6/17/2019 Geriatrics Literature Updates Disclosures Kenneth Covinsky, MD @Geri_Doc • Eric Widera Eric Widera, MD @EWidera • Associate Editor, Social Media Editor, for the Journal of the American University of California San Francisco Geriatrics Society (JAGS) San Francisco VA Medical Center • Ken Covinsky • Editorial Board for the Journal of the American Geriatrics Society (JAGS); Associate Editor, JAMA Internal Medicine • Alex Smith • Deputy Editor, Journal of the American Geriatrics Society (JAGS) 1
6/17/2019 Methods for AGS Updates Talk • Search of leading journals • January 2018-December 2018 • JAGS, NEJM, JAMA, JAMA-IM, Annals, Health Affairs, Lancet, BMJ, Academic Medicine, JGIM, J Geron-Med Sci, JPM, JPSM, Annals of Family Medicine • Search of social media: • Twitter (i.e. @AGSJournal), Blogs, PC-FACS, podcasts, Health In Aging Research Summaries (healthinaging.org) • Selection Criteria • Impact and Interest 2
6/17/2019 BMJ 2018. http://dx.doi.org/10.1136/bmj.k3503 Methods Percentage with elevated inpatient BP • Retrospective cohort study • 14,915 Veterans aged 65 years or over (median age 76) with HTN admitted to hospital with non-cardiac conditions: • Pneumonia, urinary tract infection, or venous thromboembolism. Elevated Normoten • Exclusions: Inpatient sive BP • Secondary discharge diagnoses that might necessitate an acute change in inpatient 23% BP antihypertensive treatment (eg. A fib, ACS) • Primary Outcome: • A new or higher dose antihypertensive agent at discharge compared with drugs used before admission. 3
6/17/2019 Percentage with elevated inpatient BP Measuring Matters!!!! • How SPRINT did it • Average of 3 office BP readings taken with proper cuff size • Participants seated with their back supported Well Controlled • 5 minutes of rest before measurement Pre-hospital BP Elevated 47% • No conversation during the rest period or BP determinations. Normoten Inpatient sive • Conventional Auscultatory SBP BP inpatient 23% • Up to 20mmHg higher than this technique BP Elevated Pre- hospital BP Myers MG, et tal. Hypertension. 2010;55:195–200 Percentage of intensified antihypertensive Percentage of intensified antihypertensive treatment post-hospitalization treatment post-hospitalization 62% started on one new antihypertensive Intensified HTN Intensified HTN No treatmet treatmet Intensification 14% 14% 14% started on multiple new antihypertensives No change Intensified HTN treatmet No change Intensified HTN treatmet 4
6/17/2019 Care driven by numbers and not the clinical context Percentage of intensified antihypertensive treatment post-hospitalization Well Controlled Pre- hospital BP No Intensified HTN 52% treatmet Intensification 14% Elevated Outpatient BP Well controlled Outpt BP No change Intensified HTN treatmet Take Home Points • 1 in 7 older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. • More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. • Decisions to intensify antihypertensive in the hospital seem to be driven by numbers and not the clinical context 5
6/17/2019 Clinicians would be wise to adopt Sin City’s famous tagline, “What happens in Vegas, stays in Vegas;” often the safest approach to inpatient chronic disease management should be to let what happens in hospital stay in hospital. Nathan Stall & Chaim Bell Warning: Hospitals Are Bad For Your Health • Hospital-Acquired Disability • One-Third of persons over age 70 leave hospital with new ADL disability • Less than half will recover after discharge • May be related to processes of hospitalization • Immobilization • Delirium induction • Malnutrition • Evidence that changing hospital processes reduced risk of hospital acquired disability JAGS 67:11 – 16, 2019 6
6/17/2019 Multi Component Hospital Exercise Intervention • Setting: ACE Unit: Pamplona Spain • Enrollment Criteria (n=370) • Medical admissions over age 75 • Barthel Index at least 60 • Able to ambulate (assistance OK) • Able to communicate and collaborate with research team • LOS at least six days • Enrolled subjects • Mean age = 87 • 57% women • Almost all with multimorbidity • CHF, Infection most common reasons for admission JAMA IM. 2019 doi:10.1001/jamainternmed.2018.4869 Effect of Intervention The Intervention Control Intervention Difference • Two daily 20 minute sessions Barthel Index • Am session with fitness specialist -5.0 +1.9 +6.9 (+4.4, +9.5) Change • Progressive resistance: 8-10 reps X 2, 30-60% capacity, 4 muscle groups SPPB change +0.2 +2.4 +2.2 (+1.7, +2.6) • Balance and gait training: Semi tandem foot standing, line walking, +1.8 (+1.3, 2.3) walking around obstacles, walking on unstable surfaces MMSE Change +0.3 +2.1 • Unsupervised PM session • Lower extremity exercises with anklets, corridor walking • No difference in falls • Costs • No difference in 3 month mortality • No difference in 3 month readmission • Fitness specialist • No difference in 3 month institutionalization • $5000 worth of exercise equipment 7
