Workshop Guide

Open Workshop Guide

 


 

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Open Instructor Guide

Challenging Patient Curriculum Instructor Guide^

PGY-1: Older Patient with Co-Morbidities

Goals:

A PGY-1 resident will be able to evaluate and develop a treatment plan for a young-old patient with several co-morbidities that accounts for changes related to aging.

Patient Care

  • Demonstrate an ability to perform a “diabetes visit,” including assessment of end-organ damage, disease control, and recognition and management of co-morbid conditions, particularly hypertension and hyperlipidemia
  • Demonstrate the diabetic foot exam

Medical Knowledge

  • Describe common physiologic changes with aging
  • Describe common aging-disease interactions that might affect a patient with diabetes
  • Describe principles of prescribing for an older patient with multiple co-morbidities
  • Describe treatment goals for patients with diabetes

Practice Based Learning and Improvement

  • Assess the quality of care they provide for patients with diabetes

Interpersonal and Communication Skills

  • Demonstrate an ability to adapt to history taking and exam skills to accommodate a person with a hearing impairment

Professionalism

  • Demonstrate compassion and empathy in the care of the older patient with a chronic illness

Systems-based Practice

  • Identify local resources for a patient with diabetes

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Session Guide^

 

Time Needed: 4 hours, including 30 minutes of breaks. Alternatively, this can be broken into 3 1-hour blocks.

Equipment needed:

  • Computer with DVD-ROM drive and LCD projector
  • Audience response system (optional)
  • Note cards or scraps of paper (4/participant)
  • Large note pad
  • Markers
  • “Up,” Pixar/Disney
  • Monofilaments (10 gm), 1 for each 2 participants

Suggested Reading:

American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2012:60(4);616-31

Mahoney, DO, Gallagher, P, et al.. STOPP and START criteria: A new approach to detecting potentially inappropriate prescribing in old age. Euro Geri Med. 2010;1: 45-51.

Schwartz, RA, Morgan, AJ. Diabetic Skin Ulcer. Essential Evidence Plus. 2012. Wiley-Blackwell.

Instructor Script and Notes

Part 1 – 60 minutes

        1. Introduction to the Older Patient – 10 minutes
          1. Mini-lecture: PowerPoint presention – “Challenging Patient: The Older Patient with Multiple Co-Morbidities”– a very brief overview of important issues related to Family Medicine and the aging population
            1. Goals of session
            2. Demographics of aging
            3. Chronic illness and aging
            4. Role of FM in caring for the elderly
            5. Quality in health care
        1. Aging
          1. Up – Show first 10 minutes of movie (to point after the main character’s wife has died, and he is shown getting up, going down stairs, and resting on his front porch) – 25 minutes
            1. Ask the participants to watch with an eye towards aging changes.
            2. Discuss changes with aging, beginning with those observed in the movie. Ask participants to share their observations of aging changes in the movie.
              1. Physical changes – arthritis, visual impairment, hearing impairment, mobility impairment
              2. Social changes – loss, isolation
          2. PowerPoint presentation – “Aging and the Patient Encounter” – 25 minutes
            1. Audience response system optional
            2. If audience response system not used, then have participants show hands and offer answers for the slides with questions.
            3. Two main topics:
              1. Accommodating common changes with aging in the encounter (e.g. hearing)
              2. Physical findings and aging

BREAK

Part 2 – 60 minutes

        1. Diabetes as a Prototypical Chronic Illness
              1. Diabetes Case Discussion – 25 minutes
                1. Break participants into small groups (3 to 4). Give each small group note paper to write on and markers. Hand out Diabetes Case (Part 1). Instruct groups to read case and following questions. Each group should develop a set of history questions, physical exam items and lab studies. Pass out case (Part 2). Groups develop a prioritized assessment and management plan. Each group shares their “findings” with other groups. Ask groups to discuss their rationale for their prioritization of their management list.
              2. Mini-lecture PowerPoint presentation – “Type 2 Diabetes: Prototypical Chronic Illness” – 15 minutes
              3. Mini-lecture: PowerPoint presentation – “Preventing Foot Complications in People with Diabetes”– 15 minutes
                1. Have residents examine each other’s feet, ensuring proper use of monofilament – 5 minutes

