Transcript Articles on Dementia and Delirium - 302 KB

Articles on dementia and delirium
Articles on both the benefits and
risks of drugs
Articles on assessment scales, &
preferences, knowledge &
experiences of EOL patients and
caregivers
Articles on diet, exercise and
functional interventions
Articles assessing fracture &/or
falls risk and interventions that
may impact the magnitude of the
risk
Articles on immunizations and
common cancer screening
interventions
Articles on urine, skin care, QI
initiatives and depression
This diagnosis measured by the
CAM (Confusion Assessment
Method) upon discharge is
associated with an increase in both
1-year mortality and nursing home
placement.
What is delirium?
Older adults discharged from the
hospital with delirium: 1-year
outcomes
GJ McAvay et al. JAGS
2006;54:1245-59
Cognition 100
Analysis of previous prospective cohort data from the
Delirium Prevention Trial
Delirium diagnosed by Confusion Assessment Method
(CAM)
433 patients
• 5.5% had delirium at discharge
• 7.2% had resolved delirium at discharge
• 87.3% never delirious during hospitalization
Compared to patients who were never delirious, those with
delirium at discharge:
• HR=1.53 (95%CI=0.96-2.43) for nursing home
placement or mortality at 1 year follow up
.
In outpatients with AD, this class of
medications used for treating
aggression, psychosis, and
agitation did not outperform
placebo.
What are second-generation
(atypical) antipsychotics?
Effectiveness of atypical
antipsychotic drugs in patients
with Alzheimer’s disease
LS Schneider et al. NEJM
2006;355:1525-38
Cognition 200
42-site, double-blind, placebo-controlled trial
421 outpatients with AD treated for
psychosis, aggression, or agitation
No significant difference in efficacy when
comparing olanzapine, quetiapine,
risperidone, and placebo measured by the
CGIC at 12 wks
No difference in time to discontinuation of
treatment in any group
These two risk factors are most
robustly associated with
delirium after noncardiac
surgery.
What are cognitive impairment
and use of psychotropic drugs?
Preoperative risk assessment for
delirium after noncardiac surgery:
a systematic review
M Dasgupta et al. JAGS
2006;54:1578-89
Cognition 300
Risk factor analysis of 25 articles
Cognitive impairment (pooled effect size r=0.27
weighted and r=0.29 unweighted, p<.001) with
heterogeneity across studies
Psychotropic drug use (pooled effect size r=0.19
weighted, r=0.26 unweighted) with insufficient
evidence to suggest heterogeneity
Other potential RFs: # of medical comorbidities
(r=0.15 weighted, r=0.19 unweighted), NH
residence (OR=1.8, 95% CI 1.1-3.1) & functional
impairment (OR=1.9, 95% CI 1.2-2.9)
.
As well as addressing
constipation, treating > one of
these 3 psychiatric conditions
may decrease aggression in
demented nursing home
residents. (Name one)
What are depression, delusions,
& hallucinations?
Potentially modifiable resident
characteristics that are
associated with physical or verbal
aggression among nursing home
residents with dementia
Leonard R, et al. Arch Int Med.
2006;166:1295-1300
Cognition 400
Cross-sectional study of nursing home residents
Characteristic
Adusted OR
(99% CI)
P Value
Depression
4.9 (4.5-5.3)
<.001
Delusions
2.5 (2.2.-2.8)
<.001
Hallucinations
1.6 (1.3-1.9)
<.001
Constipation
1.1 (1.0-1.2)
.10
Not significant: UTI, respiratory infections, fever,
pain, participation in recreational activities
This is one component of the
holistic, caregiver-inclusive
“collaborative care” model which
improves outcomes for AD patients
& caregivers & decreases the
behavioral and psychological
symptoms of dementia (BPSD).
What are coaching on caregiver
coping & communication skills,
legal/financial advice, exercise
guidelines or a brochure from Alz
Assoc?
Effectiveness of collaborative
care for older adults with
Alzheimer disease in primary
care
CM Callahan et al. JAMA
2006;295:2148-57
Cognition 500
Controlled clinical trial randomized to collaborative
care or augmented usual care
Collaborative care: minimum of education on
communication skills; caregiver coping skills;
legal & financial advice, exercise guidelines,
caregiver guide from Alzheimer’s Association
Outcomes
• Primary: neuropsychiatric inventory (NPI)
• Secondary: depression, cognition, ADLs,
resource use, caregiver depression severity
• Fewer BPSD per NPI at 12 mths (-5.6, p=.01) &
18 mths (-5.4, p=.01) for intervention group
In a country without folic acid
fortification in food, folic acid
supplementation slowed the
decline in this common
sensory loss in elders.
