Time Stamps

• 02:25 Initial Office Visit
• 08:08 Mobility Assessment 
• 13:25 Cognitive Evaluation 
• 19:27 Medications 
• 26:29 Throwback Pearl 

Show Notes

Pearl 1: Approach to the initial office visit 

• First understand what matters most to the patient. 
  • What do they value? 
  • What does a good day look like? 
• Functional status is the ability to perform daily activities to meet basic life needs (ADLs).  
  • There are basic and instrumental ADLs.
    • Assess baseline function, which can be used to later track disease onset and progression. 
  • Think of toenail length as the hemoglobin A1c of functional independence. 
    • If toenails are too long (>2mm increase in length per month) consider broad differential: 
      • Loss of executive function
      • Decreased flexibility/muscle strength
      • Caregiver burnout, social isolation 
      • Poor vision

Pearl 2: “Moves” for mobility 

• Falls are the leading cause of injury-related death in adults over 65 years old
• Think of gait speed as a vital sign and important predictor for fall risk. 
• Stratify fall risk by assessing mobility. 
  • Slowed gait speed increases risk 
  • Timed get up and go test (TUG): Time how long it takes for a patient to stand up from chair without pushing off with arms, walk to a line on the floor (10 feet away), turn, walk back to the chair and sit down. 
    • If the patient takes longer than 12 seconds to complete TUG they’re at risk for falling.
  • Chair stand: Have the patient cross arms over chest and stand up from chair. If they can’t stand up without using hands for support, they’re at higher fall risk.
• Interventions to decrease fall risk are most effective when combined together and  include physical and occupational therapy, home modifications (safe furniture, remove environmental hazards), use of appropriate assistive devices for ambulation and medication review. 

Pearl 3: Cognitive evaluation 

• Cognitive decline is a common concern in the primary care setting 
• Cognitive Screening Tests
  • The Mini-Cog is a quick screening test which assesses the ability to recall three words and draw a clock. If unable to complete successfully, need a more elaborate test
  • Montreal Cognitive Assessment (MOCA): Scored out of 30 points and evaluates naming, memory, attention, language, delayed recall, among other domains. 
• Delirium is an acute change in mental status from baseline. 
  • • Start with quick orientation and attention questions. Ask the patient to name days of the week or months of the year backwards 
• If cognitive tests show impairment, rule out reversible causes like hearing loss, medications, hypoglycemia, nutritional deficits, thyroid disorders, or electrolyte abnormalities.

Pearl 4:  How to manage medications 

• Ask patients to bring all their meds to the initial visit, including over the counter medications. Figure out what they’re actually taking. May need collateral from pharmacy, family members or home health aid. 
• Match the medications to the problem list. Consider de-prescribing. 
  • Are there extra medications that don’t match anything on the problem list?  
  • Are there medications with side effects that are contributing to the problem list?  
  • Is there a less frequent alternative? Example: switching metoprolol tartrate to metoprolol succinate 
  • Are the medications consistent with the person’s goals of care and life expectancy? 
• Underprescribing is a problem too
  • Osteoporosis often goes undertreated. Use bisphosphonates. 
  • Pain control with tylenol can significantly improve quality of life
  • Oral anticoagulants require weighing stroke risk versus fall risk 

Throwback Pearl: PPIs 

• Divide adverse effects of PPIs into two big buckets: Malabsorption (Vitamin B12 deficiency, Hypomagnesemia and Osteoporosis) AND Infection (C difficile colitis). 
• Strategies to take patients off PPIs include short, finite prescriptions to begin with, managing expectations and using rescue meds. 

Transcript

S: This is Dr. Shreya Trivedi, and this is Dr. Minali Nigam, a neurology resident. This is the CORE IM 5 pearls podcast bringing you high-yield evidence-based pearls. 

M: Today we’re going to dive into pearls on the geriatric assessment. 

