Latest / Morning Medical with Dr. Chow / Falls and Dementia, Suicide Prevention, and Heart Failure Breakthroughs

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Falls and Dementia, Suicide Prevention, and Heart Failure Breakthroughs · Morning Medical with Dr. Chow

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  Good morning and welcome to Morning Medical with Dr.
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  Chow.
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  I'm Dr.
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  Chi-Ming Chow, and today we're diving into a topic that's both timely and crucial for our
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  aging population: the link between injurious falls and the subsequent risk of dementia in
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  older adults.
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  A recent study suggests that falling may indeed be a harbinger of dementia.
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  A new diagnosis of Alzheimer's disease or related dementia was found to be more common
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  after falls than after other types of traumatic injuries.
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  This analysis, which looked at nearly two and a half million older adults who had a traumatic
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  injury that led to an emergency department visit or inpatient admission, revealed some
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  striking findings.
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  About half of these injuries were due to falls.
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  Within one year, new dementia diagnoses were significantly more common in people who
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  experienced falls than in those who suffered other types of injuries.
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  Specifically, 10.6 percent of those who fell were diagnosed with dementia, compared to just
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  6.1 percent of those with other injuries.
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  That's a significant difference, and it underscores the importance of monitoring
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  cognitive health after a fall.
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  The research was led by Dr.
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  Molly Jarman and her colleagues at Brigham and Women's Hospital in Boston.
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  They found that, even after controlling for potential confounders and accounting for the
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  competing risk of death, falling was tied to a 21 percent increased risk of a subsequent
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  dementia diagnosis.
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  In their study, published in JAMA Network Open, they emphasize the need for cognitive screening
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  for older adults who have a fall that involves an emergency department visit or hospital
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  admission.
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  Dr.
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  Jarman noted that the relationship between falls and dementia appears to be a two-way
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  street.
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  Cognitive decline can increase the likelihood of falls, but the trauma from those falls may
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  also accelerate the progression of dementia and make a diagnosis more likely down the line.
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  Falls, therefore, might act as precursor events that can help us identify individuals who need
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  further cognitive screening.
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  Falls are a leading cause of injury among older adults, accounting for an estimated three
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  million emergency department visits each year, according to the Centers for Disease Control
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  and Prevention.
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  In 2020, over 27 percent of older adults reported falling during the previous year.
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  However, specific recommendations for cognitive screening after a fall remain inconsistent.
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  Implementing cognitive screening after falls will require a multidisciplinary effort
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  involving various healthcare professionals, from trauma surgeons to geriatricians and
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  primary care physicians.
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  Dr.
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  Jarman and her colleagues suggest that cognitive screening recommendations should be
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  included in the American College of Surgeons Geriatric Trauma Best Practices Guidelines and
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  other guidelines concerning the care of injured older adults.
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  The study evaluated data from over two million older adults in Medicare fee-for-service
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  records from 2014 to 2015, following them for one year after their injury.
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  Participants did not have a preexisting diagnosis of dementia.
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  The findings were adjusted for patient demographics, medical comorbidities, and injury
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  characteristics.
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  In the total sample, over 62 percent were female, 91 percent were white, and the mean age
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  was 78.1 years.
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  More than one in five participants had been admitted to a skilled nursing facility in the
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  prior year.
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  Compared with those who had other traumatic injuries, people who fell were older, with a
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  mean age of 79.5 years compared to 76.7 years.
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  They were also more likely to be female and white.
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  Participants who fell were more likely to have hip fracture surgery during their index
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  admission and were also more likely to be diagnosed with delirium during their clinical
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  encounter.
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  In a subset of participants who had not recently been admitted to a skilled nursing
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  facility, falls were associated with a 27 percent increased hazard of a new dementia
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  diagnosis.
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  However, it's essential to note that causality cannot be determined from this study.
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  The relationship between falling and dementia may be bidirectional.
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  The sensitivity of identifying dementia diagnoses using Medicare claims is also low,
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  and the researchers did not have access to prescription data, which could have influenced
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  the results.
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  This study underscores the critical importance of addressing both the physical and cognitive
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  health of older adults who experience falls.
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  While we cannot definitively say that falls cause dementia, the association is strong
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  enough to warrant further cognitive screening and preventive measures.
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  As our population ages, understanding these connections will be vital for improving the
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  quality of life for our older adults.
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  Let's turn our attention to a groundbreaking study that underscores the importance of
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  primary care interventions in reducing suicide attempts.
