10/23/2014

1

2014 Update in Geriatrics

With thanks to my SGIM colleagues:

• Lee Lindquist, MD MPH MBA – Northwestern University

• Shahla Barhalou, MD –Mount Sinai

• Patricia Harris, MD, MS –University of Southern California

• Alison Huang, MD, MAS –UCSF

Screening for Cognitive Impairment:

A Systematic Review for the US

Preventive Services Task Force

Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E

Ann Intern Med. 2013 Nov 5;159(9):601-12

Sponsor: AHRQ

10/23/2014

2

What are the questions?• ~29–76% of patients with dementia are not

diagnosed by primary care clinicians

• Are screening tests for dementia adequate?

• Do interventions for cognitive impairment (early

dementia or MCI) in older adults improve decision

making, patient, family/caregiver, or societal

outcomes?

• What are the harms of interventions for cognitive

impairment?

How good are the Dementia

screening tests?

• Several instruments have adequate sensitivity/specificity to detect dementia

– MMSE best studied—long administration time and $

– More limited evidence for other instruments (Clock Draw Test, MiniCog, etc) and optimal cut points not perfectly defined

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3

Do interventions for Cognitive

Impairment in older adults improve

outcomes?

1. Drugs for dementia (AChEIs, Memantine)

2. Caregiver interventions

3. Other non-pharmacologic interventions

Results: Meta-analyses for AChEI and Memantine

on Global Cognitive Function (6 months)

6

NOTE: Weights are from random effects analysis

.

.

.

.

Donepezil

Petersen, 2005*

Salloway, 2004*

Doody, 2009

Rogers, 1996*

Rogers, 1998b*

Rogers, 1998a*

Burns, 1999*

Requena, 2004

Tune, 2003*

Seltzer, 2004*

Black, 2003*

Wilkinson, 2003*

Subtotal (I-squared = 67.6%, p = 0.000)

Galantamine

Tariot, 2000*

Brodaty, 2005*

Wilkinson, 2001*

Raskind, 2000*

Wilcock, 2000*

Rockwood, 2001*

Bullock, 2004*

Auchus, 2007

Erkinjuntti, 2002*

Subtotal (I-squared = 68.4%, p = 0.001)

Rivastigmine

Karaman, 2005*

Winblad, 2007

Feldman, 2007

Forette, 1999*

Corey-Bloom, 1998*

Rosler, 1999*

Ballard, 2008

Subtotal (I-squared = 92.6%, p = 0.000)

Memantine

Porsteinsson, 2008

Peskind, 2006*

Bakchine, 2008

Orgogozo, 2002*

Wilcock, 2002*

Subtotal (I-squared = 31.5%, p = 0.212)

Study

MCI

MCI

MCI

AD

AD

AD

AD

AD

AD

AD

VaD

VaD

AD

AD

AD

AD

AD

AD

AD

VaD

AD/VaD

AD

AD

AD

AD

AD

AD

VaD

AD

AD

AD

VaD

VaD

Disorder

27.3

27.4

27.5

18.6

19.3

19.5

20

20.8

21.1

24.2

21.8

21.8

17.8

18

18.7

19.3

19.3

19.7

20.4

20.3

20.5

12.2

16.5

18.6

19.5

19.7

19.9

19.2

16.8

17.3

18.7

16.9

17.6

MMSE

Baseline

28

270

757

161

473

468

818

46

28

153

818

616

978

971

285

636

653

386

285

767

592

44

534

497

114

699

725

698

427

394

403

321

579

Analyzed

N

36

6

11

3

6

3

6

12

6

6

6

6

5

6

3

6

6

3

6

6

6

12

6

6

4

6

3

6

6

6

6

6

6

Followup

Months

-0.06 (-1.18, 1.06)

-1.90 (-3.29, -0.51)

-0.90 (-1.63, -0.17)

-3.20 (-5.08, -1.32)

-2.88 (-4.27, -1.49)

-3.10 (-4.30, -1.90)

-2.80 (-3.41, -2.19)

-2.67 (-7.63, 2.29)

-2.09 (-4.95, 0.77)

-2.30 (-4.10, -0.50)

-1.68 (-2.80, -0.56)

-2.07 (-3.32, -0.82)

