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3 episodes with j am geriatr soc
3 episodes with j am geriatr soc
2 episodes with j am geriatr soc
2 episodes with j am geriatr soc
2 episodes with j am geriatr soc
2 episodes with j am geriatr soc
In today's episode, Matt and Lauren discuss the new CMS GUIDE model for dementia care with Dr. Brystana Kaufman, MSPH, PhD – a health services researcher at the Duke-Margolis Institute for Health Policy at Duke University. The GUIDE model aims to improve the quality of life for people living with dementia by reducing strain on caregivers and enabling individuals to remain in their homes. Brystana talks with the Minding Memory team about a spectrum of topics as related to the GUIDE model including, what motivated CMS to develop and implement the model; what defines a serious illness; how the model supports caregivers; and what an organization needs to have in terms of services in order to participate in the implementation of the GUIDE model. Dr. Kaufman is the co-author of an article in the Journal of the American Geriatrics Society titled “GUIDE Dementia Model: Opportunities for Serious Illness Care” which provides additional insight into the model. Episode Transcript Brystana Kaufman, PhD, MSPH Faculty Profile Article referenced in this episode: Kaufman BG, Grant M. GUIDE dementia model: Opportunities for serious illness care. J Am Geriatr Soc. 2024 Jun;72(6):1935-1938. doi: 10.1111/jgs.18787. Epub 2024 Feb 5. PMID: 38315037. Additional Resources: Guiding an Improved Dementia Experience (GUIDE) Model Health and Aging Policy Fellows You can subscribe to Minding Memory on Apple Podcasts, Spotify, or wherever you listen to podcasts. Hosted on Acast. See acast.com/privacy for more information.
Wie stellen wir uns das Älterwerden vor? Das ist eine Frage, die nicht erst etwas für Menschen über 50 ist. Denn gesundes Altern bedeutet, früh mit guten Gewohnheiten zu beginnen. In dieser Folge sprechen Leon und Atze mit Stephanie Hielscher: Podcasterin von “50über50” und Autorin des Buches “So alt war ich noch nie”. Sie hat sich intensiv mit dem guten Altern beschäftigt und viele spannende Frauen dazu befragt - und somit einige Weisheiten gesammelt. Fühlt euch gut betreut Leon & Atze Start ins heutige Thema: 07:30 min. VVK Münster 2025: https://betreutes-fuehlen.ticket.io/ Instagram: https://www.instagram.com/leonwindscheid/ https://www.instagram.com/atzeschroeder_offiziell/ Der Instagram Account für Betreutes Fühlen: https://www.instagram.com/betreutesfuehlen/ Mehr zu unseren Werbepartnern findet ihr hier: https://linktr.ee/betreutesfuehlen Tickets: Atze: https://www.atzeschroeder.de/#termine Leon: https://leonwindscheid.de/tour/ Bewerbung bei MTS: info@mts-gmbh.com Spannende Quellen: “So alt war ich noch nie” von Stephanie Hielscher https://www.rowohlt.de/buch/stephanie-hielscher-so-alt-war-ich-noch-nie-9783499015083 Podcast “50über50” von Stephanie Hielscher https://www.podcast.de/podcast/862747/50-ueber-50 Zur Wissenschaft des Alterns: Behr, L. C. et al. (2023). 60 years of healthy aging: On definitions, biomarkers, scores and challenges. Ageing Res Rev. 88:101934. Doi: 10.1016/j.arr.2023.101934 https://www.sciencedirect.com/science/article/pii/S1568163723000934 Borgan, B. E. et al. (2024). Surviving aging - An asset-based approach. J Am Geriatr Soc. 72(10):2965-2968. Doi: 10.1111/jgs.19126 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.19126 Redaktion: Dr. Stefanie Uhrig Produktion: Murmel Productions
Références : Goldberg RM, Mabee J, Chan L et coll. Drug-drug and drug-disease interactions in the ED: analysis of a high-risk population. Am J Emerg Med 1996;14(5):447-50. Parcours de Katherine Desforges en Australie : https://www.apesquebec.org/actualites/deprescription-et-transfert-dinformations-dans-le-parcours-de-soins-des-aines-avec-0 Brochures pour patients du Réseau canadien pour l'usage approprié des médicaments et la déprescription : https://www.reseaudeprescription.ca/ressources-patients Coe A, Kaylor-Hughes C, Fletcher S et coll. Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review. BMJ Open 2021;11(9):e052547. Panel d'experts du 2023 AGS Beers Criteria Update. AGS 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71(1):2052-81.
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we discuss principles for medication use in the geriatric patient population and summarize the updated 2023 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Key Concepts The Beer's Criteria was originally developed by Dr. Mark Beers in 1991 to identify medications in which the risks may outweigh the benefits in nursing home patients. This list is now maintained by the American Geriatrics Society and includes a variety of drug safety information related to elderly patients including medications that are considered potentially inappropriate (Table 2 and 3), medications used with caution (Table 4), drug-drug interactions (Table 5), drugs with renal dose adjustments (Table 6), and drugs with anticholinergic properties (Table 7). The newest update prefers apixaban over other DOACs for VTE and atrial fibrillation in elderly patients. This is a very controversial recommendation given that other guidelines (e.g. from the ACC/AHA) have not published a similar preference of one DOAC over another. Many of the medications that are potentially inappropriate involve drugs that have anticholinergic properties and drugs that increase the risk of incoordination and falls. Other resources exist to guide drug therapy decisions in elderly patients. As an example, the STOPP/START criteria (published in the European Geriatric Medicine journal) outlines drugs to avoid but also drugs to consider in elderly patients. References By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J AM Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. O'Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, Gudmundsson A, Cruz-Jentoft AJ, Knol W, Bahat G, van der Velde N, Petrovic M, Curtin D. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023 Aug;14(4):625-632. doi: 10.1007/s41999-023-00777-y.
In this episode, Tamara and Scott delve into the dynamic realm of pharmacogenomics within the long-term care. Covering its advantageous impacts and supported by research demonstrating its value, we offer an insightful overview of the presence and significance of pharmacogenomics in long-term care. Dr. Scott Stewart: linkedin.com/in/scott-stewart-34973870 Dr. Tamara Ruggles: linkedin.com/in/tamara-ruggles-491882251 References: - Jokanovic N, Jamsen KM, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities. Drugs Real World Outcomes. 2017;4(4):235-245. doi:10.1007/s40801-017-0121-x - Saldivar JS, Taylor D, Sugarman EA, et al. Initial assessment of the benefits of implementing pharmacogenetics into the medical management of patients in a long-term care facility. Pharmgenomics Pers Med. 2016;9:1-6. Published 2016 Jan 19. doi:10.2147/PGPM.S93480 - Kistler CE, Austin CA, Liu JJ, et al. The feasibility and potential of pharmacogenetics to reduce adverse drug events in nursing home residents. J Am Geriatr Soc. 2022;70(5):1573-1578. doi:10.1111/jgs.17679 - Hayashi M, Hamdy DA, Mahmoud SH. Applications for Pharmacogenomics in Pharmacy Practice: A Scoping Review. Res Social Adm Pharm. 2021. Epublication ahead of print. - Rodriguez-Escudero I, Cedeno JA, Rodriguez-Nazario I, et al. Assessment of the Clinical Utility of Pharmacogenetic Guidance in a Comprehensive Medication Management Service. J Am Coll Clin Pharm. 2020;3(6):1028–1037. - PGx in the Long-Term Care Environment. RxGenomix. Accessed January 30, 2024. https://rxgenomix.com/insight/pgx-in-the-long-term-care-environment/ Scott Stewart PharmD Tamara Ruggles PharmD BCGP
In this episode of the Well Nurtured Brain Dr. Pamela Hutchison sits down with Dr. Jaime de Melo, a fellow naturopathic doctor and the co-founder of Evolve Medical, to discuss the intricate world of blood sugar regulation and its profound impact on our brain health. From the basics of insulin resistance to the far-reaching consequences of blood sugar dysregulation, Dr. Jaime shares invaluable insights and practical advice on maintaining balance, and how this has far reaching effects on brain health over time. Whether you're navigating diabetes, seeking preventive measures, or simply curious about optimizing your health, this episode could transform the way you think about your body and your health. About Dr. Jaime de Melo ND Dr. Jaime de Melo (he/him) is passionate about helping people learn to self-manage chronic health conditions through lifestyle medicine. He is a co-founder of Evolve Medical, a company empowering people to live healthier and happier lives through technology, behavioural science and customized lifestyle medicine. Connect with Evolve Medical and Dr. Jaime: Evolve Medical https://www.evolvemedical.co/ Acacia Health https://acaciahealth.ca/team/jaime-de-melo/ Connect with Dr. Pamela Hutchison ND: Pamela's Instagram: https://www.instagram.com/dr_pamela_hutchison_nd The Well Nurtured Brain's Instagram: https://www.instagram.com/the_well_nurtured_brain/ Facebook: https://www.facebook.com/profile.php?id=100089475401521&mibextid=LQQJ4d Website: www.TheWellNurturedBrain.com Email: thewellnurturedbrain@gmail.com Episode References: Kleinridders A, Cai W, Cappellucci L, Ghazarian A, Collins WR, Vienberg SG, Pothos EN, Kahn CR. Insulin resistance in brain alters dopamine turnover and causes behavioral disorders. Proc Natl Acad Sci U S A. 2015 Mar 17;112(11):3463-8. doi: 10.1073/pnas.1500877112. Epub 2015 Mar 2. PMID: 25733901; PMCID: PMC4371978. He D, Aleksic S. Is it time to repurpose geroprotective diabetes medications for prevention of dementia? J Am Geriatr Soc. 2023 Jul;71(7):2041-2045. doi: 10.1111/jgs.18405. Epub 2023 May 25. PMID: 37227136; PMCID: PMC10524156. Enzinger, C., Fazekas, F., Matthews, P. M., Ropele, S., Schmidt, H., Smith, S., & Schmidt, R. (2005). Risk factors for progression of brain atrophy in aging: six-year follow-up of normal subjects. Neurology, 64(10), 1704–1711. https://doi.org/10.1212/01.WNL.0000161871.83614.BB
Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, takes us through a deep dive on delirium. This episode covers an enormous amount of material. Contrast encephalopathy and delirium before diving into the dangerousness of delirium and prevention strategies. Explore the neurobiology of delirium and tie it to validated assessment tools and treatment approaches. We also discuss areas for future research, and learn to appreciate the evolutionary function that delirium serves.This episode also deserves some references! (3:38) Lipowski ZJ. Delirium: Acute Brain Failure in Man. Springfield, IL: Charles C Thomas, 1980. (7:55) Slooter AJC, Otte WM, Devlin JW, et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med. 2020;46(5):1020-1022. (21:46) Marcantonio ER, Ngo LH, O'Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study [published correction appears in Ann Intern Med. 2014 Nov 18;161(10):764]. Ann Intern Med. 2014;161(8):554-561. (29:50) Kunicki ZJ, Ngo LH, Marcantonio ER, et al. Six-Year Cognitive Trajectory in Older Adults Following Major Surgery and Delirium. JAMA Intern Med. 2023;183(5):442-450. (41:40) Mews MR, Tauch D, Erdur H, Quante A. Comparing consultation-liaison psychiatrist's and neurologist's approaches to delirium - A retrospective analysis. Int J Psychiatry Med. 2016;51(3):284-301. = (1:08:08) Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. (1:09:33) Hui D, Frisbee-Hume S, Wilson A, et al. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial. JAMA. 2017;318(11):1047-1056. (1:31:36) By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. (1:33:54) Burton JK, Craig LE, Yong SQ, et al. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2021;7(7):CD013307. Published 2021 Jul 19. (1:35:41) Skrobik Y, Duprey MS, Hill NS, Devlin JW. Low-Dose Nocturnal Dexmedetomidine Prevents ICU Delirium. A Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med. 2018;197(9):1147-1156. (1:36:00) Subramaniam B, Shankar P, Shaefi S, et al. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial [published correction appears in JAMA. 2019 Jul 16;322(3):276]. JAMA. 2019;321(7):686-696.
Over thirty percent of individuals living with dementia living in the US each year die either of or with dementia – and almost half of those enrolled in hospice have dementia. As with so many other types of healthcare, there are disparities in both who enrolls in hospice as well as the type of care these individuals receive after enrollment. In this episode, Matt & Donovan talk with Dr. Lauren Hunt from UCSF, an expert in hospice care for persons living with dementia, about dementia at the end of life. Lauren Hunt Faculty Profile: https://profiles.ucsf.edu/lauren.hunt Article referenced in this episode: Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med. 2023 Aug;26(8):1100-1108. doi: 10.1089/jpm.2023.0011. Epub 2023 Apr 3. PMID: 37010377; PMCID: PMC10440673. Article on identifying disenrollment in claims data: Hunt LJ, Gan S, Boscardin WJ, Yaffe K, Ritchie CS, Aldridge MD, Smith AK. A national study of disenrollment from hospice among people with dementia. J Am Geriatr Soc. 2022 Oct;70(10):2858-2870. doi: 10.1111/jgs.17912. Epub 2022 Jun 7. PMID: 35670444; PMCID: PMC9588572. The transcript for this episode can be found here.CAPRA Website: http://capra.med.umich.edu/ You can subscribe to Minding Memory on Apple Podcasts, Spotify, Google Podcasts or wherever you listen to podcasts. Hosted on Acast. See acast.com/privacy for more information.
Disclaimer: This podcast is not approved for CME credit. Every diabetes treatment plan is different, individual results may vary – nothing you hear on this podcast should be considered medical advice. All claims are supported by clinical evidence referenced in the show notes. For clinical study results, please refer to the Dexcom G7 User Guide. For product-related questions, please refer to the instructions for use. For complete safety information, go to dexcom.com/safety-information. Fingersticks required for diabetes treatment decisions if symptoms or expectations do not match readings. Dexcom G7 can complete warmup within 30 minutes, whereas other CGM brands require up to an hour or longer. Smart devices are sold separately. For a list of compatible smart devices, visit: dexcom.com/compatibility. The Dexcom G7 Continuous Glucose Monitoring System (Dexcom G7 System) is a real time, continuous glucose monitoring device indicated for the management of diabetes in persons aged 2 years and older. Dexcom G7 has no limitations for use in pregnancy. About New Expanded Medicare Guidelines About Hello Dexcom Dexcom Provider website About Medicaid coverage Dexcom's partners are working to integrate insulin pumps, insulin pens, and digital health apps with Dexcom G7. Data from collaborator devices and products must be verified by those collaborator devices and products. Users should confirm data and connections with their collaborator devices and products. A separate Follow app and internet connection are required to follow CGM users' glucose readings and trends. CGM users should always confirm glucose readings on the Dexcom G7 app or receiver before making treatment decisions. Brief Safety Statement BRIEF SAFETY STATEMENT: Failure to use the Dexcom G7 Continuous Glucose Monitoring System (G7) and its components according to the instructions for use provided with your device and available at https://www.dexcom.com/safety-information and to properly consider all indications, contraindications, warnings, precautions, and cautions in those instructions for use may result in you missing a severe hypoglycemia (low blood glucose0 or hyperglycemia (high blood glucose) occurrence and/or making a treatment decision that may result in injury. If your glucose alerts and readings from the G7 do not match symptoms, use a blood glucose meter to make diabetes treatment decisions. Seek medical advice and attention when appropriate, including for any medical emergency. Dexcom Clarity Safety Information The web-based Dexcom Clarity software is intended for use by both home users and healthcare professionals to assist people with diabetes and their healthcare professionals in the review, analysis, and evaluation of historical CGM data to support effective diabetes management. It is intended for use as an accessory to Dexcom CGM devices with data interface capabilities. Caution: The software does not provide any medical advice and should not be used for that purpose. Home users must consult a healthcare professional before making any medical interpretation and therapy adjustments from the information in the software. Caution: Healthcare professionals should use information in the software in conjunction with other clinical information available to them. Caution: Federal (US) law restricts this device to sale by or on the order of a licensed healthcare professional. Dexcom, Dexcom Follow, Dexcom Clarity, and Dexcom Share are registered trademarks of Dexcom, Inc. in the U.S., and may be registered in other countries. Dexcom G7 User Guide Martens T, Beck RW, Bailey R, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Patients With Type 2 Diabetes Treated With Basal Insulin:A Randomized Clinical Trial. 2021;325(22):2262–2272. doi:10.1001/jama.2021.7444 Aleppo G, et al. The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin. Diabetes Care. 2021 Dec;44(12):2729-2737. doi: 10.2337/dc21-1304. Epub 2021 Sep 29. PMID: 34588210; PMCID: PMC8669539. Psavko S, Katz N, Mirchi T, Green CR. Usability and teachability of continuous glucose monitoring devices in older adults and diabetes educators: a task analysis and ease of use survey. JMIR Hum Factors. 2022 Nov 8. doi: 10.2196/42057 International Hypoglycemia Study Group. Diabetes Care. 2015;38:1583-1591. Boureau AS, et al. Nocturnal hypoglycemia is underdiagnosed in older people with insulin-treated type 2 diabetes: The HYPOAGE observational study. J Am Geriatr Soc. 2023;1–13. DOI: 10.1111/jgs.18341. Acciaroli G, Welsh JB, Akturk HK. Mitigation of Rebound Hyperglycemia With Real-Time Continuous Glucose Monitoring Data and Predictive Alerts. J Diabetes Sci Technol. 2022 May;16(3):677-682. doi: 10.1177/1932296820982584. Epub 2021 Jan 5. PMID: 33401946; PMCID: PMC9294577. Puhr S, Derdzinski M, Welsh JB, Parker AS, Walker T, Price DA. Real-World Hypoglycemia Avoidance with a Continuous Glucose Monitoring System's Predictive Low Glucose Alert. Diabetes Technol Ther. 2019 Apr;21(4):155-158. doi: 10.1089/dia.2018.0359. Epub 2019 Mar 22. PMID: 30896290; PMCID: PMC6477579. Shichun Bao, Ryan Bailey, Peter Calhoun, and Roy W. Beck.Effectiveness of Continuous Glucose Monitoring in Older Adults with Type 2 Diabetes Treated with Basal Insulin.Diabetes Technology & Therapeutics.May 2022.299-306.http://doi.org/10.1089/dia.2021.0494 By 2023, there had been 52 million ULS alerts from Dexcom CGM systems, and 11 million of those occurred during the night. Dexcom data on file, 2023.
