Chronic kidney disease in primary care: Time to embrace GFR

Medical Tribune March 2009 P15

Chronic kidney disease (CKD) encompasses a wide spectrum of disorders ranging from minor urinary abnormalities to end stage kidney failure. The prevalence of CKD worldwide is thought to be increasing, largely due to the rising incidence of diabetes and the rapid aging of the population.

March 12 is World Kidney Day. The message of raising awareness is particularly pertinent for primary care physicians (PCPs), who will increasingly encounter patients with CKD in its various stages. It is important, therefore, for them to know how to diagnose and manage CKD, and when to refer patients to a nephrologist.

Diagnosis

It is crucial to diagnose CKD as early as possible since complications can ensue if a referral is delayed. Indeed, most patients with CKD will die of cardiovascular disease before developing end stage kidney failure, so management of these risks by their PCP will improve outcomes. Screening of at-risk individuals is thus critical and physicians should adopt a proactive approach, as outlined in the guidelines. Diabetes is the commonest cause of CKD but a high index of suspicion should also be retained in patients with hypertension, over-50s, smokers, the obese, and those with a family history of CKD.

The diagnosis and classification of CKD should be based on a patient’s kidney function, as estimated by glomerular filtration rate (GFR) and the presence of other evidence of chronic kidney damage. These guidelines, which have been widely adopted worldwide, recognize five stages of kidney disease (Table 1).

Contrary to popular perception, a diagnosis of CKD does not routinely require 24-hour urine measurements or expensive radionuclide studies and can usually be made using three simple tests available to every PCP: serum creatinine (SCr), urine protein measurement using an early morning specimen, and urine microscopy. GFR can then be estimated by putting the patient’s data into easy-to-use mathematical formulae, which have been derived from large population studies. The 4-variable Modification of Diet in Renal Disease (MDRD) formula has widespread applicability and is currently the most commonly used formula in routine practice worldwide. Physicians can also estimate GFR using the internet: type “MDRD GFR calculator” into the search engine and input the patient’s values to calculate the estimated GFR (eGFR).

Many laboratories worldwide are already using these formulae to report eGFR but their adoption has been slower in Asia, where some nephrologists have questioned their applicability to local patients. The MDRD formula, for example, has not been validated in an Asian population, although a modified version is currently being explored in Chinese patients. Our division at National University Hospital (NUH) is also devising a Singapore-specific formula.

We should not, however, be paralyzed into inactivity while we await these new formulae. It is time to move on from the notion that 24-hour urine testing is the cornerstone of CKD diagnosis and begin routinely reporting eGFR along with SCr. It is not only easy to calculate but also more convenient for both PCPs and patients – negating the laborious and inaccurate process of collecting and labeling samples. The existing GFR formulae have limitations but they nonetheless provide a long-term view of kidney function in an individual patient, enabling CKD progression to be tracked over time. A reduction in eGFR exceeding a certain range can provide a warning sign, prompting PCPs to make an early referral to a nephrologist.

Twenty-four hour urine collection still has a place in diagnosing CKD, but should be used to further evaluate an abnormal eGFR or proteinuria rather than as a first-line diagnostic tool. Urine examination can identify protein and red cells and casts, giving further information as to the cause of CKD. Additional radiological tests are only required for further evaluation and/or in those with clinical symptoms or signs of CKD.

In evaluating patients with newly-diagnosed stage 3 to 5 CKD, clinicians should obtain previous measurements of SCr and eGFR to assess the rate of progression to date. A blood test showing an eGFR below 60 mL/min/1.73 m2 in a patient without established CKD should prompt:
· Clinical assessment for underlying conditions such as sepsis, heart failure or hypovolemia
· Clinical examination for bladder or prostate enlargement
· A review of medications, particularly non-steroidal anti-inflammatory drugs and traditional medications
· Urinalysis: haematuria and proteinuria suggest the possibility of glomerulonephritis, which may be rapidly progressive
· Repeat SCr, eGFR and potassium measurement within a maximum of 5 days

If acute kidney failure is suspected, the patient should be referred to a nephrologist. Patients with stable CKD should be followed up according to their eGFR (Table 1).

Practice Guidelines

Guidance on the diagnosis and management of CKD is available from several international sources. The guidelines from the UK Renal Association are particularly simple to follow and contain useful treatment algorithms. Helpful guidelines are also available from the US National Kidney Foundation, the Canadian Society of Nephrology, and CARI (Caring for Australasians with Renal Impairment).

Treatment

The vast majority of CKD patients being managed by PCPs will be in stages 1 and 2, but patients with early stage 3 CKD will also represent a significant proportion. Stage 3 patients who progress or are proving difficult to manage in primary care, and stage 4 and 5 patients, should be referred to nephrologists.

All CKD patients should be advised on diet and lifestyle modification as appropriate. Lipid-lowering therapy should be considered for all patients and aspirin for those at high cardiovascular risk. Meticulous control of hypertension is extremely important in CKD and most patients will need more than two drugs to achieve optimal control. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers should be given to all patients with proteinuria, diabetic patients with microalbuminuria, and patients with heart failure but combinations of these two drugs should only be initiated under specialist supervision.

Physicians should refer to the guidelines for further advice on the thresholds for initiating and maintaining antihypertensive treatment, and for who, when and how to refer. They should also familiarize themselves with the indications for early referral to a nephrologist. The need for a prompt referral is particularly pressing in acute kidney failure, as this requires emergency treatment.