-2.03 (-2.68, -1.38)

-3.10 (-4.18, -2.02)

-2.80 (-3.76, -1.84)

-3.00 (-5.23, -0.77)

-0.10 (-1.24, 1.04)

-2.90 (-4.00, -1.80)

-1.70 (-2.80, -0.60)

-3.10 (-4.59, -1.61)

-1.40 (-2.28, -0.52)

-2.70 (-3.95, -1.45)

-2.25 (-2.94, -1.55)

-5.27 (-5.72, -4.82)

-1.60 (-2.71, -0.49)

-3.00 (-4.28, -1.72)

-4.80 (-6.03, -3.57)

-3.78 (-4.88, -2.68)

-1.60 (-2.83, -0.37)

-1.10 (-2.58, 0.38)

-3.06 (-4.48, -1.65)

-0.70 (-1.80, 0.40)

-1.37 (-2.27, -0.47)

-0.85 (-2.03, 0.33)

-2.85 (-4.40, -1.30)

-1.75 (-3.49, -0.01)

-1.36 (-2.02, -0.70)

Mean Change (95% CI)

Difference in

-0.06 (-1.18, 1.06)

-1.90 (-3.29, -0.51)

-0.90 (-1.63, -0.17)

-3.20 (-5.08, -1.32)

-2.88 (-4.27, -1.49)

-3.10 (-4.30, -1.90)

-2.80 (-3.41, -2.19)

-2.67 (-7.63, 2.29)

-2.09 (-4.95, 0.77)

-2.30 (-4.10, -0.50)

-1.68 (-2.80, -0.56)

-2.07 (-3.32, -0.82)

-2.03 (-2.68, -1.38)

-3.10 (-4.18, -2.02)

-2.80 (-3.76, -1.84)

-3.00 (-5.23, -0.77)

-0.10 (-1.24, 1.04)

-2.90 (-4.00, -1.80)

-1.70 (-2.80, -0.60)

-3.10 (-4.59, -1.61)

-1.40 (-2.28, -0.52)

-2.70 (-3.95, -1.45)

-2.25 (-2.94, -1.55)

-5.27 (-5.72, -4.82)

-1.60 (-2.71, -0.49)

-3.00 (-4.28, -1.72)

-4.80 (-6.03, -3.57)

-3.78 (-4.88, -2.68)

-1.60 (-2.83, -0.37)

-1.10 (-2.58, 0.38)

-3.06 (-4.48, -1.65)

-0.70 (-1.80, 0.40)

-1.37 (-2.27, -0.47)

-0.85 (-2.03, 0.33)

-2.85 (-4.40, -1.30)

-1.75 (-3.49, -0.01)

-1.36 (-2.02, -0.70)

Mean Change (95% CI)

Difference in

Favors Intervention Favors Control

0-7.63 0 7.63

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Clinical meaning of magnitude of

benefit

• Benefit on global cognitive function: 0-3 pt change in ADAS-cog

– ADAS-cog (0–70): change of 4 points (over 6 months) considered meaningful in mild-mod dementia

• Benefit on global functioning for AChEI: ~0.5 pt in CIBIC-plus

– CIBIC-plus (7-point scale): 1= very much better vs. 7=very much worse, any change in score is considered meaningful

Acetylcholinesterase Inhibitors (AChEI)

and Memantine- HarmsTreatment

# of Studies

Quality

Summary of results of adverse events

FDA approved

medications for AD

1 SER (50 RCT)

and 13 RCT

and 7 OLE

and 10

observational

studies

Fair to good

Discontinuation from AChEI (k=44), but not memantine

(k=7) is more common than placebo. Across trials, there

does not appear to be a difference in total serious adverse

events for any of these medications.

Observational studies examining AChEI (k=9, n=94,042)

suggest that the most common serious adverse events are

CNS, heart rate/rhythm, and GI disorders; and that

bradycardia, and adverse events related to bradycardia

(e.g., fall, syncope) are increased due to their use.