Un nouvel épisode du Pharmascope est maintenant disponible! Dans de ce 115ème épisode, Sébastien, Nicolas et Isabelle terminent leur série d'épisodes sur l'ostéoporose. Dans cette troisième et dernière partie, on aborde la prise en charge suite à une fracture, les marqueurs du remodelage osseux, l'ostéoporose induite par les corticostéroïdes et la prise concomitante de suppléments de calcium et de vitamine D lors de l'utilisation d'un traitement pharmacologique. Les objectifs pour cet épisode sont les suivants: Discuter de la prise en charge des patients qui ont subi une fracture de fragilisation Discuter de l'utilité des marqueurs biochimiques du remodelage osseux Résumer la prise en charge de l'ostéoporose induite par les corticostéroïdes Conseiller adéquatement la prise d'un supplément de calcium et de vitamine D aux patients prenant un traitement pharmacologique contre l'ostéoporose Ressources pertinentes en lien avec l'épisode Qaseem A et coll; Clinical Guidelines Committee of the American College of Physicians. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. 2023;176:224-38. National Osteoporosis Guideline Group - UK. Clinical Guideline for the Prevention and Treatment of Osteoporosis 2021. Septembre 2021. Moe S, Paige A, Allan GM. Osteoporosis in postmenopausal women. Can Fam Physician. 2021;67:346. Nayak S, Greenspan SL. Osteoporosis Treatment Efficacy for Men: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2017;65:490-95. National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture. London; 2017. Papaioannou A et coll. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182:1864-73. Management of Osteoporosis in Postmenopausal Women: The 2021 Position Statement of The North American Menopause Society'' Editorial Panel. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021;28:973-97. Bessette L et coll. The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporos Int. 2008;19:79-86. Deng J et coll. Pharmacological prevention of fractures in patients undergoing glucocorticoid therapies: a systematic review and network meta-analysis. Rheumatology. 2021;60:649-57. Calculateur FRAXCentre for Metabolic Bone Diseases. FRAX: Fracture Risk Assessment Tool. University of Sheffield, UK. Outil d'aide à la décisionMayo Foundation for Medical Education and Research. Bone Health Choice Decision Aid. Mayo Clinic, USA.
Dr. Moyer unpacks myths of aging and challenges us to rethink the use of assistive devices and vigorous physical activity in our older adults to help prevent falls and fractures. See the show notes for links to the articles referenced by Dr. Moyer in this fun and informative conversation. References: Cruz A de O, Santana SMM, Costa CM, Gomes da Costa LV, Ferraz DD. Prevalence of falls in frail elderly users of ambulatory assistive devices: a comparative study. Disabil Rehabil Assist Technol. 2020;15(5):510-514. Accessed at: https://pubmed.ncbi.nlm.nih.gov/30907182/ Gell NM, Wallace RB, LaCroix AZ, Mroz TM, Patel KV. Mobility device use in older adults and incidence of falls and worry about falling: findings from the 2011-2012 national health and aging trends study. J Am Geriatr Soc. 2015;63(5):853-859. Accessed at: https://pubmed.ncbi.nlm.nih.gov/25953070/ Hildebrand A, Martini D, Fling B, Cameron M. Ambulation Assistive Device Training Prevents Falls, Increases Device Satisfaction and May Decrease Sitting and Increase Walking in MS: A Randomized-Controlled Pilot Study (S24.004). Neurology. 2017;88(16 Supplement):S24.004. Accessed at: https://n.neurology.org/content/88/16_Supplement/S24.004.short Harding AT, Weeks BK, Lambert C, Watson SL, Weis LJ, Beck BR. A comparison of bone-targeted exercise strategies to reduce fracture risk in middle-aged and older men with osteopenia and osteoporosis: LIFTMOR-M semi-randomized controlled trial. J Bone Miner Res. 2020;35(8):1404-1414. Accessed at: https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbmr.4008 Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial. Osteoporos Int. 2019;30(5):957-964. Accessed at: https://link.springer.com/article/10.1007/s00198-018-04829-z Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211-220. Accessed at: https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbmr.3284 Open-Access Resources from APTA Geriatrics on Best Practice, Hip Fractures, Falls, and more: https://aptageriatrics.org/practice/evidence-based/ APTA Geriatrics Website: https://aptageriatrics.org/ Community Falls Prevention Programs Toolkit: https://aptageriatrics.org/sig/balance-falls-special-interest-group-bakup/falls-prevention-awareness-toolkit-updated/ Balance and Falls Outcome Measures Toolkit: https://aptageriatrics.org/sig/balance-falls-special-interest-group-bakup/bfsig-outcome-toolkit-updated/ Cognitive and Mental Health-Delirium Fact Sheet: https://aptageriatrics.org/wp-content/uploads/2022/02/APTA-Geriatrics-CMH-SIG-Delirium.pdf Falls Prevention is a Team Effort from NCOA: https://ncoa.org/article/falls-prevention-is-a-team-effort
Holala! Un premier épisode du Pharmascope enregistré devant public est maintenant disponible! En direct de Jonquière, Sébastien, Nicolas et Isabelle continuent leur série d'épisodes sur l'ostéoporose. Dans cette deuxième partie, on aborde le calcium, la vitamine D ainsi que les différentes options pharmacologiques dans le traitement de l'ostéoporose. Les objectifs pour cet épisode sont les suivants: Discuter des avantages et des inconvénients à la prise de calcium et de vitamine D Expliquer les avantages et les inconvénients des traitements pharmacologiques de l'ostéoporose Ressources pertinentes en lien avec l'épisode Qaseem A et coll; Clinical Guidelines Committee of the American College of Physicians. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. 2023;176:224-38. Bolland MJ et coll. Calcium intake and risk of fracture: systematic review. BMJ. 2015;351:h4580. Avenell A, Mak JC, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014;2014:CD000227. Moe S, Paige A, Allan GM. Osteoporosis in postmenopausal women. Can Fam Physician. 2021;67:346. Nayak S, Greenspan SL. Osteoporosis Treatment Efficacy for Men: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2017;65:490-95. National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture. London; 2017. Papaioannou A et coll. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182:1864-73. Management of Osteoporosis in Postmenopausal Women: The 2021 Position Statement of The North American Menopause Society'' Editorial Panel. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021;28:973-97. Calculateur FRAXCentre for Metabolic Bone Diseases. FRAX: Fracture Risk Assessment Tool. University of Sheffield, UK. Outil d'aide à la décisionMayo Foundation for Medical Education and Research. Bone Health Choice Decision Aid. Mayo Clinic, USA.
Gabapentin is the 10th most prescribed drug in the United States and use is increasing. In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin). By 2015 that number increased to 4% of US adults. There are a lot of reasons that may explain the massive increase in use of these drugs. One thing is clear, it is not because people are using it for FDA approved indications. The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications. On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer. It's a big episode covering a lot of topics. First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug). Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later). Donovan discusses the growth of “mood stabilizers/antiepileptics” (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin). Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug. This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial. I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies: Gabapentin in the Perioperative setting: Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022 Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022 Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort. JAMA Surgery 2018 Gabapentin and mood stabilizers in the Nursing Home Setting: Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022 Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020 Efficacy of Gabapentinoids: Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019 Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017 The Illegal Marketing Practices by Pharma promoting ineffective: The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009 Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006
MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: November 19, 2020 The mental status examination is a keystone of the neurologic assessment. Dr. Andrea Casher (Cooper University Hospital) builds upon this metaphor in our program this week. Making a special appearance is US President Donald Trump, who underwent a mental status examination and recounts his experience. Produced by James E Siegler and Andrea Casher. Music courtesy of Unheard Music Concepts, Purple Planet Music, Lee Rosevere, and Scott Holmes. The opening theme was composed by Jimothy Dalton. Sound effects by Mike Koenig and Daniel Simion. Unless otherwise mentioned in the podcast, no competing financial interests exist in the content of this episode. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Dong Y, Sharma VK, Chan BP, et al. The Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of vascular cognitive impairment after acute stroke. J Neurol Sci 2010;299(1-2):15-8. PMID: 20889166 Gorno-Tempini ML, Hillis AE, Weintraub S, et al. Classification of primary progressive aphasia and its variants. Neurology 2011;76(11):1006-14. PMID 21325651 Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53(4):695-9. Erratum in: J Am Geriatr Soc 2019;67(9):1991. PMID 15817019 Ng KP, Chiew HJ, Lim L, Rosa-Neto P, Kandiah N, Gauthier S. The influence of language and culture on cognitive assessment tools in the diagnosis of early cognitive impairment and dementia. Expert Rev Neurother 2018;18(11):859-69. PMID 30286681 Rabinovitz B, Jaywant A, Fridman CB. Neuropsychological functioning in severe acute respiratory disorders caused by the coronavirus: implications for the current COVID-19 pandemic. Clin Neuropsychol 2020;34(7-8):1453-79. PMID 32901580 Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc 1992;40(9):922-35. PMID 1512391 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.
