geriatricsphilippines.org Blog

Developed by:
American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents American Academy of Neurology American Geriatrics Society American Society for Preventive Cardiology American Society of Hypertension, American Society of Nephrology Association of Black Cardiologists European Society of Hypertension

Clinical Evaluation

Note: The reader should view the expert consensus document as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice.

Aside from a good and targeted history and physical examination, guidelines on laboratory testing were presented. The diagnosis is established with at least 3 blood pressure readings in at least 2 clinic visits.

Ambulatory BP monitoring (ABPM) is indicated when hypertension diagnosis or response to therapy is unclear from office visits, when syncope or hypotensive disorders are suspected, and for evaluation of vertigo and dizziness. The case for using out-of-office BP readings in the elderly, particularly home BP measurements, is strong due to potential hazards of excessive BP reduction in older people and better prognostic accuracy versus office BP.

The most important role for testing in an elderly patient
with hypertension is to assess for organ damage and modifiable
CVD risk factors, including tobacco smoking, hypercholesterolemia,
diabetes mellitus, and excessive alcohol intake.

Information on the following laboratory tests should be available:
1. Urinalysis to look for any evidence of renal damage,
especially albuminuria/microalbuminuria
2. Blood chemistry to assess electrolytes and renal function, especially potassium and creatinine with eGFR
3. Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides, preferably fasting levels
4. Fasting blood sugar and, if there are concerns about diabetes mellitus, hemoglobin A1c
5. ECG

Lifestyle Modification

Weight reduction, salt reduction, DASH diet, regular physical activity and moderation in alcohol consumption are recommended.

The general recommended BP goal in uncomplicated hypertension is 140/90 mm Hg. However, this target for elderly hypertensive patients is based on expert opinion rather than on data from randomized controlled trials (RCTs). It is unclear whether target SBP should be the same in patients 65 to 79 years of age as in patients 80 years of age.

Drug Treatment and other details may be viewed thru this link to the Journal of the American College of Cardiology Expert Consensus Document on Hypertension in the Elderly 2011

The Alzheimer’s Association USA released the following Alzheimer’s Disease Facts and Figures 2011.
Go to the link to access the following information:

• Overall number of Americans with Alzheimer’s disease nationally and for each state
• Proportion of women and men with Alzheimer’s and other dementias
• Estimates of lifetime risk for developing Alzheimer’s disease
• Number of family caregivers, hours of care provided, economic value of unpaid care nationally and for each state, and the impact of caregiving on caregivers
• Use and costs of health care, long-term care and hospice care for people with Alzheimer’s disease and other dementias
• Number of deaths due to Alzheimer’s disease nationally and for each state, and death rates by age

Alzheimer’s is the sixth-leading cause of death in United States and the only cause of death among the top 10 in the United States that cannot be prevented, cured or even slowed. Based on mortality data from 2000-2008, death rates have declined for most major diseases while deaths from Alzheimer’s disease have risen 66 percent during the same period.

The conclusions in this report reflect currently available data on Alzheimer’s disease. They are the interpretations of the Alzheimer’s Association.

Details are available in the website Alzheimer’s Association

The DSM-5 Task Force and Work Group members (American Psychiatric Association) are working to develop criteria for diagnoses that not only reflect new advances in the science and conceptualization of mental disorders, but also reflect the needs of our patients.

The Neurocognitive Disorders Work Group has been responsible for addressing these disorders. Among the Work Group’s proposals is the recommendation that the category be divided into three broad syndromes: Delirium, Major Neurocognitive Disorder, and Mild Neurocognitive Disorder. The Neurocognitive Disorders Work Group has posted the draft criteria for the Alzheimer Disease Subtype as an illustration of how they propose to organize other subtypes. They are inviting comment on the general approach. Work on other subtypes is currently in progress, and the Work Group is in consultation with various expert groups that work in those areas (e.g. vascular cognitive impairment and dementia, frontotemporal lobar degeneration, dementia with Lewy bodies, Huntington’s disease, Parkinson’s disease, traumatic brain injury, etc.).

