Geriatric Medicine Update

Dr Elena MucciConsultantPhysician/Geriatrician

Leadership TutorOctober 2013

Is the approach to HTN in the elderly different?HYVET trial

• HYVET: 3845 subjects, 80+ and functional– SBP > 160; goal 150/80– Indapamide and ACEi vs. Placebo

30% reduction in all cause mortality

• ABP Substudy (112 subjects at baseline)– Mean CBP 172/90 mm Hg– No orthostasis– Mean daytime ABP: 136/78– Mean 24 hr ABP: 133/77

Beckett NS, NEJM, 2008; 358: 1887 1898‐Bulpitt CJ, Hypertension, 2013; 61: 89 94‐

Anticoagulation and Fall RiskShould we be prescribing anticoagulants in

patients with fall risk?

• Prospective study▫ 515 pts, median age 71, treated w/ vitamin K antagonists▫ Fall risk associated with risk for major bleeding?▫ High fall risk if: fall in past yr, gait/balance/mobility issue▫ 60% were high risk• Outcomes▫ No difference in time to first major bleeding event including fatal or

intracranial within 12 months f/u.▫ Risk for major bleed independently associated with polypharmacy.• 12% increased risk for each additional drug taken.

Am J Med 2012. PMID: 22840664

Anticoagulation and Fall Risk

• Take Home Point:▫ Patient > 65 yrs with CHADS2 score of 2-3

would have to fall 295 times yearly for risk of fall-related SDH to outweigh benefits of stroke prevention.

▫ Polypharmacy greater risk.▫ Use this opportunity to stop unnecessary

medications.

Aspirin to prevent recurrent DVT

• Recurrence of unprovoked VTE after stopping anticoagulants

▫ 5-15% at one year, 30-50% at 5-10 yrs▫ Highest risk: male, mod-severe post-thrombotic

syndrome, proximal DVT, elevated D-dimer 3-4 weeks after stopping therapy.

• Extending anticoagulants associated with increased risk of bleeding.

• Is the use of low dose aspirin an alternative?

Low Dose Aspirin for prevention of recurrent DVT

• Double blind placebo controlled RCTs• WARFASA (402 pts) and ASPIRE (822 pts) Trials▫ Pts with first unprovoked VTE who stopped anticoagulation after 6-18 months

of therapy.▫ Randomized to ASA 100 mg daily vs. Placebo

• VTE recurrence▫ Pooled data from both trials▫ 32% reduction in rate of recurrent VTE▫ 34% reduction in rate of major vascular events▫ Low risk of bleeding

NEJM 2012.PMID: 22621626, 23121403, 231 21404

Update on drugs commonly used in the Elderly

• Omeprazole impairs absorption of calcium, iron, and levothyroxine• Omeprazole is a cause of acute interstitial nephritis• Omeprazole can cause B12 deficiency• Omeprazole contributes to C Dif and delays recovery• Fenofibrate and losartan significantly lower serum uric acid levels• Longterm use of metformin may result in significant B12 deficiency• Trimethoprim causes reversible elevation of serum creatinine and potassium

AF and new anticoagulatnts

• Dabigatran, direct Thrombin inhibitor, 110mg BD; 150 mg BD, 75mg BD if eGFR 15-30, renal excretion. Non inferior to warfarin.

• Rivaroxaban, 10a inhibitor, 20mg OD, 15mg OD in renal disease, also licensed for PE/DVT, renal/liver excretion. Non inferior to warfarin.

• Apixaban, 10a inhibitor, 5mg BD and 2.5 mg BD, mainly liver excretion-safer in renal disease. The only one which showed reduction in all cause mortality, including reduction in major bleeding, GI bleeding-no difference.

AF, rate control• RACE II• Goal heart rate <80bpm vs. <110bpm• Permanent atrial fibrillation• <80 years of age• Resting atrial fibrillation rate >80bpm• Primary outcome composite:– Death from cardiovascular causes– Hospitalization for heart failure– Stroke or systemic embolism– Major bleeding– Arrhythmic events including syncope or VT– Implantation of pacemaker or ICD• Van Gelder et al. NEJM 2010;362:1363-1373

2011 ACC/AHA Updates• Treatment to a goal resting heart rate<80bpm is not beneficial compared to<110bpm in patients with atrial fibrillationwho have LVEF >40% and no or minimalsymptoms (Class III)

Treatment Options

• Beta-blockers-sympathetic pathway– Carvedilol less effective than others• Verapamil-Diltiazem• Digoxin-As adjunct only-parasympathetic

pathway– Use if heart failure also• Amiodarone-Rarely for rate control• AV node ablation and pacing

