Maura Brennan Md

Potentially inappropriate medication use in hospitalized elders

BACKGROUND Prescribing of potentially harmful medications has not been well documented in hospitals. OBJECTIVE The objective of the study was to determine the rate of and factors associated with potentially inappropriate medication (PIM) prescribing in a large inpatient sample. DESIGN The study was a retrospective cohort of the period between September 1, 2002, and June 30, 2005. We used multivariable logistic regression to identify patient, physician, and hospital characteristics associated with PIM prescribing. SETTING The study collected data from 384 US hospitals. PATIENTS The sample was composed of patients aged >or=65 years admitted with 1 or more of 7 common medical diagnoses. MEASUREMENTS The percentage of patients prescribed PIMs as defined using a modified Beers list was measured. Multivariable-adjusted odds ratios for PIM use were computed. RESULTS Of the 493,971 patients, 49% received at least 1 PIM, and 6% received 3 or more, most commonly promethazine, diphenhydramine, and propoxyphene. Patient, physician, and hospital characteristics were all associated with PIM use. Patients with myocardial infarction or heart failure were most likely (61% and 52% vs. 46% for pneumonia), men (47% vs. 49% for women) and those in managed care plans (44% vs. 49% for other plans) were less likely, and patients >or=85 years were least likely (42% vs. 53% for patients aged 65-74 years) to receive PIMs (P < .0001 for all comparisons). For high-severity PIMs, internists and hospitalists had similar prescribing rates (33%), cardiologists had a higher rate (48%), and geriatricians had the lowest rate (24%). The proportion of elders receiving PIMs ranged from 34% in the Northeast to 55% in the South, and variation at the individual hospital level was extreme. At 7 hospitals, PIMs were never prescribed. CONCLUSIONS Wide variation in the use of PIMs is associated with hospital and physician characteristics. Care may be improved by minimizing this non-patient-centered variation.

AJM onlineReviewPostprandial Hypotension

Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.

Do Elderly Patients Fare Well in the ICU

BACKGROUND A recent update of the Mortality Probability Model (MPM)-III found 14% of intensive care patients had age as their only MPM risk factor for hospital mortality. This subgroup had a low mortality rate (2% vs 14% overall), and pronounced differences were noted among elderly patients. This article is an expanded analysis of age-related mortality rates in patients in the ICU. METHODS Project IMPACT data from 135 ICUs for 124,885 patients treated from 2001 to 2004 were analyzed. Patients were stratified as elective surgical, emergency/unscheduled surgical, and medical and then further stratified by age and whether additional MPM risk factors were present or absent. RESULTS Mortality rose with advancing age within all patient categories. Elective surgical patients without other risk factors were the least likely to die at all ages (0.4% for patients aged 18-29 years to 9.2% for patients aged ≥ 90 years), whereas medical patients with one or more additional risk factors had the highest mortality rate (12.1% for patients aged 18-29 years to 36.0% for patients aged ≥ 90 years). In these two subsets, mortality rates approximately doubled in the elective surgical group among patients aged in their 70s (2.4%), 80s (4.3%), and 90s (9.2%) but rose less dramatically in the medical group (27.0%, 30.7%, and 36.0%, respectively). CONCLUSIONS Although mortality increased with age, the risk differed significantly by patient subset, even among elderly patients, which may reflect a selection bias. Advanced age alone does not preclude successful surgical and ICU interventions, although the presence of serious comorbidities decreases the likelihood of survival to discharge for all age groups.

From hospital to community: Use of antipsychotics in hospitalized elders

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium. Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders, but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

Elderly‐Onset Neuromyelitis Optica Spectrum Disorders

To the Editor: Neuromyelitis optica (NMO), also known as Devic disease, is a demyelinating disorder of the central nervous system primarily affecting the spinal cord and optic nerve. Since the discovery of the NMO-immunoglobulin (Ig)G antibody or aquaporin-4 antibody, it has been discovered that there are different variants of NMO, classified as NMO spectrum disorders (NMOSDs). A case of elderly-onset NMOSD is reported.

Being a “Good Doctor”

