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Don’t have to see it to believe it – The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy

Don’t have to see it to believe it:

The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial Arthroscopy. 2007 Nov;23(11):1167-1173.e1

Multiple pathologies of the knee cannot be picked up on x-ray and ultrasound. Increasing prevalence of MRI has led to increased use. We as physicians may not see the bill for these investigations but they are still a considerable expense for our system. Due to long wait times, the National Health Service (UK) has started to perform MRIs to try and reduce the number of patients that will actually require surgery while in the US, they are questioning whether MRI will actually add value.

A randomized control trial was performed using 252 patients on a waiting list for knee arthroscopy. All patients had an MRI of their knee performed. They were then randomized into two groups; one had their MRIs read by their surgeons prior to surgery and the other did not. Even though the group whose MRIs were read had a diagnosis change in 47% of cases, compared to 1% in the control group, ultimately, the rate of surgery was the same.

Important to highlight that this is American data and they may be more likely to proceed with arthroscopy than their Canadian colleagues. Important to note that a diagnosis change occurred in 47% meaning information from MRI was still of value.

Take away message to consider: Don’t wait for an MRI report to refer to orthopaedics because it is unlikely to change the management plan in patients you suspect will require arthroscopy but still order the MRI as it can provide valuable information for operative planning.

 

Anthony Caragianis, PGY3

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Falls Prevention Planning in Champlain: Article 7

CME Certified Fall Prevention module

In a cross Canada review, there were few certified Fall Prevention programs targeted towards Primary Care physicians and their healthcare professional teams. Dr. Frank Molnar, Geriatrician, and his team have changed that! The Champlain Fall Prevention Steering Committee, Dr. Molnar and the Regional Geriatric Program of Eastern Ontario have worked together to deliver an interactive Fall Prevention module which utilizes the Champlain Fall Prevention tools. This online group learning program meets the certification criteria of the College of Family Physicians of Canada and has been certified by the University of Ottawa’s Office of Continuing Professional Development for up to 2 MainPro+ credits.

The sequential modules focus on education, client self-screening using the Staying Independent Checklist, and delivery of the appropriate and evidence-based follow up assessment and diagnosis to determine the root cause of the fall. Selecting the right intervention and referral is also covered in the module.

A complement to this CME program includes access for non-registered health care workers to an online PSW Fall Prevention module. It can be useful for volunteers, receptionists and other non-registered team members as it provides information to enable them to act as a coach and guide for their older clients and to understand the importance of self-screening and the use of the Staying Independent  Checklist as part of the Champlain Fall Prevention Algorithm.

These two modules are components of the Fall Prevention education framework to reinforce the delivery of the best practices in Fall Prevention across the continuum. Work is now being undertaken to provide other registered healthcare professionals with similar support,

All of these resources and the link to sign up for the CME module can be found through the www.stopfalls.ca website

Falls Prevention Planning in Champlain: Article 6 – Exercise Class Navigation Flow Chart: Evaluation

 

As described in our last article physical activity plays a very important role in Fall Prevention but it has often been complicated in the past, for seniors to find the class with the right fit for them to enable them to continue to participate. The purpose of developing the exercise class navigation tool was to make it easier for seniors to access LHIN funded exercise classes across the region. The Champlainhealthline.ca link  “Exercise Classes for Seniors” shows the “Which Exercise Class is Best for Me” flowchart and a list of the available classes in the senior’s locality.

The chart was launched nine months ago for Fall prevention month in November 2016 and the time has come to ask users what they think of it, and to understand whether it has achieved its purpose and what improvements can be made.

To do this a questionnaire has been developed and will be visible when seniors, family members, and caregivers as well as referrers use the Champlain Healthline at  www.champlainhealthline.ca

We would like to ask you as referrers and health care providers to give us your feedback as well as encouraging your patients and clients to complete the very short survey which can also be found here.

Thank you for your time and your help in making sure that the navigation chart is relevant and useful for seniors and their care providers alike.

