Evaluation of postoperative delirium in geriatric patients given acetaminophen with and without melatonin: A retrospective cohort study.

OBJECTIVE: Postoperative delirium has many consequences and should be prevented when possible. Non-opioid pain treatments have known delirium prevention benefits, while melatonin has promising prevention data in non-surgical populations. The incidence of postoperative delirium was retrospectively compared in patients prescribed acetaminophen with and without melatonin following orthopedic surgery. METHODS: Retrospective data was analyzed in adults ≥65-years-old who were hospitalized within one health system following an orthopedic procedure. Patients receiving at least acetaminophen 1000 mg/day with and without melatonin 1 mg/day for at least 48 hours perioperatively were included. Patients were excluded if they had prior delirium, an intensive care unit placement >24 hours, or other risk factors for developing delirium to reduce confounders. The primary outcome was delirium incidence or positive CAM-ICU score. Key secondary endpoints included hospital length of stay and 30-day hospital readmission. RESULTS: Two hundred patients were assessed, and 134 patients were included in the analysis (ie, 66 acetaminophen plus melatonin, 68 acetaminophen alone). There was a lower rate of delirium when comparing the combination vs acetaminophen alone (5% vs 25%; P = 0.001). There were no differences in 30-day readmission. Patients taking the combination had a longer length of stay than acetaminophen alone (5 vs 4 days; P = 0.04). CONCLUSION: Geriatric patients taking acetaminophen plus melatonin after orthopedic surgery had a significantly lower risk of delirium than patients receiving acetaminophen alone. Using combination melatonin and acetaminophen before orthopedic surgery is a promising delirium prevention strategy and should be considered in future prospective trials.

Diabetic Peripheral Neuropathy: Prevention and Treatment.

Diabetic peripheral neuropathy occurs in up to 50% of patients with diabetes mellitus and increases the risk of diabetic foot ulcers and infections. Consistent screening and clear communication are essential to decrease disparities in assessment of neuropathic symptoms and diagnosis. Physicians should address underlying risk factors such as poor glycemic control, vitamin B12 deficiency, elevated blood pressure, and obesity to reduce the likelihood of developing neuropathy. First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin; however, these medications do not restore sensation to affected extremities. Evidence for long-term benefit and safety of first-line treatment options is lacking. Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin. Periodic, objective monitoring of medication response is critical because patients may not obtain desired pain reduction, adverse effects are common, and serious adverse effects can occur. Opioids should generally be avoided. Nondrug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation. Peripheral transcutaneous electrical nerve stimulation is well tolerated and inexpensive, but benefits are modest. Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA need further study in patients with diabetic peripheral neuropathy.

Arrhythmias and Sudden Cardiac Death.

Ventricular tachyarrhythmias remain a major cause of sudden cardiac arrest (SCA) that leads to sudden cardiac death (SCD). Primary prevention strategies to prevent SCD include promoting a healthy lifestyle, following United States Preventive Service Task Force recommendations related to cardiovascular disease, and controlling comorbid conditions. For a patient experiencing SCA, early cardiopulmonary resuscitation and defibrillation should be performed. Implantable cardioverter defibrillators are more effective at secondary prevention compared with drug therapy but medications such as amiodarone, beta-blockers, and sotalol may be helpful adjuncts to reduce the risk of SCD or improve a patient's symptoms (eg, palpitations and inappropriate defibrillator shocks).

Thyroid and Parathyroid Conditions: Hyperthyroidism.

Hyperthyroidism is an excess in thyroid hormone production caused by such conditions as Graves disease, toxic multinodular goiter, and toxic adenoma. Overt hyperthyroidism is defined as a low or undetectable thyrotropin (TSH) level with elevated triiodothyronine (T3) or thyroxine (T4) values, whereas subclinical hyperthyroidism is defined as low or undetectable TSH with normal T3 and T4 levels. Symptoms of hyperthyroidism include nervousness, heat intolerance, weight loss, and fatigue. The long-term consequences of unmanaged or poorly managed hyperthyroidism include increased risk of all-cause mortality, cardiovascular events, atrial fibrillation, sexual dysfunction, and osteoporosis. Overt and subclinical hyperthyroidism can be managed effectively with antithyroid drugs (eg, propylthiouracil, methimazole) or with definitive therapies (eg, radioactive iodine ablation, thyroidectomy). Subclinical hyperthyroidism is not always treated, although close monitoring is needed to prevent disease complications or progression to overt hyperthyroidism. Treatment for subclinical hyperthyroidism is recommended for patients 65 years or older with TSH levels lower than 0.10 mIU/L. Treatment also is recommended for symptomatic patients or those with cardiac or osteoporotic risk factors. Thyroid storm is a life-threatening complication of unmanaged or inadequately managed hyperthyroidism that warrants urgent treatment in a hospital setting.

