American Geriatrics Society (AGS) 2011 Annual Scientific Meeting
May 11-14, 2011; National Harbor, MD
Decision Aid Reduces Feeding Tube Placements in Individuals With Advanced Dementia
National Harbor, MD—Individuals with advanced dementia often have feeding problems, resulting in feeding tubes being placed. However, numerous studies show that feeding tube placement in these patients is unlikely to improve their survival or quality of life. Because surrogate decision-makers are often responsible for making decisions regarding feeding tube placement, researchers led by Laura C. Hanson, MD, MPH, University of North Carolina, Chapel Hill, sought to assess whether educating decision-makers on feeding problems in advanced dementia patients would improve the quality of decision-making in this arena. Hanson presented the findings of this research during a plenary paper session at the AGS 2011 Annual Scientific meeting, noting that this study is the “first randomized decision-support trial in the nursing home setting.” The study enrolled a total of 256 residents (mean age, 85 years) from 24 nursing homes in North Carolina and their surrogate decision-makers (mean age, 59 years), 70% of whom were residents’ children. Of the residents, 67% were white and 79% were women. Patients were randomized to an intervention group (n = 127) or to controls (n = 129). Those in the intervention group received a decision aid on feeding options in advanced dementia, which was constructed at a 6th-grade reading level and took 20 minutes to review. The aid encouraged surrogate decision-makers to think about their feelings and indicated that not eating is sometimes natural. Decision-makers in the control group received usual decision-making support. At 3 months, the intervention surrogates had lower Decisional Conflict Scale scores (the primary outcome measure) compared with controls (1.65 vs 1.90, P <.001), indicating less decisional conflict in the intervention group. The intervention surrogates were also more likely than controls to discuss feeding options with a healthcare provider (46% vs 33%, respectively, P <.001), resulting in more residents with a surrogate in the intervention group receiving a dysphagia diet (89% vs 76%, respectively; P = .04). In addition, 20% of residents with a surrogate in the intervention group received staff assistance for eating, compared with 10% of residents with a surrogate in the control group (P = .08). By 9 months, at which time there was 85% participation, only 1 patient in the intervention group had a feeding tube placed versus 3 patients in the control group (P = .34). There was also less weight loss in the intervention group than in controls (6% vs 10%, respectively) and less mortality (27% vs 29%, respectively). Based on these findings, Hanson noted that “Decision aids may be useful” in the nursing home setting, but that “such interventions are likely most effective when they are paired with communication training of healthcare professionals.” She also noted several limitations of her study, including that the study could not be double-blinded, that cluster randomization may have introduced bias, and that there were only clinically modest effects. Nevertheless, since decision aids are a simple to employ, they are likely worth implementing.
Advance Directives Important for Geriatric Patients
National Harbor, MD—Nearly two-thirds of geriatric patients hospitalized for cancer at Mount Sinai Medical Center in New York between 2006 and 2010 completed an advance directive (AD), which is markedly higher than the typical AD completion rate of approximately 21% reported in previous studies. Samantha Zuckerman, a rising third-year medical student at Mount Sinai School of Medicine, and colleagues presented their quality analysis on AD use in elderly patients receiving palliative care for cancer during a poster session at the recent AGS annual meeting in Washington, DC. In an interview with Annals of Long-Term Care, Zuckerman said, “Advance directives are important because they allow patients to have control over their healthcare in the event that they lose the ability to make medical decisions for themselves.” The researchers identified charts of hospitalized patients >65 years of age who received a palliative care consult for cancer at Mount Sinai and randomly selected 205 for analysis. They found that 60% (n = 123) of the charts had an AD, and they analyzed the data looking for any correlation between completion of an AD and patient demographics, cancer diagnosis and treatment preferences, comorbidities, and reason for the consultation. A multivariate analysis found patients were significantly more likely to have an AD if they had requested a consultation to establish a plan of care (odds ratio [OR], 2.664; P = .045). “Our study indicated that Hispanic patients and/or patients who were diagnosed with cancer within a year of hospitalization but not during hospitalization were least likely to have an advance directive [OR, 0.319; P = .0403; and OR, 0.293; P = .0012, respectively],” said Zuckerman. The study was not designed to evaluate why Hispanic patients might have lower AD completion rates, but Zuckerman said the research team conjectured that it might be because of “language barriers, obstacles to accessing medical care, and cultural differences.” The poster abstract noted that the study’s sample size was too small to draw statistically significant conclusions for each data set analyzed. The investigators did observe nonsignificant correlations between AD completion and age, discharge site, cancer type, Karnofsky Performance Status, and the patient’s history of dementia and delirium. Zuckerman