CHAPTER 11 OFFICE PRACTICE
Practice of Geriatrics
CHAPTER 11 OFFICE PRACTICE
Eric G. Tangalos, M.D., C.M.D.
Health Recommendations for Disease Prevention
Preoperative Assessment of Older Adults
The Structured Office Visit
The Organized Office
The office practice of geriatric medicine offers primary care physicians as well as subspecialists a greater opportunity to provide preventive services to patients. It also allows physicians to evaluate issues that confront the elderly in everyday life at a more measured pace. An office-based functional assessment of an older patient may include evaluation of daily activities, cognition, continence, special senses, mobility, and specific psychosocial issues. This is the time and the place to discuss immunizations, advance directives, the game of golf, and grandchildren. This is also the setting in which a practice must run most efficiently because reimbursement in such situations is weakest for those who still provide primary care in the fee-for-service environment. A few selected items in this context are discussed in this chapter. In the following pages the author’s experiences at the Mayo Clinic are offered not necessarily as gold standards but rather as examples of approaches that have proved to be of some benefit.
Studies have shown that formalized comprehensive geriatric assessment can result in improved survival, reduced hospital and nursing home stays, lower medical costs, and improved functional status for individuals undergoing such assessments. The modern office and the web of services available to today’s practitioners allows all of the individual elements of geriatric assessment to come forward on behalf of patient care. Simple measures that are part of most office practices do make a difference.
Office-based geriatric assessment can help in determining patient placement, assistance needed for daily activities, medication selection, and prognosis. A shift from disease-oriented to function-oriented care entails a knowledge of social, cognitive, and mobility factors that are all elements of geriatric care. Older persons can benefit from this broadened definition of health and from preventive services. The clinician who can help patients achieve small improvements in functional, psychological, or cognitive abilities may provide significant benefits to the patient’s quality of life.1 Although the elderly can be categorized by age cohorts, there is no consensus about which age groups are considered the “young old” or the “old old.”2 Categorization by functional ability, number of co-morbid conditions, and presence of infirmity has also been recommended. Those with the poorest health status are considered frail or “at risk” elderly.3
HEALTH RECOMMENDATIONS FOR DISEASE PREVENTION
Most studies evaluating preventive services use reduction of disease-specific mortality as an outcome. In the elderly there are clearly additional and more relevant health outcomes to be considered. Health in old age can be said to consist of three related factors: (1) the absence of disease, (2) the maintenance of optimal function, and (3) the presence of an adequate support system.4 However, while older adults tend to have a greater burden of disease than younger persons, individuals may still be considered “healthy.” Therefore, the major goals of preventive care in the elderly are a delay or reduction in morbidity and prevention of disease to maximize the quality of life, satisfaction with life, and productivity.
The primary physician must also navigate a variety of practice environments. For the best care of the patient all these different worlds come into play as part of a continuum. An understanding of the patient’s environment is as important as an assessment of his or her physical well-being in evaluating a patient’s ability to be healthy. The physician’s ability to maintain good health in an elderly patient goes beyond knowing what drugs are appropriate therapy. Understanding their environment, how they perceive it, and how they move around in it are hallmarks of geriatric care. Environmental modification can be a shared responsibility with other disciplines such as occupational therapy. Protecting brittle bones from injury should be a consideration at all times. Handrails on stairways and in the bathroom may prevent falls. Removing throw rugs and using night lights may also prevent accidents.
Sensory deprivation is another important determinant in the health and well-being of elderly patients. Bright colors and adequate lighting can help counter the loss of depth perception that comes with age. Hearing aids may transform a dull withdrawn individual back into a person in touch with his family and environment. Poor vision and cloudy mental images may both regain clarity with cataract surgery. For the patient with poor position sense, poor balance, or peripheral neuropathy, a cane provides not only support but the reassurance of additional sensory input.
Demented patients present a particular challenge because the pharmacologic agents capable of treating these disorders are still limited. Care of the individual is enhanced at any stage of disease if the environment is stable and certain needs are met. Caregivers should not disrupt familiar routines, and habits should be maintained. For example, brushing teeth in the safety of one’s own bathroom requires almost no cognition or memory function, yet the same task during a visit to a son or daughter may unmask severe intellectual deficits. Encouraging these patients to keep lists and keep paper and pen close to the telephone are helpful strategies. For patients with more limited function, habits should be vigorously maintained, and overlearned behaviors should be reinforced.
