Geriatrics and Palliative Care Disclosures Literature Updates · 2017. 6. 13. · 5/22/17 1...

5/22/17

1

Geriatrics and Palliative Care Literature Updates

KennethCovinsky,MD@geri_docEricWidera,MD@ewidera

UniversityofCaliforniaSanFranciscoSanFranciscoVAMedicalCenter

Disclosures

• EricWidera• AssociateEditor,SocialMediaEditor,fortheJournaloftheAmericanGeriatricsSociety(JAGS)

• KenCovinsky• EditorialBoardfortheJournaloftheAmericanGeriatricsSociety(JAGS);AssociateEditor,JAMAInternalMedicine

Methods

• Searchofleadingjournals• January2016-December2016• JAGS,NEJM,JAMA,JAMA-IM,Annals,HealthAffairs,Lancet,BMJ,AcademicMedicine,JGIM,JGeron-MedSci,JPM,JPSM

• Searchofsocialmedia:• Twitter(i.e.@AGSJournal),Blogs,PC-FACS,podcasts,HealthInAgingResearchSummaries(healthinaging.org)

• SelectionCriteria• ImpactandInterest

JAMAInternMed.2017;177(1):34-42.

5/22/17

2

Background

• Deliriumcommon• Especiallyneartheendoflife

• Deliriumassociatedwithpooroutcomes• Significantanddistressingsymptomatology

• Therearecurrentlynodrugsapprovedforthetreatmentofdelirium• Antipsychoticsusedin9%ofnon-psychiatricadmissions,mostfordelirium(1)

(1)HerzigSJ,etal.JAGS2016

StudyDesign:• RCTofrisperidone,haloperidol,orplacebo• 247adultspatientsinwithadvanceddisease• 11inpatienthospicesorhospitalpalliativecareunitsinAustralia• Inclusionsincluded:

• DSMIVdiagnosisofdelirium• MemorialDeliriumAssessmentScale(MDAS)scoreof≥7(deliriumseverity)

• Thepresenceofatleastoneof3targetsymptomsofdeliriumonNursingDeliriumScreeningScale(NuDESC)• inappropriatecommunication• inappropriatebehavior• illusions/hallucinations

• AbilitytotakeoralsolutionofmedicationsJAMAInternMed.2017;177(1):34-42.

ExclusionsIncluded

• Deliriumsecondarytosubstancewithdrawal• Regularuseofantipsychoticdrugswithin48hours• Previousadverseeventwithantipsychoticdrugs• Clinicianpredictedsurvivalof≤7days

≤ 65YearsofAge

> 65YearsofAge

RisperidonevsHaloperidolvsPlacebo

1mgthen0.5maintenanceq12h

0.5mgthen0.25maintenanceq12h

NuDESCScoreq8h

Dosereductionif:• Adverseeffects

• Resolution(MDASscore<7orNuDesc<1for48hrs)

Doseincreaseif:• ≥1onNuDESC:increase0.25then0.5

If>2&safetyissueordistress:midazolam2.5mgSQq2hprn(or5mgifcrisisornoresponse)

5/22/17

3

≤ 65YearsofAge

> 65YearsofAge

RisperidonevsHaloperidolvsPlacebo

1mgthen0.5maintenanceq12h

0.5mgthen0.25maintenanceq12h

NuDESCScoreq8h

Dosereductionif:• Adverseeffects

• Resolution(MDASscore<7orNuDesc<1for48hrs)

Doseincreaseif:• ≥1onNuDESC:increase0.25then0.5

If>2&safetyissueordistress:midazolam2.5mgSQq2hprn(or5mgifcrisisornoresponse)

PrimaryOutcome

• Changesinsymptomsofdeliriumassociatedwithdistressfrombaselinetoday3• inappropriatebehavior• inappropriatecommunication• illusions/hallucinations

Scale0-6

Scale0-6

5/22/17

4

Scale0-6

DeliriumSeverity(M

DAS)

SecondaryOutcomes

•Antipsychoticshad:• Greaterextrapyramidaleffects• Greateruseofrescuemidazolam•Worseoverallsurvival• Forrisperidonethisdidn’treachsignificance• Mediansurvival:• placebogroup=26days• risperidone=17days• haloperidol=16days

Limitations

• InclusionCriteria:MDAS>7• DeliriumSymptomScorewasnotapreviouslyvalidatedtool• Benzodiazepineasarescuemedication• Didtheyjustusethewrongantipsychoticsornotenough?• Canyougeneralizetootherdeliriouspatients?