What is (low frequency)
hearing loss?
Effects of folic acid
supplementation on hearing in
older adults: a randomized,
controlled trial
J Durga et al. Ann Intern Med.
2007;146:1-9
Drugs 100
Double-blind, randomized, placebo-controlled
trial in the Netherlands
Folic acid 800mcg or placebo for 3 years
Rate of change for low frequency hearing loss
was less in the group receiving folic acid (1.0
dB 95% CI 0.6-1.4) when compared to
placebo (1.7 dB 95% CI 1.3-2.1), p=.020
No difference in the rate of change for high
frequency loss
May not be relevant for countries that
supplement foods with folic acid
Older adults taking serotoninreuptake inhibitors (SSRIs) may be
at increased risk for this potentially
life-threatening gastrointestinal
event.
What is upper GI bleeding?
Selective serotonin reuptake
inhibitors and risk of upper GI
bleeding: confusion or
confounding?
Y Yuan et al. Am J Med. 2006;
119: 719-27
Drugs 200
3 cohort and 1 case-control study combined SSRIs & had
differing control groups & conflicting conclusions
Cohort (317,824 pts):
• SSRI+NSAID vs SSRI users (RR 2.8, 95% CI, 2.4-3.3)
• SSRI +ASA vs SSRI only (RR 1.7, 95%CI, 1.4-2.0)
• AOR for fx rose with duration of Rx (1 yr=1.22 [95% CI,
1.15-1.30]; 2 yrs=1.41[95% CI, 1.28-1.56] and 4 yrs=1.59
[95% CI,1.39-1.80]
Case control study (1651 cases and 10,000 controls)
showed higher risks than above but a similar pattern
Concurrent use of NSAIDs or low dose ASA if combined with
SSRI seem to increase risk of UGIB
Need better designed studies
Supplementation with this B
vitamin in healthy pts with high
homocysteine levels did not
show a significant
improvement in cognitive
testing.
What is folic acid, B12 or B6?
Effect of 3-year folic acid
supplementation on cognitive
function in older adults in the
FACIT trial: a randomized, double
blind, controlled trial
J Durga et al. Lancet
2007;369:208-16
Drugs 300
Randomized, double-blind, placebo-controlled trial
Folic acid 800mcg or placebo for three years
(3 year change in
cognitive
performance)
Folic acid
Z score
Placebo
Z score
Folic acid vs.
Placebo (95%CI)
P
Memory
0.480
0.348
0.132
(0.032-0.233)
0.010
Information
processing speed
-0.072
-0.159
0.087
(0.016-0.158)
0.016
Sensorimotor speed
-0.042
-0.087
0.064
(-0.001-0.129)
0.055
This expensive new medication
slows visual loss from agerelated macular degeneration
What is ranibizumab?
Ranibizumab for neovascular
age-related macular
degeneration
RJ Rosenfeld et al. NEJM
2006;355:1419-31
Drugs 400
Study: 716 pts in 3 groups, ranibizumab (recombinant
monoclonal ab ag vascular endothelial growth factor A)
at 0.3 mg, 0.5 mg or PBO via mthly intravitreal injections
Design-2 yr double-blind, randomized, sham-controlled
Results: Acuity improved >15 letters for 25% & 34% in the
active arms and 5% of controls. Active groups improved
mean of 7 letters and control declined a mean of 10
letters (p<.001 for both comparisons)
ADEs: 2% combined endophthalmitis/uveitis
Cost: $1950 wholesale for drug monthly
Conclusion: Beneficial but expensive
A recent meta-analysis suggests
this class of commonly-prescribed
antihypertensives should not be
first line therapy for older patients
without another indication.
What are beta blockers (BB)?