So when I’m meeting an older adult patient, whether it’s in the clinic or in the hospital, I always look at the feet. Toenails are like the A1C of functional independence.  when you look at, at the feet and you see this long toenail sign, you really get a sense how someone’s been managing over the last few months and whether they’re able to do this self care task or get help for themselves, if they can no longer do it. 

M: That’s Dr. Andrea Schwartz,  a geriatrician at the Boston VA. [pause] She gave me that advice to look at the toenails when we were on rounds. We were seeing this 90-year-old whose mobility seemed fine so we were asking if physical therapy really needed to see him. 

S: So Minali, what did his toenails look like?

M: Sure enough his toenails were several centimeters in length and clearly hadn’t been clipped in months so we got PT onboard. Thinking about that toenail gem a bit more, it got me thinking about what are the other high-yield pearls when meeting someone for the first time, especially our geriatric patients. 

S: So let’s get into those pearls we’ll be covering in the episode. Test yourself by pausing after each of the 5 questions. Remember, the more you test yourself the deeper your learning gains. 

M: Pearl 1: Approach to the initial office visit

• S: What high-yield questions should we be asking when we first meet an older patient? 

M: Pearl 2: “Moves” for mobility 

• S: How do you test someone’s mobility and assess their fall risk? 

M: Pearl 3: Cognitive Evaluation 

• S: What are the main differences to know about the different cognitive assessments ? 

M: Pearl 4: Managing Medications

• S: What is your approach to deprescribing medications? And what are some of the meds that we underprescribe?

M: Pearl 5: Throwback Pearl

• S: How can we deprescribe PPIs? 

Pearl 1: Approach to the initial office visit: what questions should we ask? 

S: Okay Minali, I remember so many times being in clinic and chart reviewing for an older patient I was about to meet. It was easy feeling overwhelmed because oftentimes I can tell from the chart that they had a ton of things going on and I wasn’t actually sure where to start. 

SCHWARTZ: start with what matters to the patient. So we may have our long checklist we want to get through, but making sure that we’ve really heard why the patient is there and what they are worried about, uh, can make sure that our care is aligned with their current goals.

M: So what does that goal setting conversation look like? 

S: So what I have learned from my geri colleagues over time is that opening with something like, “Mr. Jones, you have gone through so much, I’m curious after all of this, what matters the most to you?” or “could you tell me what a good day for you look like?” can be a really good starting point

SCHWARTZ:  So in the outpatient setting, that may mean that an older person is worried about falls or insomnia, where we, as the clinicians, may want to get through our checklist of preventive health care or, um, you know, their blood pressure goals. So if it’s someone’s goal is to be able to stay at home independently for as long as possible, then we may end up speaking more about their balance problems and less about their specific diabetes numbers.

M: You know, I relate to this so much because I can’t tell you how many times in resident clinic I’ve thought the patient is coming in for one thing only to find out they want to talk about something completely different

PERRY:  For me being a geriatrician, what’s different is I let go of the idea that I’m going to learn the whole story in my initial encounter. 

PERRY: I think about what are the next periods of time that I’m going to meet this person? What do I absolutely have to do now and what can wait? 

S: That’s Dr. Laura Perry, primary care doctor and geriatrician at the San Francisco VA’s Community Living Center. 

M: Ok so once we get a sense of the patient’s priorities, the geriatricians we spoke with said the next step is to  gauge  the patient’s functional status

SCHWARTZ: : You could look at two 80 year olds that have the exact same problem list, the exact same list of comorbidities, but one of them is living in the community independently, maybe working, driving, you know, involved with family. And that same list of co-morbidities in a different 80 year old…they might be in a nursing home dependent on others for all of their activities of daily living like bathing and dressing. And so you can’t tell that from that one-liner of an 80 year old with heart failure and diabetes. So get in the habit, even with that, one-liner thinking, is this a community dwelling, older person, is this a person who lives in an institution and trying to understand what their baseline is, is then critical to figure out what kind of care they might need.

M: And this is where that toenail length  can be helpful, because it can serve as a proxy for a patient’s functional status. And I learned this as I was researching the episode. Apparently, toenails grow at a rate of 2mm per month, which is like the thickness of a nickel! 

