Co-morbidity: assessing the patient with complex needs

1. Co-morbidity: assessing the patient with complex needs Dr Ninian Hewitt General Practitioner Dr Jackie Taylor Consultant in Physician Department of Medicine for the Elderly Glasgow Royal Infirmary Respiratory MCN Learning Forum 03/09/10

2. The next 90 minutes.....

3. Outline of the session • What are the common co-morbidities in respiratory disease? • Illustrative INTERACTIVE case studies • A framework for assessment

4. Background • COPD Prevalence 2-4% of the population • Prevalence rises with age • 1 in 8 emergency admissions to hospital • 1 million bed days • 30,000 deaths each year, 90% in >65 years • 5th leading cause of death in UK • As population ages, increasing prevalence/mortality predicted

5. Common co-morbidities • Cancer-lung • Cardiovascular disease • Cachexia/obesity • Metabolic syndrome • Musculoskeletal abnormalities Co-morbidities cluster • 50% of >65 years have 3 chronic conditions • 20% of > 65 years have 5 chronic conditions

6. What causes co-morbidity? • Common risk factors eg smoking • Ageing-cumulative cell damage and defects • Cigarette smoke causes lung and systemic inflammation, systemic oxidative stress, marked changes of vasomotor and endothelial function and enhanced circulating concentrations of pro-coagulant factors and cytokines

7. Case study 1 • 68 year old female • 3 day Hx increasing dyspnoea, mild ankle swelling, cough with mildly purulent sputum • Background of IHD, previous PTCA, Type 2 diabetes, Hypertension, osteoarthritis, COPD • Drug Hx: Aspirin, Simvastatin 40mg, Atenolol 25mg bd, Amlodipine 5mg Gliclazide 80mg bd, Diclofenac 75mg bd, Cocodamol, Salbutamol inhaler prn, Tiotropium inhaler 18mcg nocte, serevent 125 I puff bd • Lives alone, housebound, ex smoker, mobile with stick, HH twice weekly Thoughts?

8. Case study 1 Examination findings: • SOB at rest RR 24/min, temp 37.2 • Sats 90% on air • Pulse 96, BP 124/78 • Bilateral varicose veins, pitting oedema to lower shin, JVP elevated 1cm • HS 1 and 2 • Hyperinflated chest, mild wheeze bibasal crepitations

9. Hb 107, MCV 74 WBC 11.6, • urea 10.2, creat 136 (eGFR 42), normal LFTs, TFTs, Ca/Po4 • Blood glucose 10.2 Thoughts?

10. Working diagnosis “acute infective exacerbation of COPD” • Management Nebulised Salbutamol 28% Oxygen Prednisolone 40mg Amoxycillin 500mg tds 1 bolus IV Frusemide 50mg • Other diagnoses: • Probable iron deficiency anaemia • Chronic renal impairment Following day, “much improved” Plan home with ESD Check Haematinics and OP Ix

11. Old notes arrive • 3rd such admission in 6 months • Evidence of infection unconvincing Thoughts? Mild LVH, mild/moderate LVSD with inferior WMA, Ejection fraction 38%, mild MR

12. Revised diagnosis • Decompensated heart failure • Aetiology -IHD • Precipitant-anaemia+- infection Management • Regular oral frusemide 40mg • Stop diclofenac • Initiation of Ramipril 2.5mg • Switch atenolol to bisoprolol • Refer Heart Failure specialist nurses for education, disease management, uptitration • OP Ix anaemia

13. Unrecognised HF in COPD Rutten FH et al Eur. H Journal 2005;26,1887-1894

14. Prevalence and incidence of COPD in Heart Failure population NM Hawkins et al Eur J Heart Failure 2010;12:17-24

15. NM Hawkins et al Eur J Heart Failure 2010;12:17-24

16. NM Hawkins et al Eur J Heart Failure 2010;12:17-24

17. All patients with heart failure due to left ventricular systolic dysfunction of all NYHA functional classes should be started on beta blocker therapy as soon as their condition is stable(unless contraindicated by a history of asthma, heart block or symptomatic hypotension). • Bisoprolol, carvedilol or nebivolol should be the beta blocker of first choice for the treatment of patients with chronic heart failure due to left ventricular systolic dysfunction.

18. Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, Including: • – older adults and • – patients with: • PVD, interstitial pulmonary disease, erectile dysfunction, diabetes mellitus, COPD (without reversibility) • Switch stable patients who are already taking a beta-blocker for a comorbidity to a beta-blocker licensed for heart failure

19. Chronic lung disease • COPD often misdiagnosed as HF • HF often misdiagnosed as COPD • Frequently co-exist, relative contributions important • 10-46%of patients with COPD have LVSD • Reluctance to prescribe B –blockers • But no absolute contraindication if no reversibility ARB CCB EuroHeart 2 EHJ (2003)24,464-75

20. Case study 2 82 year old female • Admitted with a fall, back and hip pain, confusion • Unintentional overdose of theophylline • Background of deteriorating mobility and increasing confusion for 4 months • Past history of falls, osteoporosis, previous fracture NOF, IHD, gastritis, stroke, COPD • Drug history-Adcal D3, Risedronate, cocodamol, aspirin, atenolol, simvastatin, omeprazole, dipyridamole retard, bendrofluazidesalbutamol and tiotropium inhaler.

21. Case study 2 Examination findings • Frail, dehydrated, disorientated, AMT 6/10 • Soft tissue injury to head, temp 37.2, O2 sats 90%, pulse 120, BP110/76, soft ESM • Reduced range of movement L hip • Chest wheezy • Suprapubic tenderness • Mild R weakness • Thoughts? Results WCC 12.2 Na 127 Urea 13.7, Creat 145, eGFR 32ml CRP 47 Adjusted Ca 3.03 Urinalysis +ve Toxic theophylline level

22. Case study 2 ECG CXR

23. Case study 2 Problem list • Underlying sepsis • Dehydrated/renal impairment • Hypercalcaemic/hyponatraemic • Theophylline toxic • Confusion and focal neurological signs (?duration) Thoughts?

24. Case study 2 Management • Treat UTI/LRTI • Rehydration • Monitor Ca/Na • ? IV Pamidronate • Nebulised Salbutamol Further Investigations? • Further history/information from family • MSSU/sputum cultures • Urine/plasma osmolality • CT chest/abdomen • CT brain • Bone scan • Myeloma screen

25. CT results

26. Progress Further background • Slow progressive decline in mental state over 12-18 months • Difficulty cooking • Increasing dependence on family • Poor drug adherance • Weight loss • Frequent falls • Housebound • GP and DNs concerned • Inflammatory markers settle • Renal function improves to baseline • Ca falls following rehydration • Confusion improves dramatically

27. What next? • Referral to Respiratory Physicians • Multidisciplinary assessment

28. Physiotherapy Transfers/mobility Muscle strengthening balance stairs Occupational therapy ADLs-personal care Bathroom/kitchen Cognitive assessment Home assessment visit Old Age Psychiatry Diagnosis CPN Patient Social Work Day care Home care

29. Outcome Diagnoses UTI Infective exac COPD Hypercalcaemia secondary to Adcal Hyponatraemia secondary to omeprazole Acute on chronic renal failure secondary to sepsis and dehydration Falls secondary to muscle wasting, osteoporosis, old stroke, previous NOF Delirium secondary to metabolic upset and sepsis Mixed vascular /Alzheimer’s dementia Osteoporosis Possible lung cancer Discharged home: • Mobile with ZWA/AMT 9 • New equipment • Multidisciplinary outreach team • Homecare support • Locked box for medication • Rationalisation of drugs • Day care • CPN follow up • Respiratory follow up

30. What is Comprehensive Geriatric Assessment (CGA)? A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow up • Improves survival at one year • Reduces need for institutional care • Improves physical and cognitive functioning Ellis G Langhorne P British Med B 2005;71

31. How is CGA delivered? • Coordinated multidisciplinary assessment process • Identification/documentation of medical, functional,social,psychological problems • Development of a plan of care including appropriate rehabilitation • Formation of patient-centred goals • Regular multidisciplinary review of progress/goals • Discharge planning Ellis G Langhorne P British Med B 2005;71

34. The complex patient • Full assessment and documentation of problems • Prioritise • Optimise • Compromise