Palliative Medicine and Care of the Elderly

Question 1

Progressive frailty

Answer 1

• Slow, dwindling decline, often with sarcopenia and weight loss
• Multiple comorbidities and progressive functional/cognitive impairment
• Gradual loss of functional reserve, increased susceptibility to illness, reduced capacity to recover from acute illness
• Many will need LTC

Question 2

When to initiate a palliative approach in an elderly patient with chronic illness

Answer 2

1. Positive surprise question
2. Newly diagnosed life-limiting condition
3. Worsening prognostication markers for a specific disease
4. Downward step in response to treatment
5. Multiple hospital admissions
6. Admission to a nursing home
7. Spouse has recently died

Question 3

Palliative needs assessment aims

Answer 3

• Match types and levels of need to most appropriate providers/services
• Determine which needs can be met in which setting, and where specialist care is required
• Facilitate communication between primary and specialist care providers regarding needs and interventions

Question 4

Geriatric oncology (practice)

Answer 4

• Involves the integration of a multi-dimensional comprehensive geriatric assessment for all people aged >70 with cancer
• Identifies health/psych issues that may interfere with proposed treatments
• Identifies correctable conditions and helps in establishing treatment goals
• Limited by time and cost with lack of data to prove improved outcomes

Question 5

Heart failure clinics (practice)

Answer 5

• Aim is to reduce mortality and rehospitalization rates and improve quality of life through individualized patient care
• Focus on disease management, functional assessment, quality of life, and optimized medical therapy and drug evaluation

Question 6

Pulmonary rehabilitation (practice)

Answer 6

• If patient with COPD is well enough to participate, likely to have clinically significant benefit in terms of dyspnea, fatigue, and well being.
• Patients should not be excluded based on age

Question 7

Breathlessness clinics (practice)

Answer 7

• Nurse or PT led interventions to improve dyspnea

- Some evidence to suggest this improves outcomes of patients with advanced lung CA

Question 8

Transitional care

Answer 8

• Models of care that facilitate smooth transitions across health care settings
• Logistical arrangements and coordination amongst services to facilitate movement of a person from hospital, subacute and post acute nursing facilities, home, outpatient care etc. within the same setting
• Integrated ‘shared care’ model can reduce ED presentations and prevent avoidable admissions

Question 9

Impact of living alone on care of the edlerly

Answer 9

• Influences place of care and death - more likely to be in hospital
• ‘Ageing in place’ is typically contingent upon caregiver support

Question 10

Core elements of a palliative approach for Community Dwelling elderly

Answer 10

1. Timely access to specialist PC
2. Case management, coordination, and communication across care settings
3. Support for home-based care (including after hours access)
4. Tailoring and targeting services to the population and setting (esp. cultural needs)
5. Consideration of workforce issues across the care continuum
6. Collaboration across the health care continuum (LTC, community acute care, etc.)
7. Integration health and social services to support community PC

Question 11

Challenges to the provision of PC for Dementia

Answer 11

1. Difficulties in identifying a clearly defined terminal phase
   - Consider use of tools (e.g. KPS, FAST, ADEPT tool)
2. Protracted duration of end stage illness (weeks to months)
3. Issues relating to communication and decision making
   - Families may not be clear on prognosis, leading to inappropriate interventions
4. Assessment of pain/symptoms in the cognitively impaired
5. Behavioural disturbances

Question 12

Adverse consequences of PEG tube placement in dementia

Answer 12

• Pain
• GI bleeding
• Use of restraints
• Fecal incontinence
• Aspiration and pneumonia
• No survival benefit as per systematic review

Question 13

Treatment of BPSD (acutely)

Answer 13

Quetiapine if PD (preferred for psychosis)
Risperidone (preferred for LBD)

Benzos and first gen antipsychotics (e.g. Haldol) should generally be avoided.

Elderly patients treated with antipsychotics have an increased risk of death compared to placebo, mostly due to cardiovascular events and infections. Indicated only for short-term, symptomatic management of aggression or psychotic symptoms in patients with severe AD unresponsive to non-pharmacologic approaches and risk of harm to self or others.

Question 14

Risk factors for delirium in elderly patients

Answer 14

• Increasing age
• Dementia and cognitive impairment
• Visual impairment
• Admission to hospital for fracture
• Severe medical illness

Question 15

Preventative strategies for delirium

Answer 15

• Orienting approaches
• Managing dehydration and constipation
• Avoidance of unnecessary catheterisation
• Optimizing oxygen sats
• Encouraging mobility
• Resolving reversible causes of sensory impairment (e.g. glasses, hearing aids)

Question 16

Depression in the elderly

Answer 16

• Older age is a known risk factor for depression

Risk factors:

• Unmarried status
• Living alone
• Lack of social supports
• Negative life events (e.g. bereavement)
• Lower SES
• Certain medical disorders (CVD, PD, cancer, stroke, lung disease, arthritis, dementia)

Question 17

Impact of depression on the elderly

Answer 17

• Symptoms may mirror comorbid medical illness
• Validated scales (Geriatric depression scale) may be useful
• May contribute to cognitive deficits, but these sometimes do not fully resolve with effective antidepressant treatment
• Sertraline, citalopram, escitalopram are first line tx - least drug interactions and best safety profile

Question 18

Assessment of delirium in the elderly

Answer 18

Confusional Assessment Method

CAM requires following:
- Acute onset and fluctuating course
- Inattention
And one of:
- Disorganized thinking
- Altered LOC

Question 19

Ddx for hearing loss

Answer 19

• Presbycusis (age related hearing loss)

- Cerumen impaction

Question 20

Vision impairment in elderly patients

Answer 20

• Age related macular degeneration
• Glaucoma
• Cataracts
• Diabetic retinopathy

Question 21

Ddx of xerostomia

Answer 21

• Age related changes (contested)
• Anticholinergic meds
• Radiation
• Medical conditions (sjogren’s, DM, AD, dehydration)
• Chemo

Meds

• Antidepressants
• Sedatives
• Antihistamines
• Antihypertensives
• Cytotoxic agents
• Anti-epileptics
• Levodopa

Question 22

Impact of aging on skin

Answer 22

• Epidermis thins, stratum corneum loses ability to retain water, cell replacement, barrier function, and would healing decrease
• May change absorption of transdermal meds and increase risk of pressure ulcers

Question 23

Changes in drug metabolism in the elderly

Answer 23

1. Reduction in hepatic first-pass metabolism (decreased liver mass and perfusion)
   = Reduced bioavailability of some drugs that require first-pass activation (e.g. perindopril)
   = Increased bioavailability of some drugs that would normally have extensive first pass metabolism (e.g. opioids!)
2. Changes in body composition, less lean body mass and more body fat and total body water
   = Smaller volume of distribution for hydrophilic drugs ( = higher plasma concentrations), e.g. digoxin, lithium
   = Larger volume of distribution for lipophilic drugs (prolonged half life) e.g. diazepam, fentanyl
3. Age related decline in renal function
   = Drug accumulation in some renally excreted drugs
4. Fragile brain
   = More risk with psychoactive drugs and polypharmacy