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5

Results: Meta-analyses for Caregiver

Interventions on Caregiver Burden

9

NOTE: Weights are from random effects analysis

Overall (I-squared = 54.7%, p = 0.001)

Gitlin 2008

Jansen 2011

REACH-PaloAlto 2003

Finkel 2007

Callahan 2006

Teri 2005

REACH-Boston 2003

Chu 2011

Study

Martin-Carrasco 2009

Hepburn 2005

Hepburn 2001

REACH-Memphis 2003

REACH-Philadelphia 2003

Hebert 2003

Ulstein 2007

Wright 2001

Brennan 1995

Gallagher-Thompson 2008

Gitlin 2010 (ACT)

REACH-Birmingham 2003

Ostwald 1999

Gitlin 2001

Fortinsky 2009

Individual

Case/Care Mgmt

Group

Phone/Virtual

Case/Care Mgmt

Intervention

Individual

Phone/Virtual

Group

Type

Individual

Group

Group

Individual

Individual

Individual

Group

Individual

Phone/Virtual

Group

Individual

Group

Group

Individual

Case/Care Mgmt

56

99

105

25

153

N

74

79

60

Analyzed

82

131

94

120

191

116

171

93

96

184

220

99

80

171

69

4

12

6

6

12

Months

6

6

4

Followup

10

12

5

6

6

4

12

12

12

6

6

6

5

3

12

-0.23 (-0.35, -0.11)

0.05 (-0.47, 0.56)

0.17 (-0.22, 0.56)

-0.30 (-0.71, 0.12)

-0.69 (-1.47, 0.09)

-0.17 (-0.49, 0.14)

-0.26 (-0.71, 0.20)

-0.61 (-1.06, -0.16)

-0.33 (-0.83, 0.17)

Hedge's g (95% CI)

-1.16 (-1.63, -0.70)

-0.29 (-0.66, 0.08)

-0.52 (-0.94, -0.10)

-0.23 (-0.59, 0.12)

-0.39 (-0.68, -0.11)

-0.18 (-0.54, 0.18)

-0.01 (-0.30, 0.29)

0.23 (-0.22, 0.68)

0.18 (-0.22, 0.58)

-0.40 (-0.69, -0.11)

-0.14 (-0.40, 0.12)

-0.12 (-0.51, 0.27)

-0.71 (-1.17, -0.25)

-0.04 (-0.34, 0.26)

0.14 (-0.34, 0.63)

100.00

3.28

4.41

4.18

1.83

5.27

%

3.78

3.85

3.39

Weight

3.70

4.64

4.09

4.79

5.66

4.74

5.50

3.83

4.35

5.59

5.94

4.42

3.74

5.49

3.53

-0.23 (-0.35, -0.11)

0.05 (-0.47, 0.56)

0.17 (-0.22, 0.56)

-0.30 (-0.71, 0.12)

-0.69 (-1.47, 0.09)

-0.17 (-0.49, 0.14)

-0.26 (-0.71, 0.20)

-0.61 (-1.06, -0.16)

-0.33 (-0.83, 0.17)

Hedge's g (95% CI)

-1.16 (-1.63, -0.70)

-0.29 (-0.66, 0.08)

-0.52 (-0.94, -0.10)

-0.23 (-0.59, 0.12)

-0.39 (-0.68, -0.11)

-0.18 (-0.54, 0.18)

-0.01 (-0.30, 0.29)

0.23 (-0.22, 0.68)

0.18 (-0.22, 0.58)

-0.40 (-0.69, -0.11)

-0.14 (-0.40, 0.12)

-0.12 (-0.51, 0.27)

-0.71 (-1.17, -0.25)

-0.04 (-0.34, 0.26)

0.14 (-0.34, 0.63)

100.00

3.28

4.41

4.18

1.83

5.27

%

3.78

3.85

3.39

Weight

3.70

4.64

4.09

4.79

5.66

4.74

5.50

3.83

4.35

5.59

5.94

4.42

3.74

5.49

3.53

Favors Intervention Favors Control

0-1.63 0 1.63

Psychoeducational Interventions

Results: Other non-Pharmacologic

InterventionsTreatment

# of Studies

Quality

Summary of Results

Cognitive

intervention

13 RCT

Fair

Overall cognitive interventions (n=887) had inconsistent findings of benefit but

cognitive stimulation (k=6, n=513) can improve global cognitive function in

persons with MCI or dementia in the short term (6 to 12 months). However,

pooled analyses for global cognitive outcomes had very wide confidence

intervals, SMD -0.59 (95% CI -0.93, -0.25, I-squared 52.7%).

