Finding the Best Answers to Clinical Questions – Quickly and Effectively Karen Odato Educ. Coordinator, Biomedical Libraries David Nierenberg SBM Program Director

Objectives Select appropriate resources to answer specific clinical questions. Identify quality information on which to base patient care.

You are a third-year clerk doing your inpatient medicine rotation on the M2 service at MHMH. You admitted a patient the previous evening who is a 79- year-old man who is widowed (about four months ago), and trying to care for himself at home. He says he does a pretty good job, but sometimes gets confused about which medications he has taken, and when he should be taking them. He has limited driving to local neighborhoods, because he sometimes gets stressed or lost driving in unfamiliar areas.

He was admitted through the emergency room after he accidentally started a stove fire at his house (he forgot he was heating up some spaghetti sauce, and the pot caught fire), ran for a fire extinguisher, fell, bumped his head on the table, and was shaken and confused. You suspect from his history and physical exam and admission lab data, that he has Alzheimer’s Disease. His CT scan done last night (because of the head trauma) shows moderate atrophy and is consistent with that Dx.

Several issues come up on walk rounds with the attending the next day. Many of the questions will be “referred” to the DMS 3 student. Where would you go to quickly find the “best (evidence-based) answers” in the most efficient manner? There are a number of issues that come up - and not much time to look for the answers.

Issue 1 There is disagreement among the team as to whether the patient has normal aging and forgetfulness, or “mild cognitive impairment”, or Alzheimer’s Disease.

Issue 1 There is disagreement among the team as to whether the patient has normal aging and forgetfulness, or “mild cognitive impairment”, or Alzheimer’s Disease. How are these conditions different? We need some background information on all three…

Issue 1 There is disagreement among the team as to whether the patient has normal aging and forgetfulness, or “mild cognitive impairment”, or Alzheimer’s Disease. How are these conditions different? We need some background information on all three… Try looking in textbooks (print or online) or a synthesis resource (e.g., UpToDate or eMedicine).

Issue 2 The team finally agrees that the patient has Alzheimer’s Disease, but isn’t sure what the currently recommended workup should be to “make sure” they aren’t missing some other treatable process. They disagree about whether the CT was needed, and about whether an LP should be done.

Issue 2 The team finally agrees that the patient has Alzheimer’s Disease, but isn’t sure what the currently recommended workup should be to “make sure” they aren’t missing some other treatable process. They disagree about whether the CT was needed, and about whether an LP should be done. What are current consensus guidelines for a thorough but cost effective workup for a patient with clinically suspected Alzheimer’s Disease?

Issue 2 The team finally agrees that the patient has Alzheimer’s Disease, but isn’t sure what the currently recommended workup should be to “make sure” they aren’t missing some other treatable process. They disagree about whether the CT was needed, and about whether an LP should be done. What are current consensus guidelines for a thorough but cost effective workup for a patient with clinically suspected Alzheimer’s Disease? Try looking in the National Guideline Clearinghouse, Cochrane Database, eMedicine, or MEDLINE (limit to Publication type “Practice Guideline).

Issue 3 The team now agrees that with a mini-mental status exam of 24/30, the patient has “early” Alzheimer’s Disease. However, they can’t agree on what FDA-approved prescription drug should be given at this point.

Issue 3 The team now agrees that with a mini-mental status exam of 24/30, the patient has “early” Alzheimer’s Disease. However, they can’t agree on what FDA-approved prescription drug should be given at this point. What drugs have been approved by the FDA specifically for the treatment of AD?

Issue 3 The team now agrees that with a mini-mental status exam of 24/30, the patient has “early” Alzheimer’s Disease. However, they can’t agree on what FDA-approved prescription drug should be given at this point. What drugs have been approved by the FDA specifically for the treatment of AD? Try a search by indication in Clinical Pharmacology Online. CPOnHand and Epocrates Rx are similar resources for the PDA.

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Issue 4 The team decides to start the patient on (donepezil). However, the intern has heard that Vit E might be useful and the resident recently heard about statins being used for treating AD.

Issue 4 The team decides to start the patient on (donepezil). However, the intern has heard that Vit E might be useful and the resident recently heard about statins being used for treating AD. Is there any research indicating that vitamin E or statins might be useful in this situation? Is there an ongoing clinical trial in which the patient can participate?

Issue 4 The team decides to start the patient on (donepezil). However, the intern has heard that Vit E might be useful and the resident recently heard about statins being used for treating AD. Is there any research indicating that vitamin E or statins might be useful in this situation? Is there an ongoing clinical trial in which the patient can participate? Try CPO, Cochrane, or MEDLINE; Clinicaltrials.gov for ongoing trials.

Issue 5 After several days of working with your patient, you become convinced that the patient is depressed as well - partly about the new diagnosis, but also about the loss of his wife a few months earlier.

Issue 5 After several days of working with your patient, you become convinced that the patient is depressed as well - partly about the new diagnosis, but also about the loss of his wife a few months earlier. Is depression a common complication of AD? What antidepressant drugs are indicated and contraindicated in this situation? What kind of psychotherapy works best with these patients?

Issue 5 After several days of working with your patient, you become convinced that the patient is depressed as well - partly about the new diagnosis, but also about the loss of his wife a few months earlier. Is depression a common complication of AD? What antidepressant drugs are indicated and contraindicated in this situation? What kind of psychotherapy works best with these patients? Try looking in Cochrane, MEDLINE (Clinical Queries section), or PsycINFO.

Issue 6 The patient’s daughter shows up the next day. She heard about the use of fish oil and ginkgo biloba in Alzheimer patients and asks about other possible alternative treatments.

Issue 6 The patient’s daughter shows up the next day. She heard about the use of fish oil and ginkgo biloba in Alzheimer patients and asks about other possible alternative treatments. Are there any safe, effective complementary treatment options?

Issue 6 The patient’s daughter shows up the next day. She heard about the use of fish oil and ginkgo biloba in Alzheimer patients and asks about other possible alternative treatments. Are there any safe, effective complementary treatment options? Try looking for studies in PubMed (limit to the Complementary Medicine subset) and HerbMed (see the Libraries’ Alternative Med subject guide.)

In summary: Identify appropriate resources for your clinical questions Use handouts and the EBM subject guide Use librarians: Library Advisors and the reference desk