Michael Maddens

Low bone mass and postfall fracture risk among elderly nursing home men.

OBJECTIVE To study postfall fracture risk in relation to bone mineral density. SETTING The study was conducted in men residing in nursing homes. PARTICIPANTS A total of 212 men above the age of 65 years were recruited, and of these, 172 satisfied the inclusion criteria of the study. Among them, 82 were less than 85 years old, and 90 were at least 85 years old. INTERVENTION Bone mineral density (BMD) of the calcaneus was measured, using the Lunar PIXI Bone Densitometer (version 1.43) and charts were reviewed for age, falls, and fractures. MEASUREMENTS The values of BMD were expressed as T-scores, and the Lunar criteria equivalents of T-scores were used (T-scores more than -0.6 for normal BMD, -0.6 to -1.6 for osteopenia, and below -1.6 for osteoporosis). RESULTS The median age of all participants was 84 years (range 65 to 102 years), and their mean T-score at the calcaneus was -1.51. In about 51% of them, the T-score was in the osteoporotic range. For subjects less than 85 years old, the mean T-score was -1.19, and for those 85 years and older, the mean T-score was -1.81; the mean bone density of those in the older old group was significantly lower than those in the younger old group if there was a history of a fracture. Analysis by age quartiles showed a progressive decline in BMD with advancing age. About 53% of the subjects who fell (37.2%) sustained a nontraumatic fracture. Among them, 67.6% had osteoporosis. CONCLUSION At any given age after age 65, men who sustained a postfall fracture had a significantly lower BMD than those who did not sustain a postfall fracture.

Do Hemoglobin and Creatinine Clearance Affect Hospital Readmission Rates from a Skilled Nursing Facility Heart Failure Rehabilitation Unit

OBJECTIVES Cardio renal anemia syndrome is being increasingly recognized in patients with congestive heart failure (CHF) and is associated with increased mortality and rehospitalization rates. Our objective was to assess the relationship between hemoglobin (Hb), creatinine clearance (C(Cr)), and hospital readmission in elderly patients enrolled in a skilled nursing facility (SNF)-based CHF rehabilitation unit. METHODS We retrospectively identified 127 consecutive patients admitted to an SNF-based CHF rehabilitation unit between July 2001 and September 2002. The patients were grouped into quintiles of hemoglobin and creatinine clearance (C(Cr)) The rate of hospital readmission between quintiles of above variables was compared using the chi-square test. RESULTS We found a higher prevalence of anemia than reported earlier in the literature for CHF patients discharged from hospital. Rehospitalization rates were increased two- and fivefold in lower compared to higher quintiles of hemoglobin and creatinine clearance, respectively. Anemia predicted rehospitalization in patients with renal dysfunction. CONCLUSION Our study suggests an association between anemia and rehospitalization rates in patients with renal dysfunction enrolled in an SNF-based CHF rehabilitation unit.

Enhancing Cognitive Screening in Geriatric Care: Use of an Internet-Based System

Cognitive screening measures for age-related cognitive impairment have been found to have only fair validity, and the risks of harm even may outweigh the benefits at this time (U.S. Preventative Service Task Force, 2003). A large-scale project designed to assess elder care in Primary Care Physician offices noted that dementia evaluation and treatment was one of the most overlooked aspects of care. Taken together, these studies cited the lack of time and technical expertise in test administration as the most prominent barriers to the accurate detection of dementia in Primary Care Physician offices. It was for these reasons that the Cognitive Screening Test (CST) was created. The CST requires no physician time or training to administer or interpret it. The current study investigated the clinical utility of this cognitive screening system by comparing the results of 102 patients to those of expert geriatricians, using consensus conference methods for diagnosis. Overall clinical utility demonstrated scores at .80 or above for sensitivity, specificity, and positive and negative predictive power. In contrast, the MMSE had only a .38 sensitivity. A Receiver Operating Curve (ROC) analysis indicated a .863 accuracy rating for the predetermined cut score on the CST.

Eye Care in the Skilled Nursing Facility: A Pilot Study of Prevalence and Treatment Patterns of Glaucoma

OBJECTIVE The objective of this study was to determine the rates of ophthalmic examinations for glaucoma, prevalence rates of glaucoma, ongoing evaluation (follow-up) rates and rates of treatment for a population of residents in a skilled nursing facility. DESIGN We conducted a retrospective evaluation and chart review of glaucoma-related ophthalmology services. SETTING This study was conducted in a skilled nursing facility located in a large metropolitan area located in the Midwest. PARTICIPANTS We studied all nursing home residents of the facility on October 1, 2002 (n = 160). METHODS We conducted a retrospective evaluation and chart review of glaucoma-related ophthalmology services for 160 patients. The medical records used for review included admission records, physician history and physical records, hospital notes, nursing assessments, consultation notes, and medication reviews (including medications administered during hospital stays). Minimum data set (MDS) data and individual patient interviews were used to supplement and verify chart abstraction findings. RESULTS Eighty-three residents (52%) had evidence of assessment for glaucoma. Thirty-three of these residents (40%) had documentation of a diagnosis of glaucoma; 25 (76%) had current treatment orders for a topical ophthalmic agent. Nine patients were using combination therapy; four used topical and oral beta-adrenergic-blocking agents. CONCLUSIONS Visual impairment remains a serious problem for nursing facility residents. Assessment of visual abilities is infrequent or nonexistent. Education for nursing home personnel, discussion and activation among nursing home thought leaders, and guidelines for the evaluation and management of glaucoma in this care environment are needed.

