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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Medication modification following fracture in older adults (September 2016)
Adverse drug effects are a particularly important issue for geriatric patients and may be unrecognized as a cause of illness or injury. A study reviewed data from a sample of 168,000 Medicare patients seen for treatment of hip, shoulder, or wrist fractures . In the four months prior to presentation, three-quarters of the patients had been taking a nonopioid drug associated with increased fracture risk (eg sedatives, atypical antipsychotics, tricyclic antidepressants, or antihypertensives). In the four months after the fracture, such drugs were discontinued for 7 percent but were newly prescribed for another 7 percent. Review of drug therapy, with assessment of the need for ongoing therapy and discontinuation of nonessential medications, is indicated when patients present with an injury or illness that might relate to an adverse effect of a medication. (See "Drug prescribing for older adults", section on 'Review current drug therapy'.)
Complications of dopaminergic therapy for restless legs syndrome (August 2016)
The main complication of long-term dopaminergic therapy for restless legs syndrome/Willis-Ekbom disease (RLS/WED) is “augmentation,” or an increase in symptom severity with increasing doses of medication. This may present as earlier onset of symptoms during the day, increased intensity of symptoms, or spread to previously uninvolved body parts (eg, arms, trunk). New consensus-based guidelines on the identification and management of augmentation recommend avoiding dopaminergic drugs as first-line therapy for RLS/WED when possible, screening patients on dopaminergic therapy for augmentation as part of routine clinical follow-up (table 1), and using the lowest doses possible to control symptoms . Treatment options for augmentation reviewed in the guideline include altering the dopaminergic dosing schedule, switching to an extended release preparation, and transitioning to an alpha-2-delta calcium channel ligand (eg, gabapentin enacarbil, pregabalin). In addition, alternative causes of worsening symptoms should be sought, such as low iron stores, sleep deprivation, and certain drugs such as serotonergic antidepressants. (See "Treatment of restless legs syndrome/Willis-Ekbom disease and periodic limb movement disorder in adults", section on 'Augmentation'.)
USPSTF recommendations for colorectal cancer screening (July 2016)
The United States Preventive Services Task Force (USPSTF) issued new guidelines for colorectal cancer screening in average risk adults . The guidelines make a strong recommendation for screening, starting at age 50 years and continuing to age 75 for most patients, but in a departure from prior recommendations do not give preference for any one of seven screening test strategies over another. Options for screening are shown in a table (table 2). We agree with this screening test strategy based on shared decision making. Incorporating patient personal preferences may increase the likelihood that ongoing screening will occur. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'USPSTF guidelines'.)
Goal blood pressure in older adults (June 2016)
Goal blood pressure in older adults was examined in the Systolic Pressure Intervention Trial (SPRINT) . SPRINT enrolled a subgroup of more than 2600 ambulatory adults aged 75 years or older, including 349 categorized as being fit, 1456 as less fit, and 815 as frail according to a validated frailty index. At 3.1 years, rates of both the primary cardiovascular endpoint and all-cause mortality were significantly lower among those assigned more intensive (goal <120 mmHg) versus less intensive (goal <140 mmHg) systolic blood pressure lowering. The benefit from more intensive blood pressure control was present in both fit and frail older adults. Serious adverse events were similar in the two treatment groups, and did not depend upon frailty. (See "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension", section on 'Goal blood pressure'.)
Clinical practice guideline for chronic insomnia in adults (May 2016)
The American College of Physicians has released a new clinical practice guideline for the management of chronic insomnia in adults . The guideline recommends that all patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. The guideline suggests that clinicians use a shared decision-making approach, including discussion of benefits, harms, and costs of short-term use of medications, to decide whether to add medication to CBT-I in patients with persistent symptoms. This approach is consistent with our preference for behavioral therapy over medication in most patients with chronic insomnia, particularly in older adults and patients with organ dysfunction, who are at increased risk for side effects from sedative-hypnotic drugs. (See "Treatment of insomnia", section on 'General approach'.)
GERIATRIC ENDOCRINOLOGY AND DIABETES
Postmenopausal estrogen and cognitive function (August 2016)
While limited observational and clinical trial data have suggested that early, but not late, postmenopausal exposure to estrogen provides protection against later cognitive impairment, a new randomized trial found no benefit of estrogen regardless of when it was started. In the Early versus Late Intervention Trial with Estradiol (ELITE), 643 postmenopausal women, stratified according to time since menopause (<6 years [early] versus >10 years [late]), received oral estradiol (with progesterone for women with a uterus) or placebo for a median of five years . When compared with placebo, estradiol, whether it was started early or late, had no effect on verbal memory, executive function, or global cognition. (See "Estrogen and cognitive function", section on 'Younger menopausal women'.)
GERIATRIC INFECTIOUS DISEASES
Investigational inactivated vaccine to prevent zoster and postherpetic neuralgia (September 2016)
The live attenuated zoster vaccine reduces the risk of herpes zoster with a reported vaccine efficacy of 60 to 70 percent in adults 50 years and older but appears to have decreased efficacy in adults 70 years and older. In an initial trial of the experimental recombinant inactivated zoster vaccine (HZ/su), administered in two doses, overall vaccine efficacy was 97 percent in adults 50 years and older. In a subsequent randomized, placebo-controlled trial of 13,900 patients aged 70 and older, vaccine efficacy for preventing herpes zoster and postherpetic neuralgia was each approximately 90 percent after a mean 3.7-year follow-up . No serious adverse events were reported in either trial; however, reactions such as pain at the injection site and myalgias were more common among those who received the vaccine. If approved, this inactivated vaccine may be particularly useful for such older individuals and immunocompromised individuals who cannot receive live vaccines, but it requires two doses for initial protection. (See "Vaccination for the prevention of shingles (herpes zoster)", section on 'Investigational vaccines'.)
