Families’ Influence on End-of-Life Care
Family and friends are considered the predominant providers of long-term and end-of-life care, although nationally representative data are lacking. This study draws from the 1999 National Long-Term Care Survey and its Informal Caregivers Survey to characterize caregivers’ experiences in caring for community-dwelling, chronically disabled older adults. The authors studied 1149 primary informal caregivers, stratified by care recipients’ survival or death during the following 12 months. Results showed that an estimated 11.2% of the chronically disabled community-dwelling older adults died within 1 year of being interviewed. Among persons who died, 72.3% were receiving help from an informal caregiver at the time of the interview. End-of-life primary informal caregivers helped an average of 43 hours per week, 84.4% provide daily assistance, and caregiver support services were infrequently used. While end-of-life caregivers reported significant emotional, physical, and financial strains, more than two-thirds endorsed personal rewards related to their helping role. Compared with primary informal caregivers of persons who survived the following 12 months, end-of-life caregivers provided significantly higher levels of assistance and reported more challenges and strains, but they were no less likely to endorse rewards related to their helping role. The investigators concluded that end-of-life caregivers provide frequent and intense assistance with few supportive services. These data underscore the relevance of families to end-of-life care, and the potential benefit of better integrating families in patient care.

Wolff JL, Dy SM, Frick KD, Kasper JD. End-of-life care: Findings from a national survey of informal caregivers. Arch Intern Med 2007;167:40-46.

Long-Term Effects of Cognitive Training on Functional Outcomes
Cognitive training has been shown to improve cognitive abilities in older adults; however, the effects of the training on everyday function have not been demonstrated. Prior interventions with older adults have targeted those with cognitive deficicits or functional disabilities and have focused on remediation rather than prevention. Prior studies have shown that cognitive interventions can improve cognitive abilities in normal elderly persons but have not included functional outcome measures and have been limited by small, homogeneous samples and lack of randomization.

This study sought to determine the effects of cognitive training on daily function and durability of training on cognitive abilities. It was a five-year follow-up of a randomized controlled single-blind trial with four treatment groups. A volunteer sample of 2832 persons (mean age, 73.6 yr; 26% black), living independently in six U.S. cities, was recruited from senior housing, community centers, and hospitals and clinics. The study was conducted between April 1998 and December 2004. Five-year follow-up was completed in 67% of the sample. The interventions were a 10-session training for memory (verbal episodic memory), reasoning (inductive reasoning), or speed of processing (visual search and identification); 4-session booster training at 11 and 35 months after training in a random sample of those who completed training. Main outcome measures were self-reported and performance-based measures of daily function and cognitive abilities.

Results showed that the reasoning group reported significantly less difficulty in the instrumental activities of daily living (IADL) than the control group (effect size, 0.29; 99% confidence interval [CI], 0.03-0.55). Neither speed of processing training (effect size, 0.26; CI, -0.002 to 0.51) nor memory training (effect size, 0.20; 99% CI, -0.06 to 0.46) had a significant effect on IADL. The booster training for the speed of processing group, but not for the other two groups, showed a significant effect on the performance-based functional measure of everyday speed of processing (effect size, 0.30; 99% CI, 0.08-0.52). No booster effects were seen for any of the groups for everyday problem-solving or self-reported difficulty in IADL. Each intervention maintained effects on its specific targeted cognitive ability through 5 years (memory: effect size, 0.23 [99% CI, 0.11-0.35]; reasoning: effect size, 0.26 [99% CI, 0.17-0.35]; speed of processing: effect size, 0.76 [99% CI, 0.62-0.90]). Booster training produced additional improvement with the reasoning intervention for reasoning performance (effect size, 0.28; 99% CI, 0.12-0.43) and the speed of processing intervention for speed of processing performance (effect size, 0.85; 99% CI, 0.61-1.09).

The investigators concluded that the reasoning training resulted in less functional decline in self-reported IADL. Compared with the control group, cognitive training resulted in improved cognitive abilities specific to the abilities trained that continued 5 years after the initiation of the intervention.

Willis SL, Tennstedt SL, Marsiske M, et al. Long-term effects of cognitive training on everyday functional outcomes in older adults. JAMA 2006;296(23):2805-2814.

Medicare Screening Reimbursement and Colon Cancer
Medicare’s reimbursement policy was changed in 1998 to provide coverage for screening colonoscopies for patients with increased colon cancer risk, and expanded further in 2001 to cover screening colonoscopies for all individuals. This study looked to determine whether the Medicare reimbursement policy changes were associated with an increase in either colonoscopy use or early-stage colon cancer diagnosis. Investigators looked at patients in the Surveillance, Epidemiology, and End Results Medicare-linked database who were age 67 or older and had a primary diagnosis of colon cancer during 1992-2002, as well as a group of Medicare beneficiaries who resided in Surveillance, Epidemiology, and End Results areas but who were not diagnosed with cancer. They found that colonoscopy use increased from an average rate of 285/100,000 per quarter in period 1 to 889 and 1919/100,000 per quarter in periods 2 and 3. During the study period, 44,924 eligible patients were diagnosed with colorectal cancer. The proportion of patients diagnosed at an early stage increased from 22.5% in period 1 to 25.5% in period 2 to 26.3% in period 3. The changes in Medicare coverage were strongly associated with early stage at diagnosis for patients with proximal colon lesions but weakly associated, if at all, for patients with distal colon lesions. The investigators concluded that expansion of Medicare reimbursement to cover colon cancer screening was associated with an increased use of colonoscopy for Medicare beneficiaries, and for those who were diagnosed with colon cancer, an increased probability of being diagnosed at an early stage. The selective effect of the coverage change on proximal colon lesions suggests that increased use of whole-colon screening modalities such as colonoscopy may have played a pivotal role.

