An approach to mulitmorbidity in frail older adults
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An approach to mulitmorbidity in frail older adults
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An approach to mulitmorbidity in frail older adults
- 1. A n A p p r o a c h t o C h r o n i c D i s e a s e M a n a g e m e n t i n F r a i l O l d e r A d u l t s Dr. Camilla Wong, MD MHSc FRCPC 06.22.2017 Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, Dopey
- 3. Proportion of Canadians aged 65 and older with zero to four self- reported major chronic diseases (cancer, cardiovascular disease, chronic respiratory disease, diabetes) Canadian Community Health Survey, 2014
- 4. Time Medication Non-pharmacologic All Day Periodic 7:00 Ipratropium MDI Alendronate weekly Check feet Sit upright 30 mins Accuchek Appropriate foot wear Limit alcohol Avoid COPD environmental exacerbation exposures Energy conservation Joint protection Exercise (non-weight bearing if foot disease, weight bearing for osteoporosis), ROM, aerobic. Albuterol MDI prn Pneumonia and influenzae vaccine BP, foot, glucose monitoring HgA1c q3months Creatinine, lytes, cholesteral, microalbumin yearly Physical therapy, pulmonary rehab Eye exam q1yr DEXA scan q2yr Education on diabetes, foot care, inhalers 8:00 Breakfast HCTZ, Lisinopril, Glicazide, ASA, Metformin, Naproxen, Omeprazole, Vitamin D 2 g sodium, 90 mmol K, diabetic diet, low cholesterol and saturated fat, DASH diet 12:00 Lunch Metformin, Ipratropium MDI Diet as above 17:00 Dinner Diet as above 19:00 Metformin, Ipratropium MDI, Naproxen, Atorvastatin 23:00 Ipratropium MDI JAMA. 2005;294:716-724
- 5. A comp rehens ive g eriatric as s es s ment (CG A) is a multidimens ional, interdis ciplinary diagnos tic proces s to determine the medical, p s ycholog ical, and functional cap abilities of a frail elderly p ers on in order to develop a coordinated and integ rated p lan for treatment and long - term follow - up.
- 6. Cochrane Database of Systematic Reviews 2011 MDTeaCochrane Database Syst Rev. 2011 Jul 6;(7):CD006211.
- 9. Concordant Conditions S i m i l a r p a t h o p h y s i o l o g i c p r o f i l e a n d d i s e a s e m a n a g e m e n t p l a n s .
- 10. Discordant Conditions N o t d i r e c t l y r e l a t e d i n e i t h e r p a t h o g e n e s i s o r m a n a g e m e n t .
- 11. Public Health Reviews. 2010;32:451-74. COMORBIDITY MULTIMORBIDITY
- 12. Proportion of Canadians aged 65 and older with zero to four self- reported major chronic diseases (cancer, cardiovascular disease, chronic respiratory disease, diabetes) Canadian Community Health Survey, 2014
- 17. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 18. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 19. WHAT MATTERS TO YOU? Moving from “What is the matter?”
- 21. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 22. NNT Number Needed to Treat number of patients who need to be treated to prevent one outcome
- 23. Intervention Comparator Outcome NNT CGA General medical care Death or deterioration 17 Statin Placebo Cardiovascular mortality in established disease 34 Live zoster vaccine Placebo Herpes zoster 50 Apixaban Coumadin Stroke or embolism 51 Indapamide and Perindopril Placebo Death in diabetes 79 Alendronate Placebo Secondary prevention hip/wrist fracture 100
- 24. S U R R O G AT E E N D P O I N T S m a y b e s t r o n g l y a s s o c i a t e d w i t h c l i n i c a l o u t c o m e s , b u t t h e i n t e r m e d i a t e e n d p o i n t s m a y n o t b e r e l e v a n t i n t h e
- 25. Disease Intervention Surrogate Endpoint Clinical Outcome (what matters) Alzheimer’s disease Cholinesterase inhibitor ADAS-Cog Skilled nursing facility Diabetes DPP-4 inhibitors Hemoglobin A1c Microvascular/m acrovascular complications Osteoporosis Bisphosphonate Bone mineral density score Hip fracture Diabetic nephropathy ACE inhibitor Microalbuminuria Dialysis
- 26. T I M E TO B E N E F I T ( T T B ) T h e t i m e u n t i l a s t a t i s t i c a l l y s i g n i f i c a n t b e n e f i t i s o b s e r v e d i n t r i a l s o f p e o p l e t a k i n g a t h e ra p y c o m p a re d t o a c o n t ro l g ro u p n o t t a k i n g t h e t h e ra p y.
