A-TAPER: A Framework for Deprescribing Medications effectively

Inappropriate medication use creates avoidable safety issues for older adults. Deprescribing medications that are high risk and/or of minimal benefit is important for reducing morbidity and adverse effects, especially in this population. A variety of deprescribing resources and algorithms are available, but a singular framework to effectively approach and implement the deprescribing of unnecessary medications in practice does not exist. An interprofessional team of pharmacists, geriatricians, and researchers developed a framework to guide providers in deprescribing medications. This framework is represented by the acronym A-TAPER, which stands for Assess medication use, Talk about risks versus benefits, select Alternatives, Plan next steps, Engage patient, and Reduce dose. Within this framework, comprehensive, medication-specific deprescribing toolkits can be created.

A pilot study to determine predictors of behavioral treatment completion for urinary incontinence

Although a program of pelvic floor muscle exercises augmented with biofeedback is a safe, efficacious way to treat urinary incontinence, many patients do not finish the program. The only significant predictor of treatment completion in one outpatient referral clinic for urinary incontinence was keeping a 7-day bladder diary.

Self-care practices used by older men and women to manage urinary incontinence: results from the national follow-up survey on self-care and aging

OBJECTIVES

To estimate the extent to which self-care practices are employed by older adults with urinary incontinence (UI); to determine how demographic and functional status measures are associated with self-care practice use; and to explore the relationship between contacting a doctor and disposable pad use.

DESIGN

A cross-sectional analysis of a national probability sample using multiple logistic regression.

SETTING

Responses of subjects with UI (n = 787) from the 1993-1994 National Follow-up Survey on Self-Care and Aging, a follow-up survey of older Medicare beneficiaries living in the community within the contiguous United States drawn in 1990-1991

MEASURES

Subject responses about UI, fecal incontinence, dressing, eating, bathing, Instrumental Activities of Daily Living (IADL), Mobility Activities of Daily Living (MADL), age, gender, place of residence, race, education, proxy response to the survey, and self-reported medical conditions.

RESULTS

Self-care practices used by more than 25% of respondents with UI included using disposable pads, limiting trips, and limiting fluids. Among older adults with incontinence, more women used disposable pads (44.5%; 95% CI, 36.9-52.1) and performed exercises (14.2%; 95% CI, 9.7-18.9) than did men (15.1%; 95% CI, 8.1-22.1; and 4.3%; 95% CI, 1.0-7.7, respectively). Bi-variate analysis showed respondents with severe UI or fecal incontinence reported greater use of self-care practices. In multivariate models of the three most commonly used self-care practices, measures of UI severity were not always associated independently with self-care practice use, whereas ADL measures of functional status were. Disposable pad use was positively independently associated (OR 3.36; 95% CI, 2.01-5.63) in multivariate models with contacting a doctor about incontinence, even after controlling for age, gender, demographics, and self-reported medical conditions.

CONCLUSIONS

Use by older adults of self-care practices to manage urinary incontinence is predicted independently in multivariate models by measures of functional status such as dressing, eating, bathing, IADLs or MADLs, but not by all UI measures. Disposable pad users had increased odds of contacting a doctor, suggesting that self-care practices and formal medical care are not always inversely related.

On the number of automated timed manual performance trials to administer

OBJECTIVE

To determine the number of trials needed to obtain satisfactory results when evaluating function in older subjects using the automated version of the Williams short (three-door) Timed Manual Performance (TMP) test.

DESIGN

Administration of from one to five trials in succession on a given test date.

SETTING

A Continuing Care Retirement Community (CCRC), assisted living centers, nursing homes, and a community residence, all located in central North Carolina.

PARTICIPANTS

The subject population consisted of 182 older volunteers, aged 63 to 100 years. One hundred nineteen lived independently in a CCRC, 33 were assisted-living residents, 29 lived in nursing homes, and one lived independently in the community. Each subject was administered at least three trials in succession on his or her first test date; 23 of the independently living CCRC residents were given three trials on a second test date. The community-dwelling volunteer was administered from one to five trials on each of 26 test dates over an approximately 16-month period.

