Osteoporosis treatment in older adults undergoing rehabilitation post-hip fracture

OBJECTIVE

Osteoporosis treatment in patients who have sustained a hip fracture has been reported to be less then 20%. The objective of this study is to determine the current rate of adherence to osteoporosis practice guidelines in elderly patients post-hip fracture who have undergone rehabilitation.

METHODS

Osteoporosis treatment in patients who have sustained a hip fracture has been reported to be less then 20%. The objective of this study is to determine the current rate of adherence to osteoporosis practice guideline in elderly patients post-hip fracture who have undergone rehabilitation.

RESULTS

Osteoporosis therapy (any type) was prescribed to 90 (63%) patients, with bisphosphonates prescribed in 90% of these cases. Calcium and vitamin D was prescribed to 130 (90.9%) patients. Of all the study patients, 76 (53%) of patients had at least one contraindication to osteoporosis therapy identified. Having a diagnosis of osteoporosis was the only factor associated with receiving osteoporosis therapy (OR 13.3, p<0.001).

CONCLUSION

In this selected patient population the rates of osteoporosis treatment are higher than previously reported but remain suboptimal.

EXACT: rivastigmine improves the high prevalence of attention deficits and mood and behaviour symptoms in Alzheimer's disease

The objective of this study was to investigate the impact of rivastigmine therapy on attention, apathy, anxiety and agitation in patients with mild-to-moderate Alzheimer's disease (AD) in a real-world clinical setting. Patients with mild-to-moderate AD were enrolled in the study by physicians across Canada. They were treated with open-label rivastigmine (dose at the discretion of the prescribing physicians) for a period of 6 months. Changes from baseline in attention, apathy, anxiety and agitation were assessed using an abbreviated Clinician's Global Impression of Change at 3- and 6-month visits. The Mini Mental State Examination (MMSE) was also used at these visits. Use and changes in use of psychotropic medications were recorded, as were changes in caregiver burden. Analyses of subgroups (outpatients vs. institutionalised patients) were also performed. A total of 2119 patients were enrolled in the study by 375 physicians. At baseline, 91% had deficits in attention, 85.4% had symptoms of anxiety, 78.5% exhibited apathy and 70.1% showed agitation. At 6 months, 67.5% of evaluable patients had improved on the symptom of attention, while 62.3%, 62.6% and 56.0% had improvements in anxiety, apathy and agitation respectively. The percentages with improvements were higher in the institutional subgroup than among outpatients. There was an overall mean improvement of 1.1 points on the MMSE at 6 months. Approximately four times as many caregivers reported a reduced burden than an increased burden at 6 months (40.3% vs. 10.3%). The majority of patients treated with rivastigmine experienced improvements in attention, anxiety, apathy and agitation. These real-life findings further demonstrate the proven efficacy of rivastigmine in patients with mild-to-moderate AD.

Case studies in osteoporosis: a problem based learning intervention for family physicians

OBJECTIVE

To develop and evaluate a practice based small group (PBSG) learning intervention on osteoporosis for primary care physicians.

METHODS

A needs assessment on osteoporosis was performed and objectives for a continuing medical education (CME) program developed by an interdisciplinary advisory committee. Nine clinical cases were developed for evaluation by CME participants with a trained facilitator and content expert using the PBSG format. The effect of the CME intervention was evaluated using a pre and post-test consisting of objective structured clinical examination stations and standardized patients.

RESULTS

Fifty-four family physicians participated in 4 pilot PBSG learning sessions. The program format, content, and participant satisfaction was highly rated (> 3.35:4.0). Participants expected the program to have a significant effect on the practices (3:40:4.0). Ninety-eight percent of participants improved their pretest scores, with a mean increase of 13% (range 1-36%).

CONCLUSION

Based on our experience, we advocate the use of PBSG learning interventions as an effective and acceptable method of providing CME by rheumatologists for their family physician colleagues. This format appears to be associated with a significant effect on knowledge, skills, and behavior as assessed by our study.

