Geriatric Times. Dear Colleagues: Barbara Messinger-Rapport, MD, PhD Interim Chair, Geriatric Medicine Cleveland Clinic Medicine Institute

Transcription

1 Geriatric Times An Update for Physicians from Cleveland Clinic Medicine Institute Winter 2009 Dear Colleagues: I am pleased to have this opportunity to update you on geriatric care at Cleveland Clinic. We hope that the knowledge we share will help improve the care of older adults who represent the most vulnerable and frail of our patients. The unique needs of the elderly often require multidisciplinary assessment and management, in conjunction with the care and attention provided by dedicated primary care physicians. Our long history of caring for older adults, expertise in providing comprehensive geriatric care, educational programming and unique Geriatric Fellowship Program have made Cleveland Clinic s Section of Geriatric Medicine one of the top programs of its kind in the United States. We are at the leading edge of basic and clinical research in memory disorders and other geriatric conditions. Barbara Messinger-Rapport, MD, PhD Interim Chair, Geriatric Medicine Cleveland Clinic Medicine Institute Our goal is to reach out to physicians, nurses, therapists, social workers, other clinical health providers and caregivers to improve care of geriatric patients. We believe that by involving the spectrum of health professionals and social services, and sharing best practices with colleagues, we can impact the quality of life for the elderly. also in this issue Clinic Joins Collaborative Effort to Improve Health Literacy Falls Prevention is Goal of Cleveland Clinic Pilot Program These articles represent a small fraction of our efforts to make a difference in geriatric care. We hope you find this publication informative and worthy of your review. To receive more information or to refer a patient here, please call or visit clevelandclinc.org/geriatrics. Kind regards, Vitamin D Deficiency Plays a Role in Falls Patient Information on Falls Barbara Messinger-Rapport, MD, PhD Interim Chair, Geriatric Medicine Cleveland Clinic Medicine Institute clevelandclinic.org/geriatrics

2 clevelandclinic.org/geriatrics Clinic Joins Collaborative Effort to Improve Health Literacy The Sisters of Charity Foundation of Cleveland sounded an alarm. Nearly half of all adults in America have difficulty understanding and acting on health information. And problems caused by low health literacy directly impact the development of healthy communities. The Sisters challenged Cuyahoga County organizations to develop programs to address the problem, and Senior Outreach Services (SOS) answered the call. SOS partnered with the Cleveland Clinic Section of Geriatric Medicine, University Hospitals Center for Geriatric Medicine and Cuyahoga Community College to create the SOS Elder Health Literacy Collaborative. The group is developing an evidencebased, multi-faceted health literacy program for older African Americans. We know that low health literacy leads to problems including missed appointments, medication errors and poor health outcomes, says SOS Director Delores Lynch. Our goal is to understand the contributing factors in ineffective communication between older African Americans and their physicians and nurses, and develop a model that will help seniors manage their health. Cleveland Clinic geriatrician Barbara Messinger-Rapport, MD, PhD, Interim Chair of Geriatric Medicine, says the coalition is conducting focus groups of physicians, nurses, seniors and their caregivers to learn what does and doesn t work in communicating about health. We plan to develop a subsequent health literacy program that capitalizes on best practices we glean from the focus groups. The SOS Elder Health Literacy Collaborative is funded by a grant from the Sisters of Charity Foundation of Cleveland. n Cleveland Clinic Geriatric Medicine Staff U.S.News Ranks Cleveland Clinic One of America s Best Hospitals Geriatric Care Ranked #14 Barbara Messinger- Rapport, MD, PhD Interim Chair Specialty Interests: Geriatrics, older women s health, aging body and aging brain, optimizing function in older adults, quality of life in dementia, palliative care for older adults, geriatrics Ronan Factora, MD Specialty Interests: Geriatrics, functional assessment, dementia, delirium, apoptosis and aging, normal aging physiology, frailty Theodore Suh, MD, PhD Specialty Interests: Geriatrics, geriatric assessment, medical student education, falls/gait assessment, geriatric oncology, sleep disorders in older adults To receive more information or to refer a patient to Geriatric Medicine, please call or visit clevelandclinic.org/geriatrics Cleveland Clinic has been ranked among America s top hospitals since U.S.News & World Report began its annual survey of America s Best Hospitals in For the 14th consecutive year, Cleveland Clinic s cardiac care has been ranked No. 1 in the nation. The 2008 survey recognized Cleveland Clinic as one of the nation s best hospitals overall, ranking the hospital as No. 4 in the country. Cleveland Clinic ranked in all 16 specialties surveyed by the magazine. Ten of its specialties were listed among the Top 10 in the United States.

