With the continued destigmatization of some forms of mental illness in the community (namely, the diagnoses of depression and anxiety), it comes as no surprise that we are more willing than ever to discuss treatment and prevention more openly. Oh, and it also doesn’t hurt that — within the general population at any given time — 10 percent of Americans are taking an antidepressant.

According to the Centers for Disease Control, the rate of antidepressant use has skyrocketed by a factor of 4X over the past 25 years. Females lead the pack in all age demos save for the youngest — ages 12-17. Interestingly, income status was not a predictor of use, the agency cites; although, slightly more than 1 in 12 persons taking the drugs is Caucasian. Most disturbingly, though, is the apparent lack of care access or followup once these drugs are prescribed: just under a third of patients have seen a mental health professional (or primary care physician — assuming the drugs are possibly given for off-label uses) within the previous 12 months. Excellent survey data here.

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Sign of the times: social media’s use in increasing interaction among patients with dementia. A researcher, part of a team, is busy at work on a web-based app based upon Facebook for utilization among cognitively impaired elders. She states:

“We have already carried out some practical testing of other web-based communications systems. Among other things, we have tested a “digital diary” and a “scrapbook” containing personal photos, newspaper cuttings and information found online.”

What is both curious and puzzling at the same time regarding this research is that it is being conducted in Norway, of all places. Why not here in the good ol’ U.S. of A? Innovation of this type began and germinated here. Social media’s global function of “keeping one in the loop”, including the elderly, can not be understated in its potential in non-pharmacologic dementia research. Here’s to hoping it gains ground on these shores.

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Much has been written of late regarding the initial media presentations of the virus that causes AIDS and the de rigueur comparisons to how far awareness, activism, and innovation have propelled its discussion to every corner of the planet in 2011. Its chilling descriptions more than thirty years ago cannot belie the fact that, in spite of advances, there is still much to be done on the road to eradication and cure. Within this paradigm is the notion that an entire generation or two have witnessed how the existence of HIV/AIDS has shaped healthcare policy in this country and worldwide.

Here in the U.S., the specter of the aging patient with this now “manageable chronic disease”, the numbers of patients this will represent, and the availability of physicians knowledgeable enough to not only treat chronic HIV disease but also its unknown effects in the increasingly “geriatric” patient — are gaining consideration and acknowledgement in policy circles. Discussion almost always leads to the role of the primary care physician in not only screening but also becoming an active treatment provider.

In 2009, a record 82.9 million American adults were tested for HIV. [...] By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.

Today’s generation of physicians has inhereted the mantle of providing care for a disease whose spurred innovations ranks as one of the greatest medical achievements of the last century. It is time to consider the primary care approach to chronic HIV disease as another fundamental skill set as reform redefines healthcare delivery in the 21st century. | LINK

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First, and almost immediately out of the box, it was the concern for serious mental health effects.^[1] Now, somewhat controversial smoking cessation drug varenicline (Chantix) is the target of the FDA with respect to the increased risk of heart disease for those taking it. Of course, the FDA rates this as only a “small” risk as it “continues to evaluate its safety”.

The new warning comes from a 700-person trial in which patients who took Chantix (varenicline) over 12 weeks were more likely to experience an adverse heart event after one year than those who received a placebo. All of the patients had already been diagnosed with heart disease. For both groups, the heart attack risk was still small: 7 out of 353 patients taking Chantix had a nonfatal heart attack, versus 3 out of 350 who took a placebo.

1. Pfizer, the drug’s manufacturer was also the target of claims of an increased risk of suicidal ideation for those taking the drug — to a lesser extent, night terrors and delirium.

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Many physicians, including myself, who see a majority of elderly patients are always interested in ways we can educate patients and concerned family members of the wide spectrum of clinical presentations of cognitive decline. For many Boomers who are now just turning 65 (as the first and oldest cohort does this very year) the specter of that “senior moment” possibly belying something more ominous and progressive is a little more than just an afterthought that can be dismissed. When the moment came for a discussion with the patient and the family over the concern of cognitive impairment, it was always a delicate balance with respect to validating patient concerns with the real world possibility of subclinical disease.

New diagnostic indicators and guidelines for primary care providers and their patients as recommended and formulated by the National Institute on Aging are out to demystify the process, while making research more goal focused, tangible, and accessible with respect to discovering therapies that can actually reverse progressive dementia.

While laudable in these efforts, the three-stage set of guidelines for diagnosis and treatment insertion offered by the NIA and Alzheimer Association is just the beginning. It certainly complements what we geriatricians have been doing quite adeptly for a couple of decades now — informing and educating patients and their families while squelching myths that could delay or, worse, prevent treatment from ever occurring. Of course, the ability for researchers to recruit the most appropriate patients for targeted clinical trials doesn’t hurt, either.

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Euphemistically, the population of gay and lesbian adults in this country has always been labeled “the ten percent”, owing to the presumptive political implications that have become significantly mainstream since this century began. Epidemiologic research done since the late-1990s had, perhaps more accurately pegged the true LGBT population at around 1 to 2 percent of US adults. The 2000 census is somewhat noteworthy for the initial inclusion of gays and lesbians into its data aggregates.

