Dementia: Dementia Types.

Dementia, also called major neurocognitive disorder, is characterized by a chronic progressive loss of cognitive function in the absence of fluctuating consciousness. It represents a primarily geriatric syndrome that may be caused by one of several underlying conditions. There is insufficient evidence to support universal screening for cognitive impairment in older adults; however, clinicians should be alert to patient and caregiver concerns about cognitive changes and investigate such concerns with validated cognitive assessment tools. Alzheimer disease is the leading cause and prototypical form of dementia, presenting insidiously and causing progressive cognitive impairment with increasing severity over a period of years. Vascular dementia is the second most common form of dementia and often co-occurs with other progressive cognitive disorders. Lewy body dementias encompass Parkinson disease dementia and dementia with Lewy bodies, which have similar features and are differentiated primarily by the order of motor and cognitive symptom onset. Frontotemporal dementias occur earlier than other forms of dementia, progress rapidly, and often have a genetic component. An understanding of the conditions that cause dementia will assist clinicians in making an accurate diagnosis and providing appropriate treatment recommendations and counseling regarding the diagnosis and prognosis.

Ischemic Stroke Management: Posthospitalization and Transition of Care.

Ischemic stroke is a major cause of morbidity and mortality worldwide. Ischemic stroke and transient ischemic attack exist on a continuum of the same disease process. Ischemic stroke is common, and more than 85% of stroke risk is attributed to modifiable risk factors. The initial management of acute stroke is usually performed in the emergency department and hospital settings. Family physicians have a key role in follow-up, ensuring that a complete diagnostic evaluation has been performed, addressing modifiable risk factors, facilitating rehabilitation, and managing chronic sequelae. Secondary prevention of ischemic stroke includes optimization of chronic disease management (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia), nonpharmacologic lifestyle interventions (e.g., diet changes, exercise, substance use counseling), and pharmacologic interventions. Dual antiplatelet therapy with aspirin and clopidogrel is generally indicated for minor noncardioembolic ischemic strokes and high-risk transient ischemic attacks and should be converted to single antiplatelet therapy after 21 to 90 days. Secondary prevention of cardioembolic stroke requires long-term anticoagulation. Direct oral anticoagulants are preferred over warfarin for patients with nonvalvular atrial fibrillation. Poststroke problems with mobility, balance, cognition, dysphagia, and depression are common. Rehabilitation involves a multidisciplinary, multimodal approach that includes physical therapy, speech therapy, and treatment of chronic pain and poststroke depression.

How accurate are geriatricians' fall predictions?

BACKGROUND: Older patients are at increased risk of falling and of serious morbidity and mortality resulting from falls. The ability to accurately identify older patients at increased fall risk affords the opportunity to implement interventions to reduce morbidity and mortality. Geriatricians are trained to assess older patients for fall risk. If geriatricians can accurately predict fallers (as opposed to evaluating for individual risk factors for falling), more aggressive and earlier interventions could be employed to reduce falls in older adult fallers. However, there is paucity of knowledge regarding the accuracy of geriatrician fall risk predictions. This study aims to determine the accuracy of geriatricians in predicting falls. METHODS: Between October 2018 and November 2019, a convenience sample of 100 subjects was recruited from an academic geriatric clinic population seeking routine medical care. Subjects performed a series of gait and balance assessments, answered the Stay Independent Brochure and were surveyed about fall incidence 6-12 months after study entry. Five geriatricians, blinded to subjects and fall outcomes, were provided the subjects' data and asked to categorize each as a faller or non-faller. No requirements were imposed on the geriatricians' use of the available data. These predictions were compared to predictions of an examining geriatrician who performed the assessments and to fall outcomes reported by subjects. RESULTS: Kappa values for the 5 geriatricians who used all the available data to classify participants as fallers or non-fallers compared with the examining geriatrician were 0.42 to 0.59, indicating moderate agreement. Compared to screening tools' mean accuracy of 66.6% (59.6-73.0%), the 5 geriatricians had a mean accuracy for fall prediction of 67.4% (57.3-71.9%). CONCLUSIONS: This study adds to the scant knowledge available in the medical literature regarding the abilities of geriatricians to accurately predict falls in older patients. Studies are needed to characterize how geriatrician assessments of fall risk compare to standardized assessment tools.

Post-ICU Care in the Outpatient Setting.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually, and an increasing percentage of patients treated in the ICU survive to hospital discharge. Because these patients require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications. Risk factors for complications after ICU discharge include previous ICU admissions, preexisting mental illness, greater number of comorbidities, and prolonged mechanical ventilation or higher opioid exposure while in the ICU. Early nutritional support and mobilization in the ICU decrease the risk of complications. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause. Exercise regimens are beneficial for reducing several post-ICU complications. Patients who were treated for COVID-19 in the ICU may require additional instruction on reducing the risk of virus transmission. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices.