5/22/17

5

ShowMetheEvidence

• JAGS2016systematicreviewandmeta-analysis:• Notassociatedwithchangein:• Deliriumincidence• Duration• Severity• HospitalorICULengthofStay

NeufeldKJ,etal.JAGS.2016

ConcludingTweet

Antipsychotic drugs don’t improve symptoms of delirium associated with distress in patients receiving #palliative care.

Non-pharmacologic approaches are not only the first line therapy, but one of the only evidence based therapies for delirium. #geriatrics

May 20

May 20

BMJ 2016;352:h6781

5/22/17

6

ResearchQuestion

• Doesanurseledtargetedmulticomponenttargetedfallpreventionprogramreducefallsinthehospital?

Whatisthesix-pack?(Hint:NotBeer)• Fallriskassessmenttool•Targetedapplicationofsixinterventions• FallAlertSignonPatientDoor• SupervisionofPatientinthebathroom• Placingwalkingaideswithinreach• Establishmentofatoiletingregimen• Useofalowbed• Useofabedalarm

StudyDesign

•Clusterrandomizeddesign•24hospitalwardsrandomizedto6-packorcontrol•MedicalandSurgicalwards•46000patients(meanage67,25%overage80,50%women,77%emergencyadmits)

Results:6-Packpacksnopunch

Usual Care Six-Pack RiskRatio

Falls/1000beddays

7.03 7.46 1.04(0.78-1.37)

Fallinjury/1000beddays

2.53 2.33 0.96(0.72-1.21)

5/22/17

7

Whatisthesix-pack?(Hint:NotBeer)• Fallriskassessmenttool•Targetedapplicationofsixinterventions• FallAlertSignonPatientDoor• SupervisionofPatientinthebathroom• Placingwalkingaideswithinreach• Establishmentofatoiletingregimen• Useofalowbed• Useofabedalarm

ConcludingTweet

TheSix-PackInterventionProgramdidpreventfallsorfallinjuriesinthehospital.#geriatrics

Ann Intern Med. 2012;157:692-699 JAMAInternMed.2016l176(7):921-7

5/22/17

8

HospitalsareBadforOlderPersons• Familyobservation:• Grandmawenttohospital.Docssaidshewasallbetterbutshehadtroublewalking,neededlotsofhelp,andwasneverthesameagain

• EmpiricData:HospitalAcquiredDisability• 1/3ofpatientsover70willbedischargedwithanewADLdisabilitytheydidnothavebeforehospitalization• Majordeclinesinmobilityfollowinghospitalization• Mostofthesearepermanent

HospitalizedPatientsarePuttoBedandStayThere• AccelerometerswornbyolderpatientsatBirminghamVA• Allcouldwalkbeforehospitalization• 80%couldwalkunassistedattimeofadmission

• Anaverageday• 83%lyinginbed(20hours!)• 13%sitting(3.1hours)• 4%standingorwalking(55minutes)

BrownCJ;JAmGeriatrSoc;2009:1660-65

StudyDesign/Participants

• RandomizedTrialcomparinghospitalmobilityprogramtousualcare• Participants• 100patientsadmittedtomedicalserviceatBirminghamVA(meanage73)• Abletowalkwithoutassistance2weeksbefore(butcouldusemobilityaid)• Nodementiaordelirium

MobilityIntervention• Gradedmobility:assistedsitting,standing,walking• 2walksperday–20minutes• Mobilityaids(ie,walker)providedasneeded

• Interventionist:Researchassistant(nobackgroundinmedicine,nursing,ortherapy)• Trainedinsafepatienthandlingbyphysicaltherapist

