Geriatrics Abstracts: Abstracts from Recent Literature for the Geriatrics Practitioner

Hypertension and the Risk of Mild Cognitive Impairment

The objective of this study was to explore whether hypertension is associated with the risk of mild cognitive impairment (MCI), an intermediate stage of dementia, because there are conflicting data relating hypertension to the risk of Alzheimer disease. This was a retrospective community-based cohort study conducted in northern Manhattan. Multi-variate proportional hazards regression analyses were used, relating hypertension to incident all-cause MCI, amnestic MCI, and nonamnestic MCI in 918 persons without prevalent MCI at baseline followed up for a mean of 4.7 years. Results showed that there were 334 cases of incident MCI, 160 cases of amnestic MCI, and 174 cases of nonamnestic MCI during 4337 person-years of follow-up. Hypertension was associated with an increased risk of all-cause MCI (hazard ratio, 1.40; 95% confidence interval, 1.06-1.77; P=.02) and nonamnestic MCI (hazard ratio, 1.70; 95% confidence interval, 1.13-2.42; P=.009) after adjusting for age and sex. Both associations were slightly attenuated in models additionally adjusting for stroke and other vascular risk factors. There was no association between hypertension and the risk of amnestic MCI (hazard ratio, 1.10; 95% confidence interval, 0.79-1.63; P=.49). Consistent with this association, hypertension was related with the slope of change in an executive ability score, but not with memory or language score. There was no effect modification of the association between hypertension and MCI by ApoE4 genotype or use of antihypertensive medication. The authors concluded that a history of hypertension is related to a higher risk of MCI. The association seems to be stronger with the nonamnestic than the amnestic type of MCI in the elderly. These findings suggest that prevention and treatment of hypertension may have an important impact in lowering the risk of cognitive impairment.

Reitz C, Tang MX, Manly J, et al. Hypertension and the risk of mild cognitive impairment. Arch Neurol 2007;64(12): 1734-1740.
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Physical Activity Recommendations and Decreased Risk of Mortality

Whether national physical activity recommendations are related to mortality benefit is incompletely understood. The authors of this study prospectively examined physical activity guidelines in relation to mortality among 252,925 women and men aged 50 to 71 years in the National Institutes of Health–American Association of Retired Persons (NIH-AARP) Diet and Health Study. Physical activity was assessed using 2 self-administered baseline questionnaires. Results showed that during 1,265,347 person-years of follow-up, 7900 participants died. Compared with being inactive, achievement of activity levels that approximate the recommendations for moderate activity (at least 30 minutes on most days of the week) or vigorous exercise (at least 20 minutes 3 times per week) was associated with a 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.68-0.78) and 32% (RR, 0.68; 95% CI, 0.64-0.73) decreased mortality risk, respectively. Physical activity reflective of meeting both recommendations was related to substantially decreased mortality risk overall (RR, 0.50; 95% CI, 0.46-0.54) and in subgroups, including smokers (RR, 0.48; 95% CI, 0.44-0.53) and nonsmokers (RR, 0.54; 95% CI, 0.45-0.64), normal weight (RR, 0.45; 95% CI, 0.39-0.52) and overweight or obese individuals (RR, 0.48; 95% CI, 0.44-0.54), and those with 2 h/d (RR, 0.53; 95% CI, 0.44-0.63) and more than 2 h/d of television or video watching (RR, 0.50; 95% CI, 0.45-0.55). Engaging in physical activity at less than recommended levels was also related to reduced mortality risk (RR, 0.81; 95% CI, 0.76-0.86). The authors concluded that following physical activity guidelines is associated with lower risk of death. Mortality benefit may also be achieved by engaging in less than recommended activity levels.