A Curriculum for Teaching Clinical Efficiency Focusing on Specific Communication Skills While Maximizing the Electronic Health Record.

Introduction: All physicians must learn comprehensive patient care delivery within the electronic health record (EHR). No studies have considered EHR communication training with an emphasis on clinical efficiency. This curriculum provides a method of teaching clinic efficiency while practicing effective patient communication in any EHR clinical situation. The target audience is resident physicians, fellow physicians, faculty physicians, and physician extenders practicing in a primary care setting where the EHR is present. Methods: This curriculum of four separate workshops provides a structured EHR approach while addressing communication strategies for preclinical preparation, rapport building, encounter initiation, agenda setting, and visit closure. The curriculum contains interactive presentations, tools, and an evaluation survey. Presenting efficiency issues with the EHR using the ATTEND mnemonic and agenda setting allows documentation while practicing communication techniques that maximize efficiency. Results: Postworkshop surveys revealed that participants felt the workshops were helpful (84%). One measurement of efficiency revealed improvement through decreased number of days to note completion after workshop participation. At the Program Directors Workshop, curriculum value was demonstrated by high attendance, with 94% feeling the workshops provided easily utilizable strategies. Discussion: The curriculum utilized only the EPIC EHR but would be generalizable. Future directions could include measurement of effective communication and visit efficiency through direct observation and expanded EHR timing data.

Goldilocks and Entrustment: Finding the Amount of Learner Autonomy That's Just Right.

Introduction: Faculty and residents strive for appropriate autonomy and entrustment. Initial direct supervision of clinical care gradually shifts to increasing levels of resident independence over time. Faculty members are inconsistent in resident supervision leading to missed opportunities for resident independence. Methods: Family medicine faculty workshop participants completed teaching style self-evaluations prior to discussion of clinical examples with excessive or insufficient autonomy. Participants reviewed real resident feedback examples to increase insight into teaching styles. Participants were presented with cases to discuss varying degrees of resident autonomy and entrustment. Learners committed to one specific behavior to calibrate the degree of autonomy they provide. Results: Of the faculty, 113 members participated in the workshop with the majority (98%) finding the workshop relevant in helping them to identify strategies for reflecting on their degree of autonomy allowed and to look for appropriate situations for enhancing their resident entrustment. Discussion: This interactive workshop provided clear ways for addressing the issue of independence versus control in supervision of patient care. It provided a feedback mechanism for educators who provide too much or too little autonomy for the best resident learning. Additionally, this conversation encouraged participants to engage in self-reflection on the autonomy given to their resident.

Muscle Weakness in Adults: Evaluation and Differential Diagnosis.

Although the prevalence of muscle weakness in the general population is uncertain, it occurs in about 5% of U.S. adults 60 years and older. Determining the cause of muscle weakness can be challenging. True muscle weakness must first be differentiated from subjective fatigue or pain-related motor impairment with normal motor strength. Muscle weakness should then be graded objectively using a formal tool such as the Medical Research Council Manual Muscle Testing scale. The differential diagnosis of true muscle weakness is extensive, including neurologic, rheumatologic, endocrine, genetic, medication- or toxin-related, and infectious etiologies. A stepwise approach to narrowing this differential diagnosis relies on the history and physical examination combined with knowledge of the potential etiologies. Frailty and sarcopenia are clinical syndromes occurring in older people that can present with generalized weakness. Asymmetric weakness is more common in neurologic conditions, whereas pain is more common in neuropathies or radiculopathies. Identifying abnormal findings, such as Chvostek sign, Babinski reflex, hoarse voice, and muscle atrophy, will narrow the possible diagnoses. Laboratory testing, including electrolyte, thyroid-stimulating hormone, and creatine kinase measurements, may also be helpful. Magnetic resonance imaging is indicated if there is concern for acute neurologic conditions, such as stroke or cauda equina syndrome, and may also guide muscle biopsy. Electromyography is indicated when certain diagnoses are being considered, such as amyotrophic lateral sclerosis, myasthenia gravis, neuropathy, and radiculopathy, and may also guide biopsy. If the etiology remains unclear, specialist consultation or muscle biopsy may be necessary to reach a diagnosis.

Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review.