• BehavioralIntervention• Goal:increasetimespentoutofbed• Dailygoalsetting,barrierassessment,activitydiary• Encouragedhighestlevelofsafeactivity(ie,situpinbedandstandfor3minutes)

5/22/17

9

Outcomes

• ADLDisabilityat30days• LifeSpaceMobilityat30days• Abilitytomovethroughonescommunity• Considersdistancemoved,frequency,anddegreeofindependence

• Adverseeffects(Falls)

ResultsAdmission 30days

ADLScore

MobilityIntervention

8.4 8.2

UsualCare 8.7 8.0LifeSpaceScore

MobilityIntervention

54 52

UsualCare 53 42

Falls:NoneinMobilityIntervention,3inUsualCare

LifeSpaceDifference:Goingtotownwithoutassistance1-3timesaweekvsgoingtotownlessthanonceaweek,needingcane

BottomLine

• Alowtechinterventionconsistingofwalkinghospitalizedpatientstwiceday& encouragingpatientstowalkledtomarkedimprovementsincommunitymobility30daysafterdischarge• Timefordefinitivestudy• Multicenter• Includecognitivelyimpaired

• Actionshouldhappennow

FallsasaNeverEvent:TheCMSWaronMobility• CMSdoesnotpayforfallrelatedinjuriesinthehospitalandimposesfinancialpenaltiesonhospitalswithhighestfallinjuryrates• “currentfallpreventioneffortsreflectatroublingunderlyingassumptionthatkeepingpatientsfrommovingcanstopfalls”• “treatingfallsas“neverevents”hasledtooverimplementationofmeasureswithlittleefficacyforfallsyetprofoundcontributiontoimmobility”

Growdon,Shorr,Inouye;JAMAIM;april 242017;onlineearly

5/22/17

10

Frenchlilac

Glumetza(metforminER)$10,000 for3monthsupply(withfreecoupon)

Source:https://www.goodrx.com/glumetza

Glumetza(metforminER)$10,000 for3monthsupply(withthecoupon)

Source:https://www.goodrx.com/glumetza

5/22/17

11

Glumetza(metforminER)$10,000 for3monthsupply(withfreecoupon)

Source:https://www.goodrx.com/glumetza

N Engl J Med 2016;374:611-24.

TheProblem

• Lowtestosteronelevelshavebeenallegedtobecontributorstovirtuallyallailsofaging• Heavilymarketedtopatient$throughdirecttocon$umeradverti$ing• InstituteofMedicinepanelcallfortrialstodeterminewhetherthereisanybenefitoftestosteronetreatmentinmenwithlowlevels

5/22/17

12

TestosteroneTrialsApproach• Targetedpatients(Age65+):• LowTestosterone(<275ng/dl)nocauseotherthanage)• Exclusion:Prostatecancer,severeBPH• Symptomspossiblyreferabletolowtestosterone• SexualFunction(decreasedlibido)• PhysicalFunction(difficultywalking,slowgaitspeed)• Vitality(selfreport,Highfatiguescore)

• Trialpoweredtoassessbenefit.Notharm• Goalofdeterminingwhetherfullscalestudyappropriate

Treatments

• Testosterone• 1%androgelpumpbottle:Startingdose5grams• Levelcheckedperiodically:Doseadjustedtokeeplevelinnormalrangefor19-40yomen• Treatmentsuccessfulinraisingtonormallevelinover90%ofsubjects(mean490ng/dl)

• Placebo• Placebogeldesignedtolooklikeandrogel

Subjects

•790/51000screenedsubjectsenrolled•Characteristics•Meanage72• 71%withHypertension• 63%withBMI>30• 20%withHistoryofMIorstroke•Meantestosteronelevel239ng/dl

MainResults•ModestEffectoftestosteroneonsexualfunction• Averageincreaseof0.58pointsonpsychosexualdailyquestionnaire• Improvementgreaterearlierintrialthatat12months

• NoImpactofTestosteroneonphysicalfunction• 50meterincreaseinsixminutewalktest:15.1%testosteronevs11.8%placebo(p=0.20)