In episode 13 we discuss opioids and cognitive changes in older adults.Warner, NS, Hanson, AC, Schulte, PJ, Habermann, EB, Warner, DO, Mielke, MM. Prescription opioids and longitudinal changes in cognitive function in older adults: A population-based observational study. J Am Geriatr Soc. 2022; 1- 12. doi:10.1111/jgs.18030 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18030----------We also discuss the new (and old) CDC opioid prescribing guidelines.---------Episode 13 Credits:Original theme music: composed and performed by Benjamin KennedyAudio production: Angela OhlfestVideo production: Paul Kennedy----------This is Addiction Medicine Journal Club with Dr. Sonya Del Tredici and Dr. John Keenan. We practice addiction medicine and primary care, and we believe that addiction is a disease that can be treated. This podcast reviews current articles to help you stay up to date with research that you can use in your addiction medicine practice. The best part of any journal club is the conversation. Send us your comments on Twitter, Facebook, YouTube, email, or join our Facebook group. Email: addictionmedicinejournalclub@gmail.com Twitter: @AddictionMedJC Facebook: @AddictionMedJC Facebook Group: Addiction Medicine Journal Club YouTube: addictionmedicinejournalclub Addiction Medicine Journal Club is intended for educational purposes only and should not be considered medical advice. The views expressed here are our own and do not necessarily reflect those of our employers or the authors of the articles we review. All patient information has been modified to protect their identities.
This week we feature a recent study by Katherine Ornstein and colleagues that was published in the Journal of the American Geriatrics Society. Dr. Ornstein studies family caregiving and the home-based clinical care. The study used Medicare claims linked to the National Health and Aging Trends Study to estimate the degree to which people living with dementia use health services from home. We'll discuss what exactly home-based health services are (and how they are typically categorized) and discuss the role these services are expected to play for people living with dementia. The transcript for this episode can be found here. Dr. Ornstein Faculty Profile: https://nursing.jhu.edu/faculty_research/faculty/faculty-directory/katherine-ornstein Article Referenced in Podcast: Ornstein KA, Ankuda CK, Leff B, et al. Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism. J Am Geriatr Soc. 2022;70(4):1127-1135. doi:10.1111/jgs.17621 CAPRA Website: http://capra.med.umich.edu/ You can subscribe to Minding Memory on Apple Podcasts, Spotify, Google Podcasts or wherever you listen to podcasts. Hosted on Acast. See acast.com/privacy for more information.
Today's episode features two interviews, taking different lenses on news in hearing loss. We first talk with Frank Lin, MD, PhD, at the Johns Hopkins School of Medicine about the various obstacles to hearing health, including new advice on the just FDA-approved OTC hearing aids. He has been part of the FDA rule from the start and tells us a little about how this came to be, as well as some of the benefits. We then speak with Susan D. Emmett, MD, MPH, from the University of Arkansas. She recently led a randomized controlled trial in 15 communities in rural Alaska, looking at whether telemedicine specialty referral can improve time to follow-up for school hearing screening compared with standard primary care referral. Enjoy listening! Additional reading Lin FR, Reed NS. Over-the-counter hearing aids: How we got here and necessary next steps. J Am Geriatr Soc. 2022 Jul;70(7):1954-1956. Emmett SD, et al. Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial. Lancet Glob Health. 2022 Jul;10(7):e1023-e1033
Balance Matters: A neuro physical therapist’s journey to make “Sense” of Balance
Classic texts say that tai chi will help you become “Strong as an oak, flexible as a willow, and [mentally] clear as still water.”It's often called meditation in motion. Scientific studies are showing more and more health benefits that you can get from this practice. Dianne Bailey, CSCS, FAS, CTCIAs a fitness professional, martial artist, and owner of a successful personal training studio in Denver, Dianne is passionate about creating the best opportunities for the mature adult to enjoy health and fitness. This passion has led her to create a system for learning Tai Chi which will empower fitness professionals to be able to offer this amazing form of exercise to their clientele and help others learn this wonderful form of “movement meditation.” Dianne is the author of three books: Eating Simply Open the Door to Tai Chi . . . Tai Chi for the Everyday PersonHealthy, Happy and Fit – Ageless Exercise to enjoy Your Best Years YetDianne is a CSCS, a Functional Aging Specialist and a Certified Tai Chi Instructor. She has presented the benefits of Tai Chi at the Functional Aging Summit, ICAA Conference and Fitness Fest. In her engaging, easy-going yet commanding style, she hopes to encourage people to include Tai Chi in their offerings.Here are some Tai Chi resources.New 30 Days of Tai Chi. Here is the link to Day 1.A link to Diane's presentation, 'Who can use Tai Chi' Tai Chi for Balance - VeDA (vestibular.org)Articles: (So many choices)Wang LC, Ye MZ, Xiong J, Wang XQ, Wu JW, Zheng GH. Optimal exercise parameters of tai chi for balance performance in older adults: A meta-analysis. J Am Geriatr Soc. 2021 Jul;69(7):2000-2010. doi: 10.1111/jgs.17094. Epub 2021 Mar 26. PMID: 33769556.Hu C, Qin X, Jiang M, Tan M, Liu S, Lu Y, Lin C, Ye R. Effects of Tai Chi Exercise on Balance Function in Stroke Patients: An Overview of Systematic Review. Neural Plast. 2022 Mar 9;2022:3895514. doi: 10.1155/2022/3895514. PMID: 35309256; PMCID: PMC8926482.Zhang T, Lv Z, Gao S. Tai Chi Training as a Primary Daily Care Plan for Better Balance Ability in People With Parkinson's Disease: An Opinion and Positioning Article. Front Neurol. 2021 Dec 24;12:812342. doi: 10.3389/fneur.2021.812342. PMID: 35002945; PMCID: PMC8739955.Li G, Huang P, Cui SS, et al. Mechanisms of motor symptom improvement by long-term Tai Chi training in Parkinson's disease patients. Transl Neurodegener. 2022;11(1):6. Published 2022 Feb 7. doi:10.1186/s40035-022-00280-7Guo G, Wu B, Xie S, et al. Effectiveness and safety of Tai Chi for chronic pain of knee osteoarthritis: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2022;101(2):e28497. doi:10.1097/MD.0000000000028497Winser SJ, Tsang WW, Krishnamurthy K, Kannan P. Does Tai Chi improve balance and reduce falls incidence in neurological disorders? a systematic review and meta-analysis. Clin Rehabil. (2018) 32:1157–68. 10.1177Zou L, Han J, Li C, Yeung AS, Hui SS-C, Tsang WWN, et al. . Effects of tai chi on lower limb proprioception in adults aged over 55: a systematic review and meta-analysis. Arch Phys Med Rehabil. (2019) 100:1102–13. 10.1016/j.apmr.2018.07.425
Drs. Molly Sinert and Jon Furuno join Dr. David Ha (@DHpharmd) to discuss the prevalence of antibiotic use and its harms and benefits in reducing suffering and providing comfort during end-of-life care. Learn more about the Society of Infectious Diseases Pharmacists: https://sidp.org/About Twitter: @SIDPharm (https://twitter.com/SIDPharm) Instagram: @SIDPharm (https://www.instagram.com/sidpharm/) Facebook: https://www.facebook.com/sidprx LinkedIn: https://www.linkedin.com/company/sidp/ References: Sinert et al. Guidance for Safe and Appropriate Use of Antibiotics in Hospice Using a Collaborative Decision Support Tool. Accessed October 6, 2021. https://oce-ovid-com.laneproxy.stanford.edu/article/00129191-202008000-00005/HTMLA Albrecht JS, McGregor JC, Fromme EK, Bearden DT, Furuno JP. A Nationwide Analysis of Antibiotic Use in Hospice Care in the Final Week of Life. Journal of Pain and Symptom Management. 2013;46(4):483-490. doi:10.1016/j.jpainsymman.2012.09.010 Furuno JP, Noble BN, Fromme EK. Should we refrain from antibiotic use in hospice patients? Expert Review of Anti-infective Therapy. 2016;14(3):277-280. doi:10.1586/14787210.2016.1128823 Servid SA, Noble BN, Fromme EK, Furuno JP. Clinical Intentions of Antibiotics Prescribed Upon Discharge to Hospice Care. Journal of the American Geriatrics Society. 2018;66(3):565-569. doi:10.1111/jgs.15246 Gaw CE, Hamilton KW, Gerber JS, Szymczak JE. Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care. Infection Control & Hospital Epidemiology. 2018;39(4):383-390. doi:10.1017/ice.2018.6 Broom J, Broom A, Good P, Lwin Z. Why is optimisation of antimicrobial use difficult at the end of life? Internal Medicine Journal. 2019;49(2):269-271. doi:10.1111/imj.14200 Kwon KT. Implementation of Antimicrobial Stewardship Programs in End-of-Life Care. Infect Chemother. 2019;51(2):89-97. doi:10.3947/ic.2019.51.2.89 Datta R, Topal J, McManus D, et al. Perspectives on antimicrobial use at the end of life among antibiotic stewardship programs: A survey of the Society for Healthcare Epidemiology of America Research Network. Infection Control & Hospital Epidemiology. 2019;40(9):1074-1076. doi:10.1017/ice.2019.194 Lopez S, Vyas P, Malhotra P, et al. A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life. Am J Hosp Palliat Care. 2021;38(4):391-395. doi:10.1177/1049909120951748 Ito H. Antibiotics in end-of-life care: What is the driving factor? Infectious Diseases Now. Published online July 7, 2021. doi:10.1016/j.idnow.2021.07.003 Kates OS, Krantz EM, Lee J, et al. Association of Physician Orders for Life-Sustaining Treatment With Inpatient Antimicrobial Use at End of Life in Patients With Cancer. Open Forum Infectious Diseases. 2021;8(8). doi:10.1093/ofid/ofab361 Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011; 59(11): 2091–2099. doi:10.1111/j.1532-5415.2011.03656.x. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, Volume 62, Issue 10, 15 May 2016, Pages e51–e77, https://doi.org/10.1093/cid/ciw118