6/17/2019 Summary • An intensive hospital based exercise intervention combining strength training, balance, and walking had substantial positive effect on post discharge function in very old medicine inpatients • Caveats • Careful selection process (excludes most physically and cognitively challenged) • Requires extra staffing • Much longer length of stay than typical US hospital patient • Probably requires intervention continuation in SNF/home • Very important proof of concept that hospital acquired disability can be prevented in some patients 8
6/17/2019 Pimavanserin (Nuplazid) Cost: $3,000/month Lancet Neurology 2018; 17: 213–22 Background Methods • Pimavanserin serotonin 5HT2A inverse agonist and antagonist with no • Study Design: Phase 2, randomized, double-blind, placebo-controlled dopamine D2 affinity • Nursing home residents age >=50 with possible or probable AD • Psychotic symptoms including hallucinations or delusions severe enough to • Available in the US since 2016 for treatment of psychosis in patients warrant treatment. with Parkinson Disease related psychosis • Randomly assigned to pimavanserin (n=90) or placebo (n=91) for 12 • Largely based on one trial with marginal benefit (a gain of 3 points on a 45- weeks point scale) • Does it work for Alzheimer’s disease psychosis? • Primary outcome: • Mean change in the NPI–NH psychosis score (hallucinations + delusions) at 6 weeks • NPI-NH ranges from 0 to 24 with lower scores correspond to less severity Lancet Neurology 2018; 17: 213–22 9
6/17/2019 Adjusted mean change in the psychosis score Adjusted mean change in the psychosis score *Range 0 to *Range 0 to 24. Lower 24. Lower scores scores correspond correspond to less to less severity severity Primary Outcome Measures in Subgroup analysis for psychosis score based ClinicalTrials.org on severity • NPI-NH, CMAI-Short form, ADCS-Clinical Global Impression of Change at 12 weeks 2014 Baseline NPI-NH < 12 • NPI-NH at 12 weeks 2014 NPI-NH >=12 • NPI-NH at 12 weeks 2016 • NPI-NH at 12 weeks 2016 • NPI-NH Psychosis domains at 6 weeks (dosed total of 12 weeks) 2017 • “Change from Baseline to Day 43 in the NPI-NH psychosis score” 2017 10
6/17/2019 Subgroup analysis for psychosis score based Adjusted mean change in psychosis score for on severity patients with baseline score ≥12 Baseline NPI-NH < 12 NPI-NH >=12 Adverse Events Pimavanserin (n=90) Placebo (n=91) Any serious adverse event 17% 11% Pimavanserin Agitation 21% 14% Aggression 10% 4% (Nuplazid) Peripheral edema 8% 2% Cost: $3,000/month Anxiety 6% 2% Behavioral and psychiatric 6% 2% symptoms of dementia 11
6/17/2019 Cummings et al. JAMA. 2015;314(12):1242-1254 Ken’s Conclusions from 2016 • Conclusion A: • Dextromethorphan efficacious for reducing agitation with tolerable side effects • Conclusion B: • Dextromethorphan efficacious in increasing falls with some additional mild benefits of reduced agitation • Should you consider Dextromethorphan for off-label use for patients with dementia agitation? • Evidence of effectiveness is very modest, and risk for harm substantial JAMA Intern Med. 2019;179(2):224-230. 12
6/17/2019 JAMA Intern Med. 2019;179(2):224-230. doi:10.1001/jamainternmed.2018.6112 JAMA Intern Med. 2019;179(2):224-230. doi:10.1001/jamainternmed.2018.6112 The National Partnership to Improve Dementia Care in Nursing Homes • CMS program to reduce antipsychotic use in persons with dementia • Limited effectiveness reducing behavioral symptoms • Bad side effects • Partnership between CMS, state agencies, surveyors, advocacy groups • Public reporting of antipsychotic use • No reporting of other mood stabilizing meds • Anticonvulsants such as carbamazepine, valproic acid • Less evidence of efficacy, side effects at least as bad • No measures of nonpharmacologic treatment Maust et al. JAMA Intern Med. 2018 13
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