Exercise

7 RCT

Fair to good

Exercise interventions (k=7, n=888) had inconsistent findings of benefit. Two

best quality trials (n=323) showed that exercise could have very small benefit

in global cognitive function (for MCI) or small benefit in physical functioning

and HRQL (for dementia) at 18 months.

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Clinical Bottom Line

• AChEI and memantine may improve global cognitive

function and global function in the short term (6 months)

– Clinical relevance uncertain

– Discontinuation of AChEI is common and serious harms of

medications can include CNS, CV, and GI symptoms

• Complex interventions aimed at caregivers and patients

can improve caregiver burden and depression

• Cognitive stimulation can improve global cognitive

function

11

Summary Task Force Recommendation

• Still an “I” (insufficient evidence) for screening

for cognitive impairment

• Screening tools ARE good enough

• Drugs, cognitive therapy, and caregiver interventions provide some benefit, but clinical relevance uncertain

• Not enough studies on how diagnosis of dementia affects decision making for overall care

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Summary Task Force Recommendation

“…while the overall evidence on routine screening

is insufficient, clinicians should remain alert to

early signs or symptoms of cognitive

impairment and evaluate as appropriate”

Effect of Tai Chi on Cognitive Performance in

Older Adults: Systematic Review and Meta-

Analysis

Wayne PM, Walsh, JN, Taylor-Piliae RE, Wells,

RE, Papp, KV, Donovan, NJ, Yeh, GY

JAGS.2014;62:25-39

Sponsor: National Center for Complementary

and Alternative Medicine

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What’s the question?

• We know that tai chi reduces

falls and injurious falls in

older adults; it also improves

sleep, arthritis pain,

fibromyalgia pain, blood

pressure, and other

important outcomes

• Does tai chi also have

cognitive benefits?

Methods• 11 RCTs* of adults over 60 living in the community or

long term care setting, cognitively impaired or not, tai chi vs exercise control (eg, walking) OR no exercise control (eg, usual care)

• Outcomes assessed:

– Cognitively intact: executive function (trail making test, Stroop, others)

– Cognitively impaired: global cognition (MMSE, ADAS-cog)

*used additional Non-RCT trials (N=9) as ‘confirmatory’

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Results

• 4 RCTs of cognitively intact, community dwelling (N=421): age ~69, MMSE 25-30

• 7 RCTs of cognitively impaired, some community and some institutionalized (N=843): age ~80, MMSE 15-26

• Tai chi 40-60 min classes 2-3 days/week

• Control: walking, healthy aging class, contemporary dance, etc

• Intervention 10 weeks to 1 year

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Clinical Bottom Line• Effect size small to moderate (hard to interpret; some studied in

impaired group reported MMSE scores increasing 1.5-3.5 points)

• Tai chi positive even compared to walking/other exercise groups

• Risks of tai chi extremely low, even in somewhat fragile

populations

• There is probably a senior center or gym near you that offers tai

chi!

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Ten-Year Effects of Advanced Cognitive

Training for Independent and Vital Elderly

Cognitive Training Trial on Cognition and

Everyday Functioning in Older Adults

George W. Rebok, PhD, et al. for the ACTIVE Study Group

J Am Geriatr Soc 62:16–24, 2014.

Sponsor: NIH – NIA/NINR

What’s the question?

• To determine the effects of Cognitive Training on

Cognitive Abilities and Everyday Function over 10

years

• Does Cognitive Training work?

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Methods

• Single Blind, multi-site, RCT (recruitment March 1998- Oct. 1999) with 10 year follow-up with 3 intervention arms and no-contact control group.

• 2832 volunteers, Mean Age 73.6 yrs, 26% AA, living independently

• Inclusion:– Community dwelling adults aged 65 and older.

• Exclusion:– Severe cognitive dysfunction (MMSE <23)

– Functional Impairment (dependency or regular assistance with ADLS)

– Self reported dx of Alzheimer’s, CVA in last 12 mos., Cancers, current chemo or radiation therapy

– Poor vision, hearing, or communicative ability.