I've found that I can often increase compliance with statins by having pt take them 3x/week or QOD. I try this often especially in my secondary prevention group. I understand "any statin is better than none", but do data support this approach? -- any is better than none! No rct with this but yes data supports every other day but that is observational..what about vascepa in reducing CAD risk both primary and secondary risk? Vascepa is now the first and only drug approved by the FDA as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride (TG) levels (≥150 mg/dL) and established cardiovascular disease or diabetes mellitus and two or more additional risk factors for cardiovascular diseaseReduce it trial---The big trial which showed all the promise used mineral oil as a placeboAND then we have evaporate trial—which showed steady plaqueThe groups didn't start off the same!When you do an RCT- everything is random and therefor EVERYTHING IS EQUAL—but that idnt happen. And yes the people were blinded but they don't say that the people reading the CT was blindedThe placebo group had higher CRP and dramatically worse cholesterol panels after taking mineral oilThen most recently we have the strength it trial- which showed no difference and should have had high bioavailability! Like LDL that went up 50 points in the placebo group!! That shouldn't happen!What about fibrates for triglycerides > 400 or 500 to prevent complications like pancreatitis? No – no- no- no evidence for fibrates, period, throw them away. DRUGECTOMY for everyoneGiven evidence is only for patient to age 79, what do you recommend for patients over 79 with high lipids or on who are on a statin if concern for risk of negative cognitive effects of statins in this group? Remember 5 years or less to live. stop the statin. And the cognitive declinePlease comment on lipophilic vs hydrophilic statins and possible detrimental effects on cognition.If cognitive risk is so small, why is there a black-box warning? It makes it difficult to convince the patient to take a statin when they read this warning.ano M, Bell KL, Galasko D, et al. A randomized, double-blind, placebo-controlled trial of simvastatin to treat Alzheimer disease. Neurology 2011;77(6):556-563.In this multicenter trial, the authors gave simvastatin or placebo to 406 patients with mild to moderate Alzheimer disease, aged at least 50 years, with a Mini-Mental State Examination score between 12 and 26, who otherwise would not have been taking a statin. Simvastatin was no better than placebo in slowing cognitive deterioration in patients with mild to moderate Alzheimer disease. (LOE = 1b)Steenland K, Zhao L, Goldstein FC, Levey AI. Statins and cognitive decline in older adults with normal cognition or mild cognitive impairment. J Am Geriatr Soc 2013;61(9):1449-55.These researchers serially assessed approximately 3500 elderly patients for 3.4 years. The elders did not have dementia at baseline and approximately one third were using a statin. After 3.4 years of follow-up, the rate of cognitive decline among statin users was comparable with that of nonusers. https://www.ahajournals.org/doi/10.1161/circ.128.suppl_22.A10589Results: Significantly higher proportional reporting ratios (PRRs) were observed for lipophilic statins, which more readily cross the blood-brain barrier, (range: 1.48-3.50) compared to hydrophilic statins (range: 0.68-1.60). However, fluvastatin, lovastatin, and pitavastatin (lipophilic) had relatively few adverse reports in the AERS database. The signal of higher risk of cognitive dysfunction was observed for the lipophilic statin atorvastatin (PRR = 2.68, 95% confidence interval: 2.52-2.85) followed by simvastatin (PRR = 2.20, 95% confidence interval: 2.02-2.40).Conclusions: Inconsistent with the FDA class warning, highly lipophilic statins with specific pharmacokinetic properties (atorvastatin and simvastatin) appear to confer a significantly greater risk of adverse cognitive effects compared to other lipophilic statins and those with hydrophilic solubility properties.“Keep in mind that cohort studies are unable to account for 2 important phenomena: the healthy-user effect and reverse causality. The healthy-user effect, the primary explanation for older theories of the "benefits" of hormone replacement, refers to the observation that healthy people are more likely to use preventive measures and that the outcomes are due to good health, not the intervention. In reverse causality, we find that patients in declining health stop using treatments because they no longer perceive a potential benefit. It takes a randomized trial to overcome these phenomena.”Last but not leastZhou Z et al. Effect of statin therapy on cognitive decline and incident dementia in older adults. J Am Coll Cardiol 2021 Jun 29; 77:3145. (https://doi.org/10.1016/j.jacc.2021.04.075)They followed 18,846 study participants for a median of 4.7 years. Participants' median age was 74 years, and 56% were women. With 85,557 person-years of follow-up, the investigators identified 566 incident cases of dementia. Statin use was associated with nonsignificant increases in all-cause dementia (hazard ratio, 1.16) and probable Alzheimer disease (HR, 1.33; 95% CI 1.00 to 1.77). Statin use was not associated with mild cognitive impairment, but there was a nonsignificant increase in association with Alzheimer disease (HR, 1.44).Any thoughts on coronary CTA (rather than calcium score) or carotid intimal medial thickness as a tool for risk assessment? No—no prospective RCT—all retrospective. And the people are baseline high risk to begin with. if you would choose one single best statin for primary and secondary prevention, which one would you pick? The one the pt will takeshould take a statin if it increases LFT?? YES remember we are decreasing heart attacks and strokes!! We have no evidence on was a smell increase in your LFT does long term but we have evidence that long term these drugs have a 30% RR reduction in heart attacks and strokes!Some patients like to take Co Q10 with their statin. What is your experience with this? Taking it for muscle aches and remember there is no real difference in muscle aches compared to placebo. If you don't check cholesterol but every 10 years, how do you know that further risk reduction is needed for secondary prevention or additional medication to statin is needed -- you do it based on their risk reduction! There are 3 criteria – 1. 1 event in last 12 months. 2. 2 eents in their life. 3. An event with 3 or more risk factors. what are the real risks of statins increasing risks of DM? depends where you read—cocochane has the HR at 1.18 but that is a 2 yr study. For our calculation of the risk of diabetes the answer likely lies between 0.4% and 4%, and we have chosen what we believe to be a conservative estimate of 2% as a midway point in this credible interval.The raw numbers of 270 and 216 new onset diabetes cases from 24 months of exposure to a statin and a placebo (respectively) can be extrapolated, assuming that increased diabetes risk is likely to continue linearly with exposure. This yields 675 and 540 cases at 5 years. How long do you do washout between statin? No hard science to this they have not randomized different months of wash out as far as I am aware of so 3-6 months and you will be fine. Anything to say about Nexletol?Is there any benefit in obtaining lipoprotein profiles? NO—not for the events we care about. There is evidence that you can get this panels and then you could add a drug or increase a dose and decrease a lab value but we treat patients not lab values and there is no evidence It improves patient orientated outcomes. WHATPCSK9 DO YOU USE? Whatever insurance will pay for and remember they are still really really really expensive and IV only so this should be dead last line and only in the highest of the highest of the highest risk.
The mental status exam is a keystone of the neurologic assessment. Dr. Andrea Casher (Cooper University Hospital) builds upon this metaphor in our program this week. Making a special appearance is US President Donald Trump, who underwent a mental status exam and recounts his experience. Produced by James E. Siegler and Andrea Casher. Music courtesy of Unheard Music Concepts, Purple Planet Music, Lee Rosevere, and Scott Holmes. The opening theme was composed by Jimothy Dalton. Sound effects by Mike Koenig and Daniel Simion. Unless otherwise mentioned in the podcast, no competing financial interests exist in the content of this episode. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Tombaugh TN and McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922-35. Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL and Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-9. Dong Y, Sharma VK, Chan BP, Venketasubramanian N, Teoh HL, Seet RC, Tanicala S, Chan YH and Chen C. The Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of vascular cognitive impairment after acute stroke. Journal of the neurological sciences. 2010;299:15-8. Gorno-Tempini ML, Hillis AE, Weintraub S, Kertesz A, Mendez M, Cappa SF, Ogar JM, Rohrer JD, Black S, Boeve BF, Manes F, Dronkers NF, Vandenberghe R, Rascovsky K, Patterson K, Miller BL, Knopman DS, Hodges JR, Mesulam MM and Grossman M. Classification of primary progressive aphasia and its variants. Neurology. 2011;76:1006-14. Ng KP, Chiew HJ, Lim L, Rosa-Neto P, Kandiah N and Gauthier S. The influence of language and culture on cognitive assessment tools in the diagnosis of early cognitive impairment and dementia. Expert review of neurotherapeutics. 2018;18:859-869. Rabinovitz B, Jaywant A and Fridman CB. Neuropsychological functioning in severe acute respiratory disorders caused by the coronavirus: implications for the current COVID-19 pandemic. Clin Neuropsychol. 2020:1-27.
