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GM18 Geriatric Medicine Toronto Notes 2023

Landmark Geriatric Medicine Trials

Trial Name Reference Clinical Trial Details

FRAILTY

GailSpeed and Survival in Older

Adults.Studenskietal. 2011

JAMA 2011;305:50-58 Title:GailSpeed and Survival in Older Adults

Purpose:Evaluate the relationship between gait speed and survival.

Methods:Pooled analysis ol 9 cohort studies of adults >

65 yr withbaseline gait speed data,followed up for 6 - 21yr. The

main outcomes weic survivalandlife expectancy.

Results:lire overall 5-yt survival was 84.8% and 10-yr survival was 59.7%.Gait speed was associated with survival in all

studies (pooled hazard ratio per 0.1m/s.0.88;95% Cl 0.87 to 0.90:P‘

0.001).Survival increased across therange of gait

speeds with significant increments at 0.1mis.

Conclusions:Gait speed was associated with 10-yr survival in all studies,with considerable variability in predicted 10-yr

survival across the range of gait speeds,at 75 yr.

Title:frailty inOldei Adults:Evidence for a Phenotype

Purpose: Develop phenotype of frailty as a clinical syndrome.

Methods:Saselme and annual follow up for outcomes of incident disease, hospitalization,falls,disability,and mortality in

an oiiginal cohort of 4735 participants and later-recruited cohort of 582 African American participants.All participant data

from the prospective observational Cardiovascular Health Study.

Results:Frailty may be defined as the presence of three or more of:unintentional weight loss (10 lbs in pastyr).selfreported exhaustion,weakness (grip strength).slow walkingspeed,low physical activity,frailty is associated with

increased risk of comorbidity and disability.

Conclusions:frailly m community dwelling older adults may be defined as above. While comorbidity is a risk factor for

Irailty and disability is an outcome of frailly,frailty itself does nol equal comoibidily or disability. Assessment loi frailly is

vital in identifying patients at increased risk for comorbidity and disability.

frailty inOlder Adults:Evidence for a J Gerontol A Biol Sci Med Sci

Phenotype. Fried elal. 2001 2001:56(3): M146 56

NEJM 2021:385:203-216 Title:Physical Rehabilitation for Older Patients Hospitalized for Heart Failure

Purpose:Investigate interventions to address physical frailly in older patients hospitalized for acute decompensated heart

failure.

Methods:Multicentci.randomized,controlled trial to evaluate transitional,tailored,progressive rehabilitation

inlervention.including four physical

- function domains initiated dunng or soon after heart failure hospitalization and

continued post discharge for 36 sessions.Piimary outcome was Short PhysicalPerformance Battery score, and secondary

outcome was 6 monthichospitalizalionrale.

Results:Older adults hospitalized for acute decompensated heait failure produce improved clinical outcomes when treated

with this rehabilitation intervention program.

REHAB-AF

DELIRIUM

Delirium is aStrong Risk Factor Brain 2012:135|9):2809 16

loi Dementia in the Oldest Old: A

Population Based Cohort Study, Oavis

etal. 2012

Title:Delirium is a Strong Risk Factor lor Dementia in the Oldest - Old:A Population- Based Cohort Study

Purpose: Use a Irue population sample to determine if delirium is an incident risk factor for incident dementia and cognitive

decline.

Methods:553 individuals aged *85 yr were used to assess associations between delirium and incident dementia,as well

as decline in MMSE scores. The relationship between dementia common neuropathological maikers was modelled and

stratified.

Results:Delirium increased the risk of incident dementia (OR 8.7;95% Cl 2.1to 35).worsened dementia severity (OR 3.1;

95% Cl1.S to 6.3) and deterioration in global function score|0R 2.8;95% Cl1.4 to 5.5).Delirium was associated with a loss

of 1.0more MMSE points per yr (95% Cl 0.11 to 1.89) than those withno history of delirium.

Conclusions:Delirium is a stiong risk faclor for incident dementia and cognitive decline in elderly patients

Title:A Multicomponent Inlervention toPrevent Delirium in Hospitalized Older Patients

Purpose:Evaluate the effectiveness of a multicomponent strategy foi delirium prevention among older inpatients.

Methods:A total of 852 inpatients >70 yr were included in the study.In lieu of randomization,prospective individual

matching was used to compare patients admitted to an intervention unit vs.one of two usual care units.In the intervention

unit,the multicomponent approach sought to address cognitive impairment,sleep deprivation,immobility,visual

impairment,hearing impairment,and dehydration.

Results: Delirium developed in 9.9% of patients in the intervention unit.vs. 15% in the usual care unit|95% Cl0.39 to 0.92).

Iota! number of days with delirium (105 d vs.161d. P'

0.02!and tolal number of delirium episodes (62 vs.90.P'0.03) were

both lower in the inteiventionunit.

