Using Antipsychotics for Elderly Patients Boosts Kidney Risks

Using antipsychotic drugs to treat older patients with dementia increases the risk of kidney injury, a new study found. (Image: JAMA, ©AMA)

Using antipsychotic drugs to treat older patients with dementia increases the risk of kidney injury, a new study found. (Image: JAMA, ©AMA)

Older adults treated with atypical antipsychotics are at increased risk of kidney injury, according to a study published today in the Annals of Internal Medicine. The findings add to previous evidence that this class of drugs is risky for older adults.

Although atypical antipsychotics are commonly prescribed for older adults to treat agitation and other behavioral symptoms of dementia, the US Food and Drug Administration has not approved the drug for this purpose. In fact, since 2005 the agency has warned that use of these drugs to treat older adults with dementia was associated with a 2-fold increased risk of death. An agency analysis of 17 placebo-controlled trials found the risk of death among patients with dementia taking olanzapine, aripiprazole, risperidone, or quetiapine was 4.5% compared with 2.6% among those taking a placebo.

Use of atypical antipsychotics is associated with a range of adverse effects, including hypotension, pneumonia, heart attack, and the breakdown of muscle tissue, that may contribute to kidney injury. But the extent of the potential kidney risk was unclear, so Y. Joseph Hwang, MSc, of the London Health Sciences Centre in Ontario, Canada, and colleagues conducted a cohort study comparing 97 777 patients aged 65 years or older receiving a new atypical antipsychotic prescription with 97 777 matched controls to assess the risk of kidney injury within 90 days. Patients who received an atypical antipsychotic medication were more likely to be hospitalized with a kidney injury. Use of the medication was also associated with low blood pressure, urine retention, and death.

In addition, the researchers looked at a subgroup of patients with creatinine levels available (a measure of kidney function). They found the absolute risk of hospitalization for kidney injury was about 2% higher in the treated group (5.46% vs 3.34%).

The authors conclude that the study adds to evidence that use of atypical antipsychotics in elderly patients should not be taken lightly.

“The drugs should be used only after other approaches have been exhausted; when prescribed, patients must warned about potential adverse events,” they wrote.

They recommend careful monitoring of blood pressure, creatinine levels, and other potential signs of kidney problems in older patients receiving atypical antipsychotics. Physicians treating older patients with kidney injury should consider these medications a potential cause and stop use of the drugs if possible, they wrote.

Taking Steps to Curb Limitations From Knee Arthritis

Walking 6000 steps daily may reduce the risk of functional limitations from knee osteoarthritis, according to new research. (Image: ©iStock.com/PeskyMonkey)

Walking 6000 steps daily may reduce the risk of functional limitations from knee osteoarthritis, according to new research. (Image: ©iStock.com/PeskyMonkey)

Walking at least 6000 steps a day may be the ideal amount of physical activity to help ward off mobility problems from knee osteoarthritis, according to new research.

Previous studies have reported that osteoarthritis in knees is the leading cause of functional limitations among older adults, making walking and climbing stairs difficult. Additional research has shown that a physically active lifestyle including structured exercise can be therapeutic for arthritic knees.

But investigators in a large, multicenter, longitudinal study of older adults with or at risk of knee osteoarthritis wanted to know whether unstructured activity such as walking could reduce the likelihood of functional limitations.

Enrolled in their study were 1788 adults whose average age was 67 years. The participants had or were at risk of knee osteoarthritis based on x-rays and their own assessments of how much pain they felt. Each was given an ankle device that recorded the number of strides taken daily for 7 days as a baseline measurement. Two years later, investigators evaluated the participants’ walking speed and scores on a pain scale to determine whether their steps per day correlated with functional decline.

Their analysis, published online today in Arthritis Care & Research, showed that walking 5000 to 7499 steps daily halved the risk of developing functional limitations compared with participants who walked fewer than 5000 steps. Walking 7500 or more steps a day reduced the risk by 60% to 70% compared with fewer than 5000 steps. Every additional 1000 daily steps conferred a 16% to 18% reduction in risk. The investigators found that 6000 steps per day was the best threshold to determine which participants did or did not develop functional problems.

