PREVENTIVE CARE IN GERIATRICSAMANDA ARNOLD MD, ANNA SCHWEIKERT MD, NICOLE SORIA MD

THE CHRIST HOSPITAL/UNIVERSITY OF CINCINNATI GERIATRIC FELLOWS

OBJECTIVESPreventive care

PrinciplesTeam effortPreventing common reasons for medical visits

ED transitions

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#1 PRINCIPLE BASICS

What can you do?Using a mask

Hand cleaning

5% doing it right

Does this count?

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20 seconds

PREVENTIVE PRINCIPLES:THINGS TO

KNOW

Not just cancer screening

Different considerations

Underused

PREVENTION: ANNUAL WELLNESS VISIT

Once a year

NOT mandatoryLess than 25% of eligiblepatients receive this visit

Extensive amount to cover

Topics covered include:Medical history, family history, medication list, treatment teams and other providers

Depression screen

Fall risk assessment

Functional assessment

Immunizations

Screening tests

Optional: Advance directives

PREVENTION

IT TAKES A TEAM!

GLADYS… and herTerrible, Horrible, No Good, Very Bad Day

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COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest painPneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

CHEST PAIN

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CAUSES

• Coronary artery disease, acute heart failureC

Cardiac

• Respiratory infections – pneumonia, bronchitis, asthma exacerbationsR i i f i

Pulmonary/pleural

• Gastroesophageal reflux and esophageal spasmG h l fl

Gastrointestinal

MOST MODIFIABLE RISK FACTOR

Smoking cessation

https://www.iconfinder.com/icons/2699404/no_cigarette_no_smoking_no_smoking_sign_non_smoking_area_quit_smoking_icon

WHY QUIT? Smokers benefit from quitting

smoking even after development of smoking-related

diseases

S k b fi f i i

Reduced risk Heart disease Cancer Lung

diseases Infections Hip fracture

IT’S NEVER TOO LATE

STEP 1 – ASK Ask about tobacco use

“Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?”

“I take time to ask all of my patients about tobacco use—because it’s important.”

“Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?”

“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?”

STEP 2 – ADVISE Advise smokers to quit (clear, strong, personalized)

“Occasional or light smoking is still harmful.”

“Cutting down while you are ill is not enough.”

“It is important you quit as soon as possible, and I can help you.”

“Quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”

Refer to other resources:

Referral options:Clinicians - doctors, nurses, pharmacists, etc.

Local groups - Nicotine Anonymous

Quit lines - Ohio Tobacco Quit Line (1-800-QUIT-NOW) National Cancer Institute (NCI) Quit Line1–877–44U–QUIT

Websites – Quitnow.net, Smokefree.gov

STEP 3 – REFER SMOKING CESSATION AIDS Over-the-counter Nicotine gumNicotine lozengeNicotine transdermal patch

PrescriptionNicotine nasal spray/inhalerBupropion SR (Zyban)Varenicline (Chantix)

SMOKING CESSATION AIDS Over-the-counter Nicotine gumNicotine lozengeNicotine transdermal patch

PrescriptionNicotine nasal spray/inhalerBupropion SR (Zyban)Varenicline (Chantix)

Electronic cigarettes (e-cigarettes)

• Not approved by FDA as a smoking cessation aid. Can contain harmful substances such as lead and carcinogens in addition to nicotine. Limited evidence they are effective in smoking cessation.

SMOKING CESSATION

AIDS

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

PneumoniaStroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

IMMUNIZATIONS

https://www.medscape.com/viewarticle/823109 https://media.makeameme.org/created/when-my-teacher-5c1523.jpg

IMMUNIZATIONSImmunity wanes as we age, regardless of health status

Age increases susceptibility to illnesses

In 2015, for adults age 65 and older:

64% had a pneumonia vaccine

57% had a tetanus vaccine in the past 10 years

34% had a zoster vaccine (Shingrix or Zostavax)

PNEUMONIA VACCINES: OLD V. NEW

Old recommendation:Pneumovax PPSV23 and Prevnar PCV13 recommended for all adults 65 and older.

New in 2019:Pneumovax (PPSV23) recommended for all adults 65+ and shared-decision making regarding Prevnar PCV13.

