Summary of Articles from the Journal of the American Geriatrics Society: June 2010, Volume 58
08/09/2010
Reviewed, prepared, and submitted by Joseph G. Ouslander, MD, Executive Editor, Journal of the American Geriatrics Society
Title:
Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing Facilities
Authors:
Marantonio, E; Bergmann, M; Kiely, D; et al
Summary:
The authors sought to determine whether a delirium abatement program (DAP) could shorten the duration of delirium in new admissions to postacute care (PAC). They conducted a cluster randomized controlled trial in 457 residents of eight skilled nursing facilities. Nursing facility residents with delirium defined according to the Confusion Assessment Method were eligible for participation after obtaining proxy consent. The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. Researchers blind to intervention status re-assessed participants for delirium 2 weeks and 1 month after enrollment. Among those diagnosed with delirium by research staff, nurses at DAP sites detected delirium more often than in usual care sites (41% vs. 12%). However, the DAP intervention had no effect on delirium persistence based on two measurements at 2 weeks (DAP 68% vs. usual care 66%) and one month (DAP 60% vs. usual care 51%). Adjusting for baseline differences between DAP and usual and restricting analysis to DAP participants in whom delirium was detected did not alter the results.
Comment:
Although the results of this carefully conducted trial in a challenging setting in a difficult population to study are disappointing, they are not surprising. Interventions for other geriatric syndromes such as urinary incontinence and falls in long-term care settings have shown some efficacy when carried out by trained research staff. However, translating these results into practice by implementing the interventions using indigenous nursing home staff has proven very challenging. In an editorial accompanying this paper entitled “Paper Geriatrics”, Dr. Steven Levenson notes that efforts to improve nursing home care have probably focused too much on developing tools and protocols and not enough on training in these important underlying processes and skills. Moreover, care in nursing homes is critically dependent on the infrastructure available – including registered nurses who are supported by interested and available physicians and nurse practitioners, consultant pharmacists, and other members of the interdisciplinary team; as well as incentives that are aligned with high quality care. The study by Marcantonio et al is a laudable effort to improve the management of one of the most common, morbid, and potentially reversible causes of morbidity and mortality in the long-term care population. The results highlight the critical importance not only of evidence-based tools and practices, but of adequate infrastructure and incentives in order to improve the care in the nursing home setting.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
Title:
Protein Intake and Incident Frailty in the Women’s Health Initiative Observational Study
Authors:
Beasley, J; LaCroix, A; Neuhouser, M et al
Summary:
In order to evaluate the association between protein intake and incident frailty the authors conducted a prospective cohort study in a subset of the Women’s Health Initiative Observational Study that included 24,417 women aged 65 to 79 at 40 centers who were free of frailty at baseline and who had self-reported energy intakes of 600–5,000 kcal/day according to the Food Frequency Questionnaire (FFQ). Baseline protein intake was estimated from the FFQ. Calibrated estimates of energy and protein intake were corrected for measurement error using objective measures of total energy expenditure (doubly labeled water) and dietary protein (24-hour urinary nitrogen). After 3 years of follow-up, frailty was defined as having at least three of the following components: low physical function (measured using the Rand-36 questionnaire), exhaustion, low physical activity, and unintended weight loss. Of the 24,417 eligible women, 3,298 (13.5%) developed frailty over 3 years. After adjustment for confounders,a 20% increase in uncalibrated protein intake was associated with a 12% (95% confidence interval (CI) 58–16%) lower risk of frailty, and a 20% increase in calibrated protein intake was associated with a 32% (95% CI 23–50%) lower risk of frailty. The authors conclude that higher protein consumption, as a fraction of energy, is associated with a strong, independent, dose-responsive lower risk of incident frailty in older women, and that incorporating more protein into the diet may be an intervention target for frailty prevention.