3 Geriatric Times winter 2009 Falls Prevention is Goal of Cleveland Clinic Pilot Program Short-Course Physical Therapy Ideal for Geriatric Patients Falls can cost elderly patients their independence, but many interventions can reduce the risks of falling. Cleveland Clinic Physical Medicine and Rehabilitation Department specialists are piloting a program that identifies patients at risk of falling and steers them to the appropriate interventions. We find that short courses of targeted physical therapy improve patients mobility and increase their confidence in getting out of the house. This stalls a downward spiral of immobility and fear, says Frederick Frost, MD, Interim Chair of Physical Medicine and Rehabilitation. He is also an Associate Professor in Cleveland Clinic Lerner College of Medicine. Dr. Frost and internal medicine specialist Stephen Hayden, MD, are leading a mulitidisciplinary team in developing a protocol for patients over 65 who see internal medicine and family practitioners at four Cleveland Clinic sites. The team includes members of Cleveland Clinic s Nursing Quality Department, Geriatric Medicine Program, Regional Medical Practice and Information Technology. A painless process We wanted the assessment to be as painless for the physician as possible, to take just seconds in an office visit that might only last minutes, says Dr. Frost. So we structured it in a way that easily stratifies their decision-making. We know that intensive medical intervention for falls prevention is probably not cost effective. Yet minimal interventions don t prevent falls either. We are striving to promote an intervention strategy that is of intermediate intensity, and test its effectiveness. Patients are first asked by a nurse if they have fallen twice in the last year or have fallen once and sustained injuries. We let the patient define injury. It can be as serious as a broken hip or as minimal as bruising, explains Dr. Hayden, who oversees the pilot program at four locations. Flagging the medical record Patients who say yes undergo a brief physical assessment by the nurse to evaluate balance and equilibrium. Those who fail are flagged in the electronic medical record for the physician s attention as the visit begins. If a flagged patient is deemed at minimal risk of falling, the physician may offer a list of community resources, referring to local tai chi classes or Arthritis Foundation exercise programs. Physician recommendation matters Patients with multiple risk factors may be referred for physical therapy. Some patients may be reluctant to seek out these services themselves because they don t want to bother family members to drive them, but when a physician recommends it, their interest goes up, notes Dr. Hayden. Those with orthopaedic, neurological or spinal disorders that cause significant mobility deficits and require further assessment and intervention are referred to the Department of Physical Medicine and Rehabilitation. Dr. Frost says that in that department, staff members have observed that many older patients resist the standard 15 Medicare PT sessions recommended. They are reluctant to inconvenience family members who have their own children to drive around, for rides to the therapy gym. So physiatrists and physical therapists collaborated to develop a short course of therapy targeted at falls prevention. Compliance through the roof When you tell patients that they only need to go to three or four sessions, their compliance rates go through the roof, says Dr. Frost. And when an adult son or daughter hears that a short course of therapy will help, they encourage the parent to go. In the first session, physical therapists specializing in falls prevention evaluate patients gait and balance. Then they teach simple exercises to do at home to improve their performance. Patients are re-tested at the third or fourth visit to see how much they have improved. This brief regimen is offered at four community locations.