While they welcome comments and suggestions on any and all aspects of the proposal, they are particularly interested in obtaining input regarding the following issues:

1) Removing the term “Dementia” and adding “Major Neurocognitive Disorders”,

2) Adding a category of “Mild Neurocognitive Disorders”,

3) Categorizing behavioral disturbances, particularly the syndromes of psychosis and depression, associated with Neurocognitive Disorders, and

4) Selecting specific domains as well as measures of severity of cognitive functional impairment

Please Click this link to DSM 5 Delirium, Dementia, Amnestic, and Other Cognitive Disorders

The U.S. Food and Drug Administration (FDA) is informing the public that prescription proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued.

PPIs work by reducing the amount of acid in the stomach and are used to treat conditions such as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus.

Prescription PPIs include Nexium (esomeprazole magnesium), Dexilant (dexlansoprazole), Prilosec (omeprazole), Zegerid (omeprazole and sodium bicarbonate), Prevacid (lansoprazole), Protonix (pantoprazole sodium), and AcipHex (rabeprazole sodium). Vimovo is a prescription combination drug product that contains a PPI (esomeprazole magnesium and naproxen). Over-the-counter (OTC) PPIs include Prilosec OTC (omeprazole), Zegerid OTC (omeprazole and sodium bicarbonate), and Prevacid 24HR (lansoprazole).

For Medical Professionals:
# Consider obtaining serum magnesium levels prior to initiation of prescription PPI treatment and checking levels periodically thereafter for patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics).
# Hypomagnesemia occurs with both loop diuretics (furosemide, bumetanide, torsemide, and ethacrynic acid) and thiazide diuretics (chlorothiazide, hydrochlorothiazide, indapamide, and metolazone). These agents can cause hypomagnesemia when used as a single agent or when combined with other anti-hypertensives (e.g., beta-blockers, angiotensin receptor blockers and/or ACE inhibitors).
# Advise patients to seek immediate care from a healthcare professional if they experience arrhythmias, tetany, tremors, or seizures while taking PPIs. These may be signs of hypomagnesemia.
# Consider PPIs as a possible cause of hypomagnesemia, particularly in patients who are clinically symptomatic.
# Patients who develop hypomagnesemia may require PPI discontinuation in addition to magnesium replacement.
# Be aware that consumers either on their own, or based on a healthcare professional’s recommendation, may take OTC PPIs for periods of time that exceed the directions on the OTC label. This is considered an off-label (unapproved) use. Healthcare professionals should communicate the risk of hypomagnesemia to patients if they are recommending prolonged use of an OTC PPIs.

Learn more by clicking this link to USFDA

The 32-year relationship between cholesterol and dementia from midlife to late life. Neurology. November 23, 2010 75:1862-1863
Authors: Mielke, Zandi, Shao, et al

Methods:
The Prospective Population Study of Women, consisting of 1,462 women without dementia aged 38–60 years, was initiated in 1968–1969 in Gothenburg, Sweden. Follow-ups were conducted in 1974–1975, 1980–1981, 1992–1993, and 2000–2001. All-cause dementia was diagnosed according to DSM-III-R criteria and AD according to National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association criteria. Cox proportional hazards regression examined baseline, time-dependent, and change in cholesterol levels in relation to incident dementia and AD among all participants. Analyses were repeated among participants who survived to the age of 70 years or older and participated in the 2000–2001 examination.

Results:
Higher cholesterol level in 1968 was not associated with an increased risk of AD (highest vs lowest quartile: hazard ratio [HR] 2.82, 95% confidence interval [CI] 0.94–8.43) among those who survived to and participated in the 2000–2001 examination. While there was no association between cholesterol level and dementia when considering all participants over 32 years, a time-dependent decrease in cholesterol over the follow-up was associated with an increased risk of dementia (HR 2.35, 95% CI 1.22–4.58).

Conclusion:
These data suggest that midlife cholesterol level is not associated with an increased risk of AD. However, there may be a slight risk among those surviving to an age at risk for dementia. Declining cholesterol levels from midlife to late life may better predict AD risk than levels obtained at one timepoint prior to dementia onset. Analytic strategies examining this and other risk factors across the lifespan may affect interpretation of results.

