Miguel A. Paniagua

Atypical Antipsychotics for the Treatment of Delirious Elders

BACKGROUND Delirium occurs frequently in hospitalized patients and is reported to occur at a rate of 10% to 40% in hospitalized elderly patients. The gold standard of treatment is to treat the underlying cause of delirium and use high-potency antipsychotics such as haloperidol to target the behavioral disturbances. Since the development of atypical antipsychotics, many psychiatric conditions that were previously only treatable using high-potency antipsychotics may now be managed with the atypical agents. This review will examine the current literature on atypical antipsychotics and summarize the results from published trials in order to evaluate the efficacy and potential benefits of atypical antipsychotics for the treatment of delirium in the elderly population. METHODS A search of the published literature was conducted using MEDLINE and PubMed. The PubMed search was limited to articles that were (1) written in the English language, (2) focused on human subjects above age 65, and (3) were in the format of review articles, randomized controlled trials (RCTs), clinical trials, or meta-analyses. The initial PubMed search was conducted in March 2006 with follow-up investigations in April 2006 and July 2007. RESULTS Risperidone, the most thoroughly studied atypical antipsychotic, was found to be approximately 80% to 85% effective in treating the behavioral disturbances of delirium at a dosage of 0.5 to 4 mg daily. Studies of olanzapine indicated that it was approximately 70% to 76% effective in treating delirium at doses of 2.5 to 11.6 mg daily. Very few studies have been conducted using quetiapine; it also appears to be a safe and effective alternative to high-potency antipsychotics. In comparison to haloperidol, the frequency of adverse reactions and side effects was found to be much lower with the use of atypical antipsychotic medications. In the limited number of trials comparing atypical antipsychotics to haloperidol, haloperidol consistently produced a higher rate (an additional 10% to 13%) of extrapyramidal side effects. CONCLUSIONS A review of current literature supports the conclusion that atypical antipsychotic medications demonstrate similar rates of efficacy as haloperidol for the treatment of delirium in the elderly patient, with a lower rate of extrapyramidal side effects. There is limited evidence of true efficacy, since no double-blind placebo trials exist.

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

ABSTRACTInternal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

The Use of Nintendo Wii with Long‐Term Care Residents

retain the acquired fall-resisting skills between S1 and 6 months, with a reduction from 44% to 0% in falls (P = .002) and from 100% to 52% in BLOB (P = .001). Only 4% (1/25) of participants reported a real-life fall over the 6 months. There was a similar parallel adaptation and retention in stability over 6 months (F(2,74) = 107.44, P < .001). There was significant improvement in COM stability from S1 to S24 (P < .001), which was maintained for a long period (P < .001 from S1 to 6 months, Figure 1B). Nonetheless, there was still measurable motor memory decay characterized by a significant increase in incidence of BLOB and decrease in stability from S24 to 6 months (P < .001 for both). The findings of retention were similar in older and younger adults and lend support to the potential usefulness of the perturbation training paradigm for fall prevention. Significant improvements in stability have led to lower risk of falls and BLOB in younger adults, as well as in older adults for 6 months in the present study. There is also evidence that older adults can retain newly acquired fine motor skills for years without intervening rehearsals. Attempts were also made to examine longer-term effects of laboratory-based perturbation training in older adults. Low kinematic intensity in those cases might not be challenging enough to induce true experience of falls. Hence, the postulated training effects for fall prevention are yet to be verified. The optimal level of perturbation to induce sustainable fall resistance also needs to be determined. It is possible that the demonstrated improvement in stability and slip outcome (fall and BLOB) could be specific to the training environment, with limited translation to real life. Recent findings have demonstrated that the effects of platform perturbation training could generalize to real-life floor slips in young adults. In addition, the lower incidence of real-life falls after (4%) than before training (40%) in this participant group lends some support for translation of this paradigm from laboratory to real-life settings. The past fall incidence recorded in the study sample is consistent with the reported rate of falls in the older adult population. One of the next steps is to systematically determine and quantify carryover of the laboratory training to everyday living. This is the first piece of evidence on the preservation of fall-resisting motor memory in older adults, which could be analogical to “learning from falling” observed in early childhood. One of the differences between childhood learning and learning in older adults is that adults may be able to draw upon motor memory components built from previous error-driven learning experience to modify their behavior. In contrast, children possesses only a limited repertoire and are still building such experiencerelated motor memory. This may partially explain the rapidness of the adaptive change in outcomes induced through the perturbation training in this study, compared with the hundreds of falls that children may experience before they are able to establish their full and stable postural control. In summary, perturbation training that mimics real-life conditions could have far-reaching clinical implications by facilitating learning of fall-resisting skills in a well-protected environment (similar to training wheels on a bicycle). Based on such emerging evidence, it may be possible in the future to “inoculate” older adults to reduce their likelihood of falls.

