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Liu Z, Zhang C, Liu L, Zhang J, Wang X, Wang J, Zhao J, Zou S, Ma X, Li J. The Time-Point Distribution Characteristics of Laryngopharyngeal Reflux in Elderly Patients. Otolaryngol Head Neck Surg 2024; 170:845-852. [PMID: 37870231 DOI: 10.1002/ohn.565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To identify the characteristics of the time-point distribution of the occurrence of hypopharyngeal-proximal reflux episodes (HREs) in elderly and younger patients with laryngopharyngeal reflux (LPR). STUDY DESIGN Retrospective cohort study. SETTING Analysis of data from patients with LPR-related symptoms and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-hour HEMII-pH) monitoring from February 2017 to September 2022 at Sixth Medical Center of PLA General Hospital. METHODS Patients were divided into 2 age groups: the elderly group (>60 years) and the younger group (≤60 years). The time series of HREs and meals within 24 hours were analyzed based on HEMII-pH. RESULTS A total of 305 patients were included (126 elderly patients). In younger patients, except for nonacid-gas HREs, the incidence of the remaining types of HREs tended to increase within 2 hours after meals, especially after dinner. The incidence of all types of HREs pre- and postmeal was not significantly different in the elderly group (χ2 = 0.080, P = .777). The incidence of nighttime HREs in elderly patients was statistically higher than in younger patients (6.23% vs 3.96%, P = .030), particularly acid-/nonacid-liquid HREs. CONCLUSION HREs tend to increase within 2 hours after meals in younger LPR patients, except for nonacid-gas HREs. In elderly LPR patients, the incidence of all types of HREs pre- and postmeal were not significantly different, and nighttime fluid HREs was more prone to occur than in younger patients.
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Affiliation(s)
- Zhi Liu
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
- Department of Otolaryngology, Navy Clinical College, The Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
| | - Chun Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Lianlian Liu
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jinhong Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Xiaoyu Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
- Department of Otolaryngology, Navy Clinical College, The Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
| | - Jiasen Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jing Zhao
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Shizhen Zou
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Xin Ma
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jinrang Li
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
- Department of Otolaryngology, Navy Clinical College, The Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
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Fernandes YR. Unraveling the Dynamics of Esophageal Motility, Esophagitis Severity, and Age in GERD Patients: A Cross-Sectional Exploration. Cureus 2024; 16:e53979. [PMID: 38468980 PMCID: PMC10927278 DOI: 10.7759/cureus.53979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is characterized by prolonged exposure of the esophageal mucosa to gastric content, with esophageal motility playing a pivotal role in its pathophysiology. This study employs a cross-sectional design to investigate the interplay between esophageal motility, the severity of esophagitis, and age in individuals presenting with GERD symptoms. OBJECTIVE The primary objective is to assess proximal and distal esophageal contractions in individuals with GERD symptoms, exploring potential correlations with the severity of esophageal lesions and age. METHODS A total of 47 patients reporting heartburn and acid regurgitation underwent diagnostic investigations, including esophageal manometry, radiological examinations, and endoscopy. Patients were categorized into groups based on the presence and severity of esophagitis. Esophageal contractions were monitored using a manometric method at various distances from the UES after swallowing 5 mL of water. RESULTS Patients with severe esophagitis (SE) exhibited a reduced distal esophageal contraction amplitude compared to those without esophagitis (WE) or with moderate esophagitis (ME). No significant age-related differences were observed in esophageal contractions. Analyses included contraction amplitude, duration, area under the curve (AUC), and propagation time. CONCLUSION This study provides insights into the nuanced relationship between esophageal motility, esophagitis severity, and age in GERD patients. The findings highlight the significance of distal esophageal contractions in SE cases, suggesting potential implications for disease progression. Age did not emerge as a significant factor influencing esophageal motility in this patient cohort.