BREAK

Part 3 – 60 to 90 minutes

        1. Prescribing Principles for Older Patients
          1. Mini-lecture: PowerPoint presentation – CHAMP Model – 15 minutes
            1. Review CHAMP model. Use discussion to highlight components of the model.
          2. Cases with discussion
            1. There are a number of cases – select ones you want to do. Allot about 15 minutes for each case discussion. For each case, hand out the learner guide and keep the discussion guide.
            2. Do with entire group (if no larger than 8), otherwise break into groups of manageable size.
            3. Hand out one case at a time. Reader reads case. All write down answers on note cards, pass to reader, who reads them. Facilitate group discussion, using “CHAMP” model to review medication lists and proposed changes.

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Open Handout

Older Patient Diabetes Case ^

Part 1

 

You are seeing Mr. H, a 70 y/o male with a history of hypertension and hyperlipidemia and diet-controlled type 2 DM. He has recently moved here and is presenting for an initial visit. He has no complaints

Past Medical History

Hypertension for 12 years
Hyperlipidemia for 6 years
Type 2 DM for 2 years

Past Surgical History

Appendectomy in early 20’s
ORIF of right forearm fracture in early 30’s
Colonoscopy 5 years ago – normal

Social History

Married for 46 years, 2 children
Retired electrician

Family History

Hypertension, diabetes

Medications

Lisinopril, 20 mg a day
Simvastatin, 20 mg a day
Aspirin, 81 mg a day

Allergies: NKDA

Vital Signs

BP 148/89, P 72, R 18, T 36.8, 171 cm, 98 kg

Assignment

        1. What information do you need to obtain?
          1. Write a list of the questions you are going to ask
          2. Write a list of the physical exam components you will complete
          3. What lab studies do you want to order?

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Part 2

 

Mr. H is feeling well, and has no particular complaints or concerns. His last eye exam was about two years ago, and everything was “OK.” He has never been told that he has any sort of kidney trouble, and he has had no trouble with his urination. He wears full dentures. He has had no chest pain, shortness of breath, orthopnea, or pedal edema. He has never had any TIA or stroke symptoms. He has no claudication symptoms. His feet don’t bother him, and he has never had any foot problems. He has some trouble with erectile dysfunction. Other review of systems is non-contributory.

He smokes cigarettes, about ½ PPD , and has an occasional beer or glass of wine – maybe 3 or 4 a week. He watches his sugar intake, and tries to walk about 1 mile per day.

He had a flu vaccine this year, but isn’t sure if he has had a pneumovax, and he has not had a zoster vaccine.

He does not check his blood sugar or blood pressure at home.

Physical Exam

HEENT – Edentulous, with dentures, o/w normal
Chest – Normal
Cardiac – Normal, pulses 2+ throughout
Abd – Normal
Extremities – Nl
Neuro – Nl
Feet – No abnormalities, sensation intact to 10 gram monofilament

Lab

CMP – Normal, with Cr 0.9, except glucose of 174
Hemoglobin A1c – 8.2%
Lipids – TC 230, HDL 42, LDL 140, TG 180

Assignment

  1. What is your plan?
    1. List your recommendations for management
    2. Prioritize this list
  2. What are possible “disease-aging” interactions that might occur in a patient with diabetes?

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Open Handouts

Prescribing in the Elderly^

Case 1^

 

Mr. P-R is a 90 y/o male with HTN, Type 2 DM, hyperlipidemia, peripheral neuropathy, visual impairment, hearing impairment and disequilibrium.  Although he no longer drives secondary to visual impairment, he is otherwise functionally independent, and enjoys reading, taking walks with his wife and his family.

He presents now with 3 falls in the past 4 weeks. He has no new symptoms – all of the falls involved “losing his balance.” He has not had syncope, and he fortunately has not suffered serious injury.  He otherwise feels well and has had no changes in his daily routine. He has had no symptoms of hypoglycemia

Medication list

Hctz 25 mg a day

Amlodipine 5 mg a day

Lisinopril 40 mg a day

Metoprolol 25 mg bid

Metformin XR 1 gm a day

Simvastatin 40 mg a day

ASA 81 mg a day
Vital signs

AF, R 16, Supine BP 120/70, P 68. Standing BP 100/60, P 72 (orthostasis new)

Has several bruises on his shins, but otherwise his exam shows a non-focal neuro exam, with no obvious change in his long-standing peripheral neuropathy. On “get-up and go” test he has normal muscle strength, and some gait unsteadiness.

