Update in Geriatrics2020

Suzanne Salamon, MD

Chief Clinical Geriatrics Programs

Division of Gerontology,Dept. of Medicine

Beth Israel Deaconess Medical Center

Assistant Professor Harvard Medical School

No Disclosures

Structure

• Background which led to study

• Study structure

• Results

• Conclusion

• Title and Reference

Topics• Post-op care-home or inpatient rehab?

• Can a smartwatch reliably detect a. fib?

• COVID 19 ,Telemedicine, LTC

• B12 deficiency-shots or pills?

• Best exercise to prevent falls

• Relation between brain MRI white matter disease and gait?

• Age-related low testosterone-should we treat?

• Amyloid PET scans-ready for prime time?

• Myths about getting older

What is the best place for

post-acute care discharge?

Home or Inpatient Rehab?

Assessment of Outcomes on Inpatient

or Clinic-Based vs Home-Based

Rehabilitation After Total Knee

Arthroplasty

Jama Network Open.2019:2(4):3192810.doi:10.1001

Buhagiar et al

Background• TKA one of most common OR procedures

• Expense has led to bundled payments

• Studies show sig.cost differences from 5X to 26 X between inpatient vs outpatient rehab

• Options for post-op rehab include inpatient rehab and outpt. rehab (1:1 or group), home visits by PT, telerehabilitation, or unmonitored home program

• This meta-analysis was done to look at whether inpatient rehab is superior to home-based program in regard to pain and function after elective, unilateral TKA

The Study• Meta-analysis of 5 studies involving 752

patients from 2015-2018 who had unilateral

TKA and had rehab within 6 postoperative

weeks either inpatient or home-based

• Primary outcomes : mobility (6 minute walk

test) and patient-reported and function reported

at 10 and 52 post-op weeks.

Results

• 752 patients, 60% female

• Mean age 68

• No clinically important difference between

inpatient and home-based programs for

mobility at 10 weeks and 52 weeks in pain

and function, quality of life, and knee flexion.

Conclusion

• Outcomes at 10 and 52 weeks were similar for mobility (6-minute walk), range of motion, pain, and quality of life, and knee flexion regardless of rehabilitation setting following TKA.

• Patients with no social support at home might require brief inpatient rehabilitation

• Suggests there may be no basis for requiring TKA rehab to take place in inpatient setting

Patient Outcomes After Hospital Discharge

to Home with Home Health Care vs to a

Skilled Nursing Facility

• Jama Intern Med.2019;179(5):617-623

Werner et al

Background• >40% Medicare beneficiaries receive postacute care after

hospital discharge

• 90% of those go either to a SNF or home with care from a home health agency

• 2015,Medicare spent > $60 billion on post-acute care

• Many new alternative payment models being introduced, yet unclear what the risks and benefits are of various choices

• This study done to look at 30-day readmission, 30-day mortality, functional outcomes and Medicare payment in pts d/c’d to home with home health care vs SNF

The Study• Retrospective study using Medicare claims data from

short-term acute-care hospitals in U.S., and SNF and home health assessment data from 2010-2016 on Medicare beneficiaries who were discharged from hospital to home with home health care or to a SNF.

• Main outcomes:

-Readmission within 30 days of hospital discharge

-Death within 30 days of hospital discharge,

-Improvement in functional status in postacute period

-Medicare payment for 60 days after hospital d/c

Results• >17 million hospitalizations ( 5 most common:THR/TKR,

sepsis, CHF, pneumonia, UTI)

• 62% women , average age 80

• 39% discharged to home with home health care, 61% discharged to /SNF.

• D/c to home had a 5.6% higher 30 day readmission rate compared to SNF

• No sig.difference 30-day mortality rates or improved functional status

• Medicare payment sig lower for d/c to home compared to d/c to SNF as was total Med.payment 60 days following admission (± $5000)

Conclusion

• Medicare beneficiaries discharged to home with home health care was associated with higher rates of readmission, no difference in mortality or functional outcomes and lower Medicare payments, even after accounting for lower costs from fewer readmission from SNF’s,

Large-Scale Assessment of a

Smartwatch to Identify Atrial

Fibrillation

N Engl J Med 2019 ;381:1909-17

Perez et al

Background• Atrial fibrillation-significant cardiac arrhythmia

• 6 million in US, lifetime risk as high as 1 in 3

• Increases risk of stroke X5

• Diagnosis easily missed, since often paroxysmal

• Often asymptomatic

• High risk often identified with Zio patch, Holter, but

even these are time limited

Background• USPSTF current evidence is insufficient to support ECG

screening for a.fib, but acknowledges that newer devices including wearables and smartphones may fill a gap on ECG monitoring

• Both AHA and ASA recommend active screening for a-fib for adults >65 using pulse palpation or ECG

• Widespread use of internet-connected devices could provide large, easy way to detect a-fib, but ability of smartwatch app to identify a-fib during typical use unknown

• This study done to evaluate ability of an irregular pulse notification app to identify a fib.

