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An approach to mulitmorbidity in frail older adults
1. A n A p p r o a c h t o C h r o n i c D i s e a s e M a n a g e m e n t i n F r a i l O l d e r A d u l t s
Dr. Camilla Wong, MD MHSc FRCPC
06.22.2017
Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, Dopey
2.
3. Proportion of Canadians aged 65 and older with zero to four self-
reported major chronic diseases (cancer, cardiovascular disease,
chronic respiratory disease, diabetes)
Canadian Community Health Survey, 2014
4. Time Medication Non-pharmacologic All Day Periodic
7:00 Ipratropium MDI
Alendronate weekly
Check feet
Sit upright 30 mins
Accuchek
Appropriate foot wear
Limit alcohol
Avoid COPD
environmental
exacerbation exposures
Energy conservation
Joint protection
Exercise (non-weight
bearing if foot disease,
weight bearing for
osteoporosis), ROM,
aerobic.
Albuterol MDI prn
Pneumonia and
influenzae vaccine
BP, foot, glucose
monitoring
HgA1c q3months
Creatinine, lytes,
cholesteral,
microalbumin
yearly
Physical therapy,
pulmonary rehab
Eye exam q1yr
DEXA scan q2yr
Education on
diabetes, foot care,
inhalers
8:00 Breakfast
HCTZ, Lisinopril,
Glicazide, ASA,
Metformin, Naproxen,
Omeprazole, Vitamin D
2 g sodium, 90 mmol K,
diabetic diet, low
cholesterol and
saturated fat, DASH
diet
12:00 Lunch Metformin,
Ipratropium MDI
Diet as above
17:00 Dinner Diet as above
19:00 Metformin, Ipratropium
MDI, Naproxen,
Atorvastatin
23:00 Ipratropium MDI JAMA. 2005;294:716-724
5. A comp rehens ive g eriatric as s es s ment
(CG A) is a multidimens ional,
interdis ciplinary diagnos tic proces s to
determine the medical, p s ycholog ical,
and functional cap abilities of a frail
elderly p ers on in order to develop a
coordinated and integ rated p lan for
treatment and long - term follow - up.
12. Proportion of Canadians aged 65 and older with zero to four self-
reported major chronic diseases (cancer, cardiovascular disease,
chronic respiratory disease, diabetes)
Canadian Community Health Survey, 2014
21. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
22. NNT
Number Needed to Treat
number of patients who need to be
treated to prevent one outcome
23. Intervention Comparator Outcome NNT
CGA General
medical care
Death or
deterioration
17
Statin Placebo Cardiovascular
mortality in
established disease
34
Live zoster
vaccine
Placebo Herpes zoster 50
Apixaban Coumadin Stroke or embolism 51
Indapamide and
Perindopril
Placebo Death in diabetes 79
Alendronate Placebo Secondary prevention
hip/wrist fracture
100
24. S U R R O G AT E E N D P O I N T S
m a y b e s t r o n g l y a s s o c i a t e d w i t h c l i n i c a l o u t c o m e s ,
b u t t h e i n t e r m e d i a t e e n d p o i n t s m a y n o t b e r e l e v a n t i n t h e
25. Disease Intervention Surrogate
Endpoint
Clinical Outcome
(what matters)
Alzheimer’s
disease
Cholinesterase
inhibitor
ADAS-Cog Skilled nursing
facility
Diabetes DPP-4 inhibitors Hemoglobin A1c Microvascular/m
acrovascular
complications
Osteoporosis Bisphosphonate Bone mineral
density score
Hip fracture
Diabetic
nephropathy
ACE inhibitor Microalbuminuria Dialysis
26. T I M E TO B E N E F I T ( T T B )
T h e t i m e u n t i l a s t a t i s t i c a l l y s i g n i f i c a n t b e n e f i t i s o b s e r v e d i n
t r i a l s o f p e o p l e t a k i n g a t h e ra p y c o m p a re d t o a c o n t ro l g ro u p
n o t t a k i n g t h e t h e ra p y.