Diastolic DysfunctionHFpEF

• Prevalence: increasing with the aging population and increasing recognition

• Systolic HF: CAD, HTN, DM• Diastolic HF: Age, Female, HTN, Obesity• Precipitating factors: labile HTN, Med

noncompliance,Diet non-compliance,• Iatrogenenic (NSAIDS, fluids), Infections

HFpEF

• Treatment:• Class I:• Control of BP (<130/80)• Agents not specified• Control of tachycardia in Afib• Reduction of central blood volume-with diuretics• Class IIa: coronary revascularization if ischemic• Class IIb:• Restoration of NSR• Digitalis use not well established• ACE/ARB/BB/CCB

Medications Used to Treat Hallucinations,Delusions and Agitation

• Antipsychotics (Black Box Warning!)– Haloperidol– Risperidone– Olanzapine– Quetiapine• Anticonvulsants– Carbamazepine• Antidepressants– Sertraline• Β-adrenergic receptor antagonists– Propanolol• Antianxiety agents– Clonazepam, lorazepam

Statin induced Myopathy

• MyalgiaNormal CK, reduce the dose, try different drug, stop the

drug, restart at lower dose or different one.

• MyositisElevated CK, stop the drug till CK/symptoms normalised,

restart with a statin with high half life, like Rosuvastatin+/- Co-Enzyme Q10.

• Rhabdomyalisis CK 10 times the normal level, myoglobinuria, AKI, death.

Stop statin and never use again.

Continuation of donepezil in patients with moderate-to severe ‐Alzheimer’s disease may improve cognition at 52 weeks.

• RCT• 295 community-dwelling patients, mean age 77.1; 65%

females; 95% white, mean MMSE 9; taking Donepezil for at least 3 months.

• 4 groups: Continue donepezil with placebo memantine Continue donepezil and starting memantine Discontinue donepezil with placebo memantine Discontinue Donepezil an starting MemantineFollow up period 52 weeksOutcome measures: Cognition (SMMSE) and functional status (BADLS) Howard R, McShane R, Lindesay J, Ritchie C et al. Donepezil and Memantine for Moderate-

Severe Alzheimer’s Disease. N Engl J Med. 2012 Mar 8;366(10):893-903.

Continuation of donepezil in patients with moderate-to severe Alzheimer’s disease may ‐improve cognition at 52 weeks.

• Clinically important difference SMMSE of 1.4 points or more BADL score of 8 points or more

• Donepezil v no Donepezil: 1.9 points difference on SMMSE and 3.0 points difference on BADLS.

• Memantine v no Memantine: 1.2 points and 1.5 points difference respectively

• No difference Donepezil+Memantine

Clinical Bottom Lines

• NICE 2011: treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms.

• This study suggests that cognitive outcomes can be improved with continuing Donepezil treatment.

• What do I do: If patient is on Donepezil I continue If not on any treatment I start on Memantine If on Donepezil and developed severe behavioural problems

I stop Donepezil and start Memantine I stop everything in the EoLC

Medications to treat mooddisorders in dementia

• Selection of antidepressant usually based on previous response to the drug:

– trazodone (50mg at bedtime) – sedating and useful with agitated depression and insomnia – also consider nortriptyline 10mg at bedtime

– Sertraline 25-50mg per day (proven effective in clinical trials, may especially be useful with agitated depression)

• May see improvement in sleep and agitation soon after instituting therapy but full relief of depression delayed by 4-6 weeks

Medications to treat sleepdisturbances

• Trazodone 50-100mg po bedtime• Quetiapine begin with 12.5mg bedtime but

can work up the dose. Use only if sleep disturbance is severe and associated with agitation.

• Avoid usual sleep medications such as zopiclone

Medications to treat apathy

• May try a low dose of methylphenidate (5– 10mg early morning but never after 2pm)

• If depressed, may try a more stimulating antidepressant such as fluoxetine (10mg to begin with)

Tight control of DM in NH eligible older adults may be associated with poor outcomes

• Cohort study• 367 NH patients with DM, mean age 80 (+/-9)• 67% female. Almost one-third on oral and 50% on

insulin, 79% cognitive impairment , mean ADLs 8, follow up 2 years

• Outcome measures: functional decline and death at 2 years

• 4 groups: less than 7%, 7-8%, 8-9% and over 9%

Yau, C. Glycosylated Hb and Functional Decline in Community-Dwelling NH-Eligible Elderly Adults with DM. J Am Geriatr Soc. 2012 Jul;60(7):1215-21

Clinical bottom lines

• HbA1c level of 8-9% appears to be associated with less functional decline or death at 2 years

• Current AGS recommends AbA1c target of 8.0% or less for frail elderly adults with limited life expectancy may be lower than necessary to maintain function and delay death for this vulnerable population.

• ADA Position Statement suggests a patient-centred approach in the management of type 2 DM and recommends less stringent HbA1c goals.

• Although this study was conducted in NH patients, it suggests that clinicians should consider less aggressive glycaemic targets when managing vulnerable older adults.