Lecture SummaryThis podcasts talks about an epidemic in the United States called polypharmacy. This is when a person takes multiple medications and it is becoming an increasing problem in the elderly. Key Points- The opioid epidemic is still happening- Polypharmacy occurs when an individual takes 5 or more medications- Many people are being harmed by the drugs which are meant to help them- Polypharmacy is one of the biggest ways that healthcare harms people and why iatrogenesis is thought to be the third leading cause of death in the United States.ReferencesCharlesworth et al. Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci. 2015.Morin et al. The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clin Epidemiol. 2018.Rawle et al. Assocations Between Polypharmacy and Cognitive and Physical Capabilities. J Am Geriatr Soc. 2018.Fried et al. Health outcomes associated with polypharmcy in community-dwelling older aduls: a systematic reveiew.. J Am Geriatr Soc. 2014.Wimmer et al. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2017.Beers Criteria/List. American Geriatrical Society. 2019 addition
Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition. In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics.Additional Resources/ReferencesBeers Criteria:By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767Anticholinergic Risk Scale:Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106Recent arge study associating anticholinergics with dementia:Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677This episode is accredited for CPE. For CE details and to claim credit click here: https://bit.ly/2UT97Ww See omnystudio.com/listener for privacy information.
Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition. In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics. Additional Resources/References Beers Criteria: By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767 Anticholinergic Risk Scale: Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106 Recent arge study associating anticholinergics with dementia: Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677 This episode is accredited for CPE. For CE details and to claim credit click here: https://bit.ly/2UT97Ww See omnystudio.com/listener for privacy information.
Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition. In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics. Additional Resources/References Beers Criteria: By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767 Anticholinergic Risk Scale: Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106 Recent arge study associating anticholinergics with dementia: Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677 This episode is accredited for CPE. For CE details and to claim credit click here: https://bit.ly/2UT97Ww
Pallicast - Podcast da Academia Nacional de Cuidados Paliativos
Apresentação: Cláudia Inhaia – cinhaia@gmail.comInstagram @cinhaiaTwitter @cinhaiaConvidada:Sabrina Corrêa da Costa Ribeiro – sabrina.ribeiro@hc.fm.usp.br Instagram @papopaliativo Twitter @Uti.CorreaQuem tiver interesse em enviar seus comentários, sugestões de temas e participantes para o PodCast basta enviar um e-mail para pallicast.ancp@paliativo.org.brSiga também a ANCP em suas redes sociais:https://www.facebook.com/ANCPaliativoshttps://twitter.com/ancpaliativoshttps://www.youtube.com/user/TVANCP/https://www.linkedin.com/company/ancp/CHAMADA De acordo com a Organização Mundial de Saúde, em torno de 40 milhões de pessoas necessitam de cuidado paliativo, estando 78% delas em países de média ou baixa renda. Apenas 14% destas pessoas conseguem ter acesso a cuidado paliativo. Paciente com doenças crônicas e incuráveis, idosos frágeis, pacientes com doenças degenerativas ou sintomas mal controlados muitas vezes têm na emergência seu único acesso imediato a atenção em saúde. Habilidades em cuidado paliativo são essenciais não só para identificar pacientes com esta necessidade como para aliviar corretamente os sintomas, comunicar más notícia de forma adequada e elaborar um plano de cuidado que respeite os valores do paciente, mesmo em uma situação em que o paciente é desconhecido, não pode falar por si e decisões precisam ser tomadas rapidamente.Nesse episódio Sabrina Corrêa da Costa Ribeiro, coordenadora do comitê de Cuidados Paliativos em Emergências da ANCP fala sobre os desafios do atendimento na emergência.Informamos que a opinião do entrevistado não necessariamente reflete a opinião da ANCP.INDICAÇÕES DOS ENTREVISTADOS: 1- Ensaio sobre a cegueira. José Saramago 19952- Elza o Musical - Direção Duda Maia 2019-20203- Bacurau - Direção Kleber Mendonça, 20194- Palliative aspects of emergency care. Paul Desandre e Tammie Quest, Oxford University Press 20135- Forte D, Kawai F, Cohen C. A bioethical framework to guide decision-making process in the care of seriously ill patients. BMC Medical Ethics 2018;18:786- Palliative care for adults in the emergency department. Tammie Quest, Sangeeta Lamb uptodate.com (acessado em 29/1/2020)7- Duncan R., Thakore S. Decreased Glasgow Coma Score does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009; 37(4):451-4558- Ouchi K, Jambaulikar G, Hohman S et al. Prognosis after emergency department intubation to inform shared decision-making. J Am Geriatr Soc 2018; 66 (7): 1377-1381 EDIÇÃO: Press Start - Arte e Entretenimento (@abc_ishie)DIRECIONAMENTO METADADOS#emergência #emergency #cuidadopaliativo #palliativecare #epec #CPnaemergencia #ancp #symptommanagement #controledesintomas #necpal #autonomia #ortotanasia #GOC #goalsofcare #bioetica #bioethics #decisaocompartilhada #intubação #rebaixamento #idosos #elderly #comitêsancp
Contributor: Aaron Lessen, MD Educational Pearls: Emergency department evaluation of falls, particularly in the elderly, should include an assessment of risk factors Common causes of falls in the elderly include medications. Review medication list for sedating medications amongst others Consult with your hospital physical therapist to discuss fall prevention techniques with the patient One study has shown that a comprehensive interdisciplinary approach to geriatric falls in the ED can reduce return visits and hospital admissions. References Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study. J Am Geriatr Soc. 2004;52(9):1417–23. Albert M, Rui P, McCaig LF. Emergency department visits for injury and illness among adults aged 65 and over: United States, 2012-2013. NCHS Data Brief. 2017;(272):1–8. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD
In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes. And in a new segment from MDedge, called This Week in Psychiatry, we’d like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Introduction to normal aging Changes in cognitive abilities are part of normal aging. Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging. Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so. Episodic memory performance, the ability to learn new verbal information, declines 30% between ages 65 to 80, followed by another equivalent decline from ages 80 to 90. Alzheimer’s disease and amnestic mild cognitive impairment are characterized by signature memory loss called rapid forgetting, which occurs in cases in which a person is unable to remember information right after being told. Older people who are self-aware and sensitive to their age-related cognitive changes have a better prognosis. Technology and aging Individuals in their 80s to 90s might have retired before the advent of technological advances such as ATMs, cell phones, the Internet, smartphones, and other touch screen devices. For these individuals, vital aspects of daily living, such as accessing finances online, requires using Internet navigation skills, and those skills were not acquired at a younger age. A direct connection exists between cognitive abilities and learning how to use technology for the first time. Healthy older people will be challenged by new technology the first time because of their lack of exposure. Yet, their ability to learn how to use technology is comparable to that of younger people. Embracing technology to prevent normative cognitive decline The ACTIVE study, sponsored by the National Institute on Aging, enrolled 2,800 older healthy adults, with a mean age of 75, to evaluate the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults. Participants were randomized to either computerized speed training, memory training, problem solving training, or psychosocial intervention. The computerized speed training produced the most significant benefit in cognitive functioning. Participants randomized to computerized speed training sustained their functioning of instrumental daily activities of living and had a 50% lower rate of at-fault motor vehicle collisions, compared with controls, over a 6-year follow-up period. The ACTIVE study results suggest that age-related changes might be reversible with 14 1-hour sessions of brain training. Normative age-related cognitive decline can be attenuated through the use of affordable, accessible technology. In summary, not all age-related cognitive complaints are pathological Clinicians must ask specifically about memory loss and rapid forgetting of information to differentiate normative age-related changes from Alzheimer’s dementia. Patients should be empowered to use technology to intervene for their cognition. Both brain and physical fitness are paramount to preventing dementia. Physical fitness is essential to prevention, because chronic illnesses such as type 2 diabetes are primary risk factors for dementia, and being overweight in middle age is a major predictor for developing type 2 diabetes. Physical exercise, brain exercise, and embracing technology are essential to preventing social isolation and subsequent dementia. References Antidepressants for pediatric patients by Jennifer B. Dwyer, MD, PhD; Michael H Bloch, MD, MD An evidence-based review from Current Psychiatry: 2019 September:18(9):26-30,32-36,41-42,42A-42F Click here for the webpage Click here for the downloadable PDF Tennstedt SL and FW Unverzagt. The ACTIVE study: Study overview and major findings. J Aging Health. 2013 Dec;25(8 0):3S-20S. doi: 10.1177/0898264313118133. Rebok GW et al. Ten-year effects of the ACTIVE cognitive training trial on cognition and everyday functioning of older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24. Harvey PD and MT Strassnig. Cognition and disability in schizophrenia: Cognition-related skills deficits and decision-making challenges add to morbidity. World Psychiatry. 2019 Jun;18(2):165-7. Brem AK and SL Sensi. Towards combinational approaches for preserving cognitive function in aging. Trends Neurosci. 2018 Dec;41(2):885-97.
