Marcel E. Ooms

Ultraviolet Irradiation Corrects Vitamin D Deficiency and Suppresses Secondary Hyperparathyroidism in the Elderly

The objective of this study was to compare the effect of ultraviolet radiation (UV) and oral vitamin D3 on the vitamin D status and parathyroid hormone (PTH) concentration in elderly nursing home patients. The design of the study was a randomized clinical trial. The setting was a psychogeriatric nursing home. Subjects included 45 female psychogeriatric patients with a mean age of 85 years. Exclusion criteria were going outdoors more than once a week and the presence of actinic or cancer skin lesions. Intervention was random allocation of UV‐B irradiation at half the minimal erythemal dose of the lower back, three times per week during 12 weeks (UV‐B), or oral vitamin D3 400 IU/day during 12 weeks (VIT‐D), or no treatment (CONTR). Main outcome measures were change in fasting serum levels of vitamin D metabolites at 0, 2, 4, 8, and 12 weeks in the treatment groups, compared with the control group. PTH(1–84) was measured at 0 and 12 weeks. Baseline serum 25‐hydroxyvitamin D (25(OH)D) was lower than 30 nmol/l in 95% of the participants. It increased to a median value of around 60 nmol/l after 12 weeks both in the UV‐B and VIT‐D groups, whereas there was no change in the CONTR group. Serum 1,25‐dihydroxyvitamin D increased significantly in the UV‐B group. Serum calcium increased significantly in both treatment groups. Serum PTH decreased more than 30% in both treatment groups (p < 0.001), whereas there was no significant change in the control group. Irradiation with UV‐B in the very elderly for a few minutes per day leads to adequate improvement of the vitamin D status. It is as effective as oral vitamin D3 in increasing serum 25(OH)D and suppressing secondary hyperparathyroidism.

Recent developments in pain in dementia

Epidemiological studies show that, worldwide, the number of people aged over 65 will increase substantially in the next decades and that a considerable proportion of this population will develop dementia.1 Ample evidence shows that ageing is associated with a high rate of painful conditions, irrespective of cognitive status.2 The number of patients with dementia who will experience painful conditions is therefore likely to increase. A key question relates to whether and how patients with dementia perceive pain. Patients with dementia may express their pain in ways that are quite different from those of elderly people without dementia.3 Particularly in the more severe stages of dementia, therefore, the complexity and consequent (frequent) inadequacy of pain assessment leads to the undertreatment of pain.nnThe most commonly used pain assessment instruments seem to be selected primarily according to the communicative capacity of the patient (self report pain rating scales for communicative patients and observation scales for non-communicative patients) instead of according to two main aspects of pain—the sensory-discriminative and motivational-affective aspects. In particular, the motivational-affective aspects of pain are assessed by observation scales, which should therefore be applied to every patient, irrespective of ability to communicate. Distinction between the sensory-discriminative and motivational-affective aspects of pain is of great clinical relevance, as the motivational-affective aspects are particularly likely to reflect pain that needs treatment.4 Moreover, differentiating between these two aspects of pain in relation to the neuropathology of the various subtypes of dementia provides insight into the basis of the alterations in the pain experiences of elderly people with dementia. Future experimental and clinical studies should not only focus on subtypes of dementia but should go a step further and assess pain in disorders in which pain is already present at a stage without cognitive impairment and during the course …

The Effect of Vitamin D Supplementation on the Bone Mineral Density of the Femoral Neck Is Associated with Vitamin D Receptor Genotype

Recent studies suggest that variations of the vitamin D receptor (VDR) gene are related to bone mineral density (BMD). In this study, we examined the effect of vitamin D3 supplementation on BMD at the femoral neck in relation to VDR genotype. We analyzed 81 women, age 70 years and over, who participated in a placebo‐controlled clinical trial on the effect of vitamin D3 supplementation (400 IU daily for at least 2 years) on BMD and fracture incidence. VDR genotype was based on the presence (b) or absence (B) of the BsmI restriction site. Mean BMD of the right and left femoral neck was measured at baseline and after 1 and 2 years. Dietary calcium, body mass index, and years since menopause were assessed at baseline while biochemical markers were measured at baseline and after 1 year. There was no difference among the BB, Bb, and bb genotype for baseline measurements of BMD at the femoral neck (mean and SD, g/cm2: 0.70 (0.10), 0.71 (0.12), and 0.69 (0.10), respectively), nor for any of the biochemical indices. The mean increase of BMD in the vitamin D group relative to the placebo group, expressed as percentage of baseline BMD, was significantly higher (p = 0.03) in the BB (ΔBMD: 4.4%, p = 0.04) and Bb genotype (ΔBMD: 4.2%, p = 0.007) compared with the bb genotype (ΔBMD: −0.3%, p = 0.61). No significant changes were found for any of the other measured parameters. The VDR genotype‐dependent effect of vitamin D supplementation in these elderly subjects suggest a functional involvement of VDR gene variants in determining BMD.

