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September, 2017 EDITION

EVIDENCE ISCONFIDENCE

Practicing “Safe” Medicine; Can’t Dodge this Issue Anymore

Agitation and Behaviors in Dementia: Calm Down, There are Options!

a Signature HealthCARE publication

A recent piece1 in JAMA eloquently emphasizes what Geriatrics has taught me for years; less is more! The author uses the soccer penalty-kick analogy to make a key point. He shares that analyses have confirmed that to stop a penalty kick, the goalkeepers have a better chance to succeed if they hold their ground in the center versus making a spectacular dive to either left or right! But in reality, majority end up choosing to dive. Clinicians in their day to day practice in medicine face many decision points where just curious observation and monitoring (staying in the center) would suffice but they too, quite often make an aggressive dive.

Again, using the goalkeeper analogy, this behavior may be explained. Imagine if you are the goalkeeper who decides to hold their ground in the center but the soccer ball ends in the net on the right, how silly you would feel. The stakes are even higher in healthcare because taking on the blame for a severe harm or death of a patient can result in serious professional, legal and psychological repercussions for the clinician. Thus, many of us aim to take the apparent safer route. But is this always the most evidence-based and efficient approach? I am afraid not. The piece provides great advice on how healthcare systems can prevent wastage of precious resources by promoting a culture of evidence-based restraint.

I recommend this excellent piece because it provokes reflection among clinicians regarding the practice of medicine. During my 14 years of practice in this setting, I am first to admit to several spectacular dives to the right or left. I know that I can do better and the system, in general can do better. We all need to assure that we are aware of new evidence based practices and are also assuring that our teams are promoting a culture of evidence-based restraint. We just can’t afford overuse of labs and interventions that lead to poor patient care.1Sinha P. Don’t Just Do Something, Stand There! JAMA Intern Med. Published online August 21, 2017. Available at: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2649266

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Agitation is a common symptom among nursing home patients with dementia. Not only it leads to poor quality of life, but also results in caregiver burden and costly interventions. Most importantly, patients with agitation are at a risk of polypharmacy and adverse effects.

A recent, well done randomized trial2 in Italy compared the effectiveness of citalopram to quetiapine and olanzapine for agitation management in dementia patients in nursing homes. Researchers randomized 75 patients to receive either of the three medicines and followed them for 24 weeks. Several characteristics including cognition, function and chronic comorbidities were assessed at baseline and periodically. They also monitored residents for medication-related side effects including falls, infections, hospitalizations and QTc interval prolongation. So what did the results reveal?

It was clear that Citalopram was effective in reducing agitation starting week 8 and improving further by week 24. Though this improvement was similar between the three groups, patients treated with atypical antipsychotics (olanzapine and quetiapine) had significantly higher number of side effects including falls and hospitalizations. This study does have limitations that need to be kept in mind i.e. small study size, absence of a placebo arm and study done in a foreign country which limits its generalizability to patients in US.

I am excited about these results. This trial provides me the rationale to try a relatively safer option for a problem (agitation) that can trump clinical teams. In majority of the cases, non-pharmacologic maneuvers work but for several others, who are at a of personal harm or harm to others, I am encouraged to try citalopram first.

2Efficacy and Safety of Citalopram Compared to Atypical Antipsychotics on Agitation in Nursing Home Residents With Alzheimer Dementia. Viscogliosi, Giovanni et al. Journal of the American Medical Directors Association, Volume 18, Issue 9, 799 – 802

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EVIDENCE IS CONFIDENCE

Dr. Arif Nazir Chief Medical Officer

Verdict on the effectiveness of Docusate (Colace)? In Summary, it’s Crap!

a Signature HealthCARE publication

PPIs and Pneumonia in Dementia Patients; What a Heart Burn!

Constipation is very common in geriatric patients and particularly common in frail elderly patients in nursing facilities. Not only it impacts life-quality but also leads to life-threatening complications. As a result many classes of medications are available to address this serious issue.

Whereas, literature has confirmed the benefits of various classes (stimulants, osmotics etc.), many credible studies have confirmed the ineffectiveness of docusate in this context;3 basically no better than a placebo. It is time that we, the prescribers remove it from our list of viable management options. A nice article in Family Practice News shares the data on the ineffectiveness of docusate (http://www.mdedge.com/familypracticenews/article/104548/gastroenterology/myth-month-does-colace-work).

A recent publication4 reminds us to focus on unnecessary utilization of docusate during hospitalizations and other transitions and recommends aggressive de-prescribing. It is important that like any other chronic issue, a detailed evaluation and assessment be done before we attempt to address constipation in long-term care patients. Docusate may not have serious side effects but it still causes polypharmacy, costly care and occasional discomfort. It also results in wasted resources due to prescribing and administration costs. Most importantly, like any other ineffective option, its use may delay effective care delivery to patients in need.3Missed Opportunity to De-prescribe: Docusate for Constipation in Medical Inpatients. MacMillan, Thomas E. et al. The American Journal of Medicine , Volume 129 , Issue 9, 1001.e1 - 1001.e74Koronkowski, M. J., Semla, T. P., Schmader, K. E. and Hanlon, J. T. (2017), Recent Literature Update on Medication Risk in Older Adults, 2015–2016. Journal American Geriatric Society, 65: 1401–1405. doi:10.1111/jgs.14887

Pneumonia is a common and highly dreaded complication among patients with advanced dementia that results in morbidity, hospitalization and mortality. It is critical that we minimize any risk factors for pneumonia among dementia patients. Use of proton pump inhibitors (PPIs) has been suggested as one of the risk factors. It is postulated that PPIs may impair the mucociliary clearance systems in the stomach resulting in proliferation of microbes that are then apirated. A recent retrospective study in Taiwan examined pneumonia outcomes among 1500 dementia patients5. They used propensity matching to compare those on PPIs to those without PPI usage.

Researchers found that the risk of pneumonia in dementia patients was 1.89 times higher if they were PPI users (confidence interval= 1.5-2.3). Other risk factors for pneumonia included age, use of antipsychotic medications and chronic pulmonary disease.

This important study adds oil to the fiery debate around many hazards of PPI use. Pneumonia risk can now be added to other potential risks including cognitive impairment, fractures, and impaired immunity. Older patients with dementia benefit from PPIs but it is important that we continue to monitor the ongoing need of these medications and aim for proactive de-prescribing.5Ho, S.-W., Teng, Y.-H., Yang, S.-F., Yeh, H.-W., Wang, Y.-H., Chou, M.-C. and Yeh, C.-B. (2017), Association of Proton Pump Inhibitors Usage with Risk of Pneumonia in Dementia Patients. J Am Geriatr Soc, 65: 1441–1447. doi:10.1111/jgs.14813