• NoImpactofTestosteroneonfatigue• Improvementof4pointsonFACITFatiguescale:69.5%testosteronevs65.4%placebop=.30

5/22/17

13

JAMA. 2017;317(7):708-716

CVstudyoutcomes

• CoronaryCTangiographyperformedonsubsetoftrialparticipants(n=140)• Testosteronegrouphadincreaseintotalnoncalcifiedplaquevolume(thebadstuff)• Testosteronegrouphadincreaseintotalplaquevolume• Nochangeincalcifiedplaquevolume

JAMA. 2017;317(7):708-716

Summary

• Testosteronetreatmentledtomodestimprovementsinsexualfunction• Smallerthanimpactofphosphodiesteraseinhibitors• Pearls:“Givenhighlevelsofobesity,mightdietaryandphysicalactivityinterventionhavemoreeffect”

• Testosteroneledtonoimprovementsinphysicalfunctionorfatigue• Trialnotpoweredtodetectharms,butsomeevidenceofacceleratedatherosclerosis

Wheredothingsstandwithtestosterone

• Testosteroneshouldnotbegiventomentotreatdecreasingphysicalfunction,fatigue,orgeneralsymptomsofmalaise• Testosteroneprobablydoesleadtomodestimprovementsinsexualfunctioninmenwithdecreasedlibido• However,itcannotberecommendedwithoutatrialfullypoweredtoassessharms• Questionabletreatmentinsettingofothereffectivetherapies

• Wehavenotfoundthefountainofyouth!

5/22/17

14

“Wearedisappointedthatthisveneratedjournalsupportedthepublicationofthetrialandutilizeditasaplatformtoselectivelydiscreditpreviouslypeer-revieweddata.”

TheCranberryInstitute

Juthani-Mehta.JAMA2016

Background• Asymptomaticbacteriuriacommon,makingUTIdiagnosisdifficult• UTIsarethemostcommoninfectioninnursinghomes

• E. coli accountsforapproximately50%ofuropathogensinnursinghomeresidents

• Cranberryproanthocyanidin(PAC)• activeingredientincranberry• inhibitsadherenceofPfimbriated Escherichiacoli touroepithelialcells

• Priorstudyshowedthatcranberryjuicereducedbacteriuriapluspyuriainolderwomen(1)• Analysiswasnotbyintentiontotreat• Moreoftheplacebogroup(25%)thanthecranberrygroup(7%)hadahistoryofrecurrentUTI

JAMA.1994;271(10):751-754

5/22/17

15

Methods

• 185femalenursinghomeresidentsaged65yearsorolderwithorwithoutbacteriuriapluspyuriaatbaseline• Randomizedto2oralcranberrycapsulesorplacebo• 72mgproanthocyanidin=or20ouncesofcranberryjuice

• PrimaryOutcome• Anypresenceofbacteriuriapluspyuriaassessedevery2monthsoverthe1-yearstudysurveillance

Juthani-Mehta.JAMA2016

Results– PrimaryOutcome

• Nosignificantdifferenceinbacteriuriapluspyuria• Adjustedrates,29%vs29%• Oddsratio,1.01;95%CI,0.61-1.66; P=0.98

SecondaryOutcomes

• Nosignificantdifference(interventionvscontrol)• SymptomaticUTIs(10vs12)• Mortality(17vs16)• Hospitalization(33vs50)• Multidrug-resistantgram-negativebacillibacteriuria(9vs24)• AntibioticsadministeredforsuspectedUTI(692vs909)• Totalantimicrobialutilization(1415vs1883)

Limitations

• Primaryoutcomewasbacteriuriaandpyuria• Dowecareaboutthis?

• Cranberry-containingproductsmaybemoreeffectiveinwomenwithrecurrentUTIs(1)• 69%ofpatientsdidnotexperienceaUTItheyearprior

• Itjustmaybesomethingelseinthejuice

1.ArchInternMed. 2012;172(13):988-996

5/22/17

16

ConcludingTweet

Cranberrycapsulesdonotsignificantlydecreasethepresenceofbacteriuriapluspyuriainfemalenursinghomesresidents*.

