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Chapter 4. Care oftheElderly Patient
113
• Benzodiazepines generally worsen delirium unless being
used for delirium related to ETOH withdrawal.
• In the treatment of depression as with all meds in the geri-
atric population, start with low doses and titrate to thera-
peutic dose. Maintain therapeutic dose for 6–12months.
• In the treatment of depression, monitor for side effects
such as hyponatremia in the first weeks of treatment and
periodically thereafter.
• In the treatment of depression, avoid highly anticholiner-
gic medications which may cause hypotension, sedation,
and falls, e.g., tricyclic antidepressants (imipramine, doxe-
pin, amoxapine, trimipramine).
• Be familiar with the Beers criteria to avoid medications
that should not be used in older adults. See: Beers Criteria:
onlinelibrary.wiley.com/doi/10.1111/jgs.1370
• In treating insomnia, avoid diphenhydramine. Evaluate
carefully for fall risk before prescribing any sedating
medications.
Don’t Miss This!
• Minimize use of medication whenever possible. Review
the patients’ medication list at every visit, and remove
unnecessary and duplicative medications. Review the
Beers criteria to avoid medications that can be harmful to
older adults.
• Assessing and improving function and social supports is a
major focus of geriatric care.
• Care of the older adult is best delivered by a multidisci-
plinary team including social work, physical and occupa-
tional therapy, and mental health and nutrition services.
• Advanced directives and goals of care should be clarified
initially and updated periodically with any change in
health status.
• Dementia care requires education and support of the
patient and caregiver. Recognizing and alleviating care-
giver stress should be part of good dementia care.
114
V. M. LoFaso
References
1. U.S.Department of Health and Human Services. Administration
on aging statistics. Administration for Community Living. Last
modified 9/8/2014.
2. Warshaw G, Bragg E, Fried L, Hall W. Consensus among
directors of geriatrics academic programs. J Am Geriatr Soc.
2008;56(10):1796–801.
3. Lachs M, Feinstein A, Cooney L, etal. A simple procedure for
general screening for functional disability in elderly patients.
Ann Intern Med. 1990;112(9):699–706.
4. Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction. Ann Intern Med.
1992;117:1003–9.
5. Pahor M, Guralnik J, Salive M, etal. Disability and severe gastrointestinal hemorrhage. A prospective study of communitydwelling older persons. J Am Geriatr Soc. 1994;42:816–25.
6. Trang V, Farish S, Jenkins M.A meta-analysis of effectiveness of
influenza vaccine in persons aged 65 years and over living in the
community. Vaccine. 2002;20(13–14):1831–6.
7. Centers for Disease Control and Prevention (CDC). Updated
recommendations for use of tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis (Tdap) vaccine in adults aged
65 years and older–Advisory Committee on Immunization
Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep.
2012;61(25):468–70.
8. Weinberg A, Zhang JH, Oxman MN, et al. Varicella-zoster
virus-specific immune responses to herpes zoster in elderly participants in a trial of a clinically effective zoster vaccine. J Infect
Dis. 2009;200:1068.
9. USPSTF. Recommendations for primary care practice. https://
www.uspreventiveservicestaskforce.org
10. Lee SJ, et al. Eprognosis: estimating prognosis for elders.
Division of Geriatrics at the University of California San
Francisco. eprognosis.org. Accessed 29 Sept 2015.
11. Nelson M, Rejeski W, Blair S, etal. Physical activity and public
health in older adults: recommendation from the American
College of Sports Medicine and the American Heart Association.
Circulation. 2007;116(9):1094–105.
12. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK.The relationship
between social support and physiological processes: a review
Chapter 4. Care oftheElderly Patient
with emphasis on underlying mechanisms and implications for
health. Psychol Bull. 1996;119(3):488–531.
13. Alzheimer’s disease facts and figures. Alzheimer’s Association.
Alzheimers Dement. 2016;12(4):459–509.
14. Inouye SK, van Dyck CH, Alessi CA, etal. Clarifying confusion:
the confusion assessment method: a new method for detection
of delirium. Ann Intern Med. 1990;113(12):941–8. https://doi.
org/10.7326/0003- 4819- 113- 12- 941.
15. Taylow W, Aizenstein H, Alexopoulos G.The vascular depression
hypothesis: mechanisms linking vascular disease and depression.
Mol Psychiatry. 2013;18:963–74.
16. American Geriatrics Society and British Geriatrics Society.
AGS/BGS clinical practice guideline: prevention of falls in
older persons: summary of recommendations. J Am Geriatr Soc.
2011;59(1):148–57.
1 7. Mathias S, Nayak USL, Isaacs B.Balance in elderly patients: the
“get-up and go” test. Arch Phys Med Rehabil. 1986;67:387–9.
18. American Geriatrics Society 2015 Beers Criteria Update Expert
Panel. American Geriatrics Society 2015 updated beers criteria
for potentially inappropriate medication use in older adults. J
Am Geriatr Soc. 2015;63:2227–46.
19. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and
validation of a tool to improve physician identification of elder
abuse: the Elder Abuse Suspicion Index (EASI) ©. J Elder
Abuse Negl. 2008;20(3):276–300. In Press. Haworth Press Inc1.
20. Unwin B, Maj MC. The home visit. Am Fam Physician.
1999;60(5):1481–8.
21. Abrams A, Baron E, et al. In: Ramsdell JW, Schwartzberg
JG, eds. American Medical Association/American Academy of
Home Care Physicians: medical management of the home care
patient. 2007.
115
Chapter 5
Care at theEnd ofLife:
Palliative andHospice
Care—Symptom
Management
TabithaN.Goring andIngridL.Nelson
History
The modern palliative care movement began in Great Britain
in 1967 when Dame Cecily Saunders founded St. Christopher’s
Hospice in London. She had been inspired by one of her
patients, a Polish refugee named David Tasma. Tasma had
survived the Holocaust—the only member of his family who
did—and emigrated to London where he worked in a restaurant. In 1947, he was diagnosed with cancer. Dame Saunders
cared for him at the end of his life, and they formed a very
close attachment. In their conversations she realized that,
along with his physical suffering, he was struggling to under-
T. N. Goring
Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical
College, New York, NY, USA
e-mail: Goringt1@mskcc.org
I. L. Nelson (*)
Department of Medicine, Albert Einstein College of Medicine,
Jacobi Medical Center, New York, NY, USA
e-mail: Ingrid.nelson@nychhc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_5
117
118
T. N. Goring and I. L. Nelson
stand the meaning of the life he had lived—why he had survived while so many others had died—as he approached his
own death. When he died, Tasma left a bequest to Saunders,
predicting: I’ll be a window in your home.
At St. Christopher’s, Dame Cecily and her colleagues formulated the first principle of palliative care: that the experience of serious illness is physical, emotional, and spiritual and
that attention to all three domains is necessary to successfully
treat any one. The logical corollary that a team of physicians,
nurses, social workers, pastors, and psychologists need to be
involved followed. The model that Dame Cecily developed
was an early instance of patient-centered care, and this is how
she described its focus and power: “You matter because you
are you, and you matter to the last moment of your life. We
will do all we can, not only to help you die peacefully, but also
to live until you die.”
Today, palliative care is recognized on every continent, and
in almost every country, as a medical subspecialty. In the
United States, at last count, more than 70% of hospitals with
more than 50 beds have a palliative care service.
Palliative Care/Hospice Care
The introduction of focused palliative care, in addition to
standard medical care, is appropriate for patients with serious illnesses who have significant symptom burdens no matter the stage of their disease (Fig.5.1). In the United States,
patients with heart failure, COPD, liver disease, dementia,
and serious cancers are the most common candidates;
patients with ALS, PD, renal disease, and advanced AIDS
will also benefit. The goal is to ameliorate symptoms such as
pain, SOB, and anxiety and also provide patients and their
families with social and spiritual support. Inpatient palliative care is typically delivered by a team that includes physicians, nurses, social workers, pastors, and psychologists;
outpatient palliative care teams should follow the same
Palliative Care/Hospice Care
Intergrati
Chapter 5. Care at the End of Life: Palliative…
Curative Care
Exacerbations and
Remissions of Diseases
Bereavement
119
Prevention
ve
Health
F . The increasing importance of palliative care and hospice
as disease progresses. From: Roth, Alan R.; Canedo, Angelo
R. Introduction to Hospice and Palliative Care. Primary Care:
Clinics in Office Practice.2019-09-01, Volume 46, Issue 3, Pages
287–302, Copyright © 2019 Elsevier Inc.
model, as much as possible. The ultimate goal is to improve
quality of life by the following:
• Providing pain and symptom control.
• Helping family members care for the patient.
• Informing patients about treatment options and their risks
and benefits.
• Helping patients prepare for the future.
• Giving patients and their families a sense of control.
Along with improving quality of life, the early introduction
of palliative care has been shown to have another, unexpected benefit: an increase in life span. In a study published
in the New England Journal of Medicine in 2010 [1], 151
patients with newly diagnosed metastatic NSCLC were
randomized into two groups: one received standard oncologic
care and one received standard oncologic care along with
early integrated palliative care. Those in the second group
had less pain and depression, received less chemotherapy, and
lived longer—results that have given impetus to the establish-
Diagnosis of
Chronic Life
Limiting Illness
Palliative Care
Time
Months Years
Progression of Serious Illness
12
months
6
months
hospice
Death
120
T. N. Goring and I. L. Nelson
ment of palliative care services in hospitals across the country. Palliative care also saves money: a JAMA meta-analysis
published in 2018 concluded that hospitalized patients who
received palliative care in addition to routine treatment used
fewer medical resources and were less costly to treat [2]. Thu s,
the benefit of palliative care is both humanistic and practical—a fact not lost upon the medical administrators who support it, and a reason for the introduction of dedicated
palliative care services in more outpatient settings.
