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

Geriatrics Evidence Alert
September 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.  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

    Current evidence base weak for selecting nonpharmacologic strategies to manage agitation in older palliative care patients

    Question: What does the current evidence say about nonpharmacologic management of agitation in older palliative care patients?

    Bottom Line: The literature on nonpharmacologic interventions to manage restlessness, agitation, or delirium in older adults receiving palliative care consists mainly of anecdotal evidence from case reports, expert opinion articles, and general reviews of the literature. Overall, well-defined, systematic controlled studies that examine the use of behavioral and environmental strategies to manage agitation or delirium in palliative or terminal care settings are lacking; however, several interventions such as playing quiet music, continually orienting the patient, diverting patient attention during hallucinations, educating and involving family members, and consistently keeping the same care providers are commonly described as useful approaches throughout the published literature. [full text »]


    More randomized trials needed to determine best management approach for delirium in hospitalized older adults without critical illness

    Question: What is the current evidence based management of delirium in hospitalized older adults without critical illness?

    Bottom Line: Overall, the amount of high quality evidence (i.e. randomized trials) currently available on the management of delirium in older hospitalized patients is low, making generalization to practice difficult. More large randomized controlled trials with subgroup stratification, hard endpoints, and longer follow-up are needed to elucidate the most effective course of treatment for hospitalized patients in general medical units who develop delirium. [full text »]


    Clinical indicators of frailty in the elderly: Clear definition needed before reliable indicators can be identified

    Question: What are the clinical indicators of frailty in elderly adults?

    Bottom Line: Frailty is a multifaceted syndrome that involves physical, cognitive/psychological, nutritional and social risk factors, in addition to the general process of aging and occurrence of comorbidity and disease. Multiple descriptions characterizing frailty exist in the literature; however, consensus on a clear definition has not yet been reached, making identification and validation of clinical indicators more difficult (Abellan van Kan et al, 2008; Walston et al, 2006). [full text »]


    Literature on Milk of Magnesia lacks strong evidence for/against its efficacy and safety

    Question: How does milk of magnesia (MOM) compare to other agents regarding effectiveness, and is there toxicity associated with magnesium?

    Bottom Line: A paucity of quality research evidence (i.e. randomized trials) exists regarding the efficacy and safety of Milk of Magnesia, or magnesium hydroxide, for treating chronic constipation in adults. Only one direct comparison study (Kinnunen and Salokannel, 1987) and no comparative effectiveness studies were found that assessed MOM versus other agents for relieving chronic constipation in adults. Given the dearth of studies, information on its safety profile and toxicity are limited mainly to case reports of acute hypermagnesemia in patients with and without pre-existing renal dysfunction. Adverse effects, such as hypotension, cardiac dysfunction, hypoventilation, paralytic ileus, electrolyte imbalance, muscle weakness, and cardiac arrest have been consistently reported as resulting from hypermagnesemia due to consumption of magnesium hydroxide or magnesium citrate. [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

    American Academy of Neurology provides practice recommendations on driving risk in dementia patients

    Bottom Line: This practice parameter from the Quality Standards Subcommittee of the American Academy of Neurology provides evidence-based recommendations on the evaluation and management of driving risk in patients with dementia. Patient characteristics considered useful for identifying patients at risk of unsafe driving include: Clinical Dementia Rating scale score, Mini-Mental State Examination scores of 24 or less, marginal or unsafe driving reported by a caregiver, patient reports of situational avoidance or low driving mileage, a history of crashes or traffic citations, and aggressive or impulsive personality traits. Stronger evidence is needed for/against neuropsychological testing.
    Reference: Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010 Apr 20;74(16):1316-24. Epub 2010 Apr 12. Review. PubMed PMID: 20385882;PubMed Central PMCID: PMC2860481.


    International Osteoporosis Foundation suggests supplemental vitamin D requirements for elderly patients

    Bottom Line: Following a review of the current research evidence, the International Osteoporosis Foundation, which includes representatives from the United States, estimated an average vitamin D requirement of 20 to 25 µg/day (800 to 1,000 IU/day) for adults ages 65 years and older to achieve a serum 25OHD level of 75 nmol/L (30 ng/ml). Patients who are obese, have osteoporosis, limited sun exposure, malabsorption, or are of non-European high risk populations, such as those in the Middle East or South Asia, may need as much as 50 µg/day (2,000 IU/day).
    Reference: Dawson-Hughes B, Mithal A, Bonjour JP, Boonen S, Burckhardt P, Fuleihan GE,Josse RG, Lips P, Morales-Torres J, Yoshimura N. IOF position statement: vitamin D recommendations for older adults. Osteoporos Int. 2010 Jul;21(7):1151-4. Epub 2010 Apr 27. PubMed PMID: 20422154.


