Informatics Center Knowledge Management / Eskind Biomedical Library Geriatrics Evidence Alert

Geriatrics Evidence Alert
September 2008


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 monthly 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.  FDA 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

    Limited evidence for management of recurrent infection with chronic indwelling urinary catheters

    Question: What is the current management for recurrent infection with chronic indwelling urinary catheters?

    Bottom Line: There appears to be a dearth of information pertaining to recurrent infections in patients with long-term catheterization. Several guidelines and review articles exist for the management and prevention of urinary tract infection (UTIs) in both long-term and short-term catheterized patients, but with little mention of managing recurrence. This summary includes information from guidelines and review articles on the treatment and prevention of catheter-associated infections. [full text »]


    Conflicting evidence for efficacy and duration of benefit with Synvisc for elderly patients with osteoarthritis

    Question: What is the efficacy of Synvisc in elderly patients with osteoarthritis? What is average duration of benefit (if any)? Note: ok to include international studies with other injectable forms of synthetic cartilage replacement.

    Bottom Line: The available research on Hylan GF-20 injection restricted to elderly patients only is sparse overall. Few randomized trials were located that directly targeted patients age >65 years or that stratified subjects by age prior to randomization. The following paragraphs and table summarize five prospective studies selected for their emphasis on use of Hylan GF-20 injection and/or a study population of >60 years old. As may be expected given variance in study methodologies, some of the findings and author conclusions in the studies conflict. [full text »]


    Adding low-dose aspirin to anticoagulation therapy may aid patients with artificial heart valves

    Question: What is the evidence for adding low-dose aspirin to full warfarin anticoagulation in patients with an artificial heart valve?

    Bottom Line: Included in this summary are two meta-analyses (Massel, 2001; Larson, 2004) analyzing randomized controlled trials, which evaluate the safety and efficacy of adding aspirin to warfarin in patients with mechanical heart valves. Both studies recommend the addition of aspirin to warfarin therapy in reducing the risk of mortality and thromboembolic events. Due to aspirin's association with increased risk of hemorrhage, Massel et al suggests the use of low-dose aspirin. Also included in the summary is a randomized trial by Trudie et al (1993) as it is an oft-cited article, investigating the addition of low-dose aspirin (100 mg/day) to warfarin in mechanical valve patients. According to the authors, this combination therapy significantly reduced the risk of mortality and thromboembolic events. While bleeding events occurred significantly more frequently in those taking aspirin compared to the placebo group, the number of major bleeding events did not differ significantly between the two groups. [full text »]


    Literature lacks strong evidence for management of UTI in adults with chronic urinary calculi

    Question: What is the current management for recurrent infection with chronic urinary calculi?

    Bottom Line: Following an extensive search of the biomedical research and related clinical practice guidelines, it appears there is a dearth of literature that specifically addresses management strategies for recurrent urinary tract infection (UTI) in adults with chronic urinary calculi, including recurrent infection due to kidney stones. Recommendations based on expert opinion and consensus reported in clinical guidelines from the European Association of Urology suggest that complicated UTIs associated with urinary stones should be managed by complete stone removal, antimicrobial therapy, and urine culture prior to and after antimicrobial therapy to identify resistant micro-organisms and prevent recurrent infection. Long-term antimicrobial therapy should be considered if stones cannot be completely removed (Grabe et al, 2008). The American Urological Association has developed a report on best practices on antimicrobial prophylaxis for urologic surgery to reduce the incidence of surgical site infection and postop UTIs (AUA, 2008). [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

    USPSTF concludes available evidence is insufficient regarding prostate cancer screening

    Bottom Line: Following a literature review of the available evidence, the USPSTF concluded that there is insufficient evidence to determine the balance of benefits and harms of prostate cancer screening in men younger than age 75 years (Level I). The Task Force recommended against screening men ages 75 years and older based on moderate or high certainty that screening has no net benefit or that the harms outweigh the benefits (Level D). [full text »]
    Reference: U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive services task force recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 August. [Accessed September 09, 2008]


    USPSTF recommends screening asymptomatic adults for type 2 diabetes based on blood pressure level