Comment:
Although the results of observational studies have to be interpreted with caution, the results of this particular study have important clinical implications for counseling older women about healthy aging. Previous research has demonstrated that increasing protein intake is beneficial in undernourished people who have lost muscle mass. However, this is the largest prospective study to date to show an association of higher protein intake with reduced incidence of frailty in women, a condition with well known effects on morbidity, function, quality of life, and mortality. Although precise recommendations for the amount and nature of adequate protein intake to prevent frailty await future studies, these results should assist clinicians in encouraging adequate protein intake among healthy older women, regardless of what dietary fad the patient or the practitioner believes in.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
Title:
Neuropsychological Predictors of Driving Errors in Older Adults
Authors:
Dawson, J; Uc, E; Anderson, S; et al
Summary:
The authors conducted a cross-sectional observational study in order to identify neuropsychological factors associated with driving errors in older adults. The study included drivers 111 older drivers (aged 65–89; mean age 72.3) and 80 middle-aged drivers (aged 40–64; mean age 57.2). Subjects were assessed in a neuropsychological laboratory and by an instrumented vehicle on a 35-mile route on urban and rural roads. The outcome variable was the safety error count, as classified according to video review using a standardized taxonomy. Older drivers committed an average of 35.8 safety errors per drive, which was significantly higher than the average of 27.8 for middle-aged drivers For older drivers, there was an increase of 2.6 errors per drive observed for each 5-year age increase. After adjustment for age, education, and sex, a composite cognitive score was a significant predictor of safety errors in older drivers, with an approximately 10% increase in safety errors observed for a 10% decrease in cognitive function. Individual significant predictors of more safety errors in older drivers included poorer scores on the Complex Figure TestFCopy, the Complex Figure TestFRecall, Block Design, Near Visual Acuity, and the Grooved Pegboard task. The authors conclude that driving errors in older adults tend to increase, even in the absence of neurological diagnoses. Age-related decline in cognitive abilities, vision, and motor skills explain some of this increase. Changes in visuospatial and visuomotor abilities appear to be particularly associated with unsafe driving in old age.
Comment:
Loss of the ability to drive rivals the loss of child in terms stressful life-changing events for older people. Unsafe driving poses a risk to our older patients, their families, the general public, and in some states, to the practitioner who does not report their patients who they feel may be unsafe on the road. Despite numerous studies in this area, there are no simple ways to predict older adults who may be prone to care crashes. State-of –the- art neuropsychological and on-road testing is available at the clinic where I work, but the psychologist who conducts these exams is constantly amazed at how impaired someone can be yet “pass” the on-road exam. Families and physicians depending on these tests to make a clear recommendation against driving are often disappointed with the recommendation that driving can continue in safe conditions. Indeed, as the authors point out, several critical factors that are often not measured also influence safety. These include decisions such as what vehicle to drive, how often and where and when to drive, road conditions, the distractions allowed in the vehicle (e.g., eating, smoking, listening to radio, cell phones), and the relative value that drivers put on safety and performance. While this study is valuable because of its careful assessment of on-road driving errors, the authors recommend that a variety of approaches are needed to study at-risk older drivers, ranging from closely controlled neuropsychological tests, which tend to lack real-world context, to driving simulation to field studies using instrumented vehicles. Readers who are interested in this area may want to look at the April 28, 2010 issue of JAMA which contains a comprehensive review relevant to the topic.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
Title:
Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing Facilities
Authors:
Marantonio, E; Bergmann, M; Kiely, D; et al
Summary:
The authors sought to determine whether a delirium abatement program (DAP) could shorten the duration of delirium in new admissions to postacute care (PAC). They conducted a cluster randomized controlled trial in 457 residents of eight skilled nursing facilities. Nursing facility residents with delirium defined according to the Confusion Assessment Method were eligible for participation after obtaining proxy consent. The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. Researchers blind to intervention status re-assessed participants for delirium 2 weeks and 1 month after enrollment. Among those diagnosed with delirium by research staff, nurses at DAP sites detected delirium more often than in usual care sites (41% vs. 12%). However, the DAP intervention had no effect on delirium persistence based on two measurements at 2 weeks (DAP 68% vs. usual care 66%) and one month (DAP 60% vs. usual care 51%). Adjusting for baseline differences between DAP and usual and restricting analysis to DAP participants in whom delirium was detected did not alter the results.