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Affiliation(s)
- Ygor R Fernandes
- General Surgery and Digestive Endoscopy, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital São Paulo, São Paulo, BRA
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Lechien JR. Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date. Clin Interv Aging 2022; 17:1625-1633. [PMID: 36411760 PMCID: PMC9675328 DOI: 10.2147/cia.s371992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose The clinical presentation and therapeutic outcomes of elderly patients may be different from those in younger populations, leading to additional diagnostic and therapeutic difficulties. The present study reviewed the findings on the epidemiology, and clinical, diagnostic, and therapeutic outcomes of elderly patients with laryngopharyngeal reflux (LPR). Methods A PubMed, Cochrane Library, and Scopus literature search was conducted on the epidemiological, clinical, diagnostic, and therapeutic findings of elderly LPR patients. Findings The prevalence of LPR in the elderly population remains unknown. From a clinical standpoint, older LPR patients report overall lower symptom scores and related quality-of-life outcomes at the time of the diagnosis. The required treatment time to obtain symptom relief appears to be longer in older compared with younger patients. Particular attention needs to be paid to prolonged medication use because the elderly population is characterized by polypharmacy and there is a higher risk of proton-pump inhibitor (PPI) interactions and adverse events. The plasma clearance of most PPIs is reduced with age, which must be considered by practitioners in the prescription of antireflux therapy. Conclusion The clinical presentation and treatment efficacy of elderly LPR patients differ from those in younger patients. Practitioners need to carefully consider the risk of drug interactions and adverse events in elderly patients.
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Affiliation(s)
- Jerome R Lechien
- Polyclinic of Poitiers, Elsan Hospital, Poitiers, France
- Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology–Head and Neck Surgery, EpiCURA Hospital, University of Mons, Baudour, Belgium
- Correspondence: Jerome R Lechien, Department of Otolaryngology–Head and Neck Surgery, EpiCURA Hospital, University of Mons, Rue L. Cathy, Mons, Belgium, Tel +32 65 37 35 84, Email
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Toki Y, Yamauchi R, Kayashima E, Adachi K, Kishi K, Suetsugu H, Wada T, Endo H, Yamada H, Osaga S, Kamiya T, Nakada K, Iwakiri K, Haruma K, Joh T. Predictive Factors for Future Onset of Reflux Esophagitis: A Longitudinal Case-control Study Using Health Checkup Records. J Neurogastroenterol Motil 2022; 28:86-94. [PMID: 34980691 PMCID: PMC8748855 DOI: 10.5056/jnm20237] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/08/2021] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background/Aims Although risk factors of reflux esophagitis (RE) have been investigated in numerous cross-sectional studies, little is known about predictive factors associated with future onset of RE. We investigated time courses of clinical parameters before RE onset by a longitudinal case-control study using health checkup records. Methods We used health checkup records between April 2004 and March 2014 at 9 institutions in Japan. A multivariate logistic regression analysis was performed to evaluate associations of baseline clinical parameters with RE. The time courses of the clinical parameters of RE subjects were compared with those of non-RE subjects by the mixed-effects models for repeated measures analysis or longitudinal multivariate logistic analysis. Results Initial data were obtained from 230 056 individuals, and 2066 RE subjects and 4132 non-RE subjects were finally included in the analysis. Body mass index, alanine aminotransferase, smoking, acid reflux symptoms, hiatal hernia, and absence of atrophic gastritis at baseline were independently associated with RE. The time courses of body mass index, fasting blood sugar, triglyceride, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, percentages of acid reflux symptoms, feeling of fullness, and hiatal hernia in the RE group were significantly worse than in the non-RE group. Conclusions The RE group displayed a greater worsening of the clinical parameters associated with lifestyle diseases, including obesity, diabetes, hyperlipidemia, and fatty liver for 5 years before RE onset compared with the non-RE group. These results suggest that RE is a lifestyle disease and thus lifestyle guidance to at-risk person may help to prevent RE onset.