- 27. Intervention Time to Benefit Outcome NNT Statin 5 years Cardiovascular mortality in established disease 34 Indapamide and Perindopril 5 years Death in diabetes 79 Alendronate 2-3 years Secondary prevention hip/wrist fracture 100 Fecal occult testing 10 years Colon cancer prevention 1000
- 28. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 32. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 33. Time Medication Non-pharmacologic All Day Periodic 7:00 Ipratropium MDI Alendronate weekly Check feet Sit upright 30 mins Accuchek Appropriate foot wear Limit alcohol Avoid COPD environmental exacerbation exposures Energy conservation Joint protection Exercise (non-weight bearing if foot disease, weight bearing for osteoporosis), ROM, aerobic. Albuterol MDI prn Pneumonia and influenzae vaccine BP, foot, glucose monitoring HgA1c q3months Creatinine, lytes, cholesteral, microalbumin yearly Physical therapy, pulmonary rehab Eye exam q1yr DEXA scan q2yr Education on diabetes, foot care, inhalers 8:00 Breakfast HCTZ, Lisinopril, Glicazide, ASA, Metformin, Naproxen, Omeprazole, Vitamin D 2 g sodium, 90 mmol K, diabetic diet, low cholesterol and saturated fat, DASH diet 12:00 Lunch Metformin, Ipratropium MDI Diet as above 17:00 Dinner Diet as above 19:00 Metformin, Ipratropium MDI, Naproxen, Atorvastatin 23:00 Ipratropium MDI JAMA. 2005;294:716-724
- 36. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 37. NNH Number Needed to Harm number of patients who need to be exposed to incur one adverse event
- 38. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 39. Ms. A Does she have multimorbidity? Are the conditions concordant or discordant? Is there a dominant condition? 72 year old lady. Past Medical History 1. COPD, mild 2. CAD – prior NSTEMI 3. CHF (grade II LV) 4. Type II diabetes (HgA1c 7.2%) with neuropathy 5. CKD (CrCl 50) Medications 1. Aspirin 80 mg daily 2. Perindopril 4 mg daily, 3. Atorvastatin 10 mg daily 4. Metformin 1000 mg bid 5. Sitagliptin 100 mg daily 6. Atrovent prn Function • Cane • Independent with ADLs and IADLs • Does not drive
- 40. Ms. A Would you propose any changes in management? Do you need more information? Social History • Married, lives with husband • Daughter nearby • Smokes 1 pack per day • No alcohol • Loves to go to church and spend time with family Geriatric ROS (pertinent findings) • Cognitively intact, no falls, continent • No vision or hearing concerns • BMI = 25, appetite good • High self-rated quality of life Examination (pertinent findings) • BP 160/90 • BMI = 25 Labs (pertinent findings) • HgA1c = 7.2% • LDL 3.2 • Cholesterol 4.8 • Minimal microalbuminuria
- 41. eprognosis All-cause 10 year mortality risk: 46%
- 42. Ms. A Pharmacologic Interventions 1. COPD • Counsel on smoking cessation 2. Diabetes • HgA1c target of ~7.0% • BP target < 140/90 (add Indapamide) • Reduce Metformin (CrCl = 50) • Change Sitagliptin to Linagliptin (CrCl = 50) 3. Cardiovascular Disease • Increase Atorvastatin (LDL target < 2.0 in established coronary disease)
- 44. Ms. A 10 years later. Does she have multimorbidity? Are the conditions concordant or discordant? Is there a dominant condition? History of Presenting Illness • Abdominal pain, nausea, vomiting, peritonitis • Obstructing colonic lesion • Urgent ileostomy • Pathology: Stage III colon cancer • Postoperative delirium resolving Past Medical History 1. COPD, mild 2. CAD – prior NSTEMI 3. CHF (grade II LV) 4. Type II diabetes (HgA1c 5.7%) with neuropathy 5. CKD (CrCl 50) 6. Recurrent UTIs Medications 1. Aspirin 80 mg daily 2. Perindopril 4 mg daily, 3. Indapamide 1.25 mg daily 4. Atorvastatin 20 mg daily 5. Metformin 500 mg bid 6. Linagliptin 5 mg daily 7. Canagliflozin 100 mg daily 8. Atrovent prn
