Annals for Educators - 7 November 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives7 November 2017Annals for Educators - 7 November 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201711070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsDiscontinuing Inappropriate Medication Use in Nursing Home Residents. A Cluster Randomized Controlled TrialInappropriate prescribing of medications is a common problem associated with increased risk for adverse outcomes in older adults. This randomized controlled trial examined the effect of a multidisciplinary medication review performed by physicians and pharmacists on the discontinuation of inappropriate medication use and clinical outcomes among nursing home residents.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Teach at the bedside! Review with your team the admitting medication list of several nursing home residents on your service. Are the lists long? Are all of the drugs necessary? Do any present potential problems?Ask your learners how they would define polypharmacy. In what ways might it lead to adverse events? The authors address these issues in the introduction to their study. Need the list be long for it to include inappropriate drugs?Review the intervention used in this cluster randomized controlled trial (Table 1). Who was involved? How were medications assessed?Do your learners think they assess the appropriateness of each medication for all of their patients? Ask them to do so for each of the patients on their service (or each of the outpatients they see) before your next meeting. Did they identify any potentially inappropriate drugs?Ask whether your learners ever leave patients on drugs they do not think or are not sure are needed. Are they hesitant to discontinue drugs they did not prescribe? How should they approach this issue? To whom should they talk?Who reviews a patient's discharge medication list at your hospital? Look at the Annals Graphic Medicine piece described below. How do patients end up using long lists of medicines they no longer need?Ask what a cluster randomized trial is. How does it differ from more traditional clinical trials? What is the unit of randomization in each? How does this difference influence what may be learned?This study did not find a difference in the secondary outcomes that were assessed. The authors note that the trial was not powered to assess them. What does it mean if a study is “underpowered”? Look at the 95% confidence intervals around the point estimates for the secondary outcomes (Table 4). How should they be interpreted?Why might the study have found only modest effects? Use the accompanying editorial to help frame your discussion. The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension. A Cohort StudyPrimary aldosteronism is the most common and modifiable form of secondary hypertension and is usually considered when the classic phenotype of severe hypertension or hypokalemia is encountered. This study assessed whether a spectrum of subclinical primary aldosteronism that increases risk for hypertension exists among normotensive persons.Use this study to:Ask your learners which patients require an evaluation for secondary causes of hypertension. What should the evaluation include? Use In the Clinic: Hypertension to quickly find answers. What are the presenting signs and symptoms of primary aldosteronism? How is it currently diagnosed? Use the information in DynaMed Plus: Primary Aldosteronism (a benefit of your ACP membership). Review with your learners the regulation of renin and aldosterone. How is urinary sodium affected by renin and aldosterone concentrations? Invite a nephrologist to join your discussion.Review the key results of this study. The authors suggest that a state of clinically relevant renin-independent aldosteronism might be common and could affect the risk for subsequent cardiovascular disease. Do your learners think that we should test normotensive patients for this? What additional studies would they want before adopting such a practice? Use the accompanying editorial to help inform your discussion. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes MellitusThis synopsis summarizes key features of the 2017 joint clinical practice guideline from the U.S. Department of Veterans Affairs and the U.S. Department of Defense for the management of type 2 diabetes mellitus.Use this guideline synopsis to:Introduce the topic to your learners by watching the authors' 3-minute video explaining several of the guideline's key messages. Go down the list of recommendations in Table 1 with your team. Check off items your learners believe they should address with each of their diabetic patients. How would they assess whether they are doing these things? Can your EHR help? Should they review the charts of several of their own patients?Does your practice have a telehealth system available to improve the care of patients with diabetes? What members of the health care team are available to assist in providing diabetes care?The authors discuss the importance of individualizing glycemic goals according to patients' risks, life expectancy, personal goals, and other variables. How should each of these be considered when determining glycemic goals? Do your learners know how to discuss them with patients when choosing a goal, and what questions to ask?The authors discuss how their guideline differs from others. Why do glycemic targets differ in this manner? Use the accompanying editorial to help frame your discussion. Does your institution have protocols for inpatient glycemic control among diabetic patients? What do the authors recommend? Why don't they recommend as tight control for patients outside the ICU compared with those in the ICU? The authors recommend a “basal–bolus-plus-correction” approach to care outside the ICU but note that many inpatients are managed only with “correction” doses of insulin on a sliding-scale basis. What is the difference? What is done at your center, and why?In the Clinic: Acute Kidney InjuryAcute kidney injury (AKI) occurs in approximately 20% of hospitalized patients, with major complications that include volume overload, electrolyte disorders, uremic complications, and drug toxicity. Are your learners prepared to prevent and manage AKI?Use this feature to:Ask your learners to list risk factors for AKI. Compare their list with the one provided in the Box.What measures are effective at preventing AKI, and in which patients should