The Study

• Participants without known atrial fibrillation (AF)

used an Apple iPhone app to consent to monitoring.

• If irregular pulse identified possible AF, wearers were

notified and an ECG patch was mailed to be worn for

up to 7 days.

• Main objectives were to see what proportion of

notified participants did have AF based on ECG patch

Results• 419,297 participants.

• Over 117 days of monitoring, 2161 (0.52%), received

notifications of irregular pulse (only 3.2% > 65).

• 450 returned the ECG patches.

• A fib was present in 34% overall, all ages

Conclusion• Probability of receiving an irregular pulse notification

was low

• Of those who did receive a notification of an irregular pulse, 34% had AF on ECG patch readings, w/majority lasting > 1 hour

• >50% sought medical attention after notification

• Future wearable devices facilitate research, detection, monitoring and treating diseases

Does Telehealth Delivery of a Dementia Care

Program Provide a Noninferior Alternative to

Face to Face delivery of the Same Program

Am J Geriatr Psychiatry 2020 Mar 2

Laver, et al

Background

• Before COVID-19,studies done to evaluate whether

telehealth had same benefits as office visits

• >70 % people with dementia cared for by family/aids

• Nonpharmacologic intervetions help reduce

functional decline and service utilization, and

improve QOL. Caregivers need support,training.

• Telehealth programs compared to in person

The Study• Participants randomized to receive either

telehealth or home visit delivery of the same intervention program.

• Primary outcomes were caregiver’s perceptions of ADL, behavioral symptoms of person with dementia.

• Therapists recorded time spent in the intervention as well as travel time.

Results

• Both groups had sig.improvements in caregiver’s perceptions of change.

• Time spent was 256 minutes in the travel group vs 77 minutes in telehealth group.

CONCLUSION

Telahealth and in person interventions had similar benefits for families

COVID 19 and Telehealth

• Starting March 6,2020, Medicare will pay for

Medicare telehealth services at same rate as in-

person visits.

• Medicare coinsurance/deductible would

generally apply, but allows flexibility for

reduction or waiving

Pros

-Convenience. Can schedule visit when caregiver is

there,can loop in another person onto visit

-Less time waiting. Waiting for ride both ways, finding

a ride, waiting in waiting room

-Reduce travel expenses

-Clinicians can bill for phone visits, any time of day

-HIPPA protected

Cons

• Electronic issues. Does patient have a smart phone for video visits, or a phone for phone visits?

• Resistance by clinicians-Takes getting used to, training

• Inadequate assessment. Miss non-verbal cues, can’t listen to heart, lungs, do palpation. But can visualize how “well” or “sick” a patient is, see a rash, see patient in their home environment

Epidemiology of COVID-19 in a long-term

care facility in King County, Washington

McMihael, Kimball et al.

N Engl J Jed 2020 Mar 27:

Findings• First LTC facilities in Wash.with outbreaks

• Most infected residents had resp.sx,but 7 asymptomatic

• Hospitalization rates:residents 55%(ave 83 YO),visitors

50%(ave 63YO) ,6% staff(ave 44 YO)

• Death rate 34% residents

• 30% residents tested tested +,>1/2 asymptomatic; 7 days

later,10/13 had symptoms

• Asymptomatic may have high viral loads-helps explain

acquisitions w/o known exposure.

