CCFP Topic: Elderly

There’s no official standard for what ‘polypharmacy’ is, but we know that the more medications an older adult is taking, the more likely they are to experience adverse events as a result of their medications.

We also know that up to 40% of adult Canadians over 65 years, take 5-9 medications. And almost 20% take 10 or more. There are numerous risks that come with polypharmacy:

• More adverse drug reactions including side effects
• More drug interactions
• Higher cost for both the patient and the system
• Greater risk of non-adherence
• More likely to have medication errors
• More risk of worsening geriatric syndromes:
  • falls,
  • functional impairment,
  • cognitive impairment,
  • urinary incontinence,
  • impaired nutrition,
  • dehydration,
  • constipation

Betty is currently on five medications, but is this polypharmacy?

There is a great primer presentation from the Regional Geriatric Program of Toronto that we will link to, and includes the following approach.

Assess Polypharmacy Risk

Your radar should be up that your patient is at risk for polypharmacy if they have:

1. multiple medical issues requiring multiple medications
2. chronic organ dysfunction, such as renal impairment
   and
3. frailty, or acute illness requiring changes to medications

Annual Medication Review for all older (>65) adults

There are two well known resources available to you here, the Beer’s list and the STOPP/START lists:

1. Beer’s list
   The Beer’s list was produced by Dr Mark Beers and colleagues. It’s a consensus list of medications that are inappropriate for long-term care facility residents. Each has a related grade of ‘A’ to avoid in most elderly. ‘C’ to use with Caution, and ‘H’ is high risk in the elderly.
   
   Many warnings are listed for their: Risk of orthostasis, risk of SIADH such as from many antidepressants, and the anticholinergic effects from antipsychotics and antihistamines.

We will of course link to this list in the shownotes.
https://www.pharmacyquality.com/wp-content/uploads/2019/05/Beers-List-350301.pdf

2. STOPP/START
   The STOPP list is of medications that are potentially inappropriate for your elderly patient, categorized by body system affected.
   While the START list is for meds that should be considered for these folks, where there is no contraindication otherwise.

These lists of course can be helpful both when first prescribing for your elderly patient, but also when reviewing their medications annually, or reviewing as a result of changes in their quality of life.

Inform Caregivers of any Medication Changes

This helps to recognize any problems as early as possible and empowers any primary caregivers, including if it is the patient themselves, to be part of their medical care.

Of course if your patient has some memory issues, this should be a safety step to ensure the plan is communicated to those who need to know. That may include homecare or another provider.

Choose Medications with fewer side effects

This is covered by the two common lists that we discussed when reviewing before initiating, or annually.

But we should keep in mind that elderly patients are prone to some common geriatric presentations that can actually be a result of their medications, not just plain old effects of aging:

Stop unnecessary Medications

This is accomplished by regularly doing medication reviews with your elderly patients. Discussing why they are taking a particular medication, and is it still needed?

Consider Medication Impact on their quality of life

Often medications layer onto more medications making things like dry mouth, or lightheadness worse.

Or long term medications mix with the effects of aging and these side effects seem to spring up spontaneously. If they could probably do with a slightly higher sBP in return for less dizzy spells, this could improve life for them quite a bit.

Consider patients ability to take medications

Swallowing difficulties?

Would they benefit from blister packs?

Consider whether there will be a benefit from preventative medications, or whether these should be stopped.

As alluded to, less stringent goals for blood pressure or glycemic control may have quality of life benefits by avoiding the risks like falls or hypoglycemia. However, also consider whether your patient is likely to live long enough to see the benefits from tight control of these things. Your perfectly healthy 75 year old with elevated cholesterol may see the benefit of being on a statin, but your other patient that’s the same age but with a life limiting condition may not.

So looking at Betty with this approach, you note she does have multiple conditions requiring medications, but she doesn’t have any chronic organ failure, and kidneys were last checked 3 months ago and looked good, and no new acute illnesses. You checked her meds against the Beer’s list:

• You’re a kick-ass physician so you have her on Apixaban instead of Warfarin and Beer’s only notes risk if her renal function goes below 25 mL/min.
• The Calcium channel blocker is listed as ‘A’ to avoid in the context of HFrEF. Betty has never shown any signs of HF, with good exercise tolerance, no fluid on the lungs or pedal oedema, so you decide to watch this closely in case.
• For the gout, her colchicine comes with multiple side effects if her renal function goes below 30, and they recommend corticosteroids as an alternate in this case. The allopurinol is not on the Beer’s list and she is happy with the reduced flares since starting this, so you continue this
• Her anxiety med is Escitalopram, and there is a generic risk of SIADH, and anticholinergic effects
• Her sleeping pill is a carry over from her previous GP and is zopiclone. On Beer’s this comes with similar warnings to benzodiazepines A/H avoid and high risk.

you make a reminder for yourself to discuss sleep hygiene and alternate options with her at the next visit and asking around memory, delirium, falls and fractures.

This means asking them at each review appointment if they have started taking any supplements, herbals, vitamins.

