#GeriMedJC: January 30, 2015

The two articles critically appraised during  #GeriMedJC on January 30th were:

Bauer DC, Schwartz A, Palermo L, Cauley J, Hochberg M, Santora A, Cummings SR, Black DM. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: the FLEX study. JAMA Intern Med. 2014 Jul;174(7):1126-34. 

Kiosses DN, Ravdin LD, Gross JJ, Raue P, Kotbi N, Alexopoulos GS. Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial. JAMA Psychiatry. 2015 Jan 1;72(1):22-30. 

Thanks especially to the #PsychJC participants who chimed in on the discussion! 

This is what Symplur analytics had to say about the January tweet chat:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

Thanks again to all those who participated in the Tweet chat:

The next #GeriMedJC will be on February 27, 2015 08:00 EST / 13:00 GMT.  See you then!

Long article for January 2015 #GeriMedJC chosen.

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, the first 45 minutes of the hour is devoted to the presentation and discussion of the article.

Because the balance between potential benefits and risks of bisphosphonates becomes less clear after extended use, some authorities recommend interrupting bisphosphonate therapy after about 5 years. However, the best way to follow patients who discontinue these drugs is unknown. Do age, BMD results or markers of bone turnover help in this difficult clinical decision?

Bauer DC, Schwartz A, Palermo L, Cauley J, Hochberg M, Santora A, Cummings SR, Black DM. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: the FLEX study. JAMA Intern Med. 2014 Jul;174(7):1126-34. 

The full text of the article can be found here and the abstract is posted below. 

Engage in the discussion on Twitter on January 30, 2015 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

IMPORTANCE:
Discontinuation of bisphosphonate therapy after 3 to 5 years is increasingly considered, but methods to monitor fracture risk after discontinuation have not been established.

OBJECTIVE:
To test methods of predicting fracture risk among women who have discontinued alendronate therapy after 4 to 5 years.

DESIGN, SETTING, AND PARTICIPANTS:
The prospective Fracture Intervention Trial Long-term Extension (FLEX) study randomized postmenopausal women aged 61 to 86 years previously treated with 4 to 5 years of alendronate therapy to 5 more years of alendronate or placebo from 1998 through 2003; the present analysis includes only the placebo group. Hip and spine dual-energy x-ray absorptiometry (DXA) were measured when placebo was begun (FLEX baseline) and after 1 to 3 years of follow-up. Two biochemical markers of bone turnover, urinary type 1 collagen cross-linked N-telopeptide (NTX) and serum bone-specific alkaline phosphatase (BAP), were measured at FLEX baseline and after 1 and 3 years.

MAIN OUTCOMES AND MEASURES:
Symptomatic spine and nonspine fractures occurring after the follow-up measurement of DXA or bone turnover.

RESULTS:
During 5 years of placebo, 94 of 437 women (22%) experienced 1 or more symptomatic fractures; 82 had fractures after 1 year. One-year changes in hip DXA, NTX, and BAP were not related to subsequent fracture risk, but older age and lower hip DXA at time of discontinuation were significantly related to increased fracture risk (lowest tertile of baseline femoral neck DXA vs other 2 tertiles relative hazard ratio, 2.17 [95% CI, 1.38-3.41]; total hip DXA relative hazard ratio, 1.87 [95% CI, 1.20-2.92]).

CONCLUSIONS AND RELEVANCE:
Among postmenopausal women who discontinue alendronate therapy after 4 to 5 years, age and hip BMD at discontinuation predict clinical fractures during the subsequent 5 years. Follow-up measurements of DXA 1 year after discontinuation and of BAP or NTX 1 to 2 years after discontinuation are not associated with fracture risk and cannot be recommended.

#GeriMedJC invites #PsychJC to join in the January 2015 short article discussion.

For this month’s short article, #GeriMedJC would like to extend a warm invitation to the fans of #PsychJC, a Twitter-based psychiatry journal club.  This article is sure to be of interest to both groups.

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, the last 15 minutes of the hour is devoted to the presentation and discussion of the article.

Antidepressants have limited efficacy in older adults with major depression, cognitive impairment and disability. Can problem adaptation therapy (PATH), which uses strategies consistent with the process model of emotion regulation when delivered in the home setting work?  Join the discussion when we focus on this randomized trial:

Kiosses DN, Ravdin LD, Gross JJ, Raue P, Kotbi N, Alexopoulos GS. Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial. JAMA Psychiatry. 2015 Jan 1;72(1):22-30. 

The article can be found here: and the abstract is posted below.

Engage in the discussion on Twitter on January 30, 2015 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

OBJECTIVE:
To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability.

DESIGN, SETTING, AND PARTICIPANTS:
A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ≥65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate).

INTERVENTIONS:
Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy.

MAIN OUTCOMES AND MEASURES:
Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment.

RESULTS:
Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F1,179 = 8.03; P = .005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F1,169 = 14.86; P = .001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; χ2 = 5.74; P = .02; number needed to treat = 4.11) (secondary outcome).

CONCLUSIONS AND RELEVANCE:
Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options.

We're invited by @psychiatryjc!

In the spirit of collaboration, which is really at the heart of Twitter-based journal clubs, @psychiatryjc has invited @GeriMedJC to join in the next #PsychJC discussion. Thanks for the invitation! 

Tune into Twitter and use the hashtag, #PsychJC, on January 22, 2015 for a discussion on an interesting Canadian-based RCT led by Montreal-based geriatrician Dr. Cara Tannenbaum, on reducing benzodiazepine use in the elderly.  

Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.
JAMA Intern Med. 2014 Jun;174(6):890-8.

The University of Toronto Geriatric Medicine Journal Club discussed this study at the live version of the journal club in July 2014, a month before #GeriMedJC was launched but this will surely be a lively Twitter discussion, so don't miss out!

The article can be accessed by clicking here.  You will also want to check out the intervention which is a sedative-hypnotic deprescribing brochure here.

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