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  Following the launch of an integrated suicide prevention program across Washington state,
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  researchers observed a notable 25 percent drop in the rate of attempted suicides.
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  This finding comes from a secondary analysis of a randomized stepped-wedge trial.
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  The program, which introduced suicide screening and safety planning to 19 primary care
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  practices, led to a significant 14 percent increase in safety planning within 14 days—from
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  32.8 to 38.3 per 10,000 patient visits.
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  Julie Angerhofer, Doctor of Philosophy and Master of Public Health, of Kaiser Permanente
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  Washington Health Research Institute in Seattle, and her co-authors reported these
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  findings in the Annals of Internal Medicine.
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  Notably, suicide attempts within 90 days of a primary care visit fell from 6.0 to 4.5 per
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  10,000 patient visits, a significant reduction compared with usual care.
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  "We know that most people seek primary care prior to suicide attempts.
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  So, we know that there are potentially a lot of opportunities for suicide prevention in that
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  setting," Angerhofer told MedPage Today.
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  Some health systems already screen for depression in primary care, but the findings
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  suggest that going a step further to address suicidality in clinical practice could be
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  potentially life-saving.
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  Given that suicide is fortunately "pretty rare," researching suicide-related outcomes can
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  be challenging, Angerhofer noted.
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  For that reason, she was surprised to see such a marked impact.
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  To her knowledge, this is the first real-world experiment to demonstrate the effectiveness of
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  this kind of suicide prevention work in primary care.
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  Primary care teams did express concerns about having the time and resources to address
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  suicide during routine visits, but that's where the team-based element of the program came in.
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  "Having integrated mental health specialists available for warm hand-offs was really
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  integral to the whole design, because we don't want it to be a box-checking exercise" without
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  adequate follow-through, Angerhofer explained.
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  She added that a patient may have visited the doctor planning to get a wart removed or
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  address some other non-mental health-related issue.
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  However, if thoughts of suicide in the last month are noted during screening, then that
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  becomes the primary issue—one for which patients are ideally connected to mental health
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  specialists the same day.
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  Interestingly, rates of newly initiated psychotherapy fell slightly by 8.5 encounters
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  per 10,000 visits during the suicide care period compared to usual care periods.
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  Angerhofer and her team suggested this may be due to short-term counseling conducted by
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  clinical social workers offsetting demand for specialized mental healthcare.
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  The study was conducted at Kaiser Permanente Washington and originally funded to examine the
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  integration of alcohol-related care in primary care.
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  Upon request, Angerhofer and her team added a focus on suicidality and other drug use
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  disorders.
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  Following the development of a more holistic program, the team conducted a secondary
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  analysis of the original trial.
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  From January 2015 to July 2018, over 228,000 patients made more than 615,000 visits during
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  the suicide care period, compared with over 255,000 patients who made more than 953,000
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  visits during the usual care period.
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  Both clinical processes in the study and patient outcomes were tracked through
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  electronic medical records and insurance claims data.
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  The intervention involved annual screening with the two-item Patient Health Questionnaire for
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  depression, the three-item Alcohol Use Disorders Identification Test–Consumption, a
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  cannabis use frequency question, and a question about illegal drug or nonmedical use of
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  prescription medications frequency.
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  Positive screens were followed by symptom assessment with further questionnaires and
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  connection with designated members of the care team for same-day safety planning as needed.
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  The trial was divided into a usual care period before the intervention launch date, and an
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  intervention period after the launch date that included the four-month period of active
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  practice facilitation.
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  The mean age of participants was 49.3 years for usual care and 50.2 years for suicide care.
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  Fifty-eight point five percent of participants were female, 71.8 percent were white
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  non-Hispanic or Latinx, 10.9 percent were Asian or Asian American, 6.7 percent were Black or
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  African American, and 6 percent were Hispanic or Latinx.
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  Additionally, 17 percent had depression, 12.8 percent had anxiety, and 1.9 percent had
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  alcohol use disorder.
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  Regarding alcohol use, 84.5 percent in the suicide care group and 19.9 percent in the
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  usual care group were screened for alcohol misuse, with 21.7 percent compared with 19.9
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  percent screening positive.
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  In all, 0.67 percent versus 0.79 percent received an alcohol use disorder diagnosis, and
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  0.51 percent compared with 0.14 percent received brief alcohol counseling for the
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  suicide care and usual care groups, respectively.
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  Patient characteristics during the first visit of the usual care period and suicide care
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  periods were overall similar, except for slightly lower rates of commercially insured
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  patients in the suicide care group—61 percent versus 56.3 percent—and a greater share of
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  private pay patients—9.4 percent versus 13.5 percent, respectively.
