Geriatric Times - Cleveland Clinic...geriatric care can be difficult; as always, we are happy to...

Ensuring Effective Care for Older Adults with COPD Understanding cost and treatment limitations p 6

Geriatric TimesAn Update for Physicians from Cleveland Clinic’s Medicine Institute | Spring 2014

Evaluating Safety, Outlook in Patients with Dementia

p 3

Tailoring Treatment for Patients with Diabetes

p 8

Assessing and Treating Pressure Ulcers

p 11

Addressing Challenging

Hypertension

p 13

ALSO IN THIS ISSUE

91755_CCFBCH_ACG.indd 1 4/16/14 11:05 PM

Dear Colleagues:In each issue of Geriatric Times, it is my distinct pleasure to highlight different Cleveland Clinic specialties that help our Center for Geriatric Medicine fulfill its mission to improve care for the oldest and frailest members of society.

Our center serves as a central resource for physicians, nurses, therapists, social workers and other providers across Cleveland Clinic’s eight hospitals and 16 family health centers, coordinating and participating in clinical, educational and research programs.

In this issue, we focus on the efforts of our specialists to keep older patients as healthy and active as possible in the face of chronic diseases such as:

• Diabetes: Dr. Vinni Makin explains that HbA1c targets should be adapted with age and function in mind, especially for those who are frail.

• COPD: Dr. Loutfi Aboussouan reviews options for preventing exacerbations and maintaining quality of life in older patients.

• Hypertension: Dr. Leslie Wong demystifies blood pressure treatment goals for elderly patients.

We also address two issues affecting many elderly patients:

• Dementia: Social worker Rosemary Truchanowicz offers insights on evaluating outlook on life and the support network for aging patients.

• Pressure ulcers: Dr. Stephen Schwartz, who (among other duties) guides the Connected Care wound team in managing post-acute patients, offers practical advice on assessment and care.

Finally, we profile an active 92-year-old man who, grateful for cardiac and pulmonary care at Cleveland Clinic, decided to “give back” by sharing his insights as a dementia caregiver with internal medicine residents.

These articles represent a small sample of the work we do every day to help make a difference in the quality of our patients’ lives.

We understand that deciding where to send patients requiring comprehensive geriatric care can be difficult; as always, we are happy to offer our input and to work in partnership with you.

Please don’t hesitate to contact me with any questions, concerns or suggestions on how we might improve our services to you and your patients at 216.444.6801 or [email protected].

Kind regards,

Barbara Messinger-Rapport, MD, PhD, FACP, CMD

Director, Center for Geriatric MedicineCleveland Clinic Medicine Institute

Medical Editor Barbara Messinger-Rapport, MD, PhD

Managing Editor Cora M. Liderbach

Art Director Anne Drago

Cover Photo Tom Merce

Illustrations Joe Pangrace

Geriatric Times is published by the Center for Geriatric Medicine in Cleveland Clinic’s Medicine Institute. The institute also encompasses Family Medicine, Internal Medicine, Infectious Disease, Primary Care Women’s Health, and one of the nation’s largest Hospital Medicine programs. Primary care providers within the institute use the patient-centered medical home model to coordinate basic, chronic and complex care for patients at the main campus and 16 family health centers.

The Medicine Institute is one of 27 institutes at Cleveland Clinic, a nonprofit academic medical center ranked among the nation’s top hospitals by U.S. News & World Report. More than 3,000 physicians and researchers in 120 specialties at Cleveland Clinic collabo-rate to give every patient the best possible outcome and experience.

Geriatric Times is written for physicians and should be relied on for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient.

© 2014 The Cleveland Clinic Foundation

Geriatric Times Spring 2014

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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e

Evaluating Older Patients with Dementia Part 2: Assessing Outlook on Life and Support Network

By Rosemary Truchanowicz, MSW, LISW-S, C-SWHC

OUTLOOK ON LIFE

Sixty percent of older adults who take their own lives see

their primary care physician within a few months of their

death. Educating members of the patient’s social support

network about suicide prevention and warning signs is

imperative. Older adults may not have been at high risk for

suicide in the past, but aging, eroding health and deterio-

rating coping skills can change that.

Assess suicide risk. Although older adults attempt suicide

less often than younger adults, their completion rate is

higher (American Association of Suicidology, 2012). Non-

Hispanic white men 85 or older have the highest death

rate. According to the Substance Abuse and Mental Health

Services Administration (SAMHSA), older people who

attempt suicide are more frail, more isolated, more likely

to have a plan and more determined than younger adults.

(See box on suicide risk factors on page 4.)

Ask about weapons in the home. The most common means

of suicide in older adults involves firearms (followed by

poisoning and suffocation). Older adults are nearly twice

as likely as people under age 60 to commit suicide using

firearms. Guns should be locked separately from ammuni-

tion at all times, and patients with dementia should not

have access to either.

Assess homicide risk. Asking whether anyone is bothering

an older adult may reveal paranoid ideation not otherwise

evident. One older adult, complaining that an upstairs

tenant listened to her conversations through heating

ducts and made noise to annoy her, said she intended to

use her deceased husband’s gun to protect herself if he

came near her.

Screen for depression. Routine screening of all older

patients for depression is recommended because depres-

sion raises risks of suicide and homicide. A more thorough

evaluation, a safety plan and possible admission may be

required if older adults seem depressed, agitated or restless.

Ask patients with mild dementia if they are responsible for

other family members. Caring for an adult child with

a disability, for grandchildren or for great-grandchildren

can lead to increased agitation, guilt and despondency.

Consider caregivers’ outlook. Attending to both caregiv-

ers’ and older adults’ emotional well-being is crucial to

prevent homicide and suicide. Family members may vastly

underestimate the care an older adult requires. They may

suffer under the weight of responsibility, or feel guilty or

hopeless. Overwhelmed caregivers need to know what

to monitor and report so that practical interventions or

referrals to appropriate agencies can be implemented in a

timely way. During a crisis, they will need to be relieved of

caregiving responsibilities and will require support. Long

before a crisis occurs, have them develop an emergency

plan for contacting social service resources or respite care

facilities on short notice.

SUPPORT NETWORK

It’s important to review older adults’ family and support

systems in detail. A thorough understanding of who pro-

vides care, and the type and frequency provided, is critical.

