Geriatrics Literature Updates Eric Widera Kenneth Covinsky, MD - - PowerPoint PPT Presentation

6/19/2018 1

Geriatrics Literature Updates

Kenneth Covinsky, MD @geri_doc Eric Widera, MD @ewidera University of California San Francisco San Francisco VA

Disclosures

• Eric Widera
• Associate Editor, Social Media Editor, for the Journal of

the American Geriatrics Society (JAGS)

• Ken Covinsky
• Editorial Board for the Journal of the American Geriatrics

Society (JAGS); Associate Editor, JAMA Internal Medicine

Methods

• Search of leading journals
• January 2017-December 2017
• JAGS, NEJM, JAMA, JAMA-IM, Annals, Health Affairs,

Lancet, BMJ, Academic Medicine, JGIM, J Geron-Med Sci, JPM, JPSM, Annals of Family Medicine

• Search of social media:
• Twitter (i.e. @AGSJournal), Blogs, PC-FACS, podcasts,

Health In Aging Research Summaries (healthinaging.org)

• Selection Criteria
• Impact and Interest

JAMA Int Med. 2017 Aug; 177(8): 1102-1109

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Background

• Most older adults have not engaged in advance

care planning

• Potential barriers:
• Clinicians’ lack of time, training, and resources
• Advanced directives are difficult to understand
• 3 out of 4 patients won’t be able to participate

in some or all of their end-of-life decisions

• Surrogates are often feel unprepared

Methods

• Single blind parallel group comparative

effectiveness RCT

• Everyone got some form of advance care planning

(ACP)

• Included
• 414 Veterans >= 60 years (9% women, 43% non-white)

receiving primary care at the SFVAMC

• 2 chronic medical conditions
• 2 additional visits to the clinic, ED or hospital
• Excluded:
• Dementia or delirium
• Blindness or deafness

6/19/2018 3

PREPARE Advance Directive Only PREPARE + Advance Directive P New ACP Documentation in EMR 25% 35% 0.04 Legal Forms (i.e AD, POLST, DPOA) 13% 20% 0.04 Documented Discussions 20% 26% 0.13

* adjusted for prior ACP documentation and potential clustering by physician

Primary Outcome at 9 months* Other Outcomes

• Greater increase in self-reported ACP

engagement in Prepare + AD group

• No differences in ease-of-use scales or

satisfaction scales

• No differences in depression or anxiety

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Limitations

• Generalizability: 9% women, single site
• Materials viewed in study offices not in

homes

Bottom Line

It’s time we flip the classroom on advance care planning! PREPARE, a free, patient facing ACP tool increases advance directive

• documentation. #AGS18

prepareforyourcare.org

6/19/2018 5

Williams et al. Ann Intern Med. 2017

Falls In Assisted Living: Is ER For All Really Necessary?

• Assisted Living: The Wild West of Geriatrics
• Rapidly growing, largely unregulated
• Falls extremely common (> 1/year)
• Default protocol: Call EMS with ER transfer
• Is this really good for residents?
• Highly burdensome on patients and families
• Significant risk of iatrogenic complications

Collaboration to Safely Reduce ER Visits

• Collaboration between
• 22 Assisted Living Facilities in Wake County, NC
• Large physician house call practice
• Primary care provider for over 60% of residents
• 24/7 availability
• Same day appointments
• Wake County Emergency Medical Services
• Use of advanced practice paramedic with additional

training in decision making and patient navigation

• Assisted Living Residents
• Ground level fall, cared for by house calls practice
• 359 residents with 840 falls (mean age 86, 73%

women)

The Protocol: Assessing Urgency and Risk

• Paramedic did directed history and physical to assign resident

to one of three tiers

• Tier 1: OMG!!! This could be bad: Transfer to ER
• Hemorrhage, hypotension, altered mental status, hip

pain + limited ROM

• Tier 3: Why worry?: No ER
• No complaint, no hip pain, simple contusion or

laceration

• Tier 2: Not sure: (Phone consultation with housecall

physician)

