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Geriatrics Update 2004

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Title: Geriatrics Update 2004


1
Geriatrics Update 2004
  • Steven Zweig, MD
  • Family and Community Medicine
  • MU School of Medicine

2
Strategies
  • Sample had to be primarily older patients
  • Either most interesting, most dramatic, or most
    prevalent serves as selection criterion
  • Articles collected over the last year
  • Final selection is thematic and somewhat
    arbitrary
  • Common journals searched include JAMA, NEJM,
    JAGS, BMJ, Lancet, JAMDA,reviews from InfoPOEMs,
    abstracts from various sources

3
Falls and Vitamin D
  • Fall prevention
  • Vitamin D for fall prevention
  • Under use of calcium and vitamin D in nursing
    facilities

4
Can we prevent falls in the elderly?
  • Chang JT et al. BMJ 2004328680-687

5
Background and Design
  • 30 of 65 fall each year, 50 for those over 80
  • 3-10 of falls result in serious injury, leading
    to 40 of nursing home admissions
  • Meta-analysis of all randomized controlled trials
    (RCT) examining impact of fall prevention
    interventions including multifactorial risk
    assessment and management, exercise programs, and
    education

6
Results
  • 40 trials identified
  • Reduction in risk of falling (risk ratio 0.88,
    95 confidence interval 0.82 to 0.95) and
    reduction in monthly fall rate (rate ratio 0.80,
    0.72 to 0.88)
  • Multifactorial risk assessment and management
    most effective on risk of falling (number needed
    to treat NNT 11) and monthly fall rate (11.8
    fewer falls per 100 persons).
  • Exercise interventions were also effective (NNT
    16)

7
Does Vitamin D reduce the risk of falling?
  • Bischoff-Ferrari HA et al. JAMA
    20042911999-2006.

8
Background and Design
  • Moderate protective effect of vitamin D on
    fracture risk attributed to bone changes
  • Vitamin D may also improve muscle function,
    reduce body sway, and thereby additionally
    reducing fracture risk
  • Meta-analysis to assess effectiveness in
    preventing falls
  • RCTs using vitamin D in elderly including
    community and nursing home subjects

9
Results
  • Based on 5 RCTs with 1237 participants, vitamin D
    reduced falls (odds ratio OR, 0.78 95 CI,
    0.64-0.92) compared with placebo or calcium. NNT
    15
  • Inclusion of 5 studies for sensitivity analysis
    confirmed benefits of vitamin D
  • Effect size independent of calcium, 800 IU/day
    appears to be required dose

10
Are we using calcium and vitamin D in nursing
homes?
  • Kamel HK. JAMDA 2004598-100.

11
Background and Design
  • Prevalence of osteoporosis up to 85 in nursing
    homes calcium and vitamin D caused 43 reduction
    in nonvertebral fractures
  • Vitamin D deficient due to age-related decline in
    production, lack of sunlight, and inadequate oral
    intake and absorption
  • This is a cross sectional study of 177 residents
    from one facility in New York

12
Results
  • Subjects age 65-98 years
  • Calcium and vitamin D prescribed in only 12 and
    9 of subjects more if diagnosis of osteoporosis
    was made, only 25 if history of hip fracture
  • Small study, but points to a simple need for more
    appropriate prescribing of inexpensive and low
    risk drugs

13
Osteoarthritis of the Knee
  • Osteoarthritis the most common cause of
    disability in the aged
  • Little progress toward cure results in symptom
    oriented therapies recent meta-analysis showed
    limited value of hyaluronate injections
  • Two studies look at steroid injections and knee
    taping as approaches to symptomatic therapy

14
Do steroid injections work?
  • Arroll B, Goodyear-Smith F. BMJ 2004

15
Background and Design
  • Most believe intraarticular steroids provide
    short term relief of symptoms
  • Concerns that multiple injections may damage
    articular cartilage
  • This meta-analysis examined RCTs comparing
    steroids to placebo injections
  • 10 trials met inclusion criteria doses ranged
    from 6.25 to 80 mg prednisone equivalents

16
Results
  • Pooled relative risk for improvement at 16-24
    weeks was 2.09 (95 CI, 1.2 to 3.7), NNT 4.4
  • Higher doses more effective than lower doses,
    especially after 16 or more weeks
  • One study used q 3 month injections for 2 years
    and saw no change in joint space narrowing
    suggesting no negative effects