Disease management tools

Partnerships with nephrologists play a crucial role in helping PCPs to recognize the variability in CKD progression and to treat each patient individually. At NUH and National Healthcare Group in Singapore we are developing a ”Right-Siting” program for patients with early CKD so that they can be managed and tracked to optimize outcomes. The initiative is still in the planning stages but is due to launch in the coming months. We hope that this program will give PCPs greater knowledge and confidence with managing CKD, facilitate referrals, and provide patients with greater continuity of care and a more holistic approach to their management.

Conclusion

Our understanding of CKD has come a long way in recent years and it is important for physicians to familiarize themselves with the latest guidelines. The use of GFR in particular should be embraced, and patients should be classified into the 5 stages of CKD to enable appropriate referrals. Forging closer ties with nephrologists will help PCPs to tackle the ever-increasing burden of CKD and improve quality of care and outcomes for patients.

Managing diabetic retinopathy in primary care

Medical Tribune January 2009 P14-15

Diabetic retinopathy is a leading cause of visual loss in Asia and one of the major chronic eye diseases handled by GPs. Left untreated, it can result in permanent blindness from neovascular glaucoma or tractional retinal detachment arising from proliferative diabetic retinopathy.

The condition is expected to become more common as the prevalence of diabetes continues to rise in Asia.

A recent study found that 38.1 percent of diabetics who were referred for retinal assessment as part of a nationwide screening program in Singapore had retinopathy. [Ann Acad Med Singapore 2008 Sep;37(9):753-9] The Singapore Malay Eye Study, meanwhile, demonstrated a retinopathy prevalence of 35 percent among diabetics of Malay ethnicity, of whom 9 percent had vision-threatening retinopathy. [Ophthalmology 2008 Nov:115(11):1869-1875]. This high rate of diabetics suffering from retinopathy is consistent worldwide. The proportion of type 2 diabetics having retinopathy has been reported to be 40.3 percent in the US, 35 percent in Taiwan and 10.5 – 26.2 percent in India.

Pathogenesis

Diabetic retinopathy is a highly specific microvascular complication of both type 1 and type 2 diabetes mellitus, resulting from progressive damage to the retinal blood vessels caused by hyperglycemia in the blood. The condition is caused by increased vascular permeability at onset, leading to fluid accumulation in the retina. With time, there is vascular shutdown, causing ischemia of the retina. This leads to retinal neovascularization at the disc or elsewhere, vitreous hemorrhages, fibro-proliferative changes and retinal detachment. Neovascular glaucoma can also develop. The prevalence is strongly related to the duration of diabetes mellitus, and most diabetic patients will develop retinopathy with time.

See the sidebar for a classification of the different disease stages.

Screening

As patients with sight-threatening retinopathy may not show any symptoms, fundal screening of diabetic patients is crucial in helping to identify those at risk of developing complications that will impact on their vision and quality of life. The importance of regular screening for diabetics, therefore, cannot be understated.

All diabetic patients should be screened for retinopathy on an annual basis at the very least, beginning from the point of diagnosis. Those who are at high risk for developing retinopathy need to be monitored more closely and should be screened at least twice yearly. The major risk factors to consider are hypertension, high cholesterol, smoking, patient’s age, duration of diabetes and a history of poor glycemic control. The Singapore Malay Eye Study also found that a history of stroke, cardiovascular disease or chronic kidney disease was associated with vision-threatening retinopathy.

Female diabetics who are planning to conceive should be screened prior to conception and again in the first trimester. The regularity of follow-up should then be determined based on the results of the first trimester examination.

For patients with established retinopathy, the timing of follow up examinations depends on their disease status.

Physicians who are involved in providing diabetic care have a pivotal role in ensuring that patients are screened. This can be performed via fundal photography, indirect fundoscopy or direct ophthalmoscopy through a dilated pupil.

While the need for regular screening is well accepted by the medical community, it is an unfortunate reality that patients are often not screened as frequently as they should be. Many patients do not understand the progressive nature of the disease process, mistakenly believing that if there is nothing wrong with their vision, then they do not need to see an eye doctor. Many appointments are missed as a result, and the early signs of diabetic retinopathy can often go undetected. Accessibility can also be a problem, particularly in rural areas, and can also contribute to the missing of screening appointments.

We must educate patients on the importance of these check-ups, and help them to understand that by the time they discover they have developed visual problems, it may already be too late to treat them. GPs can also help patients to attend their screening appointments by checking regularly whether they are compliant with their schedules, reminding them about upcoming
visits and making sure that they are referred to the most appropriate and convenient center.

Practice guidelines

The most widely-used guidelines on diabetic retinopathy come from the American Academy of
Ophthalmology. These have been incorporated into clinical practice guidelines on the management of diabetic retinopathy from Singapore’s Ministry of Health, published in January 2004, which help GPs plan their management and screening schedules for their patients. Diabetic retinopathy guidelines are also available from the Academy of Medicine of Malaysia.

Treatment

Laser treatment is the major therapy for diabetic retinopathy but can lead to long-term side effects such as a reduced field of vision.