End-of-Life Care in the Nursing Home

By virtue of its structure, Western medicine is characterized by its cure-oriented approach to the patient. We pretend to master death and the fear of death, according to Dr Elizabeth Kübler-Ross. We are uncomfortable in situations when the patient’s prognosis is poor, because as health care providers, we are instilled with the idea that the ultimate goal in patient care is curing the patient. Thus, the fear of failure looms when aggressive treatment is no longer possible and many providers are reluctant to be straightforward with families in discussing end-of-life (EOL) care options. Unfortunately, this pandemic attitude of denial and avoidance has the unintended consequence of alienating both the dying and the aged and is a true disservice to all patients. Additionally, the current approach to EOL care often fails to accept the inevitable notion that just as there is a time for living, there is also a time for dying. With the advances in medical technology, one of the real challenges of modern medicine is accepting that dying is part of life’s journey for all individuals and that death does not represent a failure of the health care system or health care providers. While working as a nurse and social worker with cancer patients, Cicely Saunders became aware of the extremely inadequate care provided for dying patients in England. She felt that the dying patient was not approached in a holisticmanner and that the spiritual and emotional aspects of the dying process were most often neglected. After becoming a physician, Dr Saunders founded the first hospice in London in 1967 and spent most of her life researching pain management. Her philosophy and tireless work on behalf of the dying ultimately led to the creation of themedical specialty of palliative care and has undoubtedly resulted in making death a more humane process for countless numbers of patients. No doubt this movement has beenmarked by the increasing importance of nurses in the role of direct caregivers of dying patients. One quarter of American elders die while institutionalized and one third of those die within 12 months of admission to a facility. This certainly underscores the notion that EOL care in nursing homes (NHs) has received special attention

Palliative Care in the Intensive Care Unit: Are Residents Well Trained to Provide Optimal Care to Critically ill Patients?

Palliative care (PC) and end-of-life (EOL) care are gaining importance in the management of critically ill patients in the ICU. Residents form a significant work force in the ICU and most often are the only group that provides round the clock coverage. Methods: We conducted a cross sectional study where residents were surveyed to assess their knowledge, skills and perceived barriers towards palliative care in the ICU. Results: The most common barrier identified by our residents was discrepancies in goals of care between the medical team and patients/families (18.7%). A palliative care consult was most commonly obtained when the patient was terminally ill (22.9%). Discussion: Teaching should focus on overcoming the identified barriers especially communication with patients and their families. More studies are needed to identify the best method to teach Palliative care in the ICU.

Testing and evaluation: the present and future of the assessment of medical professionals

The aim of this review is to highlight recent and potential future enhancements to the United States Licensing Examination (USMLE) program. The USMLE program is co-owned by the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards. The USMLE includes four examinations: Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills, and Step 3; every graduate of Liaison Committee on Medical Education-accredited allopathic medical schools and all international medical graduates must pass this examination series to practice medicine in the United States. From 2006 to 2009, the program underwent an indepth review resulting in five accepted recommendations. These recommendations have been the primary driver for many of the recent enhancements, such as an increased emphasis on foundational science and changes in the clinical skills examination, including more advanced communication skills assessment. These recommendations will continue to inform future changes such as access to references (e.g., a map of metabolic pathways) or decision-making tools for use during the examination. The NBME also provides assessment services globally to medical schools, students, residency programs, and residents. In 2015, >550,000 assessments were provided through the subject examination program, NBME self-assessment services, and customized assessment services.

Plombage Migration Outside the Thoracic Cavity: A Complication of Tuberculosis Treatment

