Recent Abstracts From Medical Literature For the Geriatric Practitioner

HMG-CoA Reductase Inhibitors and the Risk of Fractures The results of recent animal studies propose that 3-hydroxy-3-methylglutaryl coenzyme A (HMG- CoA) reductase inhibitors (statins) increase bone formation, volume, and density. However, it is unknown whether the use of these statins can decrease the risk of fractures in humans.

In this study, the authors endeavored to determine whether exposing humans to statins, fibrates, or other lipid-lowering drugs is associated with reduced bone fracture risk. They designed a population-based, nested case–control analysis. The setting involved the United Kingdom–based General Practice Research Database (GPRD), consisting of 300 practices, with data collection from the late 1980s until September 1998.

Of the 91,611 individuals age 50 years and older in the base population, 28,340 were taking lipid-lowering drugs; 13,271 had a diagnosis of hyperlipidemia but were untreated; and 50,000 were without a diagnosis of hyperlipidemia and were randomly selected. The investigators identified 3940 case patients who had a bone fracture and 23,379 control patients matched for age, sex, general practice attended, calendar year, and years since enrollment in the GRPD. They measured the use of statins, fibrates, or other lipid-lowering drugs in the case patients versus the control patients.

After controlling for body mass index, smoking, number of physician visits, and corticosteroid and estrogen use, the authors found that current use of statins was correlated to a significant reduction in fracture risk, compared with nonuse of lipid-lowering medications. Therefore, it is suggested by this study that current exposure to statins is associated with a decreased risk of bone fractures in individuals age 50 years and older. The authors state that this is a finding with an important public health impact and should be confirmed with further research from controlled prospective trials.

Meier CR, Schlienger RG, Kraenzlin ME, et al. HMG-CoA reductase inhibitors and the risk of fractures. JAMA 2000;283(24):3205-3210.

--------------------------------------------------------------------------------

Effectiveness of a Nurse-Based Outreach Program for Identifying and Treating Psychiatric Illness in the Elderly Elderly individuals with psychiatric disorders are less likely than their younger counterparts to be diagnosed with a mental disorder and to receive the appropriate treatment, possibly because of their lack of access to care. The authors' objective was to confirm whether a nurse-based outreach program for severely mentally ill elderly patients would be more effective than standard care in decreasing levels of depression, psychiatric symptoms, and undesirable moves (eg, nursing home placement, board and care placement, eviction).

The authors conducted a prospective randomized trial in six urban public housing sites for the elderly in Baltimore, MD, between March 1993 and April 1996. The purpose of the trial was to evaluate the effectiveness of the Psychogeriatric Assessment and Treatment in City Housing (PATCH) program.

In all, 945 residents were screened for psychiatric illness, of whom 342 were positive and 603 were negative. Investigators selected for a structured psychiatric interview all those age 60 years and older who screened positive, and a 10% random sample of those age 60 years and older who screened negative. Eighty-two percent of the screen-positive group and 88% of the screen-negative group were evaluated further for psychiatric disorders. The data collected provided an estimate of the prevalence of psychiatric disorders at the six sites. Residents in three buildings were randomized to receive the PATCH model intervention, and residents in the other three buildings were randomized to receive usual care (the comparison group). The PATCH intervention involved educating staff members, assessing the residents' apartments, and providing care when necessary.

The main outcome measures were the Montgomery–Asberg Depression Rating Scale (MADRS), which assesses depressive symptoms, and the Brief Psychiatric Rating Scale (BPRS), which evaluates psychiatric symptoms and behavioral disorders. The investigators found that the psychiatric cases at the intervention sites had considerably lower MADRS and BPRS scores than at the comparison sites. However, they found no significant difference between the groups in undesirable moves. These studies suggest that the PATCH intervention program was more effective than standard care in alleviating psychiatric symptoms in elderly persons with psychiatric disorders, and in those with elevated levels of psychiatric symptoms.

Rabins PV, Black BS, Roca R, et al. Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA 2000;283(21):2802-2809.

--------------------------------------------------------------------------------

Role of Exercise Stress Testing and Safety Monitoring for Older Persons Starting an Exercise Program The benefits of physical activity and exercise among older adults are becoming increasingly clear, but the role of exercise stress testing and safety monitoring for the elderly interested in beginning an exercise program is unclear. The current guidelines for exercise stress testing typically do not apply to the majority of people age 75 years and older who wish to improve their physical function through a program of physical activity and exercise.

Routine exercise stress testing is expensive, and its benefits are unknown. The current policy of exercise stress testing could potentially discourage many elderly persons from participating in a program. The authors stress that further research is needed to explore physician practices, determine the risk of adverse cardiac events, evaluate the role of pharmacologic stress testing, and measure and compare absolute and relative exercise intensities.

The article reviews the evidence supporting the risks and benefits of physical activity and exercise among older persons, and evaluates the current guidelines for exercise stress testing, with emphasis on their clinical applicability. The authors also offer a set of recommendations to assist clinicians, regarding the precautions that can be taken to reduce the risk of adverse cardiac events among older adults who were previously sedentary, do not have symptomatic cardiovascular disease, and are interested in starting an exercise program.

Gill TM, DiPietro L, Krumholz HM. Role of exercise stress testing and safety monitoring for older persons starting an exercise program. JAMA 2000;284(3):342-349.

