Clinical Briefs
March 30, 2017 3 minutes read
A Melodious Path to Addressing Dementia Issues
SOURCE: Long EM. The effect of a personalized music playlist on a patient with dementia and evening agitation. Ann Longterm Care 2016;24:31-33.
A substantial minority of the Medicare population suffering from dementia (31%) live in long-term facilities, and staff often must contend with such issues as agitation, aggression, wandering, and other mood changes.
Patients who present behavior problems often are treated with antipsychotic medications, since few other tools are known to be beneficial, despite the observation that antipsychotic medications feature a well-established adverse effect profile, including increased risk of death. Might music therapy be beneficial?
The author presented a case report of a dementia patient who had been treated with antipsychotics. A nursing student visited with the patient and shared headphones with her that played popular music from the time of the patient’s youth and young adulthood. Ultimately, the patient began to demonstrate progressively more involvement with the music, including singing along and tapping her fingers. The previously reticent patient became progressively more communicative. Problem behaviors diminished to the point that caregivers discontinued antipsychotics (previous weaning efforts had failed).
I have had a similar experience with one 95-year-old dementia patient. She has been very religious through much of her life, and her personality blossoms forth if I bring in an old hymnal and sing songs with her (somehow, despite her inability to remember her own children or any specifics about her prior life, she remembers dozens of lengthy hymns).
Learning music that is meaningful to our patients is a time-intensive endeavor. On the other hand, problematic behavior issues also can be quite taxing. Clinicians might consider informing involved family members or caretakers of the potential positive effects of music therapy.
The Way to a Man’s Heart Is Through His Stomach?
SOURCE: Afsar B, Vaziri ND, Aslan G, et al. Gut hormones and gut microbiota: Implications for kidney function and hypertension. J Am Soc Hypertens 2016;10:954-961.
Our primary concerns about hypertension relate to adverse cardiovascular effects. Who would have guessed that the gastrointestinal tract could play an important role?
As an example, glucagon-like peptide-1 (GLP1; agents such as exenatide, liraglutide, etc.) has been shown in animal studies to increase sodium excretion. In type 2 diabetes, GLP1 treatment reduces blood pressure. Indeed, a trial with liraglutide even found a reduction in cardiovascular events.
The microbial population of the gastrointestinal tract also may play a role. Two of the primary bacterial teams of the gastrointestinal microbiome, Bacteroidetes and Firmicutes, have been demonstrated to be elevated in spontaneously hypertensive rats; rebalancing of the flora by antibiotic treatment improved blood pressure.
Alimentary bacteria generate a variety of short-chain fatty acids, some of which can stimulate the sympathetic nervous system and induce renin release from the afferent arteriole. Pharmacologic treatments that address potential toxicities produced by the gastrointestinal microbiome are under study and show some promise.
Although the aphorism “the way to a man’s heart is through his stomach” may have been intended to reflect another agenda, it may turn out to be far more true than most of us expected.
Cardiovascular Risk Induced by NSAIDs
SOURCE: Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med 2016;375:2519-2529.
Ever since the publication of the VIGOR trial, in which it was noted that cardiovascular (CV) events were four times more frequent in patients receiving rofecoxib (subsequently withdrawn from the market) than naproxen, warnings about the risk of CV events attributable to nonsteroidal anti-inflammatory drugs (NSAIDs) have become progressively more strident. For instance, the most recent American College of Cardiology/American Heart Association guidelines on acute coronary syndromes place NSAIDs at the bottom of the list of choices to treat musculoskeletal pain, preferring instead even opioid agents such as tramadol.
How does the CV safety profile of various NSAIDs stack up? To address that question, the administrators of the PRECISION trial randomized a large group of arthritis patients (n = 24,081) who were high risk for CV events to naproxen, ibuprofen, or celecoxib. The population was followed for approximately three years.
Although celecoxib produced fewer adverse gastrointestinal and renal events, there was no statistically significant difference among the three agents for CV events. No safe harbor among the NSAIDs has yet been confirmed in a large randomized trial, and the previous supposition that naproxen was a safer NSAID (from the CV perspective) appears to be incorrect.
In this section: soothing dementia with music; the gastrointestinal tract and cardiology; NSAIDs might pose cardiovascular risks.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content