy Nguyen

• Jed Shimizu

• Relationships with financial sponsors: None

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http://cfpc.timedright.com/

mailto:[email protected]

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What to do with BP Meds at Hospital Discharge?

Anderson TS, Jing B, Auerbach A, et al. JAMA Intern Med [Internet]. 2019 [cited 2019 Nov 1];E1-E10

Background

• Outpatient medications are frequently changed during hospitalization of older adults

• Antihypertensive medications are a common example of this

• This study aimed to evaluate outcomes of intensification of antihypertensive regimens in hospitalized older patients.


Study Design

• Retrospective cohort study of 65 years or older

• Study included those patients with HTN and an admitting diagnosis of pneumonia, UTI, VTE

• Excluded patients admitted with secondary Dx of atrial fib, ACS, or CVA

• Intensification defined as – new BP meds or increase dose of >20%

• Propensity score matching to control for differences in intensified and non-intensified groups.


Study Design

• Primary outcomes:

– 30 day all cause readmissions

– 30 day medication related serious adverse events

– 1 year cardiovascular events.

• Secondary outcomes:

– 1 year all cause readmissions, SAEs, all cause mortality

– 30 day all cause mortality and cardiovascular events

– Change in outpatient SBP at 1 year.


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Results

• Identified 14915 patients meeting criteria, 2074 were discharged with intensification of BP meds

• Propensity score matching resulted in a cohort of 4056 equally split groups

• Average age 77, primarily male.


Results

• 30 day readmission – intensified group 21.4% vs 17%

• 30 day SAEs – intensified group 4.5% vs 3.1%

• 1 year cardiovascular events – intensified 13.8% vs 11.9% (not significant).


Results

• What about subgroups based on prehospitalization blood pressure control?


Results

• What about subgroups based on prehospitalization blood pressure control?

• Well controlled baseline SBP:

– Intensified group more likely to be readmitted, experience SAEs, and have higher 1 year CV events.

• Elevated baseline SBP:

– No significant differences in outcomes between intensified group and not intensified.


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Conclusion

• Intensification of antihypertensive meds at hospital discharge increases short term risks (readmissions and SAEs)

• Possible reasons:

– HTN overtreatment and orthostatic hypotension, falls

– Discharge period higher risk for SAEs due to other medication changes, potential for errors

• Increase in admissions beyond increased SAE risk

– Increase polypharmacy, potential med compliance issues.


Conclusion

Take home:

• In patients with previously controlled BP, avoid intensification of BP meds at discharge

• Even in those with higher baseline SBP intensifying BP meds at discharge may confer unnecessary risk

• may be safer to defer med changes to outpatient care.


Alternatives to Hearing Aids

Cho YS, Park SY, Seol HY, et al. JAMA Otolaryngol Head Neck Surg. 2019; 145(6):516-522.

Background

• Hearing loss is common in older adults, in S Korea affects 45% of 70 years or older

• Untreated hearing loss associated with isolation, depression, cognitive impairment and dementia

• In US, <20% of people with hearing loss reported hearing aid (HA) use

• Reasons – cost, inconvenience.


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Background

• Personal sound amplification products (PSAPs) or OTC hearing aids are much less expensive ($40-400) and do not require fittings

• Study aim: Compare conventional HAs with PSAPs in patient with mild, moderate, and moderately-severe hearing loss.

VS


Study Design

• 56 adults (avg age 57) assessed for hearing loss and divided into mild, moderate, and mod-severe

• 3 Interventions – PSAP, basic HA, premium HA

• Outcomes:

– Two speech intelligibility in noise (SIN) tests, the K-HINT (at 2 levels of background noise) and SIBN

– Two tests of listening effort, the SIN with dual-task paradigm and pupillometry

– Self-rating questionnaire.


Results

K-HINT - Korean Hearing in Noise Test

MHL – mild hearing loss

MDHL – moderate hearing loss

MSHL – moderately severe hearing loss

PSAP – personal sound amplification product

HA – hearing aid


Results

• In mild and moderate hearing loss groups, no significant difference between PSAPs and the basic and premium HAs in benefit

• Premium HAs performed better in mod-severe hearing loss

• Questionnaires:

– No significant difference in sound quality

– Moderate hearing loss group preferred PSAP (50%)

– Mod-severe loss group preferred premium HA (70%).


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Conclusion

• PSAPs are a reasonable alternative to traditional hearing aids in those with moderate hearing loss

• In moderately-severe hearing loss, premium hearing aids perform better.


Coupland CAC, Hill T, Dening T, et al.JAMA Intern Med. 2019;179(8):1084-1093

Is Anticholinergic Use Associated with Dementia?