SCHWARTZ: It prompts us to ask why, why can’t this person get their toenails? What else is going on? Do they have emotional support? Do they have, um, cognitive or financial, um, uh, limitations?

SCHWARTZ: So when we see that long toenail sign, it means that somebody wasn’t able to access the care that they needed for their feet, or maybe they didn’t have the cognition, or, um, maybe they were depressed and didn’t want to attend to, to that need. 

 It actually takes a lot of flexibility and you can easily think of things that would get in the way of being able to reach whether it’s spinal stenosis or, um, vision impairment or dexterity of your hands. 

M: The one other thing i’m gonna add the ddx of long toenails is caregiver burnout – I’ve def seen that! 

S: i would def fall into that category, seeing i haven’t cut my toenails since my son was born!

M: In addition to the toenails, shreya what else should we think of when assessing someone’s functional status? 

S: Classically we think  about digging into activities of daily living. These are  things that I help my 1 year old with -things like bathing, eating, feeding, walking, toileting. Then asking also about their instrumental activities of daily living  

SCHWARTZ: So these are the things that I like to joke that when you’re in the middle of night float or finals, may fall by the wayside. Things like laundry, cooking, finances, um, even something like telephone use and keeping up with your messages. And so these are your instrumental activities of daily living, and they include things like transportation, grocery shopping in medication management. And these are often the first areas where we start to see difficulties with functional status when someone has either cognitive impairment or mobility impairment. So for example, if somebody has mobility impairment and they walk with a walker, they need to get creative about how they’re going to do their grocery shopping.

S: Amen to those scooter grocery carts!  But you know when we’re asking our patient’s functional status it can sometimes be a little awkward or even make our patients feel a little self-conscious

SCHWARTZ: So instead of saying something like, are you still driving or are you still able to dress yourself? Um, which could be potentially an embarrassing question. I usually start with an open ended question. Like, can you walk me through a typical day from the moment you get out of bed in the morning and often the patient will spontaneously tell me about how they get dressed or their aid helps them get dressed, how they take a shower or their son helps them get in the shower, how they make themselves breakfast or their spouse prepares breakfast for them, or they open the door for their meals on wheels delivery.

M: Alright so to recap pearl 1: Some take-aways on best practices for an initial office visit are to to ask explicitly what matters most to the patient, figure out what they can do and something i never considered was looking at the patient’s toenails – As Dr. Schwartz says the HgA1c for functional independence 

Pearl 2: Moves for Mobility – what tests can we do to decrease fall risk? 

S: Ok so we get a good history on how much this patient can do and in what care setting, but then i see a lot of people gloss over seeing how they move objectively on the physical exam 

SCHWARTZ:  So our physical exam of the older adult should always include a measure of function and mobility in almost any setting… Because again, it tells us so much about how this older person is doing at baseline and what kind of support they might need 

S: Yep the support they need, especially to prevent a fall. Ok so whats the best way to go about assessing functional status objectively? 

SCHWARTZ: So in terms of which functional or mobility assessments to use, the best one to use is one that you’ll actually use and be able to integrate into your practice. 

S: Ouch i feel like that was a little burn. But its true, the best functional test  is just one you can actually incorporate into your practice. Noted.

M: I can say even for neurologists, sometimes we end up not really examining how a patient walks because it takes time and effort

S: Wow even coming from a  neurologist I really appreciate that realness. Maybe it would be good for us to go over what the different objective assessments are so we can tailor which one might be the best to incorporate for a particular patient.

M: Probably the most well known test that we all learn in med school, is the Timed Get Up & Go. As a refresher, here’s how the test works: the patient sits in the back of a chair and is asked to walk to a line about 10 feet away on the floor. You time the patient and say  “go,” at which point the patient stands up from the chair without using their hands for assistance, walks to the line, turns, walks back to the chair and sits down again. 