27. Intervention Time to Benefit Outcome NNT
Statin 5 years Cardiovascular
mortality in
established
disease
34
Indapamide and
Perindopril
5 years Death in
diabetes
79
Alendronate 2-3 years Secondary
prevention
hip/wrist
fracture
100
Fecal occult
testing
10 years Colon cancer
prevention
1000
28. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
32. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
33. Time Medication Non-pharmacologic All Day Periodic
7:00 Ipratropium MDI
Alendronate weekly
Check feet
Sit upright 30 mins
Accuchek
Appropriate foot wear
Limit alcohol
Avoid COPD
environmental
exacerbation exposures
Energy conservation
Joint protection
Exercise (non-weight
bearing if foot disease,
weight bearing for
osteoporosis), ROM,
aerobic.
Albuterol MDI prn
Pneumonia and
influenzae vaccine
BP, foot, glucose
monitoring
HgA1c q3months
Creatinine, lytes,
cholesteral,
microalbumin
yearly
Physical therapy,
pulmonary rehab
Eye exam q1yr
DEXA scan q2yr
Education on
diabetes, foot care,
inhalers
8:00 Breakfast
HCTZ, Lisinopril,
Glicazide, ASA,
Metformin, Naproxen,
Omeprazole, Vitamin D
2 g sodium, 90 mmol K,
diabetic diet, low
cholesterol and
saturated fat, DASH
diet
12:00 Lunch Metformin,
Ipratropium MDI
Diet as above
17:00 Dinner Diet as above
19:00 Metformin, Ipratropium
MDI, Naproxen,
Atorvastatin
23:00 Ipratropium MDI JAMA. 2005;294:716-724
34.
35.
36. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
37. NNH
Number Needed to Harm
number of patients who need to be
exposed to incur one adverse event
38. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
39. Ms. A
Does she have
multimorbidity?
Are the conditions
concordant or discordant?
Is there a dominant
condition?
72 year old lady.
Past Medical History
1. COPD, mild
2. CAD – prior NSTEMI
3. CHF (grade II LV)
4. Type II diabetes (HgA1c 7.2%) with neuropathy
5. CKD (CrCl 50)
Medications
1. Aspirin 80 mg daily
2. Perindopril 4 mg daily,
3. Atorvastatin 10 mg daily
4. Metformin 1000 mg bid
5. Sitagliptin 100 mg daily
6. Atrovent prn
Function
• Cane
• Independent with ADLs and IADLs
• Does not drive
40. Ms. A
Would you propose any
changes in management?
Do you need more
information?
Social History
• Married, lives with husband
• Daughter nearby
• Smokes 1 pack per day
• No alcohol
• Loves to go to church and spend time with family
Geriatric ROS (pertinent findings)
• Cognitively intact, no falls, continent
• No vision or hearing concerns
• BMI = 25, appetite good
• High self-rated quality of life
Examination (pertinent findings)
• BP 160/90
• BMI = 25
Labs (pertinent findings)
• HgA1c = 7.2%
• LDL 3.2
• Cholesterol 4.8
• Minimal microalbuminuria
42. Ms. A
Pharmacologic Interventions
1. COPD
• Counsel on smoking cessation
2. Diabetes
• HgA1c target of ~7.0%
• BP target < 140/90 (add Indapamide)
• Reduce Metformin (CrCl = 50)
• Change Sitagliptin to Linagliptin (CrCl = 50)
3. Cardiovascular Disease
• Increase Atorvastatin (LDL target < 2.0 in
established coronary disease)
43.
44. Ms. A
10 years later.
Does she have
multimorbidity?
Are the conditions
concordant or discordant?
Is there a dominant
condition?
History of Presenting Illness
• Abdominal pain, nausea, vomiting, peritonitis
• Obstructing colonic lesion
• Urgent ileostomy
• Pathology: Stage III colon cancer
• Postoperative delirium resolving
Past Medical History
1. COPD, mild
2. CAD – prior NSTEMI
3. CHF (grade II LV)
4. Type II diabetes (HgA1c 5.7%) with neuropathy
5. CKD (CrCl 50)
6. Recurrent UTIs
Medications
1. Aspirin 80 mg daily
2. Perindopril 4 mg daily,
3. Indapamide 1.25 mg daily
4. Atorvastatin 20 mg daily
5. Metformin 500 mg bid
6. Linagliptin 5 mg daily
7. Canagliflozin 100 mg daily
8. Atrovent prn
45. Ms. A
10 years later.