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  While the real-world study design makes the findings more meaningful, it is also the
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  study's biggest limitation, given the difficulty of parsing which program elements
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  were most effective in preventing suicide, Angerhofer said.
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  "We think that safety planning was probably a really important ingredient in this whole
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  intervention, but addressing substance use could have been really helpful for people too,"
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  she added.
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  As for future research, Angerhofer and her team are studying ways to optimize firearm suicide
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  prevention and hope to explore ways to implement suicide prevention in virtual care
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  settings.
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  If you or someone you know may be experiencing a mental health crisis, contact the
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  nine-eight-eight Suicide and Crisis Lifeline by dialing or texting "nine-eight-eight."
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  A recent study suggests that there may be a promising future for cardiac myosin inhibitors
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  in treating heart failure with preserved ejection fraction, also known as HFpEF.
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  This insight comes from the proof-of-concept EMBARK-HFpEF trial.
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  Mavacamten, an established cardiac myosin inhibitor used for hypertrophic cardiomyopathy,
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  showed potential for reducing myocardial wall stress and cardiomyocyte injury in a small
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  group of HFpEF patients with a left ventricular ejection fraction in the upper range of normal
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  or higher, specifically 60 percent and up.
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  Theoretically, this improvement could be due to better diastolic function and enhanced
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  myocardial energetics, as explained by Dr.
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  Sanjiv Shah of Northwestern University Feinberg School of Medicine in Chicago.
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  This trial involved 30 patients with HFpEF who underwent a 26-week course of mavacamten.
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  Significant improvements were observed in key cardiac biomarkers eight weeks after treatment.
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  N-terminal pro-B-type natriuretic peptide levels dropped by 26 percent, high-sensitivity
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  troponin T decreased by 13 percent, and high-sensitivity troponin I fell by 20 percent.
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  However, it is important to note that these biomarker values returned to baseline eight
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  weeks after discontinuation of mavacamten, according to Dr.
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  Shah, who presented these findings during a late-breaking trial session held virtually by
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  the Heart Failure Society of America and published in JAMA Cardiology.
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  One of the main safety concerns surrounding cardiac myosin inhibitors like mavacamten is
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  their potential to reduce left ventricular ejection fraction.
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  This risk is significant enough to warrant a warning label on mavacamten, which was approved
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  for obstructive hypertrophic cardiomyopathy in 2022.
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  It currently requires patients to participate in a risk evaluation and mitigation strategy
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  that involves close monitoring of their left ventricular ejection fraction.
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  In the EMBARK-HFpEF trial, there was a notable 3.2-percentage point absolute reduction in left
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  ventricular ejection fraction among participants.
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  Although there were no deaths or drops in left ventricular ejection fraction below 30 percent,
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  six out of the 30 patients discontinued mavacamten prematurely.
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  Additionally, three patients had to interrupt their treatment because their left ventricular
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  ejection fraction dropped below 50 percent or more than 20 percent relative to baseline.
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  Thankfully, left ventricular ejection fraction recovered in all three cases, and one patient
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  even opted to restart mavacamten.
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  The study's small sample size and open-label design are limitations that could have
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  influenced the results, possibly through changes in concomitant medications or placebo
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  effects.
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  Changes in diuretics and SGLT2 inhibitor use would be particularly relevant, according to
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  Doctor Biykem Bozkurt of Baylor College of Medicine in Houston, who served as the
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  designated study discussant for the virtual session.
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  Dr.
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  Bozkurt emphasized that while these results are promising, further definitive randomized
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  studies are needed to answer key questions.
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  These include how HFpEF patients should be selected for cardiac myosin inhibitor therapy,
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  whether some subgroups benefit more than others, and how left ventricular ejection
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  fraction should be monitored in the high range.
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  Mavacamten was originally approved by the Food and Drug Administration based on the
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  EXPLORER-HCM trial.
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  This trial found that mavacamten led to better functional capacity and reduced left
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  ventricular outflow tract gradients among patients with symptomatic obstructive
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  hypertrophic cardiomyopathy and left ventricular ejection fractions of at least 55
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  percent at baseline.
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  For the EMBARK-HFpEF trial, the choice to focus on patients with left ventricular ejection
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  fractions over 60 percent was based on the belief that these patients benefit less from
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  neurohormonal therapies compared to those with HFpEF and left ventricular ejection fractions
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  between 50 percent and 59 percent.