Labs are remarkable for a Na+ of 125 (baseline 132), K+ 4.6, BUN 18, Cr 0.9, BS 147.


Case Discussion Instructions

  1. On an index card: Write the changes you recommend making in his medication list.
  2. Reader reads these changes
  3. Discuss medication list and changes using the CHAMP approach and in light of his recent falls.


Discussion

Mr. P-R presents with new onset of frequent falls. He has no evidence of new neurologic event. He has multiple reasons why he might fall – vision impairment, peripheral neuropathy and disequilibrium. New findings include orthostasis and hyponatremia.  All of his BP medications can contribute to orthostasis, and several can contribute to the development of hyponatremia. As both the hyponatremia and orthostasis increase his fall risk, one or more of the anti-hypertensives should be discontinued.


Cost and Compliance

His medications are all available in generic forms, most are on the $4 drug list at many pharmacies.

His wife has always monitored his medications and he rarely forgets to take them


Hazardous Interactions

There are several interactions here –

Amlodipine – Hctz

Amlodipine –  Lisinopril

Hctz – Lisinopril

Amlodipdine – Metoprolol

Lisinopril – Metoprolol

Hctz – Metoprolol

These interactions are all related to synergestic blood pressure lowering affects, and all of these medications can be prescribed safely together with appropriate monitoring

There is a theoretical risk of metoprolol masking signs of hypoglycemia in a patient on metformin.


Aging Pharmacology

HCTZ – Older adults are more susceptible to hctz-induced hyponatremia. HCTZ increases Na+ excretion at the level of the distal tubule

Lisinopril – ACE-I can cause SIADH, perhaps by increased levels of angiotensin-1 crossing the blood-brain barrier, leading to conversion to angiotension-2, which then acts on the pituitary to increase ADH release

Metoprolol – b-blockers can further blunt impaired baroreceptor reflexes in older adults. Older adults adrenergic receptors are also less responsive to b-blockade, so that b-blockers may be less effective anti-hypertensive agents in the elderly.

Metformin – Theoretical concern for lactic acidosis exists in older patients due to decline in renal function.


Medications to Avoid

None of these medications are contraindicated in the elderly


Medication Review

He is on multiple anti-hypertensives, and at least one should be discontinued due to his orthostasis.


Polypharmacy –
more medication than is clinically indicated

The patient is now normotensive and orthostatic, suggesting that he no longer requires all of his blood pressure medication.

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Case 2^

 

Mrs. CB is a 71 y/o woman with a h/o multiple sclerosis, htn, depression, breast ca, s/p mastectomy, ER+, and DVT.  She is wheel-chair bound secondary to her multiple sclerosis and lives in a nursing home. She has recent symptoms of urgency and dysuria. She has had no fever, and o/w feels at baseline. A nurse calls you (on call) on a Saturday with a report that the patient’s urine culture has grown E .coli sensitive only to trimethoprim/sulfamethoxazole, ciprofloxacin and amikacin. She is afebrile and her vital signs are normal.
Medication list

Interferon sub-q weekly

Femara 5 mg q day

Coumadin 4 mg a day

Lisinopril 20 mg a day

Hctz 25 mg a day

Celexa 10 mg a day


Case Discussion Instructions

  1. On an index card: Write any additional information you would like to have, and what you recommend prescribing.
  2. Reader reads the answers on the cards
  3. Discuss potential interactions and what can be done to minimize the risk of these interactions. Include the antibiotics discussed.


Discussion

The on-call resident, the nurse and the patient are now stuck between the proverbial “rock and a hard place.” The patient has a symptomatic UTI, and the only oral medications both interact with Coumadin. The aminoglycoside, which can be given daily for uncomplicated UTI, must be given by injection. Important information that must be known before a well-informed decision can be made include the patient’s weight and creatinine (or the most recent creatinine clearance), and the patient’s INR.

The patient’s INR is 2.6, her Cr is 1.8, and her weight is 74 kg.