said one reason for the substantially higher AD completion rate seen in her study might be the narrow range of patients included. “This specific population may have a higher rate of advance directive completion because they have a serious diagnosis, may be near the end of life, and may have started to have conversations about their wishes at the end of life,” she explained. “Ideally, advance directive discussions should occur before a patient becomes ill,” said Zuckerman. She recommended physicians talk to patients about completing an AD as part of a routine physical or check-up and advised them to encourage patients to discuss healthcare wishes with their designated proxy and any close family members. “Through conversations with the patient, the person designated as the healthcare proxy should have full knowledge of the patient’s wishes about healthcare.… Patients [should] specify their personal beliefs and values pertaining to medical decision making.” She said patients also need to inform family members who they have selected as their healthcare proxy. Zuckerman pointed out that conversations between physicians and patients regarding ADs take time, and with physician’s already being pressed for time, these discussions often do not take place. In 2010, an attempt was made by some in Congress to authorize Medicare to reimburse physicians for holding these important discussions, but the provision was stripped from proposed healthcare reforms, which Zuckerman described as unfortunate. “Physicians do not enter conversations about advance directives with any goals other than to help patients share and document their personal preferences about healthcare,” she said, adding that the medical literature shows patients and families want to have these discussions with their physician. Although all patients should discuss ADs with their physician and their families, Zuckerman noted that it was especially important to have these conversations with the population she and her colleagues studied—hospitalized geriatric patients with a primary diagnosis of cancer, as these individuals “are at high risk for medical complications and limited prognosis.” Zuckerman said her study also shows the need for more research to determine why Hispanic patients with cancer and patients who received a diagnosis <1 year earlier appear less likely to have an AD.
Cognitive Impairment Observed in Elderly Persons With Low Vitamin D Levels
National Harbor, MD—Global cognitive function appears to decline more rapidly in elderly persons with serum vitamin D levels below normal according to a subanalysis from the Health ABC (Dynamics of Health, Aging, and Body Composition) study that was presented at the recent AGS annual meeting. The authors note that theirs is not the first study to suggest a correlation between insufficient vitamin D levels and accelerated cognitive decline in the elderly. Health ABC is a longitudinal study initiated in 1996 to evaluate physical and mental changes over time in approximately 3000 healthy community-dwelling black and white adults 70 to 79 years of age. For this analysis, investigators reviewed data for 2786 enrollees in the Health ABC study who were described as well functioning. At years 1 and 5 of the study, researchers administered the Digit Symbol Substitution Test (DSST) and the Modified Mini-Mental State Examination (3MSE), which are used to assess memory, orientation, attention, and language. In year 2, the participants’ serum 25-hydroxy vitamin D levels were measured. Approximately 33% (n = 916) of study participants had vitamin D levels <20 ng/mL, indicating vitamin D deficiency; approximately 35% (n = 982) had vitamin D levels between 20 and 30 ng/mL, which was considered suboptimal; and the remaining 888 participants had a vitamin D level ≥30 ng/mL, categorized by investigators as sufficient. A comparison of 1-year 3MSE scores with participants’ vitamin D levels found that those with vitamin D deficiency had the lowest adjusted mean scores, at 88.9 (95% confidence interval [CI], 88.4-90.4), followed by 90.8 (95% CI, 90.4-91.3) for patients with suboptimal levels and 90.6 (95% CI, 90.2-91.1) for patients with normal levels (P = .02). DSST results reflected the same pattern, with a mean score of 35.3 (95% CI, 34.5-36.1) in the deficient group compared with 35.8 (95% CI, 35.1-36.6) in the suboptimal group and 37.0 (95% CI, 36.2-37.7) in the sufficient group (P = .01). At 5-year follow-up, 3MSE scores for individuals previously identified as having vitamin D deficiency dropped by a lower adjusted mean of -1.05 (95% CI, -01.51 to -0.58), while those with suboptimal levels experienced a decline of -0.75 (95% CI, -1.16 to -0.34) compared with -0.23 (95% CI, -0.68 to -0.21) for individuals with adequate vitamin D levels (P = .05). Test results for the DSST at 5 years showed no significant differences in deterioration of cognitive function among the three groups. Wilson and associates, who conducted the analysis, recommended further studies to determine whether administering vitamin D supplements to elderly individuals might slow or arrest declines in global cognition. Another analysis of data for this study population was presented at AGS by Kilpatrick and associates and reported no significant relationship between vitamin D status and incident cognitive impairment as measured by the 3MSE and DSST at 5 years. The 340 individuals who demonstrated cognitive impairment at baseline were excluded from the 5-year analysis. Stratifying outcomes by race showed a correlation between vitamin D deficiency and an increased risk of prevalent cognitive impairment but not incident impairment in black participants.