They pointed to animal and cell culture studies suggesting a causal link with high cholesterol leading to amyloid-beta deposition characteristic of Alzheimer’s disease. However, cholesterol declines in older age, “perhaps as a function of underlying subclinical pathology, sarcopenia, or change in appetite,” Haan explained. The study was also limited by loss of participants due to death or refusal, possible undiagnosed dementia, lack of genotyping for high-risk alleles, and unknown generalizability to men and populations outside of Sweden, the researchers noted.

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

The Philippine Society of Geriatric Medicine will host the
4th Asia-Pacific Geriatric Network Conference, with the theme

“Sharing Best Practices in Geriatric Care in the Asia-Pacific Region”

Cebu CITY
January 19-21 2011

Click here to view the SCIENTIFIC PROGRAM and COMMITTEES

[caption id=”attachment_558″ align=”aligncenter” width=”231″ caption=”Convention Registration Fees 2011″][/caption]

Convention Hotel: Marco Polo Cebu City

Registration and Housing Dates and Deadlines:

1. Registration and housing opens July 15, 2010
2. Early bird registration closes September 30, 2010
3. Last date to cancel registration and receive a refund minus an administrative fee of $75 or (peso equivalent) November 22, 2010.
4. Housing deadline to make a new reservation or change : November 30, 2010
5. On-site registration opens on January 18, 1:00 pm, Philippine time at the venue.

NOTE: Registration fee does not include housing or hotel accomodations!

For details, click this link to the Registration Page

The addition of folic acid to the list of vitamins and supplements for the prevention of memory decline is addressed in this meta-analysis. Wald et al conducted a meta-analysis of 9 randomized controlled trials on folic acid, with or without vitamin B and its effect on memory, speed of information processing, language and executive function (decision making). The median duration per study is 6 months and the median age of participants is 75 years.

The results showed no effect of folic acid in the prevention of cognitive decline (memory, speed of information processing, language and decision making) among individuals without preexisting dementia.

The pooled standardized mean difference
in cognitive function test scores was 0.01 (95% CI,
-0.08 to 0.10) after a median treatment of 6 months; an
increase of 1% of a standard deviation of a cognitive
function test score, with confidence intervals excluding
an improvement or a deterioration greater than 10% of 1
standard deviation.

Studies of longer duration are needed in order to address the role of folic acid in the prevention of cognitive decline.

Source: The American Journal of Medicine (2010) 123, 522-527

Tips from the Alzheimer’s Disease International website:

Violence and aggression

“Violence and aggression are caused by the illness.”

From time to time, the person may become angry, aggressive or violent. It is not a personal attack on you, but a part of their illness. There are many reasons why a person with dementia may feel angry. They may not like being helped with things they used to do on their own, or may simply be frustrated due to an inability to do things.

These short-term changes happen for a variety of reasons such as the person’s sense of loss of social control and judgment, loss of the ability to express negative feelings safely, and loss of the ability to understand the actions and abilities of others. It is therefore worth finding and avoiding the causes of unwanted certain reactions.

If the person feels angry, aggressive or violent, keep calm and try not to show fear or alarm. Give them more space and try to draw their attention to a calming activity.

This is one of the most difficult things to cope with for a caregiver, and if violence occurs often, you will need to seek help. Talk to someone for support, and speak with your doctor about help with managing the person.

Modified from Alzheimer’s International UK:

Alcohol and cigarettes

“Supervise drinking and smoking to make sure accidents don’t happen.”

There is no problem for a person with dementia drinking alcohol in moderation if their medication allows. However the person may forget they have just had a drink and so have another one. This cycle can lead to repetition with the person becoming drunk or unmanageable.

1. Do not buy or store alcohol at home.
- reduce the number of bottles of alcohol available in the drinks cabinet
- empty or dilute some of them.
2. Distract the person with another activity, so that they do not think about drinking.
3. Provide water, juice, light soda, and other healthy cool drinks.

Cigarettes introduce a greater danger because of the risk of fire and damage to health.
1. Do not buy or store cigarettes at home.
2. Always supervise the person when smoking
- but remember the dangers of second-hand and third hand smoke!!!
3. Discourage smoking altogether and enroll in a smoking cessation program
4. Make sure that the clothes they wear and the furniture in the house are fire-resistant.
5. Install a smoke alarm, which can alert you to any danger.