Re-examining the efficacy of
beta-blockers for the treatment of
hypertension: a meta-analysis
N Khan et al. CMAJ 2006; 174:
1737-42
Drugs 500
Meta-analysis of studies c BBs as first-line Rx for HTN in
preventing CVA, MI or death
21 RCTs (PC or active comparator) with 145,811 pts
• Split trials: younger pts (mean age 52-56.2 yrs) and older
pts (mean age 60.4-76 yrs)
In PC trials
• Younger pts had better CV outcomes (RR 0.86; 95% CI
0.74-0.99) but older pts failed to benefit (RR 0.89; 95% CI
0.75-1.05)
In active comparator trials
• Younger pts demonstrated similar efficacy to other antiHTN agents (RR 0.97; 95% CI 0.88-1.07) but BBs less
efficacious in older pts (RR 1.06; 95% CI 1.01-1.10) who
also had more strokes (RR 1.18; 95%CI 1.07-1.30)
In a recent study, severely
demented patients (MMSE < 10)
understood this pain scale the
best.
What is the Faces Pain
Scale?
Pain in severe dementia: selfassessment or observational
scales?
S Pautex et al. JAGS
2006;54:1040-45
Pall Med 100
Pts: 129 Swiss elders (mean age 84) in geri and
geripsych units with a CDR of 3
Studied 3 scales & caregiver report; assessed testretest, inter & intra rater reliability
61% of pts understood at least one scale and
“faces” fared best. (Even 49% of pts with a
MMSE of < 6 could use a scale)
44% had pain and the nurses underestimated
severity (r=0.25-0.63)
Conclusion: many severely demented pts can
accurately self-report pain
Only 11% of seriously ill older
inpatients could correctly identify
at least two components of this
common end-of-life intervention.
What is CPR?
Understanding cardiopulmonary
resuscitation decision making:
perspectives of seriously ill
hospitalized patients and family
members
DK Heyland et al. CHEST
2006;130:419-28
Pall Med 200
Cross-sectional survey of 440 Canadian pts with
adv CHF, COPD, cancer or liver disease (78%
response) & 160 contacted caregivers (91%
response) about CPR & decision-making views
Knowledge: <3% thought success rate was <10%;
only 11% identified 2 components of CPR
Role views: Only 23% pts wished to decide alone
(60% endorsed shared decisional models) but
37% of pts did not want to discuss CPR with
MDs!
Conclusion: much ambivalence, big gaps in
knowledge & need for focus on shared decisions
HCPs of severely demented NH
pts were more satisfied with care
if a health care professional
discussed this topic with them for
at least 15 minutes at the time of
admission.
What are the goals of care?
Satisfaction with end-of-life care
for nursing home residents with
advanced dementia
SE Engel et al. JAGS
2006;54:1567-72
Pall Med 300
Cross-sectional study of HCPs & 148 NH pts
(mean age=85yo & LOS=2-3 yrs) with a 10 item
scale (Satisfaction c Care at EOL in Dementia)
Assessed pt and HCP factors & performed
multivariate analysis
Final model yielded 4 variables: >15” on GOC at
admission (p <.0001), greater pt comfort (p=.01),
care in dementia unit (p=.02) & no FT (p=.02)
Conclusion: Improved communication at admission
& attention to comfort may improve caregiver
satisfaction
Over time, community dwelling
elders with adv. illness and
progressing debility may be less
willing to accept cognitive
impairment but more tolerant of
this type of limitation.
What is (mild to severe)
functional impairment?
Prospective study of health status
preferences and changes in
preferences over time in older
adults
TR Fried et al. Arch Intern Med.
2006;166:890-95
Pall Med 400
Pts: 226 dependent elders with cancer, CHF or
COPD; majority died in 2 yrs
Surveyed > 4 mthly for up to 2 yrs re acceptability:
“mild” & severe functional deficits, poor cognition
& bad pain
49% had stable views but cognitive decline
became less acceptable over time to 8% while
functional losses (esp. if pt losing ADLs) grew
more tolerable to 20% pts
Conclusion: Views on acceptable QOL may shift
with time and need ongoing reassessment
Chronically disabled elders in the
last year of life receive this much
weekly help from primary
informal caregivers.
Choose between: <15hrs, 1533hrs, 34-50hrs, or >50 hrs wkly
What is an average of 43
hours weekly?
End-of-life care: findings from a
national survey of informal
caregivers
JL Wolff et al. Arch Intern Med.