S: Right, so If that patient takes more than 12 seconds from start to finish, the patient is at an increased risk of falls.  And honestly if you don’t have 10 feet worth of space or 10 ft measured out,  Dr. Schwartz gave us an abbreviated version to assess mobility

SCHWARTZ: Some quick, uh, measures of mobility that you can use, uh, in pretty much any setting are the chair stand…You just have the patient, put their feet flat on the floor. Don’t do it. If they’re on a wheelie chair, it should be a sturdy chair, um, with, or without arms. Uh, and then you invite the patient to cross their arms over their chest, or put their arms straight up front and rise from a chair without using their arms…

And then sit back down. Some patients will need to use the arms of the chair to assist them. And that’s helpful information as well…

SCHWARTZ: I love the chair stand because even one chair stand gives you a lot of information. If a patient can’t do even one chair stand they’re at high risk for falls. And often those patients are really going to benefit from involvement of physical therapy and potentially occupational therapy. 

M: The caveat here is that we can’t just use these mobility tests as single predictors of falls —  there is so much more that goes into fall risk – the patients comorbidities and even how safe their home is

SCHWARTZ: Falls are a leading cause of morbidity and mortality in our older population right up there in the top 10 causes of deaths, along with heart disease and dementia and cance A fall can be that life-changing event, that land someone in the hospital and they never make it back home. And it can lead obviously to very severe outcomes like brain bleeds. so noticing the slow gait speed and reacting to it before it leads to a devastating fall is one of the best things we can do. 

S: Even just watching the patient walk and eyeball how fast or slow they’re going can give us a clue on subtle changes. And thats what happened with Dr. Swartz – she hadn’t seen a patient in over a year because of Covid-19 and from gait speed alone she could tell he had a major decline. 

SCHWARTZ: like in many, uh, geriatric cases, it was multifactorial. He hadn’t been leaving the house as much. Uh, his gym had closed. Uh, the partner he used to go walking with, uh, was at home caring for a loved one. And so, uh, he had had a major decline in his level of activity and he was stiffer. We were able to encourage him to do those chair stands and practice them at home when he was watching TV. And then we were able to do a little more investigation and try to figure out if anything else was wrong.

In his case, he had a painful Bunion. He needed to see podiatry. He was due for a new pair of shoes so that he could be in a steady, comfortable pair of shoes. And he benefited from the involvement of physical therapy that taught him further exercises that he could do at home as well as helped install, uh, helped him figure out where to install, grab bars and a raised toilet seat. 

M: Who would’ve thought that slow gait speed would crack the case of the bunion?

S: And probably helped prevent a future fall. And we will link a CDC website called STEADI in the show notes, which stands for Stopping Elderly Accidents, Death & Injuries. It lays out interventions and the research behind doing things like balance exercises, using safe furniture and reducing polypharmacy, which we’ll dive more into later. 

M: Great so speaking of being STEADI, let’s wrap up this pearl on moves for mobility. 

S: Let’s recap. Remember that gait speed is the 5th vital sign, especially for older patients. So yes, if you have 10 feet of space use the timed get up and go or just watch the patient walk. And the simple chair stand can also be helpful in gauging balance and coordination.

Pearl 3: Cognitive Evaluation – what’s the work-up?  

M: Here’s where the neurology nerd in me comes out — thinking about thinking.  Going back to  Pearl 1 – for many patients and families what’s most important to them is being able to think clearly. 

S: So it’s good to have some tools to assess that objectively than just going by our gestalt

SCHWARTZ:  So many times I’ve been surprised by how someone could be very facile and completely socially intact and yet do very poorly on the mini-cog.  

SCHWARTZ:  somebody who’s having trouble with the clock, maybe they’re having trouble with their medications or even with driving, uh, because those are tasks that take so much executive function.

M: Just as a quick refresher, how is the mini-cog properly administered and how do you score it

SCHWARTZ: I like this tool because it’s just a three word recall. The validated words I usually use are banana sunrise chair. And you have the patient repeat them to you two times to make sure that they’ve been able to register the words and they can hear them. And then you ask the patient to draw the face of a clock, put in all the numbers and set the time is 10 past 11 and you watch them while they draw the clock. And then you end with the three word recall and see if they can recall the banana sunrise chair. 

