Geriatrics Evidence Alert
Informatics Center Knowledge Management / Eskind Biomedical Library Geriatrics Evidence Alert

Geriatrics Evidence Alert
June 2011


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 & Drug 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

    Efficacy and cost of contrast MRI of the brain for diagnosing acoustic neuroma in patients with asymmetric hearing loss

    Question: My patients with asymmetric hearing loss are inevitably referred for a brain MRI with contrast to look for acoustic neuroma or other rare pathology. In my experience, these MRI's always return normal. What is the evidence that this is a necessary or helpful thing to do? How much does it cost to diagnose a single acoustic neuroma and does it make a difference if this is diagnosed sooner rather than later?

    Bottom Line: Based on systematic reviews and current radiology practice guidelines (Turkish et al, 2008), magnetic resonance imaging (MRI) with gadolinium contrast appears to be the current gold standard diagnostic test to detect acoustic neuroma in adults with asymmetric hearing loss (AHL), though the incidence of AN in this population is generally low overall. Guidelines from the American College of Radiology (Turkish et al, 2008) note that routine use of gadolinium contrast depends on factors such as MRI coil size, field of view, field strength, and pulse sequences. Several protocols for selecting patients to screen have been developed and tested, however, none have proved highly accurate. [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/vumcdiglib/geriatrics/info/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

    ACCF/AHA releases expert consensus on hypertension management in the elderly

    Bottom Line: In collaboration with expert representatives from multiple medical societies in the United States and Europe, the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) has published a joint consensus statement that provides clinical guidance on the management of hypertension in adults sixty-five years and older. The statement outlines the current knowledge on the epidemiology, pathophysiology, secondary causes, and end-organ effect commonly noted in elderly hypertensive patients, with special attention to its effects in various patient subpopulations. The statement also addresses interactions between aging and other cardiovascular risk conditions associated with hypertension, such as dyslipidemia, obesity, osteoarthritis and diabetes, and reviews best practices for clinical assessment and diagnosis. Due to a dearth of rigorous trials currently available on managing hypertension in the elderly, the panel developed informal consensus recommendations for management rather than formal graded guidelines. These recommendations include consensus on quality of life and cognitive function, lifestyle modification, management of associated risk factors, drug therapies for uncomplicated and complicated hypertension, and compliance with pharmacologic therapy. Strategies to consider for preventing hypertension are also briefly described as well as remaining questions and issues that should be addressed in future research.
    Reference: Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Forciea MA, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ, Harrington RA. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011 May 31;123(21):2434-506. Epub 2011 Apr 25. PubMed PMID: 21518977.


    American Academy of Neurology releases practice guidelines for treatment of painful diabetic neuropathy

    Bottom Line: Following a review of the available research published through August 2008 on pharmacologic and nonpharmacologic therapies for painful diabetic neuropathy (PDN), the guidelines panel found that 300-600 mg/d pregablin, if clinically appropriate, is effective for reducing pain (level A evidence). Other medications that may also be effective for pain reduction include venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulfate, tramadol, oxycodone controlled-release, capsaicin, and electrical stimulation, percutaneous nerve stimulation for 3 to 4 weeks (level B evidence). The available research is currently insufficient to determine the effect of treatment on physical function and quality of life, though sufficient evidence does exist showing a small effect size for pregabalin in improving patients' quality of life and sleep. The panel recommended against using oxcarbazepine, lamotrigine, and lacosamide as well as magnetic field treatment, low-intensity laser therapy, and Reiki therapy (level B evidence). The evidence was insufficient to support or refute the use of topiramate for PDN (level U evidence). The guidelines were developed by a joint panel of representatives from the American Academy of Neurology (AAN), the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. See Table 1 for a summary of all guideline recommendations.
    Reference: Bril V, England J, Franklin GM, Backonja M, Cohen J, Del Toro D, Feldman E, Iverson DJ, Perkins B, Russell JW, Zochodne D. Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 May 17;76(20):1758-65. Epub 2011 Apr 11. PMID: 21482920. See also http://www.aan.com/go/practice/guidelines.