17
What is the efficacy of knee taping for DJD?
  • Hinman RS et al. BMJ 2003327-332.

18
Background and Design
  • Knee taping provides medial glide, medial tilt,
    and AP tilt to the patella to unload
    infrapatellar fat pad or pes anserinus
  • 87 volunteers (mean age 67) randomly allocated
    into therapeutic tape, control tape, and no tape
    groups applied by community physical therapists
    for 3 wks
  • Subjects unaware which was therapeutic, assessors
    of outcomes didnt know subjects group
  • Outcomes included pain, function at 3 weeks and 6
    weeks

19
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20
Benefits of Knee Taping
21
Results
  • Therapeutic taping showed benefits in all
    outcomes at 3 and 6 weeks 73 showing
    improvement vs. 49 for control taping and 10
    for no tape group
  • Generally applicable and patients could be taught
    - but not know how pain is relieved or ideal
    duration of taping
  • Simple, inexpensive strategy

22
Can antidepressants reduce mortality from stroke?
  • Jorge RE et al. Am J Psychiatry 2003
    1601823-1829

23
Background and Design
  • Poststroke depression associated with mortality
    for up to 5 years after stroke, diagnosed in 40
    and linked to poorer cognitive and physical
    recovery
  • 343 patients (mostly from Iowa) evaluated
    poststroke 130 refused, 103 excluded due to
    life-threatening illness or unable
  • 104 (mean age 68) submitted to double-blind
    placebo controlled trial of 12 weeks treatment
    with fluoxetine or nortriptyline vs. placebo and
    mortality determined at 9 years

24
Survival after Stroke
25
Results
  • Intention to treat analysis (ITT) showed that 42
    of 71 (59.2) of treated patients were alive at 9
    years vs. 12 of 33(36.4) of placebo patients
    (p.03, log rank test, Kaplan-Meier survival
    analysis), NNT 4
  • Logistic regression controlling for other risk
    factors demonstrated no change in effect
  • No difference between fluoxetine and
    nortriptyline or between depressed vs. not
    depressed at baseline
  • Those treated for longer times did better

26
What adverse drug reactions (ADRs) are associated
with hospitalization?
  • Pirmhamed M et al. BMJ 2004 32915-19

27
Background and Design
  • ADRs account for 5 of hospital admissions based
    on studies before 1990
  • Incidence of fatal ADRs may be 0.13
  • More common in elderly patients
  • Prospective study of 18820 patients aged gt16 yrs
    admitted over 6 months to two large British
    hospitals excluded deliberate misuse each case
    reviewed twice and judged as to level of cause
    and avoid ability

28
Results
  • 1225 (6.5) of admissions caused by ADR
  • Median age 76 years (compared with 66 years for
    those without ADR)
  • In 80 ADR directly responsible for admission
    72 judged to be avoidable
  • Interactions responsible in 15.6 of cases
  • 2 died, suggesting ADRs may be responsible for
    death of 0.15 of those admitted

29
Causes of ADRs
  • Drugs of cases
  • NSAIDs (c ASA) 29.6
  • Diuretics 27.3
  • Warfarin 10.5
  • ACE inhibitors 7.7
  • Antidepressants 7.1
  • B blockers 6.8
  • Opiates 6.0
  • Digoxin 2.9
  • Prednisone 2.5
  • Clopidogrel 2.4

30
Cardiac
  • Management of newly detected atrial fibrillation
  • Using BNP to improve outcomes for dyspnea
  • Use of home monitoring to improve blood pressure
    control

31
What is the appropriate management for new onset
atrial fibrillation?
  • Snow V et al. Ann Intern Med 20031009-1017
  • McNamara RL et al. Ann Intern Med
    20031391018-1033

32
Background and Design
  • Atrial fibrillation is the most common arrhythmia
    in adults
  • Prevalence increases to 8 in 80 people
  • Palpitations, dizziness, malaise common and risk
    of stroke increased 1 to 7 fold
  • Study group reviewed 500 articles for RCTs
    paired reviewers evaluated efficacy and safety
    excluded postop or postmycardial infarction AF,
    class IV CHF, and valvular heart disease

33
Results/Recommendations (1)
  • Rate control is recommended strategy for majority
    of patients. Rhythm control not superior to rate
    control.
  • Patients should receive warfarin unless low risk
    of stroke or contraindicated (thrombocytopenia,
    recent trauma or surgery, alcoholism)
  • Rate control drugs include atenelol, metoprolol,
    diltiazem, and verapamil. Digoxin effective only
    at rest.

34
Results/Recommendations (2)
  • For those who elect cardioversion both direct
    current and pharmacological treatments are
    appropriate options
  • Both TE echo with short-term prior
    anticoagulation (in absence of thrombus) and
    delayed cardioversion with anticoagulation are
    appropriate strategies
  • Most patients converted to sinus rhythm should
    not be placed on maintenance therapy.