4 clevelandclinic.org/geriatrics Vitamin D Deficiency Plays a Role in Falls We wanted the assessment to be as painless for the physician as possible, to take just seconds in an office visit that might only last minutes, says Dr. Frost. So we structured it in a way that easily stratifies their decision-making. Aging patients are motivated Patients invariably report improved mobility and confidence in their walking. Contrary to what many people believe, older people will do the exercises you recommend for them. They have the time and they re motivated. They want to keep their independence, Dr. Frost says. Patients who require medication adjustments, who suffer from progressive frailty or other aging issues, or who have little social support are referred to Cleveland Clinic geriatricians. A geriatric consultation simplifies and organizes their care, says Dr. Frost. Tracking results Dr. Hayden notes that compiling follow-up outcomes data is a key component of the pilot program. For example, we need to know how many patients go to physical therapy, and what their incidence of falls was afterward. Dr. Frost s department plans to compare compliance with short-course physical therapy to that of longer-term therapy, and to gauge physician satisfaction with this simple, electronic decision tree for management of falls risk. n For more information, physicians may contact Dr. Frost at or frostf@ccf.org, or Dr. Hayden at or at haydens@ccf.org. As many as 50 percent of older adults have insufficient levels of vitamin D, which may cause osteomalacia, secondary hyperparathyroidism, and myopathy as well as contribute to osteoporosis.. Low serum levels of vitamin D are associated with lower levels of mood and cognition, as well as a higher prevalence of colon, prostate, and breast cancers. Vitamin D supplementation of international units (IU) with adequate calcium supplementation decreases the risk of falls and fractures. The benefit may be the greatest in the most frail elders. Vitamin D insufficiency in older adults is likely to be a combination of inadequate intake, decreased absorption and impaired metabolism. Persons with renal insufficiency may be unable to convert vitamin D to the active form. Some medications, such as prednisone, may result in an increased daily requirement for vitamin D. Older adults, particularly those with dark skin living in northern climates, do not produce enough vitamin D because of inadequate UVB exposure or utilization. The US diet tends to be deficient in vitamin D, particularly for vulnerable populations like the elderly, says Barbara Messinger- Rapport, chair of Geriatric Medicine. Most persons consume under 200 IU per day. It s actually much easier to consume adequate calcium in the diet since it s available in dairy products, and many foods are supplemented with calcium. But without sufficient vitamin D, the calcium will not be absorbed well from the intestines. The Institute of Medicine of The National Academies considers 400 IU/d an adequate intake of vitamin D for older adults. However, emerging evidence suggests that a higher intake of Vitamin D may improve muscle strength, result in fewer falls and fractures, and lower the risk of certain cancers. The Department of Health and Human Services now advises that vulnerable populations receive 1,000 IU daily of Vitamin D. As more research is published on the outcomes of vitamin D supplementation, we anticipate further recommendations for both calcium and vitamin D supplementation to emerge, she continues. Future recommendations may address the type of vitamin D (D2 or D3); how often to check serum vitamin D levels and how to interpret them; use of vitamin D analogues such as calcitriol and alfacalcidol; and the optimal dosing of calcium once adequate serum levels of vitamin D are attained. Dr. Messinger-Rapport currently suggests supplements to her patients so that between supplementation and diet, each patient receives approximately 1,000 IU daily of Vitamin D and approximately 1,000 mg of calcium. Recommendations are individualized for the patient s medical conditions. n For more information or to refer a patient to the Section of Geriatric Medicine, call

5 Take Steps to Prevent Falls 1 2 Select firm shoes with rubber soles. Avoid walking in socks or slippers. Avoid using throw rugs, or select rugs with non-skid backing. Tack down carpet. patient information Clear away clutter, particularly near stairs. Add hand rails to all step and stairs in your home. Check your lighting; add lights to dimly lit areas, especially at the top and bottom of stairs. Use nightlights in bedrooms, bathrooms and hallways. Add a no-slip mat or decals to the tub or shower. Install grab bars in the shower and near the toilet. Tips provided by Cleveland Clinic

6 1 The Cleveland Clinic Foundation 9500 Euclid Avenue/AC311 Cleveland, OH Geriatric Times winter 2009 clevelandclinic.org/geriatrics Outcomes Data Available The latest edition of outcomes data from Cleveland Clinic s Medicine Institute is now available. Our outcomes booklet Medicine Institute also offers summary reviews of medical and surgical trends and approaches. Charts, graphs and Outcomes 2007 data illustrate the scope and volume of procedures performed each year. To view outcomes booklets for the Medicine Institute, as well as many other Cleveland Clinic medical and surgical disciplines, visit clevelandclinic.org/quality. MyConsult Online Medical Second Opinion Geriatric Medicine will begin offering consults through MyConsult in early This secure online service provides specialist consultations from Cleveland Clinic experts, and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult will be particularly valuable for elderly patients with memory loss, dementia, polypharmacy, falls, dizziness, weight loss and hydrocephalus who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, eclevelandclinic@ccf.org or call , ext Are You Connected? Cleveland Clinic s DrConnect is a complimentary online service that streamlines communication from Cleveland Clinic physicians to your office. With one-click convenience, you can track your patient s treatment progress at Cleveland Clinic using the secure DrConnect Web site. To establish an account, sign up online at eclevelandclinic.org/drconnect or us at drconnect@ccf.org. Medical Editor Barbara Messinger-Rapport, MD, PhD Managing Editor Marjie Heines Art Director Anne Drago Photographer Tom Merce Geriatric Times is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient. The Cleveland Clinic Foundation GER-004