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Affiliation(s)
- Yuzuru Toki
- Department of Internal Medicine, Hidaka Hospital, Takasaki, Gunma, Japan
| | - Ryo Yamauchi
- Department of Internal Medicine, Mitsubishi Mihara Hospital, Mihara, Hiroshima, Japan
| | - Eizo Kayashima
- Junpukai Health Maintenance Center, Okayama, Okayama, Japan
| | - Kyoichi Adachi
- Health Center, Shimane Environment and Health Public Corporation, Matsue, Shimane, Japan
| | - Kiyohiko Kishi
- Department of Internal Medicine, Meiwa Hospital, Nishinomiya, Hyogo, Japan
| | - Hiroshi Suetsugu
- Department of Preventive Medicine, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Tsuneya Wada
- Public Health Center, Okazaki City Medical Association, Okazaki, Aichi, Japan
| | - Hiroyoshi Endo
- Department of Internal Medicine, Saiseikai Karatsu Hospital, Karatsu, Saga, Japan
| | - Hajime Yamada
- Department of Gastroenterology and Hepatology, Shinko Hospital, Kobe, Hyogo, Japan
| | - Satoshi Osaga
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Koji Nakada
- Department of Laboratory Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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Rogers J, Eastland T. Understanding the most commonly billed diagnoses in primary care: Gastroesophageal reflux disease. Nurse Pract 2021; 46:50-55. [PMID: 33739328 DOI: 10.1097/01.npr.0000737196.69218.b6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition encountered commonly in primary care with an estimated worldwide prevalence of up to 33%. GERD affects all age groups, races, and genders with 25% of the population in the Western world experiencing heartburn at least once a month.
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Analysis of Pepsin Concentration and Influencing Factors in Saliva of Elderly Nasal Feeding Patients. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4721812. [PMID: 33564676 PMCID: PMC7850846 DOI: 10.1155/2021/4721812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/12/2020] [Accepted: 12/18/2020] [Indexed: 12/05/2022]
Abstract
Background Elderly patients receiving nasal feeding have weaker physiological function, and placement of a nasogastric tube weakens the natural barrier of the cardia-esophageal sphincter; therefore, the risk of gastroesophageal reflux (GER) is higher. Many studies have shown that pepsin is extremely sensitive in predicting GERD, so this study intends to investigate the level of pepsin in saliva of elderly patients with nasal feeding and analyze its influencing factors. Methods This was a cross-sectional study. Patients admitted to the Chinese PLA General Hospital from April 2018 to October 2018 who received nasal feeding were included. One ml of saliva was collected from each patient in while sitting during fasting in the morning and 1 hour after lunch for 3 consecutive days. Pepsin was quantified by enzyme-linked immunosorbent assay (ELISA). The patients were predivided into two groups (≥7.75μg/ml or <7.75μg/ml) based on the median pepsin. Baseline and clinical factors were compared. Results The mean age of the patients was 91.09 ± 4.91 years. There were statistical differences in diabetes and feeding methods between the two groups. There was a positive correlation between the morning and postprandial pepsin levels (r = 0.442, P < 0.001), and has no statistical difference (P = 0.175). Multivariate analysis showed that the risk factors for higher pepsin levels were diabetes (odds ratio (OR): 2.67; 95% CI: 1.225-5.819, P = 0.013) and nasal feeding methods (OR: 2.475; 95% CI: 1.183-5.180, P=0.016). Conclusions For patients undergoing nasal feeding who are older than 80 years, the fasting and 1-hour postprandial pepsin concentration were consistent. Diabetes and feeding methods are risk factors for high pepsin levels. For the elderly over 80 years old, age has no influence on pepsin concentration.