Environmental modifications and adequate sensory input are only some of the truly preventive measures available to the practitioner and patient. Exercise to preserve mobility and improve cardiovascular tone should be encouraged. Weight loss should be accomplished by dieting, and efforts should continue to get patients to stop smoking and maintain good control of their blood pressure. Influenza vaccination should be offered yearly. Tuberculosis surveillance is extremely important in today’s environment, and testing should be maintained, especially on nursing home admission. Chapter 13 gives further details about disease prevention.
PREOPERATIVE ASSESSMENT OF OLDER ADULTS
The physician is responsible for assisting elderly patients who face surgery. Clearly, older patients can do quite well with elective operations and even have excellent survival curves for emergent procedures. Morbidity and mortality related to emergency situations are generally related to the severity of the incident and the burden of disease patients take with them into the operating room. Surgical rates are 55% higher in persons over the age of 65, and older persons are disproportionately represented in surgical admissions. Older patients account for 75% of all postoperative deaths, and there is a nearly linear increase with each passing decade of life.5
Age remains the most important risk factor for the elderly in surgery of any type. The general trend is to accept age as an independent variable in assessing risk. A useful tool for assessing preoperative general status is Dripp’s American Society of Anesthesiology (ASA) physical status scale.6 Class I comprises healthy persons less than 80 years of age. Class II includes otherwise healthy patients 80 years of age or older or those who have mild systemic disease. Class III patients have a severe systemic disease that is not incapacitating. Class IV patients have an incapacitating systemic disease that is a constant threat to life. Class V patients are moribund and are not expected to survive 24 hours with or without the operation. Activity of daily living (ADL) scales, nutritional status, and cognitive function all help to predict surgical complications. Next to age, dementia is the most important predictor of poor outcome; surgical mortality is increased by 52% compared to nondemented general surgery patients in one series.7 It is important for mental status to be assessed preoperatively to anticipate surgical risk and possible postoperative complications such as delirium.
Table 11-1 outlines an approach to assessing a patient’s risk for cardiac complications with noncardiac surgery. This system, reported by Detsky and colleagues, lets the clinician score patients according to clinical variables. The risk of postoperative cardiac complications can then be estimated from the patient’s score as noted in the table.
TABLE 11-1 THE MODIFIED MULTIFACTORIAL INDEX FOR PREOPERATIVE ASSESSMENT OF CARDIAC PATIENTS
Yet another popular approach to the issue of preoperative cardiac risk assessment has been to use imaging techniques (dipyridamole-thallium scans or dobutamine stress echocardiography). These techniques can detect occult coronary disease and define known cardiovascular disease. Fleisher and Eagle have argued that the primary benefit of these studies has been to identify patients who should undergo preoperative coronary revascularization.8 These authors believe that these studies are best used in patients who are at moderate risk of cardiac perioperative morbidity (i.e., one or two risk factors only: Q waves on electrocardiogram, angina, diabetes mellitus, age over 70 years, and treated ventricular ectopic activity). For this group of patients, these imaging techniques seem best suited to further stratifying a patient’s risk of postoperative complications.
Many surgical procedures are intended to be used in the elderly and carry relatively low risk. These include cataract surgery, prostatectomy, and hip surgery (both elective joint replacement and emergent surgery for fracture). Risky surgery involves procedures on the biliary tract and all trauma surgery. The elderly have become major consumers of cardiovascular surgery, and age should not be a determinant in either approving or denying an appropriate procedure. Severe left ventricular dysfunction remains the greatest predictor of mortality, followed by such complicating factors as renal insufficiency, chronic obstructive pulmonary disease, other vascular disease, and low body weight.9 Social support and home care also play extremely important roles in helping the patient return to function.
