DEMENTIA
New Study Offers Clearer Picture of Advanced Dementia’s Clinical Course
PAIN
Combination of Antidepressant, Anticonvulsant Drug Appears Superior to Monotherapy for Neuropathic Pain
OSTEOPOROSIS
No Clinically Meaningful Treatment Effects for Vertebroplasty in Treating Pain, Pain-related Disability Associated with Osteoporotic Compression Fractures
FALLS & FITNESS
Starting or Maintaining Physical Activity in the Oldest Old Improves Function, Survival
ELDER ABUSE
Early Identification, Prompt Intervention Needed in Elder Self-Neglect and Abuse
DIABETES/NUTRITION
Low-Carbohydrate Mediterranean-Style Diet Better than Low-Fat in Type 2 Diabetes
FOR IMMEDIATE RELEASE
THE CANADIAN GERIATRICS SOCIETY: Answering the Call to Action for an Unprecedented Health Challenge
DEMENTIA
Pathological Features of Dementia Vary with Age
DRUG SAFETY
Sedative, Hypnotics Use Associated with Increased Suicide Risk in Older Adults
MUSCULOSKELETAL DISORDERS
Total Knee Arthroplasty: A Cost-Effective Procedure for Older Adults
HEALTHY AGING
Association between Late-Life Social Activity and Rate of Change in Motor Function
WELLNESS
Life-Space Mobility after Hospitalization
NUTRITION/CARDIOVASCULAR DISEASE
The Metabolic Syndrome and Increased Blood Pressure Response to Dietary Salt
CARDIOVASCULAR DISEASE
Daily ASA Doses of 100 mg or Greater Not Associated with Clear Benefit
MENTAL HEALTH
Older Adults’ Generalized Anxiety Disorder Responds to Cognitive Behavioural Therapy
DEMENTIA
Inhaling Secondhand Smoke May Impair Cognitive Functioning
New Study Offers Clearer Picture of Advanced Dementia’s Clinical Course
 Dementia is a leading cause of death among older adults, but research has shown that patients with advanced dementia are under-recognized
as being at high risk for mortality. Further, they are known to receive suboptimal palliative care. Authors of a new study aiming to
better characterize the final stage of dementia suggested that this lack of information may at present impede the quality of care provided
to these patients, and they sought to better describe the clinical course of long-term care residents with advanced dementia (New Engl J
Med 2009;361:1529–38).
In a prospective cohort study, investigators followed 323 long-term care facility residents with advanced dementia and their health
care proxies for 18 months, collecting data to characterize residents’ survival, clinical complications, symptoms, and treatments, and to
determine the proxies’ understanding of the residents’ prognosis and the clinical complications expected in patients with advanced
dementia. Residents’ mean age was 85 years; all had severe functional disability (mean score on the Bedford Alzheimer’s Nursing Severity
Subscale, 21.0 [range is from 7 to 28; higher scores indicate greater functional disability]) and cognitive disability (72.7% had a score of 0
on the Test for Severe Impairment [range is from 0 to 24; lower scores indicate greater cognitive impairment]).
The authors reported that, over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a
febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for
residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea
(46.0%) and pain (39.1%), were common. The authors further noted that, in the last 3 months of life, 40.7% of residents underwent
at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding).
Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were
much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding
(adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37). The authors noted that only 18.0% of health care proxies stated that they
had received prognostic information from a physician. Although 81.4% of the proxies felt they understood which clinical complications to expect in
advanced dementia, only 32.5% stated that a physician had actually counseled them about these complications.
The authors concluded that pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and
these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among
such patients. When health care proxies are aware of the poor prognosis and the expected clinical complications, residents are less likely to undergo
aggressive interventions in the final days of life. The authors further noted that this study underscores the need to improve the quality of palliative care
in nursing homes to reduce the physical suffering of residents with advanced dementia.
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Combination of Antidepressant, Anticonvulsant Drug Appears Superior to Monotherapy for Neuropathic Pain
 A Canadian Institutes of Health Research–funded study aimed to assess the efficacy and tolerability of combined nortriptyline and gabapentin for neuropathic
pain compared with each drug given alone, and found that drug combinations represent the most effective strategy (Lancet 2009;374:1252–61).
Neuropathic pain, or pain caused by a primary lesion or dysfunction in the nervous system, affects more than 2–3% of the general population.
Drugs for the treatment of neuropathic pain have incomplete efficacy as well as dose-limiting side effects when given as monotherapy.
In this double-blind, double-dummy, crossover trial, 56 patients with either diabetic polyneuropathy (71%) or postherpetic neuralgia (29%) were
enrolled and randomized. Patients had a daily pain score of at least 4 (scale 0–10). Participants were randomised in a 1:1:1 ratio with a balanced Latin
square design to receive one of three sequences of daily oral gabapentin, nortriptyline, and their combination.