As a result of this and major political, policy, and mainstreaming of issues that affect and are affected by this population within the past 10 years or so, it seemed that the time was ripe for a re-evaluation of a traditionally marginalized population in heatlhcare policy research. A think tank dedicated to issues such as this has found that roughly 3.5 percent — or over 9M adults in this country — identify as gay or lesbian. (PDF link here.)

It only follows that the lives of the LGBT population are affected by changes involved with healthcare reform as in the other 97 percent of Americans who identify as heterosexual. Issues arising from preventive care coverage (HIV counseling, breast cancer screening etc.), and the specific prohibitions of claim denials for chronic diseases (active HIV infection, hepatitis C, etc.) are major wins for LGBT Americans who would have not received such comprehensive and competent coverage previously. A very good white paper [PDF] explains this in greater detail and relays the challenges that remain for the LGBT community under reform. Read it.

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For all of the policy posts here on Doctor Pundit, it is especially cool when we’re able to relay news based upon purely scientific discovery. It’s even more amazing if that discovery will lead to even more treatment avenues than previously expected or planned for. (I guess Pharma is taking note.)

Research into the pathophysiology of Alzheimer dementia (AD) continues at its earnest and deliberate pace. Each new genetic breakthrough finding gives greater insight in to previously known pathways into the development of the disorder. It’s been long known for the past 10 years, or so, that the altered tau protein hypothesis has been increasingly critical to the understanding of the progression of the disease after diagnosis. Consequently, drug development has focused on preventing or reversing the incidence of these and other proteins responsible for progression into the moderate phase of the disease.

Researchers at U Penn and in the United Kingdom have verified the existence of five new genes implicated in the very initial development in the pathology of AD. The findings are significant, as everything from laboratory testing based upon genomic information to sites of drug action can be gleaned from this discovery. All of this means that the initial development of disease is just as important to understanding how the disorder progresses.

The ADGC’s study, led by Gerard D. Schellenberg, Ph.D., at the University of Pennsylvania School of Medicine, involved researchers at 44 universities and research institutions in the U.S. The consortium analyzed genetic data from 11,000 AD patients and nearly the same number of elderly controls with no dementia. Three additional institutes contributed confirmatory data from new individuals, taking the total number of people analyzed in the study to over 54,000.

Amid all the fanfare of this news, it is important to note that we are no closer to obtaining information on the exact susceptibility of one for AD (remember apolipoprotein E?), but the breadth of information contained within this novel genetic discovery is enough to drive innovation in this sector of medical research.

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In a vain search to find something to post for New Years Eve day, a holiday for most this year, I stumbled upon this item:

Kinda reminds me of the 1970s sitcom Laverne & Shirley and its opening theme. Now it all makes sense. Take care — and party responsibly this NYE. And most important, look forward to more (serious) fun here at DP in 2011.

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The potential for adverse effects among the proton pump inhibitor (PPI) class of drugs will probably get a lot of play in 2011. It’s a class which is well known to consumers, especially those who have been bombarded with the popular “little purple pill” ads for, essentially, what seems like an interminable campaign (it doesn’t hurt that Nexium is one of the country’s top ten branded drugs in terms of sales in 2009).

The researchers systematically reviewed all relevant studies on the association suppressive medications and pneumonia that could be found up to August 2009. They found that out of every 200 inpatients being treated with acid suppressive drugs, one will develop pneumonia. [...] Since 40-70% of hospitalized patients receive these drugs it may mean that deaths from hospital-acquired pneumonia could be caused by acid suppressive medications. The impact of acid suppressive medication on community-acquired pneumonia could be much greater.

One can also add to the list, the following: osteoporotic fractures and recurrent small bowel infections. | LINK

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Since the late 20th century, innovation in long term care (LTC) has been fueled by a desire of healthcare systems  – in this case, owners of skilled nursing facilities — to achieve new quality benchmarks in healthcare delivery at a reasonable cost. Thanks to major pieces of legislation over the past 15 years emphasizing patient safety, healthful outcomes, and cheaper methods of treatment delivery; LTC as a discipline has undergone a sea change for the better. As a geriatrician, I have seen this evolution firsthand. That’s why I absolutely love seeing developments like this

Working with a psychiatrist and a pharmacist, [nurse and resident care coordinator in a Two Harbors, MN nursing home, Eva] Lanigan started a project last year to find other ways to ease the yelling, moaning, crying, spitting, biting and other disruptive behavior that sometimes accompany dementia. They wanted to replace drugs with aromatherapy, massage, games, exercise, personal attention, better pain control and other techniques. [..] Within six months, they eliminated antipsychotic drugs and cut the use of antidepressants by half.

The savings in cost due to the cessation of expensive psychotropics (even if informed consent enabled usage), the avoidance of chemical restraint and its obvious negative effect on patient safety, and the increase in patient quality of life without the need for specialized dementia care (again, at an enormous increase in care delivery cost) are at least three major reasons why innovation in geriatric care is so important in the age of reform. And it’s happening right here in Minnesota. Excellent.

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