• anticoagulation, baseline cognitive impairment, need

for pain management, need for splinting, borderline vitals, injury worse than simple contusion

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Outcome: Time Sensitive Condition

• Conditions developing within 72 hours which

indicated need for prompt evaluation

• Wound requiring repair
• Fracture
• ICU admission
• Need for surgery or cardiac catheterization
• Death

Outcomes

• 553 (64%) of 840 falls recommended for no transport
• 366 Tier 3
• 187 Tier 2 (70% of the 264 tier patients)
• 11 (2%) residents recommended for no transport had time

sensitive condition

• 4 patients requested and received transport
• 3 with minor injuries successfully treated by house call

doctor on site

• 4 patients potentially inappropriate care
• 3 fractures diagnosed and treated within one day (no

adverse outcome)

• 1 death 60 hours later unrelated to fall
• Thus, no resident had adverse outcome due to non transport

An Aspirational Endeavor?

• High quality care that most assisted living facilities

not equipped to deliver

• Need for house calls medical practice
• 24/7 telephone consultation
• Rapid follow-up
• Need for well trained and committed

paramedics

• Most EMS models pay for transport but not

evaluation

Bottom Line

• Time to reject the status quo and advocate for

better care in assisted living

• Better Care is Possible
• Partnership between assisted living facilities,

EMS, Physicians to do what is best for the resident

• A patient-centered model of care with

implications for many conditions

6/19/2018 7

Khan et al. J Am Geriatr Soc 66:254–262, 2018 (epub 2017)

Transcatheter aortic valve Replacement (TAVR) and the Brain

• TAVR is associated with an increase risk of stokes

and TIA

• Subclinical brain injury may be substantially more

frequent than stroke

• New silent cerebral ischemic lesions detected by

diffusion-weighted MRI in 98% of patients post TAVR1

• 1. Haussig et al. JAMA. 2016;316(6):592-601
• JAMA. 2016;316(6):592-601. doi:10.1001/jama.2016.10302

6/19/2018 8

Transcatheter aortic valve Replacement (TAVR) and the Brain

• TAVR is associated with an increase risk of stokes

and TIA

• Subclinical brain injury may be substantially more

frequent than stroke

• New silent cerebral ischemic lesions detected by

diffusion-weighted MRI in 98% of patients undergoing TAVR1

• Concern that silent cerebral infarcts are associated

with subtle cognitive change and with an increased risk of subsequent dementia

• 1. Haussig et al. JAMA. 2016;316(6):592-601

What did they do?

• Metaanalysis of individuals undergoing TAVR for

severe aortic stenosis

• Inclusion: studies with standardized neuropsychological

measures before and after TAVR

• 18 studies, 1,065 individuals
• Data were extracted for cognitive scores
• Before TAVR
• Perioperatively (within 7 days after TAVR)
• 1, 3, and 6 months after TAVR
• 12 to 34 months after TAVR

Cognitive Performance Before and After TAVR

• Perioperatively (11 studies, n=598))
• No difference
• 1 month (7 studies, n=287)
• Improvement in cognition
• 3 and 6 months after TAVR (4 studies)
• No difference
• 12 to 34 months after TAVR (3 studies, n=190)
• No difference

Limitations

• Not a whole lot of studies and individuals
• Used a variety of neurocognitive tests

(MOCA, MMSE, global cognitive dimension battery, etc)

• Some may not be as sensitive
• Limited to overall cognitive outcomes and

not specific domains of cognition

• Worsening cognition may be

underrepresented because because of competing risks including death and debilitating strokes.

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Take Home

• Overall cognition may be preserved after TAVR

despite multiple ”silent” microembolization

• Considerable individual variation in some

individual studies1

• Post-TAVR delirium may be associated with

cognitive decline1

• Schoenenberger. Circ Cardiovasc Interv. 2016

Chia-Hui Chen et al. JAMA Surg. 2017;152(9):827-834.