Other areas of preoperative management include antibiotic prophylaxis (see Chapter 44 for details) and anticoagulation. Numerous regimens have been advocated to reduce the perioperative risk of deep vein thrombosis or pulmonary embolism. Generally, for procedures with a high risk of thromboembolic complications (e.g., hip fracture or knee-hip replacement), more aggressive measures such as full-dose warfarin therapy or low-molecular-weight heparin are advocated. For lower risk procedures (e.g., abdominal procedures), more modest regimens such as fixed-dose subcutaneous heparin have been employed.
Preanesthetic Medical Evaluation
It is advisable to evaluate the general physical status of all patients scheduled for general anesthesia, regional anesthesia, or intravenous sedation. At the Mayo Clinic, for example, only patients with no complicated medical problems are eligible for such a preanesthetic medical evaluation (PAME). Patients with significant cardiovascular disease, bleeding diathesis, significant pulmonary disease, uncontrolled diabetes mellitus, uncontrolled hypertension, renal disease, hepatitis or jaundice, or substance abuse go on for complete medical evaluation before surgical clearance is approved.
All patients have an examination in which height, weight, vital signs, medications, allergies, review of systems, and physical examination results are recorded, with emphasis on cardiopulmonary status. Table 11-2 lists the minimum laboratory tests required before an anesthetic is administered to a healthy patient. Other tests may be indicated by the patient’s medical history, medications, and examination results.
TABLE 11-2 PREANESTHETIC LABORATORY TESTS
A complete blood count (CBC) is indicated in all patients who are typed and screened or cross-matched for blood transfusions.
Measurement of a potassium concentration is indicated in patients who are taking diuretics or are undergoing bowel preparation.
A chest radiograph is indicated for patients who have a history of cardiac or pulmonary disease or recent respiratory symptoms.
A history of cigarette smoking in patients over the age of 40 who are scheduled for upper abdominal or thoracic surgery is an indication for spirometry.
The electrocardiogram (ECG) is the principal test used for early detection of coronary atherosclerotic disease. However, there are important limitations in the sensitivity and specificity of electrocardiography when it is used as a screening test. A normal resting ECG does not rule out coronary disease.10 Conversely, an abnormal ECG does not reliably predict the presence of coronary artery disease.11 Some practitioners advocate obtaining a baseline ECG to assist in interpreting subsequent ECGs, but recent studies indicate that in actual practice, most baseline tracings uncommonly provide information that affects treatment decisions.12
THE STRUCTURED OFFICE VISIT
Two relatively new tools are used at the Mayo Clinic to assist physicians with history-taking and documentation. Current visit information (CVI) is required for each major access visit or “new” problem. It includes information provided by the patient except for the chief complaint, which is taken directly from the patient during the face-to-face interview. The patient-family history (PFH) form is required of patients every 3 years but is reviewed, updated, and signed each time the patient returns for a major access visit or “new” problem. Medications are updated on the CVI form along with advance directives, a systems review, ADL status, and the authorization to release medical information. The past medical history including hospitalizations, family history, social history, and other risk factor information is recorded on the PFH form.
Standardized forms were developed to save precious office time, avoid missed information, and establish a pattern of care that would be easy to understand by outside review agencies and third-party payers. Patients and families are asked to complete these forms before arriving at the office. They are mailed out in advance with the appointment reminders. At best, they each take 20 minutes to complete; very old patients are often best assisted by other family members. Once this information is placed in the permanent record it is available to all Mayo physicians to use in both the outpatient and hospital settings. Work is also underway to record this information electronically so that it can be instantly incorporated into summary letters and carried forward into subsequent examinations.
Information from the physical examination is also recorded on a structured form. This can be either handwritten or recorded through dictation, kept electronically, and printed when needed. Again, a standard check-off form is used to prevent missing information. By convention, underlined parts of the examination are recorded as normal, circled organ systems require explanation, and areas of the body not notated are considered not examined. This system works well to document for third-party payers that the examination proceeded in a logical fashion. The recorded information matches the clinical findings, diagnoses, test ordering, and billing records. In the future, the electronic record will prohibit ordering tests that are not backed up by the appropriate clinical diagnosis and plan of care.