Herd immunity: Risk for PCV13 disease lower due to vaccinated pediatric population.

PNEUMONIA VACCINATION

CDC recommends shared decision making regarding Prevnar (PCV13) for adults 65 and older.

Increased benefit for our patients in long-term care or nursing homes.

Higher incidence of PCV13 disease in our patients with chronic heart, lung or liver disease, diabetes, alcoholism or tobacco abuse.

https://blog.uvahealth.com/2016/09/28/pneumonia-101-qa/

HERPES ZOSTER (SHINGLES) VACCINATION

Affects 1 in 3 Americans, typically over age 50.

Shingrix: two-dose series separated by 2-6 months.

Shingrix is recommended regardless of prior Zostavax.

(postherpetic neuralgia)

https://pogoe.org/sites/default/files/AgingandImmunityGuide.pdf

2019-nCoV

SARSCoV2https://apicms.thestar.com.my/uploads/images/2020/01/31/535575.jpg

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LET’S COMPARE

?19 million infected

10,000 deaths

?4,600 infected

107 deaths

October 2019 – January 2020

LET’S COMPARE

Influenza19 million infected

10,000 deaths

Coronavirus4,600 infected

107 deaths

October 2019 – January 2020

2018: 80,000 people in US died of influenza

INFLUENZAHighest risk of complications:

>50 years old, residents of nursing homes /LTC.

High dose flu vaccine available for those 65+. 24% more effective than standard dose vaccine.

MANY misconceptions!

What is “the flu”

The flu shot gave me the flu.

But I have an egg allergy…https://health.ucmerced.edu/sites/health.ucmerced.edu/files/flu_pic_keep_calm.png

OTHER VACCINATIONS

Tetanus booster at least every 10 years.

Hepatitis vaccinations for certain at-risk groups/medical conditions.

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QUESTION 1

Older adults have accumulated more immunity over their lifetime, so they benefit less from vaccinations.

TRUEor

FALSE

QUESTION 1

Older adults have accumulated more immunity over their lifetime, so they benefit less from vaccinations.

FALSE

QUESTION 2

It is impossible to get the flu from receiving the flu shot.

TRUEor

FALSE

QUESTION 2

It is impossible to get the flu from receiving the flu shot.

TRUE

QUESTION 3

If your patient has a history of an egg allergy, they cannot receive the flu shot.

TRUEor

FALSE

QUESTION 3

If your patient has a history of an egg allergy, they cannot receive the flu shot.

FALSE

QUESTION 4

If your patient received the Zostavax vaccine, Shingrix is not recommended.

TRUEor

FALSE

QUESTION 4

If your patient received the Zostavax vaccine, Shingrix is not recommended.

FALSE

QUESTION 5

If your patient has cold symptoms, it is safe to administer a vaccine.

TRUEor

FALSE

QUESTION 5

If your patient has cold symptoms, it is safe to administer a vaccine.

TRUE

QUESTION 6

The flu shot is no longer recommended to be administered after January, because it is too late in the flu season.

TRUEor

FALSE

QUESTION 6

The flu shot is no longer recommended to be administered after January, because it is too late in the flu season.

FALSE

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

StrokeMedication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

STROKE

INCIDENCE INCREASES WITH

AGE, APPROXIMATELY

DOUBLING WITH EACH

DECADE

MAJOR CAUSE OF DEATH AND

DISABILITY AMONG OLDER

ADULTS.

~ 795,000 NEW STROKES

ANNUALLY IN THE UNITED

STATES

~ 6.8 MILLION ADULTS WHO ARE

STROKE SURVIVORS

Major risk factors:

Hypertension

Diabetes

Smoking

High cholesterol

Physical inactivity

STROKE

Two categories:

Ischemic

80-85%

Hemorrhagic

10-15%

BENEFITS OF INCREASED PHYSICAL ACTIVITY

Independently lowers risk of stroke.