2007;167:40-46
Pall Med 500
Informal Caregivers Survey (’99 Nat’l Long Term
Care Survey) with a response rate of 71-73%
1149 caregivers of dependent elders; 251 pts died
in a yr
EOL caregivers: 43 hrs weekly (84% daily), 37% c
nsng/PCA help; <5% used respite, support
groups, etc.
EOL caregivers reported greater physical, financial
and emotional burdens; remained positive about
rewards
Conclusion: large burden (but real benefits) &
minimal help
In older persons, increasing
energy expenditure by about
290Kcal/D reduced this outcome
by about 1/3.
What is all cause-mortality?
Daily activity energy expenditure
and mortality among old adults
TM Manini et al. JAMA 2006;296:171179
Nutrition/Function 100
302 hi fn community adults, 70-82 yo
Measured energy expenditure via labeled H20
All-cause mortality for a mean of 6 yrs was 18%
• Adjusted for: age, sex, race, study site, wt., ht, % body
fat, sleep duration
• Further adjusted: self-rated health, educ., previous
health conditions, smoking – little change
287 Kcal/D (1 SD) assoc. with 32% decr. mortality
• HR 0.68 (95% CI .48-.96)
• Mortality gradient, highest to lowest tertiles of energy
Factors assoc. with highest energy expend.
• Working for pay (p=.004) & climbing stairs (p=.01)
More evidence that physical activity protective
Available evidence clearly suggests
that the reduction in mortality
among undernourished elderly
given protein and energy
supplementation is found only in
this care setting.
What is
the hospital?
Meta-analysis: protein and
energy supplementation in older
people
AC Milne AC et al. Ann Intern
Med. 2006;144:37-48
Nutrition/Function 200
Meta-analysis - 55 RCTs and quasi RCTs with 9,187 participants in 3 care sites:
74% in hospital, 10% in LTC, 16% in community
Intervention: Extra 175– 1000 kcal and 10-63 gm protein for 10 days to18 mths
Outcomes (# studies): Mortality (25), morbidity (20), LOS (11), adverse effects
(18), wt change (38) and arm muscle circumference (15)
OUTCOME
Hospital
Peto OR (95%CI)
LTC
Peto OR (95%CI)
Community
Peto OR (95%CI)
Mortality
0.88 (0.49-0.90)
0.65 (0.41-1.02)
1.05 (0.57-1.95)
SUB-GROUP ANALYSIS – Peto OR (95% CI)
Undernourished
0.73 (0.56-0.94)
>400 kcal/day
0.85 (0.73-0.99)
>75 years
0.64 (0.49-0.85)
Sick persons
0.86 (0.74-1.00)
No effect: Morbidity and complications (only for hip fx), adverse effects, LOS,
functional status, QOL and MAC regardless of care site. Weight gain of 1.75%
(CI, 1.12% to 2.30%)
Bottom Line: Mortality is reduced with protein and energy supplements only if
given to undernourished hospitalized pts >75 yrs old
A recent study showed a 40%
reduction in incident AD for
people adhering to this type of
diet.
What is the Mediterranean diet?
Mediterranean diet and risk for
Alzheimer’s disease
N Scarmeas, et al. Ann. of Neurol.
2006; 59:912-21
Nutrition/Function 300
Pts: 2258 multiethnic New Yorkers
Data: Baseline 61 item Med diet survey (0-9
scale) and full CDRS eval (CDRS repeated q
1.5 yrs); mean f/u was 4 yrs; 262 pts got AD
Controlled for demographics, education, apoE,
obesity, smoking and comorbidities
Results:
• AD risk rose 10% with each point on scale
• Highest tertile for diet had 40% lower rate of
AD c/w lowest (p for trend 0.007)
• Conclusion: Med diet may decrease AD risk
A recent trial of in-home “controloriented” PT/OT improved this
outcome for functionally impaired
elders in the community.
What is a decreased mortality
rate?
Effect of an in-home occupational
and physical therapy intervention
on reducing mortality in
functionally vulnerable older
people: preliminary findings.