All examination rooms are set up in the same way. No matter what floor or what building the room is in, throughout the Mayo campus there are really no surprises. By convention, speculums and gloves can always be found in the same place. The same holds true for sheets, gowns, and even tongue depressors. The standard examination table was changed a few years ago to accommodate the aging population. The earlier version had a step that was a full 12-inch lift: a great quick screen for motor dysfunction from thyroid disease but quite a struggle for a frail 80-year-old. This step is now only 5 inches high, and with fixed stirrups almost anyone who can come to the office can lift up high enough to get onto the table. As an additional compromise for the elderly body, the examination table now breaks at midbody rather than just at the head. With so many arthritic spines and poor hearts and lungs it was very difficult to get patients to lie flat safely. Now a pneumatic cylinder assists with the appropriate positioning to get the best examination possible without compromising the patient’s comfort.
Office automation in the form of fax machines reached the author’s practice in late 1988. In an attempt to streamline the transfer of information and orders from the office back to the nursing home, nurse practitioner assessments and physician orders were initially routed back and forth to the nursing home. Although the facilities were skeptical at first, the time and cost savings have proved to be significant and have made the fax machine an indispensable tool.13,14 Building on this practice, dedicated facsimile access and auto dial functions have been provided to all local pharmacies. Prescription refills are handled through templates that have been mutually agreed to by pharmacists and physicians.
Standardized protocols provide a great opportunity for the use of nonphysicians in the office to deliver care. One of the best examples of this may be the regulation of anticoagulation therapy. For example, at the Mayo Clinic international normalized ratio (INR) values are currently followed, allowing registered nurses (RNs) to adjust therapy in patients whose condition demands either a range of 2.0 to 3.0 or 2.5 to 3.5 by following defined adjustment protocols.15 The following recommendations are also posted for use by the RN.16
MECHANICAL HEART VALVES
Target INR 2.5 to 3.5 for all mechanical heart valves.
Aspirin 100 mg/day with warfarin INR3.0 to 4.5.
Dipyridamole 400 mg/day may offer added benefit.
If full-doze warfarin is contraindicated, use warfarin INR 2.0 to 3.0 + aspirin 660 mg + dipyridamole 150 mg/day.
TISSUE HEART VALVES
Mitral valves: INR 2.0 to 3.0 for 3 months.
Aortic valves: when in normal sinus rhythm, anticoagulation is optional.
Atrial fibrillation with tissue valve: INR 2.0 to 3.0 long-term.
Left atrial thrombus at surgery: INR 2.0 to 3.0 long-term.
History of thromboembolism with tissue valve: INR 2.0 to 3.0 for 3 to 12 months.
Tissue valves in normal sinus rhythm: aspirin 325 mg/day optional.
When to stop and start warfarin (Coumadin) in the presence of elective surgery remains something of an art form in the hands of the surgeon. As a general rule, the author stops anticoagulant therapy 7 to 10 days prior to surgery and resumes it on the day of hospital dismissal. Patients are not given a loading dose when they restart the drug but resume their regular preoperative regimen. The drug can be expected to reach therapeutic levels 7 to 10 days after treatment resumes.
For patients and families who must spend some time in a waiting room (what else can you call it but a waiting room?), a series of videotapes on given disease conditions can be effective educational-entertainment vehicles. Access to understandable medical information is critical for patients in view of the fact that, no matter what is said to a patient when a diagnosis is established, very little is comprehended during that first office visit. In addition to videos, informational brochures on disease-specific conditions and medication use including cross-reactivity can be very helpful. A list of family and support services available in the community specifically for the elderly can be invaluable. Additional resources exist at the senior citizens’ center and through Mayo’s patient education library.
The availability of transportation service varies greatly with locale. Nursing homes and retirement centers may provide their own services for patients. Facilities that lack these services may have access to the full complement of wheelchair cabs and specialized van services for the handicapped. Some cities subsidize door-to-door service for people who are too impaired to use public transportation. Given the frequency of inclement weather throughout the country, the process of moving people from one indoor environment to another indoor environment often becomes a major challenge. Skyways and subways can only do so much. The Baldwin Building for community medicine at the Mayo Clinic, for example, has an easy access drive-up area that is protected from wind and snow. An outer series of sliding doors can accommodate wheelchairs and stretchers. Patients then face two inner doors and can choose from either the energy-saving revolving door or another set of sliding doors large enough to allow assisted entry. Skilled help is readily available regardless of weather conditions.