MEASUREMENTS

The time it takes to perform five door opening and closing operations as measured by the three-door Cognatemp Automated Timed Manual Performance (ATMP) system.

MAIN RESULTS

Average ATMP time for the subjects living independently decreased approximately 10% between the first two trials but negligibly between trials two and three. The more dependent groups continued to improve between trials two and three. The community-dwelling subject tended to improve in the first three or four trials and to decline by the fifth trial.

CONCLUSIONS

It is recommended that two trials be administered and the best time used; if neither trial results in a time less than 10 seconds, one or two more trials should be administered. It is generally not necessary nor advantageous to administer more than four trials.

The association of urinary incontinence with poor self-rated health

OBJECTIVES

To assess whether urinary incontinence (UI) and its severity are associated with poor self-rated health in a national sample of community-living older adults and whether this relationship persists after controlling for confounding attributable to functional status, comorbidity, and demographic factors.

DESIGN

A cross-sectional analysis using multivariate logistic regression.

SETTING

Subjects were from the 1990-1991 National Survey of Self-Care and Aging (N = 3485), a random sampling in geographic clusters of community-dwelling Medicare beneficiaries 65 years of age or older in the contiguous United States.

MEASURES

The responses to an interviewer-administered questionnaire regarding urinary incontinence, Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living (IADL), Mobility Activities of Daily Living (MADL), age, gender, place of residence, race, education, need for proxy response to the survey, and number of medical conditions.

RESULTS

Unadjusted analysis showed the presence of urinary incontinence to be associated with poor self-rated health (OR 2.7, 2.1-3.3). With gender, number of comorbid conditions, race, IADL impairment, and interaction terms of incontinence/race and incontinence/IADL in the final model, UI was associated with poor self-rated health in certain subgroups. White subjects with no IADL impairment and mild-moderate incontinence had an OR of 2.0 (95% CI 1.5-2.9) and those with severe incontinence had an OR of 4.5 (95% CI 2.4-8.4) of rating their health as poor, whereas those with no IADL impairment and no incontinence were the referent group. For those with a lot of difficulty performing one or more IADL activity, the association of UI and poor self-rated health was weak. For non-white subjects, there was no association, or a very weak association, of UI and poor self-rated health.

CONCLUSION

In this national sample, urinary incontinence was independently and positively associated with poor self-rated health after adjustment for age, comorbidity, and frailty for most community-dwelling older adults. This association between UI and poor self-rated health was weaker and statistically insignificant when IADL impairment was present or in non-white subjects. Further research is indicated to better understand the impact of urinary incontinence in specific cultural settings.

Diagnostic assessment of geriatric urinary incontinence

Urinary incontinence affects 15% to 30% of the population and 50% of those living in nursing homes. Care for incontinence is difficult because this condition is underreported by patients and underdiagnosed by physicians. This article describes the medical and nursing diagnostic assessment of urinary incontinence of geriatric populations, and the criteria for referral. Comprehensive review of urinary incontinence, including treatment, is available elsewhere. Although this article focuses on the assessment of urinary incontinence, the type of treatment being considered guides the scope of the evaluation, and therefore, treatment of incontinence is discussed.