What is her estimated creatinine clearance?

Important interactions to consider include –

  • Sulfamethoxazole and Coumadin. Sulfamethoxazole interferes with the hepatic metabolism of the s-isomer of Coumadin. This is the most active form of Coumadin. On average, sulfa will produce the greatest rise in INR of any antibiotic, and should be avoided.
  • Ciprofloxacin also interferes with the metabolism of Coumadin, through a variety of medications, including affect on gut flora and inhibition of metabolism. The affect on INR is more variable, and while ciprofloxacin and other quinolones should be avoided, if possible, cipro can be given with either reduction of the coumadin dose and/or close monitoring of the INR.

The safest choice for this patient is amikacin, which can be given once daily in this patient due to her creatinine clearance.

This patient was actually seen in the emergency room and placed on bactrim. Several days later she developed a severe headache. She was found to have a sub-dural hemorrhage, and an INR of 7.5. She underwent craniotomy with removal of a portion of her parietal bone for decompression.

Always check for potential interactions when prescribing a medication for a patient on Coumadin.

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Case 3^

 

Mr.  W is an 85 y/o man with a h/o CAD, CHF, HTN and a fib admitted for chest pain and CHF exacerbation. He is felt to have ischemia secondary to strain related to his CHF. He is placed on his home medications and his lasix dose is increased.  You are called on night float on his second hospital day because he has become hypotensive. He denies chest pain, and his shortness of breath is better than it was on admission.

VS: P 56, R18, BP 85/40, T 36.7. The patients lungs are clear, and he has no JVD or HJR. He does not appear acutely ill. His EGK is without change from admission, and shows no evidence of acute ischemia.
Medication list

Metoprolol 50 mg BID

Lisinopril 20 mg BID

Verapamil SR 120 mg BID

Warfarin 5 mg q day

KCL 10 meq q day

ASA 81 mg a day

Isosorbide dinitirate, 20 mg tid

Lasix 60 mg BID (home dose 20 mg bid).
Afternoon labs

INR 4.5, BUN 24, CR 1.2 (baseline 1 to 1.3), hgb 13.8


Case Discussion Instructions

  1. On an index card, write your differential for the patient’s hypotension and elevated INR.
  2. Reader reads answers
  3. As a group, apply the CHAMP approach to this patient’s medication list and discuss.


Discussion

The patient presents with hypotension during treatment for a congestive heart failure exacerbation. The absence of chest pain and an EKG without acute changes lowers the likelihood that ischemia is the cause. The absence of fever and generally well appearance makes sepsis less likely. The elevated INR should raise suspicion for hemorrhage, and this needs to be considered, despite the recent normal Hgb. The absence of dyspnea and well appearance, and his anticoagulation status makes a PE less likely. While overdiuresis needs to be a consideration in this setting, the relatively normal BUN/Cr ratio coupled with baseline creatinine lowers the likelihood that this is the culprit.

This patient’s hypotension was due to “compliance.” At home he was not able to manage this fairly complicated drug regimen, and thus did not take his medications as prescribed. In the hospital he was prescribed his medication list, without reviewing it carefully with him. Since he was now being given all of his medications, he suffered an adverse drug event.

The goal now is to streamline his medication regimen, using as simple and effective a regimen as possible.


Cost and Compliance

This regimen is comprised of generically available drugs, and could be purchased for less than $50/month. Compliance is obviously an issue.


Hazardous Interactions

Verapamil – metoprolol – bradycardia, heart block

b-blockers and nitrates – hypotension

Asa and warfarin—increased risk of bleeding;

enalapril and k+  – hyperkalemia

Drug-disease interaction –verapamil and CHF – increased mortality in CHF


Aging pharmacology

Pharmacodynamics

Verapamil—increased receptor sensitivity leads to more constipation and a greater HR response

Coumadin – increased receptor sensitivity to Coumadin

Pharmacokinetics

Verapimil is a high first-pass clearance drug, and decreased clearance in aging


Medications to avoid

Avoid aspirin with anticoagulants

Avoid verapamil in patients with CHF and constipation


Polypharmacy

The patient is on several medications that may not be needed or whose risk exceeds the benefits. Consider tapering/discontinuing verapamil, aspirin and isosorbide.