In 2017 a systematic review was performed and included 22 studies that reported concurrent use of prescription medicines with herbal medicinal products in adults 65 years and older, they found the most commonly used were “Ginkgo biloba, garlic, ginseng, St John’s wort, Echinacea, saw palmetto, evening primrose oil and ginger.”

They noted that “potential risks of bleeding due to the use of Ginkgo biloba, garlic or ginseng with aspirin or warfarin was the most reported herb-drug interaction. Some data suggest being female, and having a lower household income and less than a high-school education were associated with concurrent use.”
https://pubmed.ncbi.nlm.nih.gov/29196903/

Why don’t we cover some particulars about why we might care about the top couple of them here:

• Ginko Biloba
  Often used for dementia, or memory enhancement based on mixed and inconsistent data. Any effect seen seems to disappear with higher quality studies.
  
  
  • A relative contraindication is with bleeding disorders, or those on anticoagulants or chronic NSAIDs. Of course in this same wheelhouse consider discontinuation perioperatively as well.
    
    Additionally note is made of theoretical MAOi potentiation, and so caution with concomitant SSRI use is suggested.
    
    Also, due to case reports of seizure, it should be avoided with seizure disorders.
    
• Garlic https://www.nccih.nih.gov/health/garlic
  Most often used by patients and marketed for the purported cardiovascular benefits such as hypertension and dyslipidemia.
  
  There is limited evidence that it ‘may’ provide some reduction in LDL for those it is elevated in. Though the effect is quite small and can take 8 weeks to see.

It does not appear to elevate HDL levels.
It also has similarly limited evidence for blood pressure management.

• Safety
  The main one here again appears to be bleeding risk. They recommend caution if you are taking an anticoagulant, or if going for surgery.
  
  • Side Effects
    Bad breath, body odour, heartburn, stomach upset

Lexicomp, if you or your institution have a subscription, also offers an interaction checker tool if you’re concerned about specific herbs and medications.

The main takeaway here is to make you aware of some particulars of the three most commonly used supplements or herbs in the elderly, and what to watch for. It is also to ensure you ask about these things so that you can actually have this discussion and help to avoid side effects or interactions for these patients.

It’s also important to advise them about the lack of regulation on many of these products to illustrate that they likely are not actually getting the dosage listed on the bottle.

This is a great prompt for you to ask Betty about whether she is taking any supplements like this. She admits she normally does not, but her daughter was suggesting she take Ginko daily for the past few months to ward off memory loss.

More tools from the Toronto organization referenced earlier. They have a handy pocket guide that actually comes from the University of Buffalo.

They recommend screening vision with:

•  one quick question “do you have difficulty driving, watching TV, reading or doing your daily activities because of your eyesight?
• If yes to this question, check with a Snellen chart, and then
• a glance at the pupil to assess for leukocoria, aka a white pupil, which would suggest the presence of cataracts, which of course are readily removed.

For hearing:

• Look in the ears, ask them about hearing aid use.
• Get audiometry if you think there is hearing loss, and with this info consider if ENT needs to be involved.

Betty jokes she might have ‘selective hearing’ with her husband, but otherwise no concerns driving including the tractor and she’s been good about wearing ear protection when running the lounder farm equipment.

She notes the same for her vision, no concerns. You glance briefly at her eyes anyways and see no evidence of leukocoria with a nice red reflex bilaterally.

It’s important to recognize that screening of everyone over 65 is NOT recommended to assess for function. However, if there are prompts that make you worry, then it is recommended, such as accessing more and more social resources or supports, recent falls and hospitalizations, etc.

And why do we want to identify which of our patients are frail or becoming frail?

Because they are at increased risk for hospitalizations, loss of ADLs, premature mortality etc.

The gold standard is a Comprehensive Geriatric Assessment, but these are resource intensive and generally done by our fantastic colleagues who specialize in this area. For us, a few areas of screening are more reasonable.

Part of the importance of this is trajectory. As GPs we have the ability to add value of longitudinal assessments. A good record will allow you to catch any loss of function and get them the support they need before it becomes an issue.

So how do we assess function (and standardize our record of it) in the elderly patient?

A commonly used and validated tool for persons over 65 is the clinical frailty score. We’ve attached an image of this scale in the shownotes.

If you have some reading time, the Canadian Geriatrics Journal published a guideline on how to use the frailty score in a clinical setting https://cgjonline.ca/index.php/cgj/article/view/463/577

Luckily they also produced a Ten Top Tips document to help guide appropriate usage of the frailty scale for your elderly patients, a version of which we will link to from Dalhousie University.

**important to note that this is NOT validated for persons under 65 years old, even if living with a disability**

The previous chart we discussed in Objective Three actually also has a quick and dirty for assessing functional status in these folks and it looks like:

• Do they use a device to help with ambulation, such as a cane or a walker?
• Ask if they have had any falls in the past year
• And perform the ‘get up and go’ test. This is done by:
  • Timing how long it takes them to i) get up from the chair ii) walk 3 metres away iii) return to the chair and sit down
  • Anything longer than 10 seconds is considered deficient

Of course we’re all familiar with the ADLs and iADLs and so won’t review them here, just to prompt remember DEATH SHAFT, but these should be reviewed with your elderly patients on a regular basis to help identify any loss of function over time.

