15 Widera Geriatrics

5/24/16

Geriatrics Literature

Updates

2016

Eric Widera, MD

Kenneth Covinsky, MD

University of California San Francisco

San Francisco VA Medical Center

Methods

? Search of leading journals

? January 2015-December 2015

? JAGS, NEJM, JAMA, JAMA-IM, Annals, Health

Affairs, Lancet, BMJ, Academic Medicine, JGIM, J

Geron-Med Sci, JPM, JPSM

? Search of social media:

? Twitter, Blogs, PC-FACS

? Selection Criteria

? Impact and Interest

Disclosures

? No relevant financial relationships

1

5/24/16

What¡¯s in Tussin & TonicTM

Vimovo

? Naproxen and

Esomeprazole

? 60 tabs = $1,700

Duexis

? Ibuprofen and

Famotidine

? 60 tabs = $1,100

? Dextromethorphan

? Dissociative hallucinogenic, sedative, and stimulant

properties at higher doses

? Low-affinity NMDA receptor antagonist, Serotonin

reuptake, Sigma-1 receptor agonist

? Quinine

? Stereoisomer of quinidine

? Like quinidine, inhibits peripheral metabolism of

dextromethorphan

? Flavor component of tonic water

*Cost based on goodrx

Study

Cummings et al. JAMA. 2015;314(12):1242-1254

2

5/24/16

Research Question

? Does Dextromethorphan-Quinidine

Reduce agitation in patients with

dementia?

? Quinidine inhibits degradation of

Dextromethorphan, allowing higher brain

concentration

? The combination of these two very cheap

meds produces one very expensive pill

($824/30 day supply)

Study Design (URGH!!)

? ¡°Proprietary¡± sequential parallel comparison

? Phase 1: 5 weeks drug vs placebo

? Phase 2: Take ¡°placebo nonresponders¡± and Rerandomized to drug vs placebo

? This study design enriches your study with

patients who are less susceptible to placebo

effect

? This ain¡¯t real life at all.

Who was included?

? 210 patients with Alzheimer Disease

? Clinically significant agitation (such as

aggressive physical or verbal

behaviors)

? Mean age 78

? 12% nursing home or assisted living

Results: Agitation

? Improved NPI Agitation score: 1.6 point

improvement (12 point scale)

? Probably slight, but meaningful

improvement

? Some evidence the change was noticeable

to caregivers and clinicians

? Study design exaggerates the effectiveness of the

drug when used in real world

3

5/24/16

Side Effects

? Falls

? 8.6% dextromethorphan

? 3.9% placebo

? Absolute Difference: 4.7%, NNH= 21

? Diarrhea increased from 3.1% to 5.9%

(NNH=36)

? UTI increased from 3.9% to 5.3% (NNH-71)

? Dizziness increased from 2.4% to 4.6%

(NNH=45)

? Investigators conclude drug was ¡°generally well

tolerated¡± We beg to differ

Conclusion

? Conclusion A:

? Dextromethorphan efficacious for reducing agitation

with tolerable side effects

? Conclusion B:

? Dextromethorphan efficacious in increasing falls

with some additional mild benefits of reduced

agitation

? Should you consider Dextromethorphan for offlabel use for patients with dementia agitation?

? Evidence of effectiveness is very modest, and risk

for harm substantial

What Medicare Does and Doesn¡¯t

Cover

Long Term Care

Home Care Services

Caregiver Support

Kelley et al. Ann Intern Med. 2015;163:729-736.

4

5/24/16

What Do Health Conditions Cost?

? Typical Perspective

? What insurers (ie, Medicare) pay

? The Truth: Patients and Families Pay a Lot

? Out of pocket costs: stuff not paid by insurance

? Nursing home care, day health care, home health

aides, home renovations, some medicines

? ¡°Implicit¡± Costs: Family caregiving

?

?

?

?

May have no money exchanged, but incredibly valuable

Often leads to loss of employment

$ave$ Billion$ in public nur$ing home co$ts

Out of sight, out of mind: Failure to consider caregiver as

a cost devalues their contribution

Results

? Average total cost per decedent in the last 5

years of life

? Dementia

? Heart disease

? Cancer

$280 000

$175 000

$173 000

? Medicare expenditures were similar across

groups

? Average out-of-pocket spending

? Dementia

? Without dementia

$62 000

$34 000

? Average informal care costs

? Dementia

? Without dementia

$83 000

$38 000

What did they do ?

? Identified everyone who died while in Health

and Retirement Study (representative of US)

? Looked back 5 years to identify costs

? Medicare claims

? Included all claims for inpatient, outpatient, skilled-nursi ng

facility, hospice, home care

? Subject (and Family) reports of spending

? Includes insurance, medication, nursing home, hired

helpers, in-home medical care, and other expenses

? Caregiving costs (hours X home health aide wage)

? Compared those with dementia vs other

diagnoses

Asset WIPEOUT

? % of assets obliterated in last 5 years of

life

? Dementia 32%

? Other diseases 11%

? Dementia destroys savings of most

disadvantaged

? African American ethnicity: 84%

? Less than high school education: 48%

5

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download