Correlation between the Folstein Mini-Mental State Examination and three methods of clock drawing scoring

The objective of this study was to assess the correlation between (1) the Folstein Mini-Mental State Examination (MMSE) score and three methods of clock drawing scoring and (2) three methods of clock drawing scoring themselves. A convenience sample of consecutive community-dwelling seniors and attendees at a referral seniors clinic in a tertiary care hospital was used. One hundred fifty participants (72 women, 78 men) were seen with an average age of 76 years. There was a significant correlation (P = .01) between MMSE scores and all three methods of clock drawing (R = .67, .618, -.498, respectively), as well as among the three methods of clock drawing scoring. The clock drawing scores showed good correlation with the MMSE score. The clock drawing is well accepted (by the patient) and easily administered (by the health care provider). Clock drawings are recommended as the minimum requirement for cognitive assessment of elderly patients in busy primary care practices and can be used to highlight those patients requiring additional cognitive testing.

Managing elderly people's osteoporosis. Why? Who? How?

OBJECTIVE

To guide family physicians through assessment of why treating elderly people's osteoporosis is necessary, who to treat, and how to treat in a practical way.

QUALITY OF EVIDENCE

Evidence of the efficacy of treatment for osteoporosis is shown by a reduced probability of fracture. This can be ascertained by direct evaluation for bisphosphonates, calcium, and calcitonin, or indirectly by ascertaining benefit to bone mineral density for hormone replacement therapy (HRT) and exercise.

MAIN MESSAGE

Unless medically contraindicated, all elderly people should take supplementary vitamin D (800 IU/d) and calcium (1500 mg/d). Those with risk factors for osteoporosis (e.g., smoking, thinness, previous fracture when older than 50 years, fracture in first-degree relatives older than 50 years, and steroid use) should have a bone density measurement. Those meeting World Health Organization criteria for osteoporosis should also be treated with HRT or bisphosphonates or possibly with selective estrogen receptor modulators.

CONCLUSIONS

Good evidence indicates that adequate treatment of osteoporosis can prevent fractures and thus reduce associated morbidity and mortality among vulnerable elderly people. Because of the prevalence of osteoporosis, the onus falls on family physicians to be the front-line managers.

An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants

OBJECTIVE

To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications.

OPTIONS

The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined.

OUTCOMES

Reduction of complications associated with long-term use of NSAIDs.

EVIDENCE

Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996.

VALUES

Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research.

BENEFITS, HARMS AND COSTS

Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available.

RECOMMENDATIONS

Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision.

VALIDATION

These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.

Anticardiolipin antibodies in two elderly subpopulations

Previous studies have reported that the prevalence of certain autoantibodies is nonspecifically elevated in elderly subjects due to immunoscenescence. This study was undertaken to assess the prevalence of anticardiolipin antibodies (aCL) in two elderly subpopulations: Two hundred and eighteen elderly were included in this study; 63 healthy elderly had a prevalence of anticardiolipin antibodies of zero; 155 unselected frail elderly were prospectively evaluated and the prevalence of anticardiolipin antibodies in this group was found to be significantly increased at 18.7%. Subdivision of this group into those elderly clinically assessed as suffering from dementia showed a prevalence of 26.5% and stroke a prevalence of 31.6%. Both were found to be statistically significantly increased when compared with both the healthy and frail elderly population. Subdivision of the dementia patients into those suffering from multi-infarct type dementia (MID) and those suffering from Alzheimer's type dementia (AD) showed an association of 44% and 20%, respectively. The association of MID with aCL was significant. This study demonstrates therefore that anticardiolipin antibodies are not nonspecifically elevated in elderly subjects but are significantly elevated in elderly subjects with strokes and multiple infarct dementia.