6/19/2018 10

Background

• Delirium affects 13% to 50% of patients undergoing

noncardiac surgery

• Hospital Elder Life Program (HELP) has been shown

to decrease incidence of delirium, LOS, and falls1

• Can a modified Hospital Elder Life Program (mHELP)

reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

• 1. Hshieh TT, JAMA Intern Med 2015

Methods

• Cluster randomized clinical trial
• 2000-bed urban medical center in Taipei
• 377 older patients undergoing gastrectomy,

pancreaticoduodenectomy, and colectomy

• Primary indication for surgery was malignant tumor In

90%

• Inclusion:
• elective abdominal surgery
• expected LOS longer than 6 days
• Randomized by room to receive the mHELP or usual

care.

mHELP

• 3 protocols administered daily in an inpatient ward

by a trained mHELP nurse

• Orienting communication
• Oral and nutritional assistance
• Early mobilization
• Staff blinded except mHELP nurse (who did not

assess outcomes)

• Two outcome assessors specially trained for

delirium assessment using CAM

mHELP

• Median start time of mHELP: postoperative day 1
• 61% starting by post-op day 1
• 88% received by post-op day 3
• Intervention group participants received the mHELP

for a median of 7 days

• Mean time spent with each participant per session was

34 minutes

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Outcomes Results P value

Usual Care (179 patients) mHELP (196 patients) Delirium During Hospital Stay* 15% 7% .008 Length of Stay 14 days 12 days 0.04

* NNT =12

Limitations

• Single site
• Small Study
• Single mHELP nurse

Take Home

A modified Hospital Elder Life Program (mHELP) significantly reduces delirium and length of stay in patients undergoing abdominal surgery. #AGS18

6/19/2018 12

Gadbois et al JAGS 2017 Burke et al. J AmGeriatr Soc 2017.

Transfers from Hospitals to SNF

• Many older persons will spend time in SNF after

hospital

• Huge Impact
• Quickest growing part of the Medicare budget
• Pivotal point in patient’s life (many transition to

long term care)

• Lots of research
• Usually quantitative examination of practices

and outcomes measurable with big data

• Little understanding of patient perspective and

challenges of clinicians

How do patients choose SNFs?

• Approach
• Detailed interviews with 98 informants (patients

and family members)

• Interviews in 15 SNFs across 5 cities
• Interviews focused on
• Patients roles in SNF selection
• Factors that mattered most to them
• Interviews recorded, transcribed, and analyzed
• Serial coding of transcripts into thematic

domains

Key issues Identified by patients

• Overwhelming majority of comments negative
• “Deciding” how to choose a SNF
• Rushed
• Lists of facility names and addresses
• No guidance
• Bewildering; Did not know how to get help
• Factors important to patients
• Usually chose place close to home
• Most willing to choose more distant location for

better quality

• But limited understanding of quality

6/19/2018 13

Patient Voices

• “there is a push and a shove associated with it. On

the patient side they were encouraging a fairly rapid transition and on the administrative side they were encouraging a VERY rapid transition”

• “I would do anything that would be better for me

and better for my family. My daughters drive and they can either drive here or drive there”

Choosing Patients for SNF: Clinician Voices

• Interviews of 25 clinicians from 3 hospitals
• VA, University, Safety Net Hospital
• MD, RN, SW, PT
• Clinicians asked to describe recent SNF discharge
• Need for SNF care
• Evaluation of post-acute options

Drivers and Consequences SNF Decision Making Process

• Driver: Pressure to expedite discharge
• All clinicians felt pressured to “open up beds”—especially

when patient felt to have no acute needs

• Consequence: SNFs used as “safety net” for patients

unable to be cared for at home

• Solution for difficult situations, Most expeditious way of

dealing with patients who needed long term care

• Driver: Lack of hospital-based knowledge of SNF care

processes, quality, or outcomes

• Many clinicians acknowledged not understanding what

happens in a SNF

• Consequence: No standardized process for selecting

patients or SNFs

• Limited voice of patients

Process of SNF Care is One Big Mess

• The blind leading the blind
• Clinicians dont understand what SNFs do and use SNF

when they dont feel safe discharging a patient home

• Patients and families find the process bewildering
• Process is completely lacking in patient-

centeredness, focusing more on needs of hospital than need of patient

• Are quality measures and accountability

interventions missing the forest from the trees?