• MUST ASSUME ALL CONTACTS MAY BE COVID

CONTACTS

Prevalence of Inappropriateness of

Parenteral Vitamin B12

Administration in Ontario, Canada

JAMA Intern Med.2019;179(10):1434-1436

Silverstein et al

Background• Vitamin B12(aka cobalamin)present in many animal

products (meat, dairy, eggs)

• Vitamin B12 deficiency more common with age

• Causes include pernicious anemia, atrophic gastritis, meds eg PPI, H2blockers, metformin, Graves disease, lupus, vegan or strict vegetarian diets, some surgeries

• Symptoms can include neuropathy in hands/feet, balance problems, anemia, swollen tongue, memory loss, weakness, fatigue

• Estimated that 3.2% >50YO have serious low B12, up to 20% may have borderline B12 deficiency

Background, cont• Most get enough B12 through diet, but older people have

decreased absorption

• MDR approx 2-2.4 mcg/day

• B12 deficiency-treated with shots or pills

• Studies have shown that oral B12 1000 μg adequate to treat pernicious anemia & effective alternative to B12 IM injections

• B12 shot costs $20-$77/month:pills 3 cents/pill or

• $.90/month

• Yet many still give B12 injections

• This study done to determine inappropriate B12 supplementation and associated costs

The Study• Retrospective study in Ontario, Canada

• All people >65 YO who received at least 1 B12 IM injection prescription 2011-2018 included

• Primary outcome-”inappropriate” B12 supplementation defined as people with either a normal B12 level (> 221 pmol/L) or without a documented B12 level before first IM B12 prescription

• “Appropriate” when at least 1 documented low B12 level (<221) in the year before B12 injection

• Annual cost in Canadian dollars for monthly injection: physician visit $33,injection $3.89,B12 cost $6.74

Results• 405,469 IM B12 prescriptions dispensed to

146,000 people

• 25% had normal B12 levels

• 38% had no B12 level documented

• Estimated annual cost of inappropriate B12 prescribing was $45.6 million

• Only 1.7% prescribed IM B12 diagnosed with malabsorptive indication

Conclusion

• Most B12 IM injections prescribed to persons

without evidence of deficiency

• Potential reasons-patient demands and poor

physician awareness of evidence of oral B12

effectiveness

Effectiveness of a Therapeutic Tai Ji

Quan Intervention vs a Multimodal

Exercise Intervention to Prevent Falls

Among Older Adults at High Risk of

Falling

JAMA Intern Med 2018:178(10):1301-1310

Li, et al

Background• Falls in older adults are a major public health problem

• Every year 28% of community adults >65 fall, and 38% of these falls result in injuries leading to E.D. visits, hospital admissions or death.

• Falls are often preventable with exercise being a safe and effective way to reduce falls

• But what are the best fall prevention interventions?

• This study looked at the comparative effectiveness of Tai Ji Quan and multimodal (balance, aerobics, strength and flexibility activities) and stretching

The Study• Randomized clinical trial 2015-2018 in Oregon

• 670 community dwelling-adults >70 who had fallen in the last year or had impaired mobility

• Randomized to one of 3 exercise interventions:

-2 60-minutes classes/week for 24 weeks of Tai Ji

Quan

-Multimodal exercise (MME) twice/week (balance,

aerobics, strength and flexibility activities)

-Stretching

Primary outcome: incidence of falls

The Exercises

• Tai chi-balance and stability training described

as “unilateral weight bearing and weight-

shifting movements, trunk and pelvic rotation,

ankle sway and eye-head-hand movements”

• Multi-modal exercise-aerobic conditioning,

strength, balance and flexibility

• Stretching-stretching, breathing and relaxation

Results

• At 6 months, falls were reduced by 31% for the Tai

Ji group compared with the MME group and 58%

reduced incidence of falls compared with stretching.

Conclusion

• Among community-dwelling older adults at high

risk for falls, a tai Ji Quan balance training

intervention was more effective than conventional

exercise approaches for reducing the incidence of

falls

Impact of small vessel disease in

the brain on gait and balance

Sci.Rep.7,41637;doi:10.1038/srep41637 (2017)

Pinter,D. et al

Background• Gait and balance problems are common in older

people(15% at age 60, 50% at age 80)

• Cerebral small vessel disease (CSVD)-seen on MRI

• Other terms are small vessel ischemic disease, white matter disease, periventricular white matter changes, chronic microvascular (ischemic) changes, white matter hyperintensities, age-related white matter change, leukoaraiosis

• Usually only cognitive decline is the only outcome we look at MRI for, but MRI may help explain gait/balance problems.

Background, cont.• This study looked at the potential link between

SVD MRI markers and gait/balance function

in older healthy adults

• They also looked at other risk factors in

combination with the MRI results

Brain MRI

The Study

• 678 community healthy people age 71-74 who underwent risk factor and gait/balance assessment, as well as brain MRI.