There is now a considerable weight of data showing the benefits of good glycemic control on
retinopathy outcomes. The Diabetes Control and Complications Trial (DCCT) found that an intensive strategy reduced the risk of developing retinopathy by 76 percent and slowed disease progression by 54 percent. [N Engl J Med 1993 Sep 30;329(14):977-86] Recent data from the United Kingdom Prospective Diabetes Study (UKPDS) show that the benefits of intensive glucose control extended long beyond the trial intervention, with a 24 percent risk reduction for microvascular disease noted 10 years after the conclusion of the study. [N Engl J Med 2008 Oct 9;359(15):1577-89]

Tight blood pressure control is also important. The original UKPDS data demonstrated a 47 percent reduction in the risk of having decreased vision in both eyes, after 9 years of follow up. [BMJ 1998 Sep 12;317(7160):703-13] The 2008 data showed that the benefits disappeared once treatment was withdrawn, suggesting that blood pressure control needs to be maintained in order to continue to derive the maximum benefits. [N Engl J Med 2008 Oct 9;359(15):1565-76]

Medication adherence is often a major obstacle in achieving these targets. GPs should continue to ensure that patients are well-educated on the importance of taking their drugs, making them aware that failure to do so increases their risk of retinopathy. Regular HbA1c and blood pressure tests should be carried out to monitor progress, and medication adjusted accordingly.

Disease management tools

In October 2006, the Ministry of Health in Singapore launched the Chronic Disease Management Program, focusing initially on diabetes and then on hypertension, dyslipidemia
and stroke. The plan is to transform management of these diseases by forming an effective
partnership among GPs, medical specialists and patients through effective information flow within the partnership throughout the healthcare continuum. The program aims to equip GPs with a better understanding of patients’ medical histories through up-to-date electronic records and, in turn, reduce medical costs and enable the provision of quality healthcare services customized to individual requirements.

This integrated clinic management system provides GPs with a complete system to manage their patients and clinic operations. Critical clinical indicators are stored, enabling GPs to use this data to track the progress of their patients. Clinical decision support tools are also built into the system to help GPs plan effectively and communicate care plans to their patients. In this way, schedules for retinopathy screening can be built into the patients’ management plan, helping doctors keep to the intended schedules.

Conclusion

Regular screening is the cornerstone of detecting, monitoring and managing diabetic retinopathy and should be arranged from the very point of diagnosis. Patients should be educated about the importance of screening and followed up at all stages to ensure compliance to their schedules. Good glycemic and blood pressure control are also of vital importance in preventing the development and progression of this potentially sight-threatening condition. It is strongly recommended that the organization of retinopathy screening be primarily the responsibility of the GPs, who will then refer all patients with retinopathy or media opacity to an ophthalmologist for more specialized treatment.

Online Resources:

The American Academy of Ophthalmology guidelines:

www.guideline.gov/summary/summary.aspx?doc_id=4350

Managing chronic obstructive pulmonary disease in primary care

Medical Tribune December 2008 P14 & 15

Chronic obstructive pulmonary disease (COPD) is a major health problem worldwide, affecting some 210 million people. It is expected to become the third leading cause of death by 2030, according to WHO estimates.

COPD is characterized by airflow limitation, which unlike asthma, is not fully reversible. The airflow limitation is progressive and is associated with an abnormal inflammatory response to noxious particles or gases. It is a preventable disease, primarily caused by tobacco smoke. In some countries, where there is exposure to indoor air pollution, the use of biomass fuels for cooking and heating can cause COPD.

The disease has a chronic progressive course. As lung function declines the patient’s symptoms worsen and they become increasingly dependent on the healthcare system for medical care, which may include hospitalization. Although not curable, treatment is available which helps relieve symptoms and improve quality of life.

GPs can play an important role in the management of COPD in the community: in addition to providing treatment to stable patients, they can also help to educate patients and identify those who are at risk and should be screened.

Diagnosis

A diagnosis of COPD should be considered in any patient who has breathlessness, chronic cough, sputum production and a history of smoking. COPD can sometimes go unrecognized as the symptoms are commonly attributed to smoking and ignored.

Patients often seek medical attention for breathlessness. This may occur only on exertion or strenuous activity in patients with mild disease, but as the condition progresses and lung function deteriorates the breathlessness can become persistent and can be disabling and frustrating to the patient. Cough is a common symptom in COPD but its significance may not be appreciated by smokers, who may consider it to be a consequence of the habit and not seek further attention or assessment. The amount of sputum brought up is variable, and might be purulent during an infective exacerbation.

The diagnosis of COPD should be confirmed by spirometry. This is presently the gold standard for establishing the diagnosis, providing reproducible and objective results. The presence of a post-bronchodilator Forced Expiratory Volume (FEV)1 / Forced Vital Capacity (FVC) less than 70 percent, and an FEV1 above 80 percent of predicted values confirms the presence of airflow limitation that is not fully reversible. Spirometry also permits COPD to be classified into four stages of severity: stage 1, mild; stage 2, moderate; stage 3, severe, and stage 4, very severe, according to the FEV1 predicted.

Spirometry is not typically available in primary care practices but can be ordered at most hospitals and some polyclinics. GPs can facilitate an early diagnosis of COPD by identifying patients who are at risk and referring them for further testing.

Screening studies have shown that many patients who have been diagnosed with COPD are unaware of it, even when they have advanced disease. Subjects aged over 40 who have any smoking history and breathlessness, chronic cough and sputum production, are at risk of COPD and should be identified and encouraged to undergo spirometry. This represents
an opportunity for GPs to diagnose the disease and initiate treatment which may slow its progression.