Background

• Dementia is a growing problem

• Avoiding potentially modifiable risk factors could potentially reduce incidence

• Current modifiable risk factors account for 35% of dementia cases (hypertension, hearing loss, depression, diabetes, smoking)

• Is the risk of dementia among persons 55 years or older associated with the use of different types of anticholinergic medication?


Study Design

• Study type: Nested case-control

• QResearch database- anonymous research database of 30 million individuals in the UK in over 1500 general practices.

• Base cohort: Patients 55 years of age or older without dementia at study entry

• Case patients: Diagnosed with dementia during follow-up using clinical codes, death records, Rx of cholinesterase inhibitors or memantine

• Excluded: Huntington's, Parkinson's, CJD, HIV associated dementias


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Study Design• Controls: Each case matched with 5 controls-age, sex, general

practice, calendar time (incidence date sampling)

• High anticholinergic burden drugs (ABDs) : total 56

– Beers 2012 and Beers 2015 updated list

– Anticholinergic Burden Scale

– Systematic review

– British National Formulary

• Primary exposure variable: Total cumulative anticholinergic drug exposure (Total Standardised Daily Doses)

• Controlled for multiple potential confounding variables identified as risk factors for dementia (26)


Results

• Base cohort: 3.6 million individuals aged 55-100

• 20 million person-years of follow-up, 128,000 people diagnosed with dementia. After exclusions, 58,000 case patients and 225,000 matched controls.

• Case patients: mean age 82.4, 63% women. 60% AD or mixed dementia

• In the 1 – 11 years before the index date, 56.6% of case patients and 51.0% of controls were prescribed at least 1 anticholinergic drug.


Results


ResultsDrug Type Fully-adjusted

odds ratio

Antipsychotics 1.70 1.53-1.90

Bladder antimuscarinics 1.65 1.56-1.75

Antiparkinson 1.52 1.16-2.00

Antiepileptics 1.39 1.22-1.57

Antidepressants 1.29 1.24-1.34

Antihistamines 1.14 0.98-1.34

Skeletal muscle relaxants 1.10 0.47-2.55

Antivertigo/Antiemetics 1.08 0.94-1.24

GI antispasmodics 1.04 0.90-1.20

Antiarrhythmics 0.99 0.56-1.55

Antimuscarinic bronchodilators 0.97 0.90-1.05


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Conclusion

• Large cohort study (not RCT)

• Significant association between use of anticholinergic medication and dementia: higher the anticholinergic exposure, the higher the likelihood of dementia

• Specific drug categories: Antipsychotics, bladder antimuscarinics, antiparkinson, antiepileptics, antidepressants

• Further support for parsimonious prescribing of anticholinergic medications, particularly when alternatives exist


Liu-Ambrose T, Davis JC, Best JR, et al.JAMA 2019;321(21):2092-2100

Home-Based Exercise Programs and Falls

Background

• Falls are a major contributor to fracture and chronic disability in older adults (OAs)

• The most effective method to prevent additional falls among older people who have previously fallen not established

• Three prior trials showed no effect of exercise on fall prevention in OAs who have previously fallen.


Background

Otago Exercise Program (OEP)

–Individualized, home-based program

–Delivered by a physical therapist

–5 lower extremity strength exercises (graded levels of difficulty)

–11 balance exercisesLiu-Ambrose T, Davis JC, Best JR, et al.JAMA 2019;321(21):2092-2100

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Study Design

• Parallel-group, single blind, randomized clinical trial

• Greater Vancouver area (UBC affiliated academic hospital)

• Participants recruited from a university hospital falls prevention clinic (2009-2017)

• Older adults who had experienced a fall in the prior 12 months


Study Design

• Inclusion criteria:

– Participants community-dwelling adults aged 70 years or older

– Non-syncopal fall in the previous 12 months

– Deemed “high risk of future falls” by TUG>15 seconds, greater than 2 non-syncopal falls in past 12 months or 1 SD above mean on a standardised physiological assessment

• Exclusion criteria:

– Neurodegenerative disease, dementia, stroke, carotid sinus sensitivity, inability to walk 3 metres


Study Design

• Randomized to:

– Usual care

• medication adjustment (geriatrician), lifestyle recommendations, appropriate referrals such as OT, ophthalmology

– Home exercise program

• Licensed PT home visits:

• Initial training session (1 hour)

• Q 2 weeks x 3 to adjust intervention (each visit 1 hour)

• Final 5th visit 6 months after baseline.