REVERSIBLE PENILE PRIAPISM ASSOCIATED WITH NEFAZODONE

impairment of the tubulo-infundibular dopaminergic axis (TIDA). The TIDA is an important circuit that is located in the medial basal hypothalamus and uses dopamine as a neurotransmitter. It is mediated by dopamine-2 receptors, which are also responsible for the motor response to dopamine. The TIDA exerts an inhibitory control on the secretion of prolactin (PRL) and thyroid stimulating hormone (TSH). One study showed lower PRL and TSH and higher GH levels in untreated responders (IPD) to dopamine than in nonresponders.5 The investigators suggested that the lack of reaction to dopamine was correlated with impairment of the TIDA in IPD and that this impairment is progressive.5 Our finding of a significant difference in duration of symptoms between responders and nonresponders are also in agreement with this theory. Levodopa is known to stimulate GH secretion4,5 and also causes a GH response in patients with parkinsonism due to MSA without a motor improvement on levodopa.4 An explanation for this GH response could be the direct stimulation by levodopa to somatotrophic cells. Dopaminergic receptors have been demonstrated on GH cells, and a direct effect of levodopa on growth hormone releasing hormone has also been shown.4 It seems likely that the impaired GH response to clonidine in nonresponders to levodopa results from abnormalities in the neuronal systems or pathways from the hypothalamus and that these systems also include the TIDA system. Duration of symptoms may be a factor in the severity of the involvement of the striatal structures.1–3 In conclusion, this study showed a lack of GH response after clonidine in patients with parkinsonism due to IPD, MSA, and PSP not responding to levodopa therapy. The GH response to clonidine may therefore help in decisions concerning starting or discontinuing levodopa therapy in patients with parkinsonism. These findings suggest that GH response to clonidine may identify early patients with parkinsonism who will benefit from therapy with levodopa/benserazide. Furthermore, the clonidine test proved to be a safe and inexpensive test that can be performed on an outpatient basis.

Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial

Importance Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment. Objective To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women. Design, Setting, and Participants Multisite randomized clinical trial (the Group Learning Achieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire–Short Form (ICIQ-SF), symptoms of at least 3 months’ duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study. Interventions The GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD. Main Outcomes and Measures Outcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment. Results Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, −1.51 to −0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was

PNFLBA-08 IS GROUP LEARNING BEHAVIORAL MODIFICATION PROGRAM EFFECTIVE AND SAFE IN REDUCING GERIATRIC URINARY INCONTINENCE? A MULTI-CENTER RANDOMIZED CONTROLLED TRIAL.

723 at 3 months; GBT dominated at 12 months. Conclusions and Relevance The GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with UI. Trial Registration ClinicalTrials.gov identifier: NCT02001714

PSEUDO‐OBSTRUCTION DUE TO FOREIGN BODY: IMPORTANCE OF GOOD PHYSICAL EXAMINATION

INTRODUCTION AND OBJECTIVES: Primary aim: to compare the effectiveness and safety of a group-administered behavioral treatment program (GBT) to no treatment in older women with stress, urgency, or mixed urinary incontinence (UI). METHODS: Recruitment letters were mailed to women 55 years and older at three sites (Alabama, Michigan & Pennsylvania) seeking UI naïve to previous therapy. Responders were screened by phone and eligible respondents were referred to sites for clinical screening and randomization. Inclusion/exclusion criteria included age 55+, International Consultation on Incontinence questionnaire (ICIQSF) score at least 3 (1 for frequency, 2 for severity), minimum 3-months duration, no prolapse, previous bladder surgery or pelvic cancers. Primary outcome: ICIQ-SF. Secondary outcomes: 3-day voiding diary (VD), paper towel test, 24-hr pad test, Brink test, Patient Global Impression of Improvement (PGI-I) and other UI questionnaires. GBT group received a one-time 2-hour bladder health class whereas control received usual care. Both received behavioral education brochure, monitored every 3 months for 12-months; clinic visits at 3 & 12 months and mailed questionnaires at 6 & 9 months. RESULTS: 463 subjectswere randomized toGBT (232) or control (231). 34 withdrew (GBT1⁄422 & Control 1⁄412). Demographics were not significantly different between groups. Outcomes at 3, 6, 9 & 12 months showed significant differences in favor of GBT over control including ICIQ (p<0.0001) (Fig1), # leaks@VD (p0.0002), paper towel test (p0.0008), 24hr padweights (p0.0007),Medical,Epidemiologic&Social aspectsofAging questionnaire (MESA) (p<0.0001), Incontinence Quality of Life (IQOL) (p<0.0001)&PGI-I (p<0.0001)but not theBrink test for pelvicfloorstrength (p0.09-.9). No significant difference in adverse events or serious events were encountered in each group. (all p values at 12 months) CONCLUSIONS: This novel GBT bladder health education program was safe & effective in reducing UI frequency, severity and bother and improving quality of life for older women with UI in the community. This easily scaled intervention increases opportunity to reach larger populations beyond clinical into community settings.

Curriculum in cardiology: Integrated diagnosis and management of diastolic heart failure

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: Rocı́o Fernández-Ballesteros planned and implemented the study, collected the Spanish data, and wrote the letter. Luis F. Garcı́a performed all statistical analyses. All the other authors collected the data from their countries. Sponsor’s Role: There was no sponsor.