Is she frail?
Function
• Cane
• Independent with ADLs
• Does own cooking, shopping cleaning
• Missed bill payments and medications occasionally
• Does not drive
Social History
• Lives alone
• Daughter nearby
• Stopped smoking
• No alcohol
• Loves to go to church and spend time with family
Geriatric ROS (pertinent findings)
• Short term memory impairment for 3 years
• 3 falls in the last year (no injuries)
• Low weight (lost 8 pounds in past year)
• Continent
• Good self-rated quality of life
46. Ms. A
10 years later.
Should she get adjuvant
chemotherapy?
Examination (pertinent findings)
• MoCA 22/20 (deficits in memory and executive
function)
• Cannot manage day to day tasks related to
ileostomy care (emptying 6 times a day, hydration,
troubleshooting)
• Peripheral neuropathy
Proposed Adjuvant Chemotherapy Options
1. Oxaliplatin-based regimen, OR
2. Flurouracil plus leucovorin, OR
3. Capecitabine, OR
4. Supportive care
47.
48.
49. Ms. A
10 years later.
Interventions
1. Dementia, mild, probable Alzheimer’s
• CCAC referral for ileostomy support (only once
daily), daily weights, OT home safety
assessment, blister pack medications
• Referral to Alzheimer’s Society
2. Falls
• Lenient HgA1c target of < 8.5%
• BP target < 150/90
• OT home safety referral, emergency response
device
2. Adjuvant Chemotherapy
• Shared decision-making for a trial of
Capecitabine, dose-reduced
3. Advanced Care Planning
• Established POA
• Re-visit preferences and values
• Code status – DNR
• Proactive referral to palliative care
50.
51.
52. Ms. A
A year later.
In her last year of life.
History of Present Illness
• She has a fall resulting in a small subdural
hematoma, conservatively managed.
Past Medical History
1. COPD, mild
2. CAD – prior NSTEMI
3. CHF (grade II LV)
4. Type II diabetes (HgA1c 8.5%) with neuropathy
5. CKD (CrCl 35)
6. Stage III colon cancer.
Medications
1. Aspirin 80 mg daily
2. Perindopril 4 mg daily
3. Atorvastatin 20 mg daily
4. Metformin 500 mg bid
5. Capecitabine 500 mg bid (completed)
6. Atrovent prn
53. Ms. A
A year later.
In her last year of life.
Is she frail?
Is she in the terminal phase
of her multimorbidity?
Function
• Walker
• Needs assistance with transfers, dressing, bathing,
and IADLs.
Social History
• Living with daughter
• Loves to go to church and spend time with family
Geriatric ROS (pertinent findings)
• 2 falls in the last year
• Mood is good
• Weight stable
• Incontinent
Examination (pertinent findings)
• MoCA 10/20 (deficits in all domains)
54. Ms. A
A year later.
In her last year of life.
Interventions
1. Advanced Care Planning
• Re-visit preferences and values
• Code status – DNR
2. Focus on Symptom Management
• Stop non-essential medications
• Liaise with palliative care
55.
56.
57. F R A M E W O R K F O R M U L T I M O R B I D I T Y
J Am Geriatr Soc. 2012;60(10):E1-25.
58. Thank you.
Fa c u l t y / P re s e n t e r : C a m i l l a Wo n g
Notes de l'éditeur
Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, Dopey
If you let me stay, I'll keep house for you. I'll wash and sew and sweep and cook.
An approach to multimorbidity
Resources
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs
Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans.
If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her $406 per month) and a complicated nonpharmacological
regimen. Adverse interactions between drugs and diseases could result
For those not in geriatric medicine, what geriatric medicine can seem nebulous. Geriatrician perform what is known as a CGA, a multidimensional, interdisciplinary diagnostic process to determine the medical psychological and functional capabilities of a frail elderly person in order to develop a coordinate and integrated plan for treatment and long-term follow-up. Essentially, the process tool is how I would want my grandparents to be cared for, how I would want to be cared for when I’m older.
