Geriatrics Abstracts

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Alcohol Use Disorders in Elderly People: Redefining an Age Old Problem in Old Age

Alcohol use disorders are common among elderly people and are associated with significant morbidity. As populations age, the number of older people with alcohol use disorders increases. These disorders are often underidentified and misdiagnosed in the elderly because screening instruments and diagnostic criteria are geared toward younger age groups. Studies of the prevalence of alcohol use disorders have mostly been conducted in North America, so results may not be relatable to other cultures. Prevalence rates may vary depending on the limitations of the diagnostic criteria, with higher rates for excessive alcohol consumption and alcohol abuse than for alcohol dependence syndrome. The prevalence of alcohol use disorders for hospitalized inpatients is generally higher than for community-dwelling patients. It is estimated that 14% of patients in emergency departments, 18% of medical inpatients, and 23-44% of psychiatric inpatients have an alcohol use disorder. Sociodemographic factors in the elderly that may contribute to developing an alcohol disorder may include male gender, social isolation, and unmarried, separated, or divorced status. Alcohol use disorders can cause notable impairments in the elderly such as physical, social, and psychological deterioration, and decline in cognitive health. The recommended treatment for elderly people with the disorder is inpatient detoxification; however, alcohol treatment may be more appropriate for older people among their peers. There is limited information on the use of medications for abstinence in this patient group. Screening instruments, diagnostic criteria, and recommended limits for intake need to be redefined for the elderly population.

O’Connell H, Chin A-V, Cunningham C, Lawlor B. Alcohol use disorders in elderly people: Redefining an age old problem in old age. BMJ 2003;327(7416):664-667.

Prevalence Estimates of Alzheimer’s Disease in the U.S. Population Using the 2000 Census

Current and future estimates of Alzheimer’s disease are crucial for public health planning. The authors of this study sought to determine the prevalence estimates of Alzheimer’s disease in the U.S. population from 2000 to 2050. Using a stratified random sample design, Alzheimer’s disease incidence estimates from a geographically defined community of three adjacent biracial, urban, neighborhoods in Chicago, IL, were converted to prevalence estimates and applied to U.S. Census Bureau estimates of population growth. The incidence of Alzheimer’s disease was measured in 3838 people who were free of the illness at baseline. A total of 835 patients were evaluated for disease incidence. Estimates of the prevalence of clinically diagnosed Alzheimer’s disease in the U.S. population were established. The authors determined that 4.5 million people had Alzheimer’s disease in 2000, and by 2050 the number will increase threefold to 13.2 million people in the U.S. Due to the rapid growth of the oldest age groups in the population, the 85-and-older group will quadruple to 8.0 million by 2050. Those who are 75-84 years will number 4.8 million, while the 65-74 age group will remain at 0.3 to 0.5 million. The number of people in the U.S. with Alzheimer’s disease will continue to increase unless new findings are implemented to advance the prevention of the disease.

Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the US population: Prevalence estimates using the 2000 Census. Arch Neurol 2003;60:1119-1122.

Emerging Risk Factors for Atherosclerotic Vascular Disease

Atherosclerotic vascular disease is a considerable public health problem. To help identify patients who are at high risk of the disease, four new risk factors for atherosclerosis have recently been proposed: C-reactive protein, lipoprotein(a), fibrinogen, and homocysteine. The authors of this study searched the literature from January 1990 to January 2003 containing epidemiological, basic science, and clinical trial evidence regarding the four novel risk factors. Data were collected from a diverse collection of 373 original investigations and reviews that pertained to the epidemiology of atherosclerosis and standard and new risk factors with vascular risk. There are independent associations between the four new risk factors and atherosclerotic vascular disease based on the available epidemiological and basic science evidence. Relatively little data were found regarding compliance with screening for these factors versus the validated global risk assessment strategies that are currently in use. In addition, few controlled intervention studies were found that focused on individuals with these risk factors for proven risk-reduction therapies or specifically treating these factors with available therapies. The tremendous influence of the major, established cardiovascular risk factors has been systemically underestimated. The authors concluded that although the four new risk factors—C-reactive protein, lipoprotein(a), fibrinogen, and homocysteine—are related to risk of vascular disease, the optimal use of these factors in routine screening and risk stratification needs to be determined.

Hackam DG, Anand SS. Emerging risk factors for atherosclerotic vascular disease: A critical review of the evidence. JAMA 2003;290(7):932-940.