Thyroid and Parathyroid Conditions: Hypothyroidism.

Hypothyroidism is caused by deficient thyroid hormone production secondary to autoimmune disease or insufficient iodine consumption or as a complication of hyperthyroidism management. Signs and symptoms include fatigue, weight gain, dry skin, constipation, and cold intolerance. The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening for hypothyroidism, but some organizations support screening in special populations. If hypothyroidism is suspected, initial laboratory evaluation consists of a serum thyrotropin (TSH) measurement with reflex testing of free thyroxine (T4). Thyroid function tests must be interpreted carefully because acute illness, diet, and drugs may alter values. Overt hypothyroidism occurs when a patient has an elevated TSH level and a low free T4 level with symptoms of hypothyroidism. Management includes thyroid hormone replacement, ideally levothyroxine. Subclinical hypothyroidism is characterized by an elevated TSH level with a normal T4 value. The decision to treat subclinical hypothyroidism should be based on patient characteristics and shared decision-making discussions. Special consideration should be taken in treating patients with high-risk conditions, including heart disease, pregnancy, and myxedema coma, and in patients requiring high-dose levothyroxine. Thyroid hormone should be titrated based on goal TSH values, symptoms, and potential treatment adverse effects.

Thyroid and Parathyroid Conditions: Thyroid Nodules, Cysts, and Malignancies.

Thyroid nodules are identified incidentally on imaging in most patients. Controversy exists on which patients warrant evaluation of an incidental thyroid nodule. If further assessment of a nodule detected on imaging or examination is pursued, thyroid ultrasonography with cervical lymph node survey and measurement of serum thyrotropin (TSH) may guide management decisions. When the TSH level is low, a nuclear medicine thyroid scan is necessary. Based on size, ultrasonographic features, and nuclear medicine results, patients with thyroid nodules may undergo ultrasonographic surveillance or biopsy with fine-needle aspiration. When fine-needle aspiration is performed, the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) provides a classification system for biopsy results. Molecular testing can be considered in the case of nodules with indeterminate findings based on biopsy. Malignant thyroid nodules and indeterminate nodules with suspicious molecular test results warrant surgical evaluation, whereas others may be monitored with periodic ultrasonography. Approximately 10% of nodules are clinically significant malignancies, and a small number of nodules cause compressive symptoms or progress to functional thyroid disease. Thyroid cancer overall has a 5-year survival of 98%.

Thyroid and Parathyroid Conditions: Parathyroid Conditions.

Parathyroid hormone (PTH) helps regulate calcium homeostasis in a complex relationship with the gastrointestinal tract, kidneys, bone, and parathyroid glands. Abnormalities in PTH production can result in many conditions, including hypoparathyroidism, and primary, secondary, and tertiary hyperparathyroidism. Management of each abnormality centers on maintaining normal or near-normal serum calcium values to prevent complications. Most cases of hypoparathyroidism are caused by neck surgery and may result in acute hypocalcemia. Patients with chronic hypoparathyroidism are treated with a combination of calcium, vitamin D analogs, and, occasionally, exogenous PTH. A single parathyroid adenoma causes most cases of primary hyperparathyroidism, with multiglandular disease and cancer as other possible etiologies. All patients with symptomatic primary hyperparathyroidism and many with asymptomatic hyperparathyroidism undergo partial or full parathyroidectomy to correct the underlying condition. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the most common cause of secondary and tertiary hyperparathyroidism, in which hypocalcemia stimulates PTH production. Most patients with CKD-MBD are treated medically with phosphate binders, vitamin D analogs, and calcimimetics, but rare cases are managed with parathyroidectomy. Severe calcium or vitamin D deficiency also causes secondary hyperparathyroidism and is managed with calcium and vitamin D replacement.

Diabetes-Related Foot Infections: Diagnosis and Treatment.

Diabetes-related foot infections occur in approximately 40% of diabetes-related foot ulcers and cause significant morbidity. Clinicians should consider patient risk factors (e.g., presence of foot ulcers greater than 2 cm, uncontrolled diabetes mellitus, poor vascular perfusion, comorbid illness) when evaluating for a foot infection or osteomyelitis. Indicators of infection include erythema, induration, tenderness, warmth, and drainage. Superficial wound cultures should be avoided because of the high rate of contaminants. Deep cultures obtained through aseptic procedures (e.g., incision and drainage, debridement, bone culture) help guide treatment. Plain radiography is used for initial imaging if osteomyelitis is suspected; however, magnetic resonance imaging or computed tomography may help if radiography is inconclusive, the extent of infection is unknown, or if the infection orientation needs to be determined to help in surgical planning. Staphylococcus aureus and Streptococcus agalactiae are the most commonly isolated pathogens, although polymicrobial infections are common. Antibiotic therapy should cover commonly isolated organisms and reflect local resistance patterns, patient preference, and the severity of the foot infection. Mild and some moderate infections may be treated with oral antibiotics. Severe infections require intravenous antibiotics. Treatment duration is typically one to two weeks and is longer for slowly resolving infections or osteomyelitis. Severe or persistent infections may require surgery and specialized team-based wound care. Although widely recommended, there is little evidence on the effectiveness of primary prevention strategies. Systematic assessment, counseling, and comorbidity management are hallmarks of effective secondary prevention for diabetes-related foot infections.