BACKGROUND: Delirium is an acute disorder of attention and cognition that is common, serious, costly, under-recognized, and potentially fatal. Delirium is particularly problematic in the emergency department (ED) care of medically complex older adults, who are being seen in greater numbers. OBJECTIVE: This evidence-based narrative review focuses on the key components of delirium screening, prevention, and treatment. DISCUSSION: The recognition of delirium requires a systematic approach rather than a clinical gestalt alone. Several delirium assessment tools with high sensitivity and specificity, such as delirium triage screen and brief Confusion Assessment Method, can be used in the ED. The prevention of delirium requires environmental modification and unique geriatric care strategies tailored to the ED. The key approaches to treatment include the removal of the precipitating etiology, re-orientation, hydration, and early mobilization. Treatment of delirium requires a multifaceted and comprehensive care plan, as there is limited evidence for significant benefit with pharmacological agents. CONCLUSION: Older ED patients are at high risk for current or subsequent development of delirium, and a focused screening, prevention, and intervention for those who are at risk for delirium and its associated complications are the important next steps.

Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy.

Pulmonary embolism and deep venous thrombosis are the two most important manifestations of venous thromboembolism (VTE), which is the third most common life-threatening cardiovascular disease in the United States. Anticoagulation is the mainstay of VTE treatment. Most patients with deep venous thrombosis or low-risk pulmonary embolism can be treated in the outpatient setting with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants. Inpatient treatment of VTE begins with parenteral agents, preferably low-molecular-weight heparin. Unfractionated heparin is used if a patient is hemodynamically unstable or has severe renal insufficiency, high bleeding risk, hemodynamic instability, or morbid obesity. Direct-acting oral anticoagulants are an alternative; however, concerns include cost and use of reversing agents (currently available only for dabigatran, although others are in development). If warfarin, dabigatran, or edoxaban is used, low-molecular-weight or unfractionated heparin must be administered concomitantly for at least five days and, in the case of warfarin, until the international normalized ratio becomes therapeutic for 24 hours. Hemodynamically unstable patients with a low bleeding risk may benefit from thrombolytic therapy. An inferior vena cava filter is not indicated for patients treated with anticoagulation. Current guidelines recommend anticoagulation for a minimum of three months. Special situations, such as active cancer and pregnancy, require long-term use of low-molecular-weight or unfractionated heparin. Anticoagulation beyond three months should be individualized based on a risk/benefit analysis. Symptomatic distal deep venous thrombosis should be treated with anticoagulation, but asymptomatic patients may be monitored with serial imaging for two weeks and treated only if there is extension.

Surveillance of the adult cancer survivor.

The term "cancer survivor" refers to anyone living with a diagnosis of cancer. As the U.S. population ages, cancer screening increases, and cancer treatments improve, millions more Americans will be classified as cancer survivors in the future. Although many survivors wish to continue care with their oncologists, patients benefit from care provided by a family physician. Many survivors are older and have comorbidities, which should be addressed to optimize function and longevity. Common late effects of cancer and its treatment include second primary cancers, sexual dysfunction, and psychosocial issues. Cancer recurrence is a significant concern. After treatment for colorectal cancer, intensive surveillance, including colonoscopy, imaging, and serology, confers an overall survival benefit. Breast cancer survivors should receive annual mammography. Prostate cancer survivors should undergo prostate-specific antigen testing every six to 12 months. Melanoma survivors should be counseled on sun protection, including daily sunscreen use, and recognizing characteristics of potentially malignant skin lesions. Female survivors of Hodgkin lymphoma who were treated with chest or axillary radiation between 10 and 30 years of age are at high risk of breast cancer, and should be screened with mammography and magnetic resonance imaging annually starting eight to 10 years after the diagnosis. All cancer survivors treated with chest radiation are at increased risk of cardiovascular disease, and should be screened for other cardiovascular risk factors and treated as indicated.

Diagnosis of deep venous thrombosis and pulmonary embolism.

Venous thromboembolism manifests as deep venous thrombosis (DVT) or pulmonary embolism, and has a mortality rate of 6 to 12 percent. Well-validated clinical prediction rules are available to determine the pretest probability of DVT and pulmonary embolism. When the likelihood of DVT is low, a negative D-dimer assay result excludes DVT. Likewise, a low pretest probability with a negative D-dimer assay result excludes the diagnosis of pulmonary embolism. If the likelihood of DVT is intermediate to high, compression ultrasonography should be performed. Impedance plethysmography, contrast venography, and magnetic resonance venography are available to assess for DVT, but are not widely used. Pulmonary embolism is usually a consequence of DVT and is associated with greater mortality. Multidetector computed tomography angiography is the diagnostic test of choice when the technology is available and appropriate for the patient. It is warranted in patients who may have a pulmonary embolism and a positive D-dimer assay result, or in patients who have a high pretest probability of pulmonary embolism, regardless of D-dimer assay result. Ventilation-perfusion scanning is an acceptable alternative to computed tomography angiography in select settings. Pulmonary angiography is needed only when the clinical suspicion for pulmonary embolism remains high, even when less invasive study results are negative. In unstable emergent cases highly suspicious for pulmonary embolism, echocardiography may be used to evaluate for right ventricular dysfunction, which is indicative of but not diagnostic for pulmonary embolism.