Increases in high-density lipoprotein cholesterol with endurance exercise training are blunted in obese compared with lean men

The effectiveness of endurance exercise training (without concomitant weight loss) for improving lipoprotein lipid levels in obese individuals remains controversial. The purpose of this study was to determine whether lipoprotein lipid responses to endurance exercise training are affected by obesity. Healthy middle-aged and older (57 +/- 2 years) lean (n = 16; body mass index [BMI], 22 to 26 kg/m2), moderately obese (n = 15; BMI, 27 to 30 kg/m2), and obese (n = 15; BMI, 31 to 37 kg/m2) men underwent a 9-month endurance exercise training program. The groups differed in the initial degree of obesity, waist circumference, and waist to hip ratio (WHR), but not in age or maximal aerobic capacity ( VO2max). The obese group had lower baseline levels of high-density lipoprotein cholesterol (HDL-C) and HDL2-C, and higher triglyceride (TG) levels than the lean group. Exercise training increased VO2max to a comparable degree in lean, moderately obese, and obese groups (18%, 24%, and 18%, respectively, P < .01). Exercise training significantly decreased TG levels in all groups, whereas total cholesterol and low-density lipoprotein cholesterol (LDL-C) decreased only in the obese group. Exercise training increased HDL-C and HDL2-C levels in lean (14% and 81%, respectively, P < .05) and moderately obese (7% and 59%, respectively, P < .05) men, whereas neither HDL-C nor HDL2-C changed in obese men. The change in HDL-C correlated negatively with initial BMI (r = -.42, P < .01) and waist circumference (r = -.43, P < .01). These results show that the effects of exercise training on HDL-C are blunted in obese middle-aged and older men, whereas improvements in TG occur independently of the degree of obesity.

Relationship of body composition and cardiovascular fitness to lipoprotein lipid profiles in master athletes and sedentary men

A number of studies demonstrate that highly conditioned older athletes are leaner than their sedentary counterparts, and have lipoprotein profiles similar to that of young individuals. It is not clear whether the high maximal aerobic capacity (VO2max) or lean body habitus is the major determinant of the favorable lipoprotein lipid profiles present in older athletes. The objective of this study was to determine whether body composition or VO2max was the major determinant of lipoprotein lipid profiles among 61 master (age 63 +/- 6 years, mean +/- SD) athletes (VO2max > 40 mL/kg/min), 39 age-matched lean (% body fat < 25%), and 51 obese (% body fat > 25%) sedentary men. Plasma high density lipoprotein cholesterol (HDL-C) concentrations were 25% higher in that athletes than in the lean sedentary men, and 42% higher than in the obese sedentary men. Triglyceride (TG) concentrations were 24% lower in the master athletes than in the lean sedentary men, and 51% lower than in the obese sedentary group. Plasma low density lipoprotein cholesterol (LDL-C) levels were 9% lower in the athletes than in the other groups of sedentary individuals. In stepwise multiple regression analysis the percent body fat was the major independent predictor of HDL-C and TG levels accounting for 29% and 41% of the variation in these levels, respectively. The VO2max accounted for an additional 6% of the variance in HDL-C levels and 2% of the variance in TG levels. These cross-sectional results suggest that the favorable lipoprotein profile of master athletes is largely due to their lean body habitus, with a small independent contribution from their higher levels of cardiovascular fitness. Thus, regular vigorous aerobic exercise and maintenance of low body fat may prevent the commonly observed age-associated deterioration in lipoprotein concentrations.

Effects of single nightly injections of growth hormone-releasing hormone (GHRH 1-29) in healthy elderly men