If at all possible, a central office should remind patients of appointments through the mail or by phone. The PFH and CVI previously discussed are sent to patients before annual examinations and major access visits. In that the author’s clinic is a primary care practice, very few letters have to be sent to referring physicians. However, there is significant correspondence with home health agencies, nursing homes, and equipment suppliers. Until recently, special forms that made use of carboned duplicates for handwritten notes were used to communicate with other providers of care to patients. Recently the Mayo Clinic’s electronic record has been more fully implemented, and all physicians now use full dictation. Duplicates of transcribed notes are either mailed or faxed to the appropriate parties. Although the immediacy of a handwritten progress note that is identical to the clinical record has been sacrificed, significant gains in legibility have been made.
Physicians at Mayo follow a dictation template in preparing their remarks for the electronic medical record. Transcriptionists are responsible for this specific task. A complete discussion of the development of an electronic record and the different data elements that go into making such a record is unfortunately beyond the scope of this chapter.
THE ORGANIZED OFFICE
One might think that tremendous uniformity of action would result from 31 salaried physicians working collaboratively in a practice of primary care established 50 years ago to provide community care in the nation’s first group practice of medicine. Think again! True growth comes from experimentation, and within the four sections of the Division of Community Internal Medicine at the Mayo Clinic, different activities abound. All sections participate in the implementation of guidelines including uncomplicated urinary tract infection (UTI), smoking cessation, preventive services, and immunizations. However, the use of nurses and clinical assistants for office and telephone help in the different sections varies tremendously.
Emerging patterns of practice include one-on-one accountability with an “assistant.” Given the limited time physicians now have to spend with patients, more cost-effective use of additional personnel is required. In addition, the myriad of rules and responsibilities, guidelines to be followed, and documentation required for billing procedures further moves the physician away from the patient. All nonphysician activities should be done by somebody else, leaving the evaluation and management responsibilities that require physician time to the physician. Straight-forward problems such as uncomplicated UTIs, sore throats, viral upper respiratory infections (URIs), and sinusitis are now handled by RN staff using standardized algorithms (although not in the geriatric population).
In modern practice the volume of telephone calls has gone up dramatically, first because patients are too busy to come in, and second because health plans and incentive systems encourage patients to stay away. The Mayo Careline (a contract service) provides 24-hour nurse advice and appropriate triage guidance. This helps to ensure that patients receive the appropriate level of service for their particular problem. Telephone triage is handled divisionally by nurses stationed on clinical floors who work with only some protocols and even fewer algorithms.
Disease management services remain a developing concept. Although the health care team is in favor of providing better information to patients, the “fax on demand” at Mayo is used only in continuing medical education. Consideration has been given to providing multilingual instructions to patients using “smart” fax machines (computers), but this process has yet to begin. Mayo’s Web sites offer patients information about specific disease entities and provide enough information to make appointments. Questions may be answered in the public forum, much as is done with the Mayo Health Letter, but individualized responses may constitute the practice of medicine across state lines. Patients requesting appointment information are for the most part given a phone number to call when they are ready to come.
Compliance remains a major difficulty in the management of medications in the elderly. Elderly Americans spend approximately $3 billion per year on prescription medications, little of which is reimbursed by third-party payers. There is a direct correlation between advancing age and the number of drugs prescribed. At least 90% of Americans over age 65 take at least one prescription medication daily, and a majority take two or more.17 Cardiovascular drugs, antihypertensive agents, analgesics, anti-inflammatory drugs, sedatives, and gastrointestinal preparations are the most commonly used medications in the elderly.18 The more medications an individual takes, the more frequent the dosing, the more complicated the instructions, and the more expensive the drugs, the less likely it is that the patient will take the pills as prescribed. A well-informed patient and meticulous control over medication use are the keys to success. Reminders to patients to bring all their drugs (including over-the-counter medications) in for review at each office visit is critical (Fig. 11-1).
Figure 11-1 Mail reminder to patients to bring medications to office visit.