Lowers risk of several causes of stroke:• Hypertension• Type 2 Diabetes • Hyperlipidemia

RECOMMENDED COMPONENTS

AEROBIC STRENGTH FLEXIBILITY BALANCE

AEROBIC EXERCISE Guidelines

Minimum 150 minutes/week of moderate-intensity aerobic activity

OR

Minimum of 60 minutes/week of vigorous activity

OR

Combination of the twohttps://www.freepik.com/premium-photo/old-couple-relax-after-jogging-they-hold-their-hands-smile_3354314.htm

STRENGTH TRAINING

Goal – maintain or increase muscle strength

Minimum: two days/weekAny activity involving use of major muscle groups against resistance:

Lifting weights and Body weight training

AND/OR

Carrying groceries and Yardwork https://www.yahoo.com/lifestyle/what-s-the-deal-with-1294376358592566.html

Flexibility

Two days/week Minimum 10 minutes/day

Stretching is best performed after aerobic or strengthening activities when the body is warmed up

BalanceAt least two days/weekReduce risk of falls and related injuriesIncludes: walking backward or sideways, heel walking, toe walking, and standing from a sitting positionGroup exercise classes – Tai Chi, Healthy Steps in Motion, Stay Active and Independent for Life (SAIL), etc.

EXERCISE PRESCRIPTION

Can include:Specific activity

Frequency

Intensity

Short and long-term goals to help maintain motivation153 LB

http://www.johnphung.com/tag/82-year-old-granny-lifting-some-weights/

Additive• Can be accumulated throughout the day

Individuals with chronic disabling conditions should be as physically active as can be achieved without harm.

• Intensity scale 0 to 10

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effectsDehydration

Urinary problems

Injuries from falls or accidents

MEDICATION REVIEW

Complicated by:Polypharmacy

Dosing times

Prohibitively expensive

Cognitive impairment

Over-the-counter medications:Many are not safe for older adults to take and are often not reported to their healthcare providers.

Transitions of care:Medications often added, changed, or discontinued.

Whenn you review w yourr patient’sWhenn you reviewy w ouyo r patientpmedication list, which onesmedication list, which ones

raise a red flag for you?

BEWARE – ANTICHOLINERGICSAnticholinergic = blocks acetylcholine, a neurotransmitter involved in cell signaling for memory, learning and muscles.

Older adults have less neurons and receptors at baseline increased susceptibility to their side effects.

Risks include dehydration, blurred vision, dizziness, dry mouth, urinary retention, constipation, delirium and hallucinations. Commonly worsen cognition.

Common medicines! Antihistamines, sleep aids, anxiety medications etc.

BEERS CRITERIA

Clinical tool intended to improve care of older adults by reducing exposure to potentially inappropriate or harmful medications.

Long, comprehensive list

TIME OUT! LET’S

PRACTICE.WHICH MEDICATIONS ON MS. JONES LIST ARE

OF CONCERN?

DISCUSS IN GROUPS OF 2-3!

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COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

DehydrationUrinary problems

Injuries from falls or accidents

DEHYDRATION

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COMMON PRESENTATIONS

Lightheadedness

Palpitations

Kidney injury

MOST COMMON CAUSES

Decreased perception of thirst

Lack of access to water

Gastrointestinal lossesVomiting, diarrhea

Renal lossesEffects of diuretic medications

Hyperglycemia

HOW TO RECOGNIZE

Urine output:Darker color

Strong odor

Decreased output

Dry mouth and chapped lips

Constipation

Confusion

HOW TO RECOGNIZE

https://www.healthline.com/health/hydration-chart

PREVENTION

Have preferred fluidsAvailable and offered regularly

Have fresh water available Variety! Both hot & cold fluids

Provide assistance and special aids as required

NUTRITION CHALLENGES

Altered sense of taste

Decreased appetite

Less efficient nutrient absorption

PREVENTION AND

NUTRITION

Medications given with at least a full glass of fluid

Water glass next to bed to drink first thing in the morning

Ice cream

Nutrition shakes or drinks

Have snack food out/easily available

Variety!

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problemsInjuries from falls or accidents

INCONTINENCE

Very commonOften unreported

Reduces quality of life

Can lead to depression, social isolation, and increased caregiver burden.

**

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INCONTINENCE

First, ensure it is not a new problem. If it is then primary care

physician should evaluate.