Ginah Nightingale, PharmD, of the Jefferson College of Pharmacy at Thomas Jefferson University in Philadelphia chats with David H. Henry, MD, host of Blood & Cancer, about the definition of polypharmacy and the challenges it poses in treating older cancer patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the waiting that cancer patients face. Show notes Older adults comprise about 15% of the total population but account for more than 33% of prescription drug use. Polypharmacy can be defined as taking five or more medications (prescription and nonprescription), as well as being on medications that have adverse effects in older adults. Older adults are at increased risk for adverse effects from polypharmacy for multiple reasons, including multiple comorbidities and altered drug metabolism. In a study by Nightingale et al., 61% of patients already had a major drug-drug interaction on their medication list prior to initiation of cancer therapy. In a study by Sharma et al., 22% of patients were taking proton pump inhibitors concurrently with tyrosine kinase inhibitors, an interaction that was associated with increased risk of death at 90 days and 1 year. Patients who receive medications from multiple pharmacies, such as a specialty pharmacy for oncologic drugs, are at increased risk of polypharmacy errors. Tools to screen for polypharmacy include: Beers criteria by American Geriatrics Society STOPP/START criteria (commonly used in Europe) Medication appropriateness index Considerations such as patient’s life expectancy and quality-of-life goals should be taken into account when deciding which medications are necessary and what may be deprescribed. Clinicians should encourage patients to bring in all medications to every doctor’s visit, and certainly at the time of initiation of cancer treatment. Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. Additional reading American Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-94. O'Mahony Denis et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015 Mar;44(2):213-8. Nightingale G et al. Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer. J Clin Oncol. 2015 May 1;33(13):1453-9. Sharma M et al. The concomitant use of tyrosine kinase inhibitors and proton pump inhibitors: Prevalence, predictors, and impact on survival and discontinuation of therapy in older adults with cancer. Cancer. 2019 Apr 1;125(7):1155-62. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Kathleen Unroe, MD, MHA Research Scientist, Regenstrief Institute Assistant Professor of Medicine, Indiana University School of Medicine Center Scientist, Indiana University Center for Aging Research Dr. Unroe is focused on health policy relevant research in long term care, including the use of palliative care and hospice in this setting, transitions of care, quality of medical care in nursing homes, and staffing models in long term care. She is co-PI of the Optimistic model project References: Unroe KT, Nazir A, Holtz LR et al. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care approach: preliminary data from the implementation of a Centers for Medicare and Medicaid Services nursing facility demonstration project. J Am Geriatr Soc 2015;63:165-169. Hickman, S. E., Unroe, K. T., Ersek, M. T., Buente, B., Nazir, A., & Sachs, G. A. (2016). An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting. Journal of the American Geriatrics Society, 64(11), 2385–2392. Unroe, et. al., “Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2”, Journal of the American Geriatrics Association, 2018
It's not a personal goal of mine to live to be 100. I hope to live a long life--don't get me wrong--but I have no intention spending my final days in a hospital or a nursing home. There's nothing wrong with that, if that's what you want. And it turns out, more non-physician patients prefer this pathway toward dying than physician patients. Why is that? Produced by James E. Siegler. Music by Andy Cohen, Lee Rosevere, Rui, and Unheard Music Concepts. Voiceover by Erika Mejia. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision making. REFERENCES Matlock DD, Yamashita TE, Min SJ, Smith AK, Kelley AS and S MF. How U.S. Doctors Die: A Cohort Study of Healthcare Use at the End of Life. J Am Geriatr Soc. 2016;64:1061-7. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M, Cpr Quality Summit Investigators tAHAECCC, the Council on Cardiopulmonary CCP and Resuscitation. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128:417-35. Periyakoil VS, Neri E, Fong A and Kraemer H. Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives. PloS one. 2014;9:e98246. Sandroni C, Nolan J, Cavallaro F and Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive care medicine. 2007;33:237-45. Blecker S, Johnson NJ, Altekruse S and Horwitz LI. Association of Occupation as a Physician With Likelihood of Dying in a Hospital. JAMA : the journal of the American Medical Association. 2016;315:301-3. Weissman JS, Cooper Z, Hyder JA, Lipsitz S, Jiang W, Zinner MJ and Prigerson HG. End-of-Life Care Intensity for Physicians, Lawyers, and the General Population. JAMA : the journal of the American Medical Association. 2016;315:303-5.
Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-8. Mini Nutritional Assessment ------------ SRP is brought to you by the generous support of the SRP Game Changers. If you want to Join SRP, Crush Mediocrity, Join the Monthly Meetups, & Get some free swag!...go to http://SeniorRehabProject.com/Join
Relevant Links: Lundebjerg NE, Trucil DE, Hammond EC, Applegate WB. When It Comes to Older Adults, Language Matters: Journal of the American Geriatrics Society Adopts Modified American Medical Association Style. J Am Geriatr Soc. 2017;65(7):1386-1388. FrameWorks Institute tool for communication about aging ------- SRP is brought to you by the generous support of the SRP Game Changers. If you want to Join SRP, Crush Mediocrity, Join the Monthly Meetups, & Get some free swag!...go to http://SeniorRehabProject.com/Join
Polypharmacy and Health Outcomes Nebulous definitions strike again! Erinn and Tali talk about polypharmacy and health outcomes in older adults with comorbidity. This is audio from the Facebook Live broadcast in the Senior Rehab Project Facebook group on 6 Jan 2018. Fried TR, O'leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health Outcomes Associated with Polypharmacy in Community-Dwelling Older Adults: A Systematic Review. J Am Geriatr Soc. 2014;62(12):2261-72. Comorbidity Index Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies From Game Changer Celeste: List of high-risk medications / Beers List ___ SRP is brought to you by the generous support of the SRP Game Changers. If you want to Join SRP, Crush Mediocrity, Join the Monthly Meetups, & Get some free swag!...go to http://SeniorRehabProject.com/Join
Have you ever been in any of these situations? ⇒ You have a stable child who just needs fluids, but no laboratory tests ⇒ You’ve tried PO hydration, to no avail, despite anti-emetics ⇒ You’re poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis, otherwise known as subcutaneous rehydration. [Insert Player] Clysis comes from the same Greek word that “a flood” – hypodermoclysis refers to flooding the subcutaneous space with fluid, so that it can be absorbed systemically. Sound far-fetched? Well, it turns out, what is old is new again. In 1913, Dr Day first described this technique for a child with severe diarrhea who could not tolerate fluids by mouth. Hypodermoclysis then began to gain popularity with a peak of use in the 1940s, until an innovative breakthrough in 1950. Dr David Massa, a resident anesthesiologist at the Mayo clinic, invented the first catheter-over-needle apparatus. With increasing safety and ready access of IV catheters, IV quickly overshadowed SC. The subcutaneous route of hydration has also been used effectively in geriatric and palliative care for decades, and it is only now beginning to gain popularity again in its original population: children. So, how does it work? In a nutshell, you place a butterfly needle or angiocatheter in the subcutaneous space and you run fluids into it. The tissues quickly absorb the fluids, making them available systemically. That’s it. Everything else is just finesse. The ideal candidate for hypodermoclysis is the stable patient, with mild to moderate dehydration who fails a trial of fluids by mouth, or who needs a bridge to gaining IV access later, after a slow subcutaneous fluid bolus is given. Ok, so how do you do it? Place a topical anesthetic cream, such as EMLA, cover with occlusive dressing (IV dressing), wait 15-20 min "Pinch an inch" of skin anywhere, but the most practical site in young children is between the scapulae Insert a 25-gauge butterfly needle or 24-gauge angiocatheter (preferred by the author), secure Inject 150 U hyaluronidase SC, if available Infuse 20 mL/kg isotonic solution over one hour, repeat as needed or use "bolus" as bridge to IV access You can set the line to gravity, and if it is dripping in, you may leave it be. If you see a very slow drip by gravity, or worse, nothing is dripping, you can set the line on a pump, to deliver up to 20 mL/kg over an hour. Infusion at this rate optimizes the balance we want in minimal discomfort while maximizing the flow rate. This is not a “bolus” in the true sense – but then, when you compare it to the alternative – like IV therapy – and we see a time and cost savings. Dr Mace and colleagues in the American Journal of Emergency Medicine report substantially decreased cost and ED length of stay when comparing the material and human resources needed to place an IV in a squirmy young child, compared with a simple subcutaneous stick. There will be swelling There will be swelling – that is the goal. It is really painless, and your patient may lie down on his back with the pump going – it is actually pretty comfortable for most children and adults to do. Here’s a tip – since there will be swelling, we want to be careful about how we secure the line, so how you tape it down to the skin is important – we want to avoid a pulling sensation, which can be the beginning of the end of the tolerance for the procedure. Cover that with an occlusive dressing, as you would an IV site. The footprint of the occlusive dressing is relatively small, so it will travel up on top of the subcutaneous mound you’re creating. As the line exits the occlusive patch, place a thin layer of gauze between the skin and the IV tubing, so that the tubing doesn’t press into the skin. Then—as far away from the puncture site as possible—tape it down securely. The idea is not to tape on the growing mound itself, because the mound may pull