Yonder: Adverse drug reactions, comprehensive geriatric assessment, bariatric surgery, and sexual health in older people

Ahmed Rashid

doi:10.3399/bjgp20X713285

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Adverse drug reactions

As medications get more complex, and multimorbidity rises, adverse drug reactions (ADRs) will undoubtedly continue to cause significant human and economic harms for decades to come. A recent scoping review from Australia identified a total of 19 articles published over a 15-year period that primarily focused on different types of ADRs in primary healthcare.¹ The classes of drugs most commonly associated with ADRs included cardiovascular drugs, antipsychotics, and opioids. The authors additionally highlighted the issue of under-reporting, especially in children, which they consider to be a major threat to patient safety. Their suggestion that personalised medicine and pharmacogenomics is the solution to minimising ADRs is laudable, but perhaps misses some more obvious and systemic solutions to improve current systems and practices.

Comprehensive geriatric assessment

One of the most powerful lessons I learnt from my junior doctor rotation in geriatric medicine was the huge amount of patience and compassion required to perform an effective comprehensive geriatric assessment (CGA). They are generally performed in secondary care and have been shown to lead to significant improvements in a variety of outcomes. A recent systematic review from an Oxford team sought to appraise the evidence on CGA implemented within primary care settings.² Despite exhaustive searches, they were able to find only four eligible articles. These showed that CGA was acceptable and provided variable outcome benefit. Clearly, more research is needed about primary care implementation, including patient identification, and roles of different healthcare workers. Primary care might seem a natural setting for CGA but as ever, adequate time, resources, and training will be essential to make it work in practice.

Bariatric surgery

As primary care clinicians are the gatekeepers of the healthcare system, they are often vilified as the reason why secondary care services are over-or under-utilised. In the case of bariatric surgery in the US, only 1% of ‘eligible’ people are referred, and a surgical research team from Illinois recently sought to find out why.³ Their starting point, rather depressingly, was to assume a ‘lack of knowledge’ in primary care may be the problem. Through their anonymous online survey, they found that despite the generally positive attitudes and responses from primary care physicians regarding the use of bariatric surgery for obesity, concern over complication rates and ineffective weight loss remain persistent barriers to referral. Rather than exploring these concerns in any detailed way, they instead suggest educational strategies for primary care that should ‘focus on enhancing knowledge’. Not patronising at all.

Sexual health in older people

It’s difficult to know exactly what proportion of older people are sexually active but surveys from various countries consistently suggest it is over 50% and possibly much higher. Rising rates of sexually transmitted infections in older people suggest the proportion may be increasing further, and some have postulated that the rise in social media and dating apps may partly explain these trends. A recent Australian study investigated sexual health discussions in general practice.⁴ They found that older patients expect clinicians to bring up sexual concerns, whereas clinicians prefer older patients to do so. The authors conclude that changes in clinical guidelines are needed, as well as efforts to ‘normalise’ sexual counselling in older people during medical training. There should be a focus on sexual health and wellbeing as a normal part of ageing, they suggest, moving beyond an emphasis on dysfunction.

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If you’re interested in the world of medical education and want concise updates on new research in the field, check out the Academic Medicine Podcast (https://journals.lww.com/academicmedicine/pages/podcasts.aspx).

REFERENCES

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