Comment:
Although the results of this carefully conducted trial in a challenging setting in a difficult population to study are disappointing, they are not surprising. Interventions for other geriatric syndromes such as urinary incontinence and falls in long-term care settings have shown some efficacy when carried out by trained research staff. However, translating these results into practice by implementing the interventions using indigenous nursing home staff has proven very challenging. In an editorial accompanying this paper entitled “Paper Geriatrics”, Dr. Steven Levenson notes that efforts to improve nursing home care have probably focused too much on developing tools and protocols and not enough on training in these important underlying processes and skills. Moreover, care in nursing homes is critically dependent on the infrastructure available – including registered nurses who are supported by interested and available physicians and nurse practitioners, consultant pharmacists, and other members of the interdisciplinary team; as well as incentives that are aligned with high quality care. The study by Marcantonio et al is a laudable effort to improve the management of one of the most common, morbid, and potentially reversible causes of morbidity and mortality in the long-term care population. The results highlight the critical importance not only of evidence-based tools and practices, but of adequate infrastructure and incentives in order to improve the care in the nursing home setting.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
Title:
Protein Intake and Incident Frailty in the Women’s Health Initiative Observational Study
Authors:
Beasley, J; LaCroix, A; Neuhouser, M et al
Summary:
In order to evaluate the association between protein intake and incident frailty the authors conducted a prospective cohort study in a subset of the Women’s Health Initiative Observational Study that included 24,417 women aged 65 to 79 at 40 centers who were free of frailty at baseline and who had self-reported energy intakes of 600–5,000 kcal/day according to the Food Frequency Questionnaire (FFQ). Baseline protein intake was estimated from the FFQ. Calibrated estimates of energy and protein intake were corrected for measurement error using objective measures of total energy expenditure (doubly labeled water) and dietary protein (24-hour urinary nitrogen). After 3 years of follow-up, frailty was defined as having at least three of the following components: low physical function (measured using the Rand-36 questionnaire), exhaustion, low physical activity, and unintended weight loss. Of the 24,417 eligible women, 3,298 (13.5%) developed frailty over 3 years. After adjustment for confounders,a 20% increase in uncalibrated protein intake was associated with a 12% (95% confidence interval (CI) 58–16%) lower risk of frailty, and a 20% increase in calibrated protein intake was associated with a 32% (95% CI 23–50%) lower risk of frailty. The authors conclude that higher protein consumption, as a fraction of energy, is associated with a strong, independent, dose-responsive lower risk of incident frailty in older women, and that incorporating more protein into the diet may be an intervention target for frailty prevention.
Comment:
Although the results of observational studies have to be interpreted with caution, the results of this particular study have important clinical implications for counseling older women about healthy aging. Previous research has demonstrated that increasing protein intake is beneficial in undernourished people who have lost muscle mass. However, this is the largest prospective study to date to show an association of higher protein intake with reduced incidence of frailty in women, a condition with well known effects on morbidity, function, quality of life, and mortality. Although precise recommendations for the amount and nature of adequate protein intake to prevent frailty await future studies, these results should assist clinicians in encouraging adequate protein intake among healthy older women, regardless of what dietary fad the patient or the practitioner believes in.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
Title:
Neuropsychological Predictors of Driving Errors in Older Adults
Authors:
Dawson, J; Uc, E; Anderson, S; et al
Summary:
The authors conducted a cross-sectional observational study in order to identify neuropsychological factors associated with driving errors in older adults. The study included drivers 111 older drivers (aged 65–89; mean age 72.3) and 80 middle-aged drivers (aged 40–64; mean age 57.2). Subjects were assessed in a neuropsychological laboratory and by an instrumented vehicle on a 35-mile route on urban and rural roads. The outcome variable was the safety error count, as classified according to video review using a standardized taxonomy. Older drivers committed an average of 35.8 safety errors per drive, which was significantly higher than the average of 27.8 for middle-aged drivers For older drivers, there was an increase of 2.6 errors per drive observed for each 5-year age increase. After adjustment for age, education, and sex, a composite cognitive score was a significant predictor of safety errors in older drivers, with an approximately 10% increase in safety errors observed for a 10% decrease in cognitive function. Individual significant predictors of more safety errors in older drivers included poorer scores on the Complex Figure TestFCopy, the Complex Figure TestFRecall, Block Design, Near Visual Acuity, and the Grooved Pegboard task. The authors conclude that driving errors in older adults tend to increase, even in the absence of neurological diagnoses. Age-related decline in cognitive abilities, vision, and motor skills explain some of this increase. Changes in visuospatial and visuomotor abilities appear to be particularly associated with unsafe driving in old age.
Comment:
Loss of the ability to drive rivals the loss of child in terms stressful life-changing events for older people. Unsafe driving poses a risk to our older patients, their families, the general public, and in some states, to the practitioner who does not report their patients who they feel may be unsafe on the road. Despite numerous studies in this area, there are no simple ways to predict older adults who may be prone to care crashes. State-of –the- art neuropsychological and on-road testing is available at the clinic where I work, but the psychologist who conducts these exams is constantly amazed at how impaired someone can be yet “pass” the on-road exam. Families and physicians depending on these tests to make a clear recommendation against driving are often disappointed with the recommendation that driving can continue in safe conditions. Indeed, as the authors point out, several critical factors that are often not measured also influence safety. These include decisions such as what vehicle to drive, how often and where and when to drive, road conditions, the distractions allowed in the vehicle (e.g., eating, smoking, listening to radio, cell phones), and the relative value that drivers put on safety and performance. While this study is valuable because of its careful assessment of on-road driving errors, the authors recommend that a variety of approaches are needed to study at-risk older drivers, ranging from closely controlled neuropsychological tests, which tend to lack real-world context, to driving simulation to field studies using instrumented vehicles. Readers who are interested in this area may want to look at the April 28, 2010 issue of JAMA which contains a comprehensive review relevant to the topic.
The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.