    NIH State of the Science conference examines evidence on Alzheimer’s disease and cognitive decline

    Bottom Line: On April 26-28, 2010, the National Institute on Aging and the Office of Medical Applications of Research of the National Institutes of Health convened an independent panel of medical experts for a state-of-the-science conference to assess the available research evidence on preventing Alzheimer's disease and cognitive decline. This consensus statement outlines the panel's discussion and conclusions based on a systematic review of the literature, expert presentations and open public discussion by conference attendees, and private panel deliberations. Topics covered include risk reduction, intervention efficacy and safety, relationships between factors affecting Alzheimer's disease and those affecting cognitive decline, and critical gaps in the current evidence for decision-making. Dr. Elaine Sanders-Bush, Professor of Pharmacology and Psychiatry at Vanderbilt University Medical Center, was one of 21 panel members providing their expertise at the conference.
    Reference:Daviglus ML, Bell CC, Berrettini W, Bowen PE, Connolly ES Jr, Cox NJ, Dunbar-Jacob JM, Granieri EC, Hunt G, McGarry K, Patel D, Potosky AL, Sanders-Bush E, Silberberg D, Trevisan M. National Institutes of Health State-of-the-Science Conference statement: preventing alzheimer disease and cognitive decline. Ann Intern Med. 2010 Aug 3;153(3):176-81. Epub 2010 Jun 14. PubMed PMID: 20547888. Full statement available from: http://consensus.nih.gov/2010/alzstatement.htm

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  1. Recently Published Research

    AHRQ review finds evidence insufficient to determine protective factors or risk for Alzheimer's disease and cognitive decline

    Bottom Line: A review of existing observational and intervention studies (25 systematic reviews, 250 primary studies) examining risk or protective factors associated with Alzheimer's Disease or cognitive decline sponsored by the Agency for Healthcare Quality and Research (AHRQ) found that the current research evidence is insufficient to make specific recommendations about behavioral, lifestyle, or pharmaceutical interventions and modifications to prevent or treat these conditions. Only diabetes, epsilon 4 allele of the apolipoprotein E gene (APOE e4), smoking, and depression were consistently associated with increased risk of AD and cognitive decline across multiple studies; however, the quality of the evidence was low and risk modification effects of the associations were small to moderate for AD and small for cognitive decline.
    Reference: Williams JW, Plassman BL, Burke J, et al. Preventing Alzheimer's disease and cognitive decline. Evid Rep Technol Assess (Summ). 2010 April; 193:1-727. Available from: http://www.ahrq.gov/clinic/tp/alzcogtp.htm.


    Meta-analysis finds protective effect of oral vitamin D supplementation on preventing falls

    Bottom Line: This systematic review of the literature and meta-analysis by Johns Hopkins University examined 10 selected randomized controlled trials (n=2,932) published through February 2009 to assess the effectiveness of oral vitamin D supplement therapy on the prevention of falls in older adults (mean age =60) with or without vitamin D deficiency. Studies with patients residing in hospitals, nursing homes, and the community were evaluated. Pooled analysis of study results showed that 68.1 (95% CI=35.1–98.5) out of 1,000 falls were avoided by 200–1,000 IU vitamin D therapy, which translated to 14% fewer falls compared to patients receiving calcium or placebo. The authors suggested that more trials are needed to determine the optimal dose and duration of vitamin D treatment to maintain beneficial effects for preventing falls.
    Reference: Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010 Jul;58(7):1299-310. Epub 2010 Jun 23. PubMed PMID: 20579169.