6/19/2018 14

• Schoenborn. JAMA Intern Med. 2017

How do we stop cancer screening

• Cancer screening saves lives by finding asymptomatic

lesions

• Potential to be lethal many years in the future if allowed

to grow

• For breast and colon cancer about 10 years from

screening detection to lethality

• Harms accrue immediately
• Benefit/risk ratio strongly related to life expectancy
• Choosing Wisely recommends colon and breast cancer

screening only in elders with life expectancy of 10+ years

• But rates of cancer screening remain high in older

persons with limited expectancy with likelihood of harm

• Why?

Approach

• Interviews of 40 seniors (mean age 75, half life

expectancy <10 years)

• Interview approach
• Subjects provided overview of risks/benefits of

cancer screening

• Attitudes about stopping screening; reactions to

being told to stop screening

• Role of health status, functional status, life

expectancy

• Reactions to different methods of

communicating stop screening recommendation

Older Persons Often Amenable to stopping screening

• Context crucial
• Context of trusting physician-patient relationship crucial
• Most likely to be receptive if recommendation is

personalized

• Health Status vs Life Expectancy
• Agreement that poor health status or functional status

are good reasons to not screen

• Antagonism to avoiding screening based on limited life

expectancy

• “Dont recommend cancer screening if patient

unlikely to live 10 years”

• “That’s like hitting you over the head with a
• hammer. Its too harsh”

6/19/2018 15

How to make stop screening recommendation

• Dont say “You will not live long enough to benefit

from this test”

• Do say “This test will not help you live longer”
• Patients wanted to discuss health care that could help

them live longer or better

• “When patients have your conditions and need

help for day to day activities, this test can cause more harm than benefit”

• “It sounds like the doctor has considered my personal

issues and decided I should not have the test”

Bottom Line

• Patients open to being told they should not have

cancer screening

• Needs to come from a physician they have a relationship with

and trust

• Many patients dont get the relationship between

life expectancy and cancer screening benefits

• But they do seem to understand that poor health and functional

status may make screening unwise

• May help to note counter context of types of health care that

might help

Desmopressin nasal spray (Noctiva)

6/19/2018 16

Desmopressin nasal spray (Noctiva)

• Mean # of episodes of

nocturia per night

• Baseline: 3.3
• Placebo @ 12 weeks: 2.1
• Noctiva @ 12 weeks: 1.9

Desmopressin nasal spray (Noctiva)

• 50% or greater reduction in

the mean number of nocturic episodes per night

• 30% placebo
• 49% desmopressin

Desmopressin nasal spray (Noctiva)

• Hyponatremia in an easy to

use nasal spray!

• 19% of those >65 in the 2

key trials of 1.5mcg developed hyponatremia*

*FDA Briefing Document. Bone, Reproductive and Urologic Drugs Advisory Committee. October 19, 2016

Fralick M, Kesselheim AS. JAMA. 2017

6/19/2018 17

Stott DJ et at. N Engl J Med. 2017;376:2534-44

Background

• Subclinical hypothyroidism
• Normal serum free T4
• Elevated TSH
• May occur in the presence or absence of mild symptoms
• f hypothyroidism
• Prevalence rises with age
• 8-18% of adults over 65 years
• Age-adjusted shift to higher TSH levels
• Nonspecific symptoms (fatigue, low energy, or

constipation) often result in a TSH check

• Limited data on what to do in older adults

Methods

• Enrolled patients in primary care practices and

academic centers in 4 countries

• United Kingdom, Ireland, the Netherlands and Switzerland
• Inclusion
• Adults age >= 65yrs
• Persistent subclinical hypothyroidism
• TSH level 4.60-19.99 mU/L measured at least twice 3 months apart
• Normal fT4
• Exclusion
• Already on levothyroxine or other thyroid meds
• History of thyroid surgery or radioactive iodine in the

previous 12 months

• Dementia
• Acute coronary syndrome,
• Hospitalization in the previous 4 weeks

Randomized to:

• Placebo with mock adjustments
• Levothyroxine
• starting at 50mcg (25mcg for hx of CAD or weight < 50kg
• Titrated to achieve TSH level within the reference range

(0.40-4.59 mIU/L)

6/19/2018 18

Primary Outcomes

• Initial Primary Outcomes
• Cardiovascular events
• Disease Specific Quality of Life (QOL)
• Hypothyroid Symptom and Fatigue domains from the Thyroid-

related QOL patient-reported outcome measure (ThyPRO).

• Revised
• Disease Specific Quality of Life (QOL)
• Hypothyroid Symptom & Tiredness domains from ThyPRO at 12

months

Results

• 737 participants
• mean age 74 years
• 54% women
• 98% white
• Mean ThyPRO symptom score at baseline: 17
• 27% had a score of 0 (no symptoms)
• Mean ThyPRO fatigue score: 26
• 9% had a score of 0 (no symptoms)

TSH levels Mean difference (95% CI)

Levothyroxine Placebo Baseline 6.41 6.38 12 months 3.63 5.48

• 1.92 (-2.24 to -1.59)

Outcomes Mean scores at 12 months Mean difference (95% CI)

Levothyroxine Placebo Hypothyroid symptom score‡ 16.6 16.7 0.0 (−2.0 to 2.1) Tiredness score‡ 28.7 28.6 0.4 (−2.1 to 2.9)

‡ Adjusted for baseline score. Score range 0 to 100, higher score = more symptoms or more tiredness; minimum clinically important difference = 9 points.

6/19/2018 19

Secondary Outcomes

• No difference in:
• EuroQol visual-analogue scale
• Comprehensive thyroid-related quality of life
• Hand-grip strength
• Executive cognitive function
• Blood pressure
• Weight, BMI, and waist circumference
• Activities of daily living and Instrumental Activities of

Daily Living

• Fatal and nonfatal cardiovascular events.

Outcomes Event Rates RRR (CI)

Levothyroxine Placebo Serious adverse events 21.2% 27.9% 5% (0 to 10) New-onset atrial fibrillation 3.0% 3.5% 20% (−77 to 65) Study drug withdrawal 22.0% 21.4% 5% (−20 to 37)

Limitations

• Baseline symptom scores were low
• Few participants with a TSH > 10
• Underpowered for other clinical outcomes,

including cognitive impairment and cardiovascular events.

• Homogeneous population (98% white)

Bottom Line

• No benefit of levothyroxine on symptoms, mood, or

quality of life in subclinical hypothyroidism in older adults

• (mainly with TSH <10 and mild symptoms)
• Don’t be tempted to treat just because something

is outside a reference range, even if non-specific symptoms are present.

• ½ of those with previously elevated TSH level who

were screened for the trial reverted to normal. #WatchfulWaiting

6/19/2018 20

Wouters et al. Ann Intern Med. 2017

Discontinuing Inappropriate Medicines in the Nursing Home

• Polypharmacy extremely common in nursing home
• Many medicines on structured review (STOPP

criteria, Beers criteria) found to be inappropriate

• Loop diuretic for mild edema without CHF
• Full dose PPI for longer than 8 weeks
• Verapamil in those with class 3 or 4 CHF
• Increasing focus on deprescribing
• Research question
• Can multidisciplinary (physician and pharmacist)

medication reviews reduce inappropriate medicines in the nursing home

Approach

• Cluster RCT randomizing 32 nursing home

physicians and 59 nursing home wards in the Netherlands

• 125 residents (Mean age=83, 45% with dementia,

LOS=34 months)