• Asked to perform exercises 3 times per week and walk 30 minutes at least twice weekly


ParticipantsCharacteristic Exercise group Usual care group

Number 172 172

Age 81.2 81.9

Male/Female (%) 36/64 31/69

Home Assisted living/home

alone/home with others9/40/51 6/47/47

Falls in prior 12 months (%)-1/2/3/4+

Mean number falls

25/33/17/25

2.8

35/23/14/28

3.0

Injuries (none/soft/fracture) 30/52/18 27/54/19

Mobility aid (%) 27 22


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Results

• Adherence to balance and strength component = 63%

• Adherence to walking component = 127%

• Mean follow up of 338 days


Results

• 1/3 reduction in falls

– Incidence Rate Ratio = 236/366=0.64 (CI 0.46-0.90), p = 0.009

• Estimated falls/year incidence:

– Exercise = 1.4 (0.1-2.0)

– Usual Care = 2.1 (0.1-3.2)

• Absolute incidence rate difference 0.74 (0.04-1.87), p=.006

• No adverse events noted


Conclusion

• A home based exercise program using the Otago model significantly reduced future falls in community dwelling seniors who had fallen in the prior 12 months compared with usual care.

• We should go to Otago to check it out in person ☺


Surgery, Covert Stroke, and Cognitive Decline

Mrkobrada M, Chan MTV, Cowan D, et al. Lancet. 2019;394:1022-1029.

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Background

• Overt strokes are associated with significant morbidity

• Less is know about the more common perioperative covert strokes

• Study Aim: Investigate the relationship between perioperative covert stroke and cognitive decline 1 year post surgery. Mrkobrada M, Chan MTV, Cowan D,

et al. Lancet. 2019;394:1022-1029.

Study Design

• Prospective cohort study (Canadian)

• Multicentre (12 academic centres in 9 countries)

• Non-cardiac elective surgery patients 65 years or older

• Post-operative MRI in search of infarction (results masked from patients, health-care providers, outcome adjudicators)

• Preop and 1 year post operative MoCA (-2 pts).*

*indicator of cognitive decline as shown by previous research


Results

• Of 1114 participants, 7% (78) patients had a perioperative covert stroke

• Primary outcome - 1 year cognitive decline occurred in 42% (29) of participants with covert stroke vs 29% (274) patients without covert stroke - p=0,0055, increased absolute risk of 13%

• Relationship between covert stroke was independent of type of anaesthetic.


Results

• Secondary outcomes :

– Delirium in first 3 days postop occurred in 10% patients with covert stroke vs 5% without –p=0,030, absolute risk of 6%

– 1 year incidence composite of overt stroke and transient ischemic attack was increased in patients with covert stroke patients 4% vs 1% without –P=0.019, absolute risk of 3%.


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Discussion

Limitations:

• 10% did not complete 1 year MoCA

• Timing of MRIs (postop days 2-9) mean some strokes may have occurred prior to surgery

• No non-surgical group to evaluate if patients without covert stroke are at higher risk of cognitive decline

• Regarding delirium results, possible this preceded stroke (delirium assessments from postop day 1).


Conclusion

• Perioperative covert stroke increases risk of cognitive decline. Whether this is associated with dementia is not clear, and whether surgery itself without covert stroke is associated with cognitive decline remains to be proven.


Benefit of ASA in healthy elderly? No.

McNeil JJ, Woods RL, Nelson MR, et al. N Engl J Med. 2018;379(16):1499-1508.

Background

• ASA known to have benefit in secondary prevention of CV disease, and evidence to suggest some primary prevention benefits in CV and cancer

• Existing large trials assessing primary prevention show no consistent benefit

• These trials have generally been on younger populations and focused on CV endpoints.


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Background

• Goal of the ASPREE (Aspirin in Reducing Events in the Elderly) trial was to investigate whether daily ASA 100mg in healthy community-dwelling older adults would prolong healthy life span (survival free from dementia and physical disability).


Study Design

• Double-blind RCT in US and Australia.

• Community-dwelling adults 70 years and older (or 65 and older for blacks and Hispanics in the US).

• Excluded – chronic illness with <5 expected survival, dementia, known risk of bleeding, existing functional deficits or physical disability.

• Primary end point – disability-free survival.


Results


Results McNeil JJ, Woods RL, Nelson MR, et al. N Engl J Med. 2018;379(16):1499-1508.

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Results

• Mean follow-up 4.7 years

• No significant in disability-free survival

• Major hemorrhage in ASA group 3.8% and in placebo 2.8% HR 1.37 (1.18-1.62).


Conclusion

• No significant benefit of ASA 100mg in healthy community-dwelling older adults in reducing risk of disability-free survival

• Limitations:

– Small number of non-whites in study

– Relatively short duration may limit end points related to cancer and dementia

– Did not account for ASA use at earlier age.