LN Gitlin et al. JAGS
2006;54:950-55
Nutrition/Function 400
Pts: 319 cog. intact urban dwellers over 70 yrs. c >
1 fall/yr, dependent in two IADLs or one BADL
Intervention: 14 mths of home PT/OT (five 90 min
visits & 4 phone calls); focused on “controloriented” strategies
Study: Two groups, randomized, controlled, ITT,
assessors blinded
Results: 1% mortality vs 10% mortality overall
(p=.003); more pronounced if prior hosp stay
Conclusion: First report of mortality benefit to
home rehab; needs replication
In obese elders, these two 6 month
interventions caused a loss of fat
without loss of fat-free mass.
What are behavioral weight loss
therapy & exercise training?
Effect of weight loss & exercise on
frailty in obese older adults
DT Villareal et al. Arch Intern Med.
2006;166:860-66
Function/Nutrition 500
27 “frail,” obese volunteers (av. age 70, BMI 39) randomized
• Sedentary = exercise < 3x/wk
• Frail: >2 of 3 criteria : Decr. modified phys. performance test
score (18-32), decr. peak O2 consumption, self-reported
difficulty in two IADLs or one BADL
6 mth trial: 1x/wk behavioral therapy for weight loss, 3x/wk 90”
exercise training & daily multivitamin
Significant outcomes:
• Weight loss without fat-free mass loss – major finding
• Also improved physical performance score, peak O2
consumption & functional status
Comments:
• Unclear which component key; group not really frail
• Rx group enthusiastic, changed lifestyle, 85% attendance
• Preservation of muscle similar to studies with young subjects
• One fall during exercise; no abnl labs or adverse outcomes
For persons > 65 years, having
either of these 2 risk factors
yields 1:1 odds (a 50%
chance) of having a fall in the
next year.
What is a previous fall or a
problem with gait and mobility?
Will my patient fall?
DA Ganz et al.
JAMA 2007;297:77-86
Falls/Fxs 100
Systematic review, studies predicting falls in next yr
• Cohort & RCT: 37 studies, mean ages 68-85
• Clinical RFs: office history & physical findings
Calculated pre-test probability of fall next yr
• >1 fall: 27% (95%CI, 29-36%)
• RF with LR (likelihood ratio) >2 yields post-test
falls risk ~50% (1:1 odds) in next year
Authors calculated LRs for studied RF
• Fall in previous year: LRs 2.3 – 2.8
• Abnl gait or balance on exam: LR’s 1.7 – 2.4
An elder with 1 RF: 50% chance of falling yrly
In women who had taken alendronate
for 5 years, this intervention produced
no difference in non-vertebral fractures
& relatively small declines in bone
mineral density over 5 years.
What is a placebo?
Effects of continuing or stopping
alendronate after 5 years of treatment.
The fracture intervention trial long-term
extension (FLEX): a randomized trial
DM Black et al. JAMA 2006;296:2927-38
Falls/Fxs 200
1,099 post-menopausal women, av. age 73
Low baseline fem neck BMD, rx alendronate x 5 yrs
Randomized to alendronate 5/10mg/ or PBO for 5 more yrs
All taking Ca++, Vit D
Results for placebo
• BMD at or above baseline 10 yrs earlier
• 2-3% decr. BMD over 5 years
• Bone turnover markers still reduced somewhat
• No difference in non-vert. fx vs alendronate groups
• Less decr. in BMD vs. after d/c estrogen, raloxifene, PTH
Study adeq. powered to find difference in BMD
Hip fractures are associated with
the long term use of this class of
gastrointestinal medications.
What are proton pump inhibitors
(PPIs)?
Long-term proton pump inhibitor
therapy and risk of hip fracture
YX Yuang et al. JAMA 2006; 296:
2947-53
Falls/Fxs 300
UK nested case-control using database (‘87-’03)
• Users & nonusers of PPIs with a 2nd nested case control
for H2RA users
• Cases: 13,556 pts > 50 yo (mean age 77), PPI >1 yr;
135,386 controls well matched for sex, age, year of birth
and duration of up-to-standard f/u before index date
Outcome: incident hip fractures
• AOR for fx with PPI use >1 yr (1.44; 95%CI,1.30-1.59)
• Higher risk if pts taking >1 year of high-dose PPI (AOR
2.65; 95% CI, 1.80-3.90)
• Rising risk of hip fxs with increasing duration of PPI Rx
AOR for 1 yr=1.22 (95% CI, 1.15-1.30)
AOR for 2 yrs=1.41 (95% CI, 1.28-1.56)
AOR at 4 yrs=1.59 (95% CI,1.39-1.80)
An intensive, multifaceted
intervention by dietetic assistants
for hospitalized hip fracture
patients led to these 2 outcomes.