Predictors of fractures in elderly women

Abstract: In a prospective study of 348 apparently healthy women, aged 70 years and over (mean 80.3 years), we examined bone mineral density (BMD), biochemical markers of bone metabolism, and some easily measurable predictors in relation to hip and osteoporotic fractures. In addition, we constructed risk profiles for hip and osteoporotic fractures. At baseline, BMD at both hips, using dual-energy X-ray absorptiometry, body height and body weight were measured. At the same time, serum and urine samples were obtained for biochemical analysis. Serum samples were analyzed for vitamin D metabolites, sex hormone binding globulin, serum intact parathyroid hormone, osteocalcin, alkaline phosphatase, phosphate, albumin, calcium and creatinine. In 2 h fasting urine, hydroxyproline, type I collagen crosslinked N-telopeptide (NTx) and calcium excretion were measured. Furthermore, easily measurable predictors, such as previous fracture, body mass index (BMI) and mobility were assessed. During the follow-up period (mean duration 5.0 years), hip and any osteoporotic fracture (wrist, humerus or hip fracture) occurred in 16 and 33 participants, respectively. Data were analyzed using Cox regression analysis. BMD of the trochanter (per 1 SD decrease) and previous fracture were most strongly associated with hip fractures (adjusted relative risk (RR) = 3.0, 95% confidence interval (CI): 1.4–6.6; RR = 4.2, 95% CI: 1.5–11.6, respectively) and osteoporotic fractures (RR = 1.8, 95% CI: 1.1–2.8; RR = 2.9, 95% CI: 1.5–5.7, respectively). Previous fracture, BMI and mobility were identified as easily measurable predictors for hip fractures, whereas previous fracture, use of loop diuretics and age were predictors for osteoporotic fractures in the risk profile model. The risk of fractures can be predicted with three easily measurable predictors. This study confirms the importance of previous fracture as a predictor for hip fractures and other fractures. It also shows that the use of loop diuretics is a predictor for osteoporotic fractures.

Comorbidity and 1-year mortality risks in nursing home residents.

Objectives: To investigate the effect of chronic diseases and disease combinations on 1‐year mortality in nursing home residents.

The Incidence of Hip-Fractures in Independent and Institutionalized Elderly People

The incidence density of hip fractures in the population of Amsterdam, aged 70 years and over, was studied according to the type of residence. In 1989, 655 patients were admitted to nine hospitals within Amsterdam for a hip fracture. Postal codes were used to classify the residence of the population and the hip fracture cases as independent, home for the elderly or nursing home. Stepwise logistic regression was used for data analysis. The risk of hip fracture increased with age and was 1.7 times higher for women than for men. In the age group 70–74 years the relative risk (RR) was 7.6 for those in homes for the elderly and 5.8 for those in nursing homes, when compared with the independent elderly. This RR was approximately 1 for those in homes for the elderly aged 85 years and over. However, in nursing homes the RR was still 2.8 in the age group 95+. We concluded that, despite protective measures against falls, the institutionalized elderly are at greater risk of hip fracture than the independent elderly of the same age and sex. This higher risk is especially apparent in the ‘younger’ age groups.

Pneumonia: The Demented Patient's Best Friend? Discomfort After Starting or Withholding Antibiotic Treatment

OBJECTIVES: To assess suffering in demented nursing home patients with pneumonia treated with antibiotics or without antibiotics. This study should provide the first empirical data on whether pneumonia is a “friend” or an “enemy” of demented patients and promote a debate on appropriate palliative care.

Treatment of nursing home residents with dementia and lower respiratory tract infection in the United States and the Netherlands: An ocean apart

Objectives: To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands.

Different risk profiles for hip fractures and distal forearm fractures: a prospective study

In a prospective cohort of elderly persons, aged 70 years and over, we examined risk indicators for which data could be easily obtained, to construct risk profiles for hip fractures and distal forearm fractures. Participants lived independently, in apartment houses for the elderly or in homes for the elderly. At baseline, information was obtained in 2578 subjects on age, gender, residence, mobility and the frequency of going outdoors. Mobility was measured using a walking score ranging from 1 (not able to walk independently) to 3 (able to walk independently for a fair distance). During the study period (median duration 3.5 years, maximum 4 years) 106 participants sustained a hip fracture and 60 participants suffered a distal forearm fracture. Women compared with men, adjusted for age, had a higher risk of hip fracture (adjusted relative risk (RR)=2.4, 95% confidence interval (CI) 1.3–4.3) and distal forearm fracture (RR=3.7, 95% CI 1.5–9.2). Age, adjusted for gender, was related to hip fractures only: the relative risk of fracture for those in the highest age category (>85 years) was 9.5 (95% CI 4.3–21.2) compared with those in the lowest age category (70–75 years). Moderately impaired walking ability compared with normal walking ability, adjusted for age and gender, was associated with a higher risk of hip fracture (RR=1.8, 95% CI 1.2–2.7) but with a lower risk of distal forearm fracture (RR=0.4, 95% CI 0.2–0.8). The outdoor score, adjusted for age and gender, was associated with distal forearm fractures only: going outdoors less than once a week, compared with three times or more, was associated with a lower risk of fractures (RR=0.3, 95% CI 0.1–0.9). In those living in homes for the elderly the risk of hip fracture was higher compared with those living independently (RR=2.4, 95% CI 1.4–4.2), adjusted for age and gender. Risk profiles were constructed using stepwise Coxs proportional-hazards regression. The risk profile predicted probabilites of sustaining a hip fracture in a 4-year period ranging from 0.4% to 25.9%, and of distal forearm fractures ranging from 0.2% to 4.5%, depending on the subjects characteristics as defined by the risk indicators. We conclude that easily obtainable risk indicators can be used in the prediction of fractures and can discriminate among fracture types.

Severe dementia and adverse outcomes of nursing home-acquired pneumonia: evidence for mediation by functional and pathophysiological decline.

To assess whether the severity of dementia is related to unfavorable outcomes of nursing home‐acquired pneumonia and how this relationship is mediated.