Ask why the family is not involved. One-third to one-half of

all patients with dementia have no identifiable caregiver.

If the family is not involved in an older patient’s care, con-

sider whether a drug or alcohol problem or mental health

disorder may have caused the estrangement.

Educate the family. Family members may need education

about the best environment for older adults with cogni-

tive impairment. For example, playing loud, jarring music

may overstimulate older adults, who may prefer calming,

Older adults with dementia and their caregivers may face gradual or precipitous changes in personality, cognition and

functioning. To prevent adverse incidents, we recommend assessing function in three areas: Self-Care, Outlook on

Life and Support Network (SOS). In our last issue, we addressed self-care. In this issue, we explain how understanding the

patient’s outlook on life and support support can help prevent suicide, homicide, abuse and exploitation.

3


G E R I AT R I C T I M E S | S P R I N G 2 0 1 4

spiritual music. Watching a movie with scenes of war or

violence may frighten older adults with dementia because

they may think it is happening now.

Consider family abuse/neglect. Unfortunately, the most

likely perpetrators of abuse, exploitation and neglect of

older adults are in fact close family members. Unusual

answers from older adults questioned about abuse or

neglect may be real — or the result of paranoid thinking

not evident to others. Be sure to take time to assess the

feasibility of patients’ concerns.

Older adults are at risk of financial exploitation and

medication diversion. Ask patients if family members or

acquaintances ask them for money or gifts — or if they

give medications to family members who don’t have insur-

ance or can’t afford to buy them.

Consider exploitation by others. Older adults are also vul-

nerable to exploitation from paid caregivers, neighbors or

acquaintances who may seem charming. Deceitful caregiv-

ers may gradually increase older adults’ dependence on

them, take over their finances, isolate them and provide

self-serving information to family and healthcare providers.

Caregivers may portray the family in a negative light,

brainwashing older adults to bond with them. Even

when questioned privately, older patients may deny they

are being exploited. Discerning which family members

and friends visited or helped the older adult before the

caregiver became involved — and finding a plausible

explanation for their absence — is crucial.

If you find yourself questioning whether caregivers have

older adults’ best interests in mind, consider report-

ing the situation to Adult Protective Services for further

investigation. n

Ms. Truchanowicz, of Cleveland Clinic’s Ob/Gyn & Women’s Health Institute, can be reached at [email protected] or at 216.445.8701.

Evaluating Older Patients with Dementia continued

Risk Factors for Suicide

SAMHSA lists the following as risk factors for suicide in older adults:

• Depression

• Prior suicide attempts

• Marked feelings of hopelessness

• Comorbid general medical conditions that significantly limit functioning or life expectancy

• Pain and declining role function (e.g., loss of independence or sense of purpose)

• Social isolation

More specific risk factors for suicide in older adults include:

• Loss of a close relationship or a move from a long-standing residence

• Acute stressors such as a new diagnosis

• Misuse/abuse of alcohol or medication

• Sleeping more or less than usual

• Impulsivity in the context of cognitive impairment

4

91755_CCFBCH_ACG.indd 4 4/11/14 12:40 AM


Monroe Messinger was in his 20s and part of the

U.S. Army Corps of Engineers when he was tapped

for The Manhattan Project. Today he’s the last surviving

member of J. Robert Oppenheimer’s team. The retired

chemical engineer continues to fascinate listeners with

stories of his years in Los Alamos, N.M., before and after

the atomic bomb.

After World War II, Mr. Messinger settled into civilian life. He became a successful analytical research director at Chesebrough-Ponds (now Unilever). He and his wife traveled extensively throughout Europe. He loved motorcycles and rode with a motorcycle club well into his 70s.

Now 92, Mr. Messinger still leads an extraordinary life. A pacemaker, cardiac stents, hip replacement, COPD and gastrointestinal issues haven’t sidelined him.

STAYING MOBILE AND INDEPENDENT

“Mr. Messinger is a highly intelligent, conscientious and motivated man,” says Cleveland Clinic geriatric specialist Ronan Factora, MD. “He is focused on maintaining his independence and on being a dedicated spouse.”

Despite an extensive cardiac history and underlying pulmonary problems, Mr. Messinger’s quality of life is excellent. One reason is his participation in the PARTNER (Placement of Aortic Transcatheter Valves) trial. Dr. Factora recommended him for the trial comparing minimally invasive to surgical aortic valve replacement.

Participation in pulmonary rehabilitation, which combines exercise training with counseling and education, has also made a difference. Mr. Messinger no longer gets as breathless as he used to, and has not developed any infections, or required hospitalizations or steroids.

“Mr. Messinger’s age could have been a barrier for him to receive these interventions,” notes Dr. Factora. “But considering how much his medical conditions affected his quality of life, how sharp his mind was and how preserving his independence was the primary goal, our

CASE STUDY:

Maintaining an Extraordinary Life

medical team devised a plan that made these outcomes possible. Mr. Messinger’s case is an example of how age shouldn’t be the only factor in treating geriatric patients.”

GOING STRONG

Although he requires portable oxygen, Mr. Messinger wants to keep moving. In his twice-a-week exercise class at the VA hospital, he walks on a treadmill, uses a recumbent cross-trainer and lifts weights — and he uses a cross-trainer at home.

The exercise keeps him as able-bodied as ever. Mr. Messinger continues to be a caregiver for his wife, who has dementia. He’s eager to talk about the condition from a caregiver’s perspective, and thinks it is important to do so.

He shared his experiences and insights in presentations to Cleveland Clinic internal medicine residents in 2013.

“Doctors should talk to patients and their caregivers separately,” Mr. Messinger advised the group. “Caregivers can’t always say things candidly in front of the patient, particularly about dressing, incontinence and other sensitive issues.”

Caring for a loved one with dementia does cause tension, says Mr. Messinger. But he takes it in stride — it’s real life, he says.

And for Mr. Messinger, real life is still going strong. n

5


COPD in the Elderly: Diagnostic and Management Challenges Understanding cost and treatment limitations

By Loutfi S. Aboussouan, MD, and Barbara Messinger-Rapport, MD, PhD

After a decade of large, well-designed trials, it appears that current chronic obstructive pulmonary disease (COPD)

management strategies may improve outcomes such as dyspnea and quality of life, reduce exacerbations and

perhaps increase survival.