Conclusions:A multicomponent intervention model aimed ataddressing risk factors for delirium in hospitalized older

adults is effective at reducing delirium incidenceand delirium duration.

A Multicomponent Intervention to HEJM 1999:340:669 676

Prevent Oelirium in Hospitalized Older

Patients.Inouye etal.1999

FALLS

lancet 1999:353:93 97 Title:Prevention ol falls in the Elderly Irial fProlct):A Randomised Controlled Trial

Purpose: Assess the benclit ola structured interdisciplinary assessment olpeople who have fallen.

Methods:Patients >65 yr presenting to ED with a fall were randomized to Ihc intervention group (detailed medical and

OT-lherapy assessment with referral if indicated) or to a control group (usual care only).

Results:Ihe risk of falling was significantly lower in the intervention group compared to the control group (OR 0.39;95% Cl

0.23 ID 0.66) as was the risk of fallrecurrence (OR 0.33:95%Cl 0.16 to 0.68).

Conclusions:Demonstrates that an interdisciplinary approach to elderly adults with a previous history of falls can

significantly decrease the risk of further falls and limit functional impairment.

PR0FET

NEUR0C0GNITIVE DISORDERS

HEJM 2012:366:893 903 Title:Doncpezil andMemantine for Moderate- to-Severe Alzheimer's Disease

Purpose:Assess the benefits of cholinesterase inhibitorsfor the long-term treatment olmoderate-severe Alzheimer's

disease.

Methods:295 community-dwelling patients with moderate-severe Alzheimer'sdisease treated with donepezilwere

randomized to either continue donepezil.discontinue donepezil and start memantine,or continue donepezil and start

memantine.Ihe piimary outcomes were SMMSE scores and Bristol Activities of Daily living (BADLS) scores.

Results: Patients assigned to continuedonepezil.compared to those who discontinued,had a 1.9 higher average SMMSE

score 195% Cl1.3 to 2.5). Ihc score onIhc 8ADLS was lower (less impairment) by 3.0 points (95% Cl1.8 lo 4.3)IP- 0.001for

both comparisons).Patients who received memantine, compaied with placebo,had a 1.2 higher average SMMSE score (95%

Cl 0.6 to 1.8.P <0.001) and BA0LS score that was 1.5 points lower (95% Cl 0.3 to 2.8:P'

0.02).

Conclusions:Continued treatment with donepezil was associated with cognitive benefits over the course of 12 mo in

patients with moderate or severe Alzheimer's disease.

Donepezil and Memantine for

Moderate-toSevere Alzheimer's Disease.Howard

etal.2012 ri

L J

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GM19 Geriatric Medicine Toronto Notes 2023

Trial Name Reference Clinical TrialDetails

HYPERTENSION IN THE ELDERLY

Syst-Eur Lancet1997:350:757-64 Title:RandomisedDouble-blindComparison of Placebo and Active Treatment for Older Patients with Isolated Systolic

Hypertension.The Systolic Hypertension in Europe (Syst- eur) Trial Investigators

Purpose:imresbgate whether active treatment couldreduce CV complications of isolated systolic HIN.

Methods:Patients »60 yr were randomly assigned to nitrendipine 10 - 40 mg daily with the possible addition of enalapril

5-20 mg daily and hydrochlorothiazide12.5 25 mg daily,or to matching placebos.Combined fatal and nonfatal stroke was

the primary endpoint.

Results: Active treament reduced the total rate ol stroke from13.7 to 7.9 endpoints per 1000 patient- years (43% reduction:

P'

0.003)

- Nonfatal stroke reducedby 44'

.

-|P-0.007) and nonfatal cardiac endpoints decreased by 33%(P'

0.03).All- cause

mortality was not influenced.

Conclusions:Among elderly patients withisolated systolic hypertension,antihypertensive drug

treatment starting withnitrendipine reduces therate of cardiovascular complications.

Title:Treatment of Hypertension inPatients 80 Years of Age or Older

Purpose:Determine whether treatment of hypertension is beneficial inpatients »80 yr.

Methods 384$patents >80yr and a sustained s8P >160 mmHg were randomized lo receive indapamide SR 1.5 mg or

matching placebo.IheACEI perindopril 2 or 4mg was added if necessary,to achieve the target BP of 150/80 mmHg. The

primaryendpoint was fatal or nonfatal stroke.

Results: The mean BP at 2 yr was 15.0 6.1mmHg lower in the active-treatment group than in the placebo group. Active

treatment was associated witha 30%reduction in the rate of death from stroke (95% Cl1to 62;P'0.05).a 21% reduction in

all-cause mortality (95%0:4 to 35:P -0.02),fewer adverse events were reported in the active-treatment group.