Multidisciplinary Multistep Medication Review (3MR)

• Single multistep review lasting 45-60 minutes
• Assessment of patient perspective and medical

information

• Review of medications based on Beers, STOPP criteria
• Meeting between pharmacist and MD to discuss

medication changes

• Execution of plan for follow up and monitoring
• Primary outcome
• Sustained (4 month) discontinuation of inappropriate

medicine

• Without relapse or withdrawal effects

6/19/2018 21

Intervention Led to More Medicine Deprescribing

• Sustained discontinuation of inappropriate

medicine

• 39% intervention group
• 29% control group
• No impact on fall, MMSE score, neuropsychiatric

symptoms, quality of life

Bottom Line

• A focused medication review grounded in physician

and pharmacist collaboration successfully reduced inappropriate medications in the nursing home

• Shows we can move the needle, but we need to

move the freight train

• Real improvement will require more than single time

intervention

• Need to show impact on well being and quality of life
• Holmes and Sachs: Beers and STOPP medicines the tip of the

iceberg

• JAMA. 2017;318(11):1047-1056

Background

• Hyperactive delirium common at the end of life
• 51% patients in palliative care units toward the end of

their life have symptoms of hyperactive delirium

• Delirium at the end of life associated with

poor outcomes

• Significant and distressing symptomatology
• Currently no drugs approved for the treatment
• f delirium

(1) Senel et tal. Am J Hosp Palliat Care. 2017

6/19/2018 22

JAMA Intern Med. 2017;177(1):34-42.

Scale 0-6 Scale 0-6 Scale 0-6

6/19/2018 23

But What About Benzodiazepines? Study Design

• Double-blind, placebo-controlled, randomized clinical

trial of 58 patients in a palliative care unit

• lorazepam + haloperidol
• placebo + haloperidol
• Inclusion
• Diagnosis of advanced cancer
• Diagnosis of delirium
• Agitation with a Richmond Agitation-Sedation Scale (RASS)

score of >= 2 over the past 24 hours despite receiving haloperidol

• Exclusion
• Dementia, use of benzodiazepines or chlorpromazine within

the past 48 hours, contraindications to neuroleptics or benzodiazepines

Haloperidol IV 2 mg q4 hours & 2 mg q1h prn agitation

Enrolled and Randomized

(90 patients)

Lorazepam 3mg IV x1 + Haloperidol IV 2 mg (29 patients) If RASS >= 2 (later changed to >=1) & rescue medication needed then: RASS q2 Hours Placebo + Haloperidol IV 2 mg (29 patients)

Score Term Description +4 Combative Overtly combative or violent; immediate danger to staff +3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff +2 Agitated Frequent nonpurposeful movement +1 Restless Anxious or apprehensive but movements not aggressive

• r vigorous

Alert and calm Spontaneously pays attention to caregiver

• 1

Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice

• 2

Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice

• 3

Moderate sedation Any movement (but no eye contact) to voice

• 4

Deep sedation No response to voice, but any movement to physical stimulation

• 5

Unarousable No response to voice or physical stimulation

6/19/2018 24

Score Term Description +4 Combative Overtly combative or violent; immediate danger to staff +3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff +2 Agitated Frequent nonpurposeful movement +1 Restless Anxious or apprehensive but movements not aggressive