Yet physiological aging makes the accurate diagnosis of

COPD challenging, as does the increased rate of adverse

medication effects in older adults. Physical challenges and

the growing recognition of substantial cognitive impair-

ment among elders with COPD pose additional problems.

A SEVERE BURDEN ON THE ELDERLY

COPD affects more than 14 million Americans, and hos-

pitalizations related to COPD increase with age — from

40.2 per 10,000 for ages 55 to 64 to 131 per 10,000 for ages

75 and older.1 Further, mild cognitive impairment, in 36

percent of COPD patients vs. 12 percent of controls, is asso-

ciated with worse health status and a longer hospital stay.2

Diagnostic standards supporting a fixed FEV1/FVC <0.70

for COPD may lead to overdiagnosis in the elderly. The

FEV1/FVC for healthy never-smokers decreases with age;

35 percent of those over age 70 and 50 percent of those over

age 80 have an FEV1/FVC < 0.7.3 Thus, clinical context must

be considered along with spirometric results.

TWO VACCINES MAY HELP

Ninety-five percent of influenza deaths occur in patients

over age 60.4 In elderly patients with chronic lung disease,

influenza vaccination reduces hospitalizations due to

exacerbations 52 percent and risk of death 70 percent.5

High-dose vaccines are associated with a higher antibody

response, although local reactions may be more frequent.

(Preliminary results of a Phase 3 trial show that in older

adults, high-dose vaccines may reduce influenza risk 24

percent more than the usual dose, but 200 patients must be

treated in order to prevent one case.) More data is needed on

the best candidates for the new vaccines.

Pneumococcal vaccination does not reduce hospitaliza-

tions or mortality, but when combined with influenza

vaccination may reduce infectious acute exacerbations,

hospitalization and risk of death in the first years after

administration.6 Vaccination is recommended for patients

65 and older or who have COPD; revaccination is not

needed.

MEDICATION COST MATTERS

The medical management of COPD relies heavily on

inhaled medications, with generic alternatives available

only for a few nebulized treatments. The expense can

be substantial; common medication combinations cost

several thousand dollars per year. Elderly COPD patients

whose out-of-pocket inhaler costs exceed $20 per month

are at higher risk of medication non-adherence.7

There are no easy solutions for physicians, except to:

• Ask patients whether medication expense may be the

cause of non-adherence


COVER

STORY

6


COPD in the Elderly: Diagnostic and Management Challenges Understanding cost and treatment limitations

By Loutfi S. Aboussouan, MD, and Barbara Messinger-Rapport, MD, PhD

• Consolidate medications when possible

• Direct patients to assistance programs as needed

• Consider generic nebulized alternatives, which are

80 percent reimbursed under Medicare Part B

EASE OF USE A KEY FACTOR

The success of inhaled devices depends largely on

ease of preparation, simple instructions and lung deposi-

tion rates. Pressurized metered-dose inhalers are easy

to prepare but hard to inhale correctly, whereas hard-to-

prepare nebulizers are easy to inhale correctly.

Lung deposition rates may also vary by device and are gener-

ally lower in nebulizers. Sixty percent of patients 65 and older

use dry powder inhalers correctly, compared with 25 percent

who are 80 and older.8 Newer devices requiring fewer steps

prior to inhalation and no coordination between inspiration

and actuation may be easier to use correctly.

Devices should be chosen based on patient age, capabil-

ity and preference; third-party payer coverage; physician

comfort with teaching inhalation techniques; convenience;

and portability.

SIDE EFFECTS HIGHER IN ELDERLY

Pharmacodynamic and pharmacokinetic changes, comor-

bidities and the potential systemic effects of inhaled

medications help to contribute to increased side effects

for elderly patients using respiratory medications.

The adverse effects of beta-adrenergic agonists include

arrhythmias, ischemia, tremors and osteoporosis. (An

increased risk of arrhythmia with new use of a long-acting

beta agonist reported in a large case-control study of COPD

patients 67 or older was found to be insignificant after

patients with a history of arrhythmia or heart failure

were excluded.) 9

The potential adverse effects of anticholinergic agents

such as ipratropium and tiotropium include dry mouth,

confusion and urinary retention. Inadvertent eye contact

(especially with nebulizers) may cause pupillary dilatation

and precipitate acute glaucoma. Despite initial cardio-

vascular concerns, the large UPLIFT (Understanding

Potential Long-term Impacts on Function with

Tiotropium) trial found no increase in strokes, heart

attacks or cardiovascular deaths.10

ADDITIONAL CONSIDERATIONS IN FRAIL ELDERS

Beta blockade: Uncertainty about using beta blockers in

COPD patients continues, mainly due to concerns that

the drugs might induce bronchospasm and worsen lung

function. Yet emerging evidence suggests that beta block-

ers may be associated with reduced mortality in COPD.

Cardioselective beta blockade need not be withheld from

patients with COPD who have cardiovascular disease if

they are monitored for adverse effects.

Cognitive impairment: Older adults may underuse inhal-

ers and cause recurrent COPD exacerbations or overuse

inhalers and increase risks of adverse effects. Prescribing

a simple regimen and recruiting a family member to

supervise medication may be the keys to compliance.

Osteopenia and osteoporosis: Older adults are more likely

to have these conditions, which can be accelerated by

inhaled beta agonists and/or steroids. Compliance with

bone-density screening recommendations and treatment of

osteoporosis using current standards should be encouraged.

COMBINATION REGIMEN, REHAB EFFECTIVE

Inhaled corticosteroids should be prescribed in com-

bination with long-acting beta agonists for COPD. The

potential survival benefit of this combination in the

TORCH (Towards a Revolution in COPD Health) trial was

attributed to the long-acting beta agonist.11 While several

studies have linked inhaled corticosteroid use by COPD

patients with a potentially increased risk of pneumonia,

overall risk remained low.

