JAGS Abstracts - August 2006

Effects of Ultra-Low-Dose Estrogen Therapy on Muscle and Physical Function in Older Women
Anne M. Kenny, MD, Alison Kleppinger, MS, Yahzen Wang, PhD, and Karen M. Prestwood, MD

Objectives: To determine the effects of ultra-low-dose hormone therapy on muscle mass and physical function in community-dwelling women.

Design: Double-blind, placebo-controlled trial.

Setting: Clinical research center in Connecticut.

Participants: Healthy, community-dwelling women aged 65 and older (n=167).

Intervention: Eligible women were randomly assigned to treatment with 0.25 mg 17-beta estradiol or placebo for 36 months. All women (estradiol or placebo) with an intact uterus received micronized progesterone 100 mg/d for 2 weeks every 6 months. All participants received 1,300 mg elemental calcium with 1,000 IU vitamin D per day.

Measurements: Appendicular skeletal muscle mass (ASM), lean body mass (LBM), and percentage body fat were measured using dual x-ray absorptiometry. Sarcopenia was defined as skeletal muscle mass (ASM/height2) 2 standard deviations or less than young, healthy reference population mean. Physical activity (Physical Activity Scale in the Elderly (PASE)) and performance were measured. Serum estrone, estradiol, and sex hormone–binding globulin were measured.

Results: The prevalence of sarcopenia at baseline was 13%. There were no baseline differences between groups except for PASE score and chair rise time, in which the estrogen group had better performance. No changes in ASM, LBM, percentage of body fat, or physical performance were found after 3 years of estrogen therapy.

Conclusion: Sarcopenia was present in 13% of this group of community-dwelling, postmenopausal older women. Ultra-low-dose estrogen therapy neither improves nor harms ASM. Similarly, no changes in body fat or physical performance were detected. J Am Geriatr Soc 2005;53(11):1973-1977.
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Effect of Cataract Surgery on Cognitive Function in Older Adults
Tyler Andrew Hall, MD, Gerald McGwin, Jr, MS, PhD, and Cynthia Owsley, MSPH, PhD

Objectives: To assess whether cataract surgery has an effect on cognitive function in older adults.

Design: Longitudinal.

Setting: Assessment of patients seen in eye clinics.

Participants: Patients with no cataract (n= 92), patients with cataract who elected surgery (n=122), and patients with cataract who declined surgery (n=87).

Measurements: At baseline and 1-year follow-up visits, the following information was obtained: demographic, health behavior, general health status, medication use, depressive symptoms, cognitive function, and visual function information. This information was compared within and between groups at baseline and follow-up visits.

Results: Mattis Organic Mental Syndrome Screening Examination scores at baseline and follow-up varied across the three groups, with the cataract/no surgery group having the highest scores (more cognitive impairment) and the no-cataract group having the lowest scores (less cognitive impairment). For the within-group analysis, at follow-up, the cataract/no surgery group and the cataract/surgery group had significantly less cognitive impairment (P<.001), whereas the no-cataract group experienced no change. For those with cataract, there were no associations between changes in visual function and cognitive function.

Conclusion: Improvement in cognitive function may occur after cataract surgery but cannot be attributed to the cataract surgery per se or to improved visual function. Clinicians may find this information useful when discussing the nonvisual outcomes of cataract surgery with patients. J Am Geriatr Soc 2005;53(12):2140-2144.
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Increased Use of Hip Protectors in Nursing Homes: Economic Analysis of a Cluster Randomized, Controlled Trial
Gabriele Meyer, PhD, Karl Wegscheider, PhD, Jan F. Kersten, Andrea Icks, MD, and Ingrid Mühlhauser, MD

Objectives: To assess the cost-efficacy of an intervention program aimed at reducing hip fractures.

Design: Economic evaluation within an 18-month cluster randomized trial.

Setting: Forty-nine nursing homes in Hamburg, Germany.

Participants: Residents with a high risk of falling (intervention group (IG), n=459; control group (CG), n=483).

Intervention: Education session for nurses, who subsequently educated residents, and provision of three hip protectors per resident. CG care was optimized by providing brief information to nurses about hip protectors and providing two protectors per nursing home for demonstration purposes.

Measurements: Main outcomes were hip fractures, costs, and incremental cost-effectiveness ratio (ICER).