Fidaxomicin Reduces Risk of Clostridium Difficile Recurrence
National Harbor, MD—According to a study presented during a poster session at the recent AGS annual meeting, the effectiveness of fidaxomicin and vancomycin therapies for Clostridium difficile infection (CDI) appears to decline parallel to increasing age in individuals ≥40 years of age, with the worst treatment responses observed in those age 71 to 80 years. However, regardless of patient age, the study found that fidaxomicin was significantly better than vancomycin at preventing CDI recurrence. The study randomized 999 patients age 18 to 94 years with CDI to 10 days of oral vancomycin 125 mg four times daily (n = 518) or fidaxomicin 200 mg twice daily plus placebo twice daily (n = 481). Patients were eligible for the trial if they had a new diagnosis of CDI or an initial recurrence of a CDI that was first diagnosed no more than 90 days prior to randomization. All patients had failed on an initial therapy regimen consisting of at least 3 days of metronidazole and had received no other drug treatment for CDI. For purposes of the analysis, patients were stratified according to the following age groups: 18 to 40 years (n = 143), 40 to 50 years (n = 122), 51 to 60 years (n = 168), 61 to 70 years (n = 192), 71 to 80 years (n = 209), and 81 to 94 years (n = 165). The likelihood of cure was greatest in patients age 18 to 40 years and poorest for those age 81 to 94 years. Clinical cure rates were similar with both treatments regardless of patient age. The authors reported that in patients older than 40 years, the odds ratio (OR) for cure declined and the time to resolution of diarrhea (TTROD) symptoms increased progressively with age. “Each decade above age 40 was associated with an approximately 17% decrement in clinical cure of CDI,” wrote the study authors. Recurrence is common in older patients treated for CDI, and this investigation showed treatment failure and recurrence rates increased in accordance with age starting at 40 years. The researchers observed a significant 64% reduction in the rate of recurrence at 4 weeks among patients treated with fidaxomicin compared with those given vancomycin (P <.001) and a 54% reduction in recurrence overall with fidaxomicin (P <.001). Fidaxomicin was associated with declines in recurrence across all age groups except the 81-to-94 age bracket, which had a similar rate of recurrence with both treatments. Researchers determined that, compared with vancomycin therapy, treatment with fidaxomicin was associated with a 1.9-fold increased probability of cure without recurrence (P <.001). A subanalysis of patients who had the seemingly more virulent BI/027 strain of C. difficile showed that the prevalence of this variant increased with age, with nearly double the rate of BI/027-positive CDI seen in adults age >60 years versus adults ≤60 years (P <.001). The subgroup of cured patients with stool samples positive for the BI/027 strain were 74% more likely to experience recurrence than those whose stool samples tested negative for BI/027 (P = .013), although the reasons behind their increased susceptibility for recurrence were unclear. The authors hypothesized that the higher prevalence of the BI/027-positive CDI among older patients might correlate with the increased risk of recurrence observed in the older patient groups. When they assessed recurrence rates using a logistic regression model incorporating age, C difficile strain, and treatment, they found that age was no longer an independent predictor of recurrence risk. The investigators noted that “fidaxomicin treatment was associated with a significant benefit over vancomycin for the outcome of recurrence across all age groups.” The study’s findings indicate the need to take a broader look at prevention and treatment strategies for CDI, particularly in elderly patients, who typically have more severe disease and an increased risk of mortality concluded the authors.
Case Highlight
Constipation Causing Poor Nutritional Intake
National Harbor, MD—Approximately 63 million individuals in the United States suffer from chronic constipation, with risk increasing for individuals ≥65 years of age. Nursing home residents are at especially high risk because of the increased incidence of medication use, impaired mobility, inadequate fluid and food intake, and presence of a cognitive impairment in this population. In addition to causing discomfort, constipation may result in patients losing their appetites, leading to poor nutritional status. During a poster session at the AGS 2011 Annual Scientific Meeting, Zheng-Bo Huang, MD, New York Hospital Medical Center of Queens, Flushing, NY, and colleagues reported the case of a 90-year-old nursing home resident with advanced dementia who almost received a percutaneous gastrostomy (PEG) tube because of a 1-month history of failure to thrive. The patient was sent to the hospital for PEG tube placement, where a geriatrician requested an abdominal radiograph, which revealed severe constipation. Following several enemas and a bowel regimen, the patient passed a large volume of stool. Shortly thereafter, her appetite returned and she no longer required PEG tube placement. Huang and colleagues note that approximately 33% of nursing home residents with advanced dementia receive feeding tubes, and that the decision to place these tubes is often made hastily. Because communication abilities are impaired in residents with impaired cognition, constipation may go undiagnosed and untreated for an extended period of time in these individuals, as was the case with their patient. They note that their case serves as a reminder that reversible factors of poor nutritional intake, such as constipation, must be ruled out before proceeding to tube feeding.