An 80 year-old Mexican-American woman presented to the geriatric medicine clinic to establish care and for evaluation of a rapidly enlarging right breast mass. The mass was first noticed in 2003, and at that time a breast biopsy was not performed. The lesion remained relatively constant in size until December 2007. During the subsequent 3 months, the mass grew to involve most of the right breast. Her past medical history was remarkable for pulmonary Mycobacterium tuberculosis treated by right upper lobe collapse and wax plombage in Mexico in the 1950s. Other details from the operation were unavailable. Her other medical problems included hypertension, early Dementia Alzheimer’s Type, and depression. At presentation the patient was afebrile, her blood pressure was 125/70 mm Hg with heart rate of 106 beats per minute. On physical exam, she was thin and pale but in no apparent distress. Lung sounds were absent in the superior right hemithorax with dullness to percussion in that area. Breast exam revealed a painless, diffusely engorged right breast 4 times larger than the left. Superficially, there were dilated subcutaneous veins and nipple inversion. Also present were two 1 1-cm ulcerated skin erosions on the inferior-medial quadrant of the breast. The lesions were covered by a layer of necrotic, white fibrous tissue and were draining frank puslike material. Palpation of the breast expressed a white causeous substance. The breast was diffusely edematous with an approximately 8 3-cm indurated area on the medial aspect. No nipple discharge could be elicited. On palpation of the axilla, a 1 2-cm firm, fixed mass was identified. The patient denied any recent fever, chills, cough, or shortness of breath or weight loss. The patient was admitted to the hospital for evaluation of the mass. Routine laboratory work was significant for a hemoglobin and hematocrit of 9.0 g/dL and 27.5% respectively. Also of note were a decreased mean corpuscular volume of 77.5 FL, elevated ferritin of 313 ng/mL, decreased serum iron of 32 g/dL, transferritin saturation of 23%, and a reticulocyte count of 1.0%. These data suggest that the anemia was due to chronic inflammation. Exudate from one of the lesions was sent for Gram and acid-fast bacilli stain and culture. The culture was positive for coagulase-negative staphylococci, likely representing normal skin flora. These tests were negative for tuberculosis species. Computed tomography (CT) scan of the chest with and without contrast was performed. This test demonstrated a 6.5 3.5-cm soft tissue mass with areas of calcification extending into the right axilla from the pleura with several enlarged axillary, mediastinal and hilar lymph nodes (see Figure 1). There was destruction of the first through third ribs on the right side. Examination of a biopsy of the breast mass tissue showed fat necrosis without evidence of malignant cells. It was determined that this mass represented extrusion of the wax plombage from her operation over 50 years previously. Erosion of the plombage material through the chest wall caused the formation of a cutaneous fistula. The enlarged lymph nodes likely represented reactive changes as a result of a localized inflammatory reaction to the plombage material. DISCUSSION

Early exposure to geriatric care: developing an undergraduate internship in ethics and geriatric practice

According to the United States Census Bureau, there was a 15.1% increase in the sixty-five and older population between 2000 and 20101 and is expected to climb to 16.3% by 2020.2 In addition, older adults have shown a greater need for health care resource utilization in America; while only 12.8% of the U.S. population in 2008, older adults accounted for 26% of office visits, 35% of hospital stays, and 38% of emergency medical services.3The increase in care necessary for the aging population paired with the ebb of resident interest in geriatrics4 has prompted many to call for a more focused effort toward expanding awareness of and recruitment to geriatrics.5-8 Toward these ends, Saint Louis University (SLU) developed a university-level undergraduate course in ethics and geriatric care designed to expose students to the field prior to beginning formal post-baccalaureate medical education. In addition to regular classroom discussion of issues in geriatric care, students spend significant time learning through direct exposure to geriatrics by spending one hour shadowing clinicians and two hours visiting an elder at the nursing home. Students are assessed on classroom participation, completion of required hours, regular reflection papers integrating nursing-home experiences with classroom discussion, and completion of a quality improvement (QI) project.This course is unique for three reasons. First, it is one of the only university-level undergraduate courses engaging students in direct experiences with long term care residents. Second, it was designed in collaboration with undergraduate pre-professional students, who were surveyed to incorporate their needs into the course curriculum (pre-development needs analysis). Finally, it integrates reflection on and discussion of ethical issues related to geriatric long-term care with the students’ time at the nursing home, thereby grounding the practical experiences in theory and animating theory with real-world examples. Course design The course was designed to meet several stakeholders’ interest simultaneously. First, the Division of Geriatric Medicine at SLU School of Medicine expressed a desire to increase awareness of common geriatric care issues and to pursue more volunteers to spend meaningful time with nursing home residents. Second, the pre-professional students at SLU completed a needs-based assessment to delineate student-driven course objects. The survey answers were qualitatively analyzed for common themes: 1) gaining experience with patients, 2) improving medical school applications, 3) increasing shadowing opportunities, 4) understanding the geriatric population, and 5) exposure to medical-ethical discussion. Finally, the University’s Center for Health Care Ethics was seeking opportunities for students to engage in real-world health care experiences while receiving course credit toward a minor degree in Health Care Ethics.The interests of these three stakeholders were combined to develop an internship-based service-learning course with resident companion contact hours, shadowing hours, classroom discussion, and ethics education. Students gain relevant knowledge and skills through real-world learning contexts and insight through volunteer and community service experiences. Upon completion of the course, students should be able to identify: (1) medical and professional challenges to geriatric care, (2) related ethical issues inherent in geriatric and end-of-life care, (3) effective communication and patient-centered skills with elder patients, and (4) principles of ethical care-giving.