Results: The intervention was effective in reducing hip fractures (21 in the IG vs 42 in the CG) and resulted in a cost difference of $51 per participant in favor of the CG (95% confidence interval covering cost saving of $242 to cost expense of $325). Costs per additional hip fracture avoided were $1,234. Sensitivity analyses aimed at investigating robustness of the results to a real practice implementation scenario resulted in ICERs varying from $439 to $1,693. Taking into account lower hip protector reimbursement levels, the intervention program would be cost saving (break-even point within the base case analysis=$22 per hip protector).

Conclusion: A program consisting of education and provision of hip protectors might produce a slight increase in costs or might even be cost saving if the price of the hip protector could be decreased. J Am Geriatr Soc 2005;53(12):2153-2158.
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Do-Not-Resuscitate and Do-Not-Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit
Cari R. Levy, MD, Ronald Fish, MBA, and Andrew Kramer, MD

Objectives: To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders.

Design: Retrospective cohort study.

Setting: Nursing homes in the United States.

Participants: Medicare admissions to SNFs in 2001 (n=1,962,742).

Measurements: Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use.

Results: Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives.

Conclusion: Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit. J Am Geriatr Soc 2005;53(12):2060-2068.
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Healthcare Utilization of Nursing Home Residents: Comparison Between Decedents and Survivors
Anita Bercovitz, PhD, Ann L. Gruber-Baldini, PhD, Lynda C. Burton, ScD, and J. Richard Hebel, PhD

Objectives: To determine whether residents who die while in the nursing home have higher healthcare utilization than survivors and whether the utilization in the periods before death varies with length of stay in the nursing home.

Design: Descriptive, longitudinal study comparing medical service use of residents who died during the study period with that of residents who remained alive in the facility.

Setting: Fifty-nine nursing homes in Maryland. Data were collected between 1992 and 1995.

Participants: A random sample of 1,195 residents.

Measurements: Rates of hospitalization, emergency department visits, and medical visits in aggregate and in an initial 30-day and subsequent 90-day intervals after admission to the nursing home.

Results: Residents who died during the 2-year study period had significantly greater mean rates of utilization of all types of health care than residents who were not discharged from the nursing home, even when controlling for dementia diagnosis, age, functional status, and number of comorbid conditions. Those who died within a month of admission had significantly more emergency department and medical visits than those who died after a longer stay.

Conclusion: The pattern of high healthcare utilization before death is consistent with studies of the overall Medicare population that show an increase in Medicare expenditures in the period before death. J Am Geriatr Soc 2005;53(12):2069-2075.
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Late-Life Anemia Is Associated with Increased Risk of Recurrent Falls
Brenda W. J. H. Penninx, PhD, Saskia M. F. Pluijm, PhD, Paul Lips, MD, PhD, Richard Woodman, MD, Kor Miedema, PhD, Jack M. Guralnik, MD, PhD, and Dorly J. H. Deeg, PhD

Objectives: To examine whether anemia is associated with a higher incidence of recurrent falls.

Design: Prospective cohort study.

Setting: Community-dwelling sample in the Netherlands.

Participants: Three hundred ninety-four participants aged 65 to 88 from the Longitudinal Aging Study Amsterdam.

Measurements: Anemia was defined according to World Health Organization criteria as a hemoglobin concentration less than 12 g/dL in women and less than 13 g/dL in men. Falls were prospectively determined using fall calendars that participants filled out weekly for 3 years. Recurrent fallers were identified as those who fell at least two times within 6 months during the 3-year follow-up.

Results: Of the 394 persons, 11.9% (18 women and 29 men) had anemia. The incidence of recurrent falls was 38.3% of anemic persons versus 19.6% of nonanemic persons (P=.004). After adjustment for sex, age, body mass index, and diseases, anemia was significantly associated with a 1.91 times greater risk for recurrent falls (95% confidence interval= 1.09–3.36). Poor physical function (indicated by muscle strength, physical performance, and limitations) partly mediated the association between anemia and incidence of recurrent falls.

Conclusion: Late-life anemia is common and associated with twice the risk of recurrent falls. Muscle weakness and poor physical performance appear to partly mediate this association. J Am Geriatr Soc 2005;53(12):2106-2111.