Mailed fecal-immunochemical test for colon cancer screening.

Various interventions have been implemented to increase the rate of colon cancer screening. The purpose of this study was to determine if persons who are regular patients of a clinic, ages 50-64 years, and not up-to-date with colon cancer screening will complete the at-home fecal-immunochemical test (FIT) if it is mailed to them. This intervention was designed to have the subject avoid the signing of an informed consent and having to ask for the screening test; and, only one stool specimen was needed. Three hundred and fifty potential subjects were randomly selected from an electronic medical record database after meeting inclusion criteria. Eighty-seven fecal immunochemical tests were returned. Seven of the FIT kit results were positive for occult blood. Each respondent was sent a letter giving them their results. A minimal cue CRC screening intervention, a FIT kit sent in the mail without prerequisite of a signed informed consent, was offered to the study subjects. Twenty-six percent of the eligible persons were screened for colon cancer by this method. A mailed FIT kit or one handed to the patient at an office visit has minimal cost which can be recovered through insurance coverage. Commitment by health care providers is necessary for prevention. This method is one of several that could reach the hard to screen population.

The "Iowa get screened" colon cancer screening program.

OBJECTIVE: To implement a colon cancer screening program for uninsured or underinsured Iowans. METHODS: All 1995 uninsured patients or patients with Iowa Care insurance aged 50 to 64 years attending the University of Iowa Clinic or the Iowa City Free Medical Clinic were mailed information about the project. Recruitment also took place in person, by having the clinic receptionist hand subjects a research packet, and through community posters. Individuals with colonic symptoms or who were up to date with screening were ineligible. Eligible subjects received a free fecal immunochemical test (FIT), and those with positive FITs were provided with a colonoscopy at no cost to them. RESULTS: Of 449 individuals who completed eligibility forms (23% of the study population), 297 (66%) were eligible and were provided with an FIT. Two-hundred thirty-five (79%) returned a stool sample, with 49 (21%) testing positive. Thirty of the 49 (61%) individuals had a colonoscopy, and 20 individuals had at least 1 polyp biopsied. Thirteen individuals had at least 1 tubular adenoma; 2 had adenomas more than 1 cm in diameter, with no colon cancers identified. Face-to-face recruitment had the highest rate of returned FITs (72%) compared with handing the subject a research packet (3%) or a mailing only (9%) (Chi-square, P < .001). CONCLUSION: There was high interest in and compliance with colon cancer screening using a FIT among underinsured individuals. Although the FIT positivity rate was higher than expected, many individuals did not complete recommended follow-up colonoscopies. Population-based strategies for offering FIT could significantly increase colon cancer screening among disadvantaged individuals, but programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.

Prostate cancer screening: the continuing controversy.

Prostate cancer is the second most common cancer in men, with a lifetime prevalence of 17 percent. Prostate cancer symptoms generally occur in advanced stages, making early detection desirable. Digital rectal examination and prostate-specific antigen testing are the most commonly used screening tools. The goal of screening is to detect clinically significant prostate cancers at a stage when intervention reduces morbidity and mortality; however, the merits and methods of screening continue to be debated. Prostate-specific antigen levels may be less than 4 ng per mL in 15 to 38 percent of men with cancer, indicating a high false-negative rate. The positive predictive value of the prostate-specific antigen test is approximately 30 percent; therefore, less than one in three men with an abnormal finding will have cancer on biopsy. These limitations of the prostate-specific antigen test have led to variations designed to improve its accuracy (e.g., age- and race-specific cutoffs, free prostate-specific antigen tests); however, none of these modifications have been widely adopted because of unclear benefits. Although treatments have improved in the past two decades, therapy for prostate cancer is not benign and may lead to urinary incontinence, sexual dysfunction, or bowel dysfunction. New evidence affecting screening recommendations continues to accumulate, and two large randomized controlled trials of screening will be completed in the next few years. Current guidelines recommend an individualized, targeted, patient-centered discussion to facilitate a shared decision about screening plans.

Diagnosis and management of heart failure in the outpatient setting.

Heart failure is a clinical syndrome that results in diminished tissue perfusion and volume overload. Because of increasing population age and improved survival after myocardial infarction, the prevalence of heart failure is likely to increase dramatically. Primary care physicians are in an ideal position to care for patients throughout the spectrum of heart failure, from identifying patients at increased risk to managing the final stages of the disease. New understandings of heart failure pathophysiology have led to more effective treatments aimed at blocking neurohormonal pathways. There is still much to be learned about the pathophysiology and treatment of diastolic heart failure, and rapidly expanding knowledge of heart failure is likely to lead to better treatment in the coming years.