geriatricsphilippines.org Blog

In the study “Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial” , authors Maarten MJ, Roes, Honing et al concluded that Rivastigmine did not decrease duration of delirium and might have increased mortality.

The authors do not recommend use of rivastigmine to treat delirium in critically ill patients.

Delirium is frequently diagnosed in critically ill patients and is associated with adverse outcome. Impaired cholinergic neurotransmission seems to have an important role in the development of delirium. The study’s aim was to establish the effect of the cholinesterase inhibitor rivastigmine on the duration of delirium in critically ill.

Patients (aged ≥18 years) who were diagnosed with delirium were enrolled from six intensive care units in the Netherlands, and treated between November, 2008, and January, 2010. Patients were randomised (1:1 ratio) to receive an increasing dose of rivastigmine or placebo, starting at 0•75 mL (1•5 mg rivastigmine) twice daily and increasing in increments to 3 mL (6 mg rivastigmine) twice daily from day 10 onwards, as an adjunct to usual care based on haloperidol. The trial pharmacist generated the randomisation sequence by computer, and consecutively numbered bottles of the study drug according to this sequence to conceal allocation.

The primary outcome was the duration of delirium during hospital admission. Analysis was by intention to treat. Duration of delirium was censored for patients who died or were discharged from hospital while delirious. Patients, medical staff, and investigators were masked to treatment allocation. Members of the data safety and monitoring board (DSMB) were unmasked and did interim analyses every 3 months.

Findings
Although a sample size of 440 patients was planned, after inclusion of 104 patients with delirium who were eligible for the intention-to-treat analysis (n=54 on rivastigmine, n=50 on placebo), the DSMB recommended that the trial be halted because mortality in the rivastigmine group (n=12, 22%) was higher than in the placebo group (n=4, 8%; p=0•07). Median duration of delirium was longer in the rivastigmine group (5•0 days, IQR 2•7—14•2) than in the placebo group (3•0 days, IQR 1•0—9•3; p=0•06).

Interpretation
Rivastigmine did not decrease duration of delirium and might have increased mortality so we do not recommend use of rivastigmine to treat delirium in critically ill patients.

This trial is registered with ClinicalTrials.gov, number NCT00704301.

Funding
ZonMw, the Netherlands Brain Foundation, and Novartis.

Source
The Lancet, Volume 376, Issue 9755, Pages 1829 - 1837, 27 November 2010

In an effort to clarify the relationship between PPIs and C. difficile, Janarthanan and colleagues performed a meta-analysis of relevant studies published during the past 20 years. Only peer-reviewed published articles were considered. Studies published in abstract form only were excluded.
The literature review yielded 21 studies for analysis — seven cohort studies and 14 case-control studies. They involved a total of 133,054 patients hospitalized on general medicine services.
A random-effects analysis showed a 55% increased risk of C. difficile diarrhea among PPI users in the case-control studies (P<0.001) and a twofold increased risk in the cohort studies (P=0.0001). Combining all 21 studies yielded an 80% increase in the relative risk of C. difficile among PPI users (P=0.001).
Acknowledging limitations of the study, Janarthanan noted that she and her colleagues had no access to primary data from any of the studies, precluding adjustment for factors that could have led to alternative explanations for the observed results. Additionally, the data did not permit a detailed analysis of the impact of PPI-related variables, such as duration, type, and dose of the drug used.
Despite the limitations, results of the analysis point to two issues of PPI use that warrant consideration.
“Indiscriminate use of PPIs without a proper indication should be discouraged,” Janarthanan said. “There is a real need for guidelines on the use of PPIs, especially in hospitals.”
During the discussion that followed the presentation, Philip Katz, MD, disputed the notion that PPIs cause C. difficile diarrhea. “PPIs do not increase the risk of C. diff; they are associated with an increased risk of C. diff,” said Katz, of Albert Einstein Medical Center in Philadelphia. “There is no proof of causality. Until people stop doing these studies and prove causality, your final statement may actually hurt patients.
“Of course, we shouldn’t use drugs indiscriminately but things they are needed for. Somebody’s got to do this in a better way and stop just saying ‘They’re bad.’”
Janarthanan declared that she had no relevant disclosures.

By Charles Bankhead, Staff Writer, MedPage Today
Published: October 21, 2010
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Primary source: American College of Gastroenterology
Source reference:
Janarthanan S, et al “A meta-analysis of 16 observational studies on proton pump inhibitor use and risk of Clostridium difficile associated diarrhea” ACG 2010; Abstract 378.

A well written article on caring at the end of life when cure is not the goal.

Letting Go
What should medicine do when it can’t save your life?

Atul Gawande The New Yorker July 2010

Excerpt:

“It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity,” he wrote in his 1985 essay. “Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die—and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy—and I find nothing reproachable in those who rage mightily against the dying of the light.”

I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable.

The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

Atul Gawande is the author of Better and Complications. He is also a MacArthur Fellow, a general surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health.