Results• SVD-related brain changes associated with worse

performance in gait speed, chair-stands test and standing balance in older community-dwelling subjects.

Conclusion

• Presence of white matter hyperdensities seem

to be a major driving force for SVD on gait

impairment in healthy older subjects

• Consider treating these as any vascular disease

• Also helps explain gait issues to patients

Is it Low T?

Background• Age-related decline in serum total testosterone (T) levels

begins in mid-30s and continues at average rate of 1.6%/year

• In US, 20% of men>60, 30% > 70, 50%>80

• Unclear if sx such as sexual dysfunction, low energy and muscle mass, mood, BMD changes, hair loss, weakness and mortality are related to low T, or to other factors of aging, disease, medications

• Safety of testosterone replacement controversial with contradicting studies

Background, cont

• Given via transdermal gels, patches or I.M.

• No accepted threshold of T levels below which sx of androgen deficiency and adverse health outcomes occur

• In 2014,FDA released warning about T therapy and potential risk of M.I and stroke, causing decrease in prescriptions from 2.3 million men in 2013 to 1.15 million men in 2016

Association of Testosterone Therapy

with Risk of Venous Thromboembolism

Among Men with and Without

Hypogonadism

JAMA Intern Med Published online November 11, 2019

Walker et al

The Study/Results

• >39,000 men in study, 7.8% had low T

• Men with VTE (P.E. and/or DVT) matched with themselves before and after T therapy

• T therapy use associated with 20% higher risk of VTE with or without low T, many within first 3 months of therapy

• Concluded that T therapy associated with an increase by 20 % of the risk for VTE

Cardiovascular and Cerebrovascular

Safety of Testosterone Replacement

Therapy Among Aging Men with Low

Testosterone Levels

American Journal of Medicine

(2019)132:1069-1077

Loo et.al

The Study/Results• Assessed the risk of ischemic stroke, TIA, M.I. associated

w/TRT (T replacement therapy)

• 15,000 men between 1995 and 2017 age >45 with low T levels and compared risk of CVD with TRT with nonusers and found an increased risk

• Highest in 6 months-2 years after starting therapy

Conclusion

• Concluded that TRT may increase risk of CV events in aging men w/low T levels, mainly in first 2 years of use.

Testosterone Treatment in Adult Men

with Age-Related Low Testosterone: A

Clinical Guideline from the American

College of Physicians

Annals of Internal Medicine Jan, 2020

Qaseem, Diem et al

• Recommendations for T treatment in men with age-related low T based on 38 trials looking at efficacy and safety: (all low to moderated certainty evidence)

1.Men with low T may show small improvements in sexual function with T treatment, but little or no improvement on physical function, depression, energy, cognition

2.Re-evaluate symptoms within 12 months and d/c if no improvement

3. Consider IM over gel-cheaper,same effect

4. Do not start T with men with low T to improve energy, physical function or cognition

Bottom Line

• Testosterone treatment for nonspecific symptoms of

aging, especially in men without confirmed

testosterone deficiency, is not indicated

• Sexual dysfunction with documented testosterone

levels below normal may respond to treatment, but

needs discussion about potential adverse effects and

close supervision

Association of Amyloid Positron Emission

Tomography (PET)with Subsequent Change

in Clinical Management Among Medicare

Beneficiaries with Mild Cognitive Impairment

or Dementia

JAMA.2019;32(13):1286-1294

Rabinovici et al

Background• Amyloid PET can detect amyloid plaques, a core feature

of Alzheimer’s disease (Alz) 88-98% sensitivity and 80-95 % specificity compared to autopsy.

• Used now mainly in research

• Clinical criteria we use now much more limited

• 2013 CMS (Medicare & Medicaid) decided evidence insufficient to cover PET for routine clinical care.

• However, CMS agreed to cover PET scans if studies showed that PET improved health outcomes.

Background, cont.

• No disease-modifying treatments yet, what would be the outcome of those changes?

• Would PET scan change clinical management?

• To help determine this, in 2013, the IDEAS (The Imaging Dementia-Evidence for Amyloid Scanning) study was designed (largest of its kind)

• This study done to determine if amyloid PET is associated with change in management of patients with mild cognitive impairment (MCI) or dementia of uncertain etiology.

