JAMA Internal Medicine: Geriatrics/Aging Topic Collection

Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents Sleep Medication Use and Nursing Home Hip Fracture

Berry SD, Lee Y, Cai S, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents.

Objective

To conduct a case-crossover study to estimate the association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics.

Design and Setting

Case-crossover study performed in an academic research setting.

Participants

The study participants included 15 528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008.

Main Outcome Measures

Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics.

Results

Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05).

Conclusions and Relevance

The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.

What's to Blame for Falls and Fractures? Poor Sleep or the Sleeping Medication? Comment on “Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents” What's to Blame for Falls and Fractures?

Widera E. — Mon, 13 May 2013 00:00:00 GMT

Sleep in nursing homes is both cherished yet fleeting. Most nursing home residents complain about the quality of their sleep, which is notable for multiple nighttime awakenings, frequent daytime naps, and a high percentage of time spent awake in bed. This fragmented nature of sleep can be attributed to multiple causes, including a high prevalence of primary sleep disorders (eg, central sleep apnea) and a care environment that pays little attention to sleep quality and structure.

Failure to Engage Hospitalized Elderly Patients and Their Families in Advance Care Planning Advance Care Planning Between Patient and Families

Heyland DK, Barwich D, Pichora D, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Advance care planning can improve patient-centered care and potentially reduce intensification of care at the end of life.

Objectives

To inquire about patients' advance care planning activities before hospitalization and preferences for care from the perspectives of patients and family members, as well as to measure real-time concordance between expressed preferences for care and documentation of those preferences in the medical record.

Design

Prospective study.

Setting

Twelve acute care hospitals in Canada.

Participants

Elderly patients who were at high risk of dying in the next 6 months and their family members.

Main Outcome Measures

Responses to an in-person administered questionnaire and concordance of expressed preferences and orders of care documented in the medical record.

Results

Of 513 patients and 366 family members approached, 278 patients (54.2%) and 225 family members (61.5%) consented to participate. The mean ages of patients and family members were 80.0 and 60.8 years, respectively. Before hospitalization, most patients (76.3%) had thought about end-of-life (EOL) care, and only 11.9% preferred life-prolonging care; 47.9% of patients had completed an advance care plan, and 73.3% had formally named a surrogate decision maker for health care. Of patients who had discussed their wishes, only 30.3% had done so with the family physician and 55.3% with any member of the health care team. Agreement between patients' expressed preferences for EOL care and documentation in the medical record was 30.2%. Family members' perspectives were similar to those of patients.

Conclusions and Relevance

Many elderly patients at high risk of dying and their family members have expressed preferences for medical treatments at the EOL. However, communication with health care professionals and documentation of these preferences remains inadequate. Efforts to reduce this significant medical error of omission are warranted.

The Mental Activity and eXercise (MAX) Trial A Randomized Controlled Trial to Enhance Cognitive Function in Older Adults The Mental Activity and eXercise (MAX) Trial

Barnes DE, Santos-Modesitt W, Poelke G, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

The prevalence of cognitive impairment and dementia are projected to rise dramatically during the next 40 years, and strategies for maintaining cognitive function with age are critically needed. Physical or mental activity alone result in relatively small, domain-specific improvements in cognitive function in older adults; combined interventions may have more global effects.

Objective

To examine the combined effects of physical plus mental activity on cognitive function in older adults.

Design

Randomized controlled trial with a factorial design.

Setting

San Francisco, California.

Participants

A total of 126 inactive, community-residing older adults with cognitive complaints.

Interventions

All participants engaged in home-based mental activity (1 h/d, 3 d/wk) plus class-based physical activity (1 h/d, 3 d/wk) for 12 weeks and were randomized to either mental activity intervention (MA-I; intensive computer) or mental activity control (MA-C; educational DVDs) plus exercise intervention (EX-I; aerobic) or exercise control (EX-C; stretching and toning); a 2 × 2 factorial design was used so that there were 4 groups: MA-I/EX-I, MA-I/EX-C, MA-C/EX-1, and MA-C/EX-C.

Main Outcome Measures

Global cognitive change based on a comprehensive neuropsychological test battery.

Results

Participants had a mean age of 73.4 years; 62.7% were women, and 34.9% were Hispanic or nonwhite. There were no significant differences between the groups at baseline. Global cognitive scores improved significantly over time (mean, 0.16 SD; P < .001) but did not differ between groups in the comparison between MA-I and MA-C (ignoring exercise, P = .17), the comparison between EX-I and EX-C (ignoring mental activity, P = .74), or across all 4 randomization groups (P = .26).