S: The mini cog is scored out of 5 points — 1 point for each correct word & 2 points for normal clock draw. Unfortunately, they get 0 points if the clock is drawn incorrectly or did it wrong. Anything less 5 is a reason for us to get a bit more curious

M: Ok what if they miss a word or can’t draw 10 past 11 – What are the next steps? 

SCHWARTZ: So the Mini Cog takes about a minute, which is very quick, but it gives you an objective finding. First of all, if they can’t do the recal test, it tells you that you’ve got to give them written instructions from your patient encounter. If they got ⅓ recall, they’re likely to only remember about 1 out of 3 words you said. 

SCHWARTZ: The second thing prompts you to do very practical things, like look in the ears for wax.

SCHWARTZ: So the enzyme that breaks down the  cerumen, it doesn’t work as well as we get older. 

SCHWARTZ: And, um, in Dr. Soo Borson’s work and others who validated the mini-cog, um, it’s just a brief screening tool, so you can’t diagnose anything off of it, but it tells you that you need to do a longer test.

M: Right, so that’s when we can think about a longer test like the Montreal Cognitive Assessment, better known as the MoCa. But I think twice on who I administer the MOCA to in practice. 

PERRY: so the MOCA was designed and validated to detect mild cognitive impairment in a pool of largely college educated Montreal residents. So bilingual white people, um, that almost never matches my patient population. 

S: A very important caveat indeed. But say you have a college educated, white person and the patient gets a score <26 out of 30 suggesting cognitive impairment, what are the things we should be considering?

SCHWARTZ: So some of the things to consider when you get an abnormal cognitive screening test, we’ve already mentioned hearing that’s an often overlooked one, but easily modifiable. Uh, another thing to consider is medication effects in particular medications that may impair cognition, such as sleep AIDS, opioids, or medications that indirectly may impair cognition. For example, through hypoglycemia, I’ve definitely seen patients whose diabetes is too tightly controlled given their age and co-morbidities and are having frequent episodes of hypoglycemia that can manifest as confusion and impaired cognition.

M: That’s a long list of reversible causes of dementia, but there’s even more that we all learned for the boards. So checking Vitamin B12, thiamine, TSH, syphilis or if really warranted, head imaging are all part of this work-up. 

S: Practically speaking I’ve never had any of those be the culprit for me. But, what I have been amazed at how much things like depression was playing into a patient’s cognition and side effects of meds. 

M: That’s a great point. This all good stuff in the outpatient setting but these tests can’t really give you an accurate idea when someone’s acutely ill. So, if we’re in the inpatient setting, we need to think about if the patient is in a state of delirium. 

S:  The teaching point here is that the hallmark of delirium includes 1) disorientation and 2) inattention, but i see so many just asking if the patient ONLY if they are orientation to name, place and time

SCHWARTZ: 

So A&O times three on a hospitalized patient, doesn’t give you enough information to determine if they’re delirious.  You need to add a test of attention like months of the year backwards or days of the week backwards, which is a little easier. And the UB2, the ultra brief delirium screen is just orientation to day and months of the year backwards. And it’s a very sensitive test for delirium. You wanna pick up acute brain failure before the patient is agitated and pulling out their lines and quickly intervene to figure out why they’re delirious. 

S: You know since this interview I’ve actually started to ask my patients to tell me the days of the week backwards and its made me feel a lot more confident about something being off or saying the abx are actually working and their mental status is clearing up

M: I’ve started asking it too but make it more challenging  I  start with a day in the middle of the week like Wednesday and then ask them to go backwards. 

S: Yep I guess by the time we get the neurologist involved, you really wanna be sure of their cognitive status and challenge them. 

M: Happy for the consult! Alright so to wrap up Pearl 3, use the mini cog as a brief screening tool for cognitive impairment. You can do a longer test like the MoCA but in the right patient population, keeping in mind education level and race.  If impaired, get a work-up for reversible causes, most importantly the overlooked ones like hearing, depression or a medication side effect. 