What are increased po intake
and decreased 4 mth mortality?
Using dietetic assistants to
improve the outcome of hip
fracture: a randomized controlled
trial of nutritional support in an
acute trauma ward
DG Duncan et al. Age Ageing
2006;35:148-53
Falls/Fxs 400
318 Welsh hip fx pts in randomized, controlled study of usual
vs intensive DA care (assessors blinded)
Results:
NNT=11
(CI=6-89)
at 4 mths
GROUP
KCAL/D
HOSP.
MORT.
4 MTH
MORT.
DA care
1105
(P<.0001)
4.1%
(p=.048)
13.1%
(p=.036)
Usual
756
10.1%
22.9%
Conclusion: Cheaper than many approved drugs &
interventions; highlights importance of hands on care
This intervention reduces costs and
prevents hip fractures in community
dwelling men > 85 yrs and women
> 75 yrs.
What is a hip protector?
Can hip protector use costeffectively prevent fractures in
community-dwelling geriatric
populations?
LA Honkanen et al. JAGS 2006;54:1658-65
Falls/Fxs 500
Markov model, stratified by age, sex, function, comm/NH
Published data: $, NH transfers, efficacy & compliance with
hip protectors (HP); used threshold of $50,000/QALY
• Considered use of HP itself to decr. QALY
• Careful sensitivity analyses
Outcomes: fxs, life yrs, $, QALY, incremental costeffectiveness ratios
Results:
• Decr. fx & incr. life expect. – for all groups
• Decr. costs for community dwellers – use starting age 75
(women), age 85 (men)
• Incr. QALY – women starting age 80, men age 85
Limitations
• HP effectiveness, when worn, was 0.52 (48% decr. in fx)
• Used only Medicare costs; costs to society are higher
• Different HP designs not considered (results may differ)
Increasing doses of this common
vaccine are associated with higher
serum antibody levels and doserelated increases in local reaction.
What are high doses of influenza
vaccine?
Safety of high doses of influenza
vaccine and effect on antibody
responses in elderly persons
W Keital et al.
Arch Intern Med. 2006:166:1121-27
Prevention/Screening 100
N=202 outpts: 41% women, 98% white, mean age
73 yrs
Study: IM placebo vs trivalent inactivated vaccine
at 15, 30, or 60 ngs with Ab titers pre & 6 mos
post vaccine, exams at 30 min., 2 & 28 days & a
6 mo. phone call; no one lost to follow up
Local reaction (mild & transient) associated with
dose, female gender & low BMI
Dose-related Ab titers, response frequency, &
protective titers: females better responders; if
immunized in past yr. then a poorer response
60 mg dose most effective in lower half of preimmunization Ab range
Although the prevalence of this
cancer doubles after age 80,
screening results in only 15% of the
gain in life expectancy that younger
patients receive.
What is colon cancer ?
Screening colonoscopy in very
elderly patients: prevalence of
neoplasia and estimated impact on
life expectancy
O Lin et al.
JAMA 2006:295:2357-3117
Prevention/Screening 200
Participants:1244 asymptomatic pts. at teaching hospital
Design: Cross sectional
Study: Outpatient colonoscopy + polipectomy if needed
Outcomes: Neoplasia prevalence; gain in life expectancy
% with advanced neoplasia
Gain in life expectancy
Age 50-54
N=1043
3.2
0.85 yrs.
Colonoscopies/life-yr. saved 1.18
Age 75-79
N=147
4.7
0.17 yrs.
Age 80+
N=63
14
0.13 yrs.
5.77
7.95
This new vaccine reduces the
duration of a post viral pain
syndrome and is more cost
effective in the “young-old” than the
“old-old”.
What is the varicella-zoster virus
vaccine?
Cost-effectiveness of a vaccine to
prevent herpes zoster and
postherpetic neuralgia in older
adults
J Hornberger et al. Ann Intern Med.