Conclusions: Antihypertensive treatment with indapamide (sustained release),with or without perindopril.in adults »80

yr is beneficial.

HYVET NEJM 2008:358:1887 98

INAPPROPRIATE PRESCRIBING IN THE ELDERLY

EMPOWER JAMA Intern Med 2014:174:890-98 Title:Reduction ot Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education:The

Empower Ouster Randomized Trial

Purpose: Compare the effect of direct-to-consumer education against usual care on benzodiazepine discontinuation in

older adults.

Methods:303long-term users of benzodiazepines aged 65-95 were randomized to the educational intervention

(depvescnbingpatientempowerment intervention explaining risks of benzodiazepine use and a stepwise taper protocol)or

the 'wait list’control.Primary outcomes were benzodiazepinediscontinuation after 6 mo.

Results:At 6mo.27% of patients in theintervention group had discontinued benzodiazepines,compared with 5% in the

control group (risk difference 23%:95% G14% to 32%).

Conclusions:OiTect-to-consumer education describing the risks of benzodiazepine use and a stepwise tapering protocol

effectively elicits shared decision making and discontinuation of medications that increase the risk of harm in older adults.

Title:ST0PP (Screening Tool of Older Person's Prescriptions) andSTART (Screening Tool toAlert doctors to Right Treatment).

Consensus validation

Purpose:Validateanewscreening toolof older persons'prescriptions,incorporatingcriteria for potentially inaccurate

prescriptions (calledST0PP).and criteria for appropriate prescriptions (called START).

Methods:A Delphiconsensus technique was used to obtainvalidity from an18-member expert panel.Inter-rater reliability

was assessed by determining the kappa-statistic on100 datasets.

Results:ST0PP consists of 65 clinically significant criteria for potentially inappropriateprescriptions;START consists of 22

evidence-based prescribing indicators.

Conclusions:STOP?;START is a valid,reliable,and comprehensive screening tool that enables the prescribing physician to

apprase an older patient's prescription drugs in thecontext of his/her concurrent diagnoses.

ST0PP and START IntJ ClinPharmacol Ther

2008:46:72-83

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Gynaecology

Eliot Winkler, Sarah Zachariah, and Kehona Zamani, chapter editors

Chunyi Christie Tan and Vrati Mehra, associate editors

Arjan S. Dhoot, EBM editor

Ur. Michael Chaikof and Ur. Sari Rives, staff'

editors

Common Medications.

Landmark Gynaecology Trials..

References

Acronyms

Basic Anatomy Review

Menstruation

Menstrual Cycle

Stages of Puberty

Premenstrual Syndrome

Premenstrual Dysphoric Disorder

Common Investigations and Procedures

Imaging

Endometrial Biopsy

Hysterectomy

Disorders of Menstruation

Amenorrhea

Abnormal Uterine Bleeding

Dysmenorrhea

Endometriosis.

Adenomyosis

Fibroids

Contraception

Hormonal Methods

Intrauterine Device

Emergency Postcoital Contraception

Termination of Pregnancy

Pregnancy-Related Complications

First and Second Trimester Bleeding

Spontaneous Abortions

Ectopic Pregnancy.

Infertility.

Female Factors

Male Factors

Polycystic Ovarian Syndrome

Gynaecological Infections

Physiologic Discharge

Non-Physiologic Discharge

Vulvovaginitis

Sexually Transmitted Infections

Bartholin Gland Abscess

Pelvic Inflammatory Disease

Toxic Shock Syndrome (TSS)

Surgical Infections

Sexual Abuse

Sexuality and SexualDysfunction.

Menopause.

Menopause Hormone Therapy

Urogynaecology

Pelvic Organ Prolapse

Urinary Incontinence

Gynaecological Oncology

Pelvic Moss

Uterus

Ovary

Cervix

Fallopian Tube

Vulva

Vagina

Gestational Trophoblastic Disease/Neoplasia

GY2 .GY56

GY2 .GY58

GY4 .GY59

GY6

GY7

GY11

GY13

GY14

GY15

GY19

.GY20

GY21

,GY23

.GY24

.GY26

.GY34

,GY34

.GY36

.GY39

GY42

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GY1 Gynaecology Toronto Notes 2023

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GY2Gynaecology Toronto Notes 2023

Acronyms

ACEI angiotensin converting enzyme GA

inhibitors

AFP afetoprotein

AIS androgen insensitivity syndrome

AMH anti- mullerian hormone

ARB angiotensin II receptor blockers

ASCUS atypicalsquamous cells of

undetermined significance

AUB abnormal uterine bleeding

BMD bone mineral density

BSO bilateralsalpingo-oophorectomy HMG

BUC buccal administration

BV bacterial vaginosis

CA-125 cancer antigen 125

CAH congenital adrenal hyperplasia HRT

CHC combined hormonal

contraception

CMV cytomegalovirus

CRP C-reactive protein

DES diethylstilbestrol

DHEA dehydroepiandrosterone

DMPA depot medroxyprogesterone ITP

acetate or Depo-Provera’