35
Does the use of B-type natriuretic peptide (BNP)
improve patient outcomes?
  • Mueller C et al. N Engl J Med 2004350647-654

36
Background and Design
  • Congestive heart failure (CHF) is the most
    frequent cause of hospitalization in 65
  • BNP higher in CHF than other causes of dyspnea
  • Incorrect treatment strategies costly in and
    hazards
  • RCT of 452 patients with dyspnea presenting to
    emergency department of University Hospital in
    Basel, Switzerland. One group got BNP, the other
    usual evaluation (patients with trauma, renal
    failure excluded)
  • Outcome assessment blinded to group assignment

37
Results
  • Clinicians advised that BNP lt 100 made CHF
    unlikely, one of gt500 very likely
  • Mean age 71 years. Admission in BNP group lower
    (75 vs. 85 NNT 10), as was ICU admission (15
    vs. 24 NNT 11)
  • Patients in BNP group treated more quickly (63
    vs. 90 min), spent less time in hospital (8 vs.
    11 days), and cost less (5410 vs. 7264)
  • No difference in in-hospital or 30 day mortality
    or 30 day readmission rates

38
Does office or home BP predict outcomes?
  • Bobrie G et al. JAMA 2004 2911342-1349

39
Background
  • For each 10 mmHg systolic or 5 mmHg diastolic
    increase in BP, mortality from stroke up 40 and
    CAD up 30
  • BP control reduces those risks, but measurement
    in office variable

40
Design
  • To assess the prognostic value of home vs. office
    BP measurements
  • European study included 4939 patients treated for
    hypertension (mean age 70 )
  • Recruited and followed by GPs without specific
    management recommendations
  • Threshold for normal 140/90 in office, 135/85 at
    home
  • Primary outcome cardiovascular mortality, panel
    of 3 blinded to BP measurements

41
Results
  • Cohort followed an average of 3.2 years Mean of
    6 measurements defined office BP and 27 defined
    home BP
  • At baseline on 13.9 controlled by both home and
    office measures
  • Cardiovascular mortality 5.6/1000 pt-years
  • 9 of patients appeared controlled in the office,
    but were not at home vs. 13 elevated only in
    office
  • After adjustment for age, sex, prior CAD hx,
    smoking home BP linked to prognosis

42
Can morphine help dyspnea?
  • Abernethy AP et al. BMJ 2003327523-528

43
Background
  • Breathlessness is a source of distress for 50-70
    of patients requiring palliative care
  • Multifactorial causes include the underlying
    disease, cachexia, and deconditioning
  • While opiates have been used, high quality
    studies have been lacking

44
Design
  • Randomized double blind eight day crossover study
    of opiate naïve subjects with refractory dyspnea
  • Subjects came from pulmonary, cardiology, and
    palliative care clinics where their physician
    specialists had maximally managed their disease
    process
  • 20 mg of time released morphine taken in the AM
    was the study drug with identical placebo
  • Dyspnea measured on visual analogue scale along
    with exercise tolerance, BP, HR, RR, O2
    saturation, and sleep disturbance

45
Results
  • Mean age 76, 73 men, most with COPD
  • 38 of 48 subjects completed the study (5 dropped
    out of each of the groups)
  • Subjects receiving morphine reported
    significantly less dyspnea (6.6 mm in AM and 9.5
    mm in PM, plt.01), better sleep (p.o4), and more
    constipation (p.o2)
  • Exertion, respirations, and 02 saturation were
    not affected

46
Summary Conclusions (1)
  • Falls in the elderly can be reduced with careful
    assessment and exercise programs
  • Vitamin D reduces falls (800 IU/day)
  • Many in nursing homes are receiving inadequate
    calcium and vitamin D
  • Both corticosteroid injections and taping help
    symptoms of osteoarthritis of the knee

47
Summary Conclusions (2)
  • All patients without a contraindication should
    likely be treated with an antidepressant
    following a stroke
  • ADRs are a common cause of hospitalization of the
    elderly watch ASA, NSAIDs, diuretics, and
    warfarin
  • Focus on rate control and anticoagulation for new
    onset atrial fibrillation

48
Summary Conclusions (3)
  • BNP improves outcomes in evaluation of dyspnea
  • Home self- blood pressure monitoring better
    predicts outcomes than office readings
  • Sustained release morphine helps refractory
    dyspnea in older persons with minimal side
    effects in most
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