“Walking is an inexpensive activity and despite the common popular goal of walking 10 000 steps per day, our study finds only 6000 steps are necessary to realize benefits,” lead author Daniel White, PT, ScD, of Boston University in Massachusetts, said in a statement.

“We encourage those with or at risk of knee osteoarthritis to walk at least 3000 or more steps each day and ultimately progress to 6000 steps daily to minimize the risk of developing difficulty with mobility,” White added.

He and his colleagues wrote that their findings could be considered preliminary clinical recommendations for therapeutic physical activity targets for people with or at risk of knee osteoarthritis.

Benefits of Walking Extend to Chronic Kidney Disease

Walking may help people with chronic kidney disease live longer and reduce their risk of needing dialysis or a kidney transplant. (Image: ©iStock.com/blyjak

Walking may help people with chronic kidney disease live longer and reduce their risk of needing dialysis or a kidney transplant. (Image: ©iStock.com/blyjak

Chalk up another benefit of walking for exercise. New research shows that among people with chronic kidney disease, walking may help prolong life and reduce the risk of needing dialysis or a kidney transplant.

The study, published online today in the Clinical Journal of the American Society of Nephrology, evaluated 6363 patients with moderate to end-stage kidney disease at the China Medical University Hospital in Taichung, Taiwan. On average, patients were 70 years old and investigators followed up their exercise patterns for 1.3 years.

About one-fifth of the patients said walking was their most common form of exercise. During the follow-up period, walkers were 33% less likely to die and 21% less likely to need dialysis or a kidney transplant than nonwalkers. The more they walked, the more benefits they derived.

Patients who walked once or twice a week were 17% less likely to die during the study period than nonwalkers. Walking 3 to 4 times a week reduced the risk of dying by 28% and by 59% among those who walked at least 7 times a week.

Similarly, walking once or twice a week reduced the likelihood of needing dialysis or a kidney transplant by 19% compared with not walking. Taking a walk 3 or 4 times a week reduced the risk by 27% and by 44% among those who walked at least 7 times a week.

Investigators found that patients benefitted from walking regardless of their age, level of kidney function, and co-occurring illnesses such as heart disease, stroke, and diabetes.

“Walking for exercise is associated with improved patient survival and a lower risk of dialysis,” study author Che-Yi Chou, MD, said in a statement. “A minimal amount of walking—just once a week for less than 30 minutes—appears to be beneficial, but more frequent and longer walking may provide a more beneficial effect.”

 

 

 

 

Author Insights: Studies Disclose Motivations When Comparing Treatment Costs

Franklin G Miller, PhD, of the National Institutes of Health Department of Bioethics, and colleagues suggests making the cost motivations in comparative-effectiveness studies clear on consent forms. Image: NIH

Research participants should be informed when studies are being conducted to determine which treatments provide the best bang for the buck, argue the authors of a Viewpoint in today’s issue of JAMA.

Health care reform and the urgent need to cut rising health care costs have led to a growing number of comparative-effectiveness studies that may pit treatments against each other to assess the relative risks, benefits, and costs of the treatments. Franklin G. Miller, PhD, National Institutes of Health Department of Bioethics, and colleagues argue that when treatment costs are a motivating factor behind a study, participants have a right to know.

Miller and colleagues highlighted the Comparison of the Age-Related Macular Degeneration Treatment Trials (CATT) as an example of study motivated in part by differential drug costs. The CATT compared the relative costs, safety, and effectiveness of 2 drugs used to treat macular degeneration. Ranibizumab has been approved by the US Food and Drug Administration (FDA) as a macular degeneration treatment, but  many clinicians use a similar drug bevacizumab, which was originally approved as a cancer treatment, in part because it is 40 times cheaper. A report from the US Department of Health and Human Services’ Office of Inspector General (OIG) found, for example, that between 2008 and 2009, Medicare Part B “paid physicians $40 million for 936 382 Avastin (bevacizumab) treatments and $1.1 billion for 696 927 Lucentis (Ranibizumab) treatmetnts.”*

The CATT study mentioned the cost differential but did not spell out that costs were one of the motivating factors behind the study. The study by Miller and colleagues suggests simple language that could be used to let study participants know that cost is a motivating factor. Miller discussed his and his colleagues’ views with news@JAMA.

news@JAMA: Why did you decide to write this Viewpoint?