- 45. Ms. A 10 years later. Is she frail? Function • Cane • Independent with ADLs • Does own cooking, shopping cleaning • Missed bill payments and medications occasionally • Does not drive Social History • Lives alone • Daughter nearby • Stopped smoking • No alcohol • Loves to go to church and spend time with family Geriatric ROS (pertinent findings) • Short term memory impairment for 3 years • 3 falls in the last year (no injuries) • Low weight (lost 8 pounds in past year) • Continent • Good self-rated quality of life
- 46. Ms. A 10 years later. Should she get adjuvant chemotherapy? Examination (pertinent findings) • MoCA 22/20 (deficits in memory and executive function) • Cannot manage day to day tasks related to ileostomy care (emptying 6 times a day, hydration, troubleshooting) • Peripheral neuropathy Proposed Adjuvant Chemotherapy Options 1. Oxaliplatin-based regimen, OR 2. Flurouracil plus leucovorin, OR 3. Capecitabine, OR 4. Supportive care
- 49. Ms. A 10 years later. Interventions 1. Dementia, mild, probable Alzheimer’s • CCAC referral for ileostomy support (only once daily), daily weights, OT home safety assessment, blister pack medications • Referral to Alzheimer’s Society 2. Falls • Lenient HgA1c target of < 8.5% • BP target < 150/90 • OT home safety referral, emergency response device 2. Adjuvant Chemotherapy • Shared decision-making for a trial of Capecitabine, dose-reduced 3. Advanced Care Planning • Established POA • Re-visit preferences and values • Code status – DNR • Proactive referral to palliative care
- 52. Ms. A A year later. In her last year of life. History of Present Illness • She has a fall resulting in a small subdural hematoma, conservatively managed. Past Medical History 1. COPD, mild 2. CAD – prior NSTEMI 3. CHF (grade II LV) 4. Type II diabetes (HgA1c 8.5%) with neuropathy 5. CKD (CrCl 35) 6. Stage III colon cancer. Medications 1. Aspirin 80 mg daily 2. Perindopril 4 mg daily 3. Atorvastatin 20 mg daily 4. Metformin 500 mg bid 5. Capecitabine 500 mg bid (completed) 6. Atrovent prn
- 53. Ms. A A year later. In her last year of life. Is she frail? Is she in the terminal phase of her multimorbidity? Function • Walker • Needs assistance with transfers, dressing, bathing, and IADLs. Social History • Living with daughter • Loves to go to church and spend time with family Geriatric ROS (pertinent findings) • 2 falls in the last year • Mood is good • Weight stable • Incontinent Examination (pertinent findings) • MoCA 10/20 (deficits in all domains)
- 54. Ms. A A year later. In her last year of life. Interventions 1. Advanced Care Planning • Re-visit preferences and values • Code status – DNR 2. Focus on Symptom Management • Stop non-essential medications • Liaise with palliative care
- 57. F R A M E W O R K F O R M U L T I M O R B I D I T Y J Am Geriatr Soc. 2012;60(10):E1-25.
- 58. Thank you. Fa c u l t y / P re s e n t e r : C a m i l l a Wo n g
Editor's Notes
- Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, Dopey If you let me stay, I'll keep house for you. I'll wash and sew and sweep and cook. An approach to multimorbidity Resources
- For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her $406 per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result
- For those not in geriatric medicine, what geriatric medicine can seem nebulous. Geriatrician perform what is known as a CGA, a multidimensional, interdisciplinary diagnostic process to determine the medical psychological and functional capabilities of a frail elderly person in order to develop a coordinate and integrated plan for treatment and long-term follow-up. Essentially, the process tool is how I would want my grandparents to be cared for, how I would want to be cared for when I’m older.
