TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include the benefit of masks for COVID, diagnosing gestational diabetes, use of palliative care in both cancer and non-cancer illnesses, and CNS polypharmacy in adults with dementia.
0:40 Masks and COVID transmission
1:40 Those states with a mandate decreased transmission
2:41 Prudent to hold off on relaxing mandates
3:15 CNS polypharmacy in those with dementia
4:18 Just shy of 14% met criteria
5:16 Some opioids also
6:15 Have apathy that doesn’t respond
6:44 Use of palliative care in cancer and non-cancer diagnoses
7:48 In cancer patient initiated early, in the hospital
8:48 Education is necessary
9:40 Got it in last 30 days
9:55 Gestational diabetes screening
10:55 One step identified almost twice as many women
11:40 Treat the mom to improve outcomes for both
Elizabeth Tracey: What’s the best way to assess whether a pregnant woman has diabetes?
Rick Lange, MD: Palliative care for people that have cancer or other terminal diseases.
Elizabeth: How many adults with dementia are taking a number of medicines that could affect their central nervous system?
Rick: And is it wise to stop mask-wearing and allow on-premise dining?
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, since this issue of going maskless is alive and well in many places in the United States, why don’t we start with that one first?
Rick: Not only alive and well in many places, but obviously, the governor of Texas determined that we had few enough cases where he wasn’t going to mandate mask-wearing and we’re going to allow restaurants to open to 100% capacity.
This was an interesting report — it’s from the CDC in MMWR — that is, Morbidity and Mortality Weekly Report — that looked at the association of state-issued mask mandates and also allowing on-premise restaurant dining, looking at individual county-level COVID-19 cases and death growth rates.
This was over the period from March through December 31st of 2020 and it’s real simple. There were a number of different states that either enacted mask-wearing or allowed on-premise dining, and we have the data regarding the number of cases and the death rates in those counties, both before the mask mandate and afterwards, and before they allowed on-premise dining and afterwards.
Here’s what they found. For those states that mandated masks, over the ensuing weeks the risk of cases of COVID and deaths of COVID decreased by about 1% to 2% per couple of weeks. They first noticed that effect within about 20 days after that was mandated.
Conversely, what happened when they allowed people to eat on-premise dining? Within about 40 days, the number of cases and deaths increased by about 1.5% to 3%. If you wear a mask, it helps. If you allow on-premise dining, it does just the opposite. You’ll increase the number of cases and deaths.
Elizabeth: Yeah. It seems really premature, of course, in light of all of these emerging variants that we should start saying, “Look, it’s okay for you to come back in and dine, and moreover, you can take your mask off while you’re at it.”
Rick: The U.K. [variant] is the prevalent one here now in the United States. We know that it increases infectivity, and it also increases morbidity and mortality.
So until we have more vaccine rolled out — and right now about 20% to 23% of the U.S. population have received their first vaccine and less than 12% or 13% received their second — I think it would be prudent to hold off on relaxing mask mandates and allowing on-premise dining until we have more of the individuals vaccinated.
Elizabeth: Of course, we would be remiss in not mentioning that the CDC also said this week, “Hey, if you’ve been fully vaccinated, you, at least, can relax some of your personal restrictions.”
Rick: It’s limited to small groups. It’s usually family members, but, again, you have to be fully vaccinated. That’s 2 weeks after the second dose of the Moderna or Pfizer vaccine or 2 weeks after the J&J vaccine.
Elizabeth: Let’s turn to JAMA and something that really concerns me and this is a look at central nervous system active polypharmacy among older adults with dementia in the United States. “Okay. If you have dementia, you’re taking a bunch of drugs, and how many of those are going to be impacting on your central nervous system?”
Those that do, of course, may increase your impaired cognition — and you’re already impaired — and fall-related injuries, which we know are a huge problem among these folks, and ultimately death.
This is a really big study. They took a look at all those folks in traditional Medicare coverage from 2015 to 2017 who had a DSM classification that said, “Hey, there’s dementia here.” And their n was 1,159,968, and then they looked at their medication exposures.
Their primary outcome measure was, “Hey, how many of these drugs were you taking that could have been impacting on your central nervous system?” These included the usual suspects, and I won’t name all of them. They found out that just shy of 14% of these folks met this criteria for CNS active polypharmacy.
Those who did had a median age of just shy of 80 years, and just over 71% of those were female. They had multiple days of exposure to this. Almost 58% were exposed for longer than 180 days and about 7% for a full year. Almost 30% were exposed to five or more medications. 92% of these polypharmacy days included an antidepressant, 47% an antipsychotic, and almost 41% a benzodiazepine.
Rick: I was personally surprised that 1 in 7 individuals had been on three or more of these for 30 days or longer, and about ¾ of them for more than 90 days, and as you said, they fall into the groups that include antidepressants, and antipsychotics, and hypnotics, and some even opioids as well, so the combination of one or more of these medications is really surprising to me.
These are individuals, because of dementia, that oftentimes can’t complain about the side effects. This is really alarming. It behooves us to review all the medications that the older individuals are on, and certainly stop the ones that haven’t been proven to be effective for a specific condition.
Elizabeth: We know, of course, we have to juxtapose this against the behavior issues that are so frequent among people with dementia, particularly as it progresses in sort of what I’m going to call that mid-stage of dementia, before they become so impaired that a lot of that seems to damp down a little bit.
It’s unclear to me exactly what we’re going to do to help caregivers to manage that, and to me, that seems like one of the indications here — why these people get on polypharmacy to begin with.