The medications are reviewed against hospital discharge summaries, home care orders, and the patient’s own schedule. Every attempt should be made to put all prescriptions under one physician’s name (again for ease of review) and rigorously scrutinize each program to make sure it is as simple to understand and as easy to follow as possible. Patients should be encouraged to use only one pharmacy for their business, which makes an occasional call to double-check a prescription much easier for all parties. When possible, patients should know the names of each of their drugs and should have a good understanding of why they are being used.
Breaking pills in half and using a dosing schedule of more than three times a day should be discouraged. By convention, in the author’s practice warfarin (Coumadin) is dispensed only in 2.5-mg tablets, making the “currency of exchange” less complicated for anticoagulation protocols and less likely to create error among all caregivers. Examples of pill boxes that can be purchased are also made available to patients both in the office and through the hospital pharmacy. Boxes should have lids that are easy to open and be able to handle a week’s worth of medication, usually seven columns and four rows. Most important, the cover must be transparent so that one can see in a matter of seconds what is inside (Fig. 11-2). Medication organizers should not be a game of hide and seek. The newer electronic dispensers may catch on, but for now they are complex, expensive, and intimidating.
Figure 11-2 Medication organizer.
Hospitals, nursing homes, and physicians have been required since the passage of the Omnibus Budget Reconciliation Act (OBRA) 1990 and the Patient Self-Determination Act to provide information about advance directives to all patients. If possible, it is preferable to organize the patient record to accommodate advance directives with both a notifier to physicians that one exists and a repository to contain the actual documents. The information contained in the record may include a living will, an autopsy directive, an anatomic bequest, and information about a durable power of attorney. The availability of living will templates as well as information about counseling, such as that obtained through local senior citizens’ centers, can be quite helpful.
Advance directives include living wills and the durable power of attorney (DPoA) for health care matters. Living wills are explicit value-based declarations used by patients to refuse or accept various life-sustaining medical interventions in the event of terminal illness. Alternatively, the durable power of attorney is designed to allow someone to speak for the patient when the patient with certain medical conditions cannot make his or her wishes known. Despite enthusiasm for written advance directives, few adults have completed them.19 A randomized controlled trial from Kaiser Permanente found that mailing an educational pamphlet and form about the durable power of attorney to patients over 65 years of age significantly increased the number who completed the durable power of attorney form.20 The living will is an easy first start, but in some states it is less useful than the DPoA because of restrictions on implementation.
Social workers in the office setting are a luxury few can afford. Even in the hospital this resource seems to be extremely difficult to find. At times, resources available through the county or local ombudsman can augment services that are accessible through the office or hospital system. Minnesota’s legislation on vulnerable adults for example is quite strong and provides county support to at least investigate potential abuse. The ombudsman system can handle patients in the community, but its greatest impact is on nursing home patients. Home health agencies have a vested interest in generating business, as do nursing homes, and often the best service and most accurate financial advice comes from these businesses. Area Agencies on Aging, through provisions specified in the Older Americans Act (1964), provide free legal services to those in need. The “circuit rider,” often a paralegal, can usually be found holding court at the local senior citizens’ center.
Functional assessment of older persons can best be carried out in an office practice set up to handle a more complex population of patients. Activities of daily living, mobility, cognition, special senses, and psychosocial issues are only a few of the problems facing clinician and patient alike. Several tools are available to increase the effectiveness of the clinical examination (see Chapter 1 and Chapter 2). The goals of these evaluative measures are to identify impairments, prevent disabilities, and remove barriers to independence. These goals are accomplished through efforts to improve function, modify medical and social boundaries, and increase assistance given to the patient when needed. Identification of risk factors for geriatric syndromes may promote restoration of compensatory ability and prevent the onset of functional dependence. The primary care physician’s ability to attend to these functional goals may improve a patient’s quality of life and can assist in directing the management of associated chronic medical disorders.
Other chapters in this text highlight areas that should be emphasized in office geriatric practices. These include the appropriate history and physical examination (Chapter 1), functional assessment (Chapter 1 and Chapter 2), cognition assessment (Chapter 1, Chapter 26 and Chapter 27,) driving (Chapter 7), prevention assessment (Chapter 13), nutritional assessment (Chapter 15), gait and fall assessment (Chapter 1 and Chapter 19), and sensory assessment (Chapter 41 and Chapter 42).
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