Clinical Briefs

By Louis Kuritzky, MD

Clinical Assistant Professor, University of Florida, Gainesville

Dr. Kuritzky is a retained consultant for Boehringer Ingelheim, Daiichi Sankyo, Forest Pharmaceuticals, Janssen, Lilly, Novo Nordisk, Pfizer, and Sanofi.

Pain and Fall Risk Assessment in Cognitively Impaired Nursing Home Residents

Source: Burfield AH, Cooper JW. Ann Long-Term Care: Clin Care Aging 2014;22:36-41.

In senior citizens, there may be an underrecognized link between pain and falls, and even if this link is not as strong as suspected, assessments for both need to be enhanced since in the nursing home, pain and falls are key quality measures.

More than half of nursing home residents fall each year, comprising 20% of all fall-related deaths. Cognitively impaired nursing home residents are 4-5 times more likely to fall than age-matched cognitively intact individuals.

Overall, the prevalence of pain syndromes in nursing home residents is approximately 30%. The impact of cognitive impairment upon pain reporting is clear when it is recognized that reporting of pain is essentially half as frequent among persons with severe cognitive impairment as compared to the nursing home resident population as a whole. Despite cognitive impairment, clinical trial data indicate that almost two-thirds of severe dementia patients can meaningfully utilize at least one pain scale.

Falls in nursing home residents are often attributed to psychoactive medications such as sedatives, antiparkinsonian agents, anticonvulsants, opioid analgesics, and antihistamines. There are several lines of evidence to suggest that review and potential revision of psychotropic agents can have a positive effect. In one study, daily administration of acetaminophen 3 g allowed reduction of psychotropics by 75%. Similarly, a trial of psychotropic substitution with buspirone as a preferred anxiolytic resulted in reduced falls and was even associated with improved cognition. The authors provide a one page (two-sided) Checklist of Nonverbal Indicators of Chronic Pain/Fall Risk Assessment Guideline with permission for free use by clinicians.

PSA Screening: Maybe You Saw the Movie NeverEnding Story’?

Source: Carroll PR, Vickers AJ. J Natl Compr Canc Netw 2014;12:768-771.

The most recent lecture presentation I gave to an audience of clinicians about prostate cancer in May was titled: "Prostate Cancer: Game Over." And yet it seems that this controversy may be far from over. Presentations at the American Urological Association in Orlando in 2014 confirm the continued ambivalence about whether/how/when we should be addressing prostate cancer screening.

No one disagrees that routine prostate-specific antigen (PSA) screening can lead to overdiagnosis: that is, identification of disease destined to have no ultimate impact on the life span or well-being of the patient. New 2014 guidelines from the National Comprehensive Cancer Network (NCCN) include a more restricted PSA level indication for biopsy (> 3.0 ng/mL), less frequent testing, and restriction of biopsy to palpable abnormalities that are "highly suspicious" rather than "minor abnormalities." Use of PSA velocity, particularly at very low PSA levels, is now recognized to also lead to overdetection. Finally, active surveillance for low-risk disease is advocated by the NCCN.

Despite the availability of data representing more than 230,000 men from two recent randomized, controlled trials (PLCO and ERSC) that does not support the ability of PSA screening to reduce mortality, the issue continues to stimulate debate.

Screening for Lung Cancer in Asbestos Workers

Source: Ollier MD, et al. Chest 2014;145:1339-1346.

The United States Preventive Services Task Force (USPSTF) has endorsed screening for lung cancer in selected smokers by means of a series of three low-dose CT scans. This Level B endorsement has met with some resistance. The Medicare Advisory Panel has reviewed the evidence (2014), including a 20% reduction in lung cancer mortality and a 7% reduction in total mortality seen in the National Lung Screening Trial (n = 53,454), and has not advocated paying for screening. A similar position has been taken by the American Academy of Family Physicians, whose position statement expresses doubt about the achievable benefits in typical clinical settings.

Asbestos workers, even when non-smokers, are recognized to be at increased risk of lung cancer. Ollier et al reviewed data from seven clinical trials in which chest CT scans were used to screen former asbestos workers (n = 5074). Within this population, 49 cases of asymptomatic lung cancer were found, of which about one-third were stage 1, indicative of high potential for cure.

The prevalence of lung cancer detected among asbestos workers (1.1%) was quite similar to that found in the National Lung Screening Trial (1.0%). This would lead to the conclusion that specifically screening asbestos workers might be at least as beneficial as screening the recommended population of smokers suggested by the USPSTF guidance.