    Meta-analysis finds beneficial effect of multidisciplinary inpatient rehabilitation tailored for elderly

    Bottom Line: This systematic review and meta-analysis examined the effects of general or orthopedic (hip fracture) inpatient multidisciplinary rehabilitation programs tailored specifically for geriatric patients versus usual care on functional status, nursing home admissions, and mortality. The authors examined 17 randomized controlled trials selected for their use of a rehabilitation framework, called the International Classification of Functioning, Disability, and Health (ICF) Framework, set up by the World Health Organization (WHO) that includes a "multidimensional geriatric assessment, stringent assignment to therapies, regular team meetings with all health professionals involved in the care of the patient, goal setting tailored to the individual patient, interventions tailored to the patient's needs, and regular treatment evaluation with the care team and the patient." Data from 4,780 adults (intervention group, n=2,353), aged 55 years or older, were examined. Results showed that the geriatric programs had a significant beneficial effect compared to usual care on functional status, nursing home admissions, and mortality at hospital discharge and also at long term (one year) follow-up. Patients who underwent orthopedic rehabilitation showed greater functional improvement compared to those who participated in general geriatric rehabilitation. Based on an estimated nursing home admission rate between 10-30% for controls, the number needed to treat (NNT) to avoid one admission to a nursing home at hospital discharge for the intervention group was between 9 and 28. The NNT to avoid one admission to a nursing home after one year of follow-up was between 21 and 63. Regarding mortality, the NNT to prevent one death at one year follow-up was 38, using a one year mortality rate of 20% among controls.
    Reference: Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010 Apr 20;340:c1718. doi: 10.1136/bmj.c1718. Review. PubMed PMID: 20406866; PubMed Central PMCID: PMC2857746.


    Trial finds higher rate of falls and fractures with single annual high-dose vitamin D compared to placebo in older women

    Bottom Line: This single center, double-blind, randomized clinical trial assessed the effects on fall and fracture risks of a single oral dose of 500,000 IU of vitamin D (cholecalciferol) versus placebo administered once per year for 3 to 5 years. Participants were 2,256 community-dwelling women in Australia, aged 70 years or older, with a high fracture risk who were enrolled from 2003 to 2005. Results of intention-to-treat analyses in 2008 showed that the vitamin D group had significantly higher rates of fractures and falls than those taking placebo (fall rate per 100 person-years, 83.4 versus 72.7 respectively; fracture rate per 100 person-years, 4.9 versus 3.9 respectively). Compared to the placebo group, patients who received an annual oral dose of vitamin D experienced 15% more falls and 26% more fractures. Patients in the vitamin D group also experienced more fractures not associated with a fall.
    Reference: Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, Nicholson GC. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010 May 12;303(18):1815-22. Erratum in: JAMA. 2010 Jun 16;303(23):2357. PubMed PMID: 20460620.


    Study compares diagnostic accuracy of bedside instruments for detecting delirium in hospitalized adults

    Bottom Line: This systematic review examines prospective studies published from 1950 to May 2010 that compared the diagnostic accuracy of at least one delirium bedside instrument with a specialist's (geriatrician, psychiatrist, or neurologist) clinical diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a reference standard for diagnosing delirium in hospitalized adults treated in noncritical care units (acute geriatric, rehabilitation, orthopedic, oncology, palliative care, etc.). The authors examined data on on a total of 11 instruments tested across 25 studies (see box 1). Study sample sizes ranged from 26 to 791 participants (n = 3027). Despite wide heterogeneity among studies, the results of likelihood ratio analyses showed that the Confusion Assessment Method (CAM) had the best available supportive data as a bedside instrument while the Mini Mental State Exam (MMSE) was the least useful for identifying a patient with delirium among all the scales tested. This review was subject to possible publication bias since funnel plot asymmetry could not be assessed due to the small number of studies examined.
    Reference: Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA. 2010 Aug 18;304(7):779-86. Review. PubMed PMID: 20716741.

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  1. FDA News & Safety Advisories

    FDA approves new injectable osteoporosis drug

    Bottom Line: June 1, 2010 – The FDA announced approval of Prolia, a new injectable drug developed by Amgen Manufacturing Limited (Thousand Oaks, CA) to treat osteoporosis in postmenopausal women who are at high risk for factures. Approval was based primarily on data from a large randomized clinical trial involving over 7,800 postmenopausal women ages 60 to 91 years with osteoporosis that showed a reduced incidence of vertebral, non-vertebral, and hip fractures in patients taking Prolia compared to placebo.
    Reference: FDA News Release: FDA approves new injectable osteoporosis treatment for postmenopausal women. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. June 01, 2010. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm214150.htm