*Theremaybesubpopulationsnotspecificallyfocusedoninthisstudythatdobenefit(thosewithrecurrentUTIs)

JAMA Intern Med. 2017;177(2):254-262.

Background

• β-blockersareaguideline-recommendedinterventionafteranacutemyocardialinfarction(AMI)

Circulation. 2014;130(25):2354-2394.Circulation. 2013;127(4): e362-e425.

• Lessoftenprescribedtoolderadults,especiallythosewithfunctionalimpairmentormultiplecomorbidities

StudyDesign

• Design• Propensityscorematchedcohortsofthosethatdid&didn’tinitiateβ-blockertherapyafterhospitalizationforAMI

• PopulationStudied:• Nursinghomeresidents65yearsorolderhospitalizedforAMI• Focusedonnewusers(noβ-blockerswithin4monthsofAMI)

JAMA Intern Med. 2017;177(2):254-262.

5/22/17

17

Results

•Within3monthsafterhospitaldischarge:• 12%experiencedfunctionaldecline• 25%werere-hospitalized• 14%died

• Usersofβ-blockershad:• Nodifferenceinhospitalizationrates• Loweroddsofdyingwithin90days(HR,0.74;95%CI,0.67-0.83)• Higheroddsoffunctionaldeclineinthefirst90daysafterAMI(1.14(95%CI,1.02-1.28))

JAMA Intern Med. 2017;177(2):254-262.

BenefitsandBurdensofβ-blockers

NNTtoprevent1death:26

NNHtocause1functionaldecline:52

JAMA Intern Med. 2017;177(2):254-262.

5/22/17

18

NNH:25-36

AWordofCaution

• β-blockersusersaredifferentthannon-users• Cautionwithsurvivaloutcomes•Whataboutfunctionaloutcomes?• oppositedirectionofexpectedbias

•Whataboutotheroutcomesofinterest?

JAMA Intern Med. 2017;177(2):254-262.

ConcludingCelebrityTweet

β-blockersincreasesurvivalinoldernursinghomeresidentsafteracuteMI.#geriatrics

ConcludingCelebrityTweet

β-blockersincreasesurvivalinoldernursinghomeresidentsafteracuteMI.#geriatrics

β-blockersincreasesurvivalinoldernursinghomeresidentsafteracuteMI,butmayalsoincreaseriskoffunctionaldecline.#geriatrics

5/22/17

19

J Am Geriatr Soc 2016.

StudyGoal

•DoesAdherencetoahealthylifestyleleadto:• LongerLifeSpan?• LongerLifeFreeofDisability?

Methods

• Follow5248peopleenrolledinCardiovascularHealthStudyin1990• Overage65atenrollment(mean=72)

• TrackSurvival• Freedomfromdisability• Difficultyinactivitiesofdailyliving(eating,bathing,dressing,toileting,transferring,walkinhome)

• CompareOverallSurvivalandDisability-FreeLifeExpectancy(AbleLife)

YearsofRemainingLifeandDisabilityFreeLifeLife-Span Disability-

Free LifeSpan

%Disability-Free

Women 70-74 15.7 11.0 6680-84 10.1 5.4 51

Men 70-74 13.1 10.1 7380-84 7.9 5.1 60

5/22/17

20

HealthyvsUnhealthyLifeStyle

Healthy UnhealthySmoking Never CurrentAlcohol 1-7perweek 14or moreperweekBMI 18-24.9 >30ExerciseIntensity 2300 kcal/week 375kcal/weekBlockswalkedperweek

48 6

SocialNetwork Extensive LimitedSocial Support High Low

TheBestofTimes,TheWorstofTimes

• GoodNews:• LifestyleFactorsthataremodifiable• AreAssociatedwithLongerLife• Theadditionallifespanisdisabilityfree• ReducedTimeinDisability

• BadNews• Eventhosewithaveryhealthylifestylecanexpecttospendsubstantialtimedisabled

Whatdowetellthepublicaboutaging?