The Study• 946 dementia specialists in US enrolled >16,000 pts Feb

2016-Sept 2017 and follow-up thru Jan 2018.

• Specialists documented their diagnosis and management plan before PET and again 90 (±30) days after PET

• Had to meet appropriate use criteria for amyloid PET:

1.Cog. impairment with unclear etiology after eval by dementia specialist

2. May have Alz disease

3. Amyloid PET findings would change dx and management

INAPPROPRIATE CRITERIA FOR PET

-Diagnosis made clinically - To determine dementia severity - Based solely on + family history of dementia

or presence of APOE e4

-In asymptomatic individuals

-Nonmedical use (legal, insurance coverage, employment screening).

-Pts w/core clinical criteria for probable AD, typical age of onset

The Study, cont

• Primary outcomes

1-Change in clinical management in pre-and post-

PET visits (Alz drug therapy, other drug therapy,

counseling/future planning)

2-Pt clinical outcomes, to be reported at a future date

Results• 11,000 completed study, median age 75

• Amyloid PET positive in 55% with MCI and 70% with dementia

• Etiologic diagnosis changed from Alz disease to Non-Alz disease in 25% and from non-Alz dis to Alzdisease in 10.5%

• Changes in clinical management made 85% time when change in dx made (eg changes in Alz drugs, non-Alz drugs, counseling)

CONCLUSION• Among Medicare beneficiaries with MCI or dementia

of uncertain etiology evaluated by dementia

specialists, use of amyloid PET associated with

changes in clinical management within 90 days

• Further research needed to determine if PET

associated with improved clinical outcomes

Value of knowing-survey by Harvard School

of Public Health• 80% of Americans would want to know if cause of confusion

& memory loss were AD

• Of those >60, 95% said they’d want to know if AD

• >97%-would want family member w/memory problems to be evaluated for AD

• Nearly half of people w/dementia have never received a diagnosis

• Formal dx allows access to treatments, care team, support services, clinical trials

• Allows people with AD to create Advanced Directives, make financial decisions

• Search for reversible causes

What is the difference?-Pet/CT Amyloid Brain-inject PiB-PET (Pittsburgh Compound B)

-Crosses blood-brain barrier and binds to amyloid

-Correlate B-amyloid deposition in the brain can be detected years before onset of clinical sx.

-Negative amyloid brain PET is useful in excluding significant amyloid deposition and thus AD

-Pet/CT Brain Metabolic Evaluation-inject FDG

-measure of resting state cerebral metabolic rates of glucose, an indicator of neuronal activity.Cerebral metabolic alterations preceed the clinical sx of AD

-Distinct patterns of cerebral glucose metabolism help in differentiating AD from other causes of dementia (EG FT and DLB)

Review The diagnostic value of FDG and amyloid PET in

Alzheimer’s disease—A systematic review Louise Ricea,

Sotirios Bisdasb,2017• Conclusion: Both amyloid and FDG-PET techniques

have been shown to detect AD with high sensitivity and specificity compared to other neurodegenerative processes and cognitively normal age-matched individuals.

• Comparison with post-mortem diagnosis, rather than clinical diagnosis with its acknowledged flaws, would result in more powerful statistical outcomes.

Why Everything you think About Aging May

Be Wrong

Wall Street Journal

Anne Tergesen

Nov. 30, 2014

• Stereotype of later life as time of loneliness,

depression, decline, but research shows that in many

way, life gets better as we get older

• Moods and sense of well-being often improve with

age

• Expertise deepens, wisdom flourishes

• Many challenges, health related

• Several myths about aging:

Myths about Aging1.Depression is more prevalent in Old Age

-Research shows emotional well-being improves until the 70’s, when it levels off, even among centenarians

2. Cognitive Decline is Inevitable.

-Except in dementia, knowledge and wisdom help people more in real-life than on tests. To improve memory and processing speed, learning new skills (quilting, using an iPad, etc, learning a language.)

3. Older Workers are Less Productive.

-People >55 YO make up 22% of the US labor force

-No relationship between age and job performance

4. Loneliness is More Likely

-Older people report better marriages, better

friendships, higher rate of close ties

5. Creativity Declines with Age

Mark Twain, Cezanne,Frank Lloyd, Wright,Robert

Frost, Virginia Woolf , Robert Redford, Clint

Eastwood, etc