Conclusions and Relevance

In inactive older adults with cognitive complaints, 12 weeks of physical plus mental activity was associated with significant improvements in global cognitive function with no evidence of difference between intervention and active control groups. These findings may reflect practice effects or may suggest that the amount of activity is more important than the type in this subject population.

Trial Registration

clinicaltrials.gov Identifier: NCT00522899

Disregard of Patients' Preferences Is a Medical Error Comment on “Failure to Engage Hospitalized Elderly Patients and Their Families in Advance Care Planning” Disregard of Patients' Preferences

Allison TA, Sudore RL. — Mon, 13 May 2013 00:00:00 GMT

To physicians, what is encompassed by the term medical error may seem self-evident. It is the surgery performed on the wrong limb, the medication given to the wrong patient, or the medical test that falls through the cracks. Medical errors involve acts of omission as well as commission. During the past decade, we have attempted to systematically address diagnostic, treatment, and equipment-related errors and improve patient safety in medicine. Public awareness of the health care system's efforts to improve patient safety has been raised through the groundbreaking Institute of Medicine report calling for system-level change, a physician-authored New York Times bestseller on patient safeguards through checklists, and a privately instigated campaign to save 100 000 lives by reducing medical errors across 3000 American hospitals. However, do we, as clinicians, recognize the full scope of what may constitute medical errors in practice?

Can Participation in Mental and Physical Activity Protect Cognition in Old Age? Comment on “The Mental Activity and eXercise (MAX) Trial: A Randomized Controlled Trial to Enhance Cognitive Function in Older Adults” Can Mental and Physical Activity Protect Cognition

Lautenschlager NT, Cox KL. — Mon, 13 May 2013 00:00:00 GMT

With many societies around the globe experiencing increasing longevity, one challenging research question of our times is how to reduce the risk of cognitive decline in old age. Modifiable risk or protective factors for Alzheimer disease (AD) are of specific interest, because probably up to half of AD cases worldwide are potentially attributable to modifiable factors. It has been estimated, for example, that up to 1 million AD cases could be prevented globally if a 25% reduction in physical inactivity could be achieved in the world population. Although the body of literature on this topic is substantial, randomized controlled trials (RCTs) involving older adults at increased risk of cognitive decline are still quite sparse, and RCTs that combine more than a single protective lifestyle factor in their intervention are even less common.

Tailoring Chronic Pain Care by Brief Assessment of Impact and Prognosis Comment on “Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults” Chronic Pain Care

Von Korff M. — Mon, 13 May 2013 00:00:00 GMT

In 2011, an Institute of Medicine report, Relieving Pain in America, called for a cultural transformation of pain care. The report concluded that “healthcare providers should increasingly aim at tailoring pain care to each person's experience, and self-management of pain should be promoted.”^(p1) Medical treatments are often less than adequate for patients with chronic musculoskeletal pain. Ordering more diagnostic tests of uncertain value, prescribing more prescription analgesics with poorly understood risks and benefits, and providing more surgical procedures, nerve blocks, and epidural injections will not achieve the aims of improved patient outcomes, increased patient satisfaction, and more prudent use of finite health care resources. Rather, we need to help patients with chronic pain resume valued life activities by placing more emphasis on improving quality of life and less on interventions that afford only short-term pain relief with appreciable risks and costs.

Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults Musculoskeletal Pain in Older Adults

Mallen CD, Thomas E, Belcher J, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Many site-specific, multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published. The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care.

Objective

To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners.

Design, Setting, and Participants

A prospective observational cohort study conducted from September 1, 2006, through March 31, 2007, of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practices in the United Kingdom.

Main Outcome Measures

During consultation, the treating physician assessed and recorded 5 brief generic items (duration of present pain episode, current pain intensity, pain interference with daily activities, presence of multiple-site pain, and ultrashort depression screen) and recorded their overall prognostic judgment. The primary outcome was patient-rated improvement, which was measured 6 months after consultation and cross-validated with repeated measures up to 3 years.

Results

A total of 194 (48.1%) of 403 participants were classified as having an unfavorable outcome at 6 months. Inclusion of 3 generic prognostic indicators (duration of present pain episode, pain interference with daily activities, and presence of multiple-site pain) in the prognostic model improved on reliance on physicians' prognostic judgment alone (C statistic = 0.72 vs 0.62; net reclassification index = 0.136; proportion correctly classified = 69%). The improvement in prognostic accuracy was attributable to correcting physicians' tendency toward overoptimistic expectations of outcome.

Conclusions and Relevance

Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practices in the United Kingdom. Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions.