Informatics Center Knowledge Management / Eskind Biomedical Library Geriatrics Evidence Alert

Geriatrics Evidence Alert
April 2010


The Geriatrics Evidence Alert is an electronic newsletter developed by the Outpatient Clinical Informatics Consult Service (OCICS) at the Eskind Biomedical Library to provide a bimonthly update of selected evidence-based biomedical literature and recently published news and research to clinicians and other health professionals who provide clinical services for older adults at Vanderbilt University Medical Center and the Middle Tennessee area.

In this issue...


  1.  Clinical questions recently sent to the EBM Literature Request message basket in StarPanel
  2.  Clinical Practice Guidelines
  3.  Newly Published Research
  4.  Recent News & Safety Advisories

DISCLAIMER: The Informatics Center Knowledge Management / Eskind Biomedical Library Geriatrics Evidence Alert is a current awareness tool prepared solely for informational purposes for the convenience of the clinician and other healthcare professionals. Librarians at the Eskind Biomedical Library attempt to provide accurate, inclusive, and informative reports. The information provided in the alert is not a substitute for clinical judgment. Biomedical practitioners should therefore take careful consideration of the original evidence presented in the full-text of the articles cited before taking action. This educational material is produced with the support of the Vanderbilt-Reynolds Geriatrics Education Center.




  1. Clinical questions recently sent to the EBM Literature Request message basket in StarPanel

    Evidence remains weak for guideline recommendations for or against endoscopic screening for Barrett's esophagus and dysplasia in adults 50 years or older

    Question: This is a new patient to my practice who has long-standing gastroesophageal reflux. He underwent an EGD in 2003, negative for dysplasia (by report). My clinical question involves what are initial screening recommendations in a patient with GERD for dysplasia/Barrett's esophagus, and what are recommendations for following them with serial EGD (if any exist)?

    Bottom Line: A search of PubMed and the AHRQ National Guidelines Clearinghouse revealed three recent peer-reviewed evidence-based consensus statements on gastroesophageal reflux disease (GERD) from the American College of Gastroenterology (ACG) (Want et al, 2008), the American Gastroenterological Association (AGA) (Kahrilas et al, 2008), and the American Society for Gastrointestinal Endoscopy (ASGE) (Standards of Practice Committee; Lichtenstein et al, 2007). [full text »]


    Need for stronger evidence to support risks with anticoagulant use in patients with age-related macular degeneration

    Question: What risks should ophthalmologists tell internists and patients about patients using coumadin or heparin when they have wet age related macular degeneration? What is the likelihood that these medicines will make their eye disease worse?

    Bottom Line: The literature on the effects of anticoagulant use in patients with age-related macular degeneration consists predominantly of case reports and case series reporting the occurrence of ocular hemorrhage following long-term use. The case reports and one poorly designed retrospective case-control study (Tilanous et al, 2000) reviewed consistently report patients with age-related macular degeneration who were on anticoagulants and suffered an ocular hemorrhage resulting in decreased vision that was usually light perception only or total blindness in the hemorrhaged eye. No large well-designed studies were located that could estimate the risk of hemorrhage or the likelihood of worsening eye disease with coumadin or heparin use. Monitoring closely the international normalized ratio (INR) and maintaining it at the lower end of the recommended range has been suggested as a useful precaution (Ung, James & Gray, 2003). [full text »]


    Recommendations for treatment of osteoporosis in patients with end-stage renal disease on dialysis and the role of bisphosphonates

    Question: What are the current recommendations for treatment of osteoporosis in patients with end-stage renal disease on dialysis? What is the role of bisphosphonate therapy, if any?

    Bottom Line: The most recent and most comprehensive clinical practice guidelines available come from the Chronic Kidney Disease-Mineral Bone Disorder Work Group of the Kidney Disease: Improving Global Outcomes (KDIGO) organization in their August 2009 update on diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (KDIGO, 2009). After an extensive systematic review of the available literature, they developed the following treatment recommendations and rationale regarding patients with chronic kidney disease. [full text »]


For Vanderbilt University Medical Center physicians: To submit a complex clinical question via StarPanel for searching and synthesis of the medical literature, select the message basket link entitled EBM Literature Request located below the message box (also in each of the four VIM suite drop-down menus) and type your question, including preferred turn-around time. To view the evidence summaries for all geriatrics-related clinical questions previously submitted to the EBM Literature Request message basket, visit http://www.mc.vanderbilt.edu/km/geriatrics/index.html and select the paper icon under Details to view the evidence summary for each question.

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  1. Clinical Practice Guidelines

    AGS updates clinical practice guidelines for accidental falls in older adults

    Bottom Line: This peer-reviewed, evidence-based clinical practice guideline from the American Geriatrics Society and the British Geriatrics Society updates previous recommendations from 2001 on screening and assessment and interventions to prevent accidental falls by older adults. Separate intervention recommendations are provided for older persons living in the community and for those living in long-term care settings. Interventions for older persons with cognitive impairment are also addressed based on limited evidence. [full text »]
    Reference: AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. New York (NY): American Geriatrics Society. January 19, 2010. [Accessed March 31, 2010].


