Case Study #2 GUIDING PRINCIPLES FOR THE CARE … PRINCIPLES: THE CARE OF OLDER ADULTS WITH...

25th Annual Fall Symposium - Multimorbidity & The Interprofessional Team - Arizona Geriatrics Society

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Case Study #2 GUIDING PRINCIPLES FOR THE CARE

OF OLDER ADULTS WITH MULTIMORBIDITY

Panel Moderator & Panelists:

Edward Perrin, MD

Banner iCare

Scott Bolhack, MD, MBA Sandra Brownstein, PharmD Paige Hector, LMSW TLC HealthCare Companies United Healthcare Community Plan Page Ahead Healthcare Education & Consulting

DISCLOSURE OF COMMERCIAL SUPPORT

Scott Bolhack, MD, MBA, Paige Hector, LMSW and Edward Perrin, MD do not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation Sandra Brownstein, PharmD is an employee of United Healthcare.

Learning Objectives:

Develop an approach by which clinicians can care optimally for patients with multimorbidity.

Incorporate elements from five primary domains while providing care for older patients with multimorbidity.




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GUIDING PRINCIPLES: THE CARE OF OLDER ADULTS WITH MULTIMORBIDITY

Edward Perrin, MD

Scott Bolhack, MD

Sandra Brownstein, PharmD

Paige Hector, LMSW

Fall Symposium – Arizona Geriatrics SocietyNovember 9, 2013

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Domains

5 Domains that govern approach to older patients with multimorbidity

Can be applied in any order1. Patient preferences

2. Interpreting the evidence

3. Prognosis

4. Clinical feasibility

5. Optimizing therapies and care plans

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Limitations

Time-consuming

Fear of litigation

Changing landscape Clinical

Regulatory

Social

Treatments/decisions contradict one another

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PROGNOSIS

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PROGNOSIS (cont.)

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Algorithm

1. Inquire about the patient’s primaryconcern, and any additional objectives

2. Conduct complete review of care plan OR focus on specific aspect of care plan

3. Identify current medical conditions and interventions; review adherence and comfort issues

4. Consider patient preferences5. Identify relevant evidence for

important outcomes6. Consider prognosis

6. Consider interactions within and among treatments and conditions

7. Weigh benefits and harms of all elements of treatment plan

8. Decide and communicate about decision(s)

– Implementation/withholding

– Continuation/discontinuation

10. Reassess at regular intervals

– Benefits

– Feasibility

– Adherence

– Alignment with preferences

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4

Algorithm

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Case of Frieda Kaplan

72 year-old female Divorcee Accompanied by daughter Lives alone in apartment Limited income Requires daily assistance with IADLs

Independent in ADLs, but does use walker Frequent falls

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Algorithm

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Case of Frieda KaplanPatient’s Primary Concern and Objectives

Patient has heard of osteoporosis and is worried

Daughter worried that patient is “slipping”

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanComplete Review of Care Plan & Diagnoses

• Moderate-severe COPD– Tobacco use

• h/o TIAs with hospitalizations for suspected CVAs– MRI evidence of lacunar infarcts

• Peripheral vascular disease– Carotid stenosis with subclavian steal syndrome

• Hiatal hernia• Major depression

– h/o suicide attempt following divorce

• Mild cognitive impairment• Hyperlipidemia

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Case of Frieda Kaplan Complete Review of Medical Data

MMSE 22/30

FEV1/FVC 60% predicted

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Case of Frieda Kaplan Complete Review of Medical Interventions

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanAdherence & Comfort

Sometimes forgets appointments

Has difficulty keeping track of medications When adherence is raised, patient says “I take too

many medications anyway…”

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanPatient Preferences

Stay in apartment with ongoing assistance Daughter does visit 2-3x/month, though agrees patient

needs more oversight Resources are limited

Daughter worried that patient’s abilities are more limited

Everyone prefers simpler regimens

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanRelevant Evidence for Important Outcomes

Prevention of hip +/- vertebral fractures: Maintain quality of life

Maintain independent living

Decrease costs

Ca/D, weight bearing exercise, balance training, fall prevention interventions all can reduce risk of fractures

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Case of Frieda KaplanRelevant Evidence for Important Outcomes

FRAX calculation for 10-year osteoporotic fracture risk – 12% for any, 3% for hip

Benefit: bisphosphonates reduce fracture risk by 50% over 3 years 4% risk of fracture over next 3 years Reduced to 2% with medication with benefit starting 9-

18 months after initiation

Risk: bisphosphonates can aggravate hiatal hernia, require high adherence, other medical complications

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanPrognosis

64% risk of dying in 4 years

30% risk of dying in 15 months

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GROUP DISCUSSION

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Algorithm

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Case of Frieda Kaplan Medication Interactions

Clopidogrel ↔ escitalopram may↑bleeding risk

Esomeprazole may reduce efficacy of clopidogrel

Esomeprazole (all PPIs) reduce calcium absorption

Escitalopram (all SSRIs) increase fracture risk

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanBalance of Benefits and Harms

Benefits of oral bisphosphonate therapy likely outweighed by likely poor adherence and poor cognition

IV bisphosphonate therapy likely unaffordable Newer anabolic agents also likely unaffordable

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanDecide and Communicate

Trade-offs inevitable Fracture prevention is laudable goal – hip

fracture may be devastating (clinically, socially, financially) Absolute risk reduction is small, however Prognosis may be limited Treatment is complicated and/or expensive

Risks outweigh benefits Opt against medical therapy Can opt for Ca/D and weight-bearing exercise

Can defer DEXA testing

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GROUP DISCUSSION

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Algorithm

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Case of Frieda KaplanReassess at Regular Intervals

Benefits

Feasibility

Adherence

Alignment with goals/preferences

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Algorithm

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Conclusions

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GUIDING PRINCIPLES: THE CARE OF OLDER ADULTS WITH MULTIMORBIDITY

Edward Perrin, MD

Scott Bolhack, MD

Sandra Brownstein, PharmD

Paige Hector, LMSW

Fall Symposium – Arizona Geriatrics SocietyNovember 9, 2013

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Case Study #2 GUIDING PRINCIPLES FOR THE CARE … PRINCIPLES: THE CARE OF OLDER ADULTS WITH...

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