2006;145:317-25
Prevention/Screening 300
Design: Decision theoretical model
Methods: Medline data to March 2005
Population: Immunocompetent > 60 yr., hx of VZV
Intervention: VZV vaccine vs none
Outcome: Quality-adjusted survival & QALY
Results:
• Vaccination increases quality adjusted survival
• Incidence of herpes zoster increases with age
• Life expectancy & efficacy of vaccine decreases with age
• QALYs decrease with age
Limitations:
• Duration of efficacy beyond 3.1 yrs unknown (Oxman ‘05)
• Vaccine cost: $50-$500
In deciding whether to
recommend/have mammography
this patient-specific factor is
considered by doctors but largely
ignored by patients.
What is life expectancy/health
status?
Decision making and counseling
around mammography screening
for women aged 80 or older.
MA Schonberg et al. JGIM 2006;21:979-85
Prevention/Screening 400
Design: Qualitative, semi-structured interviews
23 pts. (mean age 86), academic primary care
16 M.D.’s (6 internists, 5 geriatricians, 3 GYNs, 2 radiologists) to
describe factors influencing mammo. screening of oldest old
Results:
• Patient factors: MD influence, ease of getting mammo, hx.
breast ca, previous experience; health (n=2)
• M.D factors: health (n=16), MD influence, age, habit, FH,
daughter
• Half of M.D.’s considered life expectancy; most had difficulties
discussing limiting screening
• Many M.D.’s wanted more data on risks/benefits in 80 yo’s
“Vaccine Day” and an educational
campaign were effective in
increasing influenza vaccination
rates in this population.
What are health care workers at
long-term care facilities?
The effectiveness of vaccine day
and educational interventions on
influenza vaccine coverage among
health care workers at long term
care facilities
AC Kimura et al.
Am J Public Health 2007;97:684-90
Prevention/Screening 500
70 Southern California LTCFs, 2002-2003
92% for-profit, mean 105 beds & 103 employees
Intervention informed by pre-survey of 30 LTCFs
• Misconceptions about lack of & access to influenza
vaccine
• 54% no sick leave, 30% no health insurance
Intervention
Control
(n=1517)
Educational campaign (n=821
% Vaccinated (95%CI)
28 (1.00)
34 (0.93, 1.51)
Vaccine Day
(n=832)
46 (1.17,1.71)
Combination
(n=754)
53 (1.24,1.71)
This is the urinary collection device
of choice for men without
dementia.
What is
a condom catheter?
Condom versus indwelling
urinary catheters: a randomized
trial
S Saint et al.
JAGS 2006;54:1055-61
Potpourri 100
Prospective, unblinded, RCT in VA
75 men randomized to condom catheter (n=34; mean age=73.4+11 yrs;
MMSE=16.3+8) vs. indwelling cath (n=41; mean age=73.7+10 yrs;
MMSE=20.7+7) and median LOS = 3 days
Main outcome: Incidence of bacteriuria >103 cfu
– C cath  38.2% (median time to outcome: 7 days) and
indwelling cath  41.5% (median time to outcome: 13 days)
Outcome of bacteriuria, symptomatic UTI or death: (c cath as reference)
ADJUSTED for age, MMSE, h/o UTI and h/o cath
Hazard Ratio (95% CI)
p value
ALL patients
2.11 (1.03-4.31)
0.04
Patients W/O dementia
4.84 (1.46-16.02)
0.01
Patients WITH dementia
1.20 (0.33-4.35)
0.78
Pts report condom caths  more comfortable (p=0.02) & less painful (p=0.02)
Bottom Line: For men w/o dementia, use of a condom catheter vs an indwelling
catheter reduces clinically important adverse outcomes; may not benefit men
with dementia.
With the use of the 3 Incontinence
Questions (3IQ), females with urinary
leakage complaints were best classified
with an acceptable accuracy into this
type of urinary incontinence.
What is
the urge type?
The sensitivity and specificity of
a simple test to distinguish
between urge and stress urinary
incontinence
JS Brown et al.
Ann Intern Med. 2006;144:715-23
Potpourri 200
MC, prospective study in 5 AMCs in US of 301 women (mean age,
56+11 yrs with untreated UI for average of 7 yrs+7) – gold
standard: evaluation by urologist or uroGYN
The 3 Incontinence Questions (3IQ) – self administered
1. During the last 3 mth, have you leaked urine (even a small amount)?
2. During the last 3 mths, did you leak urine: when performing physical
activity; when you had the urge or the feeling you needed to empty the
bladder; w/o physical activity or sense of urgency?