    Bottom Line: The USPSTF recommended that asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg (treated or untreated) should be screened for type 2 diabetes (Level B). It concluded that the current evidence is insufficient to determine the balance of benefits and harms of screening asymptomatic adults with blood pressure equal to or lower than 135/80 mm Hg (Level I). [full text »]
    Reference: U.S. Preventive Services Task Force. Screening for lipid disorders in adults: U.S. Preventive Services Task Force recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 June. [Accessed September 09, 2008]


    ACIP Finalizes Zoster Vaccine Recommendations

    Bottom Line: June 6, 2008 – The ACIP finalized its recommendation that all persons aged >60 years should be vaccinated with 1 dose of zoster vaccine. Persons with a previous history of zoster and persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications or precautions. The ACIP suggested that it is not necessary to ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity before routine administration of zoster vaccine. The ACIP also reported that different safety concerns are not expected in persons with a history of zoster despite a lack of research evidence to support the safety and efficacy of zoster vaccine in this group. The zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing PHN, or to treat ongoing PHN. [full text »]
    Reference: Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NS; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008.MMWR Recomm Rep. 2008 Aug 8;57(RR-7):1-60.PMID: 18685555

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  1. Recently Published Research

    Dimebon shows significant improvement in cognition for patients with mild-to-moderate Alzheimer's

    Bottom Line: This multicenter, randomized, double-blind placebo-controlled trial in Russia assessed the efficacy and safety of dimebon therapy (n=89) versus placebo (n=94) on cognition (as measured by the cognitive subscale of the Alzheimer's disease assessment scale) in patients with mild-to-moderate Alzheimer's disease. Results showed that treatment with dimebon produced significant benefits in cognition compared with placebo at week 26 (mean drug-placebo difference -4.0 [95% CI -5.73 to -2.28]; p<0.0001). Also, patients who received dimebon showed significant improvement over baseline for cognition (mean difference -1.9 [-2.92 to -0.85]; p=0.0005). [full text »]
    Reference: Doody RS, Gavrilova SI, Sano M, Thomas RG, Aisen PS, Bachurin SO, Seely L, Hung D; dimebon investigators. Effect of dimebon on cognition, activities of daily living, behaviour, and global function in patients with mild-to-moderate Alzheimer's disease: a randomised, double-blind, placebo-controlled study. Lancet. 2008 Jul 19;372(9634): 207-15. PMID: 18640457


    Randomized trial of fish oil supplementation does not show significant cognitive improvement in older adults

    Bottom Line: This double-blind, placebo-controlled, randomized clinical trial examined the effect of 1,800 mg/d eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation on cognitive performance in 302 cognitively healthy adults (MMSE scores above 23) who were aged 65 years or older. Participants were randomized to 1,800 mg/d EPA-DHA, 400 mg/d EPA-DHA, or placebo capsules for 26 weeks. Although plasma concentrations of EPA-DHA increased by 238% in the high-dose and 51% in the low-dose fish oil group compared with placebo, there were no significant differences among groups in any of the cognitive domains tested, such as attention, sensorimotor speed, memory, and executive function. [full text »]
    Reference: van de Rest O, Geleijnse JM, Kok FJ, van Staveren WA, Dullemeijer C, Olderikkert MG, Beekman AT, de Groot CP. Effect of fish oil on cognitive performance in older subjects: a randomized,controlled trial. Neurology. 2008 Aug 5;71(6):430-8. PMID: 18678826


    Problem-solving therapy as collaborative care within a primary care clinic compared to usual care effective for reducing late-life depression in older adults

    Bottom Line: This multicenter comparative study was performed as a secondary analysis of the IMPACT study which examined the effectiveness of a primary-care-based psychotherapy, called problem-solving therapy for primary care (PST-PC), compared to usual care by community-based psychotherapy for treating adults ages 60 years and older with late-life major depression and dysthymia. Secondary analysis of 433 participants who received either collaborative care with PST-PC or usual care through community-based psychotherapy revealed that participants who received PST-PC were free of depression more days at both 12 months and between 12 and 24 months and experienced significantly fewer depressive symptoms and better functioning at 12 months compared to those who received community-based psychotherapy. No differences were noted between groups at 24 months, however. [full text »]
    Reference: Arean P, Hegel M, Vannoy S, Fan MY, Unuzter J. Effectiveness of problem-solving therapy for older, primary care patients with depression: results from the IMPACT project. Gerontologist. 2008 Jun;48(3):311-23.PMID: 18591356