Hospice care is for patients in the last 6months of their
lives. It has been a benefit under Medicare since 1986. As with
palliative care, the focus of treatment is on symptom relief,
quality of life, and family support, with care delivered by a
multidisciplinary team. However, aggressive therapies such as
hemodialysis and chemotherapy with curative intent are not
part of hospice care. Hospice care can be delivered at home
by a home hospice organization; this has the benefit of reducing emergency room visits and hospitalizations and improving the chances of patients dying at home, if this is their wish.
It can also be given in a dedicated inpatient hospice setting or
as an addition to regular care in a nursing home. Generally,
patients with symptoms that need aggressive care or those
who have little support at home will do best in these
settings.
Role ofthePrimary Care Physician
inPalliative Care/Hospice
Primary care physicians are in a perfect position to identify
patients who will benefit from palliative care. Obvious candidates include patients with the following:
• High symptom burden
• Declining functional status
• New diagnosis of serious cancer
It is also helpful to consider the trajectory of diseases commonly seen in the outpatient setting (Fig.5.2)
Function
Function
Months Years
Months Years
s
Chapter 5. Care at the End of Life: Palliative…
121
High
Low
High
Low
Sudden death Terminal illness
MVA/Trauma/
Homicide/Suicide
CVA/MI/Cardiac
Arrest
Death
Time
Organ failure
CHF/COPD/ESLD/ESRD
ED visits
Hospitalizations
Time
Death
often sudden
Death
High
Function
Low
High
Function
Low
Cancer
Time
Months Years
Frailty /Dementia
prolonged dwindling
Time
6 months
Death
Death
After sepsis/
falls/fracture
F . From: Roth, Alan R.; Canedo, Angelo R.Introduction to
Hospice and Palliative Care. Primary Care: Clinics in Office
Practice.2019–09-01, Volume 46, Issue 3, Pages 287–302, Copyright
© 2019 Elsevier Inc.
This schematic provides rough prognostic information that
can help time the introduction of palliative care in appropriate patients. Decline is rapid in patients with a serious cancer
when effective treatment is no longer available. Patients with
serious chronic diseases experience a slow decline punctuated by exacerbations, from which they only partially recover.
Patients with dementia decline inexorably.
Prognostication needs to be more precise for hospice care
because of the requirement that prognosis be 6months or
less. Serious cancers have the best validated prognostic models; prognostication for chronic diseases and dementia generally rely on a complex of symptomatology. Remember that
these models are suggestions and not hard and fast rules, and
it is common for hospice services to be renewed after
122
T. N. Goring and I. L. Nelson
6 months. The CMS (Center for Medicare and Medicaid
Services) has developed disease-specific criteria for hospice
eligibility; below are criteria for diseases most commonly followed in a primary care setting. Information about other
diseases (ALS, HIV, etc.) is available on their website [3].
CMS Hospice Eligibility
Dementia
• Unable to dress independently
• Unable to bathe independently
• Urinary and fecal incontinence
• Can speak only six or fewer words
Heart Disease
• Already on optimal treatment
• NYHA Class IV with symptoms at rest
• Supporting criteria: treatment-resistant symptomatic
supraventricular or ventricular arrhythmias, history
of cardiac arrest or resuscitation, history of unexplained syncope, brain embolism of cardiac origin, or
concomitant HIV disease
Liver Disease
• INR >1.5 AND albumin <2.5
• One of the following: ascites, SBP, hepatorenal syndrome, hepatic encephalopathy, recurrent variceal
bleeding
• Supporting criteria: malnutrition, alcoholism, HCC,
Hep B, Hep C
Pulmonary Disease
• Severe disease documented by dyspnea at rest,
poorly or unresponsive to bronchodilators, and progression of disease documented by frequent physician visits or hospitalizations
• Hypoxemia on room air or hypercapnia
Chapter 5. Care at the End of Life: Palliative…
• Right heart failure secondary to cor pulmonale
• Unintentional weight loss of >10% in the past
6months
• Resting tachycardia
Renal Failure
• If acute: no dialysis, serum creatinine >8, comorbid
conditions
• If chronic: no dialysis, GFR<15, serum creatinine >8,
and accompanying conditions such as uremia, oliguria, hyperkalemia unresponsive to treatment, uremic
pericarditis, hepatorenal syndrome, and intractable
fluid overload
If your patient does not clearly fit into any of these categories, ask yourself the palliative care gut question: Would I be
surprised if this patient died within the next year? If the
answer is no, evaluate for palliative care or hospice.
123
When toRefer
In complicated cases, palliative care should be delivered by a
trained specialist. CAPC (Center to Advance Palliative Care)
is a nonprofit organization that provides information about
and educational resources for palliative care. Their website is
an excellent source of information; this is their list of suggested triggers for referral to a palliative care specialist [4]:
• Multiple recent prior hospitalizations with same symp-
toms/problems.
• Declining ability to complete activities of daily living.
• Persistent weight loss.
• Difficult to control physical or emotional symptoms
related to serious medical illness such as pain, depression,
and constipation.