May 25, 2013 – In the eyes of the Clinical Health Affairs Commission (CHAC) of the American Academy of Physician Assistants (AAPA), the top medical topics of 2013 do not include robotics or the latest cardiac monitor, but rather an emphasis on the importance of preventative care and management of chronic diseases.
Seven CHAC members presented this information to an audience of AAPA members at the organizations 41st annual IMPACT conference in Washington, D.C. Included in each topic presentation was a description of the impact of these events on public health, medical technology, and disease diagnosis and treatment.
According to Deanna Bridge Najera, MPAS, PA-C, preventable illnesses are on the rise, particularly measles, mumps, and pertussis. Additionally, global travel is easier and faster, thereby facilitating spread of disease. Finally, rates of immunization are decreasing. Taken together, these factors highlight the importance of childhood immunizations.
Najera offered three tips that PAs can use to immediately improve childhood immunization rates among their patients: (1) encourage vaccination at every visit (vaccinations can even be given when the patient is sick); (2) remember “zebras” when seeing patients, and ask about vaccination status with these conditions in mind; and (3) remember to test and report positive results.
Post-traumatic stress disorder
Described by Najera as “the new hot topic,” post-traumatic stress disorder is on the rise. PTSD has a prevalence of 3.6% in men, 5.2% among women, and 13.8% among war veterans. The anger and aggression of PTSD is very highly correlated with substance abuse. Clinicians must know that PTSD can happen in children. PTSD is not just a response to traditional trauma (e.g., rape, warfare).
Najera advised clinicians to consider PTSD as a possible diagnosis for anyone with a history of a stressful event or even secondhand exposure (e.g., police officer, ED clinicians). She also warned against forcing a debriefing. “Don’t force them to relive it. Give them the opportunity.”
Finally, Najera stressed the importance of developing relationships with PTSD counselors in your area.
To illustrate the rising prevalence of obesity, Gilbert Boissonneault, PhD, PA-C, cited CDC predictions that 42% of Americans will be obese by 2030, up from 35% in 2010. Obesity has a tremendous impact on health and disease, predominantly metabolic and endocrinologic disorders.
Obesity also places a considerable financial burden on the individual as well as society in general. In 2006, obesity made up 10% of the direct cost of health care, up from 5.9% in 1986, according to the Harvard School of Public Health.
Boissonneault presented three areas in which health-care providers can make an immediate impact in obese patients. The most important thing clinicians can do for their obese patients is promote self-efficacy. Self-efficacy, the belief that the patient can succeed, is a key component of all models of commitment to behavioral change. To improve self-efficacy in their patients, clinicians must establish a concrete, patient-specific plan that allows the patient to understand what he or she can do and agree to that plan; ensure that long-term goals are subdivided into discrete and obtainable goals; and provide frequent follow up.
The second tip offered by Boissonneault is to ensure expectations are achievable. Clinicians should select one or two limited goals, reassess the goals regularly, and reinforce the focus on behavioral change rather than a change in weight or other outcomes.
Finally, the clinician must encourage healthy habits. Target initial changes to “high yield” behaviors (i.e., dietary, activity, environment). “Start low and go slow,” Boissonneault advises.
There are reports of an increase in the prevalence of celiac disease (CD) and a change in the presentation of the disease. The prevalence of CD in the United States is currently 0.71% (1 in 141).
A change in symptomology has been noted, according to Boissonneault. In one study, only 41% of patients with CD presented with classic symptoms (e.g. malabsorption, diarrhea, iron-deficiency anemia, weight loss, growth failure). In that same study, 23% presented with non-classic CD symptoms (e.g., abdominal pain, bloating). Finally, 36% of the study participants were asymptomatic and diagnosed only after screening of high-risk groups (e.g., first-degree relative with CD, type 1 diabetes, autoimmune disorders, Down syndrome).
There are a number of readily available serologic tests for CD, but three stand out: anti-gliadin antibodies (AGA), anti-tissue transglutaminase (tTG) antibodies, and endomysial antibodies (EMA). A recent study showed 100% sensitivity for CD if all three screens were used. “We have a tool available at this point in time to positiviely identify CD without colonoscopy,” said Boissonneault.
A number of comorbidities are associated with CD. Individuals with autoimmune diseases are at increased risk for developing CD. Persons with systemic lupus erythematosus (SLE) or idiopathic thrombocytopenic purpura (ITP) have a threefold increase for also having CD. Persons with type 1 diabetes or inflammatory bowel disease face a tenfold increased risk. Other comorbidities of CD include irritable bowel syndrome, liver disease, rheumatoid arthritis, and sarcoidosis.
Thomas Moreau, MS, PA-C, began his overview with the news that the DSM-5 now classifies dementia as major neurocognitive disorder [NCD]). “I wish I could tell you the disease has been cured, but it’s just a name change,” Moreau joked. In highlighting the importance of dementia, Moreau noted that people are living longer but not free of NCDs.
There are significant social and economic costs associated with dementia. A person with dementia today, excluding all other diagnoses, costs about $50,000 per person year, which includes formal and informal care. In 2010, the total U.S. costs for dementia was between $157 and $215 billion. The lack of sensitive and specific findings and objective biomarkers for dementia hampers the ability to identify drugs that may be helpful to treat people early before the disease takes effect.
Brain defects associated with dementia cross multiple domains. Dementia complicates activities of daily living and management of comorbidities. Advanced directives become ethically very complicated after the diagnosis of minor or major NCD. Finally, aging narrows the therapeutic window for many drugs.
Moreau encourages clinicians to advise all seniors under their care to create advance directives. Clinicians must also know the warning signs of dementia. Moreau advises clinicians to model and encourage a nurturing style and to screen for dementia in multiple cognitive domains. Know the local resources available, and use them early and often.
Finally, choose medications wisely when treating patients with NCD. Do not use antipsychotics as a first choice for treating behavioral symptoms. Do not use benzodiazepines or sedatives as a first choice for insomnia, agitation, and delirium.