Geriatrics

Topic 1 - Summary
1. Citation:
  • Heckenbach, Kirsten, et. Al. “Medication and falls in elderly outpatients: an epidemiological study from a German Pharmacovigilance Network.” SpringerPlus 3.483 (2014)
2. Summary/Bottom Lines:
  • The aim of this study was to investigate the relationship between fall risk increasing drugs (FRIDS) and the risk of falls with regard to fall-related chronic diseases. This was the first study of its kind to investigate the relationship between these drugs and falls in regard to fall-related chronic diseases. According to the authors, the prescription of FRIDS had a 70% increased risk of fall, but patients with a prescription of FRIDS are more vulnerable and at a higher risk of falls, regardless of the timely connection between drug use and fall. Thus, experiencing a fall is mainly due to the disease followed by treatment and not necessarily a consequence of the treatment alone.
3. Methods:
  • This was a multicenter observational study from 2004-2010 in Germany. 39 primary care physicians were recruited for the study and documentation was evaluated from the study period. Data was included in the analysis if patients were at least 65 years old, or turned 65 during the study period and visited the physician at least twice during the study period. Drugs that were evaluated included antihypertensives, NSAIDs, hypnotics and sedatives, antidepressants, psycholeptics and psychoanaleptics. A possible connection between the intake of FRIDS and a diagnosis of fall (which included injury or poisoning) was assumed if the diagnosis was made within one month after the prescription. Fall-related chronic diseases that were included were abnormalities of gait and mobility, cerebrovascular disease, ischemic heart disease, dementia, depression, diabetes, diseases of vasculature, hearing impairment, heart failure, hypertension, intervertebral disc disorders, malignant neoplasm, osteoporosis, sleep disorders, vertigo, visual impairment, weight loss, incontinence, and disability in moving. Out of the 5,124 patients included in the analysis, there were 14 cases of a first diagnosis of fall within one month after the prescription of FRIDS.

4. Limits:
  • Each diagnosis of poisoning and injury was regarded as a fall. This might overestimate the number of falls.
  • Although physician-prescribing data were subjected to internal review, coding inaccuracies cannot be ruled out entirely.
  • Data on additional medication use in patients who visited several physicians simultaneously were unavailable and might underestimated the use of FRIDS.
5. Additional Info:
  • This study will not change our management. It is always important to be mindful of medications that are being prescribed to the elderly as they are more likely to experience adverse effects due to decreased metabolism of the drugs. However, this study does not show a clear connection between certain drugs and increased fall-risk in the elderly. Thus, not prescribing FRIDS would only avoid a small number of falls.
6. Author: Dr. Christina Ennabi

 

Topic 2 - Summary
1. Citation:
  • Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm Scheuermeyer, Frank X. et al. Annals of Emergency Medicine , Volume 65 , Issue 5 , 511 - 522.e2
2. Summary/Bottom Lines:
  • This study is a retrospective descriptive cohort conducted in Canada that compared the treatment and outcomes of attempted rate and rhythm control of patients with atrial fibrillation or flutter and an acute underlying medical illness. Patients who received attempted rate or rhythm control were compared against patients who did not receive any specific antiarrhythmic treatment. Results of the study revealed that patients who received attempted rate or rhythm control had a significantly higher adverse event rate and a significantly lower rate of successful rate or rhythm control as compared to the no treatment group. The authors also showed patients who received attempted rate or rhythm control earlier as opposed to later in their ED stay had higher adverse event rates and lower successful rate or rhythm control rates. This study demonstrates that patients with significant comorbidities and an acute underlying medical illness should likely have their treatment prioritized to their underlying medical illness rather than their arrhythmia and that performing a diagnostic work-up prior to arrhythmia treatment may be prudent based on the patient’s hemodynamic stability. Just as you would not treat sinus tachycardia in sepsis with beta-blockers, you should be wary in treating atrial fibrillation or flutter before treating the underlying cause, as this study demonstrated that patients that only received IVF for their arrhythmias had better treatment outcomes.
3. Methods:
  • This was a retrospective descriptive cohort study that was conducted at 2 medical centers in Canada.  All patient interventions were performed at the emergency physician’s discretion.  All patients who presented to the emergency department during the calendar year of 2009 with an initial ECG of atrial fibrillation or flutter were included in the study.  Exclusion criteria included any patient who was s/p CABG, PCI, or ablation within the past 7 days, referred to the ED for admission, or sent to ED solely for anticoagulation monitoring.  Chart review was based on criteria recommended by Gilbert et al and Worster et al.  Each chart was independently reviewed and the reviewers were blinded to the study hypothesis and results.  Rate control success was determined to be decrease in HR of at least 20 beats/min within 4 hrs and rhythm control defined as conversion to NSR throughout ED stay.  Primary outcome was safety as defined by occurrence of major or minor adverse events, defined a priori.  Secondary outcome was success of rate or rhythm control, again defined a priori as stated above.  Results showed that patients with attempted rate or rhythm control had an adverse event rate of 40.7%, as compared to 7.1% in the no arrhythmia treatment group (RR 5.7, OR 9).  14.1% major adverse event rate in treatment group as compared to 1.1% in no treatment group (RR 11.7).  Propensity scoring revealed an 8.3 times greater risk of adverse event with treatment.  Success of rate control was only 19% with treatment, 13.3% for rhythm control, but no treatment group had a 44.5% success rate.
4. Limits:
  • Limitations of this study include: study was performed in Canada and physician practices there may not reflect US practice patterns, there was a small sample size in rhythm control patients, the natural variation in HR in atrial fibrillation and flutter may mean recorded HR is inaccurate, this is a heterogenous cohort of patients and so it may be impossible to know if low success rate/high adverse event rate was really secondary to the antiarrhythmia treatment or other factors (but the data certainly seems to suggest so), inherent difficulty in interpreting clinical condition (chicken or egg argument: afib causing HF or HF causing Afib), and the fact that no amiodarone was used in the ED (in stark contrast to our facility practice).  Despite these limitations, however, the author’s methods were well thought out, meticulous, and without any apparent flaw or bias.  This is an excellent example of how a chart review study should be performed.
5. Additional Info:
  • Patient population in this study was old and had significant comorbidities
  •  Dr. Borron reinforced that the medicines used for rate control due have serious side effects (hypotension) and require judicious use.
  •  Dr. Borron also mentioned performing this kind of study in the US would be near impossible as we do not have the ability to track patients like they do in Canada.
  •  Dr. Watts discussed the methods of this paper and how they were well thought out and without any major flaw.  This was a very well done study. 
  •  Analogy of patient with sepsis who is either in sinus tach or afib w/RVR, if patient has underlying afib and then gets septic, RVR is their version of sinus tach. You should not attempt rate/rhythm control without addressing underlying medical illness first. 
  •  Unifying factor for many of these patients is that most may be hypovolemic, IVFs can be just as effective as beta blockers in reducing HR. 
  • Bedside echo and IVC assessment can help determine fluid status and guide management. 
6. Author:   Dr. Adam Moore