Combined Hormone Therapy Effects on Fracture Risk and Bone Mineral Density: The WHI Trial

Knowing that women assigned to active treatment had fewer fractures in the Women’s Health Initiative trial of estrogen-plus-progestin therapy, the authors set out to test the hypothesis that the relative risk reduction of this therapy on fractures differs according to risk fractures for fractures. In a randomized controlled trial from September 1993-July 2002, 16,608 postmenopausal women age 50-79 years with an intact uterus at baseline were recruited at 40 U.S. clinical centers and followed up for an average of 5.6 years. Participants were randomized to placebo (n = 8102) or conjugated equine estrogen 0.625 mg per day plus medroxyprogesterone acetate 2.5 mg per day in one tablet (n = 8506). Main outcome measures were all confirmed osteoporotic fracture events during the trial; bone mineral density (BMD) in a subset of women (n = 1024) at baseline and years 1 and 3; and global index, developed to summarize the balance of risks and benefits to test if the risk-benefit profile differed across tertiles of fracture risk. It was found that 733 women (8.6%) in the combination therapy group and 896 (11.1%) in the placebo group experienced a fracture (hazard ratio [HR], 0.76; 95% confidence interval [CI] 0.69-0.83). The effect did not differ in those stratified by age, body mass index, history of falls, smoking status, total calcium intake, personal and family history of fracture, past use of hormone therapy, BMD, or summary fracture risk score. Total hip BMD increased 0.14% after 3 years of treatment in the placebo group compared with 3.7% in the combination therapy group (P < .001). The HR for the global index was similar across tertiles of the fracture risk scale (lowest fracture risk tertile, HR, 1.20; 95% CI, 0.93-1.58; middle tertile, HR, 1.23; 95% CI, 1.04-1.46; highest tertile, HR, 1.03; 95% CI, 0.88-1.24) (P for interaction = .54). The authors concluded that their study demonstrates that estrogen plus progestin increases BMD and reduces risk of fracture in healthy postmenopausal women (seen in all subgroups examined). However, when considering the effects of hormone therapy on other important disease outcomes in a global model there was no net benefit, even in women considered to be at high risk of fracture. JAMA 2003;290(13):1729-1738.

Exercise and Behavioral Management in Alzheimer’s Disease

Exercise training for persons with Alzheimer’s disease (AD) combined with teaching caregivers how to manage behavioral problems may help decrease the frailty and behavioral impairment often prevalent in patients with AD. With this in mind, the authors sought to determine if a home-based exercise program combined with such training techniques would reduce functional dependence and delay institutionalization among individuals with AD. From June 1994 to April 1999, a randomized controlled trial of 153 community-dwelling patients who met National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer Disease and Related Disorders Association criteria for Alzheimer’s disease was conducted. Randomly assigned to the combined exercise and caregiver-training program, Reducing Disability in Alzheimer Disease (RDAD), or routine medical care (RMC), were patient-caregiver dyads. The RDAD program was conducted over 3 months in the patient’s home. Main outcome measures were physical health and function (36-item Short-Form Health Survey’s [SF-36] physical functioning and physical role functioning subscales and Sickness Impact Profile’s Mobility subscale), and affective status (Hamilton Depression Rating Scale and Cornell Depression Scale for Depression in Dementia). The authors found that at 3 months, in comparison with the routine care patients, more patients in the RDAD group exercised at least 60 minutes per week (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.25-6.39; P = .01) and had fewer days of restricted activity (OR, 3.10; 95% CI, 1.08-8.95; P < .001). Patients in the RDAD group also had improved scores for physical role functioning compared with worse scores for patients in the RMC group (mean difference, 19.29; 95% CI, 8.75-29.83; P < .001). Patients in the RMC group had worse Cornell Depression Scale for Depression in Dementia scores, while those in the RDAD group had improved scores (mean difference, -1.03; 95% CI, -0.17 to -1.91; P = .02). At 2 years, RDAD patients continued to have better physical role functioning scores than the RMC patients (mean difference, 10.89; 95% CI, 3.62-18.16; P = .003) and showed a trend (19% vs 50%) for less institutionalization due to behavioral disturbance. For participants with higher depression scores at baseline, RDAD group members improved significantly more at 3 months on the Hamilton Depression Rating Scale (mean difference, 2.21; 95% CI, 0.22-4.20; P = .04) and maintained that improvement at 24 months (mean difference, 2.14; 95% CI, 0.14-4.17, P = .04). It was concluded that exercise training combined with teaching caregivers behavioral management techniques improved physical health and depression in patients with Alzheimer’s disease. JAMA 2003;290(15):2015-2022.

Achilles Tendon Rupture With Quinolone Use

Achilles tendon rupture has been attributed to the use of quinolones in several case reports, but the epidemiologic evidence for the association is insufficient. So, the authors conducted a population-based case-control study in the General Practice Research Database in the United Kingdom from 1988-1998. All persons who had a first-time recording of an Achilles tendon rupture and who had at least 18 months of valid history before the index date were defined. As a control group, the authors randomly sampled 50,000 patients with at least 18 months of valid history who were assigned a random index date. Meeting the inclusion criteria were 1367 cases. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients age 60-79 years and 20.4 (95% CI, 4.6-90.1) in patients age 80 years or older. In those age 60 years and older, OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2-6% of all Achilles tendon ruptures in persons older than 60 years can be attributed to quinolones. The authors concluded that current exposure to quinolones increased the risk of Achilles tendon rupture, specifically among elderly patients who were concomitantly treated with corticosteroids. Arch Intern Med 2003;163(15):1801-1807.

Annals of Long-Term Care - ISSN: 1524-7929 - Volume 12 - Issue 01 - January 2004