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Gewolb IH, Vice FL. Use of a non-invasive accelerometric method for diagnosing gastroesophageal reflux in premature infants. J Perinatol 2021; 41:1879-1885. [PMID: 33758392 PMCID: PMC8342305 DOI: 10.1038/s41372-021-01034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the clinical usefulness of a non-invasive accelerometric device to diagnose GER in preterm babies. STUDY DESIGN An accelerometer was taped over the sub-xiphoid process in 110 preterm (GA 29.6 ± 3.3 wk) infants (133 studies). Low frequency, sub-audible signals were captured via digital recording (sampling rate 200 Hz), then re-sampled (rate = 60 Hz) to create a spectrogram (focused range 0-30 Hz). Mean amplitude in the focused range was calculated. RESULTS Of 85 studies with simultaneous pH-metry and accelerometry, 18 had concurrent positive and 23 had concurrent negative scores, 42 had negative pH scores when accelerometry was positive (≥1 µV), consistent with non-acid reflux. Eleven infants at high risk of aspiration received surgical interventions. All but 1 had negative pH scores while 10/11 had positive accelerometry. CONCLUSIONS The non-invasiveness of this accelerometric technique allows for GER screening and for repeated testing to assess efficacy of interventions.
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Affiliation(s)
- Ira H. Gewolb
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
| | - Frank L. Vice
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
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Abstract
As our population continues to age, the early diagnosis and optimal management of patients with gastroesophageal reflux disease becomes paramount. Maintaining a low threshold for evaluating atypical symptoms in this population is key to improving outcomes. Should patients develop complications including severe esophagitis, peptic stricture, or Barrett esophagus, then a discussion of medical, endoscopic, and surgical treatments that accounts for patient's comorbidities and survival is important. Advances in screening, surveillance, and endoscopic treatment of Barrett esophagus have allowed us to dispel concerns of futility and treat a larger subset of the at-risk population.
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Affiliation(s)
- Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, L461, 3181 SouthWest Sam Jackson Park Road, Portland, OR 97229, USA.
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SouthWest, Rochester, MN 55905, USA
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Ahmed S, Jamil S, Shaikh H, Abbasi M. Effects of Life style factors on the symptoms of gastro esophageal reflux disease: A cross sectional study in a Pakistani population. Pak J Med Sci 2019; 36:115-120. [PMID: 32063943 PMCID: PMC6994865 DOI: 10.12669/pjms.36.2.1371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background &Objective: Gastro esophageal reflux disease (GERD) broadly includes the whole spectrum of reflux disease symptoms like heartburn or acid regurgitation to endoscopic, reflux esophagitis or Barrett’s esophagus. Our aim therefore was to study the association between Gastroesophageal reflux disease symptoms and various lifestyle factors. Methods: A descriptive cross-sectional study was carried out in the outpatient department of Darul Sehat Hospital, Zubaida Medical Center and Liaquat National Hospital & Medical College, Karachi, Pakistan from January 2018 to October 2018. The selected candidates were asked to fill a validated GERD questionnaire and they were also asked about their lifestyle factors. Odds ratio and their 95% confidence interval were estimated using binary logistic regression with GERD symptoms as the study outcome. Results: A total of 2000 respondents completed the questionnaire. 69.3% gastroesophageal reflux disease cases were found in participants above 35 years of age while 56.9% subjects were male. The most common lifestyle factors associated with GERD were less exercise time (90.9%) (OR, 6.47; 95% CI, 4.91-8.53), 78.3% participants had habit of eating midnight snacks (OR, 5.08; 95% CI, 4.03-6.40), 87.3% participants reported less interval between dinner and sleep (OR, 6.98; 95% CI, 5.36-9.08). The most important factor relieving GERD symptoms was raising the head of bed during sleep (79.4%) while 43.3% subjects with the habit of post dinner walk reported fewer symptoms of GERD. Conclusion: Lifestyle factors particularly less physical activity, late evening meals, inadequate sleep, smoking and post dinner lying were found to be associated with GERD symptoms.