506 April 17th, 2002 SHE’S BACK SO SOON; what could have gone wrong?” It was a busy call day and my resident, Barry, just told me that we had a patient being readmitted. We had recently discharged an extremely complicated older lady, Mrs. Meyer, from a nursing home. During the prior admission she had struggled with congestive heart failure, pneumococcal pneumonia, bacteremia, acute renal failure, poorly controlled diabetes, and a urinary tract infection. Her other problems included coronary artery disease, a history of cerebral vascular accidents (CVAs), a large abdominal aortic aneurysm, oxygen-dependent chronic obstructive pulmonary disease (COPD), chronic pancreatitis, and diverticulitis. She also had a history of a Whipple’s procedure for pancreatic carcinoma, a splenectomy, cholecystectomy, and carotid endarterectomy. Needless to say, she had many admissions in the previous year. It was the spring of my internship year and Barry assumed I was ready to “run the show” although he tried to support me with advice when I needed it. It was frightening to think that soon I would be the resident and the new interns would be depending on me! I wasn’t sure I was ready. At this time of fragile confidence, Mrs. Meyer returned to our emergency department. Mrs. Meyer was in the emergency department with her daughter, Justine. She was in obvious respiratory distress due to florid heart failure. I quickly ordered Lasix, nitroglycerine, morphine, oxygen, and antihypertensives to control her blood pressure. I wondered what could have gone wrong so quickly. I scanned through her records and my heart sank when I saw that some of her cardiac meds and diuretics had not been given since she returned to the nursing home. I quickly reviewed my discharge summary—which was extremely detailed. However, I had neglected to list some of her drugs in the med summary although they were clearly mentioned in the body of the discharge summary. I felt responsible for her suffering. My oversight, combined with her recent battle with sepsis and extensive burden of disease, brought her closer to the brink of death than she had ever been in the past. I was overtired (my fourth month of call in 5 months), stressed, hungry, and literally and figuratively running around to evaluate many sick people scattered among different floors of the hospital; the result was a heightened emotional vulnerability. My resident joked with me saying, “If you had done a better job she wouldn’t have bounced back.” He was only trying to be funny, but I had to bite back the tears. All the fear, stress, anger, and frustration of trying to be a “good doctor” for my patients had taken its toll while I was still trying to figure out WHAT being a “good doctor” actually meant during that watershed year. Struggling not to cry, I went back into the room with my patient and Justine. In my heart of hearts I knew it wasn’t really all my fault. I had left an extremely detailed plan in the discharge summary that obviously had not been read. It also seemed likely that nobody had examined the patient recently; her heart failure was not subtle. Timely treatment might have averted this decompensation and the return to the emergency department. There was plenty of blame to go around. Still, I felt guilty. I wondered if Justine realized how I felt. I had established a bond with her during her mother’s last admission. She pulled me aside at one point in the emergency department and asked if Mrs. Meyer was going to die. I had to look at her honestly and say, “I don’t know.” They were both in distress of different types—both patient and daughter. Over the next few days Mrs. Meyer improved, but the toll of repeated admissions deeply affected her and her daughter. Justine, in particular, was having a very difficult time coping with her mother’s chronic ill

Long-term outcomes of elders discharged on antipsychotics

BACKGROUND Despite limited evidence of efficacy, antipsychotics (APs) are commonly used to treat delirium. There has been little research on the long-term outcomes of patients who are started on APs in the hospital. METHODS Using a previously described retrospective cohort of 300 elders (≥65 years old) who were newly prescribed APs while hospitalized between October 1, 2012 and September 31, 2013, we examined the 1-year outcomes of patients alive at the time of discharge. We examined number of readmissions, reasons for readmission, duration of AP therapy, use of other sedating medications, and incidence of readmission. We used the National Death Index to describe 1-year mortality and then created a multivariable model to identify predictors of 1-year mortality. RESULTS The 260 patients discharged alive from their index admissions had a 1-year mortality rate of 29% (75/260). Of the 146/260 patients discharged on APs, 60 (41%) patients experienced at least 1 readmission. At the time of first readmission, 65% of patients were still taking the same APs on which they had been discharged. Eighteen patients received new APs during the readmission hospitalizations. Predictors of death at 1 year included discharge to postacute facilities after index admission (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.10-4.73, P = 0.03) and QT interval prolongation >500 ms during index admission (OR: 3.41; 95% CI: 1.34-8.67, P = 0.01). CONCLUSIONS Initiating an AP in the hospital is likely to result in long-term use of these medications. Patients who received an AP during a hospitalization were at high risk of death in the following year. Journal of Hospital Medicine 2016;11:550-555.

Patient-doctor communication and the importance of clarifying end-of-life decisions:

cians and patients can lead to significant flaws in end-of-life (EOL) discussions. Studies show patients change their minds when given specific information regarding survival and quality of life after cardiopulmonary resuscitation (CPR) and what CPR actually entails. Residency training needs to emphasize that communication skills are as important as procedural skills in effectively caring for patients. The following report illustrates how a superficial conversation between a patient and doctor resulted in confusion that could have been avoided. Case report

The Association of Frailty with Discharge Disposition for Hospitalized Community Dwelling Elderly Patients

BACKGROUND OBJECTIVE DESIGN, SETTING, PATIENTS INTERVENTION MEASUREMENTS CONCLUSIONS

A Rare Cause of Cauda Equina Syndrome by Infiltration: Case of a Sacral Chordoma

is suggestive of variant CJD. DWI has been shown to be the most sensitive MR sequence. DW-MRI may show CJD-associated lesions 3 weeks after symptoms with high sensitivity (91%) and specificity (95%), although studies suggest that up to 80% of these abnormalities are missed, like in the current case, despite previous MRI, illustrating that awareness of MRI features of CJD is insufficient. In the current case, all other complementary investigations were inconclusive. EEG can show polymorphic and repetitive slower wave discharges, characteristic bior triphasic paroxysmal waves, or spike-slow waves in 60% of cases, but these abnormalities occur intermittently, and sensitivity of EEG periodic sharp wave complexes is only 66% with 74% specificity. With 88% sensitivity and 72% specificity, a negative CSF 14–3-3 assay does not exclude CJD, depending on of the evolution of the disease and disease subtype. Several biomarkers, including tau protein, neurospecific enolase, and S100b protein, have attracted great interest. CSF tau protein had better diagnostic accuracy than other protein detection, with 91% sensitivity and 88% specificity. In the current case, a search for prion protein gene mutation was performed for several reasons. Two of the woman’s children were alive, family history was missing, and clinical signs and course of the genetic form of the disease are usually comparable with those of the sporadic form. Geriatricians should recognize clinical and paraclinical signs of CJD, but diagnosis remains challenging. The clinical presentation can mimic dementia or stroke, but MRI, EEG, and biomarkers can assist in the diagnosis. According to international criteria, this woman had probable CJD, but no autopsy was performed.