    National Institute on Aging-Alzheimer's Association workgroup releases revised criteria for diagnosing Alzheimer's disease

    Bottom Line: Vast knowledge has been gained about the clinical manifestations and biology of Alzheimer's disease (AD) since the original diagnostic criteria were published in 1984. The National Institute on Aging in collaboration with the Alzheimer's Association therefore recently convened a workgroup charged with updating the criteria for diagnosing AD, with emphasis on measures flexible enough for use by healthcare providers and clinical researchers alike. This article outlines updates to the criteria for classifying patients as having: 1) probable AD dementia, 2) possible AD dementia, or 3) probable or possible AD dementia with evidence of the AD pathophysiological process (for use in clinical trials research). The workgroup also discusses application of biomarker support to AD diagnostic criteria. Core clinical criteria for all-cause dementia and dementia unlikely to be due to AD are also briefly addressed.
    Reference:McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr, Kawas CH, Klunk WE, Koroshetz WJ, Manly JJ, Mayeux R, Mohs RC, Morris JC, Rossor MN, Scheltens P, Carrillo MC, Thies B, Weintraub S, Phelps CH. The diagnosis of dementia due to Alzheimer's disease: Recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011 May;7(3):263-9. Epub 2011 Apr 21. PMID: 21514250.

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  1. Recently Published Research

    Study shows higher likelihood of serious postoperative morbities and mortality in smokers

    Bottom Line: This retrospective corhort study conducted by researchers from the Cleveland Clinic examined the effect of smoking versus never smoking on a composite of 30-day postoperative morbidities in 520,242 noncardiac surgical patients (including 103,795 smokers) predominantly middle-aged (<65 years old) Caucasians (75%) who were treated in 200 centers across the United States from 2005 through 2008. Patient data was obtained from American College of Surgeons National Surgical Quality Improvement Program database. Analyses of 82,304 current smokers compared to 82,304 propensity-matched never-smokers showed that smokers were 1.38 (95% CI, 1.11-1.72) more likely to die within 30 days after surgery. Smokers were also significantly more likely to experience serious 30-day postoperative complications, such as pneumonia, unplanned intubation, mechanical ventilation, cardiac arrest, myocardial infarction, stroke, superficial and deep incisional infections, sepsis, organ space infections, and septic shock.
    Reference: Turan A, Mascha EJ, Roberman D, Turner PL, You J, Kurz A, Sessler DI, Saager L. Smoking and perioperative outcomes. Anesthesiology. 2011 Apr;114(4):837-46. PubMed PMID: 21372682.


    Longitudinal study finds association between obesity and functional decline in older Americans

    Bottom Line: This longitudinal cohort study examined the association between obesity and all-cause mortality and functional decline in performing activities of daily living using survey data through April 2008 from a nationally-representative sample of 20, 975 community-dwelling older adults, ages 65 and over from the United States who had participated in the Medicare Current Beneficiary Surveys from 1994 to 2000. Results showed that 37% were overweight and 18% were obese (BMI =30 kg/m2). The mortality rate during the 14-year follow-up was 48%. Adults, particularly Caucasian men and women, with a BMI of 35 kg/m2 or greater without severe disability at baseline showed a significantly higher risk for all-cause mortality (HR, 1.49 [95% CI, 1.20 to 1.85] in men and 1.21 [CI, 1.06 to 1.39] in women) compared with the reference group (BMI of 22.0 to 24.9 kg/m2) over an intervening two-year period. Respondents who were overweight or moderately severe in obesity showed a higher likelihood of developing new or progressively worsening problems with their activities of daily living over as weight increased. As an observational study, the data were obtained through survey respondents self-report and therefore subject to recall bias.
    Reference: Wee CC, Huskey KW, Ngo LH, Fowler-Brown A, Leveille SG, Mittlemen MA, McCarthy EP. Obesity, race, and risk for death or functional decline among medicare beneficiaries: a cohort study. Ann Intern Med. 2011 May 17;154(10):645-55. PubMed PMID: 21576532.