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Affiliation(s)
- Shahid Ahmed
- Shahid Ahmed, Associate Professor, Department of Medicine, Darul Sehat Hospital, Karachi, Pakistan
| | - Sajjad Jamil
- Sajjad Jamil, Consultant, Department of Gastroenterology, Liaquat National Hospital & Medical College, Karachi, Pakistan
| | - Hafeezullah Shaikh
- Hafeezullah Shaikh, Assistant Professor, Department of Gastrenterology, National Institute of Liver and GI Diseases, Dow University of Health Sciences, & Consultant Zubaida Medical Center, Karachi, Pakistan
| | - Maryam Abbasi
- Maryam Abbasi, Research Coordinator, Darul Sehat Hospital, Karachi, Pakistan
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Woodley FW, Hayes D, Kopp BT, Moore-Clingenpeel M, Machado RS, Nemastil CJ, Jadcherla S, Di Lorenzo C, Kaul A, Mousa H. Gastroesophageal reflux in cystic fibrosis across the age spectrum. Transl Gastroenterol Hepatol 2019; 4:69. [PMID: 31620651 DOI: 10.21037/tgh.2019.08.11] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background Scientific advances have improved longevity in cystic fibrosis (CF) patients and many of these patients can expect to experience age-related gastrointestinal co-morbidities. We aimed to assess the extent to which age might impact gastroesophageal reflux (GER) in patients with CF. Methods Our esophageal pH-multichannel intraluminal impedance monitoring database was searched for tracings belonging to CF patients ≥2 years old without prior fundoplication and not taking anti-reflux medications immediately prior (within 7 days) and during the study. Tracings were retrospectively analyzed; Impedance and pH variables were evaluated with respect to age and pulmonary function. Results Twenty-eight patients were enrolled; 16 children (3.1-17.7 years) and 12 adults (18.2-48.9 years). Among pH probe parameters, correlation analysis showed DeMeester score (P=0.011) and number of acid reflux events lasting >5 minutes (P=0.047) to be significantly correlated with age. Age was not significantly correlated with any of the impedance parameters. Age was negatively correlated with baseline impedance (BI) in the distal esophagus (r=-0.424, P=0.023) and BI was negatively correlated with several pH parameters, including reflux index (r=-0.553, P=0.002), number of total acid reflux events (r=-0.576, P=0.001), number of acid reflux events lasting >5 minutes (r=-0.534, P=0.003), and DeMeester score (r=-0.510, P=0.006). Pulmonary function (percent predicted forced expiratory volume in one minute; ppFEV1) was negatively correlated with age (r=-0.494, P=0.0007). The interaction of age and ppFEV1 and any of the reflux parameters, however, was not significant (P>0.05); the strongest evidence for an interaction was found for the number of acid reflux events reaching the proximal esophagus, but this interaction still did not reach statistical significance (P=0.070). Conclusions In a small cohort, we found evidence that age may be associated with increased acid exposure and that both age and increased acid exposure are associated with reduced BI in the distal esophagus. The negative relationship between pulmonary function and age in our cohort is not related to GER. This pilot study supports the need for esophageal assessment and treatment of GER as standard components of clinical care for an aging CF population.
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Affiliation(s)
- Frederick W Woodley
- Center for Motility Disorders, Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benjamin T Kopp
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Sudarshan Jadcherla
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carlo Di Lorenzo
- Center for Motility Disorders, Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hayat Mousa
- Division of Gastroenterology, Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, University of California-San Diego, San Diego, CA, USA
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Dumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T. Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol 2019; 2019:6757524. [PMID: 30792972 PMCID: PMC6354172 DOI: 10.1155/2019/6757524] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.