Memory

Reasoning

Speed of

Processing

No Contact

Control

Initial Training = Ten 60-75 minute sessions over 5-6 weeks,

Booster Training = Four 75 minute sessions at 11 and 35 months

• Improving verbal episodic memory through instruction

and practice in strategy use.

• Improving ability to solve problems that contain a

serial pattern.

• Visual search/ ability to process increasingly more-

complex information presented in successively

shorter inspection time.

Cognitive Training Interventions

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Outcomes Measures

• Primary Outcome

o Memory Outcomes (Rey Auditory-Verbal Learning Test, Hopkins Verbal

Learning Test, and Paragraph Recall)

o Reasoning Outcomes (ID letter/word patterns)

o Speed of Processing Outcomes (Useful Field of View tasks)

• Secondary Outcome

o Functional Outcomes (IADL, MDS Home Care, Everyday Problem

Solving, Observed Tasks of Daily Living, Everyday Speed)

Outcome assessments were conducted immediately

and 1, 2, 3, 5, and 10 years after the intervention

MEMORY REASONING

SPEED

Speed

Intervention

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Control

Interventions

IADL Difficulty

Clinical Bottom Line

• Cognitive training has beneficial effects on cognitive abilities and on self-reported IADL function.

• Such interventions hold the potential to delay onset of functional decline and possibly dementia.

• If interventions that could delay onset of functional impairment by even 6 years, the number of people affected by 2050 would be reduced by 38% which would be of great public health significance.

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Antihypertensive Medications and Serious

Fall Injuries in a Nationally Representative

Sample of Older Adults

Mary Tinetti, Ling Han, David SH Lee, et al

JAMA Intern Med

February 24, 2014

Jamainternmed.2013.14764

What is the question?

• Randomized clinical trials of relatively healthy

older adults:

– reduced risk of CV events with antihypertensive

treatment (28%)

– ARR 15.3/100 to 11/100 over 4.5 years

• What is the risk of an adverse event (fall) if an

older adult with chronic conditions receives

antihypertensive medication?

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Trade-off

• Prevent strokes and myocardial infarction

• Increased risk of:

– Medication-related symptoms

– Falls

• Traumatic brain injury

• Hip fracture

Methods

• Medicare Current Beneficiary Survey

• 2004-2007

• Age over 70

• Community-dwelling at baseline

• Traditional Medicare beneficiary

– (not Medicare Advantage)

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Variables

• Chronic conditions

• Sociodemographic

• Functional (ADLs, IADLs)

• Cognitive impairment

• Prescription information

Medication Stratification

• WHO drug statistics methods:

Defined Daily Dose

None: zero to under 0.2 DDD

Moderate: 0.2 – 2.5 DDD

High >2.5 DDD

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Adverse Events

• Serious Fall:

– Emergency Department and inpatient claims

– Fracture (skull, cervical, clavicle, forearm, pelvic,

hip, fibula, tibia, ankle)

– Dislocation (hip, knee, shoulder, jaw)

– Brain injury

Participant Characteristics

• 4961 total– 3050 (61.5%) female

• Mean age age 80.2 (6.8) years

No treatment: 697 (14.1 %)*

Moderate-intensity: 2711 (54.6%)*

High-Intensity: 1533 (31.3%)*

*after adjustment, no difference in characteristics

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Agents used• Angiotensin system 2809 56.6%

• Diuretic 2691 45.9

• Beta Blocker 2277 34.2

• Calcium Channel Blocker 1695 34.2

• Other 349 7.0

• One class 1455 28.3

• Two classes 1599 35.8

• Three or more 1607 35.9

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Subgroup Analysis

(the real story?)

• If one fall

�twice the risk of a 2nd fall

�not true in no-medication subgroup

• Age (under 85 vs 85 and over)

� no change in falls risk

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21

Discussion

• Weaknesses:

– No dose-response relationship

– Many categories not statistically significant at 5%

– Cause of death not included

– No study of minor falls

• Strengths

– Large sample size, well-characterized

– Subgroup analysis (2x risk of 2nd fall)

– Control for confounders (PS adjustment, matching)

Conclusion

• Hip fracture and head contusion just as

serious as CV events.

• If chronic disease, reconsider antihypertensive

agents

• Previous fall injury likely best subgroup to

consider stopping or not starting

antihypertensives.