•Weshouldaggressivelypromotehealthylifestylesandhelpourpatientsachievethoselifestyles• Butletsplaynopartinpropagatingthemythonecanavoidthedisabilitiesofaging• Stigmatization• Avoidseriouspublicdiscussionabouttheneedsofourpatients

• HealthandSupportiveservicesthatpromotequalityoflifeandwellbeingduringthedisabledphaseoflife

5/22/17

21

J Gen Intern Med 31(9):1035–40

JAMA Intern Med. 2017;177(1):24-31.

15%

67%

13%

5%

Wheredoindividualswithdementiadie?

HospitalNursinghomeHomeOther

Mitchell SL. JAGS. 53: 299–305, 2005

5/22/17

22

NursingHomes:ADifferentBeast

• Littlephysicianinvolvement• Highturnoverofstaff• Decisionsforpatientsmostoftendonebyfamilydecisionmakers• Expressmoredissatisfactionwithcommunicationandcareinnursinghomesthananyothersetting

• Accesstotechnologylacking

Methods

• Singleblindedclusterrandomizedcontroltrial• Including302residentswithadvanceddementiaandtheirfamilydecisionmakers

• Randomized22nursinghomesto• Intervention• 18minutevideodecisionaid• Careplanmeetingwithaguidetostructurethediscussionaroundgoalsofcare.

• Control• Videooninteractingwithindividualswithdementia• Regularcareplanningprocess

https://www.med.unc.edu/pcare/resources/goals-of-care

https://vimeo.com/185866577

Methods• PrimaryOutcomeat3months• Qualityofcommunicationquestionnaire

• (0-10- higherratingsindicatingbetterquality)• Familyconcordancewithcliniciansontheprimarygoalofcare• Treatmentconsistentwithpreferences(AdvanceCarePlanningProblemscore)

• Secondaryoutcomesat9months• Familyratingsofsymptommanagementandcare• Palliativecaredomainsincareplans• MedicalOrdersforScopeofTreatment(MOST)completion• Hospitaltransfers.

5/22/17

23

Results

•Demographics•Meanagewas86.5years•82%women•13%AfricanAmerican

•Primarygoalcomfort• 65%atenrollment• 79%at9monthsordeath

Results- Outcomes• Improved• Qualityofcommunication:6.0vs5.6; P = .05• Concordanceongoalsat9months:88%vs71%, P = .001• palliativecareintreatmentplans• DoubleduseofMOST/POLST(35%vs16%,p=0.05)• Reducedhospitaltransfersbyhalf(0.078vs0.163/90persondays)

• Nodifference• Familyratingsoftreatmentconsistentwithpreferences• Familyratingofqualityofcare• Survival

TheChallenge

• Familyoftendiscussedmedicaltreatmentchoiceswithnursesorsocialworkers• Only1in4familydecisionmakerstalkedwithphysiciansduringcourseofthestudy

ConcludingTweet

Freegoalsofcaredecisionaidimprovesqualityofcommunication&lowershospitalizationsfornursinghomeresidentswithdementia.#HPM

https://www.med.unc.edu/pcare/resources/goals-of-care

5/22/17

24

J Am Geriatr Soc 64:2433–2439, 2016

HipFractureHurts

• Dilemma:HipFracturePainandOpioids• HipFracturecanbeextremelypainful• Preandpost-operativepainstronglylinkedtoadverseoutcomes• Poormobilityandfunction• Delirium

• Opioidsalsohaverisks• Sedation• Delirium

StudyGoal

• DeterminewhetheraregionalnerveblockstartedattimeofERpresentationledto• Lessopioiduseandfeweropioidcomplications• Decreasedpain• Improvedmobilitypost-operativelyandsixweeksfollowingsurgery

Subjects

• 161patientswithhipfracturepresentingto3NYCEmergencyrooms•Meanage=83,72%women• Dementiaanddeliriumexcluded

5/22/17

25

TreatmentOptions

• Interventiongroup• AtERpresentation,ultrasoundguidedfemoralnerveblock(20cc0.5%bupivacaine)• AdministeredbyERresidents

• Within24hours,anesthesiologistinsertedinfusioncatheterforcontinuousinfusionofropivacaine• OralandIVAnalgesictherapyatdiscretionoftreatingteam