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Affiliation(s)
- Igor Dumic
- 1Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
| | - Terri Nordin
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
- 3Department of Family Medicine, Mayo Clinic Health System, Eau Claire WI, USA
| | - Mladen Jecmenica
- 4Gastroenterology Fellowship Program, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | | | - Tomica Milosavljevic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
| | - Tamara Milovanovic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
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Kim GH. It Is Time to Meet the Challenges of the Changing Epidemiology of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2018; 24:507-509. [PMID: 30347932 PMCID: PMC6175555 DOI: 10.5056/jnm18152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/13/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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14
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Bryan YF, Johnson KN. Procedural difficulties during successful intubation in octogenarians: A prospective observational study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:499-505. [PMID: 28366293 DOI: 10.1016/j.redar.2017.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Octogenarians undergo anatomic and physiopathologic degradation, making airway management problematic, specific to intubation, bag mask ventilation, leading to desaturation and aspiration. Our study's aim was to examine the process of airway management regarding the steps involved in intubation and any deviations or delays in the tasks. MATERIALS AND METHODS An institutional review board-approved difficult airway prospective observational study in older adults was conducted. Inclusion criteria included airway features indicative of difficult airway, history of failed intubation, the planned use of specialized airway devices, and/or expected airway complications due to comorbidities. Patients 80 years and older were analyzed. Demographic data collected were age, weight, BMI, gender, ASA classification, airway indices, diagnosis, and procedures. Problems with intubation (INT) (≥3 intubation attempts), laborious assisted ventilation (VEN) (2-person and/or application of CPAP>20cmH2O), and complications with oxygenation (OXY) (SpO2<95%) were analyzed. RESULTS Of the 41 patients enrolled in the study, 3 (7.3%) had all 3: problematic (INT), laborious (VEN), and desaturated (OXY); 8 (19.5%) patients experienced problematic (INT), 20 (48.8%) were described as laborious (VEN), and 14 (34.1%) experienced complications with (OXY). CONCLUSION In octogenarians, we found a low incidence of difficulty with INT-VEN-OXY together. However, bag mask ventilation was found to be laborious with a high incidence of desaturation. Success rate of INT as a sole metric may not accurately describe the process of the intubation. We recommend alternative airway devices and techniques and the establishment of protocols for airway management in the elderly.
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Affiliation(s)
- Y F Bryan
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, Estados Unidos.
| | - K N Johnson
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, Estados Unidos
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16
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Lukaszuk JM, Walker DA, Shokrani M, Umoren J, Norman EJ. Assessment of vitamin B 12 tissue stores in elderly proton pump inhibitor users. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1389639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Judith M. Lukaszuk
- College of Health & Human Sciences, Northern Illinois University, DeKalb, IL 60115, USA
| | - David A. Walker
- College of Education, Northern Illinois University, DeKalb, IL 60115, USA
| | - Masih Shokrani
- College of Health & Human Sciences, Northern Illinois University, DeKalb, IL 60115, USA
| | - Josephine Umoren
- College of Health & Human Sciences, Northern Illinois University, DeKalb, IL 60115, USA
| | - Eric J. Norman
- Norman Clinical Laboratory, Inc., Cincinnati, OH 45231, USA
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Jang SH, Ryu HS, Choi SC, Lee SY. Psychological factors influence the gastroesophageal reflux disease (GERD) and their effect on quality of life among firefighters in South Korea. INTERNATIONAL JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH 2016; 22:315-320. [PMID: 27691373 DOI: 10.1080/10773525.2016.1235675] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this study was to examine psychosocial factors related to gastroesophageal reflux disease (GERD) and their effects on quality of life (QOL) in firefighters. METHODS Data were collected from 1217 firefighters in a Korean province. We measured psychological symptoms using the scale. In order to observe the influence of the high-risk group on occupational stress, we conduct logistic multiple linear regression. The correlation between psychological factors and QOL was also analyzed and performed a hierarchical regression analysis. RESULTS GERD was observed in 32.2% of subjects. Subjects with GERD showed higher depressive symptom, anxiety and occupational stress scores, and lower self-esteem and QOL scores relative to those observed in GERD - negative subject. GERD risk was higher for the following occupational stress subcategories: job demand, lack of reward, interpersonal conflict, and occupational climate. The stepwise regression analysis showed that depressive symptoms, occupational stress, self-esteem, and anxiety were the best predictors of QOL. CONCLUSIONS The results suggest that psychological and medical approaches should be combined in GERD assessment.