Rick: Well, first of all, we need to look at the evidence. For example, there is really minimal high-quality evidence to support the use of antidepressants in people with dementia. Secondly is sometimes they don’t really have depression, they have apathy, which is very different, doesn’t respond to those.
I actually think the pharmacist can play a central role because oftentimes they’re the central repository for identifying when individuals are on more than one of the medications that may have interactions.
Elizabeth: The good news is that since they are using these huge databases, there could be some kind of a flagging system that could be instituted that would say, “Hey, this is risky. Maybe we need to examine this a little more closely.”
Rick: Exactly, and that’s a good use for electronic medical records.
Elizabeth: Let’s go then, since we’re talking about older individuals, to JAMA Network Open. This is a look again at something that concerns me greatly, the relative paucity of the use of palliative care in people who don’t have a cancer diagnosis.
Rick: We know that in palliative care, for individuals that have terminal diseases it can actually improve their quality of life. It can reduce their symptom burden and decrease unwanted healthcare use, and it actually helps individuals to live the remaining part of their life exactly like they want to, most of them at home.
Most of the palliative care has been centered towards cancer patients, but there are a lot of other terminal diseases that palliative care can be used as well — terminal heart disease, or liver disease, or respiratory disease.
In order to see how effective we are, how we need to modify our systems, we need to first identify how well we’re extending palliative care to this group. That’s exactly what this study did. It looked at almost 150,000 adults who received palliative care, some for cancer and others for [non-cancer terminal] disease, and asked, “Are they similar or is palliative care delivered differently to this group?”
What they determined was that palliative care in the cancer patient was more likely to be initiated earlier. It was initiated in the hospital setting. It was delivered across multiple care settings. The same was not true for those that received palliative care for organ failure.
The patients with cancer were also more likely to receive care using a specialist model or a consultative model, people that have expertise in it, as opposed to those that had terminal disease for other reasons, more likely to receive it from a generalist, but it seems like palliative care should be delivered the same regardless of whether it’s cancer or not, and we ought to use the best practices.
Elizabeth: Clearly, we have a national shortage of palliative care specialists. It can be really challenging to get those kinds of consults, even in places like Hopkins where there are teams who are devoted to this particular approach.
Having said that, I would say that I’ve seen its multiple benefits, and at least I am in favor of the maxim that palliative care seems to live by, that you can live your best at every single stage of your life with palliative care, almost regardless of whether you even have a disease or a condition for which you might think you need it.
So I think some kind of education is definitely necessary. I’ve borne witness to clinicians who were very reluctant to call in a palliative care consult, and it’s unclear to me why.
Rick: Do you think palliative care is more mature in the cancer setting and that’s why it’s delivered earlier, and with specialists, and it’s less developed in non-cancer settings? Is that your take?
Elizabeth: That’s certainly one aspect of it. The other aspect of it I wonder about is whether clinicians in other specialties — like cardiology, where they’re accustomed to dealing with people with heart failure, or whatever — feel that they’re already well-versed in management of what might transpire as the patient’s condition gets worse.
Rick: Yep. The other thing I didn’t mention of this particular study was the higher proportion of individuals who got palliative care for organ failure got it in the last 30 days, and so we probably need to be delivering it earlier and better to non-cancer patients.
Elizabeth: I like that. Finally, let’s turn to the New England Journal of Medicine. This is a look at gestational diabetes screening. This study basically addresses the issue of whether a one-step screening procedure for glucose tolerance or a two-step screening is better. They looked at just shy of 24,000 women who were randomized to either this one-step or this two-step approach.
The one-step approach for screening is where there’s oral administration of a 75-gram glucose load with the woman coming in fasting. In the two-step procedure, it’s a glucose challenge test where blood glucose levels are obtained after a 50-gram glucose load in the non-fasting state, and if it turns out that things are a little aberrant, then the woman comes back for her challenge with 100 grams glucose load when she is fasting.
The upshot of the whole thing is that the one-step screening process identified almost twice as many women who were flagged as having gestational diabetes versus the two-step. They looked at other outcomes secondary to the potential for having diabetes during pregnancy, including fetal outcomes and maternal outcomes, and found out there was no difference between the two groups.
Should you do the one-step because it’s easier? “Oops, but you’re going to cause twice as many women to feel like they have gestational diabetes.” “Oh, but there are no deleterious impacts from that.” Or should you do the two-step? To me, it sure sounds like the two-step is the way to go and we’ve got this controversy.
Rick: Right. Because two large organizations, the American Diabetes Association and the American College of Obstetricians and Gynecologists differed about, “Should you use the one test or the two-time test?” Again, the whole reason to do this is to identify gestational diabetes and to treat the mother to try to improve maternal outcomes and fetal outcomes.
Untreated, the baby’s larger. They’re more likely to be birth trauma, but if you give a one-time test, it seems like it’s more convenient, but if you identify twice as many women, you say, “Well, that’s great, because now I can treat them and things will be better.” You treat them, and it’s really no better. That means you’ve treated twice as many people as you need to. You’ve made mothers that are concerned that the treatment doesn’t really help at all, and all for the sake of convenience.
This was a really important study because I think it really helps to settle the issue, saying, “Listen. It’s going to take a little bit longer to figure out whether you have gestational diabetes, perhaps. You may have to come twice to the office, but we’re not going to unnecessarily give you that tag and treat you if you don’t need it.”
Elizabeth: Let’s hope this is the last word, and on that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.