- And it’s evidence-based too. For every 17 hospitalized older adults who receive a CGA, death or significant deterioration is prevented for one person based on evidence in general geriatric inpatients from a Cochrane systematic review of 22 randomized trials evaluating 10,315 participants in six
- Of course, Atul Gawande said it much more eloquently in his book, Being Mortal.
- - same overall pathophysiologic risk profile - shared disease management plan Clinical practice guidelines are based on clinical evidence and expert consensus to help decision making about treating specific diseases. Clinical practice guidelines help to define standards of care and focus efforts to improve Quality. Most CPGs address single diseases in accordance with modern medicine’s focus on disease and pathophysiology.
- Examples: Cognitive impairment and urinary incontinence heart failure and chronic kidney disease PMR and diabetes Schizophrenia and parkinson’s disease Clinical practice guidelines are based on clinical evidence and expert consensus to help decision making about treating specific diseases. Clinical practice guidelines help to define standards of care and focus efforts to improve Quality. Most CPGs address single diseases in accordance with modern medicine’s focus on disease and pathophysiology.
- Conceptual Diagram of Comorbidity: Index Disease, With One or More Comorbid Condition or Diseases Affecting Its Course and Treatment. Comorbidity has often been studied and treated in clinical practice from the perspective of an index disease, and one or more comorbid diseases may typically be considered. These diseases may affect the course and treatment of the index disease to varying degrees (varied weight of connecting bars). This framework may create disjointed treatment plans for each of the diseases and become cumbersome in patients with several co-existing diseases. Conceptual Diagram of Multimorbidity within an Individual Person’s Circumstances and Preferences. The perspective of multimorbidity may be useful for treating patients with multiple conditions. Conditions include traditional diseases, but also may reflect conditions such as disability, falls, hearing impairment, and sarcopenia that fall outside the traditional disease model. These conditions may overlap to varying degrees. The intersecting conditions exist within a context of biological health and reserves, as well as the psychological circumstances of a person (i.e., positive affect). The multimorbid conditions also unfold for given people within their social, educational, cultural, economic and environmental circumstances, and these will affect management of the multimorbid conditions. The person with multimorbidity also has individual values and priorities for their life and healthcare, which need to be elicited and factored into treatment plans. Comorbidity: index disease as centre of interest, different importance of conditions, only interaction with index disease assumed Multimorbidity: no index disease, all conditions equal, chronic conditions, interaction between conditions
- More often than not, we’re not just dealing with multimorbidity, but frailty. When an individual has many diseases and have limited reserve
- The suggested management strategy is to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone .
- In the sea of multimorbidity, is there a dominant disease whereby the suggested management strategy may be to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone? The tricky part for frail individuals is that treatment of 1 condition can exacerbate other conditions that do not lead to net health improvements (eg, improved glucose control leads to hypoglycemia, resulting in falls). The suggested management strategy is to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone
- Seeing the forest for the trees. Moving from “What is the matter?” to “What Matters to You?”
- Ensure patient has an advance directive Ensure there is a designated POA Document preferences and expectations Include a discussion of possible complications, including functional decline, need for rehabilitation, or nursing home.
- SURROGATE ENDPOINTS may be strongly associated with clinical outcomes, but the intermediate end points may not be relevant in the bigger picture.
- Immediate risk of hypoglycemia Immediate risks of hyperglycemia Long term benefits of glycemic control
- Let’s give her 3 of the 4 most common chronic diseases of Canadians
- NNT = 34 for statins in secondary prevention
- Now let’s give her the forth of the top 4 chronic conditions in Canadians Canaglifozin (sodium-glucose co-transporter 2 (SGLT2) inhibitors and recurrent UTIs
- an approximately 30 percent reduction in the risk of disease recurrence and a 22 to 32 percent reduction in mortality
- Add slide on HgAc1 from quick guide
- Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs.
- Tools: eprognosis, chemotherapy toxicity calculators, deprescribing.org, trials of de-prescribing