The clinical significance of autoantibody profiles in patients with systemic lupus erythematosus

We have evaluated the autoantibody profiles in the sera of 117 patients with systemic lupus erythematosus (SLE) and compared and contrasted the clinical and laboratory features of the disease of patients segregated according to an autoantibody profile. Using this approach we are able to demonstrate that autoantibody profiles identified subsets of patients with SLE. Patients with a negative autoantibody profile had fewer clinical and laboratory features of their disease when compared to the other subsets of patients. In contrast, patients with profile A (anti-nDNA and/or anti-Sm antibodies) had a statistically significant increase in malar rash, renal and hematologic involvement and hypocomplementemia when compared to patients with a negative profile. Patients with profile B (anti-nRNP antibodies) had a clinical pattern of disease different from that of patients with profile A and had a statistically significant increase in Raynaud's phenomenon when compared to patients with a negative profile. Patients with profile C (anti-SSA and/or anti-SSB antibodies) had a statistically significant increase in lupus-related rashes and photosensitivity. None of the lupus patients reviewed in this study has profile D (antibodies to centromere and/or Scl-70), this profile being seen largely in patients with scleroderma or one of its variants. Both patients with profile E (anti-histone antibodies) had drug-induced lupus. We conclude that the use of autoantibody profiles defines subsets of patients with lupus that may have clinical, therapeutic and prognostic implications.

Antinuclear and antineutrophil cytoplasmic antibodies (ANCA) in the sera of patients with Felty's syndrome

The prevalence of antinuclear (ANA) and antineutrophil cytoplasmic antibodies (ANCA) has been studied in the sera of 62 patients with rheumatoid arthritis and 32 patients with Felty's syndrome. The presence of ANA was less in RA than Felty's syndrome (37% versus 69%). Specific autoantibody identification, where possible, was usually of SS-A or SS-B although two sera from patients with Felty's syndrome had low levels of DNA antibody. ANCA was detected in the sera of 33% of patients with Felty's syndrome and was absent in RA sera. The pattern of ANCA staining was either of a diffuse homogenous cytoplasmic or peripheral (pANCA) nature. Classical cytoplasmic granular staining (cANCA) was not identified.

Psychological profiles of patients with upper gastrointestinal symptomatology induced by non-steroidal anti-inflammatory drugs

Eighty three patients with classical or definite rheumatoid arthritis taking non-steroidal anti-inflammatory drugs (NSAIDs) were studied in an attempt to determine whether a patient's personality and psychological profile might contribute to the development of NSAID induced gastrointestinal symptomatology. It was found that the personality profile of the group of 45 asymptomatic patients was similar to that of a previously reported control group. In contrast, the 37 patients with gastrointestinal symptoms attributed to NSAIDs had a significantly higher mean score for free floating anxiety, depression, and somatisation than controls, suggesting that a patient's personality may influence the development of NSAID induced gastric symptoms.

Specificity, sensitivity and diagnostic predictive value of selected laboratory generated autoantibody profiles in patients with connective tissue diseases

We tested the hypothesis that the application of 5 laboratory generated serologic profiles facilitates the interpretation of individual autoantibodies in connective tissue diseases without loss of specificity, sensitivity or diagnostic predictive value. The predetermined laboratory generated autoantibody profiles were analyzed in 423 sera from patients with clinically diagnosed connective tissue diseases. All sera positive for one or more autoantibodies to a selected panel of nuclear antigens could be segregated into one of 5 profiles. The distribution of individual autoantibodies and profiles in the sera of patients with various connective tissue diseases were compared in terms of their respective diagnostic predictive value and sensitivity. The application of these profiles improved the sensitivity and diagnostic predictive value of these tests when compared to individual autoantibodies without loss of specificity, thus aiding clinical interpretation.

Recurrent autoimmune thrombocytopenia in a patient with systemic lupus erythematosus: treatment with repeated splenectomy!

An unusual case of thrombocytopenia as a manifestation of systemic lupus erythematosus is presented. Management was complicated by regeneration of splenic tissue resulting in recurrent thrombocytopenia and a need for repeated splenectomy.