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Category: Uncategorized

Frequent Visits to ED Associated with Diabetes

According to recently published findings in the journal Annals of Emergency Medicine, which sought to evaluate patient patterns & characteristics of emergency department (ED) use among the geriatric population, diabetes is the most common disease classification for patients 65 years and older—who are frequently admitted to hospital EDs. While health care spending in the United States continues to increase, with the study citing a 5.3% increase to $3.0 trillion from 2013 to 2014, so too does the number of seniors seeking out annual ED visits: with an increase of 24.5% between 2001 and 2009.

Edward M. Castillo, PhD, MPH, an associate adjunct professor in the department of emergency medicine at the University of California, San Diego, wrote with his colleagues: “The ED’s role in delivering care for a large proportion of the population is expanding, especially for older and sicker patients…In comparison to other age groups, older adults use the ED at a higher rate, have longer stays in the ED, and require more resources and medical interventions during their visit.”

In conducting a multicenter retrospective cohort study with data from 326 licensed, general acute care hospitals in California, Castillo and his colleagues used patients aged at least 65 years: all of whom had at least one visit to the ED in 2014. Researchers additionally identified visits in the previous year, and patients were considered ‘frequent users’ if they visited the ED at least six times in a one-year period.

In the 1,259,809 patients surveyed, 5.6% were officially classified as frequent users: comprising of 19.9% of all ED visits throughout the study period. Beyond the frequency of the visits, the researchers noted that diabetes was the most common disease classification for an ED visit (followed by chronic pulmonary disease, renal disease, congestive heart failure, and peripheral vascular disease).

The discussion portion of the report noted that given the increased focus on health care in the aging population, leading to focused interventions to improve and enhance health care delivery mechanisms and decrease the frequency of health care usage, the findings provide “an opportunity to help improve the care of geriatric patients who frequently use acute care services by highlighting specific needs of this population.” It is likely that programs specifically designed to meet the unique needs of these patients may be helpful. The findings additionally confirm the staggering costs of diabetes, and further reinforce the growing epidemic. With the total cost of diabetes and prediabetes in the United States currently at $322 billion, identifying needs and targeted interventions ‘across the care continuum, within the ED, and beyond’ are areas that must be further investigated and explored.

How to Handle High Blood Pressure

While the new guidelines from the American Heart Association and the American College of Cardiology indicate that nearly half of U.S. adults qualify for high blood pressure, the AHA has additionally noted that as many as one in seven people being treated for high blood pressure does not have the condition under control. Known as resistant hypertension, the problem is defined as having high blood pressure despite taking a diuretic and at least two other blood pressure medicines. Because there is a strong, direct correlation between high blood pressure and additional cardiovascular risks & health problems, Dr. Randall Zusman—a cardiologist at Massachusetts General Hospital—emphasizes the importance of staying below the clinically outlined thresholds, and surmounting the obstacles that prevent people from reaching specific blood pressure targets.

Quoted in an article in Harvard Health, Dr. Zusman states: “Many cases of alleged resistant hypertension occur because people don’t take their medications as prescribed, for various reasons.” Yet because some people have habits that hinder the success and efficacy of blood pressure drugs, or underlying & undiagnosed medical conditions, blood pressure can be difficult to tame and treat.

Medication Adherence

The AHA estimates that three out of four Americans do not take their medication as directed; medication adherence is a common problem that can lead to severe repercussions: in addition to growing rates of cardiovascular disease, all-cause mortality, and hospitalizations. Poor medication adherence additionally takes the lives of 125,000 Americans annually, and costs the U.S. health care system almost $300 billion each year. In other instances, Zusman cites some patients who encounter side effects, or those who try to self-manage drug regimens. “I can’t tell you how many people come in to my office and say, ‘I felt lightheaded one day, so I stopped taking one of my pills.” Many patients are unaware that various medications have ‘different modes of action,’ and the specific combination is designed to lower the blood pressure. Moreover, abruptly stopping a beta blocker can cause one’s heart rate and blood pressure to rise, which ultimately puts the heart at risk.

Pharmaceutical Options

There are more than 200 different approved pharmaceuticals on the market to treat high blood pressure. They fall into several classes, including diuretics (water pills); angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs); calcium-channel blockers; beta blockers; renin inhibitors; and aldosterone blockers. Yet there are a host of other drugs used to reach blood pressure goals, including vasodilators, alpha blockers, central-acting agenda, and more. Drugs prescribed by clinicians may depend on comorbid medical conditions such as atrial fibrillation or angina, and different people respond better to certain drugs—depending on sex, age, race, and other factors.

Issues with Drugs & Diet

Zusman states that many people do not understand the reasoning surrounding the importance of a low-sodium diet, given that “a high-sodium diet interferes with commonly prescribed blood pressure drugs, making them less effective.” Because the typical Western diet is full of prepared and processed foods, which are the primary culprits and contributors of sodium, many Americans are already predisposed to high-sodium consumption. Other issues with drugs include continuous usage of nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Advil) and naproxen sodium (Aleve): all of which can raise blood pressure.

Additional Secondary Causes

People diagnosed with resistant hypertension sometimes have an underlying medical condition that elevates blood pressure, including excess of the hormone aldosterone, which causes the body to hold on to sodium and water but lose potassium; renal artery stenosis, a narrowing of the arteries supplying the kidneys; and obstructive sleep apnea, in which the upper airway becomes blocked during sleep, causing pauses in breathing. Zusman notes that those with resistant hypertension are far more likely to have one of the aforementioned conditions, compared to the general public.