    FDA launches safety review for possible increased risk of cancer with ARBs

    Bottom Line: July 15, 2010 – The U.S. Food and Drug Administration (FDA) announced that they have begun an ongoing safety review of available research data on angiotensin receptor blockers (ARBs), a class of drugs used to treat high blood pressure or heart failure, for a link between their use and the development of new cancer. The review was sparked in response to a newly-published meta-analysis of more than 60,000 people observed in several long-term, randomized, controlled clinical trials. The results showed a small increased risk of reported new cancers in patients taking an ARB compared to those who did not. The study also found a small but nonsignificant significant difference in the number of cancer deaths between patients taking an ARB versus those who did not. However, the study included data from clinical trials that were not designed to study the effects of ARBs on cancer risk. The FDA reported that it currently believes the benefits of ARBs outweigh their potential risks and patients should continue using the drugs as recommended in their labels.
    Reference: FDA drug safety communication: Ongoing safety review of the angiotensin receptor blockers and cancer. [Internet]. Rockville, (MD): U.S. Food & Drug Administration. July 15, 2010. Available from: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm218845.htm.


    Federal report released on key indicators of well-being in older Americans

    Bottom Line: July 19, 2010 – The Federal Interagency Forum on Age-Related Statistics released a 155-page report called Older Americans 2010: Key Indicators of Well-Being that contains statistical data and trends on 37 key indicators about the health and economic status of Americans ages 65 and older. The indicators are divided into the following five areas: population, economics, health status, health risks and behaviors, and health care.
    Reference: Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: Key indicators of well-being. Federal Interagency Forum on Aging-Related Statistics. [Internet]. Washington (DC): U.S. Government Printing Office. July 2010. Available from: http://www.agingstats.gov/agingstatsdotnet/main_site/default.aspx


    CDC releases data on trends in office-based physician services and population aging

    Bottom Line: August 06, 2010 – The National Center for Health Statistics (NCHS) within the Centers for Disease Control and Prevention (CDC) published a data brief outlining trends in office-based health care services provided over the past thirty year to patients of different ages. The report uses statistical data obtained from the National Ambulatory Medical Care Survey for 1978, 1998, and 2008 to describe trends for office visits by patients ages 45 years and older and for those 65 years and older. For example, primary care visits made up 62 percent of office visits by patients aged 65 and over in 1978 compared with only 45 percent in 2008. In contrast, older patients increased their visits to medical or surgical specialty physicians from 37 percent in 1998 to 55 percent in 2008. The primary diagnoses with the largest increases in office visits by patients 65 and older from 1998 to 2008 were essential hypertension, cardiac dysrhythmias, and diabetes. See the full report for additional trends summarized from the data.
    Reference: Cherry D, Lucas C, Decker SL. Population aging and the use of office-based physician services. NCHS Data Brief, Number 41. [Internet]. Hyattsville (MD): National Center for Health Statistics. August 2010. Available from: http://www.cdc.gov/nchs/data/databriefs/db41.htm.


    CDC publishes national hospitalization rates for older patients with septicemia or sepsis

    Bottom Line: September 03, 2010 – The Centers for Disease Control and Prevention (CDC) recently published a QuickStats report outlining hospitalization rates in the United States collected via the National Hospital Discharge Survey (NHDS) for patients ages 65 years and older diagnosed with septicemia or sepsis. Data for 2000 to 2007 stratified by age group showed a 57% increase in the rate of hospitalizations for septicemia or sepsis for adults aged 65 to 74 years (6.5 per 1,000 to 10.2) and a 52% (from 11.7 per 1,000 to 17.8) increase for those aged 75 to 84 years. While the rate for patients with septicemia or sepsis aged 85 years and older increased less (18%) than the other two age groups during this period, the overall hospitalization rate for this group due to these bloodstream infections remained higher (from 24.7 per 1,000 to 29.2).
    Reference: Centers for Disease Control and Prevention (CDC). QuickStats: Hospitalization rates for patients aged =65 years with septicemia or sepsis, by age group --- National Hospital Discharge Survey, United States, 2000--2007. MMWR Morb Mortal Wkly Rep. September 3, 2010; 59(34):1108. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a6.htm?s_cid=mm5934a6_w

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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.



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