Referring older adults to pulmonary rehabilitation —

providing upper body conditioning, respiratory training

and aerobic training in a monitored environment — is

too often dismissed because of concerns about frailty or

deconditioning. Yet for motivated older adults with trans-

portation support, pulmonary rehabilitation can improve

exercise capacity, physical function and quality of life, and

is even beneficial beyond age 80.12


7


DRUG INHALED NEBULIZED

Inhaler strength* (μg/actuation)

U.S. Monthly Costs† Nebulized strength* /vial

U.S. Monthly Costs†

Short-acting beta 2-agonists

Albuterol 90 pMDI $50-$60 2.5-5 mg in 3 mL ‡ $10

Levalbuterol 45 pMDI $60 0.63-1.25 mg in 3 mL ‡

$150-$350

Pirbuterol 200 BA pMDI $490 — —

Long-acting beta 2-agonists

Salmeterol 50 DPI $135 — —

Formoterol 12 DPI $200 20 mcg in 2 mL $535

Arformoterol — — 15 mcg in 2 mL $490

Indacaterol 75 DPI $200 — —

Short-acting anticholinergic

Ipratropium 17 pMDI $260 500 mcg in 2.5 mL ‡ $10-$20

Long-acting anticholinergics

Aclidinium 400 DPI $260 — —

Tiotropium 18 DPI $310 — —

Combination beta-2 agonist and anticholinergic

Albuterol/ipratropium 100/20 SMI $290 2.5 mg/0.5 mg in 3 mL ‡

$45-$120

Combinations of inhaled corticosteroids and beta-2 agonists

Budesonide/formoterol 80-160/4.5 pMDI $220-$260 — —

Fluticasone/salmeterol 100-250-500/50 DPI

45-115-230/21 pMDI

$230-$290-$370 — —

Mometasone/formoterol 100-200/5 pMDI $240 — —

Fluticasone/Vilanterol 100/25 DPI $290 — —

pMDI = pressurized metered-dose inhaler; BA pMDI = breath actuated pMDI; SMI = soft mist inhaler; DPI = Dry powder inhaler. * Base dose reported. † Rounded prices reported based on data from Medi-Span and www.goodrx.com. Monthly cost for as needed nebulized medications assumes 60 vials per month.‡Generic available


Available Inhaled and Nebulized Medications for COPD with Cost Estimates

COPD in the Elderly continued


8


Other interventions to consider for older adults

include smoking cessation strategies, ventilatory

muscle training, airway clearance techniques, medica-

tion management and psychological support. n

Dr. Aboussouan (left), of the departments of Pulmonary and Critical Care Medicine and the Sleep Disorders Center, can be reached at [email protected] or at

216.444.0420. Dr. Messinger-Rapport (right), Director of the Center for Geriatric Medicine, can be reached at [email protected] or at 216.444.6801.

REFERENCES

1. Ford ES, Croft JB, Mannino DM, et al. COPD surveillance—United States, 1999-2011. Chest 2013;144(1):284-305.

2. Villeneuve S, Pepin V, Rahayel S., et al. Mild cognitive impair-ment in moderate to severe COPD: a preliminary study. Chest 2012;142(6):1516-23.

3. Hardie JA, Buist AS, Vollmer WM, et al. Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J 2002;20(5):1117-22.

4. Sprenger MJ, Mulder PG, Beyer WE, et al. Impact of influenza on mortality in relation to age and underlying disease, 1967-1989. Int J Epidemiol 1993;22(2):334-40.

5. Nichol KL, Baken L, Nelson A. Relation between influenza vaccination and outpatient visits, hospitalization, and mortal-ity in elderly persons with chronic lung disease. Ann Intern Med 1999;130(5):397-403.

6. Nichol KL. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine 1999;17 Suppl 1:S91-S93.

7. Castaldi PJ, Rogers WH, Safran DG, et al. Inhaler costs and medica-tion nonadherence among seniors with chronic pulmonary disease. Chest 2010;138(3):614-20.

8 Quinet P, Young CA, Heritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmo-nary disease. Ann Phys Rehabil Med 2010;53(2):69-76.

9. Wilchesky M, Ernst P, Brophy JM, et al. Bronchodilator use and the risk of arrhythmia in COPD: part 2: reassessment in the larger Quebec cohort. Chest 2012;142(2):305-11.

10. Tashkin DP, Celli B, Senn S., et al. A 4-year trial of tiotro-pium in chronic obstructive pulmonary disease. N Engl J Med 2008;359(15):1543-54.

11. Suissa S, Ernst P, Vandeemheen KL, et al. Methodological issues in therapeutic trials of COPD. Eur Respir J 2008;31(5):927-33.

12. Baltzan MA, Kamel H, Alter A., et al. Pulmonary rehabilitation improves functional capacity in patients 80 years of age or older. Can Respir J 2004;11(6):407-13.

For Your Information


The Cleveland Clinic WayBy Toby Cosgrove, MD,

CEO and President of Cleveland Clinic

Great things happen when a medical center puts

patients first. For details or to order a copy, visit

clevelandclinic.org/ClevelandClinicWay.

A Leader in Geriatric CareCleveland Clinic’s Center for Geriatric Medicine is

ranked the No. 7 geriatrics program in the country

by U.S. News & World Report. For details, visit

clevelandclinic.org/geriatricmedicine.

9


Diabetes in the Elderly: Management Challenges Tailoring treatment for a vulnerable age group

By Vinni Makin, MD

Diabetes affects more than a quarter of 65-year-olds in the United States. Older adults with diabetes face an increased

risk of mortality and institutionalization, and age-related physiological changes, depression, polypharmacy, impaired

cognition, reduced functional status and cognitive decline are prevalent. Management presents unique challenges given the

comorbidities in this population.

INDIVIDUALIZING GOALS FOR ELDERLY

Intensive glycemic management has been controversial,

especially after data from the VADT (Glucose Control

and Vascular Complications in Veterans with Type 2

Diabetes), ACCORD (Action to Control Cardiovascular

Risk in Diabetes) and ADVANCE (Action in Diabetes and

Vascular Disease: Preterax and Diamicron MR Controlled

Evaluation) trials was made public.

Evidence suggests that glycemic targets should be individ-

ualized, considering life expectancy, duration of diabetes,

presence of micro- and macrovascular complications,

and comorbidities.

Most practitioners agree that adhering to guidelines

emphasizing an HbA1c greater than 7 percent is reason-

able for physically active, robust older adults with early

type 2 diabetes when this target can be achieved without

hypoglycemia, falls or confusion.