3. During the last 3 mths did you leak urine most often: when performing
physical activity (stress); when you had the urge or the feeling you
needed to empty the bladder (urge); w/o physical activity or sense of
urgency (others); about equally (mixed).
TYPE
Sn (95% CI)
Sp (95% CI)
LR+ (95% CI)
LR- (95% CI)
Urge
0.75 (0.68-0.81)
0.77 (0.69-0.84)
3.29 (2.39-4.51)
0.32 (0.24-0.43)
Stress
0.86 (0.79-0.90)
0.60 (0.51-0.68)
2.13 (1.71-2.66)
0.24 (0.16-0.35)
Bottom Line: The 3IQ is a simple & non-invasive test with acceptable
accuracy for classifying urge and stress incontinence
A recent study of depressed
elders suggests they should be
treated at least this long to
decrease the risk of recurrence.
What is two years?
Maintenance treatment of
major depression in old age
Reynolds CF, et al. N Engl J Med
2006:354:1130-1138
Potpourri 300
195 pts > 70 yo (mean MMSE 28) with major
depression (half with first episode) given
paroxetine & psychRx
77% responded initially; randomized in 2X2
fashion to 2 yrs drug &/or psychRx
PsychRx did not prevent recurrence
RR recurrence for placebo: 2.4 (1.4-4.2)
NNT only 4 (2.3-10.9)
36% recurred even in active arm
?Like cancer? “remission rather than cure”
There is disagreement in the literature,
but in a recent systematic review of
trial data, this was the # of preventive
interventions clearly shown by highquality RCTs to decrease the incidence
of pressure ulcers in older adults.
What is
zero?
Preventing pressure ulcers:
a systematic review
M Reddy et al.
JAMA 2006;296:974-84
Potpourri 400
Systematic review of interventions to prevent pressure ulcers
• 59 RCTs – 3 categories: impaired mobility (51), nutrition (5),
skin health (3)
• 13,845 patients, 68% in acute care, 17% in LTC, 2% in
rehab, 13% mixed; length of f/up: 1 to 224 days
Methodological problems limit the quality of research on
pressure ulcer prevention.
Bottom line re available evidence:
• Impaired mobility: Static support surfaces (specialized foam
and sheepskin overlays) reduce pressure ulcer incidence
but dynamic support surface mattresses, albeit expensive,
may be more cost-effective in the long run
• Nutrition: Use of oral nutritional supplements may be of
benefit
• Skin health: Moisturizing skin, especially in sacral area, is a
reasonable strategy
These are 2 out of the 5 clinical
parameters that determine a LTC
resident with pneumonia could be
successfully treated on-site in the
nursing home.
What are:
ability to eat or drink?
pulse <100/min?
respiratory rate <30/min?
systolic BP >90 mm Hg?
O2 saturation >92%?
Effect of a clinical pathway to
reduce hospitalizations in nursing
home residents with pneumonia:
a randomized controlled trial
M Loeb et al. JAMA.
2006;295:2503-10
Potpourri 500
RCT of 680 residents in 22 NH in Canada
Usual care vs. Clinical Pathway: Use of oral antibiotics, portable CXR, O2 sat
monitoring, rehydration and close monitoring by staff
327 in clinical pathway (mean age=85.1+8 yrs; 70% female; 94% w/ pneumovax) vs.
347 in usual care (mean age=84.9+7 yrs; 70% female; 83% w/ pneumovax)
Main outcome: Hospital admission
– Pathway  10% (adj 8%) and usual care  22% (adj 20%)
– Similar for residents with CXR confirmed PNA: Pathway 18%; Usual 30%
OUTCOME
Clinical Pathway (95% CI)
Usual Care (95% CI)
p value
Hospitalizations, %
8 (4-12)
20 (15-26)
0.001
Hospital days per resident
0.79 (0.45-1.13)
1.74 (1.17-2.3)
0.004
No difference: Mortality rates (8% vs. 9%) and adverse events (10.6% vs. 14.6%) as
well as health-related QOL or function scores
Overall cost saving for clinical pathway per resident: US$1,517 ($601-$2433)
Bottom line: A clinical pathway to treat NH residents with PNA reduced
hospitalizations by >50% c/w usual care resulting in substantial cost saving