Practice Guidelines

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides helpful, informative guidelines on the diagnosis, management and prevention of COPD. These were most recently updated in 2007, and are easily accessible from the GOLD website. International
guidelines are also available from a range of other sources including the American Thoracic
Society, the European Respiratory Society and the National Institute for Health and Clinical Excellence (NICE), UK.

Locally, the Ministry of Health, Singapore, published COPD guidelines in 2006.

Treatment

The goals of management in COPD are the relief of symptoms, prevention of disease progression, improvement of exercise tolerance, improvement of health status, prevention
and treatment of complications, prevention and treatment of exacerbations, and reduction of
mortality.

All patients with COPD should be educated on the disease. This can be time-consuming in the busy practice schedule of a GP but a good understanding of the disease helps the patient to better participate in the management of his disease. Patients should be advised to stop smoking and provided with the necessary support to facilitate this. Education should also address coping skills and the use of medications and inhalers.

The majority of patients encountered by GPs will have mild (FEV1 > 80 percent predicted) or
moderate (FEV1 50 – 80 percent predicted) COPD and are usually in a stable condition. Bronchodilators are central to the management of symptomatic COPD. Many patients seek treatment because of breathlessness which restricts their activities and can be disabling. A short-acting bronchodilator – either a beta2-agonist (e.g. salbutamol) or an anticholinergic (e.g. ipratropium) – can be prescribed on an as-needed basis for relief of symptoms or on a
regular basis to prevent or reduce symptoms. The preferred route of delivery is by inhaler.

For persistent symptoms, a combination inhaler containing both a beta2-agonist and an anticholinergic can be used. If patients are still symptomatic, regular treatment with a long-acting bronchodilator is more effective and convenient than the short-acting bronchodilators. Tiotropium is a long acting anticholinergic agent which was shown in the recently-published Understanding Potential Long-Term Impacts on Function with Tiotropium (UPLIFT) study to improve lung function, reduce the risk of exacerbations and hospitalization and improve quality of life. [N Engl J Med 2008 Oct 9;359(15):1543-54] Two recent publications (a meta-analysis and a nested case-control study) suggested an increased risk of cardiovascular events in patients using inhaled anticholinergic drugs but in the UPLIFT study there was a reduction of cardiac adverse events associated with tiotropium. [JAMA 2008 Sep 24;300(12):1439-50; Ann Intern Med 2008 Sep 16;149(6):380-90]

Inhaled corticosteroids are indicated in patients with severe and very severe COPD with an FEV1 ≤50 percent of predicted, and at least 2 exacerbations in the preceding 12 months. An inhaled corticosteroid combined with a long-acting beta2-agonist is more effective than the individual components. The Towards a Revolution in COPD Health (TORCH) study, published in 2007, showed that a combination regimen of salmeterol 50 mcg and fluticasone propionate 500 mcg twice daily reduced the rate of exacerbations and improved lung function and health
status. Patients taking fluticasone were also noted to have a higher incidence of pneumonia. [N Engl J Med 2007 Feb 22;356(8):775-89]

The long-term use of oral corticosteroids should be avoided as it is associated with unwanted adverse effects. The widespread use of mucolytic agents and regular use of antitussives is not recommended.

Exacerbations are defined as a sustained worsening of the patient’s symptoms from his usual stable state which is beyond the usual day-to-day variation and is acute in onset. The common symptoms are a worsening of breathlessness, cough, increased sputum production and a change in sputum color. The change of symptoms usually necessitates a change in medication,
comprising an increase in the frequency of bronchodilators, a course of antibiotics and prednisolone for a week. Mild exacerbations can usually be treated by the GP but patients who are very breathless, unable to cope at home and in poor general condition should be referred to the hospital for management.

Exacerbations are more common in patients with advanced disease, and are a major cause of
morbidity and mortality in COPD. The use of inhaled corticosteroids (alone or in combination with a long-acting beta2-agonist) and long-acting anticholinergics, as well as influenza and pneumococcal vaccination, can reduce the incidence of exacerbations. Patients should also be taught to recognize the development of an exacerbation so that immediate measures can be
taken to control it.

COPD patients should be encouraged to participate in physical activity. Many of those with breathlessness are often apprehensive to exercise for fear of worsening the dyspnea, owing to dynamic hyperinflation of the lungs. This can be overcome with the regular use of bronchodilators which help empty the lungs and improve effort tolerance. Deconditioning will occur if they remain sedentary and passive, resulting in muscle atrophy and weakness. Patients may also be referred to the hospital for pulmonary rehabilitation programs where an exercise regime tailored to the patient can be developed to help improve their exercise capacity and their ability to cope.

Disease management tools

Singapore’s National Healthcare Group Integrated Chronic Obstructive Pulmonary Disease
(NICE) program is a hospital-based initiative aimed at reducing hospitalization and readmissions from COPD, reducing emergency room visits and improving patient quality
of life. Team members include respiratory physicians, case managers and physiotherapists. The
physicians focus on the medical aspects of care, while dedicated case managers provide a more holistic approach by helping to educate patients and encouraging them to make lifestyle changes. Subsidized medications are also available through the program. There are currently over 500 COPD patients in the program.