American Diabetes Association (ADA) goals are not tai-

lored to age, but the European Diabetes Working Party for

Older People suggests a range of 7 to 7.5 percent for older

diabetic patients without comorbidities and of 7.6 to 8.5

percent for frail diabetic patients. The aim is to minimize

diabetes-related symptoms such as urinary incontinence,

falls, infections and cognitive decline while avoiding

hypoglycemia.

ADDRESSING HOME MONITORING AND NUTRITION

Home blood-sugar monitoring is often discussed with

older patients during office visits. A periodic review of

written blood sugar logs as well as meter downloads is

often recommended to obtain an accurate picture of

blood sugar control at home. Decreased fine-motor skills,

impaired vision and the cost of testing supplies are barri-

ers to home management. Low-cost test strips as well as

non-coding and talking meters can help elderly patients

monitor blood sugar levels.

Nutrition is a special consideration for older patients due

to functional limitations that often affect food prepara-

tion as well as dental difficulties, swallowing issues and

irregular eating patterns. Medical nutrition therapy (MNT)

involving care partners, adjusted for cultural differences

and personal ability, is helpful.

TAILORING MEDICATIONS

Factors to consider in medical management of the elderly

include an increased risk of drug-related events and

hypoglycemia, high costs and medication burden. Therapy

should account for comorbidities, social situation and

financial limitations.

• Metformin: This is considered first-line therapy when

MNT does not help patients meet their HbA1c target. It

has fewer potential cardiovascular outcomes compared

with sulfonylureas, as well as low cost. It is contraindi-

cated in advanced chronic kidney disease and in heart

failure with reduced ejection fraction, two common

comorbidities in older adults. Metformin is also not a

good choice for elderly patients with sarcopenia because

it may induce anorexia. In older adults with mobility

problems, loose stools induced by metformin may cause

fecal incontinence.

• Sulfonylureas: These have good efficacy for blood sugar

control and can increase appetite in elderly patients at

nutritional risk. However, hypoglycemia — especially in

those with irregular eating patterns — is a major concern.


10


• Dipeptide peptidase-IV inhibitors: These have a lower

risk of hypoglycemia, and postprandial blood sugar

control is good. DPP-IV inhibitors are often used in com-

bination with basal insulin to control both fasting and

postprandial hyperglycemia. However, their high cost

may be a limiting factor.

• Glucagon-like peptide-1 agonists: These can be very

beneficial for obese patients with type 2 diabetes.

However, their cost, the need for injection therapy

and gastrointestinal side effects restrict their use.

• Sodium glucose co-transporter inhibitors: These inhibit

glucose reabsorption in the proximal renal tubules,

providing an insulin-independent mechanism for

lowering blood glucose. (The only FDA-approved drug

in this class, dapagliflozin, has not yet been evaluated

in frail elders.)

• Insulin therapy: Insulin is considered when the HbA1c

target cannot be met using two oral drugs. Insulin pens

are easier to use than vials or syringes because they elimi-

nate the need to draw and measure insulin. However,

they are more costly. It’s also prudent for clinicians to

emphasize to patients the importance of managing

hypoglycemia to decrease the risk of falls. This includes

keeping glucose tablets on their persons at all times and

food on their nightstands. A 2 a.m. blood-sugar check

for one to two days after adjusting therapy is a suggested

precaution. The patient and family should be taught to

use a glucagon emergency kit.

• Insulin considerations for frail elders: Older diabetic

individuals are more likely than their non-diabetic

counterparts to have cognitive impairment, and dia-

betes is a risk factor for its progression to dementia.

Because uncontrolled hyperglycemia or hypoglycemia

can lead to falls that result in hospital admission, a

simple regimen that avoids hypoglycemia may be the

key to preventing institutionalization.

For appropriately selected elderly patients with type

2 diabetes, a daily basal injection and fasting blood

glucose measurement for safety facilitate home

glycemia management. Studies suggest that daily

dosing with a basal insulin such as detimir or glargine

attains glycemic control comparable to prandial

insulin dosing with less hypoglycemia. Also, treatment

regimens should not “require” an evening snack for

older patients who may eat irregularly.

A TEAM EFFORT

Diabetes management in the elderly is often a col-

laborative effort between the patient, geriatrician,

endocrinologist, diabetes educator, pharmacist, dietitian

and caregivers. Limited literature on diabetes studies

aimed at the elderly and frail populations makes manage-

ment of this group particularly challenging. Research

efforts should be targeted at evaluation of the benefits of

glycemic intervention in this vulnerable age group with

the highest prevalence rates. n

Dr. Makin is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism. She can be reached at [email protected] or at 216.444.0539.


11


Managing Pressure Ulcers in the Elderly Patient By Steven Schwartz, MD, CWS

The physiologic changes associated with aging increase the risk of developing a pressure (decubitus) ulcer. In managing

pressure ulcers, it is important to not only implement appropriate topical care based on a proper assessment, but also to

address multiple risks that may contribute to skin breakdown.

AGING SKIN, AGING BODY

Risk factors for pressure ulcers include aging skin and

pressure, friction and shear.

• Skin changes: With aging, the skin becomes drier and

thinner. The basement membrane zone (which helps

anchor the epidermis to the dermis) flattens, making these

layers more likely to slide or separate. There is also less

subcutaneous fat between skin and bony prominences.

• Mechanical forces: Patients with chronic diseases such

as arthritis, heart disease and dementia may have dif-

ficulty maneuvering and shifting weight on their own.

Immobility contributes to pressure, friction and shear —

the three factors that combine to cause pressure ulcers.

OTHER CONTRIBUTING FACTORS

When evaluating elderly patients with pressure ulcers,

other key considerations include nutrition, continence

and medication use.

• Nutrition: Elderly patients may not consume sufficient

nutrition to heal. Protein supplements may be necessary

if patients are not getting 1.2 to 1.5 g/kg/day (depending

upon renal function and extent of the wound). Helpful

nutritional status markers that may change serially

include prealbumin, albumin and weight.

Diabetes patients with hyperglycemia may need better

control. The International Task Force of Experts in

Diabetes recommends a typical HbA1c target range

of 7 to 7.5 percent for older patients with uncontrolled

diabetes.1 Tighter control is usually unnecessary.

• Incontinence: Urinary or fecal incontinence may

create an environment that impairs wound healing.

More frequent changing of undergarments and linens,

scheduled toileting, application of barrier creams and

less permeable secondary dressings can protect skin on

these areas. A time-limited bladder catheter trial should

be a last resort for a more advanced non-healing wound.