Dr Miller: There are more comparative effectiveness studies being conducted and one of the background motivations for the studies is the relative costs of treatments. A lot of drugs are expensive, and there is some real value in seeing how these stack up. They rarely are done solely for cost. There are usually other clinical considerations. It was my perception that cost motivation is not routinely described to patients as a reason why a study is done.

news@JAMA: What makes the CATT study such a good case study?

Dr Miller: It’s an excellent study. It stands out in that you have 2 treatments that are biologically almost essentially the same—one is FDA-approved, and one is [prescribed] off label. The FDA-approved drug is 40 times more expensive. With the newly released data about Medicare payments to physicians, it turns out that ophthalmologists are among the highest paid. A fair amount of that has to do with Lucentis [ranibizumab]. I think most ophthalmologists prescribe the cheaper option.

We weren’t trying to criticize the study, it’s a very valuable study. The cost wasn’t fully described as a motivation, but that is really the norm. I was on data safety monitoring committee for the study, and we approved the consent form.

news@JAMA: What did the CATT study ultimately find?

Dr Miller: There was no difference in the safety and effectiveness of the two. This is not surprising because of the biological similarity.

news@JAMA: How might informing participants about cost motivations affect their behavior?

Dr Miller: That’s a question we don’t have an answer to. For patients with chronic conditions it might be better for them to get an equivalent, but cheaper treatment. They might be more motivated to participate, and some are altruistically motivated. There might be some who could be turned off.

news@JAMA: What is the main take-home message you’d like to pass along to researchers and potential research participants?

Dr Miller: When a part of the motivation to do a randomized study has to do with the relative costs of treatment it should be clearly laid out. We suggested some simple language.

*This blog has been updated with information from the OIG report.

Fewer Falls Among Older Adults in Simple, Short-Term Program

A simple, inexpensive Pennsylvania program reduced falls among older adults by 17%. (Image: ©iStock.com/SilviaJansen

A simple, inexpensive Pennsylvania program reduced falls among older adults by 17%, according to a new analysis. (Image: ©iStock.com/SilviaJansen).

A simple, inexpensive program based at community senior centers can help prevent falls among older adults, according to a new analysis.

Pennsylvania’s Department of Aging has offered the program at no cost to all adults 50 years old or older throughout the state since 2007. It uses the existing state network of services for older adults, such as walk-in senior centers, to offer the program components.

Adults who participate receive assessments of their balance and mobility and a referral for physician care or a home safety evaluation if their scores are below the norms for their age and sex. The program also includes a 2-hour fall prevention class that explains household hazards and a demonstration of exercises designed to improve balance and mobility.

The Centers for Disease Control and Prevention (CDC) has compiled a list of successful interventions that community-based programs can use to help prevent falls, but little evidence is available on the short-term, low-cost, population-wide type of program used in Pennsylvania. So during 2010 to 2011, researchers at the University of Pittsburgh Graduate School of Public Health compared the outcomes of 814 adults who participated at senior centers with 1019 adults at the same centers who didn’t participate. Their average age was 75.4 years.

After a year of follow-up, the incidence of falls was 17% lower among participants than nonparticipants. The difference was significant, and adults whose balance was fair or poor derived the most benefit. Further analysis would be needed to tease out which program components were most responsible for the reduction in falls, according to the researchers.

They noted that about one-fifth of the participants at high risk of falls followed up with a physician, but three-fourths carried out home safety assessments and one-third made changes to reduce their home hazards.

“Simply informing older adults of their high-risk status and heightening their sensitivity to situations involving a risk of falling may lead to reductions in falls,” the investigators wrote in their study, published online today in the American Journal of Public Health.

The State of Pennsylvania reimburses senior centers $70 per volunteer involved in administering the program. Volunteers keep program costs low, the researchers noted. During 2010 to 2011, the state allocated $1.2 million for the program. The CDC has estimated that the annual direct and indirect cost of fall injuries in the United States will reach $67.7 billion by 2020.