--------------------------------------------------------------------------------

Effect of Treating Isolated Systolic Hypertension on the Risk of Developing Various Types and Subtypes of Stroke The Systolic Hypertension in the Elderly Program (SHEP) confirmed that treating isolated systolic hypertension in older patients minimizes the incidence of total stroke, although whether all types of stroke are reduced was unknown. The authors of the present study attempted to determine the effects of antihypertensive drug treatment on the incidence of stroke by type and subtype, timing of strokes, case–fatality rates, stroke residual effects, and the relationship of attained systolic blood pressure to stroke incidence.

The SHEP study–a randomized, double-blind, placebo-controlled trial–was begun on March 1, 1985, with an average follow-up of 4.5 years. The trial included 4736 participants at 16 U.S. clinical centers, who were age 60 years and older and who had isolated systolic hypertension. Individuals were randomly administered treatment with either 12.5 mg/day of chlorthalidone (with added doses of atenolol or reserpine) or placebo. The present investigators tabulated stroke occurrence; type, subtype, and timing of first strokes; stroke fatalities; and change in stroke incidence among participants, including those who obtained a blood pressure–lowering goal and those who did not. In both the active treatment and the placebo groups, the systolic blood pressure goal was a decrease of at least 20 mm Hg to below 160 mm Hg.

Eighty-five people from the treatment group had ischemic strokes, nine had hemorrhagic strokes, and nine had strokes of unknown type. From the placebo group, 132 participants had ischemic strokes, 19 had hemorrhagic strokes, and eight had strokes of unknown type. Investigators observed four subtypes of ischemic stroke in both groups, including lacunar, embolic, atherosclerotic, and an unknown subtype. The effects of treatment were apparent within one year for hemorrhagic strokes, and within two years for ischemic strokes. In those patients who reached the study-specific systolic blood pressure goal, stroke incidence was significantly reduced.

The authors concluded from their observations that antihypertensive drug treatment decreased the incidence of both hemorrhagic and ischemic strokes. Additionally, there was a reduction in stroke incidence when a specific systolic blood pressure goal was achieved.

Perry HM Jr, Davis BR, Price TR, et al for the Systolic Hypertension in the Elderly Program (SHEP) Cooperative Research Group. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke. JAMA 2000;284(4):465-471.

--------------------------------------------------------------------------------

Association of Coffee and Caffeine Intake With the Risk of Parkinson's Disease The elderly are at highest risk for Parkinson's disease, which is predicted to expand in the next several decades. Therefore, identifying factors that contribute to or prevent the disease is especially important. The authors' goal was to examine how coffee and dietary caffeine intake is associated with the risk of Parkinson's disease.

Between 1965 and 1968, a total of 8004 Japanese-American men ages 45-68 years were enrolled in the prospective longitudinal Honolulu Heart Program. Data from 30 years of follow-up were collected and analyzed. Investigators measured the incidence of Parkinson's disease against the amount of coffee intake at enrollment and at six-year follow-up, and against total dietary caffeine intake at enrollment. They identified 102 men during follow-up as having Parkinson's disease. It was found that age-adjusted incidence of Parkinson's disease decreased repeatedly with increased amounts of coffee intake–10.4 per 10,000 person-years in men who did not consume coffee compared with 1.9 per 10,000 person-years in men who consumed at least 28 oz/day.

Investigators found that there were similar relationships with total caffeine intake and caffeine from noncoffee sources. Men who were never, past, or current smokers and who consumed increasing amounts of coffee had a lower risk of Parkinson's disease. Other nutrients in coffee (eg, niacin) were not associated with Parkinson's disease. The relationship between caffeine and Parkinson's disease was not affected by the intake of milk or sugar.

The authors concluded that higher coffee and caffeine intake is correlated to a lower incidence of Parkinson's disease, apparently independent of smoking. The data collected also revealed that the mechanism is related to caffeine intake and not to other nutrients found in coffee.

Ross GW, Abbott RD, Petrovitch H, et al. Association of coffee and caffeine intake with the risk of Parkinson disease. JAMA 2000;283(20):2674-2679.

--------------------------------------------------------------------------------

The Spectrum of Behavioral Responses to Cholinesterase Inhibitor Therapy in Alzheimer's Disease Cholinergic treatment helps to reduce the behavioral disturbances that are common in many patients with Alzheimer's disease. Delineating the pretreatment profile of patients most likely to respond to cholinergic therapy can assist in effectively using clinical resources. The authors' objective was to determine the behavioral profile at baseline for 86 patients with Alzheimer's disease who were treated with donepezil hydrochloride.

An open-label retrospective study was conducted to assess treatment-related behavior. Patients were divided into responder, unchanged, and nonresponder groups, based on a previous double-blind placebo-controlled trial using the Neuropsychiatric Inventory. Investigators also used the Mini-Mental State Examination to assess patients' cognitive responses. They found behavioral improvements in 41% of the patients, worsening behavior in 28%, and no change in 31%. In comparing the profiles of the behavioral responders and nonresponders, researchers discovered that the responders showed significantly worse delusions, agitation, depression, anxiety, apathy, disinhibition, and irritability at baseline. The responders improved considerably, while the nonresponders worsened from baseline with regard to delusions, agitation, anxiety, disinhibition, and irritability.

These behavioral changes were dose-dependent, and cognition did not change significantly within any group upon administration of donepezil treatment. Investigators concluded that donepezil has psychotropic properties and that pretreatment behaviors assist in predicting reactions of patients to the treatment.

Mega MS, Masterman DM, O'Connor SM, et al. The spectrum of behavioral responses to cholinesterase inhibitor therapy in Alzheimer disease. Arch Neurol 1999;56:1388-1393.

Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 10 - October 2000