Thanks to Lindsey Haddock for an awesome and very informative SAR report on new literature in geriatrics! We discussed several important recent trials focused on older populations:
- The “After Eighty” study: how do we treat people >80 with NSTEMI or UA?
- this study looked at invasive intervention (PCI or CABG) vs optimum medical management in an older population with a composite endpoint: death, MI, stroke, revascularization
Take away: invasive intervention for UA or NSTEMI may benefit patients >80, but there may be diminishing benefit as they get older. Remember to consider other comorbidities (dementia, cancer, advanced COPD, etc) that may diminish the benefit they get from an invasive intervention!
This study was a subgroup analysis of patients >75 who were part of the SPRINT trial.
- Again, they analyzed the two groups: intervention (goal SBP <120) and conservative (goal SBP <140) within the older subgroup. They also collected data on frailty and gait speed.
- Findings: over 3 years, intensive BP control reduced incident CV disease by 33% and mortality by 32%, with NNT = 27 to prevent one negative CV event
The major caveat to this analysis (and to SPRINT): it excludes patients with stroke, DM, HFrEF, dementia, recent unintentional weight loss, expected survival of ❤ years, or who were nursing home residents; this obviously excludes a big proportion of the patients we see!
Take away: if an older patient is tolerating a lower blood pressure, you don’t necessarily need to de-escalate; if they have a BP >120 and don’t have other major reasons not to do add on an additional agent (falls, polypharmacy, life expectancy etc), you can consider it as it may be beneficial.
This meta-analysis suggested that in-hospital use of anti-psychotics did NOT result in improvements in:
- short-term mortality
- duration or severity of delirium
- hospital or ICU length of stay
It’s important to note that many of those studies were heterogenous in terms of included patient populations, and that other studies have shown conflicting results. Many of the trials also did not evaluate for symptomatic relief, which is one of the main reasons we use antipsychotics like Haldol in the hospital
Dr. Uy pointed out that one of the reasons antipsychotics may not be as beneficial as we think is that we may just trade acute hyperactive delirium for a longer period of delirium with a longer ‘tail’, or may push them into hypoactive delirium which continues at home after discharge.
- Tegn et al. After Eighty Study. Lancet 2016.
- Williamson et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years. JAMA 2016.
- Neufeld K et al. Antipsychotics for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-analysis. J Am Geritr Soc 2016.