At present the NICE program is solely hospital-based but this represents just an early step in a continuing journey to engage primary healthcare. In the long term we hope to share the ongoing management of our patients with the GPs and polyclinics, such that care during stable periods can be administered in the community with the hospitals on standby in the event of acute exacerbations. As well as facilitating our processes of care we hope that implementing this vision will improve awareness of COPD in the community and help primary care
practitioners to become more confident with handling the disease.

Conclusion

GPs and primary healthcare doctors play a major role in the management of COPD in the community and have a real opportunity to make an impact in the management of the disease. Smokers can be identified and advised on smoking cessation in order to prevent the development of COPD, while other high-risk patients can be sent for spirometry in order to
diagnose the condition. Patients with established COPD can be educated on the disease and the
effective treatments for symptom control. GPs can work in partnership with hospital physicians to help improve the framework of care for COPD patients in the community.

Online Resources:

The Global Initiative for Chronic Obstructive Lung Disease:
http://www.goldcopd.com/

The American Thoracic Society COPD guidelines:
www.thoracic.org/sections/copd/

The European Respiratory Society COPD guidelines:
www.ersnet.org/ers/default.aspx?id=1418

The National Institute for Health and Clinical Excellence, UK, COPD guidelines:
www.nice.org.uk/guidance/CG12

Chronic disease management: Depression

Medical Tribune November 2008 P14-15

Depression is a serious global health issue. Some 121 million people are affected worldwide, according to 2001 estimates from the WHO, with 1 million committing suicide each year and a further 10 to 20 million attempting to do so.

The prevalence of depression in the general adult population of Singapore is around 5 percent. This figure is lower than in the US but comparable to most developed European countries. The prevalence in developing Asian countries is unclear but is likely to rise, placing an increasing burden on society and healthcare systems.

The WHO, as part of a new program launched on World Mental Health Day 2008, recently called on governments and donors to urgently upscale mental health services and better integrate mental health into primary care. Depression in particular is increasingly treatable, and making an early and effective diagnosis in this setting will lead to considerable improvements in outcome.

Diagnosis

Routine screening for depression is not recommended but should be carried out among those who are at the highest risk. There are several risk factors which GPs should be aware of in order to effectively target these patients.

The presence of multiple medical problems is strongly associated with depression. Chronic but stable conditions such as heart disease, stroke and cancer all place a strain upon patients’ wellbeing, and the coexistence of more than three conditions has been shown to significantly increase depression risk.

The link between depression and diabetes, for example, is well established. Depressed patients often lose the motivation to take their medications, which contributes to a worsening of their diabetes. This can be a two-way process, with the resulting deterioration of blood sugar control affecting the vessels and tissues in the brain, leading to a further worsening of depressive symptoms and an even greater loss of motivation.

GPs should also consider the social factors affecting their patients, as this type of information is invaluable in identifying those who should be screened for depression. Do they live alone? Are they recently divorced or widowed? Is there support from their family? Are they likely to have financial problems?

Once the GP has identified a high-risk patient they can initiate screening with two quick, simple questions: “Have you persistently felt depressed in the last 2 weeks to a month? Have you experienced a loss of interest in your daily activities over this time period?” If the patient answers yes to either of these questions then the physician should move on to try and identify further symptoms. A formal diagnosis can then be established according to the criteria laid out in the relevant guidelines.

There are, however, two major obstacles to initiating this process. The first is shyness on the part of the patient. Asian patients tend to perceive doctors as being primarily concerned with their physical wellbeing and may not expect to discuss mental health issues with them. They are often shy and might find the subject awkward.

Doctors nonetheless have a responsibility to overcome this barrier and broach the subject. This can be done by gradually and tactfully guiding the conversation in the right direction. Ask the patient gently about their mood, how they have been feeling in light of recent problems, and whether there are any other issues they would like to discuss. If they clam up, try not to charge in and pry them open in a single visit. Primary care physicians have the advantage of seeing patients regularly, and introducing the subject in one visit might make it easier to return to at a later date.

The second barrier, however, lies with the doctor, since the process of diagnosing depression can only begin if they are willing to ask these difficult questions. There is sometimes a reluctance to open up Pandora’s Box which, although understandable, needs to be overcome. This fear typically lies in the unknown, so doctors can avoid this by reading around the subject and being prepared for what might follow. Continuing Medical Education courses and workshops are often available to help physicians gain confidence in dealing with these issues, while there is a wide range of useful information available on the internet for further reading (see below).

Once doctors are comfortable with broaching the subject they can also use their intuition to guide them in making an early diagnosis. Depressed patients may seem withdrawn and quieter than usual, or may display a steady deterioration in chronic conditions which were previously well controlled. These signs should all arouse suspicion that the patient is not simply having a bad day and may be in need of help.

Practice Guidelines

Practice guidelines on major depressive disorder are available from the American Psychiatric Association website. The Ministry of Health in Singapore also publishes its own guidelines on depression, most recently in March 2004. These state that a diagnosis can be made when a depressed mood or loss of interest is accompanied by a minimum of four specific symptoms (from a list of eight) over a period of 2 or more weeks.

Depression can be a culturally sensitive issue, and guidelines will need to be applied within the context of the local social environment. The ability to adhere to the various guidelines will also depend heavily on the availability of local resources.

A range of advice and information is also available from the Malaysian Psychiatric Association and the Hong Kong College of Psychiatrists.