The most effective and safest treatment

recommendation for all types of incontinence is

lifestyle changes!

TRASH THE BLADDER IRRITANTS

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TREATCONSTIPATION

Older adults may avoid drinking enough fluids due to their incontinence, which worsens constipation.

Constipation can result in urinary retention

https://www.almanac.com/sites/default/files/styles/primary_image_in_article/public/image_nodes/fiber-shutterstock_1158660511.jpg?itok=vV15uVQB

https://www.niddk.nih.gov/health-information/weight-management/health-tips-african-americans

https://www.hydrationinfo.com/hydration-tips-for-seniors-how-to-get-the-elderly-to-drink-more-water/0

TIMED TOILETINGHelpful for all types of incontinence.

Choose a reasonable interval2 hours is a good starting point

Toilet at that interval regardless of urge throughout the day.

Extend interval for bladder training in select patients.

https://dailycaring.com/wp-content/uploads/2014/06/elderlytoilet1200x630.jpg

KEGELEXERCISES

Locate pelvic muscles: “Pretend you are trying to

avoid passing gas.”

Contract and relax:• Contract pelvic floor

muscles for 3-5 sec then relax 3-5 sec.

• Repeat cycle 10 times.• Goal: 10 sec contractions.

Most important: Repeat throughout the day

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HYGIENE

Over-exposure to moisture causes skin to become macerated and fragile

Dermatitis (“diaper rash”) may result

Moist warm environment is a bacteria breeding ground

P you are the pros!Change incontinence products as soon as possible after soiling occurs.

Barrier cream - use to minimize skin contact with urine.

Cleanse gently to avoid friction.

Clear the path

Add grab bars for extra support when sitting and standing

Add a raised toilet seat with arms

Make cleaning up easier

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https://www.amazon.com/Long-Reach-Self-Wipe-Bathroom-Toileting/dp/B07JQ77HK4

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

COMMON REASONS FOR MEDICAL VISITS

Chest pain

Pneumonia

Stroke

Medication side effects

Dehydration

Urinary problems

Injuries from falls or accidents

FALLS

Nearly 1/3 of older adults report falling annually.

Over 3 million ED visits/year25% hospitalized

Half of older adults do not discuss falls with their health care provider.

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SCREENING FOR FALLS

Single most predictive question for detecting high fall risk:

Have you fallen in the past year?

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FALL RISK ASSESSMENT

Modifiable risk factorsPolypharmacy

Environmental hazards

Gait impairmentMuscle weakness, Hearing or vision problems, Inappropriate footwear, Fear of falling

Acute illness

Non-modifiable risk factorsAge

Comorbidities including Cognitive disorders

History of falls/fractures

Recent hospital discharge INTERVENTIONS

INTERVENTIONS

Problem:Poor strength

Unsteady gait

Poor balance

Solution:

https://www.bethesdahealth.org/physical-therapy-rehabilitation-vital-senior-healing/

INTERVENTIONS

KEEP PRACTICING

YOUR MEDICATION

REVIEWhttp://babyboomhealth.com/elderly-polypharmacy-issue/

INTERVENTIONS

HOME SAFETY

ASSESSMENT

https://www.sherrardlaw.com/single-post/2017/06/29/Home-Modifications-and-Occupational-Therapy

http://www.onlinearchitecture.net/decorating-top-of-kitchen-cabinets-dos-and-donts.html

EMERGENCYDEPARTMENTTRANSITIONS

https://www.ems1.com/ems-products/ambulances/articles/top-10-biggest-smallest-fastest-and-strangest-ambulances-in-the-world-xUe8v0lp46J18MB1/

BACK TO GLADYS

Recap: 82

Smoker

Polypharmacy complicated by…

Environmental hazards

Fallhttps://specials-images.forbesimg.com/imageserve/962984430/960x0.jpg?fit=scale

UP TO DATE MEDICATION

INFORMATION

Should be carried with them…

ALL THE TIME

Pharmacy

Date last updated

ALL THE AIDS

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MENTAL BASELINE

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CODE STATUS

DNR-CC ARREST

DNR-CC

Medication list

Aids

Mental baseline

Code status

SUMMARY

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