Pressure Ulcer Stage I: Non-blanchable erythema Pressure Ulcer Stage II: Partial thickness

12



• Medications: Oral and topical steroids as well as

immunosuppressive agents may delay wound-healing.

In addition, warfarin, NSAIDs and ACE inhibitors may

interfere with the healing process.

FIRST STEP: REPOSITIONING

If an ulcer has developed, pressure must be kept off the

area by repositioning the patient using wedges or towel

rolls, and redistributing pressure via an air mattress or

wheelchair cushion. Heels, if affected, should “float”

using a pillow and /or foam or, more reliably, a heel-

offloading boot.

ASSESSING THE WOUND

When examining high-risk elderly patients, it’s impor-

tant to focus on areas at greatest risk of breakdown: the

sacrum/coccyx, ischial tuberosities, maleoli and heels.

To properly assess the wound, document the following:

• Location

• Size (length, width and depth)

• Presence/extent of undermining (tissue destruction

beneath intact skin along the periphery of the wound)

or tunneling

• Wound-bed tissue type(s): Granulation, necrosis, slough

or epithelialization

• Amount and type of exudate (inspect the dressing)

• Periwound area change(s): Maceration, erythema, indu-

ration or fluctuance

• Pain and/or odor

The National Pressure Ulcer Advisory Panel (NPUAP)

provides wound-staging guidelines based on the depth of

tissue involved.2,3 These guidelines apply only to pressure

ulcers. Once documented, the stage does not change even

as a wound heals; pressure ulcers are never reverse-staged.

DEBRIDING THE WOUND

Wounds generally heal faster when necrotic tissue such

as slough, scab or eschar is removed. Methods of debride-

ment include:

• Autolytic: Moisture-retentive dressings that allow

endogenous enzymes to soften and remove necrotic

tissue.

• Enzymatic: Topical enzymes that degrade and remove

necrotic tissue.

Pressure Ulcer Stage III: Full-thickness skin loss Pressure Ulcer Stage IV: Full-thickness tissue loss

13


• Mechanical: Soft abrasion with gauze and irrigation

using saline and other methods. In general, avoid anti-

septics such as Dakin’s, Betadine or peroxide to clean or

treat wounds; they are toxic to healthy tissue. Wet-to-dry

dressings are also not recommended, as they are nonse-

lective and may cause pain and trauma to healthy tissue.

• Surgical/sharp: A scalpel, forceps, curette or scissors —

avoid using on overanticoagulated patients and on limbs

with significant ischemia.

DRESSING THE WOUND

Moisture balance and bacterial control are important

considerations when choosing a dressing.

Moisture balance

Wounds heal faster when they are moist because

tissue that is too dry can desiccate and die. Yet exces-

sive moisture can cause maceration of surrounding

skin or excessive exudate, which can interfere with

healing. Options include:

• Hydrogels: These donate moisture.

• Hydrocolloid films, petrolatum and Adaptic®:

These maintain moisture.

• Alginates and foam: These absorb moisture.

• Collagen dressings: These absorb moisture and

stimulate non-healing wounds.

• Loose packing: This is best for deep wounds; typi-

cally, alginate rope, iodoform gauze, collagen or

wet-to-moist gauze are used.

• Composite dressings: These dressings combine two

or more products in one.

Antibacterials

No wound — not even a clean one — is sterile.

Antimicrobial dressings should not be used in clean

wounds due to the risk of bacterial resistance. However,

dressings with antibacterial properties are indicated

when there are signs of infection. These include:

• Topical antimicrobials: Mupirocin and other antibi-

otic products (containing iodine or silver, bacitracin

plus polymyxin B, and acetic acid) should be used for a

defined period of time — typically one to two weeks.

• PO or IV antibiotics: These may be needed when

a wound shows signs of deep or surrounding

infection. Systemic antibiotics should target gram-

positive organisms. Gram-negative or anaerobic

Managing Pressure Ulcers in the Elderly Patient continued


Unstageable/Unclassified: Full-thickness skin or tissue loss — depth unknown

Suspected Deep Tissue Injury: Depth unknown

14


1. BE CAUTIOUS WITH SILVER: Avoid combining dressings containing silver with enzymatic debriders; the silver can inactivate enzymes. Limit the duration of topical silver sulfadiazene to two weeks or less, and avoid topical silver products in those allergic to sulfa.

2. DON’T LOSE PACKING: Use a long continuous rope of gauze in deep tunnels or undermined areas instead of multiple pieces so that packing is not “lost.” Leave a small “wick” outside the wound for easy removal.

3. CONSIDER NPWT: Negative pressure wound therapy (NPWT) can help decrease edema, remove excessive exudate, increase blood flow, reduce bioburden and facilitate wound retraction in stage 3 and 4 ulcers. (Contraindications include necrotic tissue with eschar, untreated osteomyelitis, untreated coagulopathy, nonenteric and unexplored fistulas, a malignancy in the wound and an exposed vasculature, nerves, anastomosis or organ.)

4. TAKE SLOUGH SERIOUSLY: If slough is present, the ulcer is at least stage 3.

5. PRESERVE HEEL ESCHAR: Dry/stable eschar on the heel is considered to be protective and should not be debrided.

6. CONSIDER CHRONIC WOUND CAUSES: When wounds are not improving, consider inadequate nutrition, ongoing pressure, infection, excessive exudate or underlying osteomyelitis as causes.

7. AVOID HEEL ‘PAD’ PROTECTORS: Protectors that simply pad the heels are not recommended.

8. PRE-TREAT FOR PAIN: Schedule pain medication prior to wound treatment/manipulation if necessary.

9. AVOID DONUT CUSHIONS: These seat cushions are contraindicated, as they may cause pressure ulcers.

10. KEEP HEAD ELEVATION SLIGHT: Keeping the head of the bed at the lowest possible elevation will protect the sacrum/coccyx.

10 Tips for Treating Pressure Ulcers

Steven Schwartz, MD, is a geriatrician in the Center for Geriatric Medicine. He can be reached at [email protected] or at 216.445.2178.

