Common Mistakes in Geriatrics

1. Common Mistakes in Geriatrics Timothy R. Malloy, M.D.

2. Overview • Ample personal experience with making geriatric mistakes • polled 10 geriatricians/geriatric psychiatrists • “Top 20” mistakes but not in order of importance or frequency • alternative approach offered

3. #1. “My doctor told me it was because I was old”

4. #1. “My doctor told me it was because I was old” • Not true for most conditions • Conveys message that patient is no longer important enough to bother with • Is not therapeutic in any way • Viable therapeutic options go overlooked

5. #2. Talking to the daughter (ignoring the patient)

6. #2. Talking to the daughter (ignoring the patient) • Insensitive, degrading • Very commonly done in patients with hearing impairment, visual impairment, and especially cognitive impairment • Sometimes difficult to avoid • Be “on guard” and situate family and patient directly across from yourself so that both can see and hear you at the same time

7. #3. Seeing Nursing Home Patients in the Office

8. #3. Seeing nursing home patients in the office • Artificial environment of office • No collateral sources of information available (see #5) • Better seeing patients in their own environment • More efficient in nursing home • More cost-effective in nursing home (zero overhead)

9. #4. Seeing Nursing Home Patients Without a Nurse

10. #4. Seeing nursing home patients without a nurse • Nursing input is critically important (especially in this population) • 10 lb. charts - very difficult to discover information • Direct communication with nursing staff: • cuts down phone calls • improves coordination of care plan • allows opportunity for teaching (both ways)

11. #5. Making Nursing Home Rounds on Your “Day Off”

12. #5. Making Nursing Home Rounds on Your “Day Off” • Makes NH rounds into chore that interferes with personal time • Rounds should be scheduled during routine M-F work hours • Weekly for 1 hour is better than monthly for 4 hours

13. #6. Delayed Diagnosis of Dementia

14. #6. Delayed diagnosis of dementia • Dementia symptoms are usually present for 3 years before diagnosis • Over 50% of the 5 million people with dementia are undiagnosed • Always better to have the problem identified

15. #6. Delayed diagnosis of dementia • Compliance with medications and appointments • Unreliable symptom reporting (undetected, treatable medical conditions) • Safety issues, auto accidents, environmental exposure • Financial victimization • Social isolation and neglect (until crisis situation) • Missed opportunity to begin treatment at early stage

16. #7. Failure to Treat Dementia

17. #7. Failure to treat dementia • Cholinesterase inhibitors help • Cholinesterase inhibitors help cognition, preserve function, delay institutionalization, and lessen behavioral complications • Not using MMSE to help decide efficacy

18. #8. First Line Treatment of Agitation with Benzodiazepines in Patients with Dementia Related Behavioral Disturbances

19. #8. First line treatment of agitation with benzodiazepines in patients with dementia related behavioral disturbance • Seldom the most appropriate treatment • Unfavorable risk : benefit ratio • Need to determine the specific target symptom and tailor treatment to that symptom • examples: psychosis - antipsychotic, e.g. Zyprexa mood lability - mood stabilizer, e.g. Depakote depression - antidepressant, e.g. Zoloft

20. #9. PRN Analgesics for Dementia Patients

21. #9. PRN analgesics for dementia patients • Memory problems usually result in underdosing • Frequently have to “play catch-up” • Routinely schedule analgesics more effective

22. #10. Sensory Deprivation Masquerading as Dementia

24. #10. Sensory Deprivation Masquerading as Dementia • Severe hearing impairment - “irrelevant” responses to questions • Visual impairment - failed MMSE, visual hallucinations (Charles Bonet syndrome)

26. #11. Failure to Rule Out Organic Causes Masquerading as Depression

27. #11. Failure to rule out organic causes masquerading as depression • Should check TSH before treating depression • Remember medication side effects (Beta blockers, Digoxin, benzodiazepines….) • Inadequate pain management • Parkinson’s Disease, Thyroid Disease, Cognitive failure

28. #12. Polypharmacy

29. #12. Polypharmacy • Elderly receive 3Xs as many meds as young people • Elderly are less capable of “handling” medications as younger people • “Art” of recognizing medication side effects • Many examples such as cognitive SEs, EPSEs, Appetite SEs….

30. #13. Continuing Elavil When Neurologists and Rheumatologists Place Your Patients on it

31. #13. Continuing Elavil when neurologists and rheumatologists place you patients on it • Still commonly prescribed • Almost never appropriate (2nd generation TCAs better tolerated) • Highly anticholinergic • The older the patient, the more likely to be a problem • “dead give away” that you’ve never taken a course in geriatrics in the last 20 years

32. #14. Demerol as Acute Analgesic

33. #14. Demerol as Acute Analgesic • Usually causes confusion (delirium) • Several safer alternatives

34. #15. Benadryl for Insomnia

35. #15. Benadryl for Insomnia • Impairs cognition (even in younger adults) • Beware of many OTC medications such as Tylenol PM • Better alternatives available

36. #16. No Osteoporosis Treatment with Obvious Disease

37. #16. No osteoporosis treatment with obvious disease • Never too old to benefit from osteoporosis treatment • Approximately half of all hip fracture patients are on no treatment • Calcium, Vitamin D, antiresorptive agent?

38. #17. NSAIDs/COX-II Inhibitors as First and Only Treatment of Osteoarthritis

39. #17. NSAIDs/COX-II inhibitors as first and only treatment of osteoarthritis • Expensive • Numerous side effects • Patients often remain on NSAIDs for years • Many potentially better alternatives such as Acetaminophen, physical therapy, corticosteroid injections, opioids

40. #18. Mistaking Delirium for a Primary Psychiatric Diagnosis

41. #18. Mistaking delirium for a primary psychiatric diagnosis • UTIs as frequent cause of admission to geripsych. Hospital • Cause of delirium almost always “lies outside the brain” • Most common presenting symptom is fluctuating levels of alertness and confusion

42. #19. Delaying Hospice and Palliative Care

43. #19. Delaying Hospice and Palliative Care • Avoiding serious end-of-life discussion in patients with advanced irreversible conditions (AD, COPD, CHF) • Early discussion is often welcome • Prevents unnecessary procedures, hospitalizations, suffering, and expenditures

44. #20. Failure to Factor Life Expectancy into Medical Decision Making

45. #20. Failure to Factor Life Expectancy into Medical Decision Making • HCM (paps, mammography, PSA, colonoscopy) • Hyperlipidemia management • Anticoagulation for atrial fibrillation