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Articles on dementia and delirium

Articles on dementia and delirium. Articles on both the benefits and risks of drugs. Articles on assessment scales, & preferences, knowledge & experiences of EOL patients and caregivers. Articles on diet, exercise and functional interventions.

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Articles on dementia and delirium

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  1. Articles on dementia and delirium

  2. Articles on both the benefits and risks of drugs

  3. Articles on assessment scales, & preferences, knowledge & experiences of EOL patients and caregivers

  4. Articles on diet, exercise and functional interventions

  5. Articles assessing fracture &/or falls risk and interventions that may impact the magnitude of the risk

  6. Articles on immunizations and common cancer screening interventions

  7. Articles on urine, skin care, QI initiatives and depression

  8. This diagnosis measured by the CAM (Confusion Assessment Method) upon discharge is associated with an increase in both 1-year mortality and nursing home placement.

  9. What is delirium?

  10. Older adults discharged from the hospital with delirium: 1-year outcomes GJ McAvay et al. JAGS 2006;54:1245-59

  11. Cognition 100 Analysis of previous prospective cohort data from the Delirium Prevention Trial Delirium diagnosed by Confusion Assessment Method (CAM) 433 patients • 5.5% had delirium at discharge • 7.2% had resolved delirium at discharge • 87.3% never delirious during hospitalization Compared to patients who were never delirious, those with delirium at discharge: • HR=1.53 (95%CI=0.96-2.43) for nursing home placement or mortality at 1 year follow up . 

  12. In outpatients with AD, this class of medications used for treating aggression, psychosis, and agitation did not outperform placebo.

  13. What are second-generation (atypical) antipsychotics?

  14. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease  LS Schneider et al.  NEJM 2006;355:1525-38

  15. Cognition 200 42-site, double-blind, placebo-controlled trial 421 outpatients with AD treated for psychosis, aggression, or agitation No significant difference in efficacy when comparing olanzapine, quetiapine, risperidone, and placebo measured by the CGIC at 12 wks No difference in time to discontinuation of treatment in any group

  16. These two risk factors are most robustly associated with delirium after noncardiac surgery.

  17. What are cognitive impairment and use of psychotropic drugs?

  18. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review M Dasgupta et al.  JAGS 2006;54:1578-89

  19. Cognition 300 Risk factor analysis of 25 articles Cognitive impairment (pooled effect size r=0.27 weighted and r=0.29 unweighted, p<.001) with heterogeneity across studies Psychotropic drug use (pooled effect size r=0.19 weighted, r=0.26 unweighted) with insufficient evidence to suggest heterogeneity Other potential RFs: # of medical comorbidities (r=0.15weighted, r=0.19 unweighted), NH residence (OR=1.8, 95% CI 1.1-3.1) & functional impairment (OR=1.9, 95% CI 1.2-2.9) . 

  20. As well as addressing constipation, treating > one of these 3 psychiatric conditions may decrease aggression in demented nursing home residents. (Name one)

  21. What are depression, delusions, & hallucinations?

  22. Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia Leonard R, et al. Arch Int Med. 2006;166:1295-1300

  23. Cognition 400 Cross-sectional study of nursing home residents Not significant: UTI, respiratory infections, fever, pain, participation in recreational activities

  24. This is one component of the holistic, caregiver-inclusive “collaborative care” model which improves outcomes for AD patients & caregivers & decreases the behavioral and psychological symptoms of dementia (BPSD).

  25. What are coaching on caregiver coping & communication skills, legal/financial advice, exercise guidelines or a brochure from Alz Assoc?

  26. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care CM Callahan et al. JAMA 2006;295:2148-57

  27. Cognition 500 Controlled clinical trial randomized to collaborative care or augmented usual care Collaborative care: minimum of education on communication skills; caregiver coping skills; legal & financial advice, exercise guidelines, caregiver guide from Alzheimer’s Association Outcomes • Primary: neuropsychiatric inventory (NPI) • Secondary: depression, cognition, ADLs, resource use, caregiver depression severity • Fewer BPSD per NPI at 12 mths (-5.6, p=.01) & 18 mths (-5.4, p=.01) for intervention group

  28. In a country without folic acid fortification in food, folic acid supplementation slowed the decline in this common sensory loss in elders.