GERIATRIC NEPHROLOGY AND HYPERTENSION
Dialysis and survival outcomes in older adults (May 2016)
Older patients may derive little survival benefit from dialysis. A well-designed retrospective study from the Netherlands compared survival outcomes among patients >70 years who opted for conservative care versus dialysis . Survival was calculated from different starting points including the time at which the treatment decision was first made and from times at which the estimated glomerular filtration rate (eGFR) was first <20, <15, and <10 mL/min/1.73 m2. The overall median survival was higher for those patients who opted for dialysis. However, the survival advantage conferred by dialysis was substantially reduced among patients >70 years who had cardiovascular or other severe comorbidity, and there was no difference between groups among patients older than 80 years. (See "Conservative care of end-stage renal disease", section on 'Who should be offered conservative care'.)
Declining use of feeding tubes in advanced dementia (August 2016)
Patients with advanced dementia commonly have eating problems in the final stages of illness, and caregivers are faced with decisions about whether to continue oral feeding by hand or place a long-term feeding tube. The available evidence fails to demonstrate any health benefits of tube feeding over ongoing hand feeding, and an increasing number of consensus-based guidelines advocate against feeding tube placement in this setting. In keeping with these recommendations, a recent study in the United States found that the proportion of nursing home residents with advanced dementia who received a feeding tube within one year of the onset of feeding problems decreased by approximately 50 percent between the years 2000 and 2014 . Advance care planning is critical in the management of patients with dementia and should include preparatory discussions about eating problems and other common complications encountered in the advanced stages of the disease. (See "Palliative care of patients with advanced dementia", section on 'Oral versus tube feeding'.)
Early benefit of aspirin after TIA or ischemic stroke (July 2016)
The risk of recurrent ischemic stroke is highest in the first days and weeks after a transient ischemic attack (TIA) or ischemic stroke, but the benefit of aspirin in this time period has not been well studied. In a recent pooled analysis of data from over 15,000 subjects in 12 trials evaluating aspirin for secondary prevention, the benefit of aspirin was strongest in the early weeks after TIA or ischemic stroke . Compared with control (mostly placebo), aspirin reduced the relative risk of recurrent ischemic stroke within the first six weeks by 58 percent (1 versus 2.4 percent, absolute risk reduction 1.4 percent). The benefit of aspirin in this time frame was greatest for the subgroup of patients with TIA or minor stroke. These findings emphasize that aspirin should be started as early as possible after the diagnosis of TIA or ischemic stroke is confirmed. (See "Antiplatelet therapy for secondary prevention of stroke", section on 'Aspirin'.)
Initial treatment for localized, low-risk prostate cancer (September 2016)
There are many options for treating men with localized, low-risk prostate cancer. The most extensive data comparing these options come from the Prostate testing for cancer and Treatment (ProtecT) trial, in which 1653 patients with localized, low-risk prostate cancer were randomly assigned to active monitoring of serum PSA, radical prostatectomy, or radiation therapy (RT) [11,12]. At a median follow-up of 10 years, there was no difference in 10-year overall survival, which was approximately 99 percent for all three groups. However, the incidence of metastases was increased in patients randomized to active surveillance (6.3 per 1000 person-years versus 2.4 and 3.0 for those managed with radical prostatectomy or RT). Longer follow-up will be required to know whether the higher incidence of metastatic disease affects cancer-specific mortality, overall mortality, or quality of life. Decisions regarding the choice of treatment continue to be individualized based upon a consideration of patient age, comorbidity, and patient preferences. (See "Initial approach to low- and very low-risk clinically localized prostate cancer", section on 'ProtecT trial'.)
Acetaminophen for knee and hip osteoarthritis (May 2016)
Treatment with acetaminophen (paracetamol, N-acetyl-p-aminophenol [APAP]) appears to be slightly more effective than no treatment in relieving overall pain from osteoarthritis (OA), but generally less effective than nonsteroidal antiinflammatory drugs (NSAIDs). This was recently illustrated in a 2016 network meta-analysis of randomized trials involving nearly 60,000 patients with knee or hip OA receiving either APAP, one of seven NSAIDs, or placebo . The summary estimates of benefit with APAP were extremely low, although statistically significant, for the highest dose of APAP, but less than the predefined minimum clinically important effect. These results do not exclude the possibility that some patients respond, while many others do not. In patients with OA lacking signs or symptoms of inflammation, we initiate pharmacologic therapy with acetaminophen on an as-needed basis. If this is inadequate, we advise a trial of acetaminophen on a scheduled basis up to three to four times daily. Such use is consistent with evidence supporting its modest benefit compared with placebo and its relative safety. (See "Initial pharmacologic therapy of osteoarthritis", section on 'Noninflammatory OA'.)
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- Garcia-Borreguero D, Silber MH, Winkelman JW, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. Sleep Med 2016; 21:1.
- US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315:2564.
- Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315:2673.
- Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2016; 165:125.
- Henderson VW, St John JA, Hodis HN, et al. Cognitive effects of estradiol after menopause: A randomized trial of the timing hypothesis. Neurology 2016; 87:699.
- Cunningham AL, Lal H, Kovac M, et al. Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. N Engl J Med 2016; 375:1019.
- Verberne WR, Geers AB, Jellema WT, et al. Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis. Clin J Am Soc Nephrol 2016; 11:633.
- Mitchell SL, Mor V, Gozalo PL, et al. Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000-2014. JAMA 2016; 316:769.
- Rothwell PM, Algra A, Chen Z, et al. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet 2016; 388:365.
- Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med 2016; 375:1415.
- Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med 2106.
- da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet 2016; 387:2093.