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
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
- Introduction to the Older Patient – 10 minutes
A.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
- Goals of session
- Demographics of aging
- Chronic illness and aging
- Role of FM in caring for the elderly
- Quality in health care
- Aging
A.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
- Ask the participants to watch with an eye towards aging changes.
- Discuss changes with aging, beginning with those observed in the movie. Ask participants to share their observations of aging changes in the movie.
- Physical changes – arthritis, visual impairment, hearing impairment, mobility impairment
- Social changes – loss, isolation
B.PowerPoint presentation - “Aging and the Patient Encounter” – 25 minutes
- Audience response system optional
- If audience response system not used, then have participants show hands and offer answers for the slides with questions.
- Two main topics:
- Accommodating common changes with aging in the encounter (e.g. hearing)
- Physical findings and aging
BREAK
Part 2 - 60 minutes
- Diabetes as a Prototypical Chronic Illness
A.Diabetes Case Discussion – 25 minutes
- 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.
B.Mini-lecture: PowerPoint presentation – “Type 2 Diabetes: Prototypical Chronic Illness” – 15 minutes
C.Mini-lecture: PowerPoint presentation – “Preventing Foot Complications in People with Diabetes” – 15 minutes
- Have residents examine each other’s feet, ensuring proper use of monofilament – 5 minutes
BREAK
Part 3 – 60 to 90 minutes
- Prescribing Principles for Older Patients
A.Mini-lecture: PowerPoint presentation – CHAMP Model – 15 minutes
- Review CHAMP model. Use discussion to highlight components of the model.
B.Cases with discussion
- 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.
- Do with entire group (if no larger than 8), otherwise break into groups of manageable size.
- 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.
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
- What information do you need to obtain?
A.Write a list of the questions you are going to ask
B.Write a list of the physical exam components you will complete
C.What lab studies do you want to order?
Older Patient Diabetes Case – 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
- What is your plan?
A.List your recommendations for management
B.Prioritize this list
- What are possible “disease-aging” interactions that might occur in a patient with diabetes?
Prescribing in the Elderly
Resident’s Guide
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
- On an index card: Write the changes you recommend making in his medication list.
- Reader reads these changes
- Discuss medication list and changes using the CHAMP approach and in light of his recent falls.
Case 1
Instructor’s Guide
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
Case 1
Metoprolol – -blockers can further blunt impaired baroreceptor reflexes in older adults. Older adults adrenergic receptors are also less responsive to -blockade, so that -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.
Prescribing in the Elderly
Resident’s Guide
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
- On an index card: Write any additional information you would like to have, and what you recommend prescribing.
- Reader reads the answers on the cards
- Discuss potential interactions and what can be done to minimize the risk of these interactions. Include the antibiotics discussed.
Case 2
Instructor’s Guide
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.
Prescribing in the Elderly
Resident’s Guide
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
- On an index card, write your differential for the patient’s hypotension and elevated INR.
- Reader reads answers
- As a group, apply the CHAMP approach to this patient’s medication list and discuss.
Case 3
Instructor’s guide
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
-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
Case 3
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.
Prescribing in the Elderly
Resident’s guide
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
- On a note card, write down medications you would stop
- Read these aloud
- As a group, discuss this patient’s medication list using the CHAMP approach.
- Could any of his medications cause his nausea and vomiting?
Case 4
Instructor’s guide
Discussion
This patient’s nausea and vomiting could be secondary to Exelon (common side effect), or colchicine (particularly if he is taking this incorrectly).