REFERENCES

1. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. Sinclair A, Morley JE, et al. J Am Med Dir Assoc 2012 Jul;13(6):497-502. doi:10.1016/j.jamda.2012.04.012

2. National Pressure Ulcer Advisory Panel: NPUAP Pressure Ulcer Stages/Categories, available at: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/.

3. National Pressure Ulcer Advisory Panel: Pressure Ulcer Category/Staging Illustrations, available at http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/.

coverage may be added for chronic wounds and

immunocompromised patients.

• Cultures: Surface wound cultures are NOT rec-

ommended, but correctly obtaining deep wound

cultures or tissue samples from complicated wounds

may guide the antibiotic choice. Sulfamethoxazole/

trimethoprim, doxycycline and clindamycin are

good oral choices if MRSA is suspected.

LAST WORD ON WOUNDS

Despite our best efforts, not all wounds can be healed.

In debilitated elders who are unable to mobilize or replen-

ish their nutritional stores, appropriate wound-care

goals include pain reduction and infection prevention.

It is important to clarify the goals of care, to re-evaluate

the wound on a regular basis and to constantly reassess

treatment. n


15


Addressing Challenging Hypertension in the Elderly Tailoring treatment for a vulnerable age group

By Leslie P. Wong, MD, and George Thomas, MD

Expert consensus suggests that most patients 65 and older benefit from treatment of hypertension1. Older hyper-

tensive patients are more likely to develop stroke, heart failure with preserved ejection fraction (HfpEF), atrial

fibrillation and dementia.

The randomized, controlled Hypertension in the Very

Elderly Trial (HYVET) supports the use of anti-hyper-

tensive agents — particularly diuretics — after age 80 to

reduce the risk of all-cause mortality, cardiovascular and

cerebrovascular death, and heart failure.2,3 There is some

evidence of a reduced risk of dementia as well. In addition,

HYVET did not demonstrate an increased fracture risk

in treated patients; in fact, their risk of fracture appeared

to be lower than that of the placebo cohort.

The strongest evidence supports keeping blood pressure

in older adults below 150/90 mmHg, and the Eighth Joint

National Committee recommends a goal blood pressure

of < 150/90 for patients 60 and older, and of < 140/90 for

those with diabetes or chronic kidney disease.4 However,

for the “young old,” a target of < 150/90 may increase risks

of stroke and heart failure. Because of concerns about

their longevity and vascular risks, other recent guidelines

recommend a goal of < 140/90 until age 80, after which

the goal is < 150/90.5

INCREASED ARTERIAL STIFFNESS: CAUSE AND EFFECT

With aging, collagen deposition and degradation of elastic

tissue in the aorta and arterial beds reduce elasticity and

increase vascular resistance. Changes in endothelial

function and loss of vascular reactivity to endogenous

vasodilators also contribute to stiffness.

While systolic blood pressure (SBP) increases due to

greater resistance, diastolic blood pressure (DBP) often

decreases due to loss of arterial compliance. This mani-

fests as isolated systolic hypertension and, by extension,

wide-pulse pressure hypertension.

The proportion of hypertensive patients with isolated

systolic hypertension increases with age; 65 percent of

patients over 60 are affected, compared with 90 percent

of patients over 70.2

A wide pulse pressure — the difference between SBP and

DBP — directly reflects aortic stiffness and is also more

prevalent with age. DBP is key in maintaining coronary

and cerebral perfusion, so as DBP decreases, cardiovas-

cular risk increases.2 Thus, pulse pressure is a critical

determinant of hypertensive risk in older individuals.

Unfortunately, antihypertensive medications do not selec-

tively reduce SBP. Trying to reduce SBP without excessively

lowering DBP often creates a therapeutic dilemma.

AUTONOMIC DYSREGULATION: CAUSE AND EFFECT

Significant autonomic nervous system abnormalities can

cause inappropriate vasoconstriction and/or vasodilation

in elderly hypertensive patients. Orthostatic hypotension

and its opposite, orthostatic hypertension, are common

in the elderly due to loss of baroreflex function and venous

insufficiency.2

Orthostatic hypertension may be associated with abnor-

mally increased alpha adrenergic activity; responsiveness

to beta adrenergic stimulation may decline, impairing

peripheral vasodilation.2 Orthostatic hypotension has a

much higher prevalence in patients with dementia than

in age-matched controls (hypotension may not manifest

until they have been upright for two to 10 minutes).

For elderly patients with significant orthostasis (a more

than 20-point drop in SBP with standing), titrating SBP

to < 160 sitting and > 120 standing is a reasonable target.

Although there is no evidence that it reduces stroke, this

algorithm — used in HYVET — may reduce risks of ortho-

static falls and fall-related injuries.

CHRONIC KIDNEY DISEASE: CAUSE AND EFFECT

Hypertension is a leading cause of chronic kidney disease

(CKD). Diminished functional renal mass, related to

cumulative damage from hypertension and age-related


16


nephron loss, reduces the ability to excrete sodium and

regulate extracellular fluid volume.

A high-sodium diet is clearly linked to elevated BP in

elderly hypertensive patients.2 Salt sensitivity in elders is

often coupled with decreased activity of the renin-angio-

tensin-aldosterone (RAAS) axis, in part due to sclerosis

of the juxtaglomerular apparatus.1

Efforts to manage hypertension in the setting of CKD

are often complicated by the side effects of common

medications:

• Diuretics: These have the strongest evidence basis

for reducing stroke and heart failure in older adults

with hypertension. However, diuretics may exacerbate

electrolyte disturbances such as hypokalemia and

hyperuricemia, leading to volume depletion and

worsening kidney function.


• ACE inhibitors, angiotensin receptor blockers and

aldosterone antagonists: These counter the RAAS axis,

and so may exacerbate hyperkalemia; they must be used

cautiously in the setting of CKD.

Elderly CKD patients have largely been excluded from

clinical trials, so evidence to guide treatment decisions is

limited. Due to the increased risk of complications in this

population, experts stress the need to avoid adverse treat-

ment effects and to individualize BP goals, rather than

adhere to a fixed BP target.1

MANAGING CHALLENGING HYPERTENSION

The large, multicenter NIH-sponsored Systolic Blood

Pressure Intervention Trial (SPRINT) should provide a

better understanding of optimal BP goals related to end-

organ changes in community-dwelling elderly patients

who are able to participate in trials.