Treatment

Once the criteria for diagnosis are fulfilled GPs should move on to discuss treatment with their patients. If the patient is not severely agitated or suicidal then it can be useful to spread this discussion over more than one clinic visit. Start by making them aware that they have a medical condition which goes beyond just experiencing difficulties in life, and let them know that it is treatable and that safe and effective medications are available. This will give the patient time to digest the information, discuss the options with their family and do their own research before committing to a plan of action.

This approach also gives the GP a little more time to review options and prepare for prescribing an antidepressant. Medication access and guidelines will vary by country, but GPs should typically aim to begin with a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA) for 4 to 6 weeks and wait to see whether there is a response. Algorithms such as the Texas Implementation of Medication Algorithm (see below) can then be used to guide further decisions around medication use.

Patients may have common misunderstandings about medications which physicians should try to allay. They may fear that the medications are addictive, or they may expect them to provide instantaneous relief. Managing these expectations in advance is important, and can help prevent patients from becoming disappointed or frustrated and stopping their medications.

Close follow-up is also crucial. Guidelines suggest that medication use should continue for 6 months to a year even if the patient shows signs of recovery. Early discontinuation leads to a higher risk of relapse, so it is important to make sure that patients finish their course. Side effects such as gastrointestinal complaints, drowsiness, dry eyes and dry throat will also need to be managed and patients should be warned about these in advance.

Psychotherapy, where available, is also a useful tool for treating depression. Few GPs are trained in psychotherapy themselves, and they should prepare for this eventuality by thoroughly researching the options in the local community and knowing how and where to refer their patients.

Treatment can be augmented by attempting to tackle some of the underlying triggers for depression. Rather than focusing solely on medical issues, GPs should also explore a patient’s psychosocial problems to understand what is troubling them. Community resources and support groups may be on hand to help, and many patients will benefit from further advice and referrals. With patients facing many problems this approach can be time-consuming for GPs, and they may like to plan ahead and deal with these issues one session at a time.

Patients with multiple psychiatric disorders or very complex or refractory depression should generally be referred on to a specialist center, particularly if they show signs of suicidal thoughts or self-harming behavior.

These centers may also offer further training which can help primary care physicians to improve their knowledge of depression. The Institute of Mental Health, for example, offers a partnership program for GPs which seeks to provide continuity of care for stable patients and increase the accessibility of treatment within the community. Participants complete a series of lectures and guided clinical sessions on depression and other mental health disorders, and can subsequently receive case consults and phone advice for difficult cases. Having specialist advice on hand can take some of the pressure off busy GPs, and can help them feel more comfortable discussing depression with their patients.

Conclusion

Depression is becoming easier to treat as our understanding of the condition continues to improve. Medications are safer and more effective than ever before and there is a wide range of information available to guide our clinical decisions. Primary care is an important setting for making an early diagnosis, and physicians should be proactive in screening patients who are at high risk.


Online Resources:

The American Psychiatric Association practice guidelines:
http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx

The World Psychiatric Association:
http://www.worldpsychiatricassociation.org/

Texas Implementation of Medication Algorithm (TIMA):
http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm

Institute of Mental Health patient information: http://www.imh.com.sg/patient_education/depression.htm

Depression.com:
http://www.depression.com/

Managing diabetes in the primary care setting

Diagnosing and managing osteoporosis in primary care

Medical Tribune August 2008 P15-16

Osteoporosis affects around a third of women aged 60 – 70 and two thirds of those aged 80 and above. The condition also affects men – approximately one in five of whom will suffer an osteoporosis-related fracture above the age of 50. Osteoporosis carries a significant burden in terms of hospitalization for fractures, and patients will typically experience increased morbidity, disability, and a reduction in independence.

Diagnosis

Osteoporosis is a silent epidemic, and overt signs are usually absent until a patient presents with a fracture. This is likely to be a fragility fracture caused by relatively low trauma – a sign that the bones have become weakened. Compression fractures of the vertebrae are a common presentation, while other types include Colles’ fractures of the wrist and hip fractures, both of which typically result from a fall.

There are several risk factors for osteoporosis that general practitioners (GPs) should be aware of, such as increasing age, frailty, a personal history of fractures and a family history of fractures (particularly on the maternal side). Loss of height is also common among patients, and suggests that the vertebrae are collapsing. Back pain may also be present – often signifying that the patient has an undiagnosed compression fracture.

It should also be noted that osteoporosis in men tends to have a later age of onset than in women. Consequently mortality from fractures is twice as high for men, so it is important that GPs retain a high suspicion for osteoporosis among their elderly male patients.

GPs can also encourage their elderly patients to use the Osteoporosis Self-Assessment Tool for Asians, which is applicable for post-menopausal women of Asian descent. This can help to identify patients at high risk, who can then visit their doctor for screening and further assessment.

The gold standard for diagnosis of osteoporosis is a bone mineral density (BMD) scan using dual energy x-ray absorptiometry, with osteoporosis defined as a T-score of minus 2.5 or lower. In the absence of any other cause, a fragility fracture can also be considered as a diagnosis for osteoporosis. Patients should also receive the relevant x-rays to fully document their fractures. It can be challenging for GPs to pinpoint osteoporosis in patients who have not experienced a fracture, as some patients might find the cost of the tests prohibitive. Access to BMD scanners can sometimes be problematic

Practice Guidelines

The Ministry of Health (MOH) in Singapore is currently revising its guidelines for osteoporosis, which were last published in 2002. The new version is expected to be available later this year. The Academy of Medicine of Malaysia also has its own guidelines for osteoporosis, the second edition of which was released in 2002.

