common mistakes in geriatrics

Common Mistakes in Geriatrics

Timothy R. Malloy, M.D.

Overview

• Ample personal experience with making geriatric mistakes

• polled 10 geriatricians/geriatric psychiatrists

• “Top 20” mistakes but not in order of importance or frequency

• alternative approach offered

#1. “My doctor told me it was because I was old”

#1. “My doctor told me it was because I was old”

• Not true for most conditions• Conveys message that patient is no longer

important enough to bother with• Is not therapeutic in any way• Viable therapeutic options go overlooked

#2. Talking to the daughter (ignoring the patient)

#2. Talking to the daughter (ignoring the patient)

• Insensitive, degrading• Very commonly done in patients with hearing

impairment, visual impairment, and especially cognitive impairment

• Sometimes difficult to avoid• Be “on guard” and situate family and patient

directly across from yourself so that both can see and hear you at the same time

#3. Seeing Nursing Home Patients in the Office

#3. Seeing nursing home patients in the office

• Artificial environment of office• No collateral sources of information available

(see #5)• Better seeing patients in their own environment• More efficient in nursing home• More cost-effective in nursing home (zero

overhead)

#4. Seeing Nursing Home Patients Without a Nurse

#4. Seeing nursing home patients without a nurse

• Nursing input is critically important (especially in this population)

• 10 lb. charts - very difficult to discover information

• Direct communication with nursing staff:– cuts down phone calls– improves coordination of care plan– allows opportunity for teaching (both ways)

#5. Making Nursing Home Rounds on Your “Day Off”

#5. Making Nursing Home Rounds on Your “Day Off”

• Makes NH rounds into chore that interferes with personal time

• Rounds should be scheduled during routine M-F work hours

• Weekly for 1 hour is better than monthly for 4 hours

#6. Delayed Diagnosis of Dementia

#6. Delayed diagnosis of dementia

• Dementia symptoms are usually present for 3 years before diagnosis

• Over 50% of the 5 million people with dementia are undiagnosed

• Always better to have the problem identified

#6. Delayed diagnosis of dementia

• Compliance with medications and appointments• Unreliable symptom reporting (undetected,

treatable medical conditions)• Safety issues, auto accidents, environmental

exposure• Financial victimization• Social isolation and neglect (until crisis situation)• Missed opportunity to begin treatment at early

stage

#7. Failure to Treat Dementia

#7. Failure to treat dementia

• Cholinesterase inhibitors help• Cholinesterase inhibitors help cognition,

preserve function, delay institutionalization, and lessen behavioral complications

• Not using MMSE to help decide efficacy

#8. First Line Treatment of Agitation with Benzodiazepines in Patients with

Dementia Related Behavioral Disturbances

#8. First line treatment of agitation with benzodiazepines in patients with dementia

related behavioral disturbance• Seldom the most appropriate treatment• Unfavorable risk : benefit ratio• Need to determine the specific target

symptom and tailor treatment to that symptom– examples: psychosis - antipsychotic, e.g. Zyprexa

mood lability - mood stabilizer, e.g. Depakotedepression - antidepressant, e.g. Zoloft

#9. PRN Analgesics for Dementia Patients

#9. PRN analgesics for dementia patients

• Memory problems usually result in underdosing

• Frequently have to “play catch-up”• Routinely schedule analgesics more

effective

#10. Sensory Deprivation Masquerading as Dementia

#10. Sensory Deprivation Masquerading as Dementia

• Severe hearing impairment - “irrelevant” responses to questions

• Visual impairment - failed MMSE, visual hallucinations (Charles Bonet syndrome)

#11. Failure to Rule Out Organic Causes Masquerading as

Depression

#11. Failure to rule out organic causes masquerading as

depression• Should check TSH before treating

depression• Remember medication side effects (Beta

blockers, Digoxin, benzodiazepines….)• Inadequate pain management• Parkinson’s Disease, Thyroid Disease,

Cognitive failure

#12. Polypharmacy

#12. Polypharmacy

• Elderly receive 3Xs as many meds as young people

• Elderly are less capable of “handling” medications as younger people

• “Art” of recognizing medication side effects• Many examples such as cognitive SEs,

EPSEs, Appetite SEs….

#13. Continuing Elavil When Neurologists and Rheumatologists

Place Your Patients on it

#13. Continuing Elavil when neurologists and rheumatologists

place you patients on it• Still commonly prescribed• Almost never appropriate (2nd generation

TCAs better tolerated)• Highly anticholinergic• The older the patient, the more likely to be a

problem• “dead give away” that you’ve never taken a

course in geriatrics in the last 20 years

#14. Demerol as Acute Analgesic

#14. Demerol as Acute Analgesic

• Usually causes confusion (delirium)• Several safer alternatives

#15. Benadryl for Insomnia

#15. Benadryl for Insomnia

• Impairs cognition (even in younger adults)• Beware of many OTC medications such as

Tylenol PM• Better alternatives available

#16. No Osteoporosis Treatment with Obvious Disease

#16. No osteoporosis treatment with obvious disease

• Never too old to benefit from osteoporosis treatment

• Approximately half of all hip fracture patients are on no treatment

• Calcium, Vitamin D, antiresorptive agent?

#17. NSAIDs/COX-II Inhibitors as First and Only Treatment of

Osteoarthritis

#17. NSAIDs/COX-II inhibitors as first and only treatment of

osteoarthritis• Expensive• Numerous side effects• Patients often remain on NSAIDs for years• Many potentially better alternatives such as

Acetaminophen, physical therapy, corticosteroid injections, opioids

#18. Mistaking Delirium for a Primary Psychiatric Diagnosis

#18. Mistaking delirium for a primary psychiatric diagnosis

• UTIs as frequent cause of admission to geripsych. Hospital

• Cause of delirium almost always “lies outside the brain”

• Most common presenting symptom is fluctuating levels of alertness and confusion

#19. Delaying Hospice and Palliative Care

#19. Delaying Hospice and Palliative Care

• Avoiding serious end-of-life discussion in patients with advanced irreversible conditions (AD, COPD, CHF)

• Early discussion is often welcome• Prevents unnecessary procedures,

hospitalizations, suffering, and expenditures

#20. Failure to Factor Life Expectancy into Medical

Decision Making

#20. Failure to Factor Life Expectancy into Medical

Decision Making

• HCM (paps, mammography, PSA, colonoscopy)

• Hyperlipidemia management• Anticoagulation for atrial fibrillation