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Case 4^

 

Mr. RW is a 90 y/o man with moderate Alzheimer’s dementia, dysphagia, CKD (baseline Cr = 3.0), agitation and gout, admitted with nausea and vomiting, refusing food and drink. He is afebrile, his vital signs are normal, and he has a benign abdominal exam. Lab work is within normal limits, apart from an elevated BUN/CR.

He lives with his wife, who is his primary caregiver. She is 86 y/o and in poor health.

At baseline, he is able to ambulate and feed himself, but needs help with bathing, dressing and toileting.
Medication list

Exelon, 6 mg BID

Triamterene/HCTZ 37.5/25 daily

Seroquel  25 mg daily

Levothyroxine 50 mcg a day

Trazodone, 50 mg a day

Alprazolam, 0.25 mg qhs

Colchicine, 0.6 mg a day

Tolterodine, 0.4 mg a day


Case Discussion Instructions

  1. On a note card, write down medications you would stop
  2. Read these aloud
  3. As a group, discuss this patient’s medication list using the CHAMP approach.
  4. Could any of his medications cause his nausea and vomiting?


Discussion

This patient’s nausea and vomiting could be secondary to Exelon (common side effect), or colchicine (particularly if he is taking this incorrectly).


Cost and Compliance

Exelon and seroquel are both expensive medications.

How is he taking the medication? Who is monitoring medication adherence?


Hazardous Interactions

Seroquel – Trazodone – Xanax:  increased risk of sedation, psychomotor impairment (synergestic effects)

Exelon-tolterodine: Exelon is pro-cholinergic; tolterodine is anti-cholinergic. These two drugs have antagonistic effects, and Exelon will likely decrease effectiveness of tolterodine.
Disease-Drug interactions:

Thiazide diuretics – gout: thiazides increase uric acid and risk of gout attack

Benzodiazapine – dementia: increase risk of falls

Seroquel and dementia – increased risk of death in patients with dementia taking antipsychotices.


Aging pharmacology

Pharmacodynamics

Benzodiazepine—increased receptor sensitivity leads to more CNS side effects

Pharmacokinetics

Xanax is fat-soluble, older patients have lower lean body mass – volume of distribution increased, leading to longer t ½

Xanax is metabolized by hepatic oxidative pathway, which is decreased in elderly, and has active metabolites, leading to prolonged t ½.


Medications to avoid

Avoid benzodiazapines in patients with dementia (falls, confusion)

Avoid thiazides in patients with gout

Avoid colchicine in patients with significant CKD


Polypharmacy

Patient is on several medications that interact with underlying diseases, or with each other, or may synergistically cause CNS side effects, or may not be effective.

His triamterne/hctz should be discontinued, and another BP medication substituted. This may, in itself, decrease risk of gout enough to stop his colchicine.

His alprazolam should be stopped, as well. An effort should be made to stop his trazodone – its effectiveness in agitation is not proven.

His tolteridone should also be discontinued, with monitoring for recurrence of GU symptoms.

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Case 5^

 

Mr. EW is a 77 y/o male with h/o HTN, CAD s/p CABG and CKD, stage 3, BPH and hyperlipidemia. His wife brings him in because of concern for several weeks of trouble swallowing, decreased oral intake, trouble urinating and fatigue. About 3 weeks ago had developed nasal congestion and a cough. He was seen at an urgen care center, and placed on moxifloxacin (completed 5 days ago), diphenhydramine and pseudoephedrine.

On exam he is afebrile, with BP 115/72, P 74, R 16, T 36.8. He has lost 2 kg since last visit 4 weeks ago. His exam is o/w unremarkable, and he has a non-focal neuro exam.
Medication List

Lisinopril 20 mg a day

Lopressor 50 mg BID

ASA 81 mg a day

Simvastatin 40 mg a day

Diphenhydramine, 25 mg qid

Pseudoephedrine, 30 mg tid

Guiafenisin prn.


Case Discussion Instructions

  1. Write, on a notecard, your differential diagnosis
  2. Reader reads cards
  3. Analyze medication list using CHAMP and discuss as a group.