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  These patients often have small left ventricular volumes, increased passive left
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  ventricular stiffness, coronary microvascular dysfunction, and heightened left ventricular
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  end-systolic and arterial elastances, all of which may contribute to the pathogenesis of
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  heart failure.
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  The phase IIa open-label study was conducted in the United States and Canada.
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  It included a screening period, a 26-week treatment period, and an eight-week washout
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  post-treatment follow-up period.
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  Patients initially received mavacamten at a dose of 2.5 milligrams, which was titrated up
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  depending on their left ventricular ejection fraction and biomarker criteria.
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  Of the 96 people screened, 30 patients with HFpEF and left ventricular ejection fractions
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  of 60 percent or greater were selected.
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  They also had to meet criteria such as New York Heart Association class II or III symptoms and
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  elevated N-terminal pro-B-type natriuretic peptide levels.
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  The cohort had a median age of 76 years, and 53.3 percent were women.
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  Ultimately, 40 percent of patients made it to the higher dose of 5.0 milligrams at week 14.
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  Nearly 42 percent of patients showed improvement in their New York Heart Association
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  functional class, accompanied by favorable changes in echocardiographic parameters.
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  The reductions in E/e' ratio and left atrial volume at rest and peak exercise suggest that
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  cardiac myosin inhibitors like mavacamten have a lusitropic effect, reducing diastolic stress
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  on cardiomyocytes.
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  This, in turn, results in less stimulus for natriuretic peptide secretion by cardiomyocytes
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  and less troponin release due to cardiomyocyte injury.
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  Notably, four patients discontinued treatment prematurely due to adverse events such as new
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  atrial flutter or atrial fibrillation, acute heart failure and hypertensive crisis, and
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  dizziness.
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  However, these events were deemed unrelated to the study drug.
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  Another two patients were lost to follow-up or withdrew from the study.
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  Bristol Myers Squibb is currently testing a next-generation cardiac myosin inhibitor for
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  HFpEF in the AURORA-HFpEF trial.
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  Additionally, another cardiac myosin inhibitor with a different pharmacological profile,
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  aficamten, is expected to be approved by the Food and Drug Administration for obstructive
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  hypertrophic cardiomyopathy following positive results from the SEQUOIA-HCM trial.
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  In today's final segment, we're tackling a topic that's both complex and deeply impactful:
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  obesity.
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  A recent opinion piece by Julia Belluz in The New York Times brings to light some critical
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  perspectives on how we should view and treat obesity.
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  The author emphasizes the necessity of a precise medical definition of obesity and its
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  causes.
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  Since the American Medical Association classified obesity as a disease in 2013, this
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  designation has led to significant advancements.
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  These include increased funding for research, broader insurance coverage, and efforts to
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  reduce stigma.
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  Obesity is a multifaceted condition that requires a comprehensive approach, examining
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  its metabolic, physical, and psychological dimensions to ensure accurate diagnosis and
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  effective treatment.
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  The American Diabetes Association has already set clinical practice standards that address
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  the close relationship between Type 2 diabetes and obesity.
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  These standards offer a holistic diagnostic framework that moves beyond an impersonal,
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  universal approach, focusing instead on individualized care.
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  The American Diabetes Association is also developing new standards of care specifically
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  for obesity, aiming to establish clearer protocols for diagnosis and treatment.
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  This forthcoming work is expected to improve care and outcomes for those living with
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  obesity.
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  Nuha El Sayed, an endocrinologist and senior vice president for health care improvement at
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  the American Diabetes Association, wrote in to highlight the importance of these standards.
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  She emphasizes that the wider medical community must come together to establish uniform
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  standards that provide clarity for practitioners and better care for people
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  affected by obesity.
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  She argues that the price of ambiguity is too high for those affected by this complex
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  condition.
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  Another reader pointed out that the article missed a crucial aspect of the obesity problem
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  in the United States: the role of our food industry and the standard American diet.
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  This perspective underscores the need for a broader societal approach to tackle obesity,
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  one that goes beyond individual medical treatment to include public health initiatives
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  and policy changes aimed at improving the food environment.
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  As we continue to grapple with the complexities of obesity, it's clear that a multifaceted
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  approach is needed.
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  This approach should include precise medical definitions, individualized care, and broader
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  societal changes.
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  Only then can we hope to make meaningful progress in treating and preventing obesity.
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  That's it for today's episode of Morning Medical with Dr.
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  Chow.
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  Thank you for joining me.
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  Stay tuned for more updates on the latest in medical and health news.
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  Have a wonderful day, and take care!