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Affiliation(s)
- Seung-Ho Jang
- a Department of Psychiatry, School of Medicine , Wonkwang University , Iksan , Republic of Korea
| | - Han-Seung Ryu
- b Division of Gastroenterology, Department of Internal Medicine, School of Medicine , Wonkwang University , Iksan , Republic of Korea
| | - Suck-Chei Choi
- b Division of Gastroenterology, Department of Internal Medicine, School of Medicine , Wonkwang University , Iksan , Republic of Korea
| | - Sang-Yeol Lee
- a Department of Psychiatry, School of Medicine , Wonkwang University , Iksan , Republic of Korea
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18
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Bashashati M, Sarosiek I, McCallum RW. Epidemiology and mechanisms of gastroesophageal reflux disease in the elderly: a perspective. Ann N Y Acad Sci 2016; 1380:230-234. [PMID: 27526197 DOI: 10.1111/nyas.13196] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/08/2016] [Accepted: 07/13/2016] [Indexed: 12/18/2022]
Abstract
Gastroesophageal reflux disease (GERD) seems to be more common in older individuals. Disturbed esophageal motility; anatomical disorders, such as hiatal hernia, increased obesity, defective mucosal integrity, and alteration in salivary secretion; and concomitant medications all attribute to the higher rate of GERD in the elderly. In this review, we discuss the underlying mechanisms that could explain this higher rate of GERD in the elderly.
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Affiliation(s)
- Mohammad Bashashati
- Division of Gastroenterology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Irene Sarosiek
- Division of Gastroenterology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Richard W McCallum
- Division of Gastroenterology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas.
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Chen CH, Lin CL, Kao CH. Gastroesophageal reflux disease with proton pump inhibitor use is associated with an increased risk of osteoporosis: a nationwide population-based analysis. Osteoporos Int 2016; 27:2117-26. [PMID: 26860609 DOI: 10.1007/s00198-016-3510-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/29/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED Gastroesophageal reflux disease (GERD) with proton pump inhibitor (PPI) use is associated with an increased risk of osteoporosis. The risk of hip fracture is not increased in GERD patients with PPI use. INTRODUCTION The relationship between GERD with PPI treatment and the risk of osteoporosis is unclear. We aimed to determine the risk of developing osteoporosis in patients diagnosed with GERD. METHODS Patients diagnosed with GERD and received PPI treatment between 2000 and 2010 were identified from the Longitudinal Health Insurance Database as the study cohort (n = 10,620), which was frequency matched with the comparison cohort (n = 20,738) sampled from the general population according to age, sex, index year, and comorbidities. Both cohorts were followed until the end of 2011. The risk of osteoporosis was evaluated in both groups by using Cox proportional hazards regression models. RESULTS The GERD patients with PPI treatment had a greater incidence (31.4 vs 20.7 per 1000 person-year; crude hazard ratio [cHR] 1.51; 95 % confidence interval [CI] 1.40-1.63) and a higher risk (adjusted HR [aHR] 1.50; 95 % CI 1.39-1.62) of osteoporosis than that of the comparison cohort. However, the overall incidence of hip fracture was not different between the GERD with PPI use and the control cohorts (aHR 0.79; 95 % CI 0.53-1.18). CONCLUSION GERD with PPI use is associated with an increased risk of osteoporosis. The findings of our study do not support an increased risk of hip fracture in GERD patients treated with a PPI.
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Affiliation(s)
- C-H Chen
- Digestive Disease Center, Show-Chwan Memorial Hospital, Changhua, Taiwan
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan
- Meiho University of Technology, Pingtung, Taiwan
| | - C-L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - C-H Kao
- Graduate Institute of Clinical Medical Science, School of Medicine, College of Medicine, China Medical University, No. 2, Yuh-Der Road, Taichung, 40447, Taiwan.
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan.
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Abstract
By 2050, the US aging population will nearly double. It will be increasingly important for health care providers to diagnose and manage rhinitis. Nasal symptoms of rhinorrhea, congestion, sneezing, nasal/ocular pruritus, and postnasal drainage affect up to 32% of older adults, and can impact quality of life. Several underlying factors associated with aging may contribute to the pathogenesis of rhinitis in older adults. Although treatment options for rhinitis exist, special considerations need to be made because comorbidities, limited income, memory loss, and side effects of medications are common in older adults and may impact outcomes.