    Dietetics position statement stresses improvements to food and nutrition programs for community-dwelling older adults

    Bottom Line: This position paper from the American Dietetic Association, the American Society for Nutrition, and the Society for Nutrition Education discusses federal food and nutrition assistance programs in the United States, access to safe and adequate food in communities, and outlines issues related to food insecurity, hunger, and malnutrition risk in community-dwelling older adults. Recommendations target promoting healthful aging and optimal nutritional status for older adults through focusing on improving food program access and services and the availability of a healthy and adequate food supply. [full text »]
    Reference: Kamp BJ, Wellman NS, Russell C; American Dietetic Association; American Society for Nutrition; Society for Nutrition Education. Position of the American Dietetic Association, American Society for Nutrition, and Society for Nutrition Education: Food and nutrition programs for community-residing older adults. J Am Diet Assoc. 2010 Mar;110(3):463-72. PubMed PMID: 20213956.

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  1. Recently Published Research

    Randomized controlled trial finds significant effects of testosterone therapy in frail elderly men

    Bottom Line: This double-blind, randomized controlled trial from the United Kingdom examined the effects of 50 mg/d transdermal testosterone versus placebo on muscle strength, lean and fat mass, physical function, and self-reported quality of life in 274 intermediate-frail and frail elderly men with low to borderline-low testosterone levels. Participants were community-dwelling, at least 65 years old, and had a total T at or below 12 nmol/liter or free T at or below 250 pmol/liter. Results after six months of treatment showed testosterone supplementation improved lower limb muscle strength compared with placebo. Also lean body mass increased while fat mass decreased. Improvements were also noted in somatic (muscular strength, tiredness, and general well-being) and sexual symptoms and in physical function among men who were >75 years old and frailer. [full text »]
    Reference: Srinivas-Shankar U, Roberts SA, Connolly MJ, O'Connell MD, Adams JE, Oldham JA, Wu FC. Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebo- controlled study. J Clin Endocrinol Metab. 2010 Feb;95(2):639-50. Epub 2010 Jan 8. PubMed PMID: 20061435.


    Study finds association between oral health status and food avoidance in elderly, multiethnic rural population

    Bottom Line: This prospective survey conducted by Wake Forest University examined the association between oral health status and foods avoided or altered among 635 older adults from counties in rural North Carolina with large African American and American Indian populations. Subjects were asked about avoidance and/or modification strategies for various foods representing different dental challenges. Data were collected from in-home interviews and oral examinations. Results showed that the most commonly avoided foods included whole fruits and raw vegetables as well as meats and cooked vegetables. Significant associations were found between food avoidance and self-rated oral health, periodontal disease, bleeding gums, dry mouth, having dentures, and fewer anterior and posterior occlusal contacts. The authors suggested that food programs for older consider oral health status when developing meals and that improvements in health care benefits for oral care should be developed. [full text »]
    Reference: Quandt SA, Chen H, Bell RA, Savoca MR, Anderson AM, Leng X, Kohrman T, Gilbert GH, Arcury TA. Food avoidance and food modification practices of older rural adults: association with oral health status and implications for service provision. Gerontologist. 2010 Feb;50 (1):100-11. Epub 2009 Jul 2. PubMed PMID: 19574543.


    Meta-analysis examines effectiveness of inpatient geriatric evaluation and management units

    Bottom Line: This systematic review and meta-analysis from Belgium examined the effectiveness of admission to geriatric evaluation and management units (GEMUs) on mortality, institutionalization, functional decline, readmission, and length of stay for acutely sick inpatient adults aged 65 years or older hospitalized for at least 48 hours. Thirteen articles discussing seven studies met inclusion criteria. Review of these studies showed wide heterogeneity in GEMU organization and clinical team composition. Meta-analysis showed no significant effect on mortality or mean length of stay. No effect was observed on the risk of institutionalization at 3 or 6 months after discharge; however, a beneficial effect was noted at 1 year. Patients admitted to a GEMU showed significantly less functional decline at discharge, although the effect diminished somewhat 1 year afterward. [full text »]
    Reference: Van Craen K, Braes T, Wellens N, Denhaerynck K, Flamaing J, Moons P, Boonen S, Gosset C, Petermans J, Milisen K. The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. J Am Geriatr Soc. 2010 Jan;58(1):83- 92. Epub 2009 Dec 9. Review. PubMed PMID: 20002509.