For Cognitive function the BC Guidelines suggests starting with the clock drawing test ensuring they can:

• Draw the circle correctly
• Place all twelve numbers
• Space the numbers appropriately
• Put the hands at the suggested time correctly

If any difficulties with this you can plan to have them do either a MoCA or MMSE, and you’ll want to review Delirium by going back and listening again to our prior episode on this.

Those are the biggies to screen for in your patient with symptoms of frailty: cognition, mobility, ADLs and iADLs, vision and hearing. But they do suggest a few other areas you should consider screening for your elderly patient with signs of frailty in the categories of medical, psychological, functional, social, support and safety:

Medical

Immunizations:
considering annual influenza and pneumococcal vaccine, herpes zoster and Tetanus booster. We can also add COVID vaccinations and booster to this now.

Habits:

• Smoking
• Alcohol use
• Other substance use
• Sexual function

Nutrition

• Diet and appetite
• Weight loss
• Obesity
• Dentition
• Swallowing difficulties

Bowel and Bladder

• Any incontinence of either
• Constipation or diarrhoea

Pain

Psychological/Psychiatric

On top of cognition, we need to screen our frail elderly patients for mental health concerns

• Depression
• Anxiety
• Sleep issues

Functional

Falls:

• Fall history
• Fall prevention
• Osteoporosis
• Drugs that can increase risk of falls

Physical activity:

• They should still be encouraged to aim for moderate-vigorous activity on a daily basis

Social

• Hobbies and interests
• Social opportunities
• Spiritual needs
• Isolation or loneliness

Support

• Caregiver stress
• Needs and access to formal support
• Informal support from friends and family

Safety

• Feels safe at home
• Signs of elder abuse
• Financial or legal worries
• Medical equipment and supplies available at home

You ask Betty about her ADLs and iADLs she laughs and says her grandkids are a bit lazy so maybe I should ask them about their function, but that she is still working every day. She admits it takes her a little longer, but she is spreading hay, and feeding the cows just like she ever has. You laugh with her, and plant the seed to make her feel comfortable telling you if anything does change.

Pneumonia

On necropsy reviews, pneumonia was found to be the most frequently missed diagnosis in the elderly. This may be a result of elderly patients showing significantly fewer symptoms with community-acquired pneumonia. This includes less cough, dyspnoea, chills, chest pain, headache myalgia. In the elderly patient, TACHYPNEA with or without shortness of breath was the most reliable sign of an acute pulmonary condition. In fact, the only signs you might get are:

• Altered mental status, confusion, or a sudden decline in functional status with pneumonia in the elderly.

A 2016 paper from Canadian Geriatrics journal postulated a number of reasons why the aging body seems to be more predisposed to pneumonia:

• Decreased chest wall expansion and decreased cough reflex
• Decreased alveolar elasticity
• And increased functional residual capacity, causing collapse of the small airways and resulting air trapping

Click to access Atypical-Manifestations-of-Medical-Conditions.pdf

*its worth mentioning that specific signs and symptoms of infection are just less evident in the elderly population in general, and you might only get general history and exam items like: fatigue, falls, altered mentation, anorexia, incontinence and the like**

Appendicitis

A very recent paper in September 2021 reviewed the literature around appendicitis in the elderly. They found that instances of complicated appendicitis increased with age with good correlation.
A review of the Alvorado score https://www.mdcalc.com/alvarado-score-acute-appendicitis  did find that it was useful in the elderly, but recommended increasing the cutoff score up to five in this population.

Similar to pneumonia, the specific signs we sometimes look for may be less pronounced with the researchers finding “Elderly patients may not have conclusive clinical signs of acute appendicitis, but signs of peritonitis—abdominal distention, reduced abdominal wall movement, severe tenderness, localized and generalized guarding—are more pronounced”

Depression

Of course we won’t recap Depression again, you can review the Depression episode for that.

The fantastic Regional Geriatric Program of Toronto resources simply advise that aside from the usual features of depression we expect to find “Older adults are more likely to report physical symptoms than report feeling sad or “blue”, (e.g. may report aches, pain, and discomfort even though they are being treated for those symptoms).”

Click to access Mental-Illness-and-Dementia-Guide-2nd-ed-Spreads-Digital-1.pdf

• https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/geriatric-medicine
• https://choosingwiselycanada.org/geriatrics/
• https://canadiem.org/approach-to-geriatric-patients/
• https://caep.ca/wp-content/uploads/2016/03/geri_ed_guidelines_caep_endorsed.pdf
• https://www.rgptoronto.ca/wp-content/uploads/2019/07/sfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptx
• https://www.rgptoronto.ca/wp-content/uploads/2018/11/SF7-Toolkit-Polypharmacy.pdf
• https://canadiangeriatrics.ca/wp-content/uploads/2016/11/Polypharmacy-Optimizing-Medication-use-in-Elderly-Patients.pdf
• https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/frailty-full_guideline.pdf