“It’s Not Right” – Changing the Conversation to Stop Abuse of Older Adults

Become one of our 2017 Champions for Social Change

In collaboration with the Ontario Seniors’ Secretariat, Elder Abuse Ontario and Western University invite you to be part of a provincial initiative to engage our citizens in challenging social norms and encouraging bystander interventions in support of at-risk seniors.

What YOU can do to get involved:

Contact us to register for a one-day workshop in your region (below)

At the one-day regional workshop,

  • You will learn about It’s Not Right! Neighbours, Friends and Families for Older Adults (INR-NFF) – a proven, high performing education and engagement tool
  • You will meet other passionate advocates and professionals who have been identified as leaders and influencers
  • Together, we will set highly ‘do-able’ goals and make a coordinated regional plan to engage your community
  • You will take-away the INR-NFF tools and materials to be able to deliver presentations. Each participant will commit to delivering a minimum of 3 INR-NFF presentations by March 2018 and supporting the roll-out of their regional plan.

There is no cost for registration or for the materials.

INR regional workshop invitation – Dec 1 Eganville

JOIN US!

See how little things YOU do can make a BIG difference to change attitudes and behaviours to stop abuse of older adults

Regional workshops are being held across the province.

A workshop will be held in your region from 10am – 3pm:

DATE LOCATION
Dec. 1st        Eganville and District Seniors’ Centre (30 Bell St, Eganville, ON)

 Why you were chosen to attend: You are a professional, advocate or citizen who has been recognized by peers for your leadership and work in the area of older adults’ safety or elder abuse awareness in your community.

What the champion role requires: Participants should have experience with public speaking and making presentations. Be prepared to take action by committing to making a minimum of 3 INR-NFF presentations by March 2018 and supporting the roll out of a regional plan to engage your community in elder abuse prevention and intervention.

Register today! Spaces are limited. Registration is FREE.  Please contact Stéphanie Cadieux at east@elderabuseontario.com

Lunch will be provided (Please inform us of any food restrictions when registering)

Travel subsidies of up to $250 are available if you are traveling over 150 km to attend.

Falls Risk Screening Research Project

Falls are a leading cause of injury among seniors. 20-30% of seniors (age 65+) experience one or more falls each year and 85% of seniors’ injury-related hospitalizations are due to falls.

The Champlain LHIN IMPACTT Centre is conducting a research project supported with Ontario Centres of Excellence funding from the MOHLTC Ontario Chief Innovation Strategist.

This project will ddetermine the value of a falls prediction model that leverages a new technology; QTUGTM and uses trained technicians (non-professionals such as personal support workers) to engage seniors that are normally not being actively screened for falls, and to identify those at higher risk of falling prior to their first fall.

If a senior has been identified with a moderate to very high falls risk, we are suggesting they take the handout materials and speak with their physician or other healthcare professionals to better understand what may be contributing to their risk of falls and what they can do to help prevent falls.

 What is QTUGTM?

The “Timed Up and Go” or TUG test is one tool that health professionals use during a falls assessment.  It consists of the person getting up from a chair walking 3 meters, turning around, walking back the 3 meters and sitting down while the professional monitors the time it takes, the gait, steadiness, etc.

The QTUGTM uses sensors worn on the shins (over clothing) and a hand-held tablet to track the person during the TUG test.  With proven qualitative input, analytical data and algorithms it produces a Falls Risk Score.

First, the person is asked a few questions about age, weight, height, recent falls, any problems with mobility, medications, blood pressure, dizziness and/or vision. The sensors and tablet then measure the time taken to stand, average stride time, average stride velocity, step time variability, time taken to turn, number of steps in turn and time to complete the test. The sensor information combined with the short falls questionnaire determines your risk of falling.

For more information contact the IMPACTT Centre.