• UsualCare• Oralandanalgesictherapyatdiscretionoftreatingteam

ImpactonPainandPainTreatment

NerveBlock Usual CarePOD3restpain 1.8 2.9POD3transferpain 4.7 5.9POD3WalkPain 4.1 5.6DailyIVMSO4equivalents mg/d 2.1 3.5Severeopioid sideeffect 3.0% 12%

EffectonFunction

NerveBlock Control2 minutewalkPOD3,feet 171 100MissedorincompletePTsession

12.5% 21.2%

FIMMobilityScore,6weeks 10.3 9.1

Summary

• RegionalnerveblockonEDpresentation,continuingthroughpost-opday3resultedin• Betterpaincontrol• Lessopioiduseandfeweropioidsideeffect• Betterpostoperativeandweek6function

• KeyCaveat:• Exclusionofcognitivelyimpairedpatients

• Nerveblocksareapromisingtreatmentinpatientswithhipfracture

5/22/17

26

JAMA Intern Med. 2016;176(3):329-337.

Background• ChronicLowerBackPain(CLBP)

• Approximately12%to30%ofthepopulationhasCLBPannuallyandlifetimeprevalenceisapproximately75%

• Mindfulness-basedstressreduction(MBSR)• Semi-standardized8-weekprogramcreatedin1979• Basedonmeditationtechniques

• Purposeful,nonjudgmentalattentiontothepresentmoment• Increasingawarenessofbreathing,thoughts,andbodilysensationsandlearning

toobservethemfromadetachedperspective

• 2016trialofMBSRvscognitivebehavioraltherapyvsusualcare(1)• Greaterimprovementinbackpainandfunctionat26weeks• Limitation:Ages20-70.noactivecontrolgroup

(1)Cherkin.JAMA.2016;315(12):1240-1249

GrantmetheserenitytoacceptthethingsIcannotchange,

couragetochangethethingsIcan

Mindfulness

CBT

Methods• Communitydwellingadults>65yearsorolder

• functionallimitationduetochroniclowerbackpain• chronicpain(>3months)ofmoderateintensitydailyoralmosteveryday

• Randomizedto:• Mind-bodyprogram(n=140)

• 8-weekly90minutegroupsessionsfollowedby6monthlysessions• Healtheducationprogram(n=142)

• 8-weeklygrouphealtheducationsessionsfollowedby6monthlysessions

• PrimaryOutcome:• RolandandMorrisDisabilityQuestionnaire

• Range,0-24• Clinicallymeaningfulchange:2.5- toa5.0-points

5/22/17

27

FunctionalResults:RMDQ

• 57%vs45%hadatleasta2.5-pointclinicallysignificantimprovementat8weeks(p=0.51)• Nodifferenceat6months(49%inbothgroups)

INTERVENTION CONTROL ADJUSTEDDIFFERENCE(95%CI)

8week - 3.5 - 2.3 - 1.1 (-2.1to-0.01)6month - 3.4 - 2.8 - 0.4(-1.5 to0.7)

Howmuchhaveyourbacksymptomschangedasaresultofthetreatmentprovidedinthisstudy?

OtherSecondaryOutcomes

• Nodifferenceinaveragepain,butimprovementsincurrentandmostseverepaininthepastweek• Moreindividualswitha30%improvementincurrentandmostseverepaininthepastweek(8weeksand6months)• Improvedpainself-efficacybutnotsustainedfor6months• Nochangeinself-reportedmindfulness,qualityoflife,andpaincatastrophizing

5/22/17

28

Ann Intern Med. 2017;166:493-505

GrantmetheserenitytoacceptthethingsIcannotchange,

couragetochangethethingsIcan,

Mindfulness

CBT

5/22/17

29

GrantmetheserenitytoacceptthethingsIcannotchange,

couragetochangethethingsIcan,

andwisdomtoknowthedifference

Mindfulness

CBT

You

ConcludingTweet

Amind-bodyprogramforchronicLBPimprovesshort-termfunction&long-termpain.#geriatrics