they be used?What are the major causes of AKI? Review Figure 2 with your learners. What features help distinguish between decreased kidney perfusion and acute tubular necrosis? List drugs that may cause AKI, and how. Use the information in the boxes for quick lists to help teach.Teach at the bedside (or microscope)! How do urinary tract findings help differentiate among the potential causes? Do your learners know how to assess urinary sediment? Take fresh samples of urine from patients on your service with AKI to the laboratory and review the sediment. Invite a nephrologist to help.Use the multiple-choice questions to introduce new topics for discussion in a teaching session. Download the teaching slides. Log in to answer the multiple-choice questions and claim CME/MOC credit for yourself!Comics and MedicineAnnals Graphic Medicine - The “Problem” ListLaugh (or cry?) as what starts as a simple issue evolves into a complex medical problem list.Use this feature to:Show the cartoon to your learners. Do they think there is truth to what the author depicts?What drives our medical system's desire to label everything? What practices can help to prevent needless labeling and inappropriate treatment of patients?How might this cartoon relate to the use of inappropriate medications addressed in the first study noted above?Humanism and ProfessionalismOn Being a Patient: The Worst of DaysDr. Grinberg's horrible loss brings back the memories of a patient who was labeled as “crazy.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood.Accept that sometimes discussion is not needed. Just listening together might be best.Consider asking if your learners worry that we sometimes brush aside a patient's suffering as mere “hysteria.” Do we sometimes worry about looking foolish for caring too much?MKSAP 17 QuestionA 90-year-old woman is brought to the emergency department by her son for a 1-week history of worsening cognition, weakness, dizziness, and anorexia. She lives in an assisted-care facility and is generally alert. She is ambulatory when using a cane. Medical history includes hypertension, chronic heart failure, chronic kidney disease, osteoarthritis, allergic rhinitis, hyperlipidemia, and urinary stress incontinence. Current medications are lisinopril, bisoprolol, oxybutynin, loratadine, acetaminophen, pravastatin, and omeprazole.On physical examination, she appears frail but is in no acute distress. Temperature is normal, blood pressure is 100/60 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. BMI is 20. Oxygen saturation is 97% with the patient breathing ambient air. There is no orthostasis. Cardiac examination discloses an irregularly irregular rate. Pulmonary examination reveals slightly diminished breath sounds bilaterally but no crackles. The abdomen is mildly distended but nontender. Rectal examination reveals hard stool that is negative for occult blood. There is no edema. Neurologic examination is nonfocal, and the patient scores 24/30 on the Mini–Mental State Examination.Laboratory studies:Hematocrit34%Leukocyte count7100/µl (7.1 × 109/L); normal differentialCreatinine1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L])ElectrolytesNormalGlucose78 mg/dL (4.3 mmol/L)UrinalysisTrace protein, trace ketones, no cellsChest radiograph shows no evidence of heart failure or pulmonary infiltrates.Which of the following is the most likely cause of this patient's recent symptoms?A. Acute kidney injuryB. Adverse medication effectsC. Occult pneumoniaD. Urinary tract infectionCorrect AnswerB. Adverse medication effectsEducational ObjectiveManage polypharmacy in an older patient.CritiqueThis older patient's clinical findings are most likely the result of adverse medication effects related to polypharmacy, and her drug regimen requires adjustment. She has significant medical comorbidities and is taking numerous drugs. Administration of multiple medications increases the risk for inappropriate use, drug-drug interactions, adverse reactions, poor adherence, and medication errors. This patient is taking two anticholinergic agents (oxybutynin for urinary incontinence and the over-the-counter antihistamine loratadine). The American Geriatrics Society Beers Criteria recommend against the use of anticholinergic agents in older patients because they can cause confusion, urinary retention, constipation, and dry mouth. She is also on the proton pump inhibitor omeprazole without an apparent indication for treatment. In addition, the risk-to-benefit ratio of using a lipid-lowering agent to confer long-term benefits must be reassessed in very elderly adults. Prescriptions for statins are frequently carried over from previous years, but statin use results in additional cost, extra pills, and increased risk for drug-drug interactions. Lastly, parameters for blood pressure control are less stringent in older adults, and, in this patient, antihypertensive agents should be reassessed, as her hypertension is overtreated. Ongoing review of the indications, risks, benefits, and dosing of all drugs in older patients is recommended.This patient has a history of mild chronic kidney disease; however, with normal volume status, normal electrolytes, and a minimal change in her serum creatinine level, she does not have evidence of significant worsening of her kidney function. This would make acute kidney injury an unlikely cause of her current clinical findings.Infections are a frequent cause of systemic symptoms, including weakness, dizziness, anorexia, and altered mental status in older patients, with pneumonia and urinary tract infection being the most common types. However, this patient has no clinical findings consistent with pneumonia given her normal oxygenation, leukocyte count, and chest radiograph, or suggestion of urinary tract infection with a normal urinalysis. Therefore, the absence of evidence of infection makes this an unlikely cause of her current clinical findings.Key PointAdministration of multiple medications, especially in older patients, increases the risk for inappropriate use, drug-drug interactions, adverse reactions, and medication errors.BibliographyMaher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 7 November 2017Volume 167, Issue 9Page: ED9KeywordsAcute kidney injuryAdverse reactionsChronic kidney diseaseDrug interactionsDrugsElderlyHypertensionIntensive care unitsPneumonia ePublished: 7 November 2017 Issue Published: 7 November 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...