Refining your approach to hypothyroidism treatment.

Thyroid hormone supplementation can be complicated by a number of factors. These tips can help to ensure that you provide the best treatment possible.

Common Prescription Medications Used in Athletes.

Athletes of various skill levels commonly use many different types of medications, often at rates higher than the general population. Common medication classes used in athletes include analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen, inhalers for asthma and exercise-induced bronchoconstriction, antihypertensives, antibiotics, and insulin. Prescribers must be aware of the unique considerations for each of these medications when using them in patients participating in physical activity. The safety, efficacy, impact on athletic performance, and regulatory restrictions of the most common medications used in athletes are discussed in this article.

Endocrine Conditions in Older Adults: Osteoporosis.

Osteoporosis management has undergone several paradigm shifts over the past 20 years because of emerging technologies and new treatments and decision support tools to guide risk assessment. Practice guidelines in the United States and abroad differ widely on recommendations for screening, prevention, and management. Screening has evolved, with improvements in bone mineral density testing, vertebral fracture assessment, trabecular bone scores, and decision support tools. All of these have improved the identification of patients at high risk of fractures. Prevention of osteoporosis should begin early in life, with adequate dietary calcium and vitamin D intake and exercise in childhood. At older ages, patients should undergo continuous reevaluation to minimize secondary risk factors (eg, comorbid conditions, drugs). Recommended management of osteoporosis includes exercise, bisphosphonates, denosumab, and parathyroid hormone analogs. Choice of optimal management depends on efficacy, potential adverse effects, patient and societal costs, and patient characteristics (eg, severity of disease, underlying etiologies, management preferences). The ideal duration of pharmacotherapy remains unclear. There is potential continued benefit with long-term management but increased risk of some adverse effects. These include atypical fractures and osteonecrosis of the jaw with bisphosphonates and denosumab, and osteosarcoma with parathyroid hormone analogs.

Endocrine Conditions in Older Adults: Menopause.

Menopause is the cessation of menstruation due to loss of ovarian function and is diagnosed retrospectively after 12 consecutive months of amenorrhea. The average age of onset in the United States is 51 years but symptoms can be present for many years before and after. Vasomotor and genitourinary symptoms are the most common. Hormone replacement therapy (HRT) is the most effective management. Given the possible risks of cardiovascular disease and breast cancer, recommendations for HRT after the Women's Health Initiative study are to limit HRT to the lowest dose and shortest duration to relieve symptoms. Based on more recent data, women younger than 60 years and less than 10 years from menopause onset appear to be at lower risk of these factors when initiating HRT. Dosing, type of HRT, administration route, and duration of use are individualized. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and clonidine are alternative nonhormonal options with high-quality evidence supporting their use for symptom relief. However, these management options are less effective than HRT. Local vaginal therapy is effective and recommended for management of isolated vulvovaginal symptoms. Decisions to discontinue HRT should be based on symptoms and risk factors, not age.

Endocrine Conditions in Older Adults: Adrenal Tumors.

Incidentally discovered adrenal masses, referred to as adrenal incidentalomas, are fairly common given the routine use of imaging as part of clinical care in a variety of settings. Adrenal incidentalomas most frequently are benign and hormonally inactive tumors. However, approximately 11% to 15% are hormonally active, which can lead to diagnosis of clinically relevant conditions that affect morbidity and mortality. Thus, all adrenal incidentalomas should be tested for production of hormones at initial diagnosis. A 1-mg dexamethasone suppression test is the initial screening test. Patients then should be referred for appropriate treatment. Among the adrenal mass subtypes, pheochromocytomas are associated with the highest risk of mortality. Every effort should be made to exclude the presence of these tumors. Patients with hypertension and adrenal incidentalomas should be evaluated for aldosterone excess with an aldosterone to renin ratio. Primary malignancy represents a low percentage of adrenal incidentalomas. A minority of adrenal malignancies are primary adrenocortical tumors, which are associated with a poor prognosis and for which management often is palliative.

Endocrine Conditions in Older Adults: Anti-Aging Therapies.