Increase in Shingles Not Linked to Chickenpox Vaccine

A mysterious increase in shingles among older adults does not appear to be related to the addition of varicella vaccine to the US childhood vaccination schedule. Image: RosicaSabotanova/iStock.com

A mysterious increase in shingles among older adults does not appear to be related to the addition of varicella vaccine to the US childhood vaccination schedule. Image: RosicaSabotanova/iStock.com

Cases of shingles have been on the rise among older adults in the United States, but adoption of the chickenpox vaccine does not appear to be causing this increase, suggests a study published today in the Annals of Internal Medicine.

The United States began recommending routine vaccination of children against varicella, the virus that causes chickenpox, in 1996. The recommendation was met with some concern that it might increase the incidence of shingles (herpes zoster), a painful reactivation of the varicella virus, in older adults. Some speculated that fewer children with chickenpox would mean less natural boosting of the immune response in adults who had been infected as children. Without such natural boosting, older adults with weakened immune systems might see the virus reactivate, causing the painful lesions of shingles. Although most adults do not suffer serious complications related to herpes zoster, as many as 25% may experience persistent and sometimes disabling pain for months after varicella reactivation.

To probe the effects of varicella vaccination in children on shingles incidence, researchers examined health care claims for nearly 3 million Medicare beneficiaries between 1992 and 2010. They found that the rate of herpes zoster has increased over the past 2 decades by 39%, from 10 cases per 1000 person-years to 13.9 cases per 1000 person-years. But the increase began before the implementation of varicella vaccination for children in 1996. In fact, the researchers found no change in the herpes zoster rate after the implementation of this vaccination program. If routine childhood varicella vaccination were causing an uptick in herpes zoster, the rate of herpes zoster would have been expected to accelerate after the program went into effect. The authors note, however, that the data set they analyzed may miss some shingles cases, because some individuals may not seek medical care.

The findings are reassuring that the vaccination program is not likely causing the uptick in shingles, but the cause for the increase remains mysterious. To help combat this increase and protect older adults from shingles, the US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended in 2006 that older adults be vaccinated against herpes zoster. But adoption of the vaccine has been slow, with vaccinations among adults 60 years and older increasing from 1.9% in 2007 to just 14.4% in 2010.

Better-educated Middle-aged People More Likely to Adopt Healthy Lifestyle Changes When a Chronic Health Problem Arises

Middle-aged people in the United States are more likely to adopt healthy lifestyle modifications when diagnosed with a chronic condition if they are better educated, a new study shows. (Image: Willie B. Thomas/iStockphoto.com)

Middle-aged people in the United States are more likely to adopt healthy lifestyle modifications when diagnosed with a chronic condition if they are better educated, a new study shows. (Image: Willie B. Thomas/iStockphoto.com)

Better-educated people in the United States appear to be more likely to make healthy lifestyle changes when confronted with a new health problem in middle age compared with their less-educated peers, researchers report in the Journal of Health and Social Behavior.

Previous studies show that better-educated middle-aged people are less likely to smoke and are more apt to be physically active than those with less education. But study author Rachel Margolis, PhD, of the University of Western Ontario in London, Canada, said better-educated middle-aged people who smoke or who are not physically active are also more likely to make lifestyle alterations after a change in their health status.

“Health behavior changes are surprisingly common between ages 50 and 75, and the fact that better-educated middle-aged people are more likely to stop smoking, start physical activity, and maintain both of these behaviors over time has important health ramifications,” said Margolis in a release. “This finding helps explain why there are educational differences in chronic disease management and health outcomes.”

Margolis’s findings are based on data from the Health and Retirement Study, in which participants in the United States aged 50 to 75 years answered questions about their health and lifestyle every 2 years, from 1992-2010. She collected data on 16606 participants and focused on smoking cessation efforts for those diagnosed with hypertension, heart disease, diabetes, lung disease, stroke, and cancer, and exercise efforts for those diagnosed with hypertension, heart disease, and diabetes.

Among respondents in their 50s, those who had not completed high school had about a 15% to 20% probability of quitting smoking when faced with a new chronic condition, while those with a college education had more than a 30% probability of quitting. The latter also had about a 22% probability of starting physical activity following diagnosis of a new chronic condition, compared with an 18% probability for those who had not completed high school.

As for those aged 61 to 75 years, Margolis found higher educational levels were not associated with increased lifestyle modification. She speculated that perhaps the longer people expect to live when diagnosed with a chronic condition, the more likely they are to adapt lifestyle changes.