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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.
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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)
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≤ 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
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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?
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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
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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)
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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
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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)
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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
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Frenchlilac
Glumetza(metforminER)$10,000 for3monthsupply(withfreecoupon)
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Glumetza(metforminER)$10,000 for3monthsupply(withfreecoupon)
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N Engl J Med 2016;374:611-24.
TheProblem
• Lowtestosteronelevelshavebeenallegedtobecontributorstovirtuallyallailsofaging• Heavilymarketedtopatient$throughdirecttocon$umeradverti$ing• InstituteofMedicinepanelcallfortrialstodeterminewhetherthereisanybenefitoftestosteronetreatmentinmenwithlowlevels
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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
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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!
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“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
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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
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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.
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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.
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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Ann Intern Med. 2017;166:493-505
GrantmetheserenitytoacceptthethingsIcannotchange,
couragetochangethethingsIcan,
Mindfulness
CBT
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GrantmetheserenitytoacceptthethingsIcannotchange,
couragetochangethethingsIcan,
andwisdomtoknowthedifference
Mindfulness
CBT
You
ConcludingTweet
Amind-bodyprogramforchronicLBPimprovesshort-termfunction&long-termpain.#geriatrics