DUB dysfunctional uterine bleeding IUD

DVT deep venousthrombosis

EPC emergency postcoital

contraception

ESR erythrocyte sedimentation rate IVF

gestational age

gamete intrafallopian transfer JRA

gonadotropin-releasing

hormone

gestational trophoblastic

disease

gestational trophoblastic

neoplasia

heart and estrogen/progestin LNMP

replacementstudy

human menopausal

gonadotropin

hypothalamic-pituitary-ovarian

human papillomavirus

hormone replacement therapy MRKFI

hysterosalpingography

high grade squamous

intraepithelial lesion

herpessimplex virus

inflammatory bowel disease OGTT

intracytoplasmic sperm injection PCOS

immune thrombocytopenic

purpura

intrauterine device

intrauterine insemination

intrauterine system

intravenous drug use

in vitro fertilization

quantification

per the vagina administration

rapid plasma reagin

risk ratio

squamous cell carcinoma

selective estrogen receptor

modulator

sex hormone binding globulin

sonohysterography

selective progesterone receptor

modulator

selective serotonin reuptake

inhibitor

total abdominal hysterectomy

tubal embryo transfer

total hysterectomy

tension-free transobturator tape

tension-free vaginal tape

transformation zone

uterine artery embolization

vulvar intraepithelial neoplasia

venousthromboembolism

von Willebrand disease

withdrawal

Women'

s Health Initiative

zygote intrafallopian transfer

in vitro maturation

juvenile rheumatoid arthritis PV

loop electrosurgical excision RPR

procedure

luteinizing hormone-releasing SCO

hormone

last menstrual period

lymph node

last normal menstrual period SHG

low grade squamous

intraepithelial lesion

lymphovascular space

involvement

menopause hormone therapy TAH

Mayer-Rokita nsky-KiisterHauser

methotrexate

natural killer

oral contraceptive pill

oral glucose tolerance test

polycystic ovarian syndrome

prostaglandin

pelvic inflammatory disease

postmenopausal bleeding

premenstrual dysphoric disorder WHI

polymorphonuclear neutrophils 2IFT

premenstrual syndrome

pelvic organ prolapse

IVM

GIFT

GnRH LEEP

RR

GTD LHRH

SERM

GTN IMP

IN SHEG

HERS

LSIL SPRM

LVSI SSRIs

HPO

HPV MHT

Itl

HSG TH

HSIL TOT

NK TVT

HSV OCP TZ

IBD UAE

ICSI VIN

PG VTE

P1D VWD

PMB W/D

IUI PMDD

IUS PMN

IVDU PMS

POPO

Basic Anatomy Review

Anterior labial

commissure Ischiocavemosus muscle

Bulbospongiosus muscle

Prepuce

Clitoris Labium msjus

Paraurethral duct

orifice

External urinary

meatus Superficial transverse

perineal muscle

Labium minus Vestibule

Vaginalorifice

Levator ani muscle

External anal sphincter

Anus

Greater vestibular

glands of Bartholm

Anus Posterior fourchette

Ifrenulum of labia)

© Marina Chang 2013

Figure 1.Vulva and perineum

A. External Genitalia

• blood supply: internal pudendal artery,superficial external pudendal artery (labia maiora)

• sensory innervation: pudendal nerve

• lymphatic drainage: superficial inguinal lymph nodes, deep inguinal lymph nodes (clitoris)

B. Vagina

• muscular canal extending from cervix to vulva, anterior to rectum, and posterior to bladder

• lined by rugated,stratified squamous epithelium

• upper vagina separated by cervix into anterior, posterior, and lateral fornices

• blood supply:vaginal branch of internal pudendal artery with anastomoses from uterine, inferior

vesical, and middle rectal arteries

C. Uterus

• thick walled, muscular organ between bladder and rectum, consisting of two major parts:

• uterine corpus, made up of the isthmus, fundus, and body

blood supply: uterine artery (branch of the internal iliac artery, anterior division)

cervix

blood supply: cervical branch of uterine artery

• supported by the pelvic diaphragm, the pelvic organs, and four paired sets ofligaments

• round ligaments: travel from anterior surface of uterus,through broad ligaments, and inguinal

canals (canal of Nuck) then terminate in the labia majora

function: anteversion/suspension

blood supply: Sampson’

s artery (branch of uterine artery running through round ligament)

uterosacral ligaments: arise from sacral fascia and insert into posterior inferior uterus

function:mechanical support for uterus, prevent prolapse, and contain autonomic nerve

fibres

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