Gross CP, Andersen MS, Krumholz HM, et al. Relation between Medicare screening reimbursement and stage at diagnosis for older patients with colon cancer. JAMA 2006;296:2815-2822.

Fish Intake, Contaminants, and Human Health
Because finfish and shellfish may have health benefits and also contain contaminants, confusion exists over the role of fish consumption in a healthful diet. Many exposures and outcomes have been related to fish consumption. The authors of this clinical review focused on populations and topics for which evidence and concern were greatest. Investigators searched MEDLINE, governmental reports, and systematic reviews and meta-analyses to identify reports published through April 2006 evaluating: (1) intake of fish or fish oil and risk of cardiovascular events and mortality; (2) effects of methylmercury and fish oil on early neurodevelopment; (3) risks of methylmercury for cardiovascular and neurologic outcomes in adults; and (4) health risks of dioxins and polychlorinated biphenyls (PCBs) in fish.

Evidence showed that modest consumption of fish (eg, 1-2 servings/wk)—especially species higher in n-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)—reduces risk of coronary death by 36% (95% confidence interval [CI], 20%-50%; P < .001) and total mortality by 17% (95% CI, 0%-32%; P =.046) and may favorably affect other clinical outcomes. Intake of 250 mg/day of EPA and DHA appears sufficient for primary prevention. DHA appears beneficial for, and low-level methylmercury may adversely affect, early neurodevelopment. Women of childbearing age and nursing mothers should consume 2 seafood servings/week, limiting intake of selected species. Health effects of love-level methylmercury in adults are not clearly established; methylmercury may modestly decrease the cardiovascular benefits of fish intake. A variety of seafood should be consumed; individuals with very high consumption (5 or more servings/wk) should limit intake of species highest in mercury levels. Levels of dioxins and PCBs in fish are low, and potential carcinogenic and other effects are outweighed by potential benefits of fish intake, and should have little impact on choices or consumption of seafood (women of childbearing age should consult regional advisories for locally caught freshwater fish).

The authors concluded that for major health outcomes among adults, based on both the strength of the evidence and the potential magnitudes of effect, the benefits of fish intake exceed the potential risks. For women of childbearing age, benefits of modest fish intake, excepting a few selected species, also outweigh the risks.

Mozaffarian D, Rimm EB. Fish intake, contaminants, and human health: Evaluating the risks and benefits. JAMA 2006;296(15):1885-1899.

Massage Therapy for Knee Osteoarthritis
Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. The investigators in this study conducted a randomized, controlled trial of 68 adults with radiographically confirmed OA of the knee, who were assigned either to treatment (twice-weekly sessions of standard Swedish massage in weeks 1-4 and once-weekly sessions in weeks 5-8) or to control (delayed intervention). Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect a 20-point difference between groups in the change from baseline on the WOMAC and visual analog scale, with a 2-tailed alpha of .05.

Results showed that the group receiving massage therapy demonstrated significant improvements in the mean (SD) WOMAC global scores (-17.44 [23.61] mm; P <.001), pain (-18.36 [23.28]; P <.001), stiffness (-16.63 [28.82] mm; P <.001), and physical function domains (-17.27 [24.36] mm; P <.001), and in the visual analog scale of pain assessment (-19.38 [28.16] mm; P <.001), range of motion in degrees (3.57 [13.61]; P = .03), and time to walk 50 ft (15 m) in seconds (-1.77 [2.73]; P <.01). Findings were unchanged in multivariable models controlling for demographic factors.

Researchers concluded that massage therapy seems to be efficacious in the treatment of OA of the knee. Further study of cost-effectiveness and duration of treatment is clearly needed.

Perlman AI, Sabina A, Williams, AL, et al. Massage therapy for osteoarthritis of the knee. A randomized controlled trial. Arch Intern Med 2006;166:2533-2538.

Association of Height Loss in Older Men with Mortality and CVD
Height declines with age, but the impact of height loss on health outcomes has been little studied. The investigators in this study examined the relationships between height loss over 20 years (starting in middle age) and subsequent total mortality and incidence of coronary heart disease and stroke in older men. The prospective study was performed on 4213 men whose height was measured between 40 and 59 years and again between the ages of 60 and 79 years. The men were then followed up for a mean period of 6 years, during which 760 deaths occurred.

Results showed that height loss correlated significantly with initial age (r = 0.20) and weight loss (r = 0.20). Total mortality was higher in men with a height loss of 3 cm or more than in men with a height loss of less than 1 cm (age-adjusted relative risk [RR], 1.64; 95% confidence interval [CI], 1.33-2.03). The excess deaths were largely attributable to cardiovascular and respiratory conditions and other causes, but not to cancer. Adjustment for age, established cardiovascular risk factors, lung function, pre-existing cardiovascular disease, albumin concentration, self-reported poor or fair health, and weight loss had a modest impact on the increased risk of total mortality (RR, 1.45; 95% CI, 1.15-1.82). The risk of major coronary heart disease events was increased only in men with a height loss of 3 cm or more, even after adjustment (adjust RR, 1.42; 95% CI, 1.02-1.98); ≥ 3.0cm vs < 3.0 cm); no association was seen with stroke risk.

The investigators concluded that marked height loss (≥ 3 cm) in older men is independently associated with increased risk of all-cause mortality and coronary heart disease.

Wannamethee SG, Shaper AG, Lennon L, et al. Height loss in older men: Associations with total mortality and incidence of cardiovascular disease. Arch Intern Med 2006;166:2546-2552.