Age-related reductions in growth hormone (GH) and insulin-like growth factor-I (IGF-I) may contribute to decreased muscle mass and strength in older persons. The relationship of this phenomenon to skeletal muscle bioenergetics has not been reported. We sought to determine whether administration of GH-releasing hormone (GHRH) would sustain increases in GH and IGF-I and improve skeletal muscle function and selected measures of body composition and metabolism. We measured GH secretion, muscle strength, muscle histology, and muscle energy metabolism by phosphorus nuclear magnetic resonance spectroscopy (31P-NMRS), body composition, and endocrine-metabolic functions before and after 6 weeks of treatment. Eleven healthy, ambulatory, non-obese men aged 64 to 76 years with low baseline IGF-I levels were treated at home as outpatients by nightly subcutaneous self-injections of 2 mg GHRH for 6 weeks. We measured GH levels in blood samples obtained every 20 minutes from 8:00 PM to 8:00 AM; AM serum levels of IGF-I, IGF binding protein-3 (IGFBP-3), and GH binding protein (GHBP); muscle strength; muscle histology; the normalized phosphocreatine abundance, PCr/[PCr + Pi], and intracellular pH in forearm muscle by NMRS during both sustained and ramped exercise; body composition by dual-energy x-ray absorptiometry (DEXA); lipid levels; and glucose, insulin, and GH levels during an oral glucose tolerance test (OGTT). GHRH treatment increased mean nocturnal GH release (P < .02), the area under the GH peak ([AUPGH] P < .006), and GH peak amplitude (P < .05), with no change in GH pulse frequency or in levels of IGF-I, IGFBP-3, or GHBP Two of six measures of muscle strength, upright row (P < .02) and shoulder press (P < .04), and a test of muscle endurance, abdominal crunch (P < .03), improved. GHRH treatment did not alter exercise-mediated changes in PCr/[PCr + Pi] or intracellular pH, but decreased or abolished significant relationships between changes in PCr/[PCr + Pi] or pH and indices of muscle strength. GHRH treatment did not change weight, body mass index, waist to hip ratio, DEXA measures of muscle and fat, muscle histology, glucose, insulin, or GH responses to OGTT, or lipids. No significant adverse effects were observed. These data suggest that single nightly doses of GHRH are less effective than multiple daily doses of GHRH in eliciting GH- and/or IGF-I-mediated effects. GHRH treatment may increase muscle strength, and it alters baseline relationships between muscle strength and muscle bioenergetics in a manner consistent with a reduced need for anaerobic metabolism during exercise. Thus, an optimized regimen of GHRH administration might attenuate some of the effects of aging on skeletal muscle function in older persons.

Continuum of cardiovascular performance across a broad range of fitness levels in healthy older men

BACKGROUND

Although it has become clear that habitual exercise in older individuals can partially offset age-associated cardiovascular declines, it is not known whether the beneficial effects of exercise training in older individuals depend on their prior fitness level.

METHODS AND RESULTS

Ten sedentary men (S), age 60.0 +/- 1.6 years (mean +/- SEM), who were carefully screened to exclude cardiac disease underwent exercise training for 24 to 32 weeks, and eight age-matched endurance-trained men (ET) stopped their exercise training for 12 weeks. All underwent treadmill exercise and rest and maximal cycle exercise upright gated blood pool scans at baseline and after the lifestyle intervention. Before the intervention, the treadmill maximum rate of oxygen consumption (Vo2max) was 49.9 +/- 1.9 and 32.1 +/- 1.4 mL.kg-1.min-1 in ET and S, respectively. During upright cycle exercise at exhaustion, although heart rate did not differ between groups, cardiac index, stroke volume index, ejection fraction, and left ventricular contractility index (systolic blood pressure/end-systolic volume index) all were significantly higher, and end-systolic volume index, diastolic blood pressure, and total systemic vascular resistance all were significantly lower in ET versus S. After the partial deconditioning of ET men, Vo2max fell to 42 +/- 2.2 mL.kg-1.min-1, and training of S increased Vo2max to 36.2 +/- 1.6 mL.kg-1.min-1. Training of S had effects on cardiovascular function that were similar in magnitude but directionally opposite those of detraining ET. All initial differences in cardiovascular performance at peak work rate between S and ET were abolished with the intervention. Across the broad range of fitness levels encountered before and after change in training status (Vo2max of 26 to 58 mL.kg-1.min-1), cardiac index, stroke volume index, end-systolic volume index, ejection fraction, and the left ventricular contractility index were all linearly correlated with Vo2max.

CONCLUSIONS

Exercise training or detraining of older men results in changes in left ventricular performance that are qualitatively and quantitatively similar, regardless of the initial level of fitness before the intervention.