And it’s evidence-based too. For every 17 hospitalized older adults who receive a CGA, death or significant deterioration is prevented for one person based on evidence in general geriatric inpatients from a Cochrane systematic review of 22 randomized trials evaluating 10,315 participants in six
Of course, Atul Gawande said it much more eloquently in his book, Being Mortal.
- same overall pathophysiologic risk profile
- shared disease management plan
Clinical practice guidelines are based on clinical evidence and expert consensus to help decision making about treating specific diseases. Clinical practice guidelines help to define standards of care and focus efforts to improve Quality. Most CPGs address single diseases in accordance with modern medicine’s focus on disease and pathophysiology.
Examples:
Cognitive impairment and urinary incontinence
heart failure and chronic kidney disease
PMR and diabetes
Schizophrenia and parkinson’s disease
Clinical practice guidelines are based on clinical evidence and expert consensus to help decision making about treating specific diseases. Clinical practice guidelines help to define standards of care and focus efforts to improve Quality. Most CPGs address single diseases in accordance with modern medicine’s focus on disease and pathophysiology.
Conceptual Diagram of Comorbidity: Index Disease, With One or More Comorbid Condition or Diseases Affecting Its Course and Treatment. Comorbidity has often been studied and treated in clinical practice from the perspective of an index disease, and one or more comorbid diseases may typically be considered. These diseases may affect the course and treatment of the index disease to varying degrees (varied weight of connecting bars). This framework may create disjointed treatment plans for each of the diseases and become cumbersome in patients with several co-existing diseases.
Conceptual Diagram of Multimorbidity within an Individual Person’s Circumstances and Preferences. The perspective of multimorbidity may be useful for treating patients with multiple conditions. Conditions include traditional diseases, but also may reflect conditions such as disability, falls, hearing impairment, and sarcopenia that fall outside the traditional disease model. These conditions may overlap to varying degrees. The intersecting conditions exist within a context of biological health and reserves, as well as the psychological circumstances of a person (i.e., positive affect). The multimorbid conditions also unfold for given people within their social, educational, cultural, economic and environmental circumstances, and these will affect management of the multimorbid conditions. The person with multimorbidity also has individual values and priorities for their life and healthcare, which need to be elicited and factored into treatment plans.
Comorbidity: index disease as centre of interest, different importance of conditions, only interaction with index disease assumed
Multimorbidity: no index disease, all conditions equal, chronic conditions, interaction between conditions
More often than not, we’re not just dealing with multimorbidity, but frailty. When an individual has many diseases and have limited reserve
The suggested management strategy is to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone .
In the sea of multimorbidity, is there a dominant disease whereby the suggested management strategy may be to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone?
The tricky part for frail individuals is that treatment of 1 condition can exacerbate other conditions that do not lead to net health improvements (eg, improved glucose control leads to hypoglycemia, resulting in falls). The suggested management strategy is to identify and treat clinically dominant conditions that eclipse other less important conditions, which may be better left alone
Seeing the forest for the trees.
Moving from “What is the matter?” to
“What Matters to You?”
Ensure patient has an advance directive
Ensure there is a designated POA
Document preferences and expectations
Include a discussion of possible complications, including functional decline, need for rehabilitation, or nursing home.
SURROGATE ENDPOINTS
may be strongly associated with clinical outcomes, but the intermediate end points may not be relevant in the bigger picture.
Immediate risk of hypoglycemia
Immediate risks of hyperglycemia
Long term benefits of glycemic control
Let’s give her 3 of the 4 most common chronic diseases of Canadians
NNT = 34 for statins in secondary prevention
Now let’s give her the forth of the top 4 chronic conditions in Canadians
Canaglifozin (sodium-glucose co-transporter 2 (SGLT2) inhibitors and recurrent UTIs
an approximately 30 percent reduction in the risk of disease recurrence and a 22 to 32 percent reduction in mortality
Add slide on HgAc1 from quick guide
Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease.
This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs.
Tools: eprognosis, chemotherapy toxicity calculators, deprescribing.org, trials of de-prescribing