Geriatrics Update 2004

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Geriatrics Update 2004

• Steven Zweig, MD
• Family and Community Medicine
• MU School of Medicine

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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

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Falls and Vitamin D

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

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Can we prevent falls in the elderly?

• Chang JT et al. BMJ 2004328680-687

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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

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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)

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Does Vitamin D reduce the risk of falling?

• Bischoff-Ferrari HA et al. JAMA
  20042911999-2006.

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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

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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

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Are we using calcium and vitamin D in nursing
homes?

• Kamel HK. JAMDA 2004598-100.

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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

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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

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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

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Do steroid injections work?

• Arroll B, Goodyear-Smith F. BMJ 2004

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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

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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

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What is the efficacy of knee taping for DJD?

• Hinman RS et al. BMJ 2003327-332.

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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

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Benefits of Knee Taping
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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

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Can antidepressants reduce mortality from stroke?

• Jorge RE et al. Am J Psychiatry 2003
  1601823-1829

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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

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Survival after Stroke
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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

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What adverse drug reactions (ADRs) are associated
with hospitalization?

• Pirmhamed M et al. BMJ 2004 32915-19

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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

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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

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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

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Cardiac

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

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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

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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

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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.

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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.

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Does the use of B-type natriuretic peptide (BNP)
improve patient outcomes?

• Mueller C et al. N Engl J Med 2004350647-654

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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

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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

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Does office or home BP predict outcomes?

• Bobrie G et al. JAMA 2004 2911342-1349

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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

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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

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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

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Can morphine help dyspnea?

• Abernethy AP et al. BMJ 2003327523-528

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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

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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

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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

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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

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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

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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