Leitzmann MF, Park Y, Blair A, et al. Physical activity recommendations and decreased risk of mortality. Arch Intern Med 2007;167(22):2453-2460.
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Use of a Case Manager to Improve Osteoporosis Treatment After Hip Fracture

Patients who survive hip fracture are at high risk of recurrent fractures, but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10% to 20%. The authors of this study have developed an osteoporosis case manager intervention. The case manager educated patients, arranged bone mineral density tests, provided prescriptions, and communicated with primary care physicians. The intervention was compared with usual care in a randomized controlled trial. They recruited from all hospitals that participate in the Capital Health system (Alberta, Canada), including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility. Primary outcome was bisphosphonate therapy 6 months after fracture; secondary outcomes included bone mineral density testing, appropriate care (bone mineral density testing and treatment if bone mass was low), and intervention costs. The authors screened 2219 patients and allocated 220, as follows: 110 to the intervention group and 110 to the control group. Median age was 74 years, 60% were women, and 37% reported having had previous fractures. Six months after hip fracture, 56 patients in the intervention group (51%) were receiving bisphosphonate therapy compared with 24 patients in the control group (22%) (adjusted odds ratio, 4.7; 95% confidence interval, 2.4-8.9; P<.001). Bone mineral density tests were performed in 88 patients in the intervention group (80%) vs 32 patients in the control group (29%) (P<.001). Of the 120 patients who underwent bone mineral density testing, 25 (21%) had normal bone mass. Patients in the intervention group were more likely to receive appropriate care than were patients in the control group (67% vs 26%; P<.001). The average intervention cost was $50.00 per patient. The authors concluded that for a modest cost, a case manager was able to substantially increase rates of osteoporosis treatment in a vulnerable elderly population at high risk of future fractures.

Majumdar SR, Beaupre LA, Harley CH, et al. Use of a case manager to improve osteoporosis treatment after hip fracture. Arch Intern Med 2007;167(19):2110-2115.
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Palliative Medicine Update

The goal of palliative medicine is to prevent and relieve suffering, and to support the best quality of life for patients and their families, regardless of the stage of the disease or need for other therapies. Palliative care expands traditional disease model medical treatments to include the goals of enhancing quality of life, optimizing function, and helping with decision-making. Unlike hospice, it is delivered simultaneously with any appropriate life-prolonging treatments. The articles selected for this update were drawn from a keyword search followed by a review of more than 17,000 citations from 20 leading journals in general medicine, palliative medicine, anesthesia, oncology, nursing, and social work spanning September 2005 to June 2007. The authors rated a subset of these manuscripts on the basis of the quality of the science, innovativeness, and applicability to clinicians who practice palliative medicine. This last criterion applies not only to specialists in palliative medicine, but also to internists, family medicine clinicians, nurse practitioners, and subspecialists in internal medicine—all of whom care for patients with a wide range of advanced, chronic illnesses. They selected the articles ranked highest by these criteria, using a consensus process to resolve ratings discrepancies. The Table summarizing changes to clinical practice that should emerge from these articles can be found at www.annals.org/cgi/content/full/148/2/135#T1#T1

Goldstein NE, Fischberg D. Update in palliative medicine. Ann Intern Med 2008;148 (2):135-140.
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Consensus Panel Recommendations for Chronic and Acute Wound Dressings

The goal of this panel was to seek a consensus on recommendations that would help healthcare professionals choose appropriate wound dressings in daily practice, since a systematic review found only limited evidence to support reported indications for modern wound dressings. A steering committee selected a panel of 27 experts with no declared conflicts of interest from lists of nursing staff and physicians (specialists or general practitioners) with long-standing experience in wound care. The lists were put forward by 15 French learned societies. The panelists received a recent systematic review of the literature, a classification of indications established by a working group, and definitions for the dressings. The steering committee designed questionnaires on chronic wounds and on acute wounds including burns for each of the two panels. The consensus method was derived from the nominal group technique adapted by RAND/UCLA. Panelists rated the relevance of each possible dressing-indication combination on the basis of the published evidence and their own experience. After the first round of rating, they met to discuss results and propose recommendations before taking part in a second round of rating. The working group peer reviewed the final recommendations. A strong consensus was reached for use of the following combinations: for chronic wounds, (1) debridement stage, hydrogels; (2) granulation stage, foam, and low-adherence dressings; and (3) epithelialization stage, hydrocolloid and low-adherence dressings; and for the epithelialization stage of acute wounds, low-adherence dressings. For specific situations, the following dressings were favored: for fragile skin, low-adherence dressings; for hemorrhagic wounds, alginates; and for malodorous wounds, activated charcoal.

Vaneau M, Chaby G, Guillot B, et al. Consensus panel recommendations for chronic and acute wound dressings. Arch Dermatol 2007;143(10):1291-1294.