• r vigorous

Alert and calm Spontaneously pays attention to caregiver

• 1

Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice

• 2

Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice

• 3

Moderate sedation Any movement (but no eye contact) to voice

• 4

Deep sedation No response to voice, but any movement to physical stimulation

• 5

Unarousable No response to voice or physical stimulation

RASS Scores from baseline to 8 hours

Score Term +4 Combative +3 Very agitated +2 Agitated +1 Restless Alert and calm

• 1

Drowsy

• 2

Light sedation

• 3

Moderate sedation

• 4

Deep sedation

• 5

Unarousable

Lorazepam 3mg IV x1 + Haloperidol IV 2 mg Placebo + Haloperidol IV 2 mg

Score Term +4 Combative +3 Very agitated +2 Agitated +1 Restless Alert and calm

• 1

Drowsy

• 2

Light sedation

• 3

Moderate sedation

• 4

Deep sedation

• 5

Unarousable

Placebo + Haloperidol IV 2 mg Lorazepam 3mg IV x1 + Haloperidol IV 2 mg

30% 8% 62% 50% 4% 46%

6/19/2018 25

Other Results

• Lorazepam group had
• Greater perceived comfort by caregivers and

nurses

• No difference in communication capacity
• Lower use of rescue neuroleptics
• Non-significant greater severity of delirium

(MDAS scores ≥2 points higher)

Limitations

• Singe site
• Small sample size:
• Not powered for secondary outcomes like

delirium severity

• Hefty Doses

Is sedation enough?

Steinhauser et al. JAMA 2000

End-of-Life Factors Rated as Very Important by more than 90% of Patients & Physicians

Attributes Be kept clean Be free of pain Name a decision maker Say goodbye to important people Have a nurse with whom one feels comfortable Be free of shortness of breath Know what to expect about ones physical condition Be free of anxiety Have someone who will listen Have a physician with whom on can discuss fears Maintain one’s dignity Have financials in order Trust one’s physician

6/19/2018 26

Steinhauser et al. JAMA 2000

End-of-Life Factors Rated as Very Important by Most Patients but not Physicians

Attributes Patients Physicians

Be mentally aware 92% 65%

Be at peace with god 89% 65% Not be a burden to family 89% 58% Be able to help others 88% 44% Pray 85% 55% Have funeral arrangements planned 82% 58% Not be a burden to society 81% 44% Feel one’s life is complete 80% 68%

*P<.001 for all comparisons

Concluding Tweet

Benzodiazepines do a great job of converting hyperactive delirium to hypoactive delirium at the end of life.

Brach et al. JAMA Intern Med 2017

Timing and Coordination Group Exercise to Improve Walking

• Walking difficulty one of most common syndromes
• f aging
• Strength and flexibility exercises improve mobility
• But walking demands timing and coordination of

movement

• Few interventions have focused on this core skill
• Study goal: Compare an intervention focused on

timing and coordination of movement to Usual care group exercise

6/19/2018 27

Subjects

• Independent living centers, senior housing,

senior centers

• Age > 65, able to walk independently (cane OK),

gait speed >.60 m/s

• 298 subjects across 32 sites
• Mean age = 80
• 84% women
• 29% fell in past year
• Average of 2 chronic conditions

On The Move Intervention

• 50 minute class, 2x/wk for 10 weeks, delivered on site
• Led by physical therapist or PT assistant, with music
• 3 components
• Walking patterns: Timing and coordination of stepping,

weight shifting, coordination of legs and trunk

• Stepping sequences: Timing of stepping, proper weight

shifting

• Strengthening: Focus on muscles most crucial to walking (hip

abductors, ankle dorsiflexors)

• Standard Exercise Intervention
• Aerobic and strengthening exercises
• Same intensity as On the Move

Results

• On the move subjects had more improvement in

gait speed

• Improvement of .05 m/sec
• On the move subjects had more improvement in 6

minute walking distance

• 16.7 meters
• No difference in self-reported disability
• Both groups liked the intervention
• 79% felt they benefited
• 84% planned to continue exercises

Bottom Line

• Exercise intervention grounded in improving

movements essential to walking had greater benefits than standard aerobic and strength training intervention

• Improvement in gait speed and walking distance
• Multiple options for walking and mobility

interventions

• How do we individualize
• Patient need
• Patient preferences

6/19/2018 28