During each 6-week treatment period, drug doses were titrated towards maximum tolerated dose. The primary outcome was mean daily pain at
maximum tolerated dose. Analysis was by intention to treat.
The authors reported that 45 patients completed all three treatment periods; 47 patients completed at least two treatment periods and were
analysed for the primary outcome. Mean daily pain (0–10; numerical rating scale) was 5.4 (95% CI 5.0 to 5.8) at baseline, and at maximum tolerated
dose, pain was 3.2 (2.5 to 3.8) for gabapentin, 2.9 (2.4 to 3.4) for nortriptyline, and 2.3 (1.8 to 2.8) for combination treatment. Pain with combination
treatment was significantly lower than with gabapentin (–0.9, 95% CI –1.4 to –0.3, p=0.001) or nortriptyline alone (–0.6, 95% CI –1.1 to –0.1,
p=0.02). At maximum tolerated dose, the most common adverse event was dry mouth, which was significantly less frequent in patients on gabapentin
than on nortriptyline (p<0.0001) or combination treatment (p<0.0001). No serious adverse events were recorded for any patients during the trial.
The authors concluded that combined gabapentin and nortriptyline seems to be more efficacious than either agent as monotherapy for neuropathic
pain. Combination treatment reduced pain more than monotherapy in both subgroups of diabetic polyneuropathy and postherpetic neuralgia, although
the reduction was not significant for postherpetic neuralgia. Reduction in both subgroups suggests that the interaction of the drugs was favourable in
both of these disorders. The authors suggest that additional research is needed to develop the evidence base for rational combination treatment in neuropathic
pain and other neuropathic disorders.
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No Clinically Meaningful Treatment Effects for Vertebroplasty in Treating Pain, Pain-related Disability Associated with Osteoporotic Compression Fractures
 Percutaneous vertebroplasty, the injection of medical cement or polymethylmethacrylate (PMMA), into the fractured vertebral
body has gained wide acceptance as an effective method of pain relief and has become routine therapy for osteoporotic vertebral
fractures. However, due to a paucity of sound evidence, the role of active treatment effects of PMMA versus nonspecific
effects has been unclear.
In a recent study, investigators randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression
fractures to undergo either vertebroplasty or a simulated procedure without cement (N Engl J Med 2009;361:569–79). This trial,
called the Investigational Vertebroplasty Efficacy and Safety Trial (INVEST), aimed to evaluate the efficacy of PMMA infusion in vertebroplasty
for patients with painful osteoporotic compression fractures. Inclusion criteria limited participants to individuals age 50
years or older, with a diagnosis of one to three painful osteoporotic vertebral compression fractures between vertebral levels T4 and
L5, inadequate pain relief with standard medical therapy, and a current rating for pain intensity of at least 3 on a scale from 0 to 10.
The primary outcomes were scores on the modified Roland–Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23;
higher scores indicated greater disability) and patients’ ratings of average pain intensity during the preceding 24 hours at 1
month (on a scale of 0 to 10; higher scores indicated more severe pain). Patients were allowed to cross over to the other study
group after 1 month.
Investigators hypothesized that patients who had undergone vertebroplasty would report less pain and back pain–related
disability at 1 month than those in the control group.
All patients underwent the assigned intervention (68 vertebroplasties and 63 simulated procedures). At 1 month, there was no significant
difference between the vertebroplasty group and the control group in either the RDQ score (difference, 0.7; 95% confidence interval [CI], –1.3
to 2.8; p=0.49) or the pain rating (difference, 0.7; 95% CI, –0.3 to 1.7;p=0.19). Both groups had immediate improvement in disability and
pain scores after the intervention. Although the two groups did not differ significantly on any secondary outcome measure at 1 month, there
was a trend toward a higher rate of clinically meaningful improvement in pain (a 30% decrease from baseline) in the vertebroplasty group
(64% vs. 48%, p=0.06). At 3 months, there was a higher crossover rate in the control group than in the vertebroplasty group (43% vs. 12%,
p<0.001). One serious adverse event occurred in each group.
Regarding the immediate improvement in pain and disability after the procedure (sustained at 1 month), the authors suggested that factors
aside from the instillation of PMMA may have accounted for the observed clinical improvement. Extraprocedural factors may have included
the effect of local anesthesia as well as the so-called placebo effect.
The authors concluded that at 1 month, clinical improvement in patients with painful osteoporotic vertebral fractures was similar among
those treated with vertebroplasty and those treated with a simulated procedure. They advocated further study in order to determine whether
the long-term outcome is similar in the two groups.