Dolovich L, Oliver D, Lamarche L et al. CMAJ 2019;191(18):E491-500

Health Teams Advancing Patient Experience: Strengthening Quality

“Health TAPESTRY” Study Background:

• Health systems not well designed for older adults: Are there models of care that improve outcomes for OAs in primary care?

• Care models in Canada shifting towards interdisciplinary teams with community-based focus

• Focus on improving person-centred care and team-based primary care

• This study used a multi-component intervention with primary goal of increasing gaol attainment in older adults


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Research question:

What is the effectiveness of the Health TAPESTRY approach on the identificationand attainment of a person’s health goals in older adult participants compared to people not receiving the Health TAPESTRY approach?


Spoiler alert!!

• Study did not achieve its main goal but I still think interesting for discussion.


Study Design

• Unblinded pragmatic randomized controlled trial with delayed intervention

• 2 sites of the McMaster Family Health Team

– Multidisciplinary academic primary care team. Hamilton ON


Goal: Meeting person’s goals of care

• Trained community volunteers

• EMR including on-line access to Personal Health Records (PHR)

• Team-based care

• System navigation


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Overarching aim: Promote optimal aging

• Intentional, proactive conversations about a person’s life and health goals and health risks -> initiation of an action plan that supports achievement of those goals and addressing of health risks;

• Improved collaborative working within the interprofessional primary care team, community service providers, and informal caregivers;

• Training volunteers: link between the person in their home and their primary care team; and

• Using technology including the PHR that allows personal health information and patient health goals to link directly to the EMR with the primary healthcare team.


Intervention• 0-2 months after randomization:

– Volunteer home visits

• Survey questions using tablet computer

• Participants trained on McMaster Optimal Aging Portal (access to health record)

• 2-3 months after randomization– Report uploaded to EMR

– Interprofessional health care team reviews report, generates plan of care, referral to community service organizations as needed

• 3-6 months after randomization– IP team follow up

– Participant uses personal health record

– Volunteers have regular face-to-face training sessions

– IP team makes iterative changes to plan of care


• Primary outcome: Goal-attainment scale improvement

• Multiple secondary outcomes: self-efficacy for managing chronic disease; QOL optimal aging; social support; access to care; comprehensiveness of care; Pt empowerment; pt-centredness, caregiver strain; satisfaction with care; hospitalizations and ED visits


Results

• N = 312, intervention 158, control 154

• ~ 2/3 female, mean age 79, 34% over age 80. Intervention group slightly lower age, higher level of education and slightly fewer comorbidities

• Chronic conditions: HTN (67%), OA (46%), DM (26%), heart disease (43%), cancer 30%), COPD (14%), stroke (6%)

• 1-2 comorbidities (64%)

• 3 or more comorbidities (36%)

• Number of Rx medications: 5.64 +/- 3.8


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Types of goals (% ):

• Physical activity (18)

• Productivity (13)

• Social connection (14)

• Medical (12)

• Maintenance of health (14)

• Diet and nutrition (6)

• Rehab (6)

• Mental and cognitive health (2.5)

• Quit smoking, reduce alcohol (<1)

• Other-making time for travel, faith, finances, caregiving (8)


Results

• No difference in goal attainment scale; both groups made progress towards attaining goals

• No difference in vast majority of secondary outcomes such as self-efficacy, QOL, optimal aging, social support, pt empowerment, etc.

• Exercise: 81 minute increase walking in intervention group versus decrease of 120 minutes in control group

• Increased primary care visits intervention (4.93 +/- 3.86) versus control (3.50 +/- 3.53) including increased visits to interprofessional team members


Results

• Lower hospitalization rate: 0.09 vs 0.23 (IRR 0.37, 0.18-0.77)

• Lower odds of having 1 or more hospital admissions 6.96% vs 14.94% (OR 0.44, 0.20-0.95)

• Fewer people had 1 or more ED visits 8.86% vs 13.64%, but odds not significantly different (0.58, 0.28-1.20)

• Fewer medications 4.77 +/- 3.78 vs 5.39 +/-3.59

• Eleven critical incidents involving volunteers in the home (e.g. suicidal ideation, living conditions, extreme stress)

• Greater improvements in people aged 70-79 compared with over age 80


Why spend so much time on an essentially negative study?

• Health system improvement is hard.

• Promising signals very worthy of further study: shift from reactive to proactive care?– Common goal of increased activity. More exercise in

intervention group. Reduced hospitalizations and reduced medications

– Better connection to health care team, better identification of health needs not previously identified and increased health care team connections/visits


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Agitated? Try Nabilone

Herrmann N, Ruthirakuhan M, Gallagher D, et al. Am J Geriatr Psychiatry. 2019;27(11):1161-1173.

