Clinical AbstractScan

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

Pneumonia: Still the Old Man's Friend? Kaplan V, Clermont G, Griffin MF, et al. Archives of Internal Medicine 2003;163:317-323.

Almost half of all elderly patients hospitalized for community-acquired pneumonia die in the subsequent year and most deaths take place after hospital discharge.

Dr. Vladimir Kaplan of the University of Pittsburgh and colleagues observe that the hospital mortality of such patients has been well described. However, "the long-term survival of those discharged alive is less clear."

The investigators note that many patients with community-acquired pneumonia do not require hospitalization and most who are admitted to the hospital survive to discharge. Nevertheless, the condition "remains common and is still one of the leading causes of hospital admission and death throughout the world, including the United Kingdom and United States."

The researchers examined a Medicare hospital-discharge database for a three-month period in 1997. They identified 158,960 community-acquired pneumonia patients and 794,333 controls hospitalized for reasons other than pneumonia. All were aged 65 years or more.

The hospital mortality rates were 11% in the pneumonia patients and 5.5% in controls. At one year, the corresponding proportions were 40.9% and 29.1%, respectively. One-year mortality rates in hospital survivors of pneumonia were 33.6%, and in those with other conditions, 24.9%--a significant difference.

The researchers observe that one in three of those who survived hospitalization for pneumonia died in the year after hospital discharge. Although a "substantial proportion " of deaths were in the first three months after discharge, this increased risk persisted for the entire year of follow-up.

Independent predictors of such mortality were advanced age and increasing comorbidities. In fact, the team suggest that "pneumonia itself might be a more sensitive marker of comorbidities with unfavorable prognosis than commonly used measures based on patient records."

Improved understanding of the "poor long-term prognosis associated with community-acquired pneumonia," they conclude, "is needed to modify the dismal outcome of this common disease in elderly patients."

Effect of Four Monthly Oral Vitamin D3 (Cholecalciferol) Supplementation on Fractures and Mortality in Men and Women Living in the Community: Randomised Double Blind Controlled Trial. Trivedi DP, Doll R, Khaw KT. British Medical Journal 2003;326:469-474.

Taking a single vitamin D capsule every four months led to a reduction in fractures in men and women between the ages of 65 and 85 years who lived in the general population, according to UK researchers.

Dr. Daksha P. Trivedi of the University of Cambridge Clinical School of Medicine and colleagues point out that "most fracture prevention trials have focused on clinically defined groups such as people with osteoporosis or previous fractures and have mainly been conducted in women."

To gain a wider insight, the team studied 2,037 men and 649 women (mean age, 65.85 years) living in the community. Most of the participants were doctors.

In this double-blind trial, which was a pilot for a subsequently unfunded larger study, subjects were randomized to receive one 100,000 IU oral vitamin D3 capsule or placebo every four months for five years.

Over this period, 268 subjects had incident fractures. In 147, these were located at common osteoporotic sites, such as the hip, wrist, forearm, or vertebrae. Compared with the placebo group, the relative risk of any first fracture was 0.78. The corresponding figure for a first fracture at these osteoporotic sites was 0.67.

In total, 471 participants died, and compared with the placebo group, the relative risk for total mortality in the supplementation group was 0.88. These findings were consistent in men, women, doctors, and participants overall.

The investigators concede that the trial was too small for a decisive effect on fractures to be expected. Nevertheless, they note that the cost of the intervention was "minimal" and it appeared to be "acceptable, safe, and effective in reducing the risk of fractures."

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. British Medical Journal 2003;326:76-80.

Use of hip protectors by elderly nursing home residents appears to reduce the incidence of hip fractures, and educational efforts may help increase adoption of the devices, according to German researchers.

Dr. Gabriele Meyer of the University of Hamburg and colleagues observe that "trials of hip protectors in nursing homes have reported a reduction of 50% in the incidence of hip fracture. In general, however, acceptance of hip protectors is poor."

They also point out that "adherence will be largely determined by the motivation and competence of staff in nursing homes." With this in mind, the researchers conducted education sessions for nursing staff from certain homes and supplied three free hip protectors per resident.

The staff members, who were themselves encouraged to wear hip protectors, then passed on information to residents individually or in small groups. In control nursing homes, staff received a brief lecture and were given two protectors for demonstration purposes.

Forty-two nursing homes in Hamburg took part in the study. In total, 459 residents at high risk of falling were randomized to the intervention group and 483 to the control group.

Mean follow up was 15 months in the intervention group and 14 months in the control group. Over that time, 167 residents in the intervention group and 207 controls either died or moved away.

There were 21 hip fractures in 21 residents in the intervention group (4.6%) and 42 hip fractures in 39 residents in the control group (8.7%). The relative risk was thus 0.57.

The findings amount to "a relative reduction of hip fractures of more than 40% with borderline significance," note the investigators. There also was a lower rate of hospital admissions following falls in the intervention group, but this may have been due to a variety of factors, they caution, and thus "should not be overinterpreted."

After adjustment, the proportion of fallers who used a hip protector was 68% in the intervention group and 15% in the control group.

The team conclude that "a structured education programme and provision of free hip protectors can increase use." They also point out that long-term implementation "requires the provision of hip protectors on prescription for elderly people at high risk of hip fracture."

Behavioral Training With and Without Biofeedback in the Treatment of Urge Incontinence in Older Women: A Randomized Controlled Trial. Burgio KL, Goode PS, Locher JL, et al. Journal of the American Medical Association 2002;288:2293-2299.

Behavioral training appears to be helpful in reducing urge incontinence in older women, according to findings of a study of more than 200 such subjects. However, provision of biofeedback does not significantly enhance the efficacy of this approach.

Dr. Kathryn L. Burgio of Birmingham Veterans Affairs Medical Center in Alabama and colleagues point out that urge incontinence is usually treated with drugs that inhibit detrusor contractions. Nevertheless, behavioral treatments to enhance continence skills have also proven effective in dealing with the condition.

To determine whether biofeedback heightened the therapeutic efficacy of behavioral training, the researchers enrolled 222 non-demented, community-dwelling women, ranging in age from 55 to 92 years. They were stratified by type and severity of incontinence and randomly assigned to one of three groups.

The first group employed biofeedback-assisted behavioral training. This consisted of four clinic visits during which standard continence maneuvers such as increasing pelvic floor muscle control were established. Biofeedback measures--for example, using a balloon probe to measure and display sphincter responses--were also used.

The behavioral training group also made four clinic visits during which verbal feedback was provided, but the biofeedback aspect of the intervention was omitted. The remaining group, who acted as controls, were assigned to self-administered behavioral training as outlined in a self-help booklet.

Intention-to-treat analysis at the end of the 8-week intervention period showed no significant differences among groups. The biofeedback group had a mean reduction in incontinence of 63.1%. The corresponding figure for the training group without biofeedback was 69.4%,and controls showed a mean reduction of 58.6%.

Nevertheless, there were significant inter-group differences in patient satisfaction. A total of 75% of the biofeedback group were completely satisfied versus 85.5% of the verbal feedback group and 55.7% of the self-help group.

The investigators conclude that because self-help and verbal feedback programs can be successfully employed without the equipment and expertise needed for biofeedback, "they are both appropriate and practical for use in most any outpatient clinical practice."

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