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Starting or Maintaining Physical Activity in the Oldest Old Improves Function, Survival
 A recent study has reviewed the effects of physical activity (PA) among older adults, including the oldest old (age≥85 years) to determine the
evidence of survival benefit and functional or health benefits (Arch Intern Med 2009;169:1476–83).
Researchers used mortality data from individuals ages 70 to 88 years and data on health, comorbidity, and functional status at ages 70,
78, and 85 years from the Jerusalem Longitudinal Cohort Study (1990–2008). A representative sample of 1,861 people born in 1920 and 1921
enrolled in this prospective study, resulting in 17,109 person-years of follow-up for all-cause mortality.
Among physically active vs. sedentary participants, respectively, at age 70, the 8-year mortality was 15.2% vs. 27.2% (p<.001); at age
78, the 8-year mortality was 26.1% vs. 40.8% (p<.001); and at age 85 years, the 3-year mortality was 6.8% vs. 24.4% (p<.001).
In Cox proportional-hazards models adjusting for mortality risk factors, lower mortality was associated with PA level at ages 70 (hazard
ratio, 0.61; 95% confidence interval [CI], 0.38–0.96), 78 (0.69; 0.48–0.98), and 85 (0.42; 0.25–0.68). A significant survival benefit was associated
with initiating PA between ages 70 and 78 years (p = .04) and ages 78 and 85 years (p < .001). The PA level at age 78 was associated
with remaining independent while performing activities of daily living at age 85 (odds ratio, 1.92; 95% CI, 1.11–3.33). Analysis of survival
according to PA level found the primary distinction to be between sedentary vs. active participants, with no clear dose-dependent effect.
The authors described the important finding as the sustained protective effect of PA against functional decline. They stated that PA may
be instrumental in delaying the spiral of decline via numerous pathways, which may include improved cardiovascular fitness, decelerated sarcopenia,
reduced adiposity, and improved immunity, together with suppression of chronic inflammation. Among the very old, not only continuing
but also initiating PA was associated with better survival and function. They described their findings as supporting the encouragement of
PA into advanced old age.
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Early Identification, Prompt Intervention Needed in Elder Self-Neglect and Abuse
 Elder self-neglect and abuse draw increasing public concern, but the association of either elder self-neglect or abuse with mortality is uncertain. A recent study investigated the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among older adults living in the community (JAMA 2009;302:517–26).
The authors’ working definition of elder abuse was “an act referring to any knowing, intentional, or negligent act by a
caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.” Self-neglect was described
as manifesting in refusal or failure to provide oneself with adequate food, water, clothing, shelter, personal hygiene, prescribed
medication, and safety precautions.
The prospective, population-based cohort were 9,318 participants in the Chicago Health and Aging Project (CHAP; a longitudinal,
population-based, epidemiological study of residents aged ³65 years). A subset of these participants had suspected
elder self-neglect or abuse reported to social services agencies. Mortality was ascertained during follow-up and by use of
the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or
elder abuse reporting with the risk of all-cause mortality.
According to published results, 1,544 participants were reported for elder self-neglect and 113 participants were reported
for elder abuse from 1993 to 2005. In multivariable analyses, reported elder self-neglect was associated with a significantly
increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20-6.51). Mortality risk was
lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67-2.14). Reported elder abuse also was associated with significantly
increased risk of overall mortality (HR, 1.39; 95% CI, 1.07-1.84). Confirmed elder self-neglect or abuse also was associated with
mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels
of cognitive or physical function. Those cases reported as elder self-neglect (n = 1,544) and elder abuse (n=113) tended to be older,
female, black, and lower income.
Elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality. The authors described
the mortality risk as “especially alarming” during the first year after the report. They stated that their findings had direct implications for
health care professionals and social services agencies to promote early identification of elder self-neglect and prompt interventions.
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Low-Carbohydrate Mediterranean-Style Diet Better than Low-Fat in Type 2 Diabetes
 Researchers have compared the effects of a low-carbohydrate Mediterranean-style or a low-fat diet on the need for antihyperglycemic
drug therapy in patients with newly diagnosed type 2 diabetes (Ann Intern Med 2009;151:306–14).
In a randomized trial, 215 overweight people with newly diagnosed type 2 diabetes who were never treated with antihyperglycemic
drugs and had hemoglobin A1c (HbA1c) levels less than 11% followed a Mediterranean-style diet (<50% of daily calories from carbohydrates)
(n=108) or a low-fat diet (<30% of daily calories from fat) (n=107).
Investigators measured changes in weight, glycemic control, and coronary risk factors (secondary outcomes).
According to the authors, after 4 years, 44% of patients in the Mediterranean-style diet group and 70% in the low-fat diet group
required treatment (difference –26.0 percentage points [95% CI, –31.1 to –20.1 percentage points]; hazard ratio, 0.63 [CI, 0.51 to 0.86];
hazard ratio adjusted for weight change, 0.70 [CI, 0.59 to 0.90]; P<0.001). Participants assigned to the Mediterranean-style diet lost
more weight and experienced greater improvements in some glycemic control and coronary risk measures than did those assigned to
the low-fat diet.
The Mediterranean-style diet was vegetable-rich and used whole grains, and favoured poultry and fish over red meat. No more than
50% of calories were from complex carbohydrates, based on previously reported evidence that lower carbohydrate intake in the
Mediterranean diet is more beneficial than higher content for weight loss and cardiovascular risk reduction. The diet had no less than
30% calories from fat. The main source of added fat was 30 to 50 g of olive oil. The low-fat diet was based on American Heart
Association guidelines; it was rich in whole grains and restricted additional fats, sweets, and high-fat snacks, as well as saturated fats.
The authors concluded that compared with a low-fat diet, a low-carbohydrate, Mediterranean-style diet led to more favourable
changes in glycemic control and coronary risk factors and delayed the need for antihyperglycemic drug therapy in overweight patients
with newly diagnosed type 2 diabetes. They cautioned, however, that the trial was unblinded, and dietary intake was self-reported.
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THE CANADIAN GERIATRICS SOCIETY: Answering the Call to Action for an Unprecedented Health Challenge
 TORONTO, JULY 21, 2009—The International Monetary Fund (IMF) is warning governments to take action on health
care funding for the aging. Canada will need to react quickly in order to handle this looming financial burden.
Experts say that one of Canada’s strengths is that since the mid-1990s, a growing number of people past the age of 55 have been
staying in the work force. But if these people don’t stay healthy, they cannot continue to work. Good preventive care and improved
treatments for the main killers—heart disease and cancer foremost among them—are essential.
The greying wave is affecting many nations. As reported in The Globe and Mail (July 9, 2009) the United Nations estimates that birth
rates have fallen below replacement levels in more than 70 countries, including most of the developed world. The IMF projects that
age-sensitive spending on health care is threatening to become unmanageable to the governments of these countries.
The Canadian Geriatrics Society: Part of the Solution!
The physicians and professionals associated with the Canadian Geriatrics Society (CGS) are aware that aging is changing the social architecture
of Canadian society and challenging our health care system as never before. The Society is evolving to help meet these challenges.
The CGS advocates that action in the health care sector to sustain Canadas capacity for care of its aging adults must involve:
Sustained government investment in preventative programs to ensure older people stay healthy and productive
Increased efforts to recruit medical students and residents into Geriatric Medicine as a specialty, along with promotion of
training for family physicians in Care of the Elderly
Strong standards for continuing professional development (CPD) in Geriatrics for all health care professionals dealing
with older patients
Supportive programs to maximise independence in those with health issues that require some community assistance to
enable them to remain in their communities and not in institutional care
Readers of Geriatrics & Aging, one of the two CGS-associated journals, responded passionately about the themes of the IMF report
and are speaking out about the importance of quality care for older Canadians.
What the Front-line Doctors Are Saying...
"Prevention. We must spend more on prevention now to save massive spending in the future."—Dr. Bruce Fawcett
"The government has to better target and [support] prevention programs, in cooperation with the health care societies, to prevent the morbidities
and mortality associated with the polypharmacy and iatrogenic factors affecting the elderly population."—Dr. Eric Theriault
"With the increasing number of ‘over 65’ in the population we will see increasing costs. Depression, already common, will increase.
Even for those with adequate resources, the cost of aging will increase with more emotional stress and physical limitation. Programs
need to be put in place now..."—Dr. Colin Leech-Porter
To read more please visit: www.GeriatricsandAging.ca/links/TheCostofAging
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Pathological Features of Dementia Vary with Age
 Research in Alzheimer’s disease (AD) is focused mainly on younger-old persons. However, current disease-based classifications
may oversimplify the complexities of Alzheimer’s disease and dementia, and neuropathological findings may vary with
age (New Engl J Med 2009;360:23029).
The authors examined 456 brains donated to the population-based Medical Research Council Cognitive Function and Ageing
Study from persons 69 to 103 years of age at death. Using a standard neuropathological protocol that included measures of the
pathological features of AD, cerebral atrophy, and cerebrovascular disease, the authors stratified neuro-pathological variables to
represent no burden or a mild burden of pathological lesions as compared with a moderate or severe burden. They then estimated
the effect of age on the relationship between plaque-and-tangle pathological lesions and dementia.
They found that difference in the prevalence of moderate and severe AD-type pathological changes between persons
with and those without dementia decreased with increasing age. The association between neocortical neuritic plaques and
dementia was strong at 75 years of age (odds ratio [OR], 8.63; 95% confidence interval [CI], 3.81 to 19.60) and reduced at
95 years of age (OR, 2.48; 95% CI, 0.92 to 4.14). Similar attenuations with age were observed in the association between
other pathological changes related to AD and dementia in all brain areas. In contrast, neocortical cerebral atrophy maintained
a relationship with age in persons with dementia at both 75 years (OR, 5.11; 95% CI, 1.94 to 13.46) and 95 years of
age (OR, 6.10; 95% CI, 2.80 to 13.28), distinguishing the cohort with dementia from the cohort without dementia.
According to the authors, their results underscore the complex relationships between the hallmark pathological lesions and
mentation. The association between the pathological features of AD and dementia is stronger in younger-old persons than in olderold
persons. Age must be taken into account when assessing the likely effect of interventions against dementia on the population.
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Sedative, Hypnotics Use Associated with Increased Suicide Risk in Older Adults
Sedatives and hypnotics are widely prescribed to older adults who have symptoms of depression, anxiety, and sleep disturbance. A
recently published study conducted in Sweden aimed to determine whether different types of psychotropic drugs were associated with
increased risk of suicide in persons aged 65 years and above after adjustment for appropriate indications (BMC Geriatrics 2009;9:20).
A case-controlled study of suicides was performed and close informants for 85 suicide cases (46 men, 39 women; mean age 75 years)
were interviewed by a psychiatrist. A population-based comparison group (n = 153) was created and interviewed face-to-face. Primary care
and psychiatric records were reviewed for suicide cases and comparison subjects. All information was used to determine past-month mental
disorders in accordance with DSM-IV criteria. For study purposes, the authors classified the following drugs as sedatives: diazepam, alprazolam,
buspirone, hydroxizine, and dixyrazine. They classified the following as hypnotics: flunitrazepam, nitrazepam, zopiclone, zolpidem,
oxazepam, levomepromazine, propiomazine, and alimemazine.
Psychotropic drugs were found to have been widely prescribed to the suicide cases and all drug types were associated with suicide
in the unadjusted analyses. Antidepressants were prescribed to 40% of the cases at the time of the suicide. Antidepressants, antipsychotics,
sedatives, and hypnotics were associated with increased suicide risk in the crude analysis. After adjustment for affective and
anxiety disorders neither antidepressants in general nor SSRIs showed an association with suicide. Antipsychotics had no association
with suicide after adjustment for psychotic disorders. Sedative treatment was associated with an almost fourteen-fold increase of suicide
risk in the crude analyses and remained an independent risk factor for suicide even after adjustment for any DSM-IV disorder. Having a
current prescription for a hypnotic was associated with a four-fold increase in suicide risk in the adjusted model.
The authors reviewed possible explanation for the observed increase in suicide risk associated with sedatives and hypnotics in
their study, including the possibility that these drugs trigger aggressive behaviour. They further noted that interactions between
benzodiazepines and alcohol may intensify impulsive tendencies, thereby increasing risk of suicide. Some 29% of the suicide cases
in the study had a positive postmortem test for alcohol.
The authors cautioned that their finding that sedatives and hypnotics were associated with increased suicide risk does not prove causality.
They suggested that use of these drugs may be markers for some other factor related to suicide risk, such as somatic illness, functional disability,
alcohol use disorder, interpersonal problems, lack of social network, and sleep disturbance.
Nonetheless, they concluded that sedatives and hypnotics were both associated with increased risk for suicide after adjustment for
appropriate indications. They advised that, given high prescription rates for these agents, a careful evaluation of the suicide risk should always
precede prescribing a sedative or hypnotic to an older patient.
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Total Knee Arthroplasty: A Cost-Effective Procedure for Older Adults
Total knee arthroplasty (TKA) appears to be a cost-effective procedure for older adults with advanced osteoarthritis,
according to a report published in a recent issue of the Archives of Internal Medicine (2009;169:1113–21). The procedure
appears to be cost-effective across all patient risk groups, but data show it is more costly and less effective
when performed in low-volume centres.
Approximately 12% of adults older than 60 have symptoms of knee osteoarthritis, resulting in direct medical
costs estimated to range from $1,000 to $4,100 (US) per person per year. Total knee arthroplasty is known to relieve
pain and improve function in patients with end-stage knee osteoarthritis. Given changing demographics, cost projections
indicate dramatic growth in the use of TKA in the coming decades. However, cost-effectiveness of TKA and the
influences of hospital volume and patient risk on TKA cost-effectiveness had not previously been investigated.
The study’s authors employed a computer simulation model and populated it with Medicare claims data and cost
and outcomes data from national and multinational sources. They projected lifetime costs and quality-adjusted life
expectancy (QALE) for different risk populations. Cost-effectiveness of TKA was estimated across all patient risk and
hospital volume permutations.
Overall, undergoing TKA increased quality-adjusted life expectancy of the Medicare population (average age 74)
from 6.822 to 7.957 quality-adjusted life years. Total costs increased from $37,100 among individuals not receiving
total knee arthroplasty to $57,900 per person undergoing TKA, resulting in a cost-effectiveness ratio of $18,300 per
quality-adjusted life year. The authors therefore concluded that TKA is a highly cost-effective procedure for the management of
end-stage knee osteoarthritis compared with non-surgical treatments and is within the range of accepted cost-effectiveness for
other musculoskeletal procedures. They further noted that TKAs performed in a high-volume hospital confer even greater value
per dollar spent.
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Association between Late-Life Social Activity and Rate of Change in Motor Function
 Among older adults, less frequent participation in social activities is associated with a more rapid rate of motor function decline;
however, little is known about factors that predict idiopathic motor decline. A recent study investigated whether late-life social
activity is related to the rate of change in motor function (Arch Intern Med 2009;169:1139–46).
The authors studied 906 older adults participating in the longitudinal Rush Memory and Aging Project (average follow-up
4.9 years). Researchers evaluated participants’ motor function by measuring grip and pinch strength; ability to stand on one leg
and then on the toes; to walk in line in a heel-to-toe manner; place pegs on a board in 30 seconds; and tap index fingers for 10
seconds bilaterally. Participants completed a health survey to assess their physical activities and used a five-point rating scale to
measure frequency of social activity participation. The main outcome measure was annual change in a composite measure of
global motor function, based on 9 measures of muscle strength and 9 motor performances.
Mean (SD) social activity score at baseline was 2.6 (0.58), with higher scores indicating more frequent participation in social
activities. Motor function declined by approximately 0.05 U/y (estimate, 0.016; 95% confidence interval [CI], –0.057 to 0.041 [P
= .02]). Each 1-point decrease in social activity was associated with approximately a 33% more rapid rate of decline in motor
function (estimate, 0.016; 95% CI, 0.003 to 0.029 [P = .02]). The effect of each 1-point decrease in the social activity score at
baseline on the rate of change in global motor function was the same as being approximately 5 years older at baseline. This
amount of motor decline per year was associated with a more than 40% increased risk of death (hazard ratio, 1.44; 95% CI,
1.30 to 1.60) and a 65% increased risk of incident Katz disability (hazard ratio, 1.65; 95% CI, 1.48 to 1.83). The association of
social activity with the rate of global motor decline did not vary along demographic lines and was unchanged after controlling
for potential confounders.
The authors concluded that less frequent social engagement is associated with a more rapid rate of motor function decline
in old age.
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Life-Space Mobility after Hospitalization
A study that assessed effects of hospitalization on life space in older adults, and compared life-space trajectories associated with
surgical and nonsurgical hospitalizations, has found hospitalization to be clearly associated with life-space decrements (Ann Int
Med 2009;150:372–8).
“Life space” is a measure of where a person goes, how frequently, and how independently. Some researchers consider it a
more accurate measure of physical function in older adults because it reflects participation in society as well as physical ability.
The study’s authors suggested it may be a useful measure of global functional decline for recently hospitalized older patients.
In a prospective observational study, 687 community-dwelling adults at least 65 years of age with surgical (n = 44),
nonsurgical (n = 167), or no (n = 476) hospitalizations were measured to obtain Life-Space Assessment (LSA) scores before and
after hospitalization (range, 0 to 120; higher scores reflect greater mobility). Mean age of participants was 74.6 years.
Before hospitalization, adjusted LSA scores were similar in participants with surgical and nonsurgical admissions. Life-space
assessment scores decreased in both groups immediately after hospitalization; however, participants with surgical hospitalizations
had a greater decrease in scores (12.1 more points [95% CI, 3.6 to 20.7 points]; p = 0.005) than those with nonsurgical
hospitalizations. However, participants with surgical hospitalizations recovered more rapidly over time (gain of 4.7 more points
[CI, 2.0 to 7.4 points] per ln [week after discharge]; p < 0.001). Score recovery for participants with nonsurgical hospitalizations
did not significantly differ from the null (average recovery, 0.7 points [CI, -0.6 to 1.9 points] per ln [week after discharge]).
The authors concluded that, on average, patients hospitalized for any reason experience an initial decrease in life-space
mobility as shown by the LSA scores. Surgical hospitalizations are associated with immediate marked life-space declines followed
by rapid recovery, in contrast to nonsurgical hospitalizations, which are associated with more modest immediate declines and little evidence
of recovery after several years of follow-up. The authors described the effect of a nonsurgical hospitalization on life space as concerning
because participants, on average, failed to regain their previous life-space level. They cited physical function and mental status as potential
targets for intervention during hospitalization to improve life-space quality.
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The Metabolic Syndrome and Increased Blood Pressure Response to Dietary Salt
 A large, population-based dietary intervention study that aimed to examine the association between the metabolic syndrome and salt
sensitivity of blood pressure (BP) has found that people with risk factors for the metabolic syndrome (but without diabetes) may have an
increased BP response to dietary salt (Lancet 2009;373:829–35).
Insulin resistance is considered an underlying mechanism for the metabolic syndrome. The study’s authors, therefore, suspected that
affected individuals would possibly manifest sensitivity to a dietary sodium intervention. The investigators undertook a study in order to
examine the association.
The investigators studied 1,881 nondiabetic adults in rural areas of northern China. Participants completed a seven-day trial of a
low-sodium diet (51.3 mmol/day) followed by seven days on a high-sodium diet (307.8 mmol/day). Blood pressure was measured at
baseline and on days 2, 5, 6, and 7 of each intervention. Metabolic syndrome was defined as the presence of three or more of:
abdominal obesity, raised blood pressure, high triglyceride concentration, low HDL cholesterol, or high glucose. There were 283 of the
study participants who had metabolic syndrome, according to the defining criteria.
High salt sensitivity was defined as a decrease in mean arterial blood pressure of more than 5 mmHg during low-sodium or an
increase of more than 5 mmHg during high-sodium intervention.
The salt sensitivity of blood pressure increased progressively with a higher number of risk factors for metabolic syndrome. This association
was independent of age, sex, BMI, physical activity, cigarette smoking, alcohol consumption, and baseline dietary intake of sodium and
potassium. Additionally, the association between metabolic syndrome and salt sensitivity remained after the participants with hypertension
were excluded.
The blood pressure of patients with metabolic syndrome showed significantly greater sensitivity to high- and low-sodium diets
compared with a control group, researchers found. Further, the risk of salt sensitivity increased with the number of risk factors for
metabolic syndrome.
During the low-sodium period, mean systolic blood pressure decreased 8.8 mmHg in participants with metabolic syndrome compared
with 5.2 mmHg in those who did not have the syndrome (p<0.0001). Diastolic blood pressure declined by 5.3 mmHg in the metabolic
syndrome group and 2.9 mmHg in the control group (p<0.0001).
A similar pattern emerged during high-sodium intervention.
According to the authors, the results suggest that reduced sodium intake could be an important component in reducing BP in
patients with multiple risk factors for metabolic syndrome.
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Daily ASA Doses of 100 mg or Greater Not Associated with Clear Benefit
A recently published study offers guidance on how acetylsalicylic acid (ASA) should be used in both the primary and secondary prevention of coronary heart disease (Ann Intern Med 2009;150:379–86).
The optimal ASA dose for preventing cardiovascular events has been debated. The study’s authors explored the incidence
of and risk factors for adverse clinical outcomes by investigator-determined ASA dose in a primary prevention trial.
In post-hoc observational analyses of data from CHARISMA, a double-blind, placebo-controlled, randomized trial, 15,595 outpatients
who were 45 years of age or older, with cardiovascular disease or multiple risk factors, were randomized to clopidogrel,
75 mg/d, or placebo, with ASA, 75–162 mg/d, as selected by investigators.
Key outcome measures were incidence of the composite outcome of myocardial infarction, stroke, or cardiovascular
death (efficacy endpoint), and incidence of severe or life-threatening bleeding (safety endpoint), at a median of 28
months of follow-up.
Daily ASA doses were categorized as less than 100 mg (75 or 81 mg) (n = 7,180), 100 mg (n = 4,961), and greater than
100 mg (150 or 162 mg) (n = 3,454). The hazard of the primary efficacy endpoint was the same regardless of dose (adjusted
hazard ratio, 0.95 [95% CI, 0.80 to 1.13] for 100 mg vs. less than 100 mg, and 1.0 [CI, 0.85 to 1.18] for greater than 100 mg
vs. less than 100 mg). The hazard of the primary safety endpoint also did not depend on dose (adjusted hazard ratio, 0.85 [CI,
0.57 to 1.26] for 100 mg vs. less than 100 mg and 1.05 [CI, 0.74 to 1.48] for greater than 100 mg vs. less than 100 mg). In
patients also receiving clopidogrel, the harm of daily ASA doses greater than 100 mg seemed to be non-statistically significantly
associated with reduced efficacy (adjusted hazard ratio, 1.16 [CI, 0.93 to 1.44]) and increased harm (adjusted hazard
ratio, 1.30 [CI, 0.83 to 2.04]).
The authors concluded that daily ASA doses of 100 mg or greater were associated with no clear benefit in patients taking ASA only
and possibly with harm in patients taking clopidogrel. Daily doses of 75–81 mg may optimize efficacy and safety for patients requiring
ASA for long-term prevention, especially for those receiving dual antiplatelet therapy.
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Older Adults’ Generalized Anxiety Disorder Responds to Cognitive
Behavioural Therapy
 Older adults with generalized anxiety disorder who received cognitive behaviour therapy (CBT) had greater improvement on mental
health measures than patients who received usual care, according to a study in the Journal of the American Medical Association
(2009;301:1460–7).
Previous studies have shown that CBT can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have
been conducted in primary care, where older adults most often seek treatment. The present study sought to examine effects of CBT relative
to enhanced usual care (EUC) in older adults with GAD in primary care.
The investigators recruited 134 older adults (mean age, 66.9 years) in two primary care settings. Treatment was provided for 3
months; assessments were conducted at baseline, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9,
12, and 15 months. The treatment included education and awareness, relaxation training, cognitive therapy, exposure, problem-solving
skills training, and behavioural sleep management. Patients assigned to receive EUC (n = 64) received biweekly telephone calls to ensure
patient safety and provide minimal support. Primary outcomes included worry severity, as measured by the Penn State Worry
Questionnaire, and GAD severity (GAD Severity Scale). Secondary outcomes included anxiety ratings, coexistent depressive symptoms, and
physical/mental health quality of life.
According to results, CBT compared with EUC significantly improved worry severity (45.6 [95% confidence interval {CI}, 43.4–47.8]
vs 54.4 [95% CI, 51.4–57.3], respectively; p < .001), depressive symptoms (10.2 [95% CI, 8.5-11.9] vs 12.8 [95% CI, 10.5–15.1], p =
.02), and general mental health (49.6 [95% CI, 47.4–51.8] vs 45.3 [95% CI, 42.6–47.9], p = .008). There was no difference in GAD
severity in patients receiving CBT versus those receiving EUC (8.6 [95% CI, 7.7–9.5] vs 9.9 [95% CI, 8.7-11.1], p = .19).
The authors concluded that, compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and
general mental health for older patients with GAD in primary care.
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Inhaling Secondhand Smoke May Impair Cognitive Functioning
A recent study that sought to examine the association between a biomarker of exposure to secondhand smoke (salivary
cotinine concentration) and cognitive impairment has found that passive smoking and cognitive deficits are likely to be
linked (BMJ 2009;Epub ahead of print; doi:10.1136/bmj.b462).
Exposure to secondhand smoke is known to be a causative factor in the development of coronary heart disease, lung
cancer, and premature death. Further, evidence suggests that secondhand smoke exposure may be associated with airway
disease, including asthma, chronic obstructive pulmonary disease, and impaired lung function. Although passive smoking
is correlated with a substantial burden of disease, and mortality, smoke-free legislation is not yet common public policy
worldwide.
To better understand the consequences of secondhand smoke exposure, investigators in the United Kingdom conducted
a cross-sectional analysis of a national population-based study drawn from a stratified random sample of households
throughout England. Study participants included 4,809 nonsmoking adults aged 50 years or more from the 1998, 1999, and
2001 waves of the Health Survey for England. Particpants had provided saliva samples for cotinine (a by-product of nicotine)
assay and a detailed smoking history.
A battery of neuropsychological tests were then used to assess aspects of brain function such as verbal memory (recalling
words immediately and after a delay), numerical calculations, time orientation, and verbal fluency (naming as many animals
as possible in 1 minute). Results were calculated to provide a global score for cognitive function; those with scores in
the 10 percent were subsequently identified as suffering from cognitive impairment.
Participants who did not smoke, use nicotine products, or have salivary cotinine concentrations of 14.1 ng/ml or more were divided
into four equal size groups on the basis of cotinine concentrations. Compared with the lowest fourth of cotinine concentration (0.00.1
ng/ml) the odds ratios (95% CI) for cognitive impairment in the second (0.20.3 ng/ml), third (0.40.7 ng/ml), and highest fourths
(0.813.5 ng/ml) were 1.08 (0.78 to 1.48), 1.13 (0.81 to 1.56), and 1.44 (1.07 to 1.94; P for trend 0.02), after adjustment for a wide
range of established risk factors for cognitive impairment. A similar pattern of associations was observed for never-smokers and former
smokers.
Researchers concluded that secondhand smoke exposure may be associated with increased odds of cognitive impairment, and that
their findings offer support for calls to ban smoking in public places. Prospective nationally representative studies relating biomarkers of
exposure to cognitive decline and risk of dementia are needed, they advised.
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