at the anchored skin and set a nuclear chain reaction of annoyance and restlessness – and potentially a failed procedure. The swelling will look indurated, a pinkish red. It’s not an allergic reaction: even with the old preparations of hyaluronidase, allergic reactions were rare, and now they are very rare with the recombinant preparation. It is supposed to swell and look ugly. The subcutaneous tissues will swell to a point where you have a steady state fluid administration rate, and as soon as you stop the infusion, the remaining fluid will start to subside as it is absorbed. A Bridge to IV Therapy? Kuensting et al. in the Journal of Emergency Nursing in 2013 compared subcutaneous fluid infusion with intravenous fluid infusion in children with difficult IV access. They found the mean time from order entry to subcutaneous fluid infusion to be 20 min, compared to the failed IV access group with an average infusion start time of 1.5 hours. The latter group eventually received subcutaneous fluids. The investigators also found a shorter ED length of stay in the subcutaneous group. In the same study, a subgroup received subcutaneous fluids initially, and later an IV. They found a trend in ease of IV access after subcutaneous fluid therapy. In other words, if your little patient with difficult IV access is hemodynamically stable and amenable to a bolus over an hour, you may choose to start with hypodermoclysis and reevaluate. Predicting Difficult IV Access in Children Much has been studied and written about the predictors of difficult IV access in children. The most often cited are: age < 3 years, weight less than 5 kg, prematurity, obesity, and darker skin tones, where the contrast of vein to skin may not be so apparent. The three main predictors of the score validated by Riker et al. in Annals of Emergency Medicine include the most practical and universal of features: vein palpability, vein visibility, and patient age. If you’re anticipating difficult IV access in the child who can stand to wait an hour for a slow bolus, you may start with the subcutaneous route to get those veins plumper and more visible, to improve your chances of IV access in the very near future. Medications via Subcutaneous Route Certain medications have been used safely via subcutaneous infusion; always check dose, rate, and compatibility. What about catheter size? You don’t need to use larger needles or angiocathters for older children, adolescents or adults. A 25-gauge butterfly or 24-gauge angiocatheter works well from an infant to an elder. In one study of adults, a half a liter of saline was infused by gravity via a 24-gauge catheter. With IVs, the shorter and larger the bore, the faster the infusion. In subcutaneous infusion, it is not the size of the catheter, but the osmotic gradient that determines the rate of absorption. What if I don't have that fancy hyaluronidase? It’s actually increasingly readily found – and available in generic form. If you have it, please use it – it will make a believer out of you and others. Hypodermoclysis will work without hyaluronidase – the process of subcutaneous rehydration just takes a lot longer to work. In a double-blind cross-over trial Thomas et al. in 2007 compared subcutaneous administration of lactated ringer’s solution by gravity with and without hyalurondase. The hyaluronidase group received their fluids 5 times faster. The average rate of the hyaluronidase group was 382 mL/h versus the fluid only group, who did not receive hyalurinodase; they were substantially slower, at 82 mL/h. It’s worth using if you have it, but still potentially useful if you don’t. Recap: Supplies √ EMLA or any topical anesthetic used for intact skin, placed as soon as the decision is made √ A 25-gauge butterfly needle or 24-gauge angiocatheter √ IV tubing, gauze to pad, tape to anchor √ 150 U hyaluronidase, the same dose, regardless of age or size √ Isotonic fluids – you can start with 20 ml/kg √ And finally a well informed team made up by the patient, the parents, and your staff, so that everyone knows what to expect for a successful subcutaneous fluid administration. References Allen CH, Etzwiler LS, Miller MK, Maher G, Mace S, Hostetler MA, Smith SR, Reinhardt N, Hahn B, Harb G; INcreased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration Study Collaborative Research Group. Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics. 2009 Nov;124(5):e858-67. Bruno VG. Hypodermoclysis: a literature review to assist in clinical practice. Einstein (Sao Paulo). 2015 Jan-Mar;13(1):122-8. Cabañero-Martínez MJ, Velasco-Álvarez ML, Ramos-Pichardo JD, Ruiz Miralles ML, Priego Valladares M4, Cabrero-García J. Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study. Palliat Med. 2016 Jun;30(6):549-57. Kuensting LL. Comparing subcutaneous fluid infusion with intravenous fluid infusion in children. J Emerg Nurs. 2013 Jan;39(1):86-91. Mace SE, Harb G, Friend K, Turpin R, Armstrong EP, Lebel F. Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration. Am J Emerg Med. 2013 Jun;31(6):928-34. O'Hanlon S, Sheahan P, McEneaney R. Severe hemorrhage from a hypodermoclysis site. Am J Hosp Palliat Care. 2009 Apr-May;26(2):135-6. Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc. 2007 Dec;55(12):2051-5. Riker MW, Kennedy C, Winfrey BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med. 2011 Nov;18(11):1129-34. Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011 Mar;127(3):e748-57. Smith LS. Hypodermoclysis with older adults. Nursing. 2014 Dec;44(12):66. Spandorfer PR. Subcutaneous rehydration: updating a traditional technique. Pediatr Emerg Care. 2011;27(3):230-6. Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. J Palliat Med. 2007 Dec;10(6):1312-20. Vacha ME et al. The Role of Subcutaneous Ketorolac for Pain Management. Hosp Pharm. 2015 Feb; 50(2): 108–112. Zaloga GP, Pontes-Arruda A, Dardaine-Giraud V, Constans T; Clinimix Subcutaneous Study Group. Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial. J Parenter Enteral Nutr. 2016 Feb 17. pii: 0148607116629790. [Epub ahead of print] This post and podcast are dedicated to Christina L. Shenvi, MD, PhD, for her dedication to excellence in patient care and enthusiasm in #FOAMed, Emergency Medicine, and Geriatric Emergency Medicine. There are many shared lessons learned in the care of children, elders, and families. Thank you. Catch Dr Shenvi on the innovative GEMcast. Subcutaneous Infusion Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP
Tim Platts-Mills shares his pearls about pain management for older adults in the ED. See here to leave a comment: https://gempodcast.com/2016/05/02/pearls-and-pitfalls-of-pain-management-in-older-adults/ Pain is the number one reason why people seek care in the Emergency Department (ED). One major goal of acute care is diagnosing the cause of the pain, but another is helping relieve the suffering associated with pain. In older adults, some of the risks of pain management with opioids are amplified, such as the risk of sedation and falls. With NSAIDs, there is a higher risk of acute renal insufficiency and electrolyte abnormalities, as well as cardiovascular risks with longer treatment. How should we approach acute pain management in the ED, and on discharge in older patients? In this podcast episode, Tim Platts-Mills, an expert and researcher on pain in older adults talks us through some ideas for non-opiates, opiates, and other adjuncts. We discuss some of the risks of over-treatment and under-treatment, and introduce the idea of the allostatic load created by chronic pain. Selected References 1. Hwang U, Platts-Mills TF. Acute pain management in older adults in the emergency department. Clin Geriatr Med. 2013;29(1):151-164. http://www.ncbi.nlm.nih.gov/pubmed/23177605 2. Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. Ann Emerg Med. 2012;60(2):199-206. http://www.ncbi.nlm.nih.gov/pubmed/22032803 3. Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc. 2010;58(11):2122-2128. http://www.ncbi.nlm.nih.gov/pubmed/21054293 4. Terrell KM, Hui SL, Castelluccio P, Kroenke K, McGrath RB, Miller DK. Analgesic prescribing for patients who are discharged from an emergency department. Pain Med. 2010;11(7):1072-1077. http://www.ncbi.nlm.nih.gov/pubmed/20642733 5. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005;352(13):1324-1334. http://www.ncbi.nlm.nih.gov/pubmed/15800228 6. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg. 2004;99(2):510-20, table of contents. http://www.ncbi.nlm.nih.gov/pubmed/15271732 7. Jakobsson U, Klevsgard R, Westergren A, Hallberg IR. Old people in pain: A comparative study. J Pain Symptom Manage. 2003;26(1):625-636. http://www.ncbi.nlm.nih.gov/pubmed/12850645 8. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet. 1999;354(9186):1248-1252. http://www.ncbi.nlm.nih.gov/pubmed/10520633 9. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279(23):1877-1882. http://www.ncbi.nlm.nih.gov/pubmed/9634258 This podcast uses sounds from freesound.org by Jobro and HerbertBoland Image credit: https://pixabay.com/en/heart-3d-stone-white-pain-old-1463424/
For the Show Notes, see the gemcast website: http://gempodcast.com/2015/11/11/high-risk-medications-and-adverse-drug-events/ Adverse drug events (ADEs) are a major problem among older adults who present to the Emergency Department. ADEs come in 5 types. 1 in 6 hospitalizations among older adults involves an ADE, and half of the hospitalizations for ADEs are deemed preventable. What medications should be used with caution or avoided in older adults? What are safer alternatives? In this podcast we discuss the types of ADEs, which patients are at greatest risk, the highest risk medications, alternatives to the high-risk medications, and ways to prevent ADEs. Leah Hatfield, an ED pharmacist, shares her wisdom. References: 1. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015. 2. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015. 3. Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079-2086. 4. Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013;87(5):331-336. 5. Passarelli MC, Jacob-Filho W, Figueras A. Adverse drug reactions in an elderly hospitalised population: Inappropriate prescription is a leading cause. Drugs Aging. 2005;22(9):767-777. 6. Saedder EA, Lisby M, Nielsen LP, Bonnerup DK, Brock B. Number of drugs most frequently found to be independent risk factors for serious adverse reactions: A systematic literature review. Br J Clin Pharmacol. 2015;80(4):808-817. Image credit: https://pixabay.com/en/pill-capsule-medicine-medical-1884775/ Sound credits: sounds from freesound.org by Jobro and HerbertBoland
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