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Behavioral Treatment of Insomnia:

Also Effective for Nocturia

Authors: Shachi Tyagi, Neil Resnick, Subashan Perera,

Timothy Monk, Martica Hall, Daniel Buysse

Funding sources: National Institute on Aging, Hartford

Foundation, National Center for Research Resources

The problem…

• Nocturia is a common complaint of older adults,

affecting two thirds of patients over 60 years of age

• Treatments are limited and only modestly effective (e.g., fluid restriction, prostate-directed therapy)

• Nocturia is often regarded as a cause of insomnia,

but may also be a consequence of sleep problems

• There are no data on whether treatments directed a

improving sleep quality may be helpful for nocturia

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What is the question?

Among community-

dwelling adults aged

60 years and older,

does brief behavioral

treatment for chronic

insomnia also improve

comorbid nocturia?

Methods

• Design: Secondary analysis of an RCT of a short-term (4-

week) behavioral intervention for insomnia

• Setting: Urban academic medical center (University of

Pittsburgh)

• Participants: 79 adults aged >60 years meeting DSM IV

criteria for chronic insomnia

• Exclusions: Untreated psychiatric disease, substance abuse,

cancer treatment, dementia, life expectancy <6 months

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Interventions

• Brief behavioral treatment for insomnia (BBTI):

- Individual intervention session at baseline and 2 weeks, plus follow-up phone calls at 1 and 4 weeks

- Focus on: restricting time in bed, regular wake-up time, going to bed only if sleepy, getting up if not sleepy

• Information-only control (IC) intervention:

- Instructions to read and review publications on insomnia, sleep and aging, sleep hygiene

- Brief phone call to encourage adherence after 2 weeks (and option to convert to BBTI at end of study)

Assessment of nocturia

• 14-day sleep diary – each morning participants

documented their voids from the night before

• Diary did not differentiate between convenience

voids and urges resulting in an awakening

• Analyses included only those reporting an average

of at least one nocturnal voiding episode per night

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Sleep measures

• Total sleep time (by sleep diary and 14-day wrist actigraphy)

• Wakefulness after sleep onset (by 14-day wrist actigraphy)

• Sleep efficiency and fragmentation (by 14-day wrist actigraphy)

• Pittsburgh Sleep Quality Index (subjective assessment by questionnaire)

Baseline characteristics

BBTI IC P

Age in years 74 (±6) 73 (±8) .69

Female sex 57% 81% .03

Body mass index 25.7 (2.4) 25.5 (2.7) .75

Nocturia episodes/14 days 20.4 (±7.7) 20.4 (±7.4) .94

Diabetes mellitus 14% 6% .58

Cardiovascular disease 10% 10.1% .08

Hypertension 26% 24.4% .56

Genitourinary disorder 86% 31% <.01

HTN medications 36% 44% .51

Diuretic medications 7% 6% .90

Analgesic medications 100% 88% .18

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Treatment outcomesBBTI IC Adjusted

Group

Difference

P

Before After Before After

Nocturia episodes

per 14 days

20 ± 8 14 ±7 20 ± 7 22 ± 8 8 ± 4 .05

Total sleep time

(min)

378±41 332±26 384±32 365±56 -26 ± 13 .06

Wakefulness after

sleep onset (min)

60 ± 23 47 ± 22 60±27 57±16 -11 ± 5 .05

Sleep efficiency

(percent)

79 ± 9 82 ± 7 81 ± 6 80 ± 6 4 ± 2 .08

Fragmentation

index (actigraphy)

35 ± 10 30 ± 11 32 ± 10 32 ± 8 -2 ± 3 .60

Pittsburgh Sleep

Quality Index

11 ± 3 8 ± 3 10 ± 3 10 ± 3 -2 ± 1 .02

Possible explanations

• BBTI consolidates sleep and reduces awakenings,

thus reducing opportunity for nocturnal voiding

• BBTI discourages prolonged sleep duration, which

may be a risk factor for nocturia

• BBTI may restore circadian rhythmicity of plasma

renin activity and reduce nocturnal urinary volume

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Limitations

• Small sample size, possibly leading to

exaggerated treatment effect

• Treatment groups not balanced at baseline for

some important covariates

• Participants originally selected for insomnia,

not nocturia

What’s the bottom line?Specific:

• Brief behavioral therapy for insomnia may be effective in reducing nocturia in older adults

• The primary benefits of BBTI on sleep quality also apply to older adults with concomitant nocturia

Broad:

• Nocturia and insomnia are closely linked, and the direction of the relationship may not be important

• Strategies for preventing or treating these problems may benefit from targeting shared mechanisms

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Association Between POLST for

Scope of Treatment and In-Hospital

Death in OregonFromme, Erik, Zive, Dana, Tolle, Susan,

et al

JAGS 2014; 62(7):1246-51Sponsor: Samuel S Johnson Foundation

Do POLST Orders Influence Place of

Death?

• Cross sectional study of OR death records

containing cause and location of death,

matched with POLST forms from the registry

• 58,000 decedents; 17,902 (30.9%) had a

POLST

– Comfort Measures Only 11,836 (66.1%)

– Limited Interventions 4,787 (26.7%)

– Full Treatment 1,153 (6.4%)

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Results

• If Comfort Measures

Only, 6.4% died in

hospital

• If Full Treatment, 44.2%

died in hospital

• If no POLST, 34.2% died

in hospital

• NICE WORK, EVERYONE!

Effect of Medications on Physical

Function and Cognition in Nursing

Home Residents with Dementia

Dutcher, Sarah, Rattinger, Gail, et al

JAGS 2014;62:1046-55

Sponsor: NIH

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What is the question?

• Do medications used to manage Alzheimer’s Disease and Related Dementias (ADRD) impact functional status and cognition?

– Antidementia medications (AChEIs, memantine)-15%

– Antidepressants- 40%

– Antipsychotics- 13%

– Mood stabilizers- 3%

• Measures:

– ADL scores (from MDS, 0-28, higher is worse)

– Cognitive Performance Scale (0-6, higher is worse)

Methods

• 2 year longitudinal study (2007-2008)

• 18,950 nursing home residents with newly

diagnosed ADRD

– Mean age 83

– 86% white

– 75% women

– 50% dual eligible (Medicare+Medicaid)

– 33% died during 2 year study

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Clinical Bottom Line

• In this retrospective cohort study, drugs don’t appear to be as dangerous as we are led to believe

• In contrast to RCTs, PCP chose drugs/doses and probably monitored for effectiveness and adjusted/tapered as indicated

• Suggests that if we are providing high quality care to dementia patients, we can use these drugs with minimal (and known) risks; maybe even some benefit

Effect of Citalopram on Agitation in

Alzheimer Disease: The CitAD

Randomized Clinical Trial

• Porsteinsson, Anton,

Drye, Lea, et al

• JAMA 2014;311(7):682-

691

• Sponsors: NIA, NIMH

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What is the question?

• “Agitation” is common, persistent, and distressing to patients with Alzheimer disease and their families

• Most of the drugs used to treat “agitation” in Alzheimer disease have little evidence of effectiveness and high risk

• What is the effectiveness of citalopram for agitation in patients with Alzheimer disease?

• Is the benefit worth the risks?

Methods

• 186 patients with Alzheimer disease and “agitation” randomized to citalopram (starting at 10 mg daily and tapering up to 30 mg daily over 3 weeks) or placebo, followed for 9 weeks

• All subjects also got a psychosocial intervention– Trained clinician provided education, 24 hour crisis advice, and

20-30 minutes of counseling at each study visit

• Trazodone and lorazepam “allowed” as rescue medications

• Primary outcome measures:– Agitation subscale of Neurobehavioral Rating Scale (18 point

scale, higher is worse)

– Clinical Global Impression of Change (7 point scale, 1=marked improvement, 7=marked worsening from baseline)

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So, how should I change my practice?

• No screening, but excellent case finding for dementia

• Think of tai chi and cognitive training to preserve cognition

• Cognitive behavioral therapy for insomnia and nocturia

• Consider risk of falls when using antihypertensives

• Keep doing POLSTs with your patients!

• Pharmacologic management of behavioral symptoms in dementia, when used cautiously, monitored carefully, and tapered as quickly as possible, may be appropriate after all