S: And if you are in the inpatient setting testing for cognition and thinking about delirium, we really want to assess that attention part of it, which is the hallmark for delirium. Like testing for the days of the week backwards or the months backwards, can be helpful.  

Pearl 4: Managing Medications – How should we prescribe and de-prescribe medications? 

S: You know one of the big tenets with taking care of an older patient is deprescribing. And yes, in an ideal world this is probably one of the most important things we can do for our patients. But this is so hard to operationalize sometimes. M: Agreed So we asked our geriatricians how they do it

PERRY: So the first thing I do is a really good medication reconciliation. I find out what they’re actually taking, and that often involves collateral information as well, sometimes from the pharmacy sometimes from a family member or a home health aid. Because our lists that we have is just like a kitchen sink of garbage a lot of the time. So you’ve got to start with knowing what the patient’s actually taking, and sometimes it’s not consistent

S: I think we’ve all been there, burnt way too often trusting the med list on paper and there’s a big discrepancy with what the patient actually takes and how often. And it makes sense to really dig into this — until we actually learn what a patient actually takes, we can’t deprescribe anything 

PERRY: Then I actually come back to the problem list. Um, this is one of the places where I revisit it. I will take a piece of paper, fold it in half on the left-hand of the side. I write their problem list. And on the right hand side, I match the medications to each thing. And then I’ll find sometimes that I have these leftover medications and I’m like, so what is this doing? So then I either revise my problem list with things that like I haven’t looked into that need to be resolved. And I would say a common example is slow transit, constipation. Um, you know, so many people are on Senna every day, WHY?! and the slow transit constipation might be part of like, okay, they’ve got chronic pains. So they’re on an opioid or it might be that it’s the side effect of a bunch of other medications that are on this list. So I put poly-pharmacy as a problem on their problem list, um, if that’s what I’m finding

I so wish our EMR systems carried forward the initial indication- or even with the med list, grouped all the HTN ones or the DM ones would make it easier for our overburdened clinical brains to see gosh, this person is on are 4 HTN meds and tamsulosin now or jeez, they’re 3 sedative medications and just makes the work up and thinking why this person is unsteady on their feet a little bit easier. 

PERRY: And then I’ll find sometimes I’ve got the sort of leftovers, and if I really can’t find an indication or a problem, then I’ve got the things that I can be like, why are you taking this? So then there’s a sort of a negotiation with the patient. Um, sometimes it’s like the benzodiazepine that they’ve been using for sleep and they don’t want to come off of…And you’ve got to sort of take the time to like, educate them about the non-pharmacologic treatment of insomnia.  I would say nocturia is the most common one and you know, that or pain is another one.

M: I honestly think geriatricians are the true Sherlock Holmes of medicine. They really dig into all the clues to crack what’s the best medication regimen for each person.  

PERRY: at the end of, I start putting on my, like, you know, lean black belt, um, of like, you know, can I get more than one, like bang for my buck by changing a medication? You know, is there like a, um, is there a cheaper alternative, is there a less frequent alternative? You know, that’s what I’m sort of icing on the cake is what I’m changing Metoprolol tartrate to Metoprolol succinate for that once a daily bang for your buck. 

M: Another low hanging fruit are vitamins and supplements. So unless someone truly has a vitamin deficiency, most of the time you can knock the supplements off. 

S: Yep delete, delete, delete. Alright Minali, we’ve talked a good deal about the approach to deprescribing but there are other blindspots with meds. Actually thinking about things we underprescribe. 

PERRY:  I think osteoporosis in general is really undertreated. You know, people come in for it’s, it’s so poorly screened for every primary practice I’ve been part of, it’s never been, you know, DEXA is on the list of one of our quality metrics that we should be doing for everyone. And yet the evidence is so strong for how it changes people’s quality of life. If you can prevent one hip fracture, you can really make a huge difference, so thinking about the medications that decrease bone density, especially things like PPIs or other things that interfere with your GI absorption of minerals,  and especially in your smokers, that should be a screen way more than like the lung CT should be a screen that we’re still trying to figure out if it’s a good idea or not.

