Clinical AbstractScan

Summaries of recent journal articles of potential interest to long-term care professionals.

Hormone Replacement Therapy and Incidence of Alzheimer's Disease in Older Women: The Cache County Study. Zandi PP, Carlson MC, Plassman BL, et al. Journal of the American Medical Association 2002;288:2123-2129.

Previous, but not necessarily current, use of hormone replacement therapy (HRT) appears to diminish the incidence of Alzheimer's disease (AD) in women, but this seems only to be so for those who have followed such a regimen for more than 10 years, according to researchers from Johns Hopkins University in Baltimore, and other centers.

Dr. Peter P. Zandi and colleagues note that although studies have shown that HRT can reduce the risk of AD in women over the age of 80, epidemiologic findings on this association are mixed. Thus, they say, "the relationship of HRT and AD remains uncertain."

The researchers conducted a prospective study of incident dementia in 1,357 men (mean age, 73.2 years) and 1,889 women (mean age, 74.5 years) who lived in a single county in Utah. Participants were first assessed between 1995 and 1997, and were followed up between 1998 and 2000.

Over an interval of three years, between initial interview and follow-up, 35 men (2.6%) and 88 women (4.7%) developed AD. The incidence in women increased after the age of 80 and was greater than that in men of similar age (adjusted hazard ratio, 2.11).

However, analyses suggested that AD was less common in women with a history of HRT use (26) compared with non-users (58). Further analysis showed that women who had used HRT for more than 10 years had a risk similar to that of men.

Risk varied with duration of HRT use, so that women's increase in risk compared with men disappeared entirely with more than 10 years of HRT (7 cases among 427 women).

However, current use of HRT had no protective effect (hazard ratio, 1.08) unless duration of use exceeded 10 years (6 cases among 344 women, with an adjusted hazard ratio of 0.55).

The researchers thus conclude that "HRT may be effective for the primary prevention of AD--if not for its treatment--and patience in awaiting definitive trial results is indicated."

Effect on Hip Fractures of Increased Use of Hip Protectors in Nursing Homes: Cluster Randomised Controlled Trial. Meyer G, Warnke A, Bender R, et al. Neurology 2002;59:1721-1729

Behavioral symptoms such as agitation and irritability increase the cost of care in patients with Alzheimer's Disease (AD), according to researchers at Michigan State University in Lansing.

Dr. Daniel L. Murman and colleagues note that the impact of behavioral symptoms on the cost of AD care is poorly understood.

To investigate, they recruited 126 patients with probable AD from nine clinical practices in Michigan.

Caregivers were interviewed and behavioral symptoms assessed using the Neuropsychiatric Inventory (NPI). Cognitive function was measured using the Mini-Mental State Examination and medical comorbidities were gauged using the Cumulative Illness Rating Scale. Also employed was the Caregiver Activities Time Survey and the Medical Care component of the Consumer Price Index.

After adjusting for differences in severity of cognitive impairment and comorbidities, annual direct costs were significantly higher in patients at or above the median NPI score.

Overall, these patients had annual costs for services such as physician visits and hospital care (formal costs) from $3,162 to $5,919 higher than those with lower scores. Depending on the severity of cognitive impairments, total direct costs--comprised of formal costs and unpaid caregiving (informal costs)--were between $10,670 and $16,141 higher.

The researchers conclude that estimates indicate that a one-point increase in NPI score would result in an annual increase of between $247 and $409 in total direct costs, depending on the value placed on unpaid caregiving.

A Comparison of Outcomes with Angiotensin-Converting-Enzyme Inhibitors and Diuretics for Hypertension in the Elderly. Wing LMH, Reid CM, Ryan P, et al. New England Journal of Medicine 2003;348:583-592.

Diuretics and angiotensin-converting-enzyme (ACE) inhibitors seem to be equally effective in reducing blood pressure in elderly patients. However, particularly in men, use of ACE inhibitors appears to lead to better outcomes, according to Australian researchers.

Dr. Lindon M. H .Wing of Flinders University in Adelaide and colleagues conducted a study of 6,083 hypertensive patients aged 65 to 84 years from more than 1,500 family practices. This open-label randomized trial compared outcomes from use of ACE inhibitors with therapy with diuretics.

The subjects were followed for a median of 4.1 years and both agents achieved a similar and significant reduction in blood pressure over this period. Results were similar in men and in women. However, there was an 11% reduction in cardiovascular events and deaths from any cause in those receiving ACE inhibitors.

There were almost twice as many events in males as in females (907 versus 524), and the benefits of ACE-inhibitor therapy were more apparent in males. In men, there was a 17% reduction in all cardiovascular events and first cardiovascular events (hazard ratio 0.83). The corresponding hazard ratio in women was 1.00.

Overall, the rates of non-fatal cardiovascular events and myocardial infarctions decreased with ACE-inhibitor treatment. However there were a similar number of strokes in each group, and more fatal strokes in the ACE-inhibitor group.

Whether the relative benefits of ACE-inhibitor therapy are confined to men, the investigators conclude, "requires examination in large ongoing trials."

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