    Tibolone reduces fracture risk and breast cancer risk but increases stroke risk in older women with osteoporosis

    Bottom Line: This multicenter, randomized controlled trial examined the efficacy and safety of administering once-daily 1.25 mg tibolone versus placebo to 4538 postmenopausal women ages 60 to 85 years old with a bone mineral density T score of –2.5 or less at the hip or spine or a T score of –2.0 or less and radiologic evidence of a vertebral fracture to assess its effects on the development of fractures, breast cancer, and cardiovascular disease. Compared to placebo, results at a median of 34 months showed decreased risk of vertebral and nonvertebral fracture, as well as a decreased risk of invasive breast cancer and colon cancer. In contrast, the tibolone group showed an increased risk of stroke and the trial was stopped by the data safety monitoring board. No significant differences were noted between placebo and tibolone groups for the risk of either coronary heart disease or venous thromboembolism. [full text »]
    Reference: Cummings SR, Ettinger B, Delmas PD, Kenemans P, Stathopoulos V, Verweij P, Mol-Arts M, Kloosterboer L, Mosca L, Christiansen C, Bilezikian J, Kerzberg EM, Johnson S, Zanchetta J, Grobbee DE, Seifert W, Eastell R; LIFT Trial Investigators. The effects of tibolone in older postmenopausal women.N Engl J Med. 2008 Aug 14;359(7):697-708.PMID: 18703472

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  1. FDA News & Safety Advisories

    FDA warns of increased mortality risk in elderly patients treated with antipsychotics for dementia-related psychosis

    Bottom Line: June 16, 2008 – The FDA announced that it is now requiring that manufacturers of conventional and atypical antipsychotic drugs, such as haloperidol, aripiprazole, and clozapine, add a Boxed Warning and Warning to prescribing information alerting users about the risk of death in elderly patients treated for dementia-related psychosis. The FDA also advised health care providers to consider that antipsychotic drugs are not approved to treat dementia-related psychosis and that there is currently no approved drug for the treatment of this condition. [full text »]
    Reference: Information for healthcare professionals: Antipsychotics. [Internet]. Medwatch 2008 safety alerts for drugs, biologics, medical devices, and dietary supplements. Rockville, (MD): U.S. Food & Drug Administration, Center for Drug Evaluation & Research. June 16, 2008. [Accessed September 09, 2008]


    CDC releases framework monograph for translating public health research on caregiving into practice

    Bottom Line: This monograph sponsored by the Centers for Disease Control and the Kimberly Clark® Corporation focuses on the burden and impact of caregiving, the challenges of translating public health research into practice, and presents cases of how the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was applied as a framework to maximize the successful translation of evidence-based interventions for caregiving issues. [full text »]
    Reference: Centers for Disease Control and Prevention and the Kimberly-Clark Corporation. Assuring Healthy Caregivers, A Public Health Approach to Translating Research into Practice: The RE-AIM Framework. Neenah, WI: Kimberly-Clark Corporation; 2008. [Accessed September 09, 2008]


    Medicare Improvements for Patients and Providers Act of 2008 Enacted

    Bottom Line: July 15, 2008 – Several modifications have been made to the Medicare program as a result of the enactment of the Medicare Improvements for Patients and Providers Act of 2008. Modifications include Medicare Physician Fee Schedule (MPFS) rate revisions, including increases in the fee schedule amounts for specific mental health services. The mid-year 2008 MPFS rate of -10.6 percent has been replaced with a 0.5 percent update which retroactively applies from July 1, 2008. Other changes include reinstatement of therapy cap extensions for medically necessary therapy services delivered in excess of the therapy caps. Also the law delays the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. [full text »]
    Reference: Medicare improvements for patients and providers act, 2008. CMS Office of Public Affairs, Baltimore (MD): Centers for Medicare & Medicaid Services. July 16, 2008 [Accessed September 09, 2008]

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About Geriatrics Evidence Alert
The Geriatrics Evidence Alert is a monthly 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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