Email: Judy Marshall-Brunke 

Tel: 613-745-8124, ext. 5879 | Toll Free: 1.800-538-0520

Is there an association between tendinopathy and diabetes mellitus? A systemic review and analysis

Tom A Ranger, Andrea M Y Wong, Jill L Cook, Jamie E Gaida

Ranger TA et al. Br J Sports Med 2016; 50: 982-989

The prevalence of Diabetes in our population is increasing, as is the morbidity and mortality associated with this chronic disease. As a primary care provider, we are well aware of the role ‘lifestyle’ plays in the development and control of Type 2 diabetes mellitus.  For this reason, the guidelines recommend exercise and diet as first line treatment for this condition.  It has been shown that up to 50% of participants who quit exercise as part of their management do so because of musculoskeletal symptoms.  So the question arises: Does tendinopathy, a condition that reduces exercise tolerance, have a role to play in lack of adherence to an exercise program in diabetics?

Earlier studies have shown that hyperglycemia does change the collagen cross-linking of tendons and reduced their proteoglycan content (Reddy, 2003) leading to weakened tendons and predisposing them to tendinopathy.  This study investigated the potential association between diabetes and tendinopathy by systematically reviewing and meta-analysing case control, cross sectional, and studies that considered both of these conditions.  In total 31 studies were selected for the final analysis with good attention paid to exclusion criteria and reduction of bias.  Confounding variables were identified: age, sex, adiposity, statin use and hyperglycemia.  There is observational evidence that statins may induce tendinopathy (Marie I, Arthritis Rheum 2008;59:367-72) as well as an association between adiposity and tendinopathy (Gaida, Arthritis Rheum 2009; 61 840-9).

This systematic review showed that “diabetics had greater than three times the odds of tendinopathy compared to controls; and people with tendinopathy had 1.3 times increased odds of diabetes compared to controls.  Therefore there is evidence of a strong link between diabetes and tendinopathy however cause and effect cannot be established even though there are plausible biological pathways by which high blood glucose can affect tendon structures.” It was also shown that those diabetics with tendinopathy have had a longer duration of diabetes.

Regardless of the cofounders that may exist, the compelling evidence supports the link between diabetes and tendinopathy. This has important clinical implications such as careful monitoring and structuring of load progression when initiating exercise to prevent the development of tendinopathy.  A slower, more graduated approach would be crucial for these patients. As well, those who have tendinopathy and require rehabilitation should ensure tight glycemic control to speed resolution.

“Co-management by medical and allied health practitioners may be indicated for people with tendinopathy and long standing diabetes.”

Keith Morgan BSC, MD, CCFP, Sport Medicine Fellow                               February 2017

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Med

Cognitive Decline Not Impacted by Cholesterol or Blood Pressure Drugs

With populations aging in much of the world, the decline of mental capacity in later years  is of increasing concern. There has been hope in the medical community that effectively treating hypertension and atherosclerosis could slow or delay this decline.brain

In the HOPE-3 clinical trial, a study of people over the age of 70 taking either blood pressure medication or statins for the prevention of heart disease, neither drug slowed cognitive decline during treatment. These results, presented at the American Heart Association 2016 Scientific Sessions, were disappointing for researchers looking to delay or even prevent the cognitive decline that comes with aging.

However, the findings were encouraging in one respect. There have been persistent concerns among patients and regulators that the use of statins to control cholesterol could negatively impact cognitive function and memory. The trial found that the patients taking statins did not have a larger decline in cognitive ability than other participants.

Patients were randomly assigned to receive either one of three drug regimens (combination blood pressure medication, a statin, or both) or to corresponding placebo groups. At the beginning and end of the study, 1,626 older adults completed several questionnaires and tests of mental processing speed and cognitive function.

While participants in all groups experienced a decline in cognitive function over the time of the study, there was no difference in the amount of this decline between treatment or placebo groups.

