MATT BEELEN, M.D.JULY 28 , 2010

Individualized Decision Making in the Elderly

Introduction

All elderly are not alike – divergence of agingEvidence-based guidelines fall short

Age, exclusion criteria of studiesWe are still faced with clinical decisions we

need to addressAs patients age, the burden of tests and

treatments can continue to grow ? Diminishing returns

How best can we make decisions in these circumstances? “Quality” of care, Quality of Life

Individualizing Care: Objectives

Given various clinical scenarios, you will:

Estimate life expectancyDetermine “time to benefit”Determine type and magnitude of harms/risksDetermine type and magnitude of benefitDetermine patient values and preferencesIncorporate all of this information into a

management plan

Agenda

Explain each of the objectivesDemonstrate how to apply each of the

objectivesPractice applying the concept to clinical

cases

Time

Based on the amount of time we expect the patient to live, will he/she live long enough to derive benefit from the test or treatment in question? What things will help in the time remaining?

Life expectancyTime to benefit

Life Expectancy

How do we determine this?Start with a general estimate (population

statistics)Modify based on:

Comorbidities (and associated clinical data) Known illness trajectories Functional Status Symptoms Will to live

Life Expectancy - General

A starting pointGeneral health for

age Excellent Average Poor

Handout

Comorbidities

Number, status of, and symptoms related to significant medical conditions Dementia/Neurodegenerative Disease (Severity) Cerebrovascular disease/Stroke (Severity) Cardiac Disease (Type, NYHA Class) Pulmonary Disease (Stage, Gold Class) Renal Disease (Stage) Malignancy (Type, Stage, Grade) Diabetes (End Organ Disease)

Known Illness Trajectory

Disease specificPatient specific based

on current clinical changes

Functional Status

ADL and IADL Status More useful for “non-palliative” elderly

Palliative Performance Scale (derived from Karnofsky Performance Scale) – handout Correlates with survival, especially in palliative care

population Validated in multiple studies For use in the general geriatric population it can be

helpful to stratify into excellent-average-poor health status

Prognosis – Heart Failure

Unpredictable TrajectoryNYHA Class and 1 year mortality

Class II: 5-10%, Class III: 10-15%, Class IV 30-40%Other factors associated with limited prognosis:Recent cardiac hospitalizationIncreased BUN or Cr, Low Na or HgSBP < 100, HR > 100, LVEF <45%Resistant ventricular dysrhythmiasCachexia, decreased functional capacityComorbidities: DM, depression, COPD, liver, CVA,

Cancer, HIV cardiomyopathy

Reisfield GM. J Pall Med 2007;10:245-246.

Prognosis - COPD

Childers JW et al. J Pall Med 2007;10:806-807.

Prognosis - Dementia

Factors associated with worse prognosis Comorbidities (e.g. DM, CHF, COPD, cancer) Loss of physical function (related to dementia)

Bowel incontinence Bed bound, asleep most of the time Weight loss, dysphagia, poor po intake

Other complications and symptoms in advanced dementia Seizures, Hip fractures Pressure ulcers Dehydration Fever, aspiration, pneumonia Oxygen requirement, dyspnea

See Mortality Risk Index Score Handout

Tsai S. J Pall Med 2007;10:807-808.

Mitchell SL et al. JAMA 2004;291:2734-2740.

Prognosis – General Outpatient Elderly

4 and 5-year mortality: increased risk associated with Increasing age Male gender Comorbidities (DM, Ca, lung or heart disease, low

BMI, smoker) Functional dependence (bathing, finances, walking

several blocks, pushing/pulling heavy objects) Hospitalization in the last year Poor self-rated QOL

Schonberg MA et al. J Gen Intern Med 2009;24:115-1122.

Lee SJ et al. JAMA 2006;295:801-808.

Prognosis: Discharge From Hospital

Walter LC et al. JAMA 2001;285:2987-2994.

Developed and validated in 3000 adults > age 70

Will to Live

Different than patient preferencesA “fighter” vs “ready to go anytime”

Consider loss of spouse and family Consider spirituality, view of death and afterlife Consider “unfinished business” Consider what the person has to live for Is current QOL such that patient would like to prolong

life?

Practice - Life Expectancy

Handout

Ranges are probably most helpful < 5 years 2-5 years < 2 years

What is type and extent of benefit?

How can the test or treatment benefit the patient? Prevent cancer Detect and remove cancer (that may not be harming

patient) Prevent death Prevent hospitalization Prolong life Decrease symptoms – pain Improve function, maintain independence Change lab values: LDL, A1C, Hg

Time to Benefit

How long does it take for a patient to realize the benefit of a test or treatment?

Minutes to hours – pain relief from pain medication

Years – mortality benefit of cancer screeningInformation usually comes from clinical

trials that may not include patients like yours – only an estimate…

Time to Benefit – Cancer Screening

Time to mortality benefit Breast > 5 years Colon > 5-10 years Cervical Cancer 5-10 years Prostate > 10 years (if any benefit at all)

Factors to consider Prior screening Risk factors (e.g. family history)

Time to Benefit – Other Conditions

Bisphosphonates for fracture prevention in osteoporosis: 1-2 years

Statins for hyperlipidemia to prevent CV events: 1-2 years (<6 months if recent ACS)

HTN meds to prevent stroke, CHF, CV events, death: 1-2 years

Tight vs relaxed glucose control in diabetes to prevent macrovascular disease: 5-10 years

SSRI for depressive symptoms: weeksDiuretics for fluid overload: hours to days

Precision vs Estimate – many treatments unclear

Type and Magnitude of Harms

What is the negative side of testing or treatment? Financial cost (to anyone) Time, appointments Pill burden (and ECF issues) Pain, adverse effects, side effects Future ethical dilemmas: PEG tube, pacemakers Impact of false positive test results (physical,

emotional) Impact on patients with dementia

Time to harm: Harm could very likely come before benefit (e.g. hypoglycemia with DM meds)

Putting it Together – Physician Agenda

To help us focus our care efforts, we can consider Estimated life expectancy Potential harms and benefits Time to harm and benefit

With increasing frailty: “Relax your agenda”

See handouts Flaherty JH et al. J Am Geriatr Soc 2002;50:1886-

1901. Reuben DB. JAMA 2009;302:2686-2694.

Patient Values and Preferences

Quality of life vs length of lifeSpecific goals: remain at home, continue

driving, limit medication side effects, avoid needles

What kind of decision making does patient prefer: independent vs paternalistic

Does patient/surrogate understand medical issues?

What do we recommend? Based on intersection of medical information and

patient preferences

Putting it Together

Eventually integrate into every patient encounter

Many gray areas will remainPractice

Use of this model in aging population is preferable to:

Doing the same thing for everyone Using arbitrary age cutoffs routinely Over reliance on patient preference Over emphasis on physician agenda