17



In the meantime, a target BP of < 140/90 is reasonable for

adults up to 80 years of age, and a target BP of < 150/90 is

reasonable for community-dwelling adults 80 and older.4

Referral to specialized hypertension centers such as

Cleveland Clinic’s Hypertension Clinic can assist in

individualized BP management for challenging cases.

For frail elders — those with severely impaired mobility

and/or cognition, and a limited life expectancy — consider

initiating and titrating antihypertensives to function-

oriented goals such as dyspnea, edema and orthostasis.

Referral to a geriatric clinic can help delineate goals of

treatment in these cases. n

Dr. Wong (left), of the Department of Nephrology and Hypertension, can be reached at [email protected] or at 216.445.0673. Dr. Thomas (right), who heads the Hypertension Clinic

in the Department of Nephrology and Hypertension, can be reached at [email protected] or at 216.636.5420.

REFERENCES

1. Taler SJ, Agarwal R, Bakris GL, et al: KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis 62(2):201-213, 2013.

2. Aronow WS, Fleg JL, Pepine CJ, et al, ACCF Task Force: ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation 123(21):2434-2506, 2011.

3. Beckett NS, Peters R, et al, HYVET Study Group: Treatment of hyperten-sion in patients 80 years of age or older. N Engl J Med 358(18):1887, 2008.

4. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

5. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens. 2014 Jan;32(1):3-15. doi: 10.

Take-Home Points: Measuring Hypertension in the Elderly

CHECKING BLOOD PRESSURE

Pressures on both arms should be measured on the first visit; for discrepancies > 10 mmHg, the arm with higher BP should guide therapy.

Look for orthostatic changes in BP after patients stand for 2 minutes (or longer, if there is a history of syncope or dementia).

Suspect pseudohypertension, a false elevation in SBP during inflation caused by incompressible sclerotic arteries, in elderly patients with “resistant” hypertension and signs/symptoms of overmedication.1

Fully automated oscillometric devices that take multiple consecutive BP readings in the office, with patients sitting and resting alone, can reduce the “white coat” response.

Addressing Challenging Hypertension in the Elderly continued

18


Geriatric Medicine Staff

GERIATRICIANS AND GERIATRIC PSYCHIATRISTS IN THE CLEVELAND CLINIC HEALTH SYSTEM

MAIN CAMPUS

Ronan Factora, MD Do Gyun Kim, MD Amanda Lathia, MD Barbara Messinger-Rapport, MD, PhD Steven Schwartz, MD Quratulain Syed, MD Anne Vanderbilt, CNS, CNP

AVON LAKE FAMILY HEALTH CENTER

Ali Mirza, MD

BEACHWOOD FAMILY HEALTH AND SURGERY CENTER

Barbara Messinger-Rapport, MD, PhD Steven Schwartz, MD

EUCLID HOSPITAL

Geriatrics Ami Hall, DO

Geriatric Psychiatry Upma Dhingra, MD

FAIRVIEW FAMILY MEDICINE

Carl V. Tyler Jr., MD, MS

FAIRVIEW HOSPITAL

Geriatric Psychiatry John Sanitato, MD

INDEPENDENCE FAMILY HEALTH CENTER

Ronan Factora, MD

LAKEWOOD HOSPITAL/LUTHERAN HOSPITAL

Center for Brain Health Babak Tousi, MD Christine Nelson, MSN, CNP

Geriatric Psychiatry Mark Frankel, MD John Sanitato, MD

LORAIN INSTITUTE

Lynn (Chris) Chrismer, MD Itri Eren, MD Kashif Khan, MD Ali Mirza, MD Sathya Reddy, MD Pragati Singh, MD Rebecca Haney, CNP Renee Smith, CNP Wanda Williams, CNP

CLEVELAND CLINIC FLORIDA

Diana Galindo, MD Jesus Loquias, MD

JOINT APPOINTMENTS IN THE CENTER FOR GERIATRIC MEDICINE

CENTER FOR CONNECTED CARE

Michael Felver, MD Duane Kirksey, MD Renato Ramon Samala, MD Ethel Smith, MD Maidana Vacca, MD William Zafirau, MD Luanne Capon, GNP, MSN, CPHQ Carol Hall, CNP Sam Palmer, CNP

DIGESTIVE DISEASE INSTITUTE

Brooke Gurland, MD Tracy Hull, MD Matthew Kalady, MD Jamilee Wakim-Fleming, MD

EMERGENCY SERVICES INSTITUTE

Fredric Hustey, MD

ENDOCRINOLOGY & METABOLISM INSTITUTE

Angelo Licata, MD, PhD

GLICKMAN UROLOGICAL & KIDNEY INSTITUTE

Raymond Rackley, MD Sandip Vasavada, MD

HEAD & NECK INSTITUTE

Catherine Henry, MD

NEUROLOGICAL INSTITUTE

Charles Bae, MD Karen Broer, PhD Neil Cherian, MD Kathy Coffman, MD Kathleen Franco, MD Richard Lederman, MD, PhD Mark Luciano, MD, PhD Richard Naugle, PhD Leo Pozuelo, MD Babak Tousi, MD Brinder Vij, MD

Brain Tumor and Neuro-Oncology Gene Barnett, MD Glen Stevens, DO, PhD

Physical Medicine and Rehabilitation Frederick Frost, MD Vernon Lin, MD, PhD

OB/GYN & WOMEN’S HEALTH INSTITUTE

Matthew Barber, MD Marie Fidela Paraiso, MD Beri Ridgeway, MD

ORTHOPAEDIC & RHEUMATOLOGIC INSTITUTE

Abby Abelson, MD Wael Barsoum, MD Chad Deal, MD Elaine Husni, MD Bruce Long, MD

SYDELL AND ARNOLD MILLER FAMILY HEART & VASCULAR INSTITUTE

Karen James, MD Michael Maier, DPM

TAUSSIG CANCER INSTITUTE

Mellar Davis, MD Mona Gupta, MD Terence Gutgsell, MD Abdo Haddad, MD Susan LeGrand, MD Armida Parala-Metz, MD Dale Shepard, MD, PhD

All physicians in Regional Geriatrics have joint appointments in the Center for Geriatric Medicine.



The Cleveland Clinic FoundationGeriatric Times9500 Euclid Ave./AC311Cleveland, OH 44195

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