Interest in slowing or reversing the process of aging continues to grow and has encouraged the growth of an entire anti-aging industry. However, there is a dearth of data based on randomized trials in humans to support proposed therapies to address the various complex processes involved in aging. Hormonal therapies, in particular, have little data to support safe use and are associated with some degree of risk. Experimental data in animal models suggest possible molecular targets but their use in clinical medicine is far in the future. Observational data guide the current recommendations to maintain a healthy lifestyle, including consumption of a healthful diet and achieving adequate sleep, toward the goal of slowing the aging process. Patients may ask their physicians to offer opinions about treatments they hope will increase their health span. To counsel patients effectively, it is important for physicians to understand the basic principles of anti-aging science. Maintenance of supportive, nonjudgmental therapeutic relationships with patients is critical to avoid harmful and costly treatments while trying to present reliable evidence for available anti-aging therapies.

Creating a Geriatrics Curriculum in a Continuing Care Retirement Community.

INTRODUCTION: The new Accreditation Council for Graduate Medical Education (ACGME) guidelines for family medicine residencies increased training requirements for caring for older adults. These guidelines prompted changes to the current geriatrics curriculum at the Trident/Medical University of South Carolina (MUSC) Family Medicine Residency Program. Changes to the training requirements and the residency geriatric experiences reflect an increasingly aging population and many unmet needs in caring for older adults. METHODS: To meet accreditation requirements and the needs of our population, the residency program established a new partnership with a continuing care retirement community (CCRC) and hired another provider to coordinate the curriculum. Changes to the curriculum included more time spent in our CCRC, better longitudinal patient visit continuity, a coordinated interprofessional didactic curriculum, more elective opportunities in geriatrics, and online pharmacotherapy quizzes. The curriculum was assessed with a validated 10-question pre/postresident survey. RESULTS: Resident responses revealed increased comfort in caring for a geriatric population, increased desire to focus on geriatrics in their medical career, and increased participation in the geriatrics track. CONCLUSIONS: With changes in ACGME requirements, family medicine residency programs must develop a comprehensive curriculum to care for an increasing elderly population. The Trident/MUSC Family Medicine Residency provides a model curriculum for other programs seeking to improve training for their residents and meet these requirements.

Text Messaging as a Teaching Tool in a Family Medicine Clerkship Rotation.

INTRODUCTION: Today's learners use multiple forms of social communication, such as text messaging, that offer a promising teaching tool for medical education. The purpose of this study was to evaluate a diabetes care curriculum delivered through text messages for third-year medical students on a rural family medicine clerkship. METHODS: A pilot study of 119 participants were compared in a parallel group randomized controlled trial evaluating medical student learning and satisfaction with text messages throughout rotation compared to an email with the same content in their first week of rotation. Participants completed a 10-question multiple-choice test and six survey questions upon completing the rotation. The primary outcome was a difference between test scores among the two groups, and student satisfaction with the educational intervention was a secondary outcome. RESULTS: A total of 85 participants successfully completed the study protocol (34 text messages and 51 email) and were included in a per protocol analysis. The average number of correct responses per test was 3.32 (SD 1.29) in the texting group and 3.69 (SD 1.53) in the email group (P=0.259). Student satisfaction with text messages was 3.68 (SD 0.87) compared to email at 2.02 (SD 0.95) when rating the educational intervention on a 1 to 5 Likert scale (1=poor, 3=average, and 5=excellent). CONCLUSIONS: Participant knowledge on a challenging posttest was not improved with text messages compared to an email in this pilot study. Satisfaction with text messages was primarily positive. Further study is needed to determine the effectiveness of this content delivery method.

Psychopharmacology in Primary Care Settings.

Psychopharmacology requires clinicians to stay current on the latest guidelines and to use dynamic treatment strategies. Psychiatric conditions are prevalent in the primary care population. Choice of treatment with psychopharmacology should be based on controlling the patient's predominant symptoms while taking into consideration patient age, treatment compliance, patient past response to treatments, dosing frequency, patient preference, medication side effects, potential medication interactions, drug precautions/warnings, and cost. Response to therapy, as well as side effects, needs to be evaluated at regular intervals. The goal is to minimize symptoms and return patients to their maximal level of functioning.

Type 2 Diabetes Medication Review.

BACKGROUND: Patients with type 2 diabetes and their healthcare providers have a variety of medication options available for treating elevated blood glucose values. These medication choices have expanded drastically over the last 10 years with a large number of glucose lowering medications gaining FDA approval. METHODS: Here, we have included an extensive search of the type 2 diabetes literature focusing on articles which impact patient-oriented evidence that maters (POEMs). RESULTS: Choosing the best agent(s) can be challenging and requires weighing the risks and benefits of each particular medication. Tailoring medications to individual patients should be prioritized based on trials with cardiovascular outcome data, potential hemoglobin A1c reduction/goal, serious medication precautions and side-effects, co-morbid medical conditions, and cost. CONCLUSIONS: This paper will provide the reader with an overview of the pros and cons for each antiglycemic medication class and specific drugs where appropriate. Data relevant to most patient centered encounters will be provided, including safety, tolerability, efficacy, cost, and simplicity of use.