Dr. Ernesto O. Domingo, university professor emeritus of the UP College of Medicine, is the newest National Scientist of the country.
[caption id=”attachment_296″ align=”aligncenter” width=”135″ caption=”Ernesto Domingo Physician and National Scientist”][/caption]
He was nominated by the National Academy of Science and Technology (NAST), one of the two advisory bodies of government in matters of Science and Technology. Dr. Domingo has been Academician of the NAST since 1992 in the field of health sciences, particularly in his field of specialization, internal medicine and gastroenterology.

Dr. Domingo’s vital work on liver cancer remains the major source in the country of information on the disease’s etiology, manifestation and treatment. His research focuses on three areas: schistosomiasis, viral hepatitis and liver cancer. The Clinical Epidemiology Unit (CEU) of the UP College of Medicine was another significant program established by Dr. Domingo.

Dr. Domingo actively participated in the steering committee of the NAST Scientific Meeting on Active Aging and was named member of the National Advisory Council on Active Aging in July 2009.

Philippine Society of Geriatric Medicine PSGM enjoyed a night of 80’s culture and fun at The Hyatt Hotel and Casino, Manila.[caption id=”attachment_133″ align=”aligncenter” width=”300″ caption=”PSGM Fellows Winning MJ Dance”][/caption]

Mr Michael Tan, writes about Geriatrics and care of older Filipinos in a recent article in the PDI.

Click for here the complete article Philippine Daily Inquirer PDI (10.28.09).

Excerpts below:

Geriatrics is also about developing more autonomy or independence for the elderly. That includes encouraging the elderly to set their own goals for health. This is where problems often arise. Non-geriatricians tend to keep patients passive: take this medicine, don’t take that food, stay in bed. Unfortunately for the elderly people, that passive role often leads to a further deterioration of their health. This is worsened by Filipino cultural norms that also emphasize passivity and dependence for the elderly.

Less is more

Geriatricians want their patients to be active whenever possible. When it comes to medicines, less is more for geriatricians because of more risks of side effects, and of drugs interacting with each other. Again, this sometimes runs counter to local culture: our elderly sometimes boast that they are taking 10 pills a day.

We will need more geriatricians who have both the biomedical skills and cultural competence or sensitivity to care for our elderly. Moreover, geriatricians could play another important role of training caregivers, friends and relatives, somewhat like para-geriatricians. I know The Medical City offers such training workshops from time to time.

The National Conference on Aging “Promoting Wellness, Improving Quality of Life of Oder Persons” was held at the Balyuan Convention Center, Tacloban on October 28-29, 2009, completing the 5-day geriatric education outreach of the UP Manila-NIH Committee on Aging (COMADD). The event was hosted by the School for Health Sciences Palo and attracted participants from Region 8, Quezon province, Manila, and Southern Luzon.

Basic topics on Gerontology and Geriatrics were discussed, with the following objectives:
1. Discuss the myths and theories on aging
2. Discuss the value of health promotion and disease prevention such as
• Immunization
• Nutrition
• Exercise
• Risk management/lifestyle modifications
3. Explain the common medical problems/conditions in aging
a. Depression
b. Dementia/Delirium
c. Communication Disorders
d. Falls and Immobility
e. Pain
f. Polypharmacy and Rational Drug Use
g. Urinary and Bowel Incontinence
4. Recognize the emotional, spiritual and psychosocial needs of the elderly
5. State policies/laws on the rights of elderly

The COMADD shared their knowledge and led the captivated audience in plenary lectures and wet clinic demonstrations. The Overall Chairperson of the 5-day educational outreach was Dr. S de la Vega (UPM-NIH, Chair COMADD) with Co-Chairs Dean J Siega-Sur (UP SHS) and former NTTC Dean JAP Mojica. Other members of the faculty were Prof. L Manahan (UPCN), Prof. A Balagabno (UPCN), Dr. D Camagay (UP-PGH), Dr. D. Dychingbing-Agsaoay (UP-PGH), Prof. EJ Gorgon (UP CAMP), Prof. JD Agapito (UPCAS), Ms. E Limos (UP-PGH Nutrition), Prof. G Manalang (UPCPH) and Dr. M Bodo-Bernabe (PSGM), and Dr. I Alejandro Jr (PSGM VP).
Dr. de La Cruz, past President of the Federation of Senior Citizens Associations of the Philippines shared his wise thoughts about aging and advocated for better policies on geriatric education and healthcare for older persons. Dr. L Opina- Tan faculty from the UP Community Health Development Program in San Juan Batangas, gave a return-demo lecture of what she learned during the 3 day Training of Trainors workshop in Palo.