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Affiliation(s)
- Alan P Baptist
- Division of Allergy and Clinical Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Suite H-2100, Ann Arbor, MI 48106, USA.
| | - Sharmilee Nyenhuis
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, 840 S. Wood Street MC 719, Chicago, IL 60612, USA
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21
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Miyazaki K, Sato S, Kodama T, Tamura T, Kagohashi K, Satoh H, Hizawa N. Effect of acid suppressants on the efficacy of tyrosine kinase inhibitors in patients with epidermal growth factor receptor-mutated non-small-cell lung cancer. Mol Clin Oncol 2016; 4:873-877. [PMID: 27123299 DOI: 10.3892/mco.2016.810] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 02/22/2016] [Indexed: 11/06/2022] Open
Abstract
This retrospective study was conducted to evaluate whether oral acid suppressant (AS) therapy is associated with decreased efficacy of gefitinib and erlotinib, particularly in patients with mutated epidermal growth factor receptor (EGFR). A total of 46 consecutive patients with pathologically confirmed non-small-cell lung cancer (NSCLC), who were treated with tyrosine kinase inhibitors (TKIs) in two tertiary hospitals between September, 2005 and May, 2013, were retrospectively analyzed. Of the 46 patients, 11 received AS treatment. As regards age, gender, smoking history, performance status, histology of lung cancer, clinical stage, body surface area (BSA) and type of EGFR mutation, there were no statistically significant differences between patients with and those without AS treatment. There was no statistically significant difference in progression-free survival (PFS) or overall survival (OS) between the two groups of patients (P=0.296 and 0.613, respectively). As regards the relative dose of TKI/BSA and survival in patients with and those without AS treatment, there were no statistically significant differences in PFS and OS between the two groups of patients. Our study indicates that AS treatment may not compromise TKI efficacy (gefitinib or erlotinib) in NSCLC patients with mutated EGFR. Prospective studies and large-scale confirmation studies investigating the effect of AS co-administration with TKIs in patients with mutated EGFR may be meaningful in clinical practice.
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Affiliation(s)
- Kunihiko Miyazaki
- Ryugasaki Saiseikai General Hospital, Ryugasaki, Ibaraki 135-0033, Japan
| | - Shinya Sato
- Ryugasaki Saiseikai General Hospital, Ryugasaki, Ibaraki 135-0033, Japan
| | - Takahide Kodama
- Ryugasaki Saiseikai General Hospital, Ryugasaki, Ibaraki 135-0033, Japan
| | - Tomohiro Tamura
- Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Katsunori Kagohashi
- Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba Hospital, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Hiroaki Satoh
- Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba Hospital, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Nobuyuki Hizawa
- Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
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Abstract
If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4-8 weeks. This should be taken 30-60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett's oesophagus require long-term treatment with a proton pump inhibitor. Lifestyle modification strategies can help gastro-oesophageal reflux disease. Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation.
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Johnson KN, Botros DB, Groban L, Bryan YF. Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management. Clin Interv Aging 2015; 10:1925-34. [PMID: 26673904 PMCID: PMC4675650 DOI: 10.2147/cia.s93796] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it difficult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a difficult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient's risk of oxygen desaturation, and/or aspiration. For patients who may be difficult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic broncho-scope. Overall, geriatric-focused airway management is necessary to decrease complications in this patient population.
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Affiliation(s)
- Kathleen N Johnson
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Daniel B Botros
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Leanne Groban
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA ; Section on Molecular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA ; Sticht Center on Aging, Wake Forest School of Medicine, Winston-Salem, NC, USA ; Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Yvon F Bryan
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc 2015; 63:e8-e18. [PMID: 26447889 DOI: 10.1111/jgs.13807] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High-Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug-Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence-based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug-therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug-therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.
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Affiliation(s)
- Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Pharmaceutical Outcomes and Gero-Informatics Research and Training Program, University of Pittsburgh, Pittsburgh, Pennsylvania.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Todd P Semla
- Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, Illinois.,Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Psychiatry and Behavioral Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
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