Medical Grand Rounds

Geriatrics update 2012: What parts of our practice to change, what to ‘think about’

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ABSTRACTMany new guidelines and studies of interest to the geriatric population have emerged in the areas of falls and fracture prevention, cardiovascular care, depression, and Alzheimer disease. Some of these guidelines and studies translate to immediate changes that should be made to clinical practice; others are new areas of controversy.

KEY POINTS

  • To prevent falls, patients should be asked not only about recent falls but about balance. Referral for a multicomponent falls evaluation should be considered.
  • For patients age 80 and older, a target systolic blood pressure of 140 to 145 mm Hg is acceptable, and blood pressure below 130 mm Hg systolic and 65 mm Hg diastolic should be avoided.
  • The dosage of the antidepressant citalopram (Celexa) should not exceed 40 mg per day in the general population and 20 mg in patients age 60 and older.
  • Calcium supplementation may increase the risk of myocardial infarction and stroke. A large annual dose of vitamin D appears harmful, raising questions about the long-term safety of large doses given weekly or monthly.


 

References

A number of new studies and guidelines published over the last few years are changing the way we treat older patients. This article summarizes these recent developments in a variety of areas—from prevention of falls to targets for hypertension therapy—relevant to the treatment of geriatric patients.

A MULTICOMPONENT APPROACH TO PREVENTING FALS

The American Geriatrics Society and British Geriatrics Society’s 2010 Clinical Practice Guideline for Prevention of Falls in Older Persons1 has added an important new element since the 2001 guideline: in addition to asking older patients about a fall, clinicians should also ask whether a gait or balance problem has developed.

A complete falls evaluation and multicomponent intervention is indicated for patients who in the past year or since the previous visit have had one fall with an injury or more than one fall, or for patients who report or have been diagnosed with a gait or balance problem. A falls risk assessment is not indicated for a patient with no gait or balance problem and who has had only one noninjurious fall in the previous year that did not require medical attention.

The multicomponent evaluation detailed in the guideline is very thorough and comprises more elements than can be done in a follow-up office visit. In addition to the relevant medical history, physical examination, and cognitive and functional assessment, the fall-risk evaluation includes a falls history, medication review, visual acuity testing, gait and balance assessment, postural and heart-rate evaluation, examination of the feet and footwear, and, if appropriate, a referral for home assessment of environmental hazards.

Intervention consists of many aspects

Of the interventions, exercise has the strongest correlation with falls prevention, and a prescription should include exercises for balance, gait, and strength. Tai chi is specifically recommended.

Medications should be reduced or withdrawn. The previous guideline recommended reducing medications for patients taking four or more medications, but the current guideline applies to everyone.

First cataract removal is associated with reducing the risk of falls.

Postural hypotension should be treated if present.

Vitamin D at 800 U per day is recommended for all elderly people at risk. For elderly people in long-term care, giving vitamin D for proven or suspected deficiency is by itself correlated with risk reduction.

Interventions that by themselves are not associated with risk reduction include education (eg, providing a handout on preventing falls) and having vision checked. For adults who are cognitively impaired, there is insufficient evidence that even the multicomponent intervention helps prevent falls.

CALCIUM AND VITAMIN D MAY NOT BE HARMLESS

Various national groups have developed similar recommendations for calcium and vitamin D intake for older adults (Table 1).

Calcium supplements: A cause of heart attack?

Questions have arisen in recent studies about the potential risks of calcium supplementation.

A meta-analysis of 11 trials with nearly 12,000 participants found that the risk of myocardial infarction was significantly higher in people taking calcium supplementation (relative risk 1.27; 95% confidence interval [CI] 1.01–1.59, P = .038).2 Patients were predominantly postmenopausal women and were followed for a mean of 4 years. The incidence of stroke and death were also higher in people who took calcium, but the differences did not reach statistical significance. The dosages were primarily 1,000 mg per day (range 600 mg to 2 g). Risk was independent of age, sex, and type of supplement.

The authors concluded (somewhat provocatively, because only the risk of myocardial infarction reached statistical significance) that if 1,000 people were treated with calcium supplementation for 5 years, 26 fractures would be prevented but 14 myocardial infarctions, 10 strokes, and 13 deaths would be caused.

Another drawback of indiscriminate use of calcium supplementation is that it interferes with the absorption of a number of medications and nutrients (Table 2).

Comments. These data suggest that physicians may wish to prescribe calcium to supplement (not replace) dietary calcium to help patients reach but not exceed current guidelines for total calcium intake for age and sex. They may also want to advise the patient to take the calcium supplement separately from medications, as indicated in Table 2.

Benefits of vitamin D may depend on dosing

Studies show that the risk of hip fracture can be reduced with modest daily vitamin D supplementation, up to 800 U daily, regardless of calcium intake.3 Some vitamin D dosing regimens, however, may also entail risk.

Sanders et al4 randomized women age 70 and older to receive an annual injection of a high dose of vitamin D (500,000 U) or placebo for 3 to 5 years. Women in the vitamin D group had 15% more falls and 25% more fractures than those in the placebo group. The once-yearly dose of 500,000 U equates to 1,370 U/day, which is not much higher than the recommended daily dosage. The median baseline serum level was 49 nmol/L and reached 120 nmol/L at 30 days in the treatment group, which was not in the toxic range.

Comments. This study cautions physicians against giving large doses of vitamin D at long intervals. Future studies should focus on long-term clinical outcomes of falls and fractures for dosing regimens currently in practice, such as 50,000 units weekly or monthly.

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