EXECUTIVE COMMITTEE MEMBERS:

Over all Chairman: Dr. Shelley de la Vega
Co- Chairs: Dr. Jose Alvin Mojica
Dean Jusie Lydia Siega-Sur
Prof. Amabel Ganzo

Ways and Means Committee:
SHS : Prof. Amabel Ganzo
Dean Jusie Lydia Siega-Sur
Prof. Zenaida Varona
ComADD: Dr. Shelley de la Vega

Program and Commercial Exhibit Committee:
Chairman: Dr. Romeo Ceniza
Members: Dr. Norlita Arcamo
Dr. Aileen Espina
SHS Medical Students

Physical Arrangement:
Chairman: Prof. Teresita Sardan
Members: Ms. Loreta Soledad
Dr. Filedito Tandinco
Prof. Helen Gumba
Prof. Carmelita Espinosa

Registration and Awards Committee:
Chairman: Prof. Evangeline Culas-Pasagui
Members: Prof. Rolando Borinaga
Prof. Carmen Firmo
Dr. Filedito Tandinco

Social Program:
Chairman: Prof. Amabel Ganzo
Members: Ms. Esther Hope Acosta
Prof. Carmelita Espinosa
Dr. Carmen Firmo

Invitation and Publicity:
Chairman: Prof. Amabel Ganzo
Members: Prof. Sylvia Sustento
Prof. Zenaida Varona

The project was made possible by educational grants from President GMA and the Bristol Myers Squibb Foundation.

The Baseline Survey for the National Objectives of Health (BSNOH) research done by the UP Manila NIH and DOH revealed that of the 2,690 older persons surveyed, only 0.3 percent ever had a Geriatric Health Screen. The number of elderly who had screening for geriatric syndromes such as urinary incontinence, memory and affective illnesses was less than 5 percent. The BSNOH Survey also revealed that fewer that 10 percent had their height and weight determined, and only 15 percent had a hearing evaluation. Sixty one percent indicated that lack of money was the major reason for delaying medical consultation, and ninety two percent were without any form of pension.

Philhealth (PHIC) is trying to address this gap by creating responsive benefits that will address the rising prevalence of chronic diseases. These include a hypertension package, out-patient drug benefits, home peritoneal dialysis. PHIC plans to invest in long-term care bundle payments for post hospital care, integration of acute care and some coverage into one delivery system. In the open forum that followed, issues raised included the difficulty in Philhealth reimbursement of all members of the multi-disciplinary healthcare team, and the lack of coverage for nursing home and home care.

Brief History of the Committee on Aging and Degenerative Diseases

The University of the Philippines Manila is the country’s leading institution for health research and development. The creation of the National Institutes of Health was approved by the Board of Regents at its 1094th meeting on 26 January 1996, and with it, the Gerontology and Disabilities Programs Cluster, through the Committee on Aging and Degenerative Diseases. The committee is composed of various physicians, academicians, and allied medical professionals within the UP-PGH system.

The COMADD is currently comprised of volunteer consultants from various Clinical and Basic Sciences Departments of the UP-PGH system:
1. Philippine General Hospital - Clinical Departments are involved through their representatives, including: Internal Medicine, Family Medicine, Surgery, Orthopedics, Rehabilitation, Neurology, Psychiatry and Nutrition.
2. UP College of Nursing – membership representation
3. UP Manila College of Arts and Sciences - membership representation thru the Department of Behavioral Sciences (Anthropology)
4. College of Allied Medical Professionals
5. College of Pharmacy
6. College of Dentistry

Mission-Vision: Institute for Aging and Degenerative Diseases
Vision
The Filipino elderly enjoying a healthy body, mind and spirit, being treated with dignity, and valued as a productive member of society, in a dynamic process unique to himself, and beginning a life of unlimited possibilities.
Mission
The institute shall create with the aging Filipino, unlimited possibilities for their value added life through scientific research, training and education, and specialized services.

Clinical Programs
The Committee on Aging and Degenerative Diseases through it multidisciplinary membership is involved in the development and management of various clinical programs within the UP-PGH system, including:
Outpatient geriatric evaluation and wellness clinic
Inpatient geriatric medical consultation
Memory clinic
Stroke unit
Rehabilitation unit (physical, occupational and speech therapy)
Menopause clinic
Specialized services such as Spine/Osteoporosis care; Rheumatology clinic

Policy Development
The Committee and its members have been directly involved as technical advisers in the development of
The Philippine Plan of Action for Older Persons, DSWD
The Health Program for Older Persons, DOH
Baseline Surveys for the National Objectives of Health, DOH, NIH
Periodic Health Examination Guideline, PHILCLEN, DOH
Alzheimer’s Disease Association of the Philippines Recommendations on Diagnosis, Prevention and Management
Education

The Committee has undertaken 9 successful Post-graduate courses in Geriatric Medicine for physicians, nurses, and allied medical professions since 1997

Research

The Committee and its members are involved in funding and development of essential national health researches including those that resulted in the Policy and Recommendation documents above.

Welcome and share your thoughts and comments on how we can improve the health and quality of life of Older Filipinos.