Data from the trial seemed to suggest that there might be some prevention of cognitive decline in patients with the highest blood pressure and LDL cholesterol levels at the start of the study, but this would need to be confirmed in other trials, said Jackie Bosch, PhD, of McMaster University, who presented the study results at AHA.

Dr. Bosch indicated that the results of this and other recent studies should put to rest concerns about statins and cognitive decline. “We have the data…that show that there is no adverse effect of statins” on cognition, she concluded.

[This article originally appeared in The Beat.]

Falls Prevention Planning in Champlain: Article 5

Exercise Class Navigation Flow Chartexercise-class-in-action-1

Encouraging seniors to exercise and to be physically active is an important part of a fall prevention strategy. Exercise programs that promote balance training combined with strength and flexibility have been shown to be effective in significantly reducing falls and the injuries resulting from a fall.  LHIN funded exercise and Fall Prevention programs are available across the Champlain region, and different levels of programs for people of different abilities are provided.  However, determining which class is the right one is key to ensuring that participants gain maximum benefit from the class. Choosing the wrong level of class can be a lost opportunity to promote increased activity.

To simplify the choices and decisions for older adults, their families and health care providers, the Navigation Working Group of Champlain Fall Prevention Steering Committee has developed a flow chart. Each region has its own flow chart with local class details and contact information, but the descriptions for each level have been standardized across Champlain with consistent wording for each level of class.

 

Ottawa
Eastern Counties (Prescott Russell and Stormont, Dundas and Glengarry)
Renfrew County

List of locations (Renfrew County and District)

On the reverse of the chart is the Staying Independent Checklist and seniors are urged to complete this fall-risk screening tool, although it is not a determinant of exercise and activity levels. This screen is a key first step in the Champlain Fall Prevention Algorithm of Detection, Diagnosis and Intervention.  Primary care providers should encourage their older patients to complete the Staying Independent Checklist annually and to bring issues and concerns to the primary care team.

The exercise class flow chart will be launched in November 2016 (Fall Prevention month) and will be distributed to public health units, community support services, primary care providers and other agencies, to encourage seniors to choose an active lifestyle. The flow charts can be found on the www.stopfalls.ca website under the community resources tab, and also on the Champlainhealthline website , under the Exercise Classes for Seniors button, “Which Exercise Class for me?”

For more information contact:

Christine Bidmead 

Project Manager

Champlain Falls Prevention Strategy

Regional Geriatric Program of Eastern Ontario

email: cbidmead@toh.ca

Cell Phone 519 639 3000

Changes in Blood Pressure Medication Temporarily Increase Risk of Serious Falls

Elderly patients who start taking blood pressure medication or change their prescription or dosage have a temporarily increased risk of serious fall-related injury. The findings, published in Circulation: Cardiovascular Quality and Outcomes, included more than 90,000 patients in the United States aged 65 years and older.BP medicine

Between 2007 and 2012, researchers found that 272 of the patients began taking drugs for high blood pressure, 1,508 added a new drug to their existing blood pressure regimen, and 3,113 had the dose of at least one blood pressure drug increased. The likelihood of a serious fall-related injury went up 36% for patients starting a medication regimen, 16% for patients adding a new drug and 13% for patients increasing a dose.

This increased risk dissipated after two weeks following the medication changes. The authors of the study stressed that, due to its observational nature, the research could only show an association between medication changes and fall risk, not determine cause and effect. However, it identifies a time period during which elderly patients may need closer monitoring for short-term side effects.

Aortic Valve Replacement: What’s Next for TAVI?

Aortic stenosis affects more than 100,000 Canadians over the age of 65. Until recently, surgical replacement was the only treatment option, but over the last several years, TAVI, or transcatheter aortic valve implantation (often referred to as transcatheter aortic valve replacement (TAVR) in the US), has emerged as a viable alternative with advantages over surgery. Because the TAVI valve is inserted through a catheter, the incision is small and recovery times can be much shorter than for the open heart surgical procedure.