S: Ouch! I will think about that burn everytime I go to prescribe a lung CT in a older patient who smokes and not a DEXA 

PERRY  Like get people on their bisphosphonates, get your chronic pain patients on like a decent schedule dose of Tylenol. It can help like decrease how much opioid and other stuff that they need. Use the medications that don’t have a lot of risks, but like make a big difference.

M: Speaking again on underprescribing, there’s the direct oral anticoagulants or DOACs. Time and time again, clinicians are hesitant to prescribe them for elderly patients, especially ones who can fall — because there’s bleeding risk. But on the other hand, we are putting patients at a risk for debilitating stroke. Idk, maybe that’s the neurologist in me talking. 

S: No I agree. I think about that a lot when it comes to the risk/benefit conversation. There’s growing evidence that shows that patients in their 80s do benefit from being on a blood thinner to reduce their stroke risk, which as you said can be pretty devastating.

M: Alright glad to know I have some back up here! 

S: Maybe the last point to take away is if you do change around the medications, think about who you need to loop in. Especially because the reality is we have such a fragmented healthcare system

PERRY:Last thing I do is communicate, communicate, communicate. You know, write a good note to whoever’s going to take care of the patient next, whether that’s a consultant that you’re asking for help, if you’re a primary care doctor or the primary care doctor, if you’re the hospitalist, um, you know, make sure that like your note is, is like a message to who’s coming next to say, like, here’s why I did what I did. Here’s what I think is the next priority and I’m kicking the ball to you. 

PERRY:  And that’s how I do a medication deprescribing

M: [much appreciated!] To recap the approach on deprescribing and underprescribing, start with writing down the problem list and matching medications to each problem. That’s something I at least try to do mentally for each patient. Peel off the meds that are leftover or have blatant adverse effects. Quick wins are to treat osteoporosis and use tylenol when in pain. And not forgetting to weigh stroke versus bleeding risk for DOACs.

Pearl 5: Throwback Pearl – PPIs 

S: We’ve spent time talking about polypharmacy. And this would be a good time to throw back and do some spaced repetition to our episode on PPIs and think about how do we take off PPIs on our patients med list. 

M: I remember that episode. There were two big buckets of harms of PPIs: malabsorption problems and infection.

S: Nice memory. With the malabsorption bucket, people who are on PPIs for a long time we think about Vitamin B12 deficiency, hypomagnesemia and osteoporosis — huge problem for patients who have high fall risk

M: And then with infection, there’s risk C diff.  PPIs suppress gastric acid, which is great for GERD. But the teaching point I learned from the episode was that gastric acid can actually kill C diff spores. So without those gastric juices, C diff can wreak havoc. 

S: Maybe before we even get to desprecribing… one of the big take aways is thinking about best practices when we actually prescribe. So if someone is having symptoms, I know only give a short duration — 2 to 3 weeks of PPI is enough. Also educating them about lifestyle changes with foods and things like weight loss.

M: And when you do deprescribe and their symptoms come back, we can use rescue meds instead. The simple stuff like aluminum hydroxide aka Maalox can neutralize stomach acid because it’s a base. 

S: Right and i also love reaching for the H2 blockers, the famotidine, the ranitidine and i get the patients all psyched up because i tell them its a different mechanism and they get all excited about it 

M: You all unlocked so many good strategies during the episode! It’s all coming back to me! 

S: Same here. It’s so humbling how much you forget and need to re-remember. And that is wrap for today! If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! 

M: If you have feedback or questions, please email us at hello@coreimpodcast.com.  Thank you to our peer reviewers – Dr. Amy Shaw and Dr. Colleen Christmas.  Thank you to Max Had for the audio editing and Dr.  Michelle Lo for the accompanying infographic. Opinions expressed are our own and do not represent the opinions of any affiliated institutions. 

S: Alright take care!