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  1. Recent News & Safety Advisories

    FDA warns of increased risk of serious muscle injury with high doses of Zocor (simvastatin)

    Bottom Line: March 19, 2010 – The FDA released a new safety alert about an increased risk of muscle injury in hypercholesterolemia patients taking 80 mg of Zocor (simvastatin) compared to patients taking lower doses and possibly other statin drugs. The FDA based its announcement on a recent review of data from the Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) trial in which myopathy was reported in a greater number of participants who were on simvastatin 80mg/d compared to those on 20 mg/d (52 [0.9%] cases compared to 1 case [0.02%] respectively) over 6.7 years. FDA preliminary analysis also showed that more participants in the 80 mg group developed rhabdomyolysis compared to none in the 20 mg group. Analysis of prescription drug use data by the FDA showed that clinicians are continuing to prescribe higher doses of simvastatin with other medications known to increase the risk for rhabdomyolysis although dose limitations and drug-drug interaction precautions are listed in the simvastatin drug label. [full text »]
    Reference: FDA Drug Safety Communication: Ongoing safety review of high-dose Zocor (simvastatin) and increased risk of muscle injury. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. March 19, 2010. [Accessed March 31, 2010]


    FDA adds black box warning to Plavix label due to decreased effects in poor metabolizers

    Bottom Line: March 12, 2010 – The FDA added a black box safety warning for the anti-blood clotting medication, Plavix (clopidogrel) increasing its emphasis to health care providers about a subgroup of patients (approximately 2% to 14% of the population) who do not metabolize the drug effectively, which may lead to reduced benefit of Plavix in these patients. Functional metabolism of Plavix depends upon the patient's genotype of the CYP2C19 liver enzyme. Different alleles of CYP2C19 that make up a patient's genotype are discussed in the data summary section. The FDA advised use of other anti-platelet medications or alternative dosing strategies in patients who are identified as poor metabolizers. [full text »]
    Reference: FDA Drug Safety Communication: Reduced effectiveness of Plavix (clopidogrel) in patients who are poor metabolizers of the drug. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. March 12, 2010. [Accessed March 31, 2010]


    MEPS brief highlights expenditures for top five therapeutic classes of outpatient prescription drugs

    Bottom Line: This statistical brief from the Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality (AHRQ) outlines expenditures for the top five therapeutic classes of outpatient prescription drugs in 2007 for community-dwelling Medicare beneficiaries ages 65 and older in the United States. The top classes ranked by total expenses include metabolic agents, cardiovascular agents, central nervous system agents, gastrointestinal agents, and hormones, which together accounted for $54.1 billion, or 66.2%, of the $81.7 billion total prescription drug expenses by these adults. Gastrointestinal agents had the highest average expense per prescription ($114) followed by metabolic agents ($94). [full text »]
    Reference: Soni, A. Expenditures for the Top Five Therapeutic Classes of Outpatient Prescription Drugs, Medicare Beneficiaries, Age 65 and Older, 2007. Statistical Brief #280. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ) February 2010. [Accessed March 31, 2010]

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About Geriatrics Evidence Alert
The Geriatrics Evidence Alert is a bimonthly electronic newsletter developed by the Outpatient Clinical Informatics Consult Service (OCICS) at the Eskind Biomedical Library (EBL) to provide an update of selected evidence based biomedical literature published in the past 30 to 60 days to physicians practicing at the Vanderbilt Internal Medicine department at Vanderbilt University Medical Center. The newsletter is also intended for Vanderbilt University partners and affiliates in the Nashville/Middle Tennessee area who provide clinical, research, and medical education services in the field of Geriatrics.

About OCICS
The OCICS provides current research evidence to support effective clinical decision-making and evidence-based practice by linking evidence expertise into clinical workflow using informatics tools.

How to Submit Clinical Questions to the OCICS for Research
For Vanderbilt physicians: To submit a complex clinical question to OCICS, select NewMsg from within your patient's chart in StarPanel and type your question, including your preferred turn-around time. To send the message, choose the blue link entitled EBM Literature Request located below the message box, or select the basket entitled EBM Literature Request located in each of the VIM suite drop-down menus. Complex questions submitted via NoMR messages for general knowledge building are also welcomed. To view literature summaries for all clinical questions previously submitted, visit the OCICS web site at http://www.mc.vanderbilt.edu/km/ocics/index.html.

Contact Us
For more information about OCICS or the Geriatrics Evidence Alert newsletter, contact Zachary Fox at zachary.e.fox@vanderbilt.edu.

DISCLAIMER: The Informatics Center Knowledge Management / Eskind Biomedical Library Geriatrics Evidence Alert is a current awareness tool prepared solely for informational purposes for the convenience of the clinician and other healthcare professionals. Librarians at the Eskind Biomedical Library attempt to provide accurate, inclusive, and informative reports. The information provided in the alert is not a substitute for clinical judgment. Biomedical practitioners should therefore take careful consideration of the original evidence presented in the full-text of the articles cited before taking action. This educational material is produced with the support of the Vanderbilt-Reynolds Geriatrics Education Center.



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