First introduced in the early 2000s, TAVI is approved in Canada mostly for use in patients who are inoperable or whose condition makes surgery a high risk. As evidence for TAVI’s safety and durability grows and advanced technology comes on the market, the procedure is poised to become much more common.

Extending TAVI to Lower Risk Patients

“We do patients for whom surgery would be high risk, often higher risk patients than at other centres in the province,” said Interventional cardiologist Marino Labinaz, head of the TAVI heart team at the Ottawa Heart Institute.TAVI

The older and sicker high risk patients require hospital stays similar to surgical patients. In Europe, where TAVI is used in a broader range of patients, the time in hospital can be much shorter.

“In low risk patients, we are seeing expedited discharge. There is a trial underway in Vancouver where they are looking at 24-hour discharge,” he said. “Where I see the sweet spot for TAVI in the low-risk patient is in rapid recovery. You’re going to come in, get your TAVI and go home the next day. In our patients, we haven’t reaped the benefit of early discharge yet.”

“The use of TAVI in these patients will be, in part, patient choice. It may also become a societal choice,” he continued, “Because, if you can send a patient home in 24 hours, then TAVI could become very cost effective when compared to a five- to seven-day stay for surgery. This will particularly be true if the cost of the valves comes down.”

TAVI is currently a more expensive option than surgery due to the cost of the valves, but as demand for TAVI grows and as new vendors enter the market and increase competition, costs are expected to decline.

Conscious Sedation Over General Anesthetic

Another emerging benefit of TAVI over surgery is the use of conscious sedation.

“Currently, we give patients a general anesthetic and they are intubated. Conscious sedation means we give them short-acting medication,” he explained. “They are conscious, and they are never intubated. The patient doesn’t have the issue of the anesthetic to recover from, and it saves time so you can do more patients in a day.”

Given the Heart Institute’s emphasis on high-risk patients, conscious sedation is only just getting started in Ottawa.

Improved Technology

One of the limitations of TAVI is the size of the catheter. To fit the valve inside, the catheter has to be larger around than those used in angioplasty for delivering stents.

“From a patient perspective, one of the biggest changes is that the valves are becoming smaller in size,” said Dr. Labinaz. “The first generation devices were very large calibre and we would see higher rates of dissections or occlusions in the arteries. Smaller tubes mean fewer vascular complications.”

Another important advancement is retrievability. Until recently, the cardiologist had only one shot to position and deploy the valve. Poor positioning can impact the seal of the valve and cause leaking—known as paravalvular aortic regurgitation—as well as complications that can require a pacemaker. A retrievable valve allows for real-time adjustments to be made.

“They aren’t yet commercially available here, but there are three valves available on special access from Health Canada that have the ability to be retrieved,” he said. “With two of them, you can deploy the valve to 80% to get an idea how it is positioned and functioning, and then retrieve it. The only completely deployable valve that can be retrieved is the new Lotus valve. We will begin using it this spring.”

“Another advance related to leaking is the addition of flexible sleeves on the outside of the valves that provide a better seal with the calcium and nodules and crevices that can create an uneven surface. Preliminary data is positive.”

One complication of aortic valve replacement that’s common to surgery and TAVI is stroke. Material from the calcium deposits in and around the valve can break away during the procedure and travel up the bloodstream to the brain. For both surgery and TAVI, the rate of stroke is 5 to 10%. On the horizon for TAVI is the use of protective filters in the blood vessels to capture that material. Results so far have been mixed.

Looking Ahead

“TAVI has been a real game changer,” concluded Dr. Labinaz. “We’re getting lots of data now on the durability of the valves in people who have had them for five and 10 years. They have low failure rates and seem to be comparable to the surgical valves.”

“It’s my prediction that TAVI will become a standard way of doing aortic valve replacement in the next five years. In Germany, it already is. Sixty per cent of aortic valve replacements in Germany are now TAVI. That’s the way it’s going. In Canada, cost and funding are the limiting factors.”