Discussion

The patient has the subacute onset of trouble swallowing and decreased oral intake after being treated for what was likely a viral URI. In this setting, the most likely etiology of these symptoms is an ADR/ADE, likely secondary to diphenhydramine and pseudophedrine.  Other possibilities include an esophageal web or stricture, GERD, oropharyngeal muscle dysfunction, or a degenerative neurologic disease.


Cost and Compliance

This is a fairly inexpensive medical regimen.

Need to ascertain how he is taking medications.


Hazardous Interaction

Drug-Drug Interaction

Lisinopril-metoprolol: Increased blood pressure lowering through synergestic effects.

Pseudoephedrine – lisinopril/metoprolol – antagonistic effects. Pseudoephedrine may lessen anti-hypertensive effectiveness.


Drug-Disease Interaction

Pseudoephedrine-BPH: pseudoephedrine, as an a-agonist, may lead to increased difficulty urinating or urinary retention in men with BPH.


Aging pharmacology

Pharmacodynamics

Diphenhydramine: Increased receptor sensitivity, enhanced anticholinergic profile.


Medications to avoid

Diphenhydramine


Polypharmacy

On more than 5 meds. Several may not be needed any longer. No clear indication now for diphenhydramine and pseudoephedine.

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Open Handout

Principles of Drug Prescribing in Hospitalized Elderly Patients^

 

Admission:
Review all medications (include relevant OTC) taken by patient prior to hospitalization; assess previous compliance

Avoid unnecessary polypharmacy by:

  • Using drugs that treat more than one condition (e.g., betablockers for both hypertension and angina pectoris) when practical.
  • Discontinue drugs unnecessary in hospital, (e.g. urinary antispasmodic when catheter has been placed).

Safe prescribing habits:
When initiating a new medication:

  • Choose agents whose pharmacokinetic properties in elderly patients are known.
  • Begin with a short-acting agent but by discharge convert to an agent that is given once or twice daily in order to enhance patient compliance and reduce caregiver burden at home.
  • If patients require multiple medications, avoid, whenever possible, drugs that are inhibitors or inducers of Cytochrome P450 hepatic metabolism, or are highly bound to albumin. Examples:ceftriaxone, diazepam, lorazepam, phenytoin, valproic acid, warfarin.If in doubt, consult a pharmacist, on-line pharmacology program, or text source.
  • When the maintenance dose of a medication is not established, “start low and go slow”, to allow time to titrate the dose against the desired clinical effect.
  • Use lower than usual maintenance doses of medications that are renal excreted (e.g. digoxin).

Adverse drug events (ADE’s):
Anytime a patient develops a new or unexplained medical problems consider ADE as a cause: (e.g. delirium, hypotension, arrhythmias, renal failure, electrolyte disorders, constipation).

At time of discharge:

  • Review medications that were taken by patient prior to admission and evaluate which should be renewed on discharge.
  • Review all discharge medications with the patient and family, and provide written instructions.

Prescribing Guidelines for the Elderly

  1. When prescribing new medications review the following issues:
    1. Is medicine often necessary?
      (i.e. is there a nonpharmacologic treatment?)
    2. Determine therapeutic endpoints
    3. Assess: risks vs benefits
    4. Can one medication treat more than one condition?
    5. Administration time matches existing medicines?
  2. Identify all drugs by generic name and drug class.
  3. All drugs prescribed should have clinical indication.
  4. Know the side effect profile of drugs you prescribe.
  5. Understand aging pharmacokinetics and how to decrease ADE’s
  6. Stop all drugs without known benefit.
  7. Stop all drugs without clinical indication.
  8. Always attempt to substitute less toxic drug.
  9. Avoid negative prescribing cascade (i.e. treating one ADE with another drug)
  10. Brown bag inventory (Annual or biannually)
    • Have assistant go thru OTC’s, creams and “left over” meds and record for you. (25% of prescription drugs not recorded)
    • Coincide with annual major check-ups.
    • Reception staff automatically reminds patient when they schedule to bring in all meds (brown bag)
    • Offer to throw away outdated and unused meds.
  11. Follow these axioms:
    “One disease, One drug, Once a day”
    “Go-Low, Go-Slow” (start with ½ usual dose, take twice the time to increase)
    “Fix the CAN’T’s” (read, afford, open, remember, swallow)

Web site: geriatrics.unmc.edu Evv5/03