Background

• Agitation in Alzheimer’s Disease is associated with decreased quality of life, increased caregiver burden, higher mortality

• Nonpharmacologic management is first line

• Pharmacologic interventions are sometimes required and include antipsychotics, however these are associated with adverse events.


Background

• Nabilone is a synthetic THC analogue, partial agonist at CB1/2 receptors

• Study aim: To evaluate efficacy and safety of nabilone for agitation in patients with moderate-severe Alzheimer’s Disease.


Study Design

• Double-blind randomized control trial

• Involved 14 week with crossover, including 6 week treatment and 6 week placebo with 1 week single-blind placebo run-in and wash out period

• Primary outcome – agitation as measured by CMAI (Cohen-Mansfield Agitation Inventory)

• Secondary outcomes – cognition, NPS, global change, nutrition, pain.


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Study Design

Study population:

• 55 and older from long term care and geriatric psychiatry clinics

• Alzheimer’s and Alzheimer’s/Vascular Dementia

• Stable doses of cholinesterase inhibitors (for 3 months) and psychotropic medications (for 1 month)

• Exclusion – significant/unstable CV disease, significant delusions/hallucinations, hx of marijuana use.


Study Design

Intervention:

• During nabilone phase, dose uptitrated from 0.25mg to 1-2mg depending on tolerability

• In presence of intolerable adverse event noted on clinical assessment and caregiver reports, dose was reduced by 0.5mg increments

• Nabilone dose was downtitrated prior to crossover.


Results

• 39 patients (average age 87) enrolled and randomized, 1 patient dropped out in placebo run-in leaving 38 patients (N=38)

• 9 terminated from study early due to serious adverse events (5 in nabilone phase, 4 in placebo phase), but included in analysis

• Baseline medications - 53% on cholinesterase inhibitors, 45% atypical antipsychotics, 87% antidepressants.


Results Herrmann N, Ruthirakuhan M, Gallagher D, et al. Am J Geriatr Psychiatry. 2019;27(11):1161-1173.

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Results

• Primary outcome - Decrease in CMAI -4.0 (-6.5 to -1.5), p=0.003 favouring nabilone group, significant after 2 weeks

• Secondary outcomes:

– Significant decrease in NPS scores favouring nabilone

– Significant (but small) improvement in cognitive scores favouring nabilone

– Significant differences on nutritional status favouring nabilone (though no increase in weight observed)

– No significant changes in pain.


Results

• Adverse effects significantly greater in treatment phase, with sedation being most common (N=17)

– In 12 of these sedation improved following dose reduction

• No significant difference in falls (8 in nabilone vs 7 in placebo)

• No significant difference in serious adverse events (5 in nabilone vs 4 in placebo).


Conclusion

• Initial small study suggests Nabilone (1-2 mg per day) is associated with improvement in responsive behaviour in AD and AD/Vascular type dementia

– Compares favourably to similar RCTs with antipsychotics and antidepressants where CMAI scores changed -2.38 or less (-4 for nabilone in this study)

• Main side effect is sedation

• Need larger trials to determine effectiveness (Phase 3 trial at Sunnybrook should be completed in 2 year).


ReferencesAnderson TS, Jing B, Auerbach A, et al. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among OlderAdults at Hospital Discharge. JAMA Intern Med [Internet]. 2019 [cited 2019 Nov 1];E1-E10. Available from: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2747871

Cho YS, Park SY, Seol HY, et al. Clinical Performance Evaluation of a Personal Sound Amplification Product vs a Basic Hearing Aid and a Premium Hearing Aid. JAMA Otolaryngol Head Neck Surg. 2019; 145(6):516-522.

Coupland CAC, Hill T, Dening T, et al. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMAIntern Med. 2019;179(8):1084-1093.

Dolovich L, Oliver D, Lamarche L, et al. Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial. CMAJ. 2019;191(18):E491-E500.

Herrmann N, Ruthirakuhan M, Gallagher D, et al. Randomized Placebo -Controlled Trial of Nabilone for Agitation in Alzheimer’s Disease. Am J Geriatr Psychiatry. 2019;27(11):1161-1173.

Liu-Ambrose T, Davis JC, Best JR, et al. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall: A Randomized Clinical Trial. JAMA. 2019;321(21):2092-2100.

McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018;379(16):1499-1508.

Mrkobrada M, Chan MTV, Cowan D, et al. Perioperative cover stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study. Lancet. 2019;394:1022-1029.

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Session #: F221

Session Name: Care of the Older

Adult: Evidence to Change Practice

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