  29. What is (low frequency) hearing loss?

  30. Effects of folic acid supplementation on hearing in older adults: a randomized, controlled trial J Durga et al. Ann Intern Med. 2007;146:1-9

  31. Drugs 100 Double-blind, randomized, placebo-controlled trial in the Netherlands Folic acid 800mcg or placebo for 3 years Rate of change for low frequency hearing loss was less in the group receiving folic acid (1.0 dB 95% CI 0.6-1.4) when compared to placebo (1.7 dB 95% CI 1.3-2.1), p=.020 No difference in the rate of change for high frequency loss May not be relevant for countries that supplement foods with folic acid

  32. Older adults taking serotonin-reuptake inhibitors (SSRIs) may be at increased risk for this potentially life-threatening gastrointestinal event.

  33. What is upper GI bleeding?

  34. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding? Y Yuan et al. Am J Med. 2006; 119: 719-27

  35. Drugs 200 3 cohort and 1 case-control study combined SSRIs & had differing control groups & conflicting conclusions Cohort (317,824 pts): • SSRI+NSAID vs SSRI users (RR 2.8, 95% CI, 2.4-3.3) • SSRI +ASA vs SSRI only (RR 1.7, 95%CI, 1.4-2.0) • AOR for fx rose with duration of Rx (1 yr=1.22 [95% CI, 1.15-1.30]; 2 yrs=1.41[95% CI, 1.28-1.56] and 4 yrs=1.59 [95% CI,1.39-1.80] Case control study (1651 cases and 10,000 controls) showed higher risks than above but a similar pattern Concurrent use of NSAIDs or low dose ASA if combined with SSRI seem to increase risk of UGIB Need better designed studies

  36. Supplementation with this B vitamin in healthy pts with high homocysteine levels did not show a significant improvement in cognitive testing.

  37. What is folic acid, B12 or B6?

  38. Effect of 3-year folic acid supplementation on cognitive function in older adults in the FACIT trial: a randomized, double blind, controlled trial J Durga et al. Lancet 2007;369:208-16

  39. Drugs 300 Randomized, double-blind, placebo-controlled trial Folic acid 800mcg or placebo for three years

  40. This expensive new medication slows visual loss from age- related macular degeneration

  41. What is ranibizumab?

  42. Ranibizumab for neovascular age-related macular degeneration RJ Rosenfeld et al. NEJM 2006;355:1419-31

  43. Drugs 400 Study: 716 pts in 3 groups, ranibizumab (recombinant monoclonal ab ag vascular endothelial growth factor A) at 0.3 mg, 0.5 mg or PBO via mthly intravitreal injections Design-2 yr double-blind, randomized, sham-controlled Results: Acuity improved >15 letters for 25% & 34% in the active arms and 5% of controls. Active groups improved mean of 7 letters and control declined a mean of 10 letters (p<.001 for both comparisons) ADEs: 2% combined endophthalmitis/uveitis Cost: $1950 wholesale for drug monthly Conclusion: Beneficial but expensive

  44. A recent meta-analysis suggests this class of commonly-prescribed antihypertensives should not be first line therapy for older patients without another indication.

  45. What are beta blockers (BB)?

  46. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis N Khan et al. CMAJ 2006; 174: 1737-42

  47. Drugs 500 Meta-analysis of studies c BBs as first-line Rx for HTN in preventing CVA, MI or death 21 RCTs (PC or active comparator) with 145,811 pts • Split trials: younger pts (mean age 52-56.2 yrs) and older pts (mean age 60.4-76 yrs) In PC trials • Younger pts had better CV outcomes (RR 0.86; 95% CI 0.74-0.99) but older pts failed to benefit (RR 0.89; 95% CI 0.75-1.05) In active comparator trials • Younger pts demonstrated similar efficacy to other anti-HTN agents (RR 0.97; 95% CI 0.88-1.07) but BBs less efficacious in older pts (RR 1.06; 95% CI 1.01-1.10) who also had more strokes (RR 1.18; 95%CI 1.07-1.30)

  48. In a recent study, severely demented patients (MMSE < 10) understood this pain scale the best.

  49. What is the Faces Pain Scale?

  50. Pain in severe dementia: self-assessment or observational scales? S Pautex et al. JAGS 2006;54:1040-45

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