    Older African Americans less likely to utilize overnight hospital care

    Bottom Line: This study sponsored by the National Institute on Aging examined racial disparities in overnight hospitalizations based on respondent data from the participating the University of Alabama Birmingham Study of Aging, a longitudinal study containing a stratified sample of 942 community-dwelling Medicare beneficiaries ages 65 years and older. Data were collected by phone interview every six months over four years. Bivariate analyses of data collected at baseline and at least one follow-up showed African Americans were less likely to use overnight hospital stay for surgical (HR= 0.63, 95% CI, 0.41-0.98).) and nonsurgical (HR = 0.74, 95% CI, 0.59-0.93) admissions. Predictors of a higher rate of surgical admissions included older age, lower physical component scale, more depressive symptoms and anxiety, lower mental component scale, more social support, reporting less racial discrimination, more activities of daily living limitations, and poor performance on the Short Physical Performance Battery. Predictors of higher frequency of nonsurgical admissions included increased age, poor physical health, negative psychological characteristics, higher levels of social support, and low perceived discrimination. Covariate analyses also showed African Americans were less likely than Caucasians to utilize nonsurgical overnight hospital admission services (HR=0.64, 95% CI, 0.50-0.84), with the lowest rates noted by African American men who were only 0.50 times as likely as Caucasian men to report a nonsurgical admission at any given time.
    Reference: Clay OJ, Roth DL, Safford MM, Sawyer PL, Allman RM. Predictors of. Overnight Hospital Admission in Older African American and Caucasian Medicare Beneficiaries. J Gerontol A Biol Sci Med Sci. 2011 May 12. [Epub ahead of print] PubMed PMID: 21565981.

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  1. Recent News & Drug Safety Advisories

    FDA recommends new dose limitations for simvastatin

    Bottom Line: June 08, 2011 - The U.S. Food and Drug Administration released recommendations restricting use of 80 mg per day simvastatin (ie Zocor, Vytorin, Simcor, etc) to be prescribed only to patients who have been using this dose for 12 months or more without evidence of myopathy. The FDA also advised that dosing for new patients and patients already taking lower doses of simvastatin should not be started on 80 mg per day. Also, patients who need to start a drug that interacts with simvastatin should be switched to an alternate statin to reduce likelihood of drug-drug interactions. Adverse effects arising in patients taking simvastatin should be reported to the FDA MedWatch program at http://www.fda.gov/Safety/MedWatch/default.htm.
    Reference: FDA Drug Safety Communication: New restrictions, contraindications, and dose limitations for Zocor (simvastatin) to reduce the risk of muscle injury. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. June 08, 2011. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm


    FDA concludes no increased risk of cancer with ARBs

    Bottom Line: June 02, 2011 - The FDA has completed an extensive review on the safety of angiogensin receptor blocker use and a possible association with the development of cancer and concluded that it found no evidence of an increased risk of new cancer, cancer-related death, breast cancer, lung cancer, or prostate cancer with the use of ARBs. The safety review was initiated following publication of a meta-analysis in 2010 that assessed five randomized trials comparing the use of ARBs versus no ARBs in approximately 62,000 patients. Results of the meta-analysis revealed a small but significant risk of cancer associated with ARB use. However, further review by the FDA through a meta-analysis of approximately 156,000 patients treated in 31 randomized controlled trials showed no increased risk of cancer with ARB use compared to non-users. The FDA concluded that use of ARBs did not increase the risk for cancer.
    Reference: FDA Drug Safety Communication: No increase in risk of cancer with certain blood pressure drugs--angiotensin receptor blockers (ARBs). [Internet]. Rockville, (MD): U.S. Food & Drug Administration. June 02, 2011. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm257516.htm.


    FDA Approves Solesta injectable gel for fecal incontinence

    Bottom Line: May 27, 2011 - The FDA announced approval of a Solesta (Oceana Therapeutics, Edison, NJ), a sterile gel injected into tissue below the anus lining to build tissue in the surrounding area and narrow the anus opening for improved bowel muscle control in adults with fecal incontinence for whom conservative treatments have failed.
    Reference: FDA News Release: FDA approves injectable gel to treat fecal incontinence. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. May 27, 2011. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257112.htm.

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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/biolib/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.



© Copyright 2011 Vanderbilt University Medical Center
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