Various guidelines and recommendations are also available from the International Osteoporosis Foundation (IOF) website, including IOF-endorsed guidelines published in 2008 by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). This comprehensive 30-page document covers the diagnosis and management of the condition in postmenopausal women.

Recommendations and other helpful documents for the secondary prevention of osteoporosis are available from the National Institute for Health and Clinical Excellence (NICE), UK.

Treatment

There are many factors to consider when treating osteoporosis, and it is important to decide carefully on an appropriate strategy for each patient before proceeding with treatment.
Drug treatments are available but the cumulative costs can be formidable. The first decision physicians should take after making a definite diagnosis of osteoporosis, therefore, is whether or not to treat the patient. This decision should be based on the patient’s 10-year fracture risk, which can be calculated using IOF guidelines. A 65-year old at low fracture risk, for example, might not warrant the same treatment approach as a high-risk 85-year-old. In some cases it may be best to postpone treatment following diagnosis, monitor the patient closely and review the decision at a later stage.

Before initiating drug therapy it is important to obtain a BMD scan. This will provide a baseline value for comparisons, so that the long-term efficacy of therapy can be monitored.

Bisphosphonates, such as alendronate and risedronate, are the first-line therapy for patients who do merit drug treatment. Doctors should make their patients aware that these drugs must be taken according to certain instructions. Tablets should be taken on an empty stomach first thing in the morning, and the patient should refrain from eating for an hour afterwards or consuming any caffeine-containing drinks or milk products in this time. Failure to do so can render the tablet ineffective – which may be an explanation in cases where BMD is not improving. Elderly patients may also forget to take the drugs, or take them but forget that they have done so and lie down shortly after, which can cause painful esophagitis.

Other drug treatments include strontium ranelate, raloxifene and parathyroid hormone injections (such as teriparatide).. Annual injections of zoledronic acid, a form of bisphosphonate, have also been shown to reduce the risk of fractures and the data in support of this option are promising. The injection can be expensive, however, and some patients might prefer treatments that spread the cost out over the year.

GPs should prescribe calcium supplements for patients who are deficient, which can be a common problem in Asian countries where dairy consumption is low. The recommended intake at different ages can be found in the guidelines. Boosting calcium levels can also serve as a prevention strategy, and GPs should also encourage the use of supplements in non-osteoporotic elderly patients who are at high risk.

Lifestyle management is also a key aspect of treating osteoporosis in the primary care setting. Ill-health can lower general nutrition, leading to further reductions in calcium levels, so a healthy diet should be promoted for all cases. Osteoporotic patients should be advised not to drink or smoke, and should also be encouraged to perform weight-bearing exercises at least three times per week for 50 – 60 minutes at a time in order to improve strength and co-ordination and reduce bone loss.

Disease management tools

Elderly patients living in the community have a roughly 30 percent chance of falling in a year, and fall prevention strategies are an important tool for reducing the risk of fractures among those with osteoporosis.

Falls typically result from a combination of several underlying causes. Risk factors such as poor gait, eyesight, and neurological comorbidities should be addressed where possible, which may require collaboration between different medical disciplines. Psychologically-altering medications such as antipsychotics and sleeping tablets can also increase the risk of falls, and may need to be adjusted accordingly.

Physicians may also need to consult with occupational therapists and physiotherapists, and in some cases might choose to encourage patients to make modifications to their home environment. Suggestions can include improving lighting, anchoring carpets and rugs, securing loose wires and applying non-slip mats to stairs and bathroom floors.

Further information on osteoporosis and home care solutions can usually be obtained from specialist centers and clinics, and GPs should refer their patients onwards for further advice and treatment where appropriate.

Conclusion

Managing osteoporosis in the primary care setting begins with an accurate diagnosis. GPs should remain vigilant for patients who have a history of fragility fractures or falls, and remember that men are also at risk for the condition. Once osteoporosis is identified, doctors should choose carefully from the range of available treatment options and select the strategy that is best suited to the patient.

Dementia in the primary care setting

Medical Tribune July 2008 P14-15

Diagnosis
Patients with dementia typically
present with some general
symptoms that should alert the
doctor to their condition. The major
symptom is memory deterioration,
which usually begins with difficulty
in recalling recent events. As a
result patients may misplace items,
fail to recognize people, become
disorientated to time, forget that
they have eaten and become confused
in unfamiliar surroundings.
Longer-term memory, conversely,
can often remain intact during the
early stages of the condition. Behavioral
and psychiatric symptoms
can also be suggestive of dementia,
such as agitation, aggression, hallucinations
and delusions – particularly
of people wanting to harm
them or steal from them. Sleeplessness
and nighttime wandering are
also common symptoms.
Recognizing dementia in its
early stages can be challenging
as elderly people are often quite
forgetful and these warning signs
can be dismissed as normal aging.
The condition can also be confused
with depression, as depressed patients
may also present with forgetfulness
and poor attention and
concentration. Furthermore the
diagnosis is often missed in cases
where the patient visits a doctor for
other reasons and neglects to mention
that he or she is becoming forgetful,
so it is important that physicians
remain aware of the condition
in order to recognize it early.
A full psychiatric and medical
history should be taken, and
any problems with daily functioning
and aspects of self-care such
as bathing and feeding should be
noted. A mental state examination
should be performed to look for
depressed and irritable mood, hallucinations
and delusions. It is also
important to perform a full cognitive
assessment using tests, such as
the Mini Mental State Examination
and the Elderly Cognitive Assessment
Questionnaire. These can be
time-consuming, however, and
busy general practitioners (GPs)
may prefer to use quicker tests
such as the Abbreviated Mental
Test, and then refer the patient to
a geriatrician or psychologist for
more detailed assessment. The
doctor should also take the time
to perform a complete physical examination
to rule out other medical
problems.
There are a number of tests
that general practitioners should
perform to establish whether a
patient with forgetfulness has dementia.
The initial objective is to
exclude other potential causes for
the problem, many of which may
be reversible with the appropriate
treatment. Blood testing should be
used to rule out anemia, hypoglycemia,
syphilis, and vitamin B12
and folate deficiencies. Liver, kidney
and thyroid function should
be tested, and urine analysis
should be performed to exclude
infections. Suspected cases should
also receive a chest x-ray and a
computed tomography scan, and
in some cases the radiologist will
also recommend magnetic resonance
imaging.
Once the diagnosis is established
the doctor should assess
which type of dementia is present
in the patient. The most common
forms are Alzheimer’s disease,
which is caused by the formation
of amyloid plaques and neurofibrillary
tangles, and vascular dementia,
which is caused by stroke.
Physicians can make the distinction
using specific diagnostic criteria,
such as those contained in
the International Classification of
Diseases or the Diagnostic and the
Statistical Manual of Mental Disorders.
A family history for Alzheimer’s
disease should arouse suspicion
for this diagnosis, whereas a
recent history of stroke or the presence
of multiple risk factors (such
as diabetes, hypertension, high
cholesterol and smoking) would
be clues for a diagnosis of vascular
dementia.
Practice Guidelines
Internationally-recognized
guidelines for treating patients
with dementia have been published
by the American Psychiatric
Association (APA), most
recently in October 2007. These
can be downloaded from the APA
website, along with a quick reference
guide. This document contains
a wide range of information
about all aspects of the condition
and should be relevant to doctors
in most countries.
The Ministry of Health in Singapore
published its own comprehensive
dementia guidelines in
March 2007 along with an 8-page
summary card. Dementia management
guidelines are also available
from the Academy of Medicine of
Malaysia, published in July 2003.
Treatment
Alzheimer’s disease and vascular dementia are progressive
non-reversible conditions and the
overall aim of treatment is to slow
down the functional deterioration
and to reduce the severity of associated
psychiatric symptoms.
It is important that GPs explain
these facts to the patient’s family
so that they have realistic expectations
and do not expect the patient
to make a full recovery. The family
should be educated about the
nature of dementia and its symptoms,
and should be prepared to
expect the worst.
Pharmacological treatment can
be employed in order to slow the
rate of cognitive decline in dementia
patients. The use of an acetylcholinesterase
inhibitor should
be considered for this purpose in
most patients. Donepezil, rivastigmine
and galantamine are all effective
drugs from this class. Memantine,
an N-methyl D-aspartate
antagonist, can also be used – either
alone or in conjunction with
an acetylcholinesterase inhibitor.
Other pharmacological agents
such as anti-inflammatories, prednisolone
and estrogen are not recommended
for preventing cognitive
decline in dementia patients.
Drug therapy can also be used
to target the specific symptoms
that may accompany dementia
such as depression, hallucinations
and psychosis. The use of these
drugs should be decided on a caseby-
case basis.
Doctors must also give careful
consideration to the non-pharmacological
aspects of dementia
management, and should try to
improve the quality of life for
both patients and their families
wherever possible. Depression,
psychiatric symptoms and sleep
disorders can all be distressing for
the family and should be taken
into consideration. GPs should
look out for carer stress and burnout,
which can lead to frustration
and sometimes elder abuse. They
should try to assess stress levels
by asking indirectly, but this can
be challenging as carers are unlikely
to volunteer such information
readily and may be sensitive
to questioning.
Dementia patients may benefit
from being referred to a day center
in order to keep them occupied.
This may also help the patient to
sleep better at night and reduce
carer stress levels.
In patients with VaD it is important
to prevent further strokes,
and risk factors such as hypertension
and diabetes should be addressed.
These patients should also
be given aspirin to reduce the risk
of recurrence.
Disease management tools
GPs who wish to further their
understanding of dementia can
often sign up for specialist training.
Programs such as these can
increase doctors’ knowledge of
the available resources and treatment
options and help them to
feel more confident about handling
their patients.
The Institute of Mental Health
(IMH) in Singapore, for example,
has a partnership program with
GPs – offering training comprised
of lectures and workshops. Upon
completion of training the GPs
can sign up for the IMH-GP partnership
program, where they can
participate in the management of
psychiatric and dementia patients
in their own clinics.
Conclusion
Dementia is distinct from normal
aging and needs to be carefully
distinguished